Beclometasone
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Hey guys,

I'm currently an F2 working in a busy general medical ward/AMU. I have a few questions regarding microbiology that I'm not too sure about, but which I encounter pretty frequently. I would be grateful for anyone's thoughts on the below. Any/all help appreciated.


1. A problem I often get is a patient admitted after having a fall, or for exacerbation of COPD etc, and they spike a temperature whilst an inpatient, though the rest of their vital signs (BP, HR) are unremarkable. I often see my colleagues take blood cultures in this situation as a default this to do. But I also see some people just giving paracetamol. Which is right thing to do? (or what factors go into making that decision)


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Obviously, blood cultures are to look for bacteraemia, but is taking blood cultures every time a patient spikes a temperature the right thing to do? In GP-land, we didn't take cultures from patients with bacterial community-aquired pneumonia and fever. When I get a fever at home, I don't get someone to take cultures from me. So when in a hospital patient who is spiking, when can I just give paracetamol vs when do I have to blood cultures? (esp in a patient with otherwise stable obs).
I know if a patient looks unwell/septic then I have to do Sepsis 6 etc. But it's the isolated spiking ones I don't know what to do about.


2) Sometimes I have a patient being treated with IV antibiotics for pyelonephritis etc, and despite that they end up spiking and getting rigors etc. I know the thing to do is do a blood culture (and state the antibiotics they are on on the form). My question is...why?

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Is it because if they are becoming unwell on broad-spec Abx, then it suggests there is perhaps an organism that is resistant to it floating around - and we culture to look for this, and change therapy if need be. Or am I waaay off?


2b. Continuing on from the above, how do I treat the patient spiking on IV abx immediately whilst waiting for repeat culture results? (I know for pyleonephritis, we sometimes give stat doses of Gent. But what if it was CAP on co-amox etc, or cellulitis of iv flucox? How do you know the next abx to escalate to? This isn't always on hospital guidelines.


3. In treating UTI, we send off urine for MCS, and then start brod-spec abx (usually nitro or trimethoprim). I have cases where the patient finishes the course of nitro, but the cultures come back for an organism that is resistant to nitro. When I talk to the patient, they are asymptomatic, and normal obs + inflammatory markers. What's the right thing to do here? Is it to just call it a day and do nothing? Or would you give course of Abx that the organism is not resistant (even though signs of infection are now gone)?

4. If I get a patient with UTI or CAP etc, I know to start empirical Abx based on hospital guidelines. Problem is sometimes they have a previous culture that has grown an organism resistant to the first choice abx. And sometimes, they have several previous cultures from different admissions, each with different sensitivities (bronchecstasis patients typically). What is the right abx to put them on?

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Is the trick to find an antibiotic that all the previous bugs are sensitive to? Or do we just go by the sensitivities for the most recent bug that has been grown?



5. I sometimes see patients with severe cellulitis who are systemically unwell, and I know to take cultures before sticking them on abx. I usually see both blood cultures and swabs being taken. But why I can't I just do the skin swabs. Surely that's where the pathogen actually is? And surely it must be the same pathogens that are causing bacteremia and SIRS that would come up in the blood culture. So I'm not sure what a blood culture would actually add?


6. Patient sometimes come in with sepsis, and an apparent allergy to penicillin for example. Taking a history from them, however, they don;t give a convincing history (e.g. I get vomiting/diarrhoea doctor, or it upsets my tummy - i.e. not a true allergy). In the middle of the night at 2am when clerking this patient in, would you go ahead and give him/her the pencillin-based abx? Or would you deem this as too risky, and start them on the alternative? What is the procedure for giving abx that the patient reports a pseudo-allergy to? Is it done in controlled conditions with small doses of abx? Or do we just go for it if the allergy history sounds unconvincing?

7. I sometimes get patients being treated for CAP, who end up getting an UTI too. Obviously, it's sensible to put them on something that would cover both (rather than give them two separate abx). But I'm not sure how to go about knowing/deciding which one. How do people know what antibiotics would cover both - or does everyone just call Micro at this point?
Last edited by Beclometasone; 1 month ago
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Etomidate
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1. I wouldn’t bother taking blood cultures unless the patient is sick, or is repeatedly spiking blood temperatures. Be prepared to have this argument with the nurses bleeping you though.

