Luke Turner 🦠
@MicroLukas
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Clinical Scientist (HSST) @PublicHealthW - Microbiology. Focusing on #AMR and WGS 🧬 #AMStewardship #MedEd . Own opinion only. 🗿
Wales, United Kingdom
Joined April 2022
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Azole activity is like a ladder 🪜:
Fluc = Candida + crypto
Itra = (all Fluc) + aspergillus
Vori = (all Itra) + + aspergillus!
Posa = (all Vori) + mucor
Isav = (all Posa) + better tolerated
*Image simplified from
@febrilepodcast
for a UK audience
This graphic from the Febrile Podcast and created by Sarah Dong, summarises the activity of common azoles, as discussed in the podcast episode 👇
@febrilepodcast
@swinndong
#idtwitter
#meded
#medtwitter
#thinkfungus
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Two organisms we frequently see in sputum culture = Haemophilus influenzae (HINF) 🦠and Moraxella catarrhalis (MCAT) 🧫
What are the mechanisms of resistance to beta-lactams? A short 🧵....
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Wondering how beta-lactam resistance occurs in Staphylococcus aureus (e.g. MRSA)?
A short 🧵 on the two most common mechanisms of beta-lactam resistance in S. aureus ...
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A very short 🧵 on the basic aspects of antimicrobial dosing:
· Pharmacology (PK/PD)
· MIC
· Therapeutic drug monitoring
· Sex and weight
· Organ function
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Whats the most likely resistance mechanism in play?
1) OXA-48
2) AmpC + VIM
3) NDM + ESBL
4) AmpC + Porin Loss + Efflux
5) CTX-M + Porin Loss
*'Big 5' PCR results pending....
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Meningitis guidelines at a glance -
Empirical:
Ceftriaxone + Dexamethasone
(+ Amox if >60 years young)
Targeted:
N men - Ceftriaxone
H inf - Ceftriaxone
S pneumo - Ceftriaxone/benpen
Listeria - Amox
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What's the resistance mechanism?
a) KPC
b) NDM
c) CTX-M + Porin Loss
d) SHV
!Bonus points if you can show your logic!
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Quick mnemonic for remembering that AmpC usually means:
ceFOXitin - R
cefepime - S
'How can you outFox AmpCs? Cefepime!'
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Antibiotics with the highest C. difficile risk = The 4 C's:
⭐️Clindamycin⭐️
Cephalosporins (later-generation)
Co-amox
Ciprofloxacin
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What's the most likely resistance mechanism here?
*Bonus if you can guess the organism*
#AMR
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Curious about macrolide and clindamycin resistance in Enterococci 🔵🔵🔵? A little quiztorial🧵
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Enterococcus in a blood culture!😱
1) What's the most likely spp?
2) Can we maybe use Gent?
3) What's the Vanc R mechanism?
Bonus - Where might it be coming from?
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Therapeutic Drug Monitoring (TDM) 📈 is routinely recommended for only a few antifungal agents:
1 - Voriconazole
2 - Posaconazole
3 - Itraconazole
4 - Flucytosine
#antifungal
#MedEd
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Micro Rounds:
Which enzyme is most likely causing this resistance pattern and why?
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Excellent examples of a CTX-M b-lactamase!
1) Notice the classic 'key hole effect' (🟩) between AMC (co-amox) + CAZ (ceftazidime) highlighting the ESBL.
2) See how CTX (cefotaxime) is struggling to inhibit, even with AMC helping (🟥)
Why is this? 🤔
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Did you know Enterococci may aid C. difficile colonisation and increase toxin production?
Fascinating talk from
@joeyzacks
at
#CombattingCDIConference
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Microbiology heroes:
The amazing story of two Polish doctors (Eugene Lazowski and Stasiek Matulewicz) who used their microbiology knowledge to fool the Nazi’s and save over 8,000 people from concentration and forced labour camps
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There are three resistant organisms that we commonly screen hospital patients for in microbiology:
· MRSA
· CPO
· VRE
So what are the resistance mechanisms and how do we screen for them?
