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ID BOARD REVIEW 2009 Amanda Peppercorn, M.D. Assistant Professor of Medicine University of North Carolina at Chapel Hill Toxic Shock Syndrome Group A Strep: Any invasive GAS infection (bacteremia, nec fasc, gangrenous myositis “flesh eating”) complicated by case definition of TSS Exotoxin superantigens (complicated about 1/3 of invasive GAS infections) Associated bacteremia common Staph aureus toxins: Food poisoningstaph enterotoxin Staph Scalded Skinexfoliative toxin CA-MRSAPanton-valentine leukocidin toxin TSSTSST-1 superantigen (interact directly with invariant region of MHC II molecule with activation of up to 20% of all T cells with massive cytokine storm) Previous association with tampons Usually MSSA but MRSA has been reported Desquamation TSS Case Definition Fever: T>38.9C (102.0F) Hypotension: SBP<90 or <5 percentile by age for children<16 years of age orthostatic drop in DPB>15mmHg orthostatic syncope/dizziness Rash: diffuse macular erthyroderma Desquamation: 1-2 weeks after onset of illness, usually palms and soles Multisystem involvement (3 or more) GI (vomiting, diarrhea at onset of illness) Muscular (severe myalgias, elevated CPK) Mucous Membranes (vaginal, oropharyngeal or conjunctival hyperemia) Renal (creatinine>2 times ULN or pyuria>5 WBC) Hepatic (elevated bilirubin or transaminases>2 times ULN Hematologic (platelets<100K) Treatment Supportive, often hemodialysis, pressors, ICU care (intractable hypotension/capillary leak) Strep: Emergent surgical debridement if soft tissue primary source (“pain out of proportion to exam”) Empiric: Clinda (900 iv q8) + imi/dori/meropenem or pip/tazo Taylored: PCN G + Clinda IVIG ?immunomodulators ex TNFa inhibitors? MSSA: clinda + oxacillin/naf/cefazolin, IVIG MRSA: clinda + vancomycin, IVIG NECROTIZING INFECTIONS Necrotizing fasciitis, type 1 Mixed infection; anaerobes plus strep or GNR Incubation = 48-96 h; progression = hrs – days Marked pain, tenderness, swelling, crepitus, foul-smelling Necrotizing fasciitis, type 2 Grp A strep (“flesh-eating” bacteria) Incubation = 6-48 h; progression = a few days Often with toxic shock, bullae, no crepitus Pain out of proportion to exam Acute Sinusitis Acute: Fever, facial pain, edema, erythema, maxillary toothache Subacute: Presumed viral sinusitis with no improvement in 7d S. pneumoniae H. influenzae M. catarralis Also MRSA, aspergillus, anaerobes from mouth flora (rare) Amoxicillin/Clavulanate 875 mg PO Q12h x 10 d Levofloxacin 750 mg PO Q24h x 10 d Reserve antibiotics for patients failing decongestant therapy and facial pain, purulent discharge and/or severe illness Treatment for full duration of therapy is essential to prevent relapses Supportive therapy: decongestants and antihistamines Complications: extension through bone to brainbrain abscess Diabetics, immunocompromised: think rhinocerebral Mucor Actinomycosis Branching filamentous anaerobic gram positive rod, “higher order bacteria” ;appearance like a fungus Characteristic sulfur granules (balls of organisms) in tissue/pathology samples Normal part of oral flora Cause oropharyngeal disease (dental abscess, jaw osteo, etc) Also cause of uterine infection (IUDs), abdominal abscesses Differentiate from nocardia by anaerobic principally and modified AFB stain (nocardia+, actino negative) Treatment: PCN, cephalosprins (keflex), clinda Physiology and Resistance Mechanisms of S aureus S aureus is a virulent human pathogen with the ability to elaborate a range of virulence factors and toxins; gram positive cocci in clusters Resistance to methicillin first appeared in 1961, attributed to inheritance of a mecA gene found on the mobile staphylococcal cassette chromosome mec (SCCmec) Genetic analysis suggests that mecA has been transferred to S aureus over 20 times, resulting in 5 major lineages MecA gene cassette leads to genetic alteration of penicillin binding protein, WTA=wall teichoic acid; PVL=Panton-Valentine leukocidin; conferring resistance to all penicillin CHIP=chemotaxis inhibitory protein. and cephalosporin family of Zetola N et al. Lancet Infect Dis. 2005;5:275-286. antibiotics Deresinski S. Clin Infect Dis. 2005;40:562-573. Foster TJ. J Clin Invest. 