Sepsis SIRS systemic response PIRO severity staging Temp >38C - - PDF document

SLIDE 1

6/28/2011 1

Infectious Diseases

HIHIM 409

Sepsis

• SIRS – systemic response

– Temp >38C (<36C) – HR >90bpm, RR >20bpm (PaCO2<32mmHg) – WBC >12k or >10% bands

• PIRO severity staging
• TLR 4 – LPS (Gm‐)
• TLR 2 – PGN, LTA (Gm+)
• Fever, inflammation, DIC,

ARDS azotemia olyguria

• Sepsis = SIRS + Infection
• Severe Sepsis = Sepsis +

Organ Dysfunction

• Septic Shock = Sepsis +

Hypotension ARDS, azotemia, olyguria, cellulitis, purpura, GI bleeding, jaundice

• Procalcitonin diagnostic?
• Tx: ATB, supportive,

Activated Protein C (Xigris)

Fever / Hyperthermia

Fever

• Hypothalamic setpoint

shifted up by PGE2 stimulating EP‐3 Hyperthermia

• Hypothalamic setpoint

unchanged

• Does not respond to NSAIDS
• Pyogenic cytokines
• Pneumonia, drugs, PE, DVT,
• C. difficile, fungal infection,

MI, NG tubes, IV catheters

• Heat stroke,

hyperthyroidism, atropine, ecstasy, malignant hyperthermia, serotonin syndrome

Bioterrorism

Anthrax (Cutaneous) Bacillus antracis

• Direct contact with spores
• Jet black lesions (eschars)
• n skin within 7‐10d

Botulism (Inhalation) Bacillus antracis

• Inhaled spores, no person‐

to‐person transmission

• Incubation: 1w to 2 months
• Incubation 1d
• Tx: Cipro or Doxy q 60d
• Vaccine: attenuated Ag
• Mediastinal widening,

pleural effusion, infiltrates

• Initial symptoms improve,

abrupt onset of fever/ARDS, shock/death within 24‐36h

• Tx: Penicillin or Cipro/Doxy

Bioterrorism

Anthrax (GI) Bacillus antracis

• Ingested spores, no person‐

to‐person transmission

• N/V, severe abd pain,

Botulism Clostridium botulinum

• Most poisonous toxin on

earth

• Not contagious, spread by

bloody diarrhea, possibly mediastinal widening, rebound tenderness, ascites

• Incubation: 1‐7d
• Tx: Penicillin or Cipro/Doxy

aerosol/food

• 12‐72 h incubation
• N/V, diff see, swallow, speak
• Muscle weakness/paralysis

Bioterrorism

Cholera Vibrio cholerae

• Rice‐water diarrhea,

dehydration, shock

• Incubation 12h‐5d

Glanders Burkholderia mallei

• Affects horses, mules,

donkeys

• Enters cut skin, mucous
• Food/water spread

membranes, inhalation

SLIDE 2

6/28/2011 2

Bioterrorism

Plague Yrsinia pestis

• “Black Death”, infected fleas
• Bubonic – 1‐10 cm buboes on

skin w/ edema, flu‐like symptoms w/ abd pain

Q Fever Coxiella burnetii

• Nonspecific febrile

syndrome, pneumonia

• Hepatitis, endocarditis,
• Septicemic ‐ secondary

septicemia, thromboses in acral v. leading to necrosis

• Penumonic – acute fulminant

symptoms, nearly 100% mortality rate

• Tx: Streptomycin or

Doxycycline

granulomatous complications

• Tx: Doxycycline 14‐21d

Bioterrorism

Smallpox Variola major

• Officially eradicated
• Incubation 10‐14d
• High fever, HA, backache,

Tularemia Francisella tularensis

• One of most infectious

bacteria in world

• Tick/insect bites

g , , , vomiting, rash on palm/sole

• Highly contagious
• No tx, vaccine within 3‐5d
• Incubation 10‐14d
• Fever, chills, HA, cough,

lethargy, skin ulcers, lymph‐ adenopahty

Bioterrorism

GB Sarin

• Binary weapon – two non‐

lethal reagents mix to form sarin gas VX

• 1000x more toxic than GB
• Persists in soil for 6d
• Binary weapon
• Inhibit ACHe, phosphonate