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Acinetobacter spp. are intrinsically resistant to a number of antibiotics
What mechanism makes it resistant to Ertapenem? 🤔🤔
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An MSSA from a bacteraemic patient growing on a blood plate.
Why is it not growing all over the plate?
Hint: The patient is on cefazolin 🤔
#WeirdStuffYouSeeInTheLab
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Who am I?
Clinical = typical signs of pneumonia 🫁
Diagnostic = urinary antigen test
Treatment = high dose levofloxacin 💊
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Congrats to all those with the correct answer 💪:
4) AmpC + Porin Loss + Efflux
Essentially this shows how difficult PAER can be - carbapenem R without any special carbapenemases
@SIDPharm
have a great infographic and podcast on this 👇
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Why wouldn't ceftriaxone alone cover Listeria?
Because cephalosporins are LAME and don't cover:
Listeria
Atypicals
MRSA
Enterococci
#mnemomic
【Amoxicillin and ceftriaxone: a synergistic association against Listeria monocytogenes】
@OFIDJournal
May 22 2024
Interesting study!
👉15 strains
👉Synergy was found in 93% (MIC strips)
👉This association may be an alternative treatment in the future
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Ecstatic to have passed the Frcpath part 1 exam 😁😁
Hope lots of others getting good news too 🍀
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30 M, presents with fever, rash and diarrhoea
Returned from Thailand 4 weeks ago 🇹🇭
What infection do you NOT want to miss?
#DontMissThisRash
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#IDTwitter
Can we create a unified Gram+ve intrinsic Vanc R acronym?
I propose 'Vanc is No hEELLP':
No - Nocardia
h - S. haemolyticus
E - E. galli/casseli
E - Erysipelothrix
L - Lactobacillus
L - Leuconostoc
P - Pediococcus
@IDiots_pod
@sebpoule
@theAMRdoc
@PhillipaBurns
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Linezolid resistance in Enterococci is often related to:
1. Mutations in the 23S rRNA (G2576T or G2505A)
2. The presence of any of these four genes - optrA, cfr, cfr(B) and poxtA
LRE-finder
@dtutweet
is an excellent tool to elucidate the mechanism
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Daptomycin is inserted into the membrane of Gram +ve bacteria and lipid vesicles.
In the lungs it cannot distinguish between the large surfactant layer and small numbers of bacterial cells.
Insertion in to the surfactant effectively sequesters it = inactivation!
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Should we be using antibiotics for uninfected wounds as prophylaxis? 🤔
No!
1) Presence of bacteria in a wound may be colonisation rather than infection (even with Staph aureus)
2) No evidence that prophylaxis improves healing
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An excellent mnemonic for remembering important indole +ve orgs:
"Morgan the Vulgar Ox ate E. coli on the Indole Pasture with Ed." 🤓
Morganella
P. vulgaris
K. oxytoca
E. coli
Pasteurella
Edwardsiella
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A short 🧵 on MDR/DTR-Pseudomonas in a urine culture:
A 85y/o male patient has a urine culture send to the lab, it grows P. aeruginosa.
It's R to the first panel of Caz, Cip, Imi, Tob and TZP but 'I' to Mero....
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It's outbreak season in the UK for this particular bug.....but what is it? 🧐
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An idiots guide to chickenpox 🐔 + shingles + VZV.
A short 🧵 containing essential bits of basic info to help you understand this highly contagious and extremely common infection/disease.
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A🧵on viral genome architecture using the Baltimore classification
The tips and tricks that helped me (and hopefully will help you) memorise the classification of the clinically important viruses
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What disease am I? 🪷
Bonus‼️: How often does this occur following BSI with this organism?
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Everyone: Car with indistinct licence plate
Microbiologist: Car with excellent Gram +ve cover 👍
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Gram negative that's vanc susceptible?!? What could it be 🤔
Clinical Microbiology Teaching Rounds
@WCMCPathology
@WeillCornell
Gram negative rod, yellow color, oxidase positive, vancomycin susceptible, colistin resistant. What do you think?
