Stanford Antimicrobial Safety & Sustainability Program

For more info, refer to the:
🔗2025 IDSA UTI Guidelines (www.idsociety.org/practice-gui...)
🔗JAMA WikiGuidelines (doi:10.1001/jamanetworkopen.2024.44495).
🔗SHC UTI guidelines: med.stanford.edu/bugsanddrugs...

The IDSA now considers infections beyond the bladder as complicated UTIs, regardless of gender. 🏥 See IDSA's infographic on uUTI vs cUTI classifications.

A: No, he does not have a complicated UTI! 🚫 While you might think male gender or anatomical issues such as kidney stones or stents, or immunocompromised status would always qualify a UTI as complicated, this is no longer supported by IDSA.

🌟 ABX Pearl of the Day:

❓ Q: My male patient with dysuria is growing E. coli (>100,000 CFU/mL) on urine culture. 🚨 He has no systemic symptoms or signs of pyelonephritis or prostatitis. Does he have a complicated UTI? 🤔

#IDsky #medsky #meded #pharmsky #skyRX #AMSsky

🔗 For more details, refer to NCCN 2025 on the prevention and treatment of cancer-related infections. www.nccn.org/guidelines/g...

🔗SHC guidelines: med.stanford.edu/bugsanddrugs...

Guidelines strongly recommend against adding vancomycin empirically based on persistent NF of unknown etiology in those with severe mucositis who are already receiving piperacillin/tazobactam, cefepime, meropenem, or other ABX with oral flora coverage.📜🚫
(NCCN 2025)

📉 The addition of vancomycin does not appear to decrease episodes of gram-positive bacteremia or help with defervescence in FN patients with severe mucositis who are already receiving piperacillin/tazobactam compared to placebo. (NCCN 2025)

A: No. 🚫 Chemotherapy-related GI mucositis predisposes patients to bloodstream infections by viridans group streptococci and gram-negative rods.

🌟 ABX Pearl of the Day:

❓ Q: Should I add vancomycin for severe mucositis in my patient with persistent neutropenic fever (NF) of unknown etiology? 🤔 Currently on cefepime & stable. Let’s dive in! 👇

#IDsky #medsky #meded #pharmsky #skyRX #AMSsky

For more on our institution's SHC Pneumonia Guidelines, check the figure and link below! 🔗https://med.stanford.edu/bugsanddrugs/guidebook.html#pulmonary

For HAP/VAP, check procalcitonin levels. If it’s <0.3 after 48 hours or drops by 80% from initial value, consider stopping antibiotics early if the patient is improving

Guided by clinical response? 🩺 A recent RCT found that when guided by clinical response (afebrile, HD stable/off pressors), 3-7 days of treatment was just as effective as ≥8 days for VAP, plus fewer side effects! 🙌

For VAP patients on stable ventilator settings (PEEP ≤ 5, FiO2 ≤ 40%), consider stopping antibiotics in ≤3 days! 🕒 Studies show similar outcomes for shorter courses. 📉

🌟 ABX Pearl of the Day:

❓ Q: Treating HAP/VAP? 🤔 Can we go shorter than 7 days?

💡A: Yes! While 7 days is the norm, evidence supports shorter courses in specific cases. Let’s break it down! 👇

#IDsky #medsky #meded #pharmsky #skyRX #AMSsky

🩺 Clinically, identifying a lactose fermenting GNR is particularly useful for ruling out Pseudomonas.

⚠️ Many non-lactose fermenters (especially Stenotrophomonas, Burkholderia, and Acinetobacter) can be very challenging to treat. ID consultation should be considered for invasive infections.

🔍 Lactose Fermenting GNRs:
E. coli
Klebsiella
Enterobacter

🔍 Non-Lactose Fermenting GNRs:
Pseudomonas
Proteus
Acinetobacter
Stenotrophomonas
Burkholderia

💡 A: Lactose fermentation is a quick test the microbiology lab can perform on GNRs to help narrow the microbiologic differential diagnosis.

🌟 ABX Pearl of the Day:

❓ Q: Why does the lab mention when a GNR (gram-negative rod) is “lactose fermenting”?

#IDsky #medsky #meded #pharmsky #skyRX #AMSsky

📚 References:
Lipsky et al, PMID: 37779457
Senneville et al, IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023), PMID: 37779457

💊 If antibiotic treatment is warranted, focus on coverage for gram-positive organisms, including beta-haemolytic streptococci and Staphylococcus aureus.

🔄 Therapy should ultimately be adjusted based on sterile specimen cultures, NOT wound swabs.

🔍 Risk factors to consider include:
-Recent cultures isolating Pseudomonas
-Frequent exposure of the foot to water
-Treatment failure with non-pseudomonal therapy

💡 A: Contrary to common belief, you do not need to reach for Pseudomonas coverage right away. Anti-Pseudomonals are often overprescribed for DFIs.

📋 IDSA guidelines recommend against empirically covering for Pseudomonas in DFIs unless there’s a septic presentation or specific patient risk factors.

🌟 ABX Pearl of the Day:

❓ Q: When should I empirically cover for Pseudomonas aeruginosa in diabetic foot infections (DFIs)?

#IDsky #medsky #meded #pharmsky #skyRX #AMSsky

🔍 While skin swabs in patients with cellulitis are often not helpful (as they can reflect colonization), I&D (incision and drainage) of a purulent abscess is beneficial. Culture with susceptibility testing allows for targeted antibiotic use.

💡 A: The first step when evaluating a patient with SSTI is to assess for purulence, which can be manifested as “lumps, bumps, or pus.”

Empiric MRSA coverage is indicated for purulent SSTI, not non-purulent SSTI.

🌟 ABX Pearl of the Day:

❓ Q: When should you consider empiric MRSA coverage for SSTI treatment?

#IDsky #medsky #meded #pharmsky #skyRX #AMSsky

📄 See more FAQs on the nasal MRSA PCR test: Stanford Bugs and Drugs Guidebook med.stanford.edu/bugsanddrugs...

🔍If the patient has improved quickly and was never producing sputum, they are less likely to have had MRSA as a causative organism. In this case, the positive MRSA PCR likely represents colonization rather than active infection. Vancomycin can likely be discontinued after 48 hours

💡 A: The decision to de-escalate should be made clinically.

⚠️ Clinically, MRSA pneumonia tends to be aggressive, with significant local tissue destruction, leading to positive culture results. Patients are often quite ill and improve much more slowly.

🌟 ABX Pearl of the Day: (Part 2)

❓Q: If my patient with pneumonia has a positive MRSA nasal PCR but respiratory cultures are NOT available, do I need to continue vancomycin for a full course of therapy?

#IDsky #medsky #meded #pharmsky #skyRX #AMSsky