2. You’re correct. The purpose of the cultures in this instance is so try and confirm that they don’t have some resistance going on. Just spiking a temp on abx isn’t an indication to change abx. A continued deterioration after multiple doses might be, however. In which case I would discuss with microbiology in the absence of guiding cultures.

3. I wouldn’t treat. UTIs are often self limiting as in this case. If the symptoms are gone, you don’t need to treat.

4. This is particularly true of the end stage COPD patients, bronchiectasis etc.. I would use the previous cultures as a guide and deviate from the hospital protocol.

5. Skin swabs are essentially pointless. It’s difficult to know if it’s the actual bug you’ve grown or some random skin flora. If you’re growing a bug in the blood, however, that is more significant and gives you more prognostication. The blood is sterile, the skin isn’t.

6. Use clinical judgement and take a history. Be prepared for the nurses to have a hissy fit.

7. Do they REALLY have a CAP and a UTI? Or have they just got a pneumonia and a positive urine dip? This stinks of bad medicine (aka the just give a shot of tazocin crew).
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Beclometasone
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(Original post by Etomidate)
1. I wouldn’t bother taking blood cultures unless the patient is sick, or is repeatedly spiking blood temperatures. Be prepared to have this argument with the nurses bleeping you though.

2. You’re correct. The purpose of the cultures in this instance is so try and confirm that they don’t have some resistance going on. Just spiking a temp on abx isn’t an indication to change abx. A continued deterioration after multiple doses might be, however. In which case I would discuss with microbiology in the absence of guiding cultures.

3. I wouldn’t treat. UTIs are often self limiting as in this case. If the symptoms are gone, you don’t need to treat.

4. This is particularly true of the end stage COPD patients, bronchiectasis etc.. I would use the previous cultures as a guide and deviate from the hospital protocol.

5. Skin swabs are essentially pointless. It’s difficult to know if it’s the actual bug you’ve grown or some random skin flora. If you’re growing a bug in the blood, however, that is more significant and gives you more prognostication. The blood is sterile, the skin isn’t.

6. Use clinical judgement and take a history. Be prepared for the nurses to have a hissy fit.

7. Do they REALLY have a CAP and a UTI? Or have they just got a pneumonia and a positive urine dip? This stinks of bad medicine (aka the just give a shot of tazocin crew).
Thanks so much for this!! It's really clear.

Hahaha, yes, convincing the nurses that I don't need to do something is sometimes half the battle.

Cheers, much appreciated.
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nexttime
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1) Depends on circumstance. Like if someone had a reason or vulnerability for bacterial infections you'd have to treat it differently. Under normal conditions though, no need for investigation of isolated pyrexia. Paracetamol is fine.

2) Yes. What other explanation could there be? Generally give abx at least 48 hours to work - just have to be wary of wrong diagnosis. Micro are there for advice - their first questions will be regarding whether you have the diagnosis correct and whether you have sent enough cultures.

3) In almost all cases antibiotics for UTIs just reduces duration of symptoms, generally not by much. Your body has an immune system - if symptoms are gone then its done its job.
Its empirical btw, not prophylactic.

4) Yep excellent practice to check previous cultures. Very reasonable to call micro in this situation, particularly if complicated. Non-microbiologists don't tend to think of options like aztreonam, temocillin, daptomycin etc - instead just go for meropenem or whatever which is not good practice.

5) Yep skin swabs are pretty useless. If you've got a wound associated with the cellulitis that can be a bit better. You are confusing bacteremia with sepsis - someone can have a detectable and useful bacteremia without having the immune response known as sepsis. Besides - you're doing bloods and putting in a cannula anyway, why not just do cultures?

6) If someone confidently states their reaction was something that is clearly not allergic e.g. diarrhoea, I make sure I record everywhere relevant that its an intolerance, not an allergy. That is enough grounds to say that. However, unless they are really sick or really don't have an alternative, you generally don't deliberately expose your patient to intolerances either. If you were going to do that you'd have to counsel them well.
Wouldn't bother with test doses in that circumstance no. I'd only do that if it was rash or something, and in that case you are generally going under specialist guidance, or consultant instruction at minimum.