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Wondering which common UTI antibiotics should be ❌avoided❌ in pyelonephritis??
Just think: "Never For Pyelo"
N = nitrofurantoin
F = fosfo
P = pivmecillinam
They don't achieve adequate levels in renal tissue and so should be avoided!
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80 year old ♀️ presenting with fever (38.5c 🔥), hypotension (90/50) and new onset dysuria.
Blood culture taken and positive in both bottles after 5 hours of incubation.
What's the most likely organism and what's going on with this strange AST plate? 🤔
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Who am I? 🦠🧫
1. Gram described as 'lanceolate diplococci'
2. Cause of meningitis
3. Screened with optochin
4. Typically susceptible to penicillin
🤡Bonus round: Name another diplococci that causes meningitis?
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Trying to treat MDR Pseudomomas?🦠
Don't have access to IDSA guidelines?😭
Try a password strength checker 💪:
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Pithy Proteus Posts:
If you've got a Proteus 🦠that's susceptible to amp/amox, it's probably P. mirabilis!
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Updated IDSA guidelines for infant feeding for those living with HIV.
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Simple skin and soft tissue infection (SSSTI). How would you treat it?
1) Fluclox
2) Co-trim
3) Fluclox + amox
4) Cefoxitin
*SAUR = S. aureus, STRB = Strep B
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You assess a patient with:
1. Fever 🥵
2. Malaise
3. Arthralgia
4. Night Sweats 😰
5. Recent travel 🌞
What might you suspect?
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Klebsiella pneumoniae 🦠 from an admission screening swab with MICs:
Amik >64mg/L
Ceftaz >64mg/L
Ceftaz/Avi >64mg/L
Cipro >8mg/L
Imi >64mg/L
Mero >64mg/L
Cefiderocol - S
What's the most likely resistance mechanism?
ESBL
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OXA-48
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NDM
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There are two principle methods of beta-lactam resistance:
1) Enzymatic destruction via a beta-lactamase (blaZ)
2) Modified target via production of a modified PBP, e.g. PBP2a
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Helicobacter pylori 🦠
The most prevalent chronic bacterial infection
Often asymptomatic
Can cause peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue (MALT) lymphoma
How do we eradicate it 👇
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@khalideljaaly
Oxa-48 are just a bit weak vs certain cephalporins. So we can (but not always) see R vs the carbapenems, but then S vs drugs like ceftazidime and ceftolozane.
I agree with
@nkhlsngh
@maudi_ahmed
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Pasteurella multocida 🦠
Rx - Doxy 💊
#idboardreview
40 F injection drug use, 3+male partners in past month, has pets 🐈 🐶 🐠 presents with pain/swelling of hand. Severe allergy to penicillin: diffuse hives. Diagnosis? Treatment?
#medEd
#idmedEd
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Just heard that I've been accepted on to the
#HSST
to work towards becoming a consultant clinical scientist 🥳
Super hyped and can't wait to get started in September!
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@TenaciousRhys
@HpymontM
Plus, don't forget the 3 main species with moderate to high risk of clinically significant AmpC production:
⭐Enterobacter cloacae
⭐Citrobacter freundii
⭐Klebsiella aerogenes
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G6PD deficiency = susceptible to developing acute haemolytic anaemia
Some antibiotics increase this risk and are contraindicated
Top three to remember:
1. Fluoroquinolones
2. Sulfonamides (e.g. Co-trim)
3. Nitrofurantoin
Pneumocystis jiroveci pneumonia in G6PD deficiency
Your treatment of choice?
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@ABsteward
It has two intrinsic BL.
An L1 Metallo-BL hydrolysing pen, ceohalosporins and carbapenems (but not aztreonam). Plus an L2 Serine-Bl hydrolysing cephs and aztreonam.
EUCAST intrinsic resistance expert rules;
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Interestingly, when reading the zone diameter, even isolates with a very large zone can be resistant.
Look out for a sharp zone edge indicating that they are still resistant!
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Spot on
@drtimothyli
!
We seem to be getting a lot of 'they've grown Proteus so I've put them on nitrofurantoin'
Anyone else?
