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2019 CPS > Invasive GAS: Mgmt and chemoppx > Flashcards

Invasive GAS: Mgmt and chemoppx Flashcards

1
Q

Most common presentations of IGAS?

A
  • Toxic shock syndrome (TSS), with or without a focus of infection
  • Necrotizing fasciitis or myositis
  • Bacteremia with no septic focus
  • Pneumonia
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2
Q

The incidence of IGAS disease in Canada has _____ over the past decade.

A

Increased

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3
Q

In Canada and the US, rates are highest in ____, _____ and ______.

A

Infants, young children, and the elderly

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4
Q

Risk factors for IGAS among ADULTS?

A
  • HIV infection
  • Cancer
  • Heart disease
  • Diabetes
  • Lung disease
  • Alcohol abuse
  • Injection drug use
  • Postpartum period
  • Recent soft-tissue trauma
  • NSAID use
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5
Q

Risk factors for IGAS among children?

A
  • Recent pharyngitis
  • Varicella (vaccine programs have reduced varicella associated IGAS)
  • Recent soft-tissue trauma
  • NSAID use
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6
Q

IGAS is reportable in _______.

A

All provinces and territories in Canada

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7
Q

Definition of confirmed case of SEVERE IGAS?

A

-Laboratory confirmation: Isolation of GAS from a normally sterile site
+
Evidence of severe invasive disease:
-Streptococcal TSS
-Soft-tissue necrosis (including NF, myositis or gangrene)
-Meningitis
-Pneumonia (with isolation from a sterile site such as pleural fluid) BAL NOT considered to be sterile site
-A combination of the above
-Any other life-threatening condition or infection resulting in death

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8
Q

Diagnosis of Streptococcal TSS?

A
  • Laboratory confirmation of GAS from normally sterile site
  • Hypotension (SBP of =90 in adults, less than 5%ile for age in children) + AT LEAST TWO of:
  • Renal impairment (creatinine at least 2X ULN for age or 2X patient baseline)
  • Coagulopathy (platelet =100 or DIC)
  • Liver function abnormality (AST, ALT or total bili >/=2X ULN for age)
  • ARDS
  • Generalized erythematous macular rash that may later desquamate
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9
Q

Definition of confirmed case of NON-SEVERE IGAS?

A 
-Laboratory confirmation: Isolation of GAS from a normally sterile site
\+
-Bacteremia
-Cellulitis
-Wound infection
-Soft tissuue abscess
-Lymphadenitis
-Septic arthritis
-Osteomyelitis without evidence of streptococcal TSS or soft tissue necrosis
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10
Q

Definition of probable case of IGAS?

A
  • Invasive disease in the absence of another identified etiology and with isolation of GAS from a non-sterile site (e.g., BAL).
  • Pneumonia with isolation of GAS from BAL and with no other cause identified may be considered IGAS for purposes of patient management, but would not be nationally notifiable
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11
Q

True or false: Streptocccal TSS is clinically indistinguishable from staphylococcal TSS

A

True

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12
Q

Clinical features associated with necrotizing fasciitis?

A
  • Severe pain or tenderness (often out of proportion to clinical appearance)
  • Toxic appearance
  • Hemodynamic instability
  • Rapid rate of progression
  • ‘Woody induration’
  • Nerve involvement may cause anesthesia or hyperesthesia of the overlying skin
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13
Q

Crepitus is more strongly associated with ____ or _____ NF.

A

Polymicrobial, clostridial

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14
Q

GAS-related NF cases are more likely to be associated with which clinical features?

A
  • Generalized rash
  • Pharyngitis
  • Conjunctivitis
  • Strawberry tongue
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15
Q

What is fundamental to optimize outcome for NF?

A
  • Early, aggressive intervention

- Combined medical and surgical therapy

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16
Q

GAS pneumonia may be clinically indistinguishable from other causes of pneumonia, but often exhibits__________.

A

A rapidly progressive course with large pleural effusions.

17
Q

Broad principles of management of severe IGAS disease?

A
  • Supportive treatment using fluids and electrolytes
  • Specific therapy with antimicrobials
  • Measures to minimize or neutralize the effects of toxin production, when indicated
  • ID should be consulted
18
Q

Empiric therapy of TSS or suspected TSS?

A
  • Cloxacillin + clindamycin
  • Vanco for areas or populations with significant rates of MRSA colonization

-Should include coverage of staph aureus and GAS with a beta-lactamase stable beta-lactam (Clox)

19
Q

Empiric therapy for NF? What are risk factors for clostridial or polymicrobial myonecrosis?