7) This is unlikely true. If it is though, it is reasonable to treat both separately. That keeps the specturm narrow and saves your taz/co-amox for when its actually needed. Make sure you've cultured everything, in view of probable diagnostic uncertainty.
Even if aiming to cover both, remember you don't have to go straight to co-amox. Amoxicillin will treat 50% of UTIs, trimethoprim will treat most pneumonias, etc.
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Beclometasone
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(Original post by nexttime)
1) Depends on circumstance. Like if someone had a reason or vulnerability for bacterial infections you'd have to treat it differently. Under normal conditions though, no need for investigation of isolated pyrexia. Paracetamol is fine.

2) Yes. What other explanation could there be? Generally give abx at least 48 hours to work - just have to be wary of wrong diagnosis. Micro are there for advice - their first questions will be regarding whether you have the diagnosis correct and whether you have sent enough cultures.

3) In almost all cases antibiotics for UTIs just reduces duration of symptoms, generally not by much. Your body has an immune system - if symptoms are gone then its done its job.
Its empirical btw, not prophylactic.

4) Yep excellent practice to check previous cultures. Very reasonable to call micro in this situation, particularly if complicated. Non-microbiologists don't tend to think of options like aztreonam, temocillin, daptomycin etc - instead just go for meropenem or whatever which is not good practice.

5) Yep skin swabs are pretty useless. If you've got a wound associated with the cellulitis that can be a bit better. You are confusing bacteremia with sepsis - someone can have a detectable and useful bacteremia without having the immune response known as sepsis. Besides - you're doing bloods and putting in a cannula anyway, why not just do cultures?

6) If someone confidently states their reaction was something that is clearly not allergic e.g. diarrhoea, I make sure I record everywhere relevant that its an intolerance, not an allergy. That is enough grounds to say that. However, unless they are really sick or really don't have an alternative, you generally don't deliberately expose your patient to intolerances either. If you were going to do that you'd have to counsel them well.
Wouldn't bother with test doses in that circumstance no. I'd only do that if it was rash or something, and in that case you are generally going under specialist guidance, or consultant instruction at minimum.

7) This is unlikely true. If it is though, it is reasonable to treat both separately. That keeps the specturm narrow and saves your taz/co-amox for when its actually needed. Make sure you've cultured everything, in view of probable diagnostic uncertainty.
Even if aiming to cover both, remember you don't have to go straight to co-amox. Amoxicillin will treat 50% of UTIs, trimethoprim will treat most pneumonias, etc.
Perfect, thanks so much for this!!

I agree, we have a tendency to just escalate antibiotics to a more broad spectrum one when the patient starts spiking instead of calling micro. The amox to co-amox to pip/taz to meropenam sequence is pretty familiar to me.
It would help if micro were nicer when we ring them up though
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fishfacesimpson
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I have some sympathy with micro (although I have no experience in their drs being any less nice then anyone else) . Their advice is the quintessential rubbish in = rubbish out. All specialties get it but I think they're particularly exposed to phone calls where basic information isn't at hand and a lot of first line information is available
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Beclometasone
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(Original post by fishfacesimpson)
I have some sympathy with micro (although I have no experience in their drs being any less nice then anyone else) . Their advice is the quintessential rubbish in = rubbish out. All specialties get it but I think they're particularly exposed to phone calls where basic information isn't at hand and a lot of first line information is available
True this. They take a LOT of risk by depending on someone who is often a junior F1/F2 communicating information to them. Same with other 'over-the-phone specialities' such as Radiology etc. This might change with electronic and paperless records though.
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eisb
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Just something to add for 5)

Your management will change depending on if something is grown on blood cultures and what it is. For example, Staphylococcus bacteraemia will usually require 14 days+ antibiotics, and will put you high alert for possible endocarditis as a complication. Also, indewelling line changes may be indicated if they already have a central line/dialysis line in place.
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The other spanner in the works for antibiotics is if the patient has one infection and develops another one. I had a patient with haemolytic strep who then developed cellulitis - we didn’t know if the strep had spread or a new one developed, and he was getting sicker. I rang micro and ended up starting pt on linzolid 😳