esters, light brown oil

• If mild: dim vision,

salivation, chest tightness

• Tx: Atropine and 2PAMCl

y p

• Inhibits ACHe, phosphonate

esters, light brown oil

• If severe: stop breathing,

paralysis, seizures, LOC

Bioterrorism

Ricin

• Waste leftover from

processing castor beans

• V/D, dehydration,

hypotension, hallucinations, seizures, hematuria, multiple organ dysfunction

• No tx available

Bioterrorism

• Needs Immediate Treatment, Suspect …

– Respiratory Symptoms

• Acute: Cyanide

– Also nerve agents, mustard, lewisite, phosgene, SEB

D l d A h Pl T l i

• Delayed: Anthrax, Plague, Tularemia

– Also Q Fever, SEB, ricin, mustard, lewisite, phosgene

– Neurological Symptoms

• Acute: Nerve agents

– Also cyanide

• Delayed: Botulism

– Also VEE‐CNS

Bioterrorism

• “Active” Research

– Algeria – Egypt – India Iran

• “Secretly” Developing

– China – Russia

• “Former” Programs

d – Iran – Israel – N. Korea – Pakistan – Syria – Taiwan – Canada – France – Germany – Japan – S. Africa – UK, US

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6/28/2011 3

Immunocompromised

• Deficiencies in

– Complement – IG/B‐Cell – Phagocyte

• Clues

– Recurrent Neisseria inf – Recurrent pneumonia – Severe presentation – T‐cell – Pneumocystis jiroveci – Burkholderia cepacia – Non‐TB Mycobacteria – Aspergillus

Complement Deficiency

• Hereditary angioedema

– C1 inhibitor deficiency – Overactive complement – Minor stressors trigger

• DAF and CD59

– Paroxymal nocturnal hemoglobinuria

• C1, C3, C4 deficiency

attacks

• C5‐9 Deficiency

– MAC lysis defect – Neisseria bacteremia – Recurrent pyogenic sinus and respiratory infection

• C1q deficiency

– 90% have SLE

Ig/B‐Cell Deficiency

• (Bruton’s) X‐Linked

Agammaglobulinema

– Btk defect, no B‐cells, Ig – Multiple pyogenic infections – No live vaccines!

• CVID

– Low Ig, normal B‐cell – Recurrent sinus, respiratory infections – Chronic infections with Giardia, Campylobacter No live vaccines! – Tx: IvIg

• Hyper IgM Syndrome

– X‐linked, normal B‐cell – Low Ig but high IgM – Pneumocystis infections – T‐cells lack CD40L Giardia, Campylobacter – Tx: ATB, IVIg

• IgA deficiency

– Associated with CVID – Compensated by others

• Secondary Ig deficiencies

– Multiple myeloma, leukemia, skin burns

Neutrophil Deficiency

• Neutropenia

– Causes

• Blacks have lower counts
• Chemotherapy patients
• Post‐infection, sepsis
• Hereditary Cyclic N.

– AD, ELA2 mutation – Predictable cycles – Aphtous stomatitis T G CSF t id

, p

• Sulfa‐drugs, β‐lactams

– Infections

• Mucositis
• Ecthyma gangrenosum
• Disseminated candidiasis
• Aspergillosis

– Tx: G‐CSF, steroids

• Chediak‐Higashi

Syndrome

– AR, LYST mutation – Giant lysosomes, ineffective granulopoiesis – Oculocutaneous albinism

Neutrophil Deficiency

• Job’s Syndrome

– Hyper IgE, impaired chemotaxis – STAT3 gene mutation

• CGD

– Defective NADPH

• xidase, no respiratory

burst, no killing I f ti ith t l – Facies, scoliosis, skin abscesses, sinusitis

• Myeloperoxidase (MPO)

– Makes pus green – Converts H2O2 to HOCl – Deficiency impairs this – Infections with catalase positive organisms – NBT test

Spleen “Deficiency”

• Splenectomy

– Trauma, ITP, Hairy cell leukemia, abscess

• Hyposplenism

Autoimmune (Graves

• Decrease in circulating

activated B‐cells (75%)

• Risk of thalassemia >

hodgkins > sphero‐ cytosis > ITP > sepsis

– Autoimmune (Graves, Hashimoto, SLE) – Neoplasia (Hodgkin, CML, Sezary) – Amyloidosis – Alcoholism, elderly, Crohn’s, Sickle cell

cytosis > ITP > sepsis

• Infections

– S. Pneumoniae (mostly) – Haemophilus, GNR, Neisseria (less common)

