Disclosure Rapidly Fatal Infections Dr. Birnbaumer has no financial disclosures Diane M. Birnbaumer, M.D., FACEP Professor of Medicine University of California, Los Angeles Senior Clinical Educator Department of Emergency Medicine Harbor-UCLA Medical Center Rapidly Fatal Infections Rapidly Fatal Infections Infectious diseases are commonly seen in Identify the patients at risk of having a emergency medicine rapidly fatal infection A small but important subset of these Have minimal diagnostic criteria to identify cases may be rapidly fatal infections those at risk of rapid death Know the right antibiotics to start and get them going early Use aggressive resuscitation protocols 1
The Big Four A Few Zebras Meningitis / meningococcemia The atypical viral pneumonias Avian influenza, MERS MRSA pneumonia Emphysematous pyelonephritis Toxic shock syndrome Ascending cholangitis Necrotizing fasciitis • Meningitis incidence is decreasing • Sporadic outbreaks still occur • Military, universities and colleges 2
Bacterial Meningitis: General Bacterial Meningitis: General Most common organism out of neonatal stage is pneumococcus, then meningococcus, then Listeria Overall fatality rates for bacterial meningitis are 20-25%, with significant morbidity in survivors Bacterial Meningitis: Implicated organisms Bacterial Meningitis: General Presentation Meningococcus - Any age, often young adults (college, military) Streptococcus pneumoniae - Any age Classic presentation Listeria monocytogenes - Any age, but neonates Fever, nuchal rigidity, AMS, and the immunocompromised > 50 years headache; may also see Haemophilus influenzae – Children and adults photophobia, rash, (nonvaccinated) sore throat Elderly, very young, immunocompromised more likely to be atypical 3
Bacterial Meningitis: Diagnosis Bacterial Meningitis: Diagnosis If high suspicion, treat, Lumbar puncture gold standard THEN diagnose Low glucose, high WBC with polymorphonuclear cells, positive gram stain CT first if indicated clinically is classic Altered mental status, Bacterial meningitis cannot be ruled out, abnormal neurologic exam, however…. papilledema, history of Negative gram stain cancer or WBC as low as 100 WBC/mm3 immunocompromised; possibly also age > 60 years Bacterial Meningitis: Bacterial Meningitis: Diagnosis Treatment Unless history very clearly suggests Clinical suspicion should prompt nonbacterial cause, antibiotics and treatment; do not delay for diagnostic admission are advised until culture results testing are available If ALOC, severely ill or CSF WBC > 1000, steroids are indicated Dexamethasone 10 mg IV in adults If possible, give before first antibiotic dose, but do not delay antibiotics for steroid dosing 4
Bacterial Meningitis: Bacterial Meningitis: Treatment Take Home Points Elderly, immunocompromised patients may Antibiotic choice based on patient age present atypically Neonate < 1 month While CSF findings usually typical, patients may Cefotaxime and ampicillin still have bacterial meningitis with lower CSF P atient > 1 month WBC and negative gram stain Ceftriaxone and vancomycin Antibiotics should be started as soon as possible; do not delay for imaging or diagnostic Adult > 50 yr testing Ceftriaxone plus vancomycin plus ampicillin Consider steroids in the right patients Know the organisms and treatment by age Toxic Shock Syndrome General Multiorgan system syndrome Mortality rates may approach 70% 5
Toxic Shock Syndrome Toxic Shock Syndrome General Risk Factors Caused by exotoxins produced by Staph Staph aureus aureus and group A strep Tampon use, intravaginal contraceptive devices, nasal packing, postop wound Cause production of cytokines, tumor necrosis infections factor, etc Group A strep Leads to capillary leakage and tissue damage of multiple organs HIV, minor trauma, surgical procedures Also seen in diabetics, alcoholics Portal of entry unknown in up to 50% Toxic Shock Syndrome Toxic Shock Syndrome Presentation Presentation - Rash Flu-like illness of rapid onset with rash Typical Diffuse, erythematous, Hypotension macular rash involving Multi-organ system failure all skin and mucosal Acute renal failure surfaces including palms Coagulopathy and soles Hepatic dysfunction Desquamates later (1-2 weeks) ARDS May also be scarlatiniform rash; rarely is Rarely myocarditis, perihepatitis, cerebritis bullous or petechial 6
