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If you want three opinions then ask two infectious disease doctors- KBA
Fever
Its 1am and the nurse on Lakeside 65 just called you because Mrs. Price has a T of 101.5 . . . What do you do?
More cowbell!
Fever
1) Assess the patient
As always this is #1 when you are called about a patient
What are they in for? Have they been febrile? What do they look like?
Are there any symptoms consistent with infection or non-infectious causes of fever (which are?)
Fever
2) Orders Blood cultures Urinalysis, urine culture Chest x-ray
Sepsis
Documented or suspected infection
plus
Keep in mind that many clinical scenarios can produce 2 of 4 SIRS criteria
Hypotension
Systolic BP <90mmHg
or
Types of sepsis
Severe sepsis- sepsis associated with organ dysfunction, hypoperfusion, or hypotension
Septic shock- Sepsis with hypotension, despite adequate fluid resuscitation, along with the presence of perfusion abnormalities- lactic acidosis, oliguria, mental status change
Treatment
Antibiotics
Targeted at known organism or empiric treatment
Sepsis considerations
Corticosteroids
given only to adult septic shock patients after it has been confirmed that their blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy
UTI risk
Females
Atrophic vaginal mucosa with altered flora Use of diaphragms and spermaticides Foley catheter
Males
Stricture or obstruction of the urethra (e.g. BPH) Foley catheter
Etiology of UTI
Uncomplicated
E. coli- 85% of females with uncomplicated infection Staph. Saprophyticus
Recurrent
Enterococci (faecium and faecalis) Klebsiella Proteus
UTI pathogenesis
Introduction of bacteria into the urinary bladder Incomplete emptying of the bladder (as little as 10mL of residual) Fast reproduction time of many of the bacteria that cause UTI (e.g. E. coli which reproduces in 20 minutes)
Urinalysis
Leukocyte esterase- test for esterase which is released from leukocytes Nitrite- produced when bacteria convert nitrates to nitrites WBC- pyuria is defined as . . .
>5WBC per HPF in women >2WBC per HPF in men
Complicated UTI
Abnormal anatomy- residual urine, neurogenic bladder, BPH Foreign bodies- Catheters, Calculi, Tumors Vesicoureteral reflux Diabetes
IV
Cephalosporin- ceftriaxone Fluoroquinolone
54 yo male h/o HTN, DM who presents with raised erythematous lesion on right leg and subjective fevers. T 99.7 HR 86 RR 16 BP 140/90
Erysipelas
raised above the level of surrounding skin, and there is a clear line of demarcation between involved and uninvolved tissue Involves upper dermis and superficial lymphatics
PCN allergic
Consider fluoroquinolone
Risk of necrotizing fasciitis- score >6 is suggestive and score >8 is highly predictive
Serum C-reactive protein 150 mg/L (4 points) White blood cell count 15,000 to 25,000/microL (1 point) or >25,000/microL (2 points) Hemoglobin 11.0 to 13.5 g/dL (1 point) or 11 g/dL (2 points) Serum sodium less than 135 meq/L (2 points) Serum creatinine greater than 1.6 mg/dL (141 mmol/L) (2 points) Serum glucose greater than 180 mg/dL (10 mmol/L) (1 point) A total score 6 should raise the suspicion for necrotizing fasciitis while a score 8 was highly predictive (>75 percent). Among the patients with necrotizing fasciitis, 75 to 80 percent had a score 8, while only 7 to 10 percent had a score less than 6. Thus, the score is only useful when severe soft tissue infection is strongly suspected.
Initial investigation
CXR Sputum culture Blood culture Consider ABG if respiratory distress or hypoxia
None of the above should delay antibiotic treatment and guidelines dictate that antibiotics should be given within four hours of initial encounter
Epidemiology
Risk factors for CAP
Older age COPD Renal Insufficiency Congestive Heart Disease CAD Diabetes Malignancy Chronic Neurologic Disease Chronic Liver Disease
Pneumonia- Etiology
The clinical features of community-acquired pneumonia cannot be reliably used to establish the etiologic diagnosis of pneumonia with adequate sensitivity and specificity- IDSA guidelines on Community Acquired Pneumonia
CAP- Etiology
The bugs . . .
Strep. Pneumoniae Mycoplasma pneumoniae Haemophilus influenza Chlamydia pneumoniae Respiratory viruses
CHF
CKD BUN
10
10 20
Total= 113
PORT score
Class V- >130
27% mortality
The bugs
Gram-negative enteric pathogens Mouth anaerobes
Etiology of HCAP
Think of MDR pathogens
Common bugs
Strep pneumo and H. flu- usually cause early rather than late infections Staph- worry about MRSA Gram negative bacilli
Pseudonas aeruginosa E. coli Klebsiella Acinetobacter- if you suspect this then consider ID consult and utilize full barrier and respiratory precautions
Treating HCAP
Empiric antibiotics should be different classes than recently prescribed antibiotics
Empiric treatment of HAP- early onset and no known risk factors for MDR
Neutropenic fever
Fever (single oral temperature >101 or >100.4 for greater than one hour) in patient with ANC < 500 or in patient who has ANC <1000 with suspected nadir of <500
Initial workup
Blood cultures Urine cultures Sputum cultures CXR
Etiology
Gram positive cocci account for 60-70% of proven bacterial infection in these patients
Antivirals
Should be used if signs and symptoms of HSV or VZV are present to heal portal of entry for bacteria
Duration of therapy
Colony-stimulating factors
Not routinely recommended for therapy Consider in patients who are severely ill or who have documented bacterial infection, persistent neutropenia and are not responding to antimicrobial therapy
Uh-oh
Your patient that you are treating for HAP begins to have profuse, watery diarrhea!
C. Diff Infection
Clostridium difficile is the most common infectious cause of healthcare associated diarrhea in the United States
3.4 to 8.4 cases per 1000 admissions
Suspect C. diff
What do you order?
C. diff toxin assay from 3 separate stools Fecal leukocytes
Spectrum of disease
Asymptomatic carrier state
3% of healthy adults 16-35% of hospitalized patients
Pseudomembranous colitis
90-100% of antibiotic associated pseudomembanous colitis
Figure 44.1 The pathogenesis model for hospital-acquired Clostridium difficile -associated diarrhea (CDAD).]
Supportive measures
THE END