2004;114:1693-1696. COMPARISON: CA-MRSA AND HA-MRSA CA-MRSA HA-MRSA Clinical spectrum Skin and soft tissue Respiratory tract, UTI, bloodstream infections Epidemiology Clusters and outbreaks in closed populations Healthcare-associated outbreaks Underlying condition Dermatological HAI risk factors Age group Younger Older Resistance pattern Susceptible to multiple antibiotics Resistant to multiple antibiotics Genotype sccMec IV PVL present sccMec I, II, or III Race/ethnicity Virulence PVL absent Diederen BMW, et al. JID 2006;52:157-168 Risk Factors for CA-MRSA Athletes (close phyical contact) Military personnel Children Native Americans HIV MSM Prisoners Young sexually active Family members (don’t forget to ask!) Majority of patients have no identifiable risk factors Syphilis Early: primary--painless chancre, secondary (weeks to couple months after primary)—rash (infectious) rarely pustular, condyloma lata (MM, moist areas) and systemic sx (fever, HA, malaise, LAD), early latent (first year) Late: late latent, tertiary (gummas, cardiovascular, neurosyphilis— uveitis, ocular nerve damage, dementia, paresis, tabes dorsalis, meningitis, cranial neuropathies) HIV: primary and secondary can overlap Syphilis: a reportable disease Treatment: early—IM PCN, doxy as alternative, neurosyphilis—IV PCN x 14 days Response to treatment: 4 fold decrease in VDRL/RPR at 1 year Palmar involvement—secondary syphilis Labial Condyloma Lata, Secondary Syphilis CDC ISOLATION GUIDELINES Isolation Precautions Standard precautions Airborne precautions Special airborne precautions Droplet precautions Contact precautions Protective precautions STANDARD PRECAUTIONS Hand hygiene: Before and after each patient contact & after gloves removed The wearing of artificial fingernails or extenders is prohibited (based on CDC guidelines) Gloves: When touching contaminated items (blood, body fluids, secretions, excretions) Mask, eye protection, face shield: Whenever splashes or sprays of body fluids possible Gown: Whenever splashes or sprays of body fluids possible AIRBORNE PRECAUTIONS Isolation Private negative pressure room Direct out exhausted air N95 respirator Representative pathogens M. tuberculosis Varicella, Zoster (immunocompromised) Measles SPECIAL AIRBORNE PRECAUTIONS Isolation Airborne + eye shields Representative pathogens Avian influenza Monkeypox SARS Co-V Smallpox Viral hemorrhagic fever (e.g., Ebola, Lassa) DROPLET PRECAUTIONS Isolation Private room Mask Representative pathogens Invasive N. meningitidis RSV Bordetella pertussis Rubella, Mumps Group A streptococcal pharyngitis Invasive H. influenzae CONTACT PRECAUTIONS Isolation Gloves Gowns Representative pathogens Clostridium difficile HSV Varicella/zoster VRE, MRSA MDR pathogens (resistant to two or more classes of pathogens) BOARD REVIEW QUESTIONS: INFECTION CONTROL #42 – TB – airborne, removal isolation #61 – Varicella = airborne + contact #88 – Tularemia = no person-to-person #113 – C. difficile = contact + enhanced environmental cleaning (spores) POST-EXPOSURE PROPHYLAXIS Animal bite wound Anthrax Avian influenza Diphtheria Hepatitis A Hepatitis B HIV Human bite wound Influenza A Influenza B Measles Meningococcal infection Monkey bite (B virus) Monkeypox Pertussis (whooping cough) Rabies Smallpox Syphilis Tuberculosis (TB) Varicella (chickenpox) Zoster (shingles) POST-EXPOSURE PROPHYLAXIS USING VACCINES Hepatitis B*: <7 days (alternative HBIG) Measles: <3 days (alternative Ig) Rabies*: ASAP (plus RIG); prior to symptoms Tetanus*: Post-wound (no time limit) Small Pox: <4 days Varicella: <4 days (alternative VZIG or acyclovir) Outbreak control: Hepatitis A, pertussis, meningococcal * May need to be provided with an immunoglobulin preparation POST-EXPOSURE PROPHYLAXIS USING ANTI-INFECTIVES Animal bite: Amoxacillin-sulbactam x 5 days Influenza: Oseltamivir or zanimivir