Why stop Azithro after negative Lefionella antigen??

[iBS1972]

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I have asked this of all my residents, but no one has been able to give me an answer: why do we stop giving patients azithromycin after their urine legionella antigen comes back negative? What about the other atypical organisms?

 

[jdh71]

I have asked this of all my residents, but no one has been able to give me an answer: why do we stop giving patients azithromycin after their urine legionella antigen comes back negative? What about the other atypical organisms?

probably has to do with the clinical picture

if you're dealing with a lobar-type of pneumonia that has made you sick enough to wind up in the hospital or even the ICU, you are not talking about an atypical infection which is more indolent and causes a more diffuse type of disease on chest imaging

 

[Catwoman86]

I have asked this of all my residents, but no one has been able to give me an answer: why do we stop giving patients azithromycin after their urine legionella antigen comes back negative? What about the other atypical organisms?

I cant post my answer as it contained link , how can i post my answer here , sorry new to forum

 

[Catwoman86]

I have asked this of all my residents, but no one has been able to give me an answer: why do we stop giving patients azithromycin after their urine legionella antigen comes back negative? What about the other atypical organisms?

There are many factors you need to consider:
1) Broad spectrum antibiotic therapy, oriented towards specific pathogen , once cul and sensitivity is available .
2) Based on information given i assume this is pulmonary infection + ICU or active alcoholic or recent 2 w travel / COPD / + RF towards legionella : started on empiric treatment.
Now if legionella urine ag test( which is 70% sen and specific ) negative , then why you want to give treatment for something whats not there ?
Mostly all C& S available in 48-72 hours , and then treatment oriented as pathogen specific , withing 48-72 hrs you see clinical improvement, then continue treatment (Unless deteriorate ) and then step down ....(Somebody correct me if i am wrong )
3) The Legionella urine antigen is the test of choice for diagnosing legionella infection, results around 5 -6 days , i assume by then either c & s available or clinical improvement noticed .
4) According to the Centers for Disease Control and Prevention, a nosocomial case required onset of pneumonia symptoms after 10 days of hospitalisation, and a probable nosocomial case exhibited onset between the second and 10th day of hospitalisation.The remaining cases were considered to be community acquired. The urinary antigen result was assumed to have an impact on the initiation of legionella active treatment or the stopping of non-active treatment if active treatment was initiated or non-active treatment was stopped within one day of the availability of the test result, respectively. ( This i copied )
5 ) @ other atypicals they generally get better with antibiotics , for example walking pneumonia , they are generally not that severe when present . ( so you need to give more details @ your patient and symptoms)
6) And your residents , may be they want to you to be active and first find on your own answer . So if i would be @ your place i will gather my all info and again ask them .

7 )Take home messages ( copied )

• In over two thirds of cases, the urinary legionella antigen test had a direct impact on the clinical management of pulmonary legionellosis
• In seven patients, the test results prompted a legionella specific treatment, whereas in 12 cases, non-specific antibiotics were stopped within 24 hours
• Thus, the urinary antigen can have a direct impact on clinical management of pulmonary legionellosis, although patient comorbidities and individual clinical judgment are still important for determining the best treatment to be given in each individual case

8) Correct me if i am wrong as i have no clue @ patients sym and age.
Hope this helps ,
Good luck

 

[Catwoman86]

And link i am unable to post so some data i copy and paste .

 

[Psai]

Legionella does not take 5-6 days to result wtf? And is it a 5 days or 10 day course?

 

[Crayola227]

Yeah seems like the urine ag comes back quick, but as said it's not a super great test, I think the more "definitive" cx result takes longer for Legionella than for other bugs, that would make more sense here

 

[Catwoman86]

Legionella does not take 5-6 days to result wtf? And is it a 5 days or 10 day course?

Like i said correct me if i am wrong , thanks for correcting me .

 

[Catwoman86]

Can someone tell me how can i post lik @ research article from where i copy paste that information ?

 

[jdh71]

Can someone tell me how can i post lik @ research article from where i copy paste that information ?

Just copy and paste the URL?

 

[gutonc]

Just copy and paste the URL?

New users aren't allowed to post links. Keeps the spam down. Not out of course...but definitely down.

 

[jdh71]

Legionella does not take 5-6 days to result wtf? And is it a 5 days or 10 day course?

Is it your mother or your mother in law?

Lol.

Seriously though the length of time we treat people is completely made up. I mean you may find lots of expert recommendations for lots of stuff but there is no super science behind it. FWIW I too just follow the expert recommendations (except in certain types of brochirctasis related infections). It's probably overkill most of the time but in the low rate event of therapeutic failure harder to find yourself getting seriously sued. Document the recommendation or just consult ID.

 

[jdh71]

New users aren't allowed to post links. Keeps the spam down. Not out of course...but definitely down.

Oh.

#bunchanazisinhere

 

[Catwoman86]

New users aren't allowed to post links. Keeps the spam down. Not out of course...but definitely down.

Ok , thanks

 

[Catwoman86]

Is it your mother or your mother in law?

Lol.

Seriously though the length of time we treat people is completely made up. I mean you may find lots of expert recommendations for lots of stuff but there is no super science behind it. FWIW I too just follow the expert recommendations (except in certain types of brochirctasis related infections). It's probably overkill most of the time but in the low rate event of therapeutic failure harder to find yourself getting seriously sued. Document the recommendation or just consult ID.

