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Infectious Diseases for Interns 19 Oct 2012 Dr Karen Lim TNH Infectious Diseases Registrar (with acknowledgements to Dr Raquel Cowan) Overview Diagnosis Severe sepsis – alarm bells Management of the sick patient Presentations of note What to use? Check your micro… Diagnosis Why worry about fever / sepsis? 5% of ED presentations Infection the most common cause of fever of short duration Overall mortality of septic shock in Australia is about 40% emphasising the importance of early detection Gram-positive septicaemia mortality is 10 – 20% Higher in Gram-negative Infectious Diseases: A clinical approach; edited by Allen Yung et al. 3rd edition 2010 Assessment Methodical and thorough Corroborative Hx from family Vital signs Look at all covered/hidden areas axilla, groin, perineum, ears, teeth, thyroid, natal cleft, prostate… Ask a colleague for confirmation of signs Repeat the history and examination Patients are often unwell/confused/tired in ED and may not be able to give an accurate history Signs may evolve e.g. murmurs with endocarditis What’s in a “septic screen”? Bloods: FBE, U+E, CRP, LFT Blood cultures x 3, 20 minutes apart CXR Urine M/C/S Swabs Wound Respiratory Other: ABG, lumbar puncture, ascitic tap, CT scan Severe sepsis – alarm bells Abnormal vital signs Tachypnoea (99%) – acidosis (metabolic 38%), impending respiratory failure Earliest clinical sign of sepsis regardless of site of infection Tachycardia > 120bpm (97%) – often accompanied by hypotension Hypotension < 100mmHg in adults Temperature > 39*C in adults (70%) Hypothermia < 36*C (13%) Brun-Buisson C et al. JAMA 1995: 274(12) Infectious Diseases: A clinical approach; edited by Allen Yung et al. 3rd edition 2010 Other alarm bells Patient presents within the first 12 hours Profound effect on the patient Pallor, mottled skin and/or cold peripheries Inability to stand or walk Marker of impending shock Severe muscle and joint pain Early symptom Anterior thighs Infectious Diseases: A clinical approach; edited by Allen Yung et al. 3rd edition 2010 Other alarm bells Rigors Altered conscious state or behavioural change Focus of infection or sign of severe sepsis Encephalopathy 35% Repeated vomiting in the absence of diarrhoea Assume bacteraemia until proven otherwise May be a marker of bacteraemia, abdominal, CNS pathology Severe headache Can be false localising sign Brun-Buisson C et al. JAMA 1995: 274(12) Infectious Diseases: A clinical approach; edited by Allen Yung et al. 3rd edition 2010 Beware the fever… Recurrent Unexplained rash Haemorrhagic, petechial, purpuric – bacteraemia Toxic shock syndrome Back pain or neck pain Things may have progressed Non-specific to specific phase of illness Epidural abscess Focal pain Often means focal infection Infectious Diseases: A clinical approach; edited by Allen Yung et al. 3rd edition 2010 Beware the fever… Sore throat and/or dysphagia with normal looking throat Jaundice Associated with increased risk of death, ICU admit, inc LOS Bacteraemia, cholangitis, pyogenic liver abscesses, malaria Abdominal pain Epiglottitis Appendicitis Recent surgery or other medical intervention Complication Infectious Diseases: A clinical approach; edited by Allen Yung et al. 3rd edition 2010 Management of the sick patient Admission Fluid resuscitation Early antibiotics Broad spectrum if diagnosis is unclear Appropriately targeted antibiotics if localising symptoms or signs Ask for help!!! Timely antibiotics is the key Kumar A et al. Crit Care Med 2006; 34:1589-1596 Effective Abx in 1st hour of hypotension had a survival rate of 79.9% Each hour of delay was associated with average decrease in survival of 7.6% (OR 1.67; 95% CI, 1.12-2.48) From: Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock CHEST. 2009;136(5):1237-1248. doi:10.1378/chest.09-0087 Survival dropped fivefold from 52.0% to 10.3% (OR, 9.45; 95% CI, 7.74 to 11.54; p < 0.0001) with inappropriate initial therapy Impact of antimicrobial appropriateness on survival in major epidemiologic subgroups. Presentations of note Meningococcal disease 85% meningitis, 15-20% septicaemia Usually present < 24 hrs May initially have systemic prodrome, before develop specific symptoms - fever, headache, anorexia, vomiting, myalgias, pallor Honeymoon period Later severe unaccustomed headache and rash Photophobia and neck stiffness not universal Rash may be absent or atypical Endocarditis Variable clinical picture - difficult diagnosis to make in ED Acute - more common Subacute Staphylococcal RF’s - IVDU, haemodialysis, lines, prosthetic valve Systemically unwell +/- septic or cardiogenic shock Non-specific: fevers, wt loss, anorexia Specific: embolic phenomenon, murmur, cardiac failure, GN Need blood cultures prior to ABx Epidural abscess Fever and back pain is a spinal infection until proven otherwise Severe back pain - think of epidural abscess IVDU are at higher risk of spinal infections Assess vital signs and neurology Blood cultures, ABx and an urgent MRI Call for help! Cellulitis and Erysipelas Micro Streptococcus pyogenes (Group A Strep) Other beta haemolytic strep Staph aureus Risk factors Trauma to skin Skin inflammation Lymphatic dysfunction Venous disease Surgery Malignancy Tinea Cellulitis Differential diagnoses DVT Necrotising fasciitis Lipodermatosclerosis Bursitis Zoster Gout Cellulitis - Alarm features Progressive systemic toxicity Rapidly progressive erythema Severe pain Hypotension Immunosuppression Epidemiology Animal contact Water contact Travel Cellulitis - Management Inpatient versus outpatient Inpatient Any alarm signs Immunosuppressed Diabetic Ulcers Ischemia Unable to walk Shock Unable to take oral medications Cellulitis - Management Antibiotics Gram positive organisms Anti-staphylococcal penicillins 1st generation Cephalosporins Cephazolin, Cephalothin, Cephalexin Allergies Flucloxacillin or Dicloxacillin Clindamycin, Vancomycin, Cotrimoxazole Other Wound care Elevation DVT prophylaxis Diabetic feet Polymicrobial Staph, Group A Strep, Gram negatives Need to assess: vascular supply neuropathy extent of soft tissue destruction bone involvement Diabetic feet Predictors of OM Further assessment Probe to bone (very specific) Ulcer size > 2x2cm Duration > 2 weeks Soft tissue involvement: MRI Osteomyelitis: CT Beware necrotising fasciitis or gas gangrene Nosocomial sepsis Plastic Surgical procedures IDC, drain tubes, IV cannulas, CVC, PICC, ports Procedural complication e.g. leak, perforation, haematoma Wound infection Hospital acquired pneumonia C. difficile colitis Pressure wounds Management Require broad spectrum antibiotics to cover potentially resistant pathogens Issues with elderly infections Risk factors Chronic and debilitating diseases Normal physiology of aging Alteration in immune function History taking can be difficult Symptoms and signs tend to be non-specific / atypical Several organ systems affected Blunted clinical features Fever Acute septic arthritis with chronic OA Common things are common Pneumonia Urinary tract infection Bacteruria in 20% men > 70 yrs, 50% in women > 75 yrs Look at leukocytes, erythrocytes, squamous cells Soft tissue infection Be wary of diagnosing in the absence of symptoms Pressure ulcers Intra-abdominal infections Bacterial meningitis Post-operative fever Immediate peri-operative period Pre-existing infection Intra-operative manipulation of purulent material Febrile blood transfusion reactions Drug reactions Rare endocrine causes Fever within 48 – 72 hours Usually self limited and not associated with infection in a majority of patients Cytokines and tissue damage during the procedure The surgeon’s five 1) Urinary tract infection Usually enteric gram-negatives Often related to IDC insertion or operation Staph aureus usually indicates bloodstream infection Remove catheter and commence empiric antibiotics 2) Surgical site infection 1 – 5% develop wound infection, higher if pre-existing infection at site of operation Careful examination – superficial / deep The surgeon’s five 3) Pneumonia Tachypnoea and fever Usually aspiration Don’t forget adequate pain management CXR Chest physiotherapy 4) Intravenous cannula and bloodstream infection Check IVCs + document everyday Remove IVC if no longer necessary or at first signs of phlebitis/pain Change IVCs every 72 hours (or within 24 hours if inserted during an emergency) 5) Venous thrombosis (DVT / PE) Carefully examine legs O2 sats, blood gases often worse than CXR suggest CTPA or VQ scan What to use? What to use? Identify likely source Consult Guidance, Therapeutic Guidelines or friendly ID team Don’t forget renal-adjustment (Table 2.31 intranet version) Bacteraemia You won’t detect bacteraemia unless you do BC’s! No need to wait for fever! Ask the lab for morphology GPC, GNB etc Clusters or chains for GPC Repeat BC ID and sensitivities take time! BC flags + Gram stain Plated ID Sensitivities Revision II Antibiotics for registrars Basic microbiology review Basic microbiology review Gram + GPC Gram GPB GNC Neisseria GNB Staphylococcus Listeria Streptococcus Clostridium* - E. coli