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EM Infectious Dz
Emergency Medicine Infectious Dz
| Question | Answer |
|---|---|
| Drug for MRSA | Vancomycin |
| Sepsis | Presence of infection plus systemic response (SIRS) |
| Severe sepsis | sepsis plus one or more sepsis related organ dysfunction |
| Septic shock | Sepsis plus hypotension (fluid unresponsive) plus tissue hypoperfusion |
| SIRS | Remote tissue inflammation, vasodilations (decreased SVR and CO), increased microvascular permeability, Leukocyte accumulation, Temp. >38 or <36, HR>90, RR>20, PaCO2>32, WBC>12,000 or <4,000 or >10% bands |
| Sepsis commonly involved bacteria | E.coli (25%), S. pneumoniae, S. aureus, multi-drug resistant gram negative bacteria (pseudomonas, acinetobacter, proteus), Group A streptococci, anaerobic bacteria, Fungi - mostly yeast, accounts for 4% of cases |
| Labs in Sepsis evaluation | CBC with differential, Chemistries: LFTs, bicarb, creatinine, PT/PTT (fibrinogen/D-dimer if coags abnl), Lactate (becoming increasingly important as marker of global tissue hypoxia) |
| Likley focus of Sepsis infections | GU, Pulmonary, intra-abdominal and skin sites, Get blood cultures, UA, Urine C &S, sputum, CXR, Pulurent discharge from skin lesions, sterile body fluids if suspected they may be site of infxn |
| Tx priorities in Sepsis | O2, Aggressive fluid replacement, vasopressors |
| How to treat infxn in Spesis | Empiric, broad spectrum abx (3rd generation ceph: ceftriaxone) possibly vancomycin. Recombinant human activated protein C (Xigris: antithrombotic, anti-inflammatory, given in ICU only, reduces M and M, $$$), Nutritional support, Euglycemia |
| Glucose goal in sepsis | between 80-110 |
| Meningitis in the summer is more likely caused by | viral etiologies; b/c many are vector born and people are more likely to be outside. Bacterial associated with higher mortality |
| Most common bacterial cause of meningitis in people over age 5 | S. pneumoniae. (for people 0-2 and again in adolescents, N. meningitidis ranks high) |
| Clinical presentation of meningitis | fever, HA, photophobia, nuchal rigidity, altered mental status, seizures (25%). Classic triad: fever, stiff neck & AMS. All pts have at least one of these 3. |
| PE for meningitis | HEENT, fundoscopic exam:papilledema?(late finding), Neck ROM, Cardiopulmonary, Neurologic, Skin: purpura? |
| Pts with focal deficits in whom you suspect meningitis | increased risk of herniation with lumbar puncture |
| Lab workup in meningitis | Head CT (brain herniation risk), LP CSF, Blood cultures x2, CBC with diff. , PT/PTT, Chemistries (glu, Na, Creatinine), CRP |
| CSF findings in meningitis | Bacterial: WBC>1,000>80% Neutrophils, low glu. Viral: WBC<1,000 >50%Lymphocytes, norm glu, slightly increased protein |
| How many tubes of CSF are taken in evaluating Meningitis? | 4: Cell count, WBC with differential, gram stain and culture,Glu and protein. |
| Tx for bacterial meningitis | Begin abx stat, empiric tx: ceftriaxone or cefotaxime (2g IV) and vancomycin. Give dexamethasone (reduce swelling) before or w/ 1st dose and continue for 4 days |
| Supportive care for bacterial meningitis | hydration, pain meds, anticonvulsants, antiemetics. Treat contacts with ciprofloxacin (especially with N. meningitidis and H. influenza) |
| Cause of Meningococcemia | bacteremia secondary to meningeal infection with N. meningitidis. Usually epidemic outbreaks. Sx and signs: typical meningitis plus petechial rash (HALLMARK), hypotension, shock/sepsis. |
| Hallmark of Meningococcemia | Petechial rash. Fulminant Meningococcemia is "the most rapidly lethal form of septic shock" encountered in medicine |
| Tx of Meningococcemia | Ceftriaxone or cefotaxime; pen G and chloramphenicol as alternatives. Dexamethasone to decrease CNS swelling, admit to ICU, |
| Prevention of Meningococcemia | Prophylaxis: cipro, rifampin. Meningococcal vaccine (usually given between ages 11-17). Seen more in adolescents than peds |
| Risk factors for CAP | alcoholism, asthma, immunosuppression, age>70 |
| Typical organisms causing CAP | S. pneumonia (90%), K. pneumonia, P. aeruginosa. Atypicals: M. pneumoniae, C. pneumoniae, Legionalla spp., respiratory viruses |
| Causes of Pneumonia | Aspiration (aerobic and anearobic flora) more in elderly, demented pts or intubated. ETOH abuse (Klebsiella, H. flu). Nosocomial (Pseudomonas, MRSA) |
| Clinical presentation of Pneumonia | fevers, rigors, malaise, cough, SOB, pleuritic pain, AMS, myalgias/arthralgias, GI sx (20%), increased RR, change in fremitus, rales, abnl percussion |
| Lab work up for Pneumonia | CBC, CXR, sputum gram stain and culture, Blood culutres, pulse ox, ABG, UA for Streptococcal and Legionella antigen, PCR assays, Serologies, Influenza rapid antigen |
| Worrisome signs and symptoms in Pneumonia | RR>30, Pulse>125, SBP<90, presence of comorbidities. Tx: within 6-8 hrs of arrival to ED. Oxygenation, Ventilation and Rehydration |