I found this research article , which was dedicated specifically to Legionella urine antigen test , and i found there this data it takes 6 -7 days for test. And lack information @ patients symptom or diagnosis i manage to put whatever information i can. I mean in what type of cases would you start empirically AZI and get legionella urine ag test ?

 

[jdh71]

I found this research article , which was dedicated specifically to Legionella urine antigen test , and i found there this data it takes 6 -7 days for test. And lack information @ patients symptom or diagnosis i manage to put whatever information i can. I mean in what type of cases would you start empirically AZI and get legionella urine ag test ?

Any community acquired pneumonia sick enough to need the ICU or multi focal pneumonia on cxr with associated GI symptoms +/- mild hyponatremia. Ceftriaxone + azithro or levofloxacin.

 

[gutonc]

Oh.

#bunchanazisinhere

Don’t even play like you wouldn’t be the first one bitchin’ ‘bout all them spammers

 

[jdh71]

Don’t even play like you wouldn’t be the first one bitchin’ ‘bout all them spammers

Touché

You win THIS round moderator

 

[doctorbeastmode]

Back to the OPs question - maybe your resident doesn’t know what they’re talking about? If you start azithro because a patient looks sick, I’d argue you should keep it post legionella.

 

[jdh71]

Back to the OPs question - maybe your resident doesn’t know what they’re talking about? If you start azithro because a patient looks sick, I’d argue you should keep it post legionella.

Why? What are you treating?

 

[doctorbeastmode]

1. Azithro is usually a 5 day course anyway, so you probably have a day or two left to give
2. The sensitivity of the legionella ruined antigen is low - something like 70-80%
3. Azithro has anti-inflammatory properties and may be helpful if there’s COPD anyway
4. Mycoplasma, which doesn’t respond to Vanc/zosyn

If you were concerned enough to start the azithro, you may as well keep it going.

 

[jdh71]

1. Azithro is usually a 5 day course anyway, so you probably have a day or two left to give
2. The sensitivity of the legionella ruined antigen is low - something like 70-80%
3. Azithro has anti-inflammatory properties and may be helpful if there’s COPD anyway
4. Mycoplasma, which doesn’t respond to Vanc/zosyn

If you were concerned enough to start the azithro, you may as well keep it going.

Nah. You're just encouraging resistance in other bacteria. If you don't have signs pointing to legionella stop. Mycoplasma doesn't present like legionella. At all. There is no reason to keep it going in MOST cases. To keep it going is stupid and irresponsible.

 

[PlutoBoy]

Any community acquired pneumonia sick enough to need the ICU or multi focal pneumonia on cxr with associated GI symptoms +/- mild hyponatremia. Ceftriaxone + azithro or levofloxacin.

What about vanc/zosyn/levofloxacin? Or like my PD used to say, “vitamin V and vitamin Z” 😛

 

[jdh71]

What about vanc/zosyn/levofloxacin? Or like my PD used to say, “vitamin V and vitamin Z” 😛

If they don't have risk factors for MDROs then you are being stupid treating community acquired pneumonia like that.

The bugs will win but we don't have to help them.

 

[PlutoBoy]

If they don't have risk factors for MDROs then you are being stupid treating community acquired pneumonia like that.

The bugs will win but we don't have to help them.

My rationale is that if the patient is sick enough to be intubated then I’d rather start with broad spectrum abx and de-escalate when cultures are available.

 

[jdh71]

My rationale is that if the patient is sick enough to be intubated then I’d rather start with broad spectrum abx and de-escalate when cultures are available.

It's still wrong.

 

[PlutoBoy]

It's still wrong.

Well, it would suck to get a culture three days later growing MRSA. Broad —> Narrow beats Narrow —> Broad in those cases.

 

[jdh71]

Well, it would suck to get a culture three days later growing MRSA. Broad —> Narrow beats Narrow —> Broad in those cases.

There are known risk factors for MRSA. It's not even a top three bug in CAP.

 

[PlutoBoy]

There are known risk factors for MRSA. It's not even a top three bug in CAP.

Thanks, boss 🙂

 

[jdh71]

Thanks, boss 🙂

But you know everyone comes in from a nursing home or a recent hospitalization these days. So a lot of that vanc/zosyn stuff going on.

 

[PlutoBoy]

But you know everyone comes in from a nursing home or a recent hospitalization these days. So a lot of that vanc/zosyn stuff going on.

Or HD.

 

[Psai]

But you know everyone comes in from a nursing home or a recent hospitalization these days. So a lot of that vanc/zosyn stuff going on.

I thought that wasn't a thing anymore

 

[jdh71]

I thought that wasn't a thing anymore

nursing home pneumonia is completely owned in the literature and recent hospitalizations show up again and again

if you mean there is no recognized entity as "HCAP"? Maybe. I don't know about what people want to call it. I'm talking about risk factors.

 

[blub1212]

I thought that wasn't a thing anymore

Yeah, the IDSA 2018 guidelines changed their recommendations on who gets what empiric treatment. The data showed that we were way overtreating for resistant organisms. They completely got rid of healthcare-associated pneumonia, so recent hospitalizations, being in a hemodialysis unit, being in a nursing home, etc don't matter anymore. They recommend empiric treatment for MRSA and Pseudomonas if the patient has been given IV antibiotics within the last 90 days, were recently hospitalized in a unit where >20% of isolates are MRSA or unknown % are MRSA, or are at a high risk for mortality from their pneumonia. (Weak recommendation, low quality of evidence). Obviously, all just expert opinion though and as mentioned has low quality of evidence to back it up.