POTD: Pseudomonas Coverage

Today we discuss pseudomonas as I feel like it is easy to forget what antibiotics cover pseudomonas when you see someone with a very suspicious story in the ER. Pseudomonas Aeruginosa Review

Pseudomonas is a gram negative, aerobic rod that is commonly found everywhere. Common infections for immunocompetent patients include hot tub folliculitis. It is mostly opportunistic in that it will infect someone with a different systemic illness – burns, cystic fibrosis, etc.

For this reason, many ICUs have banned the presence of flowers or plant material being brought into the unit as gifts to quell the spread.

Pseudomonas Antibiotic Coverage Cefepime: 2g q8h IV Ceftazidime - only 3^rd gen cephalosporin: 2g q8h Piperacillin-tazobactam (Zosyn): 4.5g q 6h or 3.375g q4h IV Fluoroquinolones ->Ciprofloxacin: 400mg q8-12 hours IV or 750 mg Q12h PO ->Levaquin can cover both strep and pseudomonas: 750mg PO Daily Carbapenems ->Meropenem: 1g q8h IV Aztreonam: 2g q8h IV

If very critical – pursue double coverage (penicillin/beta-lactamase inhibitor with an added aminoglycoside) Gentamicin: 5mg/kg IV Tobramycin 5mg/kg IV Amikacin 15mg/kg IV (Adjusted Body Weight)

Considerations for Resistant Pseudomonas ICU Stay Bedridden Invasive Devices Prior use of antibiotics recently Diabetes Mellitus Patients undergoing surgery

Pseudomonas generally ends up being a problem for patients who have been hospitalized for significant times but it should be a consideration for patients who arrive ventilated, chronically ill or after recent admissions. Unless of course you practice in an environment with many dirty hot tubs.

Trauma Tuesday: Return to play following Infectious Mononucleosis

Did you know 110,000 condoms are being distributed across the 2018 Winter Olympics?

With all that extra interaction, there is a risk of sharing some pathogens. Let’s say one of the athletes arrives with complaints of malaise, fatigue, and pharyngitis. They also endorse some abdominal pain. After you rule out other causes your suspicion arrives upon mononucleosis.

The Question: How long do you advise that patient to stay away from contact sports?

The Answer: 28 days is when the majority of players can return to play though it should be tailored to the individual to minimize risk of splenic rupture. The risk is highest the first 21 days of illness and the risk is of rupture is less than 0.5%. A safe estimate would be 4-6 weeks for the spleen to return to normal size.

Learn More:

Becker JA, Smith JA. Return to play after infectious mononucleosis. Sports Health 2014;6:232-238.

http://www.businessinsider.com/winter-olympics-the-olympic-village-is-stocked-with-110000-condoms-that-is-37-per-athlete-2018-2

Strange, G. R. (2015). Strange and Schafermeyer's Pediatric Emergency Medicine (4th ed.). Ch 26: Abdominal Trauma

Can You ID this Seldom-Needed, but Essential EM Tool?

1) Name that tool. This device goes by the name “Compass.” It is similar to a model manufactured by Stryker, which is also highly distributed, but tends to have less accurate readings than the Compass.

2) Why do you need it?

It’s most critical function is for measurement of compartment pressures (it has other uses, as well, such as measurement of opening pressure for LP). Although compartment syndrome is really a clinical diagnosis (remember your “6 P’s”), you or your consultants may want to use this device for diagnostic confirmation before fasciotomy.

3) How does it work?

Your Compass will likely come in a kit containing the necessary accessories for its use. The kit stocked in our ED looks like this:

Ready to confirm your diagnosis? Prep skin and find your sterile gloves. Remove the caps from the ports on both ends of the Compass monitor. Attach an 18 G needle to the longer port. Attach a syringe with sterile water to the other and inject ~ 0.5 cc to remove air in the monitor. Hold down the red button on the side of the monitor until the reading “00” appears. Now you’re set to go.

For a review of how and where to check compartments, check out this video by EM:RAP (which gives instructions for the Stryker model, but the same principles apply for both devices).

https://www.youtube.com/watch?v=XXp0EtKtlF8

Finally, remember the number 30.

For the diagnosis of compartment syndrome:

Delta Pressure (= diastolic BP - compartment pressure) < 30

Or an absolute compartment pressure > 30

Want to learn more?

https://www.youtube.com/watch?v=_J4Bdssj4kk

https://lifeinthefastlane.com/trauma-library/basics/compartment-syndrome/

https://emedicine.medscape.com/article/307668-overview