Enterococcus Bacillus - Klebsiella Corynebacterium - Salmonella GNCB Coliforms - ESCHAPPM Haemophilus Pseudomonas Peptostreptococcus* Bordetella (Acinetobacter) Propionibacterium* (Acinetobacter) Bacteroides* * Anaerobes (AnO2) Bacteraemia GPC in BC Staphylococci S aureus (MSSA and MRSA) S epidermidis and coagulase negative staph Streptococci S pneumoniae S pyogenes Others: viridans, milleri etc Enterococci Initial ABx choice? Morphology? Vancomycin - severely unwell or risk of MRSA Anti-staphylococcal penicillins - Flucloxacillin 1st generation Cephalosporins Others: Clindamycin, Cotrimoxazole, Tazocin, Cefepime, Meropenem Bacteraemia GNB E coli, Klebsiella, Proteus mirabilis Haemophilus Pseudomonas Salmonella, Typhoid, Campylobacter, Shigella ESCAPPM: Enterobacter, Serratia, Citrobacter, Acinetobacter, Providencia, Proteus vulgaris, Morganella ESBLs (extended spectrum B-lactamases) ABx options Ceftriaxone, Ceftazidime, Tazocin, Ciprofloxacin, Meropenem Anti-pseudomonal: Timentin/Tazocin, Ceftazadime, Meropenem, Ciprofloxacin ESBLs: Carbapenem ESCAPPM: Meropenem, Ceftazadime, Ciprofloxacin, Cotrimoxazole Bacteraemia GNC GPB - Vancomycin Neisseria meningitidis and gonorrhoea Bacillus Corynebacterium Clostridia Anaerobes Oral - Penicillin Bowel - Metronidazole What to use? Site of infection Microorganisms Therapeutic choices Unknown source Concern GNB, GPC If in shock, MRSA colonised, vascular catheter Febrile neutropaenia Severe communityacquired pneumonia Hospital-acquired pneumonia Intra-abdominal Flucloxacillin Ceftriaxone Add in Vancomycin GNB (esp Pseudomonas), GPC Strep pneumoniae, H. influenzae, Legionella, Mycoplasma As above, E.coli, Pseudomonas, Klebsiella, Acinetobacter Enteric GNB, anaerobes Tazocin +/- Vancomycin Ceftriaxone, Azithromycin Urinary tract infection Skin / soft tissue GNB, Enterococcus Staph aureus, Strep pyogenes CNS N. meningitidis, Strep pneumoniae, Haemophilus influenzae type B, Listeria monocytogenes Ceftriaxone or if unresponsive Tazocin Ceftriaxone, Ampicillin, Metronidazole or Tazocin Ceftriaxone Flucloxacillin Diabetic ulcer: Tazocin Clindamycin for toxin Cetriaxone (2g bd) Benzylpenicillin 2.4g 4/24 ?Moxifloxacin Gentamicin Effective against Gram negative bacteria Generally not used in The Northern Hospital Irreversible ototoxicity, even after one dose Reversible nephrotoxicity Used under ID approval in rare cases http://www.wobblers.com/ Check your micro… Check the bug, check the sensitivities Healthscope Microbiology Can certainly come and bite you on the backside Generally will know Gram stain within 24 hours Organism within 24 – 48 hours Sensitivities within 48 – 72 hours Make adjustments to your treatment accordingly There are usually hidden sensitivities Extended spectrum betalactamases (ESBLs) Enterobacteriacae (eg. E.coli, Klebsiella etc) produce betalactamases that confer resistance to Penicillins ESBLs also confer resistance to first, second and third generation Cephalosporins (e.g. Cephazolin, Ceftriaxone) Plasmid mediated Increasing incidence India RR 146 Middle East RR 18 Africa RR 7.7 Asia (not India) RR 3.4 Think about it if the context is relevant Treat with Carbapenem (e.g. Meropenem) Methicillin-resistant Staph aureus Increasing problem in the healthcare system Consider for those from Institutions, nursing homes Extended hospital stays Indigenous population, Islander population Recurrent boil-like infections Pseudomonas Gram-negative Infections anywhere Beware colonisation COPD, bronchiectasis Skin In serious infections do not use ciprofloxacin alone Tazocin, Ceftazadime, Cefepime, Meropenem Ciprofloxaxin is our only oral option Antimicrobial Stewardship at Northern Health 2012 Prescriber flow chart Getting started Access Guidance DS through ‘Shortcuts’ from any networked hospital computer Guidance DS Main Menu Logging On Log on using your general Northern Hospital Username and Password Getting Approval Click on the drug name you want to prescribe Getting Approval Enter patient UR number Getting Approval Confirm patient details Getting Approval Getting Approval Confirm Approval Confirm drug name and correct indication Approval number To be written on patient drug chart Remember… History, history, history Pain is your friend Take notice of physical, laboratory and imaging studies Beware the fever and… When in doubt… look at the therapeutic guidelines … or ask Other tidbits of advice… When in doubt, ask… Multitask Know what you are asking for and why Respect the nurses Inform the patients and their families If concerned, call a MET call