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6/28/2011 4

T‐Cell Deficiency

• DiGeorge’s

– Deletion 22q11.2 – No T‐cells, hypocalcemia, velocardiofacial defects

• SCID
• Wiskott‐Aldrich

– WASP protein – Pyogenic infections, purpura, eczema – High IgA, IgE, low IgM – Combined B/T‐cell deficiency, lymphopenia, hypogammaglobulinemia – ADA, PNP, RAG1/2, Jak3 gene deficiencies

• CD4 T‐cell Deficiency

– HIV, <300 CD4+/mL

• Infections

– Mycobacteria, norcardia, legionella, cryptococcus, histoplasma, pneumocystis, herpesvirus, cryptosporidium, toxoplasma

Food Safety

• Milk pasteurization: 72C for 15s or 63C for 30m
• Botulism spores: kill with high heat + acidic
• Preservatives: weak acids, nitrites, sulfites, spices

R di ti i di ti f i t

• Radiation: γ‐irradiation for spices, meats
• Survival: Cold – Listeria; Chlorine – Giardia,

Cryptosporidum cysts; Anything home processed

• Outbreaks: Listeria (microwaved hot dogs),

Cyclospora (raspberries), Salmonella, ETEC

Tuberculosis Mycobacterium tuberculosis, bovis, africanum

• Acid‐fast, aerobic non‐motile bacillus, reduce

nitrates, produce niacin, slow growing

• BACTEC blood culture, DAT tests using PCR
• PPD (Mantoux) is killed tuberculin, positive if >15

mm indicates prior infection (LTBI) need CXR mm, indicates prior infection (LTBI), need CXR

• Risks: (normal) 1st year: 3‐4%, lifetime: 5‐15%

(HIV infected) 1st year: 40%, +10% every year

• Tx: test susceptibility, give multiple drugs

INH + RIF + ETH (+ PZA), INH prophylaxis, hepatotoxicity

Tuberculosis Mycobacterium tuberculosis, bovis, africanum

• Infected aerosolized droplets, milk (M. bovis),

replicates in middle/lower lobes alveolar space, Rasmussen’s aneurysm (pulmonary a.), pleural effusion sputum with PMNs pleural effusion, sputum with PMNs

• Spread to hilar lymph nodes in macrophages
• Reactivate in upper lobes, cavities form
• Can disseminate through blood (military TB),

skin lesions, HA, abd pain, osteomyelitis

Leprosy Mycobacterium leprae

Lepromatous Leprosy

• Poor TH1 response
• Large # of bacteria in tissue
• Infectious, non self‐limiting

Tuberculoid Leprosy

• Strong TH1 response
• Small # of bacteria
• Self‐limiting
• Tx: rifampicin (monthly)

and dapsone (daily) ‐ FREE

• Thickened peripheral nerves
• Loss of sensation, lesions,

peripheral nerve damage, hair loss, disfigurement g

• Form granulomas

AIDS HIV infection

• Lenti‐ retrovirus, persistent viremia, infects T‐cells

and macrophages (CD4 + CCR5/CXCR4)

• CD4 >500 asymptomatic, 200‐500 increased

thrush, shingles, <200 opportunistic infections, <50 MAI CMV <50 MAI, CMV CD4 drops 10/month on average

• Transmitted by breast milk (acute), blood, semen

Risk: blood 95%, pregnancy 20‐33%, MSM 10%, needlestick 1 in 300 (1 in 2400 with therapy) Acute infection “mono”‐like w/ rash, ulcers, and w/o tonsil hypertrophy and exudate.