Toxic Shock Syndrome Toxic Shock Syndrome CDC Case Definition Workup Fever > 38.9C CMP Hypotension CBC Desquamation within 1-2 weeks after Blood cultures onset of illness Cultures from other appropriate sources Involvement of 3 or more organ systems Liver panel No other pathogen identified Imaging as indicated N.B. CDC has case definitions for both Staph and Strep toxic shock syndrome Toxic Shock Syndrome Toxic Shock Syndrome Treatment Treatment Treatment should be started with initial Antibiotics suspicion of the syndrome Vancomycin or linezolid PLUS clindamycin (possibly decreases toxin production) Sepsis management with fluids (may need Add a beta-lactam if strep is suspected many liters) and pressure support as needed N.B. Antibiotics may not alter course of cases Source control – may need surgical caused by Staph but still should be started as debridement if indicated (especially cases soon as possible of group A strep) 7
Toxic Shock Syndrome Toxic Shock Syndrome Treatment Take Home Points IV Ig appears to have little effect on Source unknown in up to 50% outcome Clinical clues: SIRS with rash and multi- Steroids may decrease duration and organ system failure severity of symptoms but do not affect Treat with clindamycin to decrease toxin outcome production, plus vancomycin or linezolid; Neither treatment is recommended for add beta-lactam if strep source suspected routine treatment Remember source control Aggressive resuscitation may be necessary MRSA Necrotizing Pneumonia MRSA Necrotizing Pneumonia General General CA-MRSA incidence very high Produces a cytotoxin that causes leukocyte destruction and tissue necrosis CA-MRSA pneumonia now may account (PVL toxin) for up to 5% of all community-acquired pneumonias Significant concern is post-influenza superinfection with CA-MRSA Causes a necrotizing pneumonia with mortality rates of 30-75% 8
MRSA Necrotizing Pneumonia MRSA Necrotizing Pneumonia Presentation Treatment Initial presentation often appears like Aggressive supportive care typical community-acquired pneumonia Sepsis treatment, with IV fluids and pressure support Clinical clues to CA-MRSA pneumonia Ventilatory support as indicated Rapid progression IV vancomycin mainstay, but if suspect Severe symptoms CA-MRSA pneumonia, consult infectious Recent viral illness disease specialist Lack of comorbidities Linezolid – bacteriostatic, may be indicated MRSA Necrotizing Pneumonia Necrotizing Fasciitis Take Home Points General Suspect it in patients with recent viral Incidence rising illness and rapidly progressive pneumonia Immunocompromised patients living longer High mortality rate; aggressive Diabetes, cancer, alcoholism, transplant patients, HIV positive patients, neutropenia, resuscitative care, ventilator support often vascular disease necessary Usually middle-aged adults IV vancomycin indicated; may also use Usually begins as cellulitis, then linezolid, consider consulting infectious progresses to deeper tissues disease specialist 9
Necrotizing Fasciitis Necrotizing Fasciitis General Presentation Organisms Diagnostic clues Often polymicrobial, may be synergistic Pain out of proportion to exam organisms Rapid spread Note: MRSA necrotizing fasciitis more Bullous changes, especially if hemorrhagic indolent If area is painless, suggests very serious and Mortality usually ranges from 15-65%, but late infection rate can reach as high as 80% Crepitance, cyanotic areas, extensive edema also highly concerning Morbidity is high in survivors Necrotizing Fasciitis Necrotizing Fasciitis Diagnosis Imaging If necrotizing fasciitis is suspected… Plain films: Good PPV if ASAP gas present, Get antibiotics on board but poor Call a surgeon NPV if gas Do not delay antibiotics or consultation NOT present for imaging studies or labs 10
Necrotizing Fasciitis Necrotizing Fasciitis Imaging Imaging CT is imaging MRI excellent imaging choice, but often study of choice not available No tissue Ultrasound may have a role, but use still enhancement with being delineated IV contrast suggests necrosis Surgeons often use CT to guide surgical approach Necrotizing Fasciitis Necrotizing Fasciitis Lab Studies Treatment Often not helpful Antibiotics ASAP Cover gram positive cocci, gram negative Low sodium (< 130 mEq/L), high WBC (> rods and clostridia 16K) may be often seen, but nonspecific Examples Carbopenem plus clindamycin Vancomycin plus an aminoglycoside plus clindamycin Note: Clindamycin may decrease release of Toxin A from clostridia 11
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