Thursday, December 31, 2009

Top 10 issues in hospital medicine for 2009, issue 5: infections in hospitalized patients

The field of infectious disease is a moving target and every year brings new concerns for hospitalists. Here's what stood out in 2009:

Pandemic flu

This story's not over yet. This year I posted entries here, here, here and here.

Gram negative resistance

The big concerns this year were extended spectrum betalactamases (ESBLs), Klebsiella pneumoniae carbapenemases (KPCs which, by the way, are found in a variety of gram negative bacteria, not just Klebsiella) and Acinitobacter. With nothing in the pipeline right now clinicians are turning to tygecycline and our old friends the polymyxins. Polymyxins carry toxixity concerns. Tygecycline's high tissue penetration and consequent low serum levels raise concerns about its use in septic patients. This year I posted updates here, here and here.

Staphylococcal infections

What continues to amaze me about serious staphylococcal infections is the nuanced approach that is necessary. “Hang vanco and call it a day” just won't cut it. Here's what stood out this year:

MRSA decolonization.

Using a dying drug for all it's worth: consensus statement on vancomycin use.

Will vancomycin be enough? Look at the MIC!

What this all means is treating serious staphylococcal infections is tricky business and demands expertise. A growing literature suggests that ID consultation improves outcomes. What do the ID docs add? They know the appropriate target levels for vancomycin. They know when one of the newer antibiotics (daptomycin, linezolid, etc.) should be used instead of vancomycin. They can help to decide when and how to decolonize. They're more likely to use beta lactams over vancomycin for MSSA. They're more likely to do follow up blood cultures and treat long enough. They take a more aggressive approach to source identification and removal.

Image courtesy of the Missouri Historical Archive.

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