SLIDE 5

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AIDS HIV infection

• Presents with unexplained anemia, leukopenia,

recurrent pneumococcal pneumonias, Kaposi’s sarcoma, thrush, wasting, STD, fever

• Screen: ELISA, Confirm: Western Blot, Viral Load:

PCR, Severity: CD4 Count

• HAART Treatment: NRTI (AZT, 3TC), NNRTI

(nevirapine, efavirenz), protease inhibitors (ritonavir, nelfinavir)

• Opportunistic Infections: CMV, MAC, PCP,

Toxoplasmosis, Cryptococcosis, Candida, PML

Gonorrhea Neisseria gonorrhoeae

• Gm‐ diplococci
• Infect columnar/cuboidal epi, PMN response,

pharynx, anorectal, conjunctivitis S d i d i ll

• Spread via sex and perinatally
• Dysuria w/o frequency or urgency, pain,

discharge, cervicitis (PID complication)

• Dx by culturing swab for diplococci
• Tx with Ceftriaxone IM/cefixime PO

Chlamydia

• C. trachomatis, psittaci, pneumoniae
• Intracellular membrane‐bound inclusions
• Dx with culture, DFA (MicroTrak), ELISA,

annual screen sexually active women <25 yo i h i li bid d

• Tx Azithromycin x 1 or Doxycycline bid x 7d,

abstinence x 7d after treatment

Chlamydia

• C. trachomatis, psittaci, pneumoniae

LGV (STD)

• Endemic in Africa/SE Asia/

India/S. America

• Painless ulcer (heals) to

Urethritis

• NGU
• 7‐14d incubation
• Dysuria, scant discharge

lymphadenopathy (scars) to ulceration of genetalia

• Tx: Doxycycline po bid x 21d

y , g

• Complications

– PID, ectopic pregnancy – Reiter’s syndrome (arthritis)

Trichomonas Vaginalis

• Flagellated motile protozoa
• Yellow, purulent, frothy, foul‐smelling vaginal

discharge, itch, dysuria, lower abd pain id l ( k i )

• Tx: Metronidazole (ok in pregnancy)

Bacterial Vaginosis Gardnerella or Mobiluncus

• Mild to moderate thin, gray, adherent vaginal

discharge with odor, itch

• Clue cells (squamous cells stippled with

bacteria) bacteria)

• +Whiff test (fishy smell in KOH)
• Tx: Flagyl/Clindamycin (+Metronidazole in

pregnant women)

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6/28/2011 6

Herpes Simplex HSV‐1/2

• Vesicular lesions, grouped, painful ulcers
• Incubation 6 days, primary disease lasts 3wks
• Recurrence in 90% of patients
• Dx by Tzanck smear (Wright stain) showing

multinucleated giant cells

• Tx: Acyclovir

Syphilis Treponema pallidum

• 1⁰ ‐ localized painless chancres (ulcerated, non‐

tender, hard, smooth clean base)

• 2⁰ (25% untreated) – 3‐6 wks after chancre,

generalized rash on palms/soles, condylomata lata (flat warts) minimally pruritic lata (flat warts), minimally pruritic

• Latency – High Ab titers, 30% progress to 3⁰
• 3⁰ ‐ “gummas” (granulomatous lesions)

neurosyphilis: general paresis (insanity), tabes dorsalis (demyelination of posterior columns ‐ sensation), Argyll Robertson pupil (non‐reactive to light), gun‐barrel sight

Syphilis Treponema pallidum

• Congenital: affects muscle, skin, bones; saber

shins, saddle nose, Hutchinson’s teeth ifi ( i i ⁰ 3⁰)

• Dx: non‐specific VDRL, RPR (negative in 1⁰, 3⁰),

specific FTA‐ABS test (confirmatory)

• Tx: (1⁰, 2⁰) Benzathine – Penicillin G IM x 1

(late latent) Benzathine PCN G q week x 3 (neurosyphilis) IV PCN G q 4h

Chancroid

• H. ducreyi
• Painful ulcer/ragged edges, painful inguinal

lymphadenopathy

• Often associated with HIV infection

b i d

• Incubation 4‐7d
• Tx: Azithromycin x 1 or Ceftriaxone IM x 1

Donovanosis Klebsiella granulomatis

• Painless destructive ulcers
• No lymphadenopathy
• Tx: Doxycycline (+aminoglycoside)

TORCH Syndrome

• Mother asymtomatic but baby has: small size,

hepatosplenomegaly, rash (thrombocytopenia), CNS defects (encephalitis, seizures), jaundice

• Toxoplasma
• Other (syphilis, HIV)
• Rubella
• CMV
• HSV

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TORCH Syndrome

Toxoplasmosis

• Detect IgG for previous

infection, positive immunity

• If not immune: monitor for

Other (syphilis)

• Test all pregnant mothers
• If positive, treat monther

with penicillin, if allergic to IgM (acute), avoid undercooked meat, garden soil, wash fruits and vegetables, handwashing