That was an experience in prescribing - even had to send the kardex down to pharmacy along with the special prescription form. My only senior that day on my team was the consultant lols so was all left to me to sort! Thankfully we have an amazing pharmacist in dispensary lol.
The nurses were asking what it was/looked like - honestly hadn’t a clue 😂
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Group b strep sorry
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nexttime
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(Original post by Anonymous)
The other spanner in the works for antibiotics is if the patient has one infection and develops another one. I had a patient with haemolytic strep who then developed cellulitis - we didn’t know if the strep had spread or a new one developed, and he was getting sicker. I rang micro and ended up starting pt on linzolid 😳

That was an experience in prescribing - even had to send the kardex down to pharmacy along with the special prescription form. My only senior that day on my team was the consultant lols so was all left to me to sort! Thankfully we have an amazing pharmacist in dispensary lol.
The nurses were asking what it was/looked like - honestly hadn’t a clue 😂
I've prescribed linezolod at least 10+ times - its really not a faff at all here lol
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(Original post by nexttime)
I've prescribed linezolod at least 10+ times - its really not a faff at all here lol
It is when you’re on nights and never done it before, have a special form to fill out and have to get the on call pharmacist to come in
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Shivscape
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1) this is kind of a "they're in hospital already so lets do the cultures", if someone had a temp of 38.0 that disappeared in 30 mins and they had no symptoms i might not. If they were treated for a CAP 5 days ago and then had a fever after treatment course I would do a repeat CXR/blood cults/inflam markers etc.

2) spiking temps on Abx usually means either a resistant organism, poor organ penetration of antibiotic (e.g. nitrofurantoin won't treat pyeloneph even if the bug is sensitive), indadequate source control (need a collection/empyema draining etc) or maybe you have the wrong diagnosis. Blood cults allow you to check if the resistance is the issue: or if they are still leaking bacteria into blood from abscess etc...
If someone spikes within 18-24 hours of starting Abx and they're not unwell then I usually hold my nerve and carry on. If still systemically unwell or spiking even days into ABx then escalate : e.g. chest: amox-->co-amox-->taz--->mero. and often re-image to look for another source or deep infection (e.g. has their CAP formed an empyema?)

3) Not sure here: usually i don't treat asymptomatic bacteruria unless in pregnancy, immunosuppression etc.

4) I like to search the hospital lab reporting system an filter by "microbiology", if the patient has an antibiotic resistant previous sample: e.g. prev MRSA and come in with cellulitis then i''l ignore the fluclox 1st line and give some Teic or Vanc. If they have previous c.diff then i'll beware of coamox/cipro etc. Bronchiectasis and CF: might need to call microbiology for these, but out of hours you could give a suitable broad spec such as mero or tazocin.
Try finding an antibotic for all the previous bugs but if not then the recent ones.

5) skin swabs may be contaminated by commensals, or give a negative result: the blood culture gives you more chance of finding the organism. Also if the patient has a staph aureus bacteraemia they will need at least 2 weeks of treatment (sometimes 4-6) compared to uncomplicated cellulitis.

6) "tummy ache", "makes me nauseous": give penicillin. Rash: i generally avoid penicillins but would be happy to give cefuroxime or meropenem. (i.e. other beta lactams. A history of anaphylaxis or an unknown reaction I steer clear of it (seen colleagues get caught out by this and a patient actually sued once)

7)it's a clinical decision: e.g. if the urine bugs are sensitive to amoxicillin and they are on co-amox for their chest then that's okay. Otherwise micro can help as they may have more sensitivities than you have access to. Remember a lot of >60y/o will have asymptomatic bacteruria that does not require treatment if not immunocompromised.
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(Original post by Shivscape)
If someone spikes within 18-24 hours of starting Abx and they're not unwell then I usually hold my nerve and carry on. If still systemically unwell or spiking even days into ABx then escalate : e.g. chest: amox-->co-amox-->taz--->mero.
Its of note that none of those would cover atypical organisms. I'm sure you knew that, but an amazing number of people assume that because its tazocin it must cover everything, lets drop the clarithromycin!
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