| PORT score used to | determine whether or not to admit a pneumonia patient. (age, nursing home status, coexisting illness, PE, Lab, radiographic findings). Note: road test before anyone goes home! |
| Which drug should not be used as a first line in pneumonia? | Levofloxacin (levaquin) |
| TB precuations: High risk patients | Elderly, nursing home, immigrants, HIV+positive patients, ETOH/drug users, Residents/staff of prisons or shelters |
| Screening Questions for TB Precautions | Hx of night sweats, weight loss, hemoptysis. Protocol for suspected TB: separate waiting area, respiratory isolation, admit for work up, followup PPDs for all contacts |
| Consider _____ when you have fever of unknown origin. | Endocarditis. Most commonly associated with heart valves. |
| ____ is the causative agent associated with acute endocarditis | S. aureus. Other causes of endocarditis: S. epidermidis, S. viridians. Negative cultures in up to 1/3 of cases |
| Cutaneous findings of endocarditis (due to circulating immune complexes) | petechiae, splinter hemorrhages, Osler nodes, Janeway lesions, Roth spots |
| Major criteria at Duke for endocarditis | positive blood cultures (x2), vegetation on echocardiogram, new valvular regurgitation. Minor criteria: fever, IVDU, vascular, immunologic |
| If you have prosthetic valves, which Echo type should you get when working up Endocarditis? | Transesophageal (TEE) |
| Endocarditis Tx | Stabilization of cardiopulmonary sx, evaluate for surgical intervention, Abx tx, admit |
| In treating Endocarditis in IVDU and pts w/ prosthetic valves, include ___ in their abx regimen | vancomycin |
| Etiologic agents of UTIs | E.coli (80% of all pts), Proteus, Klebsiella, Pseudomonas, S. saprophyticus (young women) |
| Lab evaluation for Cystitis | UA (squamous epithelial cells, Heme, LE, Nitrite, WBC, RBC, casts, bacteria, yeast, Trichomonas. Urine C&S in select pts, blood cultures is suspect urosepsis, imaging rarely indicated |
| When to culture a patient for suspected Cystitis | Children, elderly, men, pregnant women, post-menopausal women, tx failures, recurrent infxn, prior resistant organisms, NOT NECESSARY IN YOUNG HEALTHY FEMALES (E. COLI 99% OF THE TIME) |
| Duration of treatment of uncomplicated cystitis | 3-5 days. Uncomplicated infxns in children, pregnant women and complicated infxns in all pt populations 7-10 days. Abx: TMP/SMZ, Nitrofurantoin, Quinolones, Cephalexin |
| Cystitis Adjunctive Tx | Urinary Anesthetics: Pyridium, Azo. Prophylaxis for yeast vaginitis: OTC creams, fluconazole |
| Ascending infection post-UTI | Pyelonephritis |
| Pyelonephritis Tx | Cipro 500 bid x7-10 days; same drugs as UTI tx, just longer |
| When to admit a pt being treated for pyelonephritis | vomiting/uncontrolled fever, elderly (at risk for sepsis), DM, renal failure, stone, immunocompromised, pregnant, failed OP therapy |
| Mucocutaneous STDs | HSV, HPV |
| painful chancre | Chancroid (may look like syphilis, but syphilis is generally painless) |
| Etiology of Impetigo | GABHS or S. aureus (MSSA or MRSA) |
| Etiology of Pyodermas | S. aureus |
| Etiology of Erysipelas | GABS |
| Reasons to admit someone with Cellulitis | failing PO tx, rapid progression of sx, unreliable for f/u, face or hand involvement (hand has lots of tendon sheaths that cannot accomodate swelling), systemic sx |
| Etiologic agents of SSTIs | GAS, perfringens, MRSA. REMEMBER: PAIN OUT OF PROPORTION, and PAIN MOVING PAST WHERE YOU CAN SEE INFXN |
| Crepitus is a finding of | Necrotizing soft tissue infection. (from gas filling the tissue) |
| Order of severity for animal bites (worst to least) | cats, humans, dogs |
| When should bites be closed? | Fresh bites less than 24 hours old post exploration and irrigation. (close if on face, head, neck) |
| Rabies causes | fatal encephalitis |
| Joint fluid analysis in septic arthritis | WBC>50,000-60,000 (<200 nl), >50% neutrophils: infectious/inflammatory. Possible gram stain and culture positive, possible presence of crystals |
| Most common agent of Osteomyelitis | S. aureus, group A/B strep next. |
| Treatment time for Osteomyelitis | 4-6 weeks IV abx |
| ANC < ___ is a medical emergency | <500cells/mL. >100 a single agent for tx is acceptable. <100, two agents necessary |
| >6 months post transplant, etiologic agent of infection is | cryptococcus neoformans |
| Add Vancomycin in Immunocompromised Pts if | MRSA risk or line sepsis |
| Add Clindamycin in Immunocompromised pts if | anerobes suspected |
| Returning travelers are at risk of infection up to ___ after they return | 1 year |
| Most common post-travel infxn | Malaria. |
| If meningitis is suspected and an LP must be delayed to get a CT (to rule out mass lesion), what should be administered? | Immediately, you can give corticosteroids (if>1yr) and THEN abx. If the time between initiation of abx and LP is less than 2 hours, culture of CSF will not be adversely affected. |
| Prophylactic abx should be given to household contacts if the patient has which type of meningitis? | bacterial due to Neisseria meningitidis |
Created by:
ltm12