• Treat infected infants

aggressively PCN then desensitize

• Infected babies commonly

show bone lesions, screen CSF for neurosyphilis

TORCH Syndrome

Other (HIV)

• Reduce transmission by

– Anti‐HIV therapy (zidovudine) during pregnancy and at birth Gi i f t ti t i l

Rubella

• Vaccinate mother
• Highest risk when mother

infected in 1st trimester, no

– Give infant antiretroviral therapy for 16 weeks – Cesarean delivery – No breast feeding

risk after 16 weeks

• Infected infant has patent

ductus arteriosus

TORCH Syndrome

CMV

• Dangerous if mother not

immune before pregnancy

• If mother not immune, 40%

HSV

• Perinatal infection by

reactivated herpes lesions

• Reduce transmission by

transmission

• 15% infected infants have

neurological symptoms (hearing loss, MR)

• Education, handwashing, no

vaccine Cesarean section

• Can treat mother with

acyclovir around birth time to reduce transmission

• Treat infected infants with

antiviral therapy

Other Congenital

• GBS

– Perinatal infection (50%), anogenital screening – Concern in newborn (meningitis), infant (sepsis)

• VSV

Primary infection during pregnancy very serious – Primary infection during pregnancy very serious, especially during first 20 weeks (later is mild) – VZV Ig given within 96h of exposure, no vaccine – Fetal infection results in short limbs, skin scars, CNS

• B19

– Most maternal infections do not lead to fetal infection – Infant symptoms: death, anemia w/ blueberry rash

Endocarditis

• Infection of the endocardial surface or valves
• Surface disrupted, platelets/fibrin deposit on

exposed collagen forming sterile thrombus, transient bacteremia infect sterile thrombus transient bacteremia infect sterile thrombus

• n low pressure side (Venturi effect),

thrombus grows, Ab cannot clear infection

• Once established, require ATB to cure
• Two types, native or prosthetic valve endoc.

Endocarditis

NVE

• Native Valve Endocarditis
• Viridans strep most

common (followed by S. PVE

• Prosthetic Valve Endocarditis
• Coagulase negative Staph

most common in early PVE aureus, Strep, Entero)

• If culture negative, can be

HACEK, intracellular pathogens, fungi

• Late PVE similar to NVE but

coag neg staph still common

• Platelets still deposit
• Infection of surgical site

leads to ring abscess

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Endocarditis

• Fever + murmur, persistent bacteremia
• Insidious onset of non‐specific symptoms
• History of heart disease, dental work

S ll d l i l / l J

• Small red lesions on palms/soles, Janeway are

non‐tender, Osler’s is tender

• Roth spots – retinal hemorrhage w/ central pallor
• Splinter hemorrhages under nails
• Anemia, elevated ESR, TEE echo

Endocarditis

• Dx: Duke – microbes on valve OR 2 major OR

1 major & 3 minor OR 5 minor

• Tx: IV Bactericidal for >4 weeks

(Viridans) IV PCN + aminoglycoside (Culture‐neg) IV Ceftriaxone (MRSA) Vancomycin + Gentamycin + Rifampin (Entero) Ampicillin + Gentamycin (Fungi) Amphotericin B + SURGERY (2+ embolic event) SURGERY

• Prophylaxis: Amoxicillin

Respiratory Diseases

Rhinitis

• Rhinovirus, parainfluenza,

RSV, coronavirus, others

• Rhinorrhea, little cellular

Influenza

• Leading infectious cause of

death in US

• Type A shifts H+N antigens

damage, self‐limiting

• Symptoms peak days 3‐4,

persist 1‐2 weeks

• Late August to early spring,

unrelated to temp easily, B less so

• Vaccine: 2 A strains, 1 B
• Amantadine resistance is

prevalent

Respiratory Diseases

Typical Pneumonia Streptococcus pneumoniae

• Rusty sputum, unilobar
• Aspirated into alveolar

space, fills with fluid and

Atypical Pneumonia Mycoplasma pneumoniae

• Dry cough, myringitis
• Inhaled, attaches to

respiratory cell, bronchitis PMN, then fills with blood (2‐3d), then fill with fibrin, then resolve w/o scarring

