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Empiric Management of Common Infections in …

Empiric Management of Common Infections in solid Organ transplant orange button to enter date: August 1, by UHN Pharmacy & Therapeutics: September 11,2017 Questions/comments: email to Fever and InfectionsBlood Stream : Infectious Syndromes & ManagementClick orange buttons to navigate and/or lung transplantIntra-abdominal (within 1 month) post-liver, kidney, pancreas transplantIntra-abdominal (>1 month) post-liver, kidney, pancreas transplantIntra-abdominal urinary tract Infections ANDA symptomatic BacteriuriaUrinary Tract Blood Stream Tract and assessmentsDiabetic Foot InfectionsAntimicrobial treatmentDiabetic Foot Asked Questions & Approach to Fever and Infections in a solid Organ transplant PatientEligible patients for this set of guidelines.

Empiric Management of Common Infections in Solid Organ Transplant Patients www.antimicrobialstewardship.com Click orange button to enter protocol.

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1 Empiric Management of Common Infections in solid Organ transplant orange button to enter date: August 1, by UHN Pharmacy & Therapeutics: September 11,2017 Questions/comments: email to Fever and InfectionsBlood Stream : Infectious Syndromes & ManagementClick orange buttons to navigate and/or lung transplantIntra-abdominal (within 1 month) post-liver, kidney, pancreas transplantIntra-abdominal (>1 month) post-liver, kidney, pancreas transplantIntra-abdominal urinary tract Infections ANDA symptomatic BacteriuriaUrinary Tract Blood Stream Tract and assessmentsDiabetic Foot InfectionsAntimicrobial treatmentDiabetic Foot Asked Questions & Approach to Fever and Infections in a solid Organ transplant PatientEligible patients for this set of guidelines.

2 solid organ transplant recipients and patients awaiting the patient received organ transplant ?Key questions to ask regarding patient history Initial investigations and tests for all patients with suspected infections123 Was there any mismatch in transplant serology?Which type of transplant and how long ago?Was there a history of rejection?Any recent sick contact, new sexual contact or exposure to animals?Are there any recent changes to patient s immunosuppressive therapy?Did patient receive T-cell depleting therapy for induction or treatment of rejection?Any travel in the last 3 months?

3 Technical or anatomical abnormalities Environmental exposure: community and hospital-associated Instrumentation, drainage catheters, stents, or endotracheal tubes Implanted devices, ventricular assistive deviceRisk factors Common to all SOT patientsIn addition to routine investigations on admission, Complete Blood Count: Blood cultures - one from CVC lumen(s) if present and one from a peripheral site Blood CMV PCR (exception: D-neg/R-neg history)Kidney transplant patients with stent in placeInclude urine culture in routine investigationsSyndrome / symptom-specific investigations:Respiratory tract infection Chest X-ray Consider chest CT if chest X-ray is abnormal Nasopharyngeal swab for respiratory viruses Legionella urinary antigenIntraabdominal infection Abdominal ultrasound or CT toxin gene PCR as appropriateUrinary tract infection (UTI): concurrently order Urine culture AND UrinalysisDid patient receive antibiotics in the last 3 months?

4 Is the patient on antimicrobial prophylaxis?Is the patient on dialysis?Reasonable to wait for results before starting treatment if patient:is hemodynamically stable ANDhas fever as the only symptom ANDdoes not have identifiable source or focus of infectionLegend: Required As clinically indicated If patient has SEPSIS, go to2a. Bloodstream Infectionvancomycin 1g IV Q12H Patient has a suspected or known source of infectionBlood culture gram stainBloodstream infection without sepsisBloodstream infection (BSI) identifiedInvestigate possible source of BSIS ource of infection unknownSyndrome/souarce specific treatment:Gram positiveCandidemiaGram negativeYeastPatient has history of vancomycin-resistant enterococci infection or colonization.

5 Daptomycin 6 mg/kg IV Q24H (consider higher doses for persistent bacteremia)meropenem 1g IV Q8H If patient has history of carbapenem-resistant Enterobacteriaceae: Consult transplant Infectious Diseases UrinaryAbdominalRespiratoryCentral lineFigure 3 Legend: Required As clinically indicated Consult clinical pharmacist renal dose adjustment and drug interactions of antimicrobials but do not delay the first dose. fluconazole 800 mg IV/PO x 1 dose, then 400 mg IV/PO once daily 2b. CandidemiaIs this a central venous catheter (CVC)-related bloodstream infection?

6 Remove CVC when safe to do so. See also Figure 2cConsults: transplant ID OphthalmologyRepeat blood cultures daily after initiation of antifungal therapy until first negative diagnostic imaging to rule out any occult source ( abscesses)Duration of therapy: Minimum 14 days after documented clearance of Candida spp. from bloodstream, in the absence of complications or dissemination attributable to was identified in blood cultureTailor antifungal based on culture and susceptibilityYes to eitherNo to bothmicafungin* 100 mg IV once daily Perform the following tasks concurrently:Is fluconazole contraindicated OR did patient receive fluconazole prophylaxis?

7 *Or other echinocandin as per hospital formularyLegend: Required As clinically indicated Consult clinical pharmacist renal dose adjustment and drug interactions of antimicrobials but do not delay the first dose. Do not use PO if patient is haemodynamically unstable or unable to tolerate oral intake Cultures are:Bloodstream infection with no other source except central lineConcordant organism from central and peripheral specimensDTP* (differential time to positivity): organism growth detected in central line specimen at least 2h before peripheral specimen*DTP contact microbiology lab for this informationDiscontinue vancomycinDefinitive diagnosis:2c.

8 Management for Central Line InfectionsObtain blood cultures before initiation of antimicrobials: Paired specimens from central venous catheters + peripheral veinCulture exudates at exit sites, insertion sites, tunnel catheter tract, or pocket of implanted cardiovascular device if present124 Bloodstream Infections due to Candida spp., Mycobacteria spp., Staphylococcus aureus, S. lugdenesis, Pseudomonas aeruginosa, and other Gram-negative organisms Persistent positive blood culture 72h after initiation of antimicrobials irrespective of pathogens isolated ( coagulase negative staphylococci, enterococci, viridans group Streptococcus, Corynebacterium spp.)

9 , Bacillus spp.) with no other source of Infections identified Ongoing or worsening signs of infection due to suspected central line Infections despite 48-72h of appropriate antimicrobials Complications (septic thrombophlebitis, endocarditis, possible metastatic seeding osteomyelitis) Extensive cellulitis around IV sites (greater than 2 cm), from catheter exit site, along the subcutaneous tract of tunneled catheter Relapse or recurrent central line Infections after antimicrobial course is completed3 Empiric therapy for suspected central line Infections : vancomycin 1g IV Q12 HFollow Figure 2a for recommendations on specific antimicrobial based on gram stainPersistent bacteremia/fungemia or ongoing signs of infection.

10 Reassess antimicrobials and organism susceptibilities to ensure there is no mismatchRule out complications ( with echocardiogram), and metastatic infectionsRemove central line if not already doneConsult transplant Infectious DiseasesRepeat blood cultures if patient has ongoing signs of Infections despite therapyNegativeat 72hPositiveLegend: Required As clinically indicated Remove central line if no longer needed. Infectious indications for removing central line:5 Duration of therapy: Depends on the organism and whether the suspected source of infection, central line, is removed.


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