Infectious Disease Nov 23-27th
Day 1
Today I spent time in the ICU and attended their rounds for the first time. During rounds I tried to take note of the teams head to toe approach and pay particular attention to those with infectious disease issues. Some of the infections I saw in ICU were H1N1 and pneumonia. I also went to a presentation by the Infection Control Nurse in the afternoon. The nurse focused on preventing the spread of certain infections such as influenza, MRSA, VRE and the norwalk virus. My reflections on todays discussion are: Infection Control Reflections
Day 2
Today I spent the morning in the microbiology lab. I was able to see what some bacteria look like on plates and under the microscope such as MRSA, pseudomonas, diptheroids and H. Influenza. I was working with lab personnel at the respiratory bench. The different kinds of specimens I saw included: nasal swabs, sputum, endotracheal swabs, corneal swabs and aqueous fluid. During the afternoon, I had a tour of the lab and then talked with a medical microbiologist about ESBL’s and IBL’s. ESBL’s acquire resistance through plasmids where IBL’s acquire resistance through gene’s encodoing AmpC beta-lactamases or plasmids. ESBL’s are generally susceptible to beta-lactamase inhibitors where AmpC beta-lactamases are not. I also attended a discussion about how to approach the infectious disease patient and reviewed the pharmaceutical care process.
Day 3
I spent another morning in the microbiology lab, except this time I was working at the urine bench. Today I saw two interesting things. The first was an AmpC. This was an ESBL where there was less then a 5mm difference in the zone between the antiobiotc and the antibiotic + Clavulin. I also saw a more rare kind of fungus called candida guilliermondii. We had to consult mycology to make this differentiation. In the afternoon I attended the Aminoglycoside therapeutic talk (see posts for details).
Day 4
Today I worked up two patients, one in Emergency and one in ICU. The first patient was admitted for cellulitis, with a history of recurring cellulitis and debridement. She arrived with red, warm, oozing and painful legs. On examination today her legs were red, scaly, peeling on the top and wet underneath. She is newly diagnosed with type II diabetes (HbA1C 12.8) that is contributing to this infection. She was started on Vancomycin and a level was done 3 hr and 12 h post infusion. I was able to interpret my first Vancomycin level and calculate the patient’s Vd, T1/2 and K. However, this patient required additional coverage of gram negative and anaerobic bacteria because of her diabetes so in consult with CTU we changed her therapy to Pip-tazo. I am not currently done working up the second patient in ICU, so I will finish this patient tomorrow.
Day 5
Today I started off by going to the VGH ICU. I worked up a patient with an aspiration pneumonia from salt water. This case was very interesting as I had to find out what kinds of organisms live in salt water and then choose appropriate antibiotic therapy. A few of the salt water organisms include: Virbio, Aeromonas, Klebsiella and Streptococcus pneumoniae. Some of the antibiotics that could treat this are an extended spectrum penicillin with a beta-lactamase inhibitor +/- an aminoglycoside or clindamycin with a fluoroquinolone in those who are penicillin allergic. I also had a therapeutic talk with my preceptor about the spectrum of activity and pharmacodynamic characteristics of antibiotics and found this to be very beneficial. In the afternoon I finished up my patient from Thursday at the RJH ICU who had an infection from an esophageal cancer surgery and started to work up a patient with bacterial peritonitis from a leakage of her bowel.