Time: every day
Place: medical wards
Person: patients admitted for heart failure, COPD, ACS, stroke, GI bleed,etc.
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The only map a microbiologist/infectious disease clinician will ever need 🦟 🗺️
Infectious diseases in a few maps
From someone yearning for travel
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Uncomplicated S aureus bacteraemia (Inc. MRSA) after 5-7 days IV - oral 💊 switch non-inferior! + fewer days as inpatient 🥳
Oral options: Co-trim (Septrin, MSSA and MRSA) and linezolid (MRSA)
#sabato
Ensayo randomizado
#SABATO
en
#ID2022
:Bacteriemia NO complicada S aureus MR o MS🩸🍇tras 5-7 días IV randomizacion a vía oral 💊o IV💉: No diferencias entre brazos. Opciones orales:Septrim(MS y MR) y linezolid (MR). Resumen fotos (📸👇🏻).
@SEIMC_
@SAMICEI_
Tomado de
@LordAlirezaF
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H. influenzae - far more frequently isolated in sputum culture (e.g. up to 50% in COPD) is susceptible to amoxicillin in 85% of cases according to EUCAST data
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A quick overview of 4 important adverse effects of fluoroquinolones 💊to remember:
1. QT prolongation – fainting, lightheadedness, fatigue
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Hope you enjoyed this short thread.
If there are any resistance mechanism based threads you'd like to see from me, please comment below 👋
Two organisms we frequently see in sputum culture = Haemophilus influenzae (HINF) 🦠and Moraxella catarrhalis (MCAT) 🧫
What are the mechanisms of resistance to beta-lactams? A short 🧵....
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Don't be an 'antibiotic steward', be an 'antibiotic sommelier' 😁🍷💉
"Don't frame your stewardship as antibiotic police, rather we are antibiotic sommeliers to help pair the best antibiotics with the bugs"
@JulieSzymczak
#IDquotes
Do you think "antibiotic sommeliers" is the best description for stewards ?
#IDTwitter
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Troubled by MRSA?😡
The solution is MRSA!😯
M - Minimise transmission (Screen/Decolonise)
R - Restrict Movement (Avoid unnecessary transfers)
S - Safe and Clean (environment and equipment)
A - Appropriate patient info ('no decision about me without me')
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Nitrocefin is a chromogenic cephalosporin - it changes from yellow🍌to red🍓when the beta-lactam ring is hydrolyzed by a beta-lactamase.
So we add a few colonies to the disc and watch what happens.....
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The Scientist Training Programme is an amazing opportunity.
I went through it myself and loved it.
🚨 Applications for the Scientist Training Programme 2023 cohort open on Monday 9th January 2023 at 11:00am 🚨
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It's because CTX-M is especially effective at hydrolysing cefotaxime.
As far as EBSL names go it's an easy one to remember. The CTX-M name is derived from 'CefoTaXime-hydrolysing b-lactamase isolated in Munich'!
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Beautiful image of Giardia
I didn't have time to get many pics today in the Tropical Medicine course at
@BCM_TropMed
, but I did snap this picture of some super cute giardia trophozoites. I love their adorable, smiling faces 🙂
Maybe one day I'll get to see their 🍂 motility in real life.
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A quick mnemonic to help remember which virus families are naked/unenveloped 🚫✉️:
'HEaVy People in CALIfornia and REO are Naked'
HEaVy = Hep E
People = Picorna e.g. Polio
CALI = Calici e.g. Noro
REO = Reo e.g. Rota
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Hope you enjoyed!
Stay tuned for a future thread on VRSA and BORSA 😃
Wondering how beta-lactam resistance occurs in Staphylococcus aureus (e.g. MRSA)?
A short 🧵 on the two most common mechanisms of beta-lactam resistance in S. aureus ...
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Common assumption that Listeria is linked to dairy 🐄 only ❌
Outbreak linked to VEGAN cheese thought to be due to use of raw nut-based milk
Listeria is ubiquitous in the environment. An important reminder to pasteurise any milk product, not only dairy
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