• Asplenic, sickle‐cell,

agammaglobulinemia at risk

• Vaccine has 23 serotypes

infiltrated by plasma cells, lasts 2‐6 wks

• Similar to Chlamydophila
• Unusual over age 40
• IgM cold agglutinins

Respiratory Diseases

Aspiration Pneumonia

• Chronic, foul sputum
• Polymicrobial anaerobic,

microaerophilic aspirated into lung

• Alcoholics, seizures,

tracheoesophageal fistula are risk factors

• Tx: Clindamycin PO x 3wks

Acute Bacterial Meningitis

• S. pneumoniae

– vaccine covers most types

• N. meningitidis

– B cause half infections – vaccine does not have B

• Stiff neck, Kernig’s sign

(leg extension resisted when supine), Brudzinski’s sign (neck flex causes hip flex)

• Dx: CNS leukocytosis
• H. influenzae

– type b vaccine

• L. monocytogenes

– neonates + elderly

• <4w GBS, <18y H.flu, 18‐

50y S.pneu, >50y L.mono

• Dx: CNS leukocytosis,

positive culture

• Tx: Ceftriaxone (+Vanco if

community acquired) (+ampicillin if immuno‐ compromised) + Dexamethasone

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Acute Viral Meningitis

• Enterovirus

– Kids > 2 wks old – Summer months – Hand‐foot‐mouth disease herpangina

• Mucosal to viremia to

BBB crossing to subarachnoid space to CSF to inflammation

• Dx: LP <1000 mostly

disease, herpangina

• HSV‐2

– Aseptic meningitis – Genital warts

• HIV

– Aseptic meningitis

• Dx: LP <1000, mostly

lymphocytes

• Tx: (enterov) nothing

(HSV‐2) acyclovir (HIV) HAART

Chronic Meningitis

• Fungal

– CSF glucose normal, protein >60, WBC <500

• Tuberculosis
• Chronic symptoms with

gradual neurologic decline

• Dx: history, PE, LP

– CSF protein >>100 – AFB smear, +culture

• Tx: most likely diagnosis

Intracranial Abscess

• Frontal: sinus, teeth

Temporal: ear, jaw, sinus Cerebellum: ear, jaw

– Strep, GNR, Bacteroides,

• S. aureus, Fusobacter
• Neurologic deficit
• 1‐3d: early cerebritis

4‐9d: late cerebritis 10‐13d: early capsule >14d: late capsule

• S. aureus, Fusobacter
• MCA: blood, lung, heart

– Staph, Strep, Fusobacter, Actinomyces, Anaerobes

• Beneath wound

– Clostridium, Staph, Strep

>14d: late capsule

• Dx: MRI/CT c contrast
• Tx: Surgical drainage,

manage ICP, culture Metronidazole + ceph + naf/vanco

Viral Encephalitis

• Non‐treatable

– EEEV, WEEV, VEEV, St. Louis Encephalitis, West Nile, Polio, Rabies, HIV, Measles

• Altered mental status,

decrease LOC, seizures

• Enter brain via blood,

retrograde transport,

Measles

• Treatable

– HSV‐1/2, VZV

exposed CN‐I

• Dx: EEG, MRI, LP/PCR
• Tx: Acyclovir if treatable

Subdural Empyema

• Bacteriology

– Strep, Staph,

• S. pneumoniae,
• H. influenzae,

anerobes, GNR U ll l i bi l

• Altered mental status,

focal neuro signs, seizures, like rapidly expanding mass lesion

• Reach via emissary

– Usually polymicrobial

• Inflammatory Source

– 50‐80% frontal/ethmoid – 10‐20% mastoid/AOM – 5% hematogenous

y vessels or osteomyelitis

• Dx: MRI
• Tx: Burr holes,

craniotomy, manage ICP Metronidazole + Ceftriaxone + Naf/Vanco

Epidural Abscess

Intracranial

• Intracranial epidural abscess

spills over into subdural space Spinal

• Mainly S. aureus (60‐90%)
• Abscess covers 4‐5 vertebra

but can extend entire length

• Focal pain radiculopathy
• 81% associated with

subdural empyema, similar bacteriology, diagnositic, treatment

Focal pain, radiculopathy, increasing paralysis

• Bacteria enter space by
• steomyelitis or

hematogenous

• Dx: MRI, myelogram
• Tx: Surgical drainage

Metro + 3rd gen ceph + Vanco

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6/28/2011 10

Nosocomial Precautions

• Standard: gloves, do not recap needles

– Infectious: blood, CSF, amniotic/vaginal fluid, semen – Low Risk: saliva, sputum, urine, feces