A
  • Pip-Tazo or Carbapenem + Cliindamycin +/-Vanco
  • Provides broad coverage for gram-positive, gram-negative, and anaerobic organisms with special consideration for GAS and clostridia
  • If otherwise healthy child with none of risk factors for organisms other than GAS, may choose penicillin plus clindamycin as initial therapy*
  • Tailor to gram-stain, culture and sensitivity results, when available
  • Depends on clinical presentation and risk factors for IGAS, MRSA, exposure to potential water-borne pathogens (aeromonas and vibrio), and RFs for clostridial or polymicrobial myonecrosis:
  • Chemotherapy
  • Recent GI surgery
  • Penetrating trauma
  • Intra-abdominal or pelvic focus of infection
  • Pregnancy complications
20
Q

What is definitive diagnosis of NF based on?

A

Emergent surgical exploration - also facilitates early debridement and expedites microbiological ID of pathogens

21
Q

Treatment of choice for confirmed GAS cases?

A

Penicillin + clindamycin - clinda strongly recommended as potent inhibitor of toxin production for all empiric and confirmed SEVERE IGAS cases
-Clinda NOT recommended for monotherapy because GAS resistance rates have increased

22
Q

When can you consider discontinuing clindamycin in severe IGAS cases?

A

After 48-72h of treatment if patient is hemodynamically stable, blood is sterile and no further progression of necrosis

23
Q

When should IVIg be considered? (IGAS)

A

-On day of clinical presentation for streptococcal TSS or other SEVERE invasive (toxin-mediated) disease, especially when patient severely ill or condition is refractory to initial aggressive therapy with fluids

24
Q

Dosing for IVIg? (IGAS)

A

150mg/kg to 500mg/kg per day for 5-6 days OR single dose of 1g/kg to 2g/kg

25
Q

Proposed mechanism of action of IVIg in IGAS?

A

-Multifactorial and includes toxin neutralization, opsonization and improved phagocytic killing, and suppression of the massive inflammatory response through Fc-receptor interactions

26
Q

Recommendation re: NSAIDS in patients with suspected IGAS?

A

Prescribe cautiously - unclear whether or not they contribute to the development of severe IGAS disease

27
Q

Definition of close contacts?

A
  • Household contacts who, within the previous 7 days have spent at least 4h/day on average or a total of 20h with the IGAS case (index case)
  • Non-household persons who have shared a bed with the case or had sexual relations with the index case
  • Persons who have had direct contact with the mucous membranes or oral or nasal secretions of the index case (e.g. by mouth-to-mouth resuscitation or open mouthed kissing) or unprotected direct contact with an open skin lesion of the index case
  • Injection drug users who have shared a needle with the index case
  • Contacts in child care settings
  • Selected hospital contacts (PHAC Guideline)
  • Selected contacts in LTC facilities (PHAC Guideline)
28
Q

What to do for close contacts of all confirmed IGAS cases, whether severe or non-severe?

A

Alert to signs and symptoms of IGAS, and advise to seek immediate medical attention should they develop febrile illness or any other clinical manifestation of GAS infection within 30 days of diagnosis in the index case

29
Q

Target group and prophylaxis window for chemoprophylaxis?

A
  • Chemoprophylaxis should only be offered to close contacts of a confirmed case of severe IGAS who have been exposed during the period from 7 days before the onset of symptoms in the index case to 24 h after initiating antimicrobial therapy in the case.
  • Chemoprophylaxis should be started as soon as possible, preferably within 24 h of identifying the case, but is still recommended up to 7 days after the last contact with the case. Provincial/territorial protocols for prophylaxis may vary; clinicians should become familiar with local policies
  • Recommended for all children and staff in FAMILY or HOME child care settings when any of the above criteria met
30
Q

Who is chemoprophylaxis not routinely recommended for?

A
  • Contacts of non-severe IGAS cases (e.g., bacteremia without toxic shock; septic arthritis). These cases tend to have milder disease and so do their contacts
  • In GROUP or INSTITUTIONAL child care centres and preschools. HOWEVER, may be considered in specific situations -e.g. more than one case of IGAS disease among children or staff within one month, or concurrent varicella outbreak
31
Q

First line choice of chemoprophylaxis agent? Dosing and duration?

A

-First-generation cephalosporin:
-Cephalexin 25-50mg/kg daily to max 1g/day in 2-4 divided doses x 10 days
or
-Cefadroxil 25-50mg/kg daily, to max 1g/day, in 2 divided doses (children) or once daily (adults) NO LIQUID PREPARATION.

32
Q

Alternative agents for chemoprophylaxis?

A

Second- and third-generation cephalosporinis e.g. cefuroxime axetil and cefixime

33
Q

Chemoprophylaxis for in individuals with beta lactam allergy?

A

Macrolides (erythro, clarithro, azithro)

34
Q

Chemoprophylaxis for patients unable to tolerate beta lactams?

A

Clindamycin

35
Q

Do you take cultures from contacts?

A

Cultures have no role in the identification of asymptomatic close contacts of sporadic IGAS cases occurring in the community. Routine cultures are not required for follow-up of contacts receiving antibiotic chemoprophylaxis.

2019 CPS (19 decks)

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