Lyme disease: can offer Doxy 200 mg x 1 (with many caveats—definite Ixodes, long attachment—36hrs, high endemic region—20% ticks with disease, present within 72hrs, adults and children>8, non-pregnant) Meningococcus: Ciprofloxaxin 400 mg (alternative ceftriaxone IM) Pertussis: Azithromycin x 5 days (alternative TMP-SMX for 7-14 days) HIV: combination antiretrovirals, data supports starting ASAP, no benefit after 72 hours (CDC 36 hours) NO POST-EXPOSURE PROPHYLAXIS Adenovirus conjunctivitis Hepatitis C Mumps Parvovirus B19 Rubella Severe acute respiratory distress syndrome (SARS) PATHOGENS ASSOCIATED WITH SKIN AND SOFT TISSUE INFECTIONS Cat bite Dog bite Human bite Rat bite Snake bite Shark bite Pig bite Animal hides Pasteurella sp (P. multocida), Franciscella tularensis P. multocida, Capnocytophaga canimorsus, CDC group EF-4 Eikenella corrodens, Fusobacterium, streptococci, Preotella, etc. Spirillum minor (systemic = Streptobacillus moniliformis) Aeromonas hydrophila Vibrio carchariae Erysipilothrix rhusiopathiae Bacillus anthracis, Franciscella tularensis PATHOGENS ASSOCIATED WITH SKIN AND SOFT TISSUE INFECTIONS Injection drug use Salt water injury Fresh water injury Fish tank exposure Fishmonger Medicinal leeches Hot tubs Plant/soil exposure Soil contamination S. aureus, Clostridium sp., E. corrodens, Grp A strep Vibrio Vulnificus Aeromonas hydrophila Mycobacterium marinum Erysipilothrix rhusiopathiae, Streptococcus iniae A. hydrophila, Aeromonas sobria, Vibrio fluvialis Pseudomonas aeruginosa Sporotrichosis Nocardia, Clostridium sp., Serratia TREATMENT OF MRSA: ORAL THERAPY Oral regimens (use only after susceptibility testing) Linezolid (expensive) Clindamycin (use only if erythromycin susceptible or D test performed to confirm susceptibility) Trimethoprim-sulfamethoxazole Minocycline Monitoring Daptomycin: CPK each week; stop if CPK >5x ULN (symptomatic) or >10x ULN (asymptomatic) or >1000 U/L Linezolid: CBC with platelets each week; do not treat >28 days BOARD REVIEW QUESTIONS: SKIN #68 – Osteo in drug user #71 – Human bite #83 – Cat bite #85 – IDU joint infection #94 – SA infection #107 - NTM CAP: PATHOGENS Outpatient Inpatient (non-ICU) Inpatient ICU S. pneumoniae M. pneumoniae H. influenzae C. pneumoniae Respiratory viruses* S. pneumoniae M. pneumoniae C. pneumoniae H. Influenzae Legionella spp. Aspiration Respiratory viruses* S. pneumoniae S. aureus Legionella spp. Gram-negative bacilli H. influenzae * Influenza A and B, adenovirus, RSV, parainfluenza Mandell LA, et al. Clin Infect Dis 2007;44(suppl 2):27-72 CAP THERAPY: OUTPATIENTS Previously healthy and no risk factor for DR-SPn No recent antibiotics: Macrolide (I), doxycycline (III) Recent antibiotics: FQ, advanced macrolide + high-dose amoxicillin, advanced macrolide + high-dose amoxicillin/clav Comorbidities: Chronic heart, lung, liver, or renal disease No recent antibiotics: Advanced macrolide, FQ Recent antibiotics: FQ (I), -lactam + macrolide (I), -lactam + doxycycline (II) {-lactam = high dose amoxicillin or amoxclav} Regions with >25% high level macrolide resistant SPn use alternative agent CAP THERAPY: INPATIENTS, NON-ICU Non-ICU FQ (I) -lactam + macrolide (I) -lactam = cefotaxime, ceftriaxone, ampicillin ICU -lactam + FQ (I) -lactam = cefotaxime, ceftriaxone, ampicillin-sulbactam -lactam + advanced macrolide (II) -lactam = cefotaxime, ceftriaxone, ampicillin-sulbactam Advanced macrolide = azithromycin or clarithromycin Pneumococcus 50% resistance at UNC to all macrolides (mechanism: alteration of ribosome binding site) Vanc susceptible--universal Resistance an issue for: Beta-lactams (penicillins, cephalosporins, and carbapenems) : 20% PCN R, 5% Cephalosporin R Macrolides (erythromycin, azithromycin, clarithromycin and lincosamines (clindamycin) Tetracyclines and folate inhibitors (trimethoprim-sulfamethoxazole [TMPSMX]) Fluoroquinolones (ciprofloxacin, levofloxacin, gemifloxacin, moxifloxacin) Meningitis: vanc (to cover R pneumococcus), ctx (better CNS penetration, good for meningococcus and