• Surgery: double glove, cover shoes, (face shield)

C t t ( l )

• Contact: gown (+gloves)

– VRE, MRSA, C. difficile

• Droplet: surgical mask

– Influenza, Mumps, Meningococcal Meningitis

• Airborne: N‐95 mask (particles <5 microns)

– TB, Chicken Pox

Nosocomial Risks and Numbers

• Accidental contaminated needlestick

– 1:300 HIV (therapy decrease risk 8‐fold) – 1:30 Hepatitis C – 1:3 Hepatitis B (without therapy) p ( py)

• Bacterial drug resistance

– 63% S. aureus in hospitals are MRSA (2007) – 80% E. faecium in this area are VRE

• Bacteruria occurs in 100% of patients with

indwelling urinary catheters after 30 days

UTIs

• We prevent UTIs by emptying bladder, valves,

normal flora distally, lack glucose, Tamm‐Horsfall protein (prevent E. coli attachment)

• Lower UTI vs Upper UTI

– Lower UTI is the lower poles and the bladder, upper UTI is the upper poles and the kidneys

• Uncomplicated vs Complicated

– Uncomplicated is adult female who Is not pregnant with normal urinary tract anatomy/fxn

• E. coli most common cause of UTIs

UTIs

Lower UTI

• Cystitis

– Dysuria, frequency, urgency – Pyuria tested by urine dipstick – Hematuria bacteruria

Upper UTI

• Fever common symptom
• Pyelonephritis

– 85% E. coli, 15% entero – Dysuria frequency urgency Hematuria, bacteruria – Uncomplicated tx Cipro x 3d – Complicated tx Cipro x 7‐14d

• Urethritis

– Usually due to STD

• Prostatitis

– Avoid rectal exam if acute – Acute tx: TMP‐SMX x 14d – Chronic difficult to treat – Dysuria, frequency, urgency – Fever, CVA/flank tenderness, N/V – “urosepsis” appear septic – Tx ampi + aminoglycoside x 14d

• Renal Abscess

– Rare complication in DM – Can be caused by S. aureus – Dx CT/Ultrasound – Tx anti‐staph PCN, cephalosporin

Other UTIs

Catheter‐related UTI

• Most common nosocomial

infection

• Indwelling = Foley cath

Pregnancy

• 5% develop asymptomatic

bacteruria

• Screened at 1st visit and 28th
• Mostly by E. coli, Proteus,

Pseudomonas, Enterococci

• Can lead to “urosepsis”
• Tx: change the catheter

broad spectrum ATB x 3‐5d week (or 16th week once)

• Associated with premature

labor, stillbirth, low infant birth weights

• Tx amoxicillin, TMP‐SMX,

cephalosporin to eradicate

Cellulitis

• Staph. aureus | Strep. pyogenes
• Source: anterior nares
• Virulence: hemolytic

toxin and leukocidin

• Source: nasopharynx
• Virulence: M‐protein

and hyaluronidase

• Entry by infected oil gland, puncture, bite, rash
• High risk: poor lymph drainage, blood supply,

neutropenia, hypogammaglobulinemia

• Tx: elevate extremity, local heat, ATB
• Variants
• Impetigo – confined to dermis with crusting
• Erysipelas – rapidly spreads, raised borders
• Furuncles – local abscesses from infected gland
• Carbuncle – several connected furuncles

SLIDE 11

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Skin and Soft Tissue Diseases

Synergistic Gangrene

• Clostridium perfringens is

synergistic with GNR, S. aureus causing cellulitis

Toxin‐Cased Skin Inflammation

• Toxic Shock Syndrome:

– Staphylcoccus protein – Desquamation of skin of h d f t t

• Necrosis of blood vessels,

gangrene of subcutaneous tissue, spreads rapidly

• Tx: Surgical removal

hands, feet, tongue – Hypotension, organ failure

• Scarlet Fever

– Streptococcus toxin – Diffuse red rash

• Scalded‐skin syndrome

– Staphylococcal toxin – Dehydration, infection

Skin and Soft Tissue Infections

Anthrax

• Bacillus anthracis, a soil

bacterium

• Marked edema, necrosis

Pasteurella Multocida

• Gm‐ coccobacillus
• Cat bites
• Pain/swelling at bite can

surrounding black ulcer

• 20% fatal if untreated
• Common in underdevelopd

world g spread to joints and bone

• Tx: opening bite, cleaning,

PCN

Skin and Soft Tissue Infections

Lymphocutaneous Granulomas

• Mycobacterium manium or

Sporothrix schenckii

• Painful papule can ulcerate,

Lyme Disease

• Borrelia burgdorferi
• Deer tick bite, expanding

disc of redness clearing in spread along lymphatics

• M. marinum: exposure to

fresh/brackish water

• S. schenckii: exposure to

plants (rose thorns, hay)

• Tx: (fungus) Itraconazole

(bac) rifampin+ethambutol center (bulls‐eye), lethargy, fever, can progress to arthritis and CNS symptoms

• Tx: PCN, tetracycline

GI Infections

• Transmission: Feces, Food, Fluids, Fingers,

Fomites, Fornication, Flies

• Lactose+ (CSEEK) Citrobacter, Serratia, E. coli,

Enterobacter Kleb Enterobacter, Kleb

• Lactose‐ (invas) Salmonella, Shigella, Yersinia
• Lactose‐ (opportunistic) Proteus
• Non‐motile Gm‐ rod: Shigella, Kleb, Yersinia

Vibrios

• Vibrio cholerae

– Cholera toxin: increase cAMP results in water loss and dehydration Ri t di h

• Vibrio parahemolyticus

– Improperly cooked seafood, oysters – GI year‐round, wound i f ti d – Rice water diarrhea, no fever, no inflammation – Halophilic, Gulf Coast – Spread via contaminated food/water infections and septicemia in summer

• Vibrio vulnificus

– Very virulent – Eating oysters can cause sepsis

Pathogenic E. coil

• ETEC (‐toxigenic)

– Traveler’s diarrhea – Contaminated food/H2O – Toxins cause diarrhea

• EHEC (‐hemorrhagic)

– Bloody diarrhea – Fever, HUS (hemolytic anemia, oliguric RF, th b t i )

• LT ↑cAMP, ST ↑cGMP
• EPEC (‐pathgenic)

– Infant diarrhea – Effacing of microvilli, increased signal transd. – Oral/fecal, hands, foods thrombocytopenia) – E. coli O157:H7 – Shiga‐like toxin, Stx – Burgers, apple juice – Do not give ATB

• EAEC (‐adhesive)

SLIDE 12

6/28/2011 12

Invasive Enteric Pathogens

• Shigella

– S. dysenteriae (developing countries, shiga toxin stops protein synthesis) sonnei (US)

• Salmonella

– S. typhi (humans), choleraesuis (pigs), typhimurium (US) T h id f synthesis), sonnei (US), flexneri, boydii – Resistant to acid – 70% <15 yo kids – Invade colon, multiply intracellularly – Typhoid fever – Bacteria invade and divide in macrophages – Carrier in gallbladder – Tx (typhi) ampicillin, cefriaxone, bactrim

Invasive Enteric Pathogens

• Yersinia

– Y. enterocolitica and pseudotuberculosis – Resist phagocytosis Blood transfusion disease

• Camphylobacter

– Small Gm‐ commas – C. jejuni (most common US gastroenteritis, poultry, unpasteurized milk, water) – Blood transfusion disease (grow at 4C) – Belgian chocolates – Mimic appendicitis – Tx: Cipro, TMP‐SMX, third gen ceph unpasteurized milk, water)

• C. fetus (spread to blood)
• C. upsaliensis (uncommon)

– Damage jejunum mucosa, ulceration, self‐limited – Guillan‐Barre sequale

Helicobacter

• H. pylori

– Spiral Gm‐ rods – Corkscrew motility – Urease production – Peptic/duodenal ulcers,

• H. cinaedi

– Gastroenteritis, septicemia, proctitis, cellulitis, sepsis in ICH – Homosexual men p / , gastritis, carcinoma, MALT lymphoma – Fecal‐oral transmission – Dx ELISA, urease breath test, silver stain, biopsy – Tx proton pump inhibitor + tetra + metro + bismuth – Tx amp and/or gent

• H. fennelliae

– Gastroenteritis, septicemia, proctitis – Homosexual men – Tx amp and/or gent