Sometimes you come across a patient who represents the perfect storm of allergies, resistance and contra-indications to antimicrobials that really make you scratch your head to come up with a way of treating them. I’m not complaining! These are the kind of clinical conundrums that stretch the brain cells and make Microbiologists earn their money
I was recently doing a ward round on the Critical Care Unit when a Doctor from overseas who was observing on the ward starting asking questions about how we give antibiotics in the UK and why we don’t use continuous infusions. This was a really good discussion, especially as we have recently been thinking about if we should be implementing this method of antibiotic administration locally.
I am really fortunate to work with a great team of diagnostic cardiologists who have a keen interest in infective endocarditis. We have an endocarditis multidisciplinary team and do a ward round of all the endocarditis patients every week, regardless of where they reside in the hospital. One of the big problems for these patients is the long courses of IV antibiotics in the current treatment guidelines, be they British, American or European. As a result patients have long periods of time where they have central venous catheters (CVC) for administering the antibiotics and prolonged hospital stays; both predisposing to further infections.
So when I saw an article in the New England Journal of Medicine from Denmark investigating whether oral antibiotics can be used in the treatment of this infection, my attention was stirred and I made the most of the present moment and ordered the paper from the library, “carpe diem”.
One of the most common bacterial infections we see in the hospital setting is cellulitis; an infection of the skin and subcutaneous tissues. Most of these are caused by Gram-positive bacteria such as Staphylococcus aureus and the Beta-haemolytic streptococci. First line antibiotic treatment is usually Flucloxacillin, or Teicoplanin or Vancomycin (if the patient is allergic to beta-lactams such as Flucloxacillin). I have recently got to thinking about new antibiotics that might be useful in the treatment of cellulitis and in particular a new cephalosporin called Ceftaroline, which is supposedly active against all S. aureus including MRSA and the Beta-haemolytic streptococci.
So what have I found out about Ceftaroline? How does it work? Why is it active against MRSA? Read on to discover the answers to these questions and many more about this new antibiotic…
While sat in the cystic fibrosis multidisciplinary team (MDT) meeting a tricky clinical question was asked…
“We have a patient with an infective exacerbation of their cystic fibrosis with Burkholderia multivorans but she is allergic to Ceftazidime and Meropenem and gets bad gastrointestinal symptoms with tetracyclines. What do you think?” asked the Respiratory Consultant.
I really like these types of MDTs when I have to scratch my head and try to work out a solution but this one was a bit of a puzzler. I know Ceftazidime and Meropenem are often used to treat infections with Burkholderia spp. and that Minocycline is also an option, but what to do when these can’t be used? I had to admit I didn’t know for sure and that I would have to go and look at the literature and get back to them. So off I went to consultant the “Interweb”.
Antibiotic resistance is a major threat to public health. This isn’t just my opinion but also that of Dame Sally Davies, the Chief Medical Officer for England, as well as the World Health Organisation and other numerous national and international groups. It is not only the treatment of infections that will become impossible but perhaps an even greater threat is that surgery will no longer be possible without an unacceptable risk that the patient will die from a postoperative infection; who would want a surgeon to operate on their bowel without the availability of antibiotics to stop bowel bacteria causing peritonitis afterwards?
So having been thinking about a case of fusarium keratitis last week I started to wonder whether the new antifungal Isavuconazole might have a role to play. I then got to thinking that it would be good to write a summary of Isavuconazole for a blog… so here it is…. :-)
I was walking down the corridor when one of the Medical Registrars walked passed looking perplexed, we said hello and passed on by, then he called after me “oh can I ask your opinion on…” A standard start to many a query for a Microbiologist! But this question was different, he was reading around the subject of endocarditis and was frustrated by the “guidelines” put out there by the expert bodies… he went on “their advice is sometimes different and even contradictory! How do you know what to follow?”
I agreed, which didn’t seem to satisfy him at all. So let me explain further in this blog, as it will take longer than a passing corridor conversation, unless you have the old Victorian corridors still, I may be able to explain it in the time it takes to walk one of those, ah the days when we all got more exercise at work.
Sometimes you come across an idea so brilliant and yet so simple that you think to yourself “I wish I’d thought of that!” Well that’s what happened to me at the Federation of Infection Societies annual conference at the beginning of December.
I guess I should start by saying I have no affiliation to, or sponsorship from, any company, pharmaceutical or otherwise. I can therefore say I am totally objective, but I was impressed!
So what was it I was so impressed by? Well, it’s a beta-lactamase… What, a beta-lactamase!?! But they’re bad, they breakdown antibiotics and stop them working, how can they be a good thing? Well, before we consider the beta-lactamase let’s think about why antibiotics can be bad for you.
The microbiologist had gone to review a patient on the wards when they were stopped and asked for an opinion about a different patient. This patient was being treated for infective endocarditis caused by Staphylococcus aureus and had been on IV Teicoplanin for 2 weeks because they said they were allergic to penicillin. The current problem was that the patient’s renal function was deteriorating and it was thought that the Teicoplanin might be part of the problem (although the patient was also on a few other nephrotoxic drugs but these couldn’t be stopped easily).
The Microbiologist knew that the best antibiotic for the infection was a penicillin, Flucloxacillin, so decided to try and get to the bottom of the penicillin allergy story. Side effects from antibiotics are common (e.g. diarrhoea and vomiting) but do not usually represent allergy. They sat down with the patient and asked them to describe what happened when they were last given a penicillin.