pneumoncoccus), steroids (particularly for pneumococcus, to prevent hearing loss and other long term complications) although steroids may decrease CNS penetration of vancomycin; ampicillin for young and old and immunocompromised (to cover listeria) No steroids in places with HIV prevalence and presumed meningitis BROAD SPECTRUM ANTIBIOTICS Carbapenems: Imipenem, meropenem (not ertapenem) Coverage: GPC, GNRs, P. aeruginosa, anaerobes Holes: MRSA, Listeria, Legionella Piperacillin-tazobactamn (not ticar/clav or amp/sulbactam) Coverage: GPC, GNRs, P. aeruginosa, anaerobes, enterococci Holes: MRSA, Listeria, Legionella Tigecycline Coverage: GPC (including MRSA, VRE), GNRs (including ESBL producers and Acinetobacter), anaerobes Holes: Pseudomonas aeruginosa, Proteus spp. BROAD SPECTRUM ANTIBIOTICS: USES Sepsis of unknown etiology (GPC, GNR) Neutropenic fever (GNR, PA, SA) Severe intra-abdominal infections (GNR, Enterococcus, anaerobes) Gangrenous soft tissue infections (diabetic) (GNR, PA, SA) Known resistant pathogens (ESBL, Acinetobacter, Burkholderia, Pseudomonas) Endocarditis Updated Duke Criteria: 2-1/3-5 (major/minor criteria) Major: sustained bacteremia by organism known to cause endocarditis (SA, S viridans, enterococcus, HACEK, CNS with pv), endocardial involvement seen by echocardiogram (vegetation, abscess OR new valvular regurgitation*) Minor: predisposing condition (PPM/vascath, HD, IVDA), fever, vascular signs (septic emboli, janeway lesions, mycotic aneurysms), immune complex phenomena (osler nodes, roth spots, glomerulonephritis) +blood culture not meeting standard criteria Categories: native valve (bicuspid, calcification, prior endocarditis, any valvular disease), prosthetic valve (high mortality, need rifampin/gent, often requires surgery), IDU (can use shorter course of treatment with right sided) Culture negative: q fever, brucella, bartonella, legionella, chlamydia, HACEK, nutritionally deficient strep Indications for valve surgery: persistent bacteremia, refractory CHF, myocardial abscess/purulent pericarditis, difficult organisms (PsA, yeast, MRSA), recurrent septic embolic complications, large vegetation Tuberculosis PPD treatment: >5mm: HIV, immunosuppressed (TNF inhibitor, prednisone 15 mg/d x 1 month), known close contact >10mm: all other high risk populations (prisoners, healthcare worker, RF, homeless, immigrants, DM, malignancy, hx gastrectomy, malnutrition, etoh, long-term care) >15mm: everyone else Treatment: rule out active disease by CXR and symptom screening TB considerations: BCG (no change in interpretation, esp if >5 years ago), prophylaxis and treatment in setting of MDR Primary diseasedisseminationcontrol or active disease (lungs, LNs, pleurisy, CNS—tuberculomas, basilar meningitis, GI, GU— uterine, kidneys, bone—Potts disease, neck LN—Scrofula), HIV, miliary AHA Guidelines for Endocarditis Prophylaxis 2007 Update IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities (eg, tooth brushing) than from bacteremia caused by a dental, gastrointestinal, or genitourinary procedure. Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo these procedures. The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is therefore more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE. Updates Patients with the following cardiac conditions were considered to meet this criterion: Prosthetic heart valves, including bioprosthetic and homograft valves Prosthetic material used for cardiac valve repair A prior history of IE Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits. Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure. Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic device. Cardiac "valvulopathy" in a transplanted heart. Valvulopathy is defined as documentation of substantial leaflet pathology and regurgitation No longer indicated — Common valvular lesions for which antimicrobial prophylaxis is no longer recommended include bicuspid aortic valve, acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation and those who have undergone prior valve repair), and hypertrophic cardiomyopathy with latent or resting obstruction Procedures that may result in transient bacteremia and are recommended for prophylaxis — All dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa. Procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa Procedures in patients with ongoing GI or GU tract infection Procedures on infected skin, skin structure, or musculoskeletal tissue Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials. Botulism: gram positive anaerobic rod, toxin releasing, spore producing, with bioterrorism potential The modern syndrome of botulism occurs in five forms, differentiated by the mode of acquisition [2]: Food-borne botulism — ingestion of food contaminated by preformed botulinum toxin Infant botulism — the ingestion of clostridial spores that then colonize the host's gastrointestinal (GI) tract and release toxin produced in vivo Wound botulism — infection of a wound by Clostridium botulinum with subsequent in vivo production of neurotoxin Adult enteric infectious botulism or adult infectious botulism of unknown source — similar to infant botulism in that toxin is produced in vivo in the GI tract of an infected adult host. Inhalational botulism — the form that would occur if aerosolized toxin was released in an act of bioterrorism. • Cranial neuropathies, symmetric descending paralysis, no fever, no sensory loss • The differential diagnosis for food-borne, wound, and adult enteric botulism includes: • • myasthenia gravis, Lambert-Eaton myasthenic syndrome (LEMS), tick paralysis, Guillain-Barré syndrome, poliomyelitis, stroke, and heavy metal intoxication. Less likely diagnoses include tetrodotoxin and shellfish poisoning and antimicrobialassociated paralysis Dx: clinical syndrome, EMG studies, reportable disease, stool studies, serum toxin assays Treatment: supportive (most need intubation), antitoxin (equine trivalent anti-toxin for >1 year of age, botulism immunoglobulin for infants), PCN G for wound botulism Giardia Flagellated protozoan parasite Cysts (live in environment), trophozoites (reproductive form)-- pear-shaped, binucleate, multi flagellated organisms,measures 9-15 µm long, 5-15 µm wide, and 2-4 µm thick Worldwide, food-borne, water-borne, person-person, especially children in developing countries Other common GI parasite is Cryptosporidium parvum—Giardia and Crypto problem in normal hosts and important in HIV and immunocompromised (less common protozoan is E. histolytica) Dx: stool O and P (cyst and troph), stool antigenic testing (ELISA) Giardia trophozoite Giardiasis 60% asymptomatic Diarrhea that is sudden in onset and may be initially watery — 90 percent Malaise — 85 percent Foul-smelling and fatty stools (steatorrhea) — 70 percent Abdominal cramps and bloating — 70 percent Flatulence — 75 percent Nausea — 70 percent Weight loss — 65 percent Vomiting — 30 percent Fever— 10 percent Manifestations often wax and wane over many months Malabsorption—lactase (causes lactose intolerance), vitamin A, B12, folate, etc Miscellaneous Remember syphilis!! African tick fever—R. africae (look for eschars, early fever/myalgias)— Amblyoma tick, doxycycline Other tick borne diseases—R. rickettsia (dog tick, RMSF), Erlichia (deertick—Ixodes or lone star tick), Borrelia (Lyme, Ixodes), Babesia (protozoa looks like malaria, only in NE, fatal in asplenic pts, Ixodes) Anthrax—cutaneous (Edema toxin), eschar; also inhalational (hemorrhagic, widened mediastinum) and GI (ingestion of infected animal) Candidemia Smallpox versus Chickenpox—degree of fever and early timing of systemic symptoms, stage of lesions Drugs: daptomycin contraindicated for MRSA pneumonia, follow CPK Linezolid—thrombocytopenia, bone marrow suppression, serotonin syndrome HIV meds—abacavir (fatal hypersensitivity syndrome, HLA B5701), protease inhibitors—elevated lipids, DM, nucleoside RTIs— mitochondrial toxicity (lipodystrophy, visceral adiposity, myalgias, neuropathy), nevirapine (fatal liver disease esp in women with high CD4) Thank You