1 Slide 1 JSOMTC, SWMG(A) Bacterial Infections PFN: SOMCML03 Hours: 2.5 Slide 2 JSOMTC, SWMG(A) Terminal Learning Objective Action: Communicate knowledge of “Bacterial Infections” Condition: Given a lecture in a classroom environment Standard: Receive a minimum score of 75% on the written exam IAW course standards Slide 3 JSOMTC, SWMG(A) References Pathophysiology for the Health Professions, 4 th Edition Merck Manual, 19 th Edition Current Medical Diagnosis & Treatment, 51 st Edition Special Operations Forces Medical Handbook,2 nd Edition Sanford’s Guide to Antimicrobial Therapy, 44 th Edition
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1
Slide 1JSOMTC, SWMG(A)
Bacterial InfectionsPFN: SOMCML03
Hours: 2.5
Slide 2JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of “Bacterial Infections”
Condition: Given a lecture in a classroom environment
Standard: Receive a minimum score of 75% on the written exam IAW course standards
Slide 3JSOMTC, SWMG(A)
References
Pathophysiology for the Health Professions, 4th Edition
Merck Manual, 19th Edition
Current Medical Diagnosis & Treatment,
51st Edition
Special Operations Forces Medical Handbook, 2nd Edition
Sanford’s Guide to Antimicrobial Therapy, 44th Edition
2
Slide 4JSOMTC, SWMG(A)
Reason
The regions that SOF personnel deploy to are among the most disease‐ridden places on the planet. Preventative measures combined with maintaining a high index of suspicion will result in more combat ready forces on the battlefield accomplishing the mission.
Slide 5JSOMTC, SWMG(A)
Agenda
Identify Group A B‐hemolytic Streptococcusand the diseases it can cause
Communicate the etiology, signs and symptoms, the Jones Criteria, diagnostic tests, and management of rheumatic fever
Communicate the etiology, signs and symptoms, diagnostic tests, and management of bacterial meningitis
Slide 6JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of anthrax, to include: pneumonic, G.I., and cutaneous forms
Communicate the etiology, signs and symptoms, diagnostic tests, and management of brucellosis
3
Slide 7JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of tularemia
Communicate the etiology, signs and symptoms, diagnostic tests, and management of typhoid
Communicate the etiology, signs and symptoms, diagnostic tests, and management of cholera
Slide 8JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of plague
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the four kinds of tetanus, to include: generalized, neonatal, local, and cephalic tetanus
Slide 9JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Clostridium perfringensinfections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Bartonella bacterial diseases, to include: Cat Scratch Disease, Trench Fever, and Oroya Fever
4
Slide 10JSOMTC, SWMG(A)
Identify Group A Beta‐hemolytic Streptococcus and the Diseases it
Can Cause
Slide 11JSOMTC, SWMG(A)
A Look at Gram‐positive Cocci
Slide 12JSOMTC, SWMG(A)
Streptococcal Infections
Group A Beta‐hemolytic Streptococcus‐GABS
Streptococcal pharyngitis
Impetigo
Necrotizing fasciitis
Indirect sequelae
Scarlet fever
Rheumatic fever
Glomerulonephritis
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Slide 13JSOMTC, SWMG(A)
Strep Pharyngitis
Slide 14JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, the Jones Criteria, Diagnostic Tests, and Management of Rheumatic
Fever
Slide 15JSOMTC, SWMG(A)
Rheumatic Fever
Acute inflammatory complication of GABS infection
Characterized by:
Chorea (involuntary writhing movements)
Carditis
Arthritis
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Slide 16JSOMTC, SWMG(A)
Rheumatic Fever
Acute Rheumatic Fever (ARF) ‐ Typically occurs approximately 19 days after untreated streptococcal pharyngitis
Have you taken your temperature or do you feel hot?
Have you felt sick for a long time?
Slide 21JSOMTC, SWMG(A)
Objective: Signs
Fever (102 F)
Rash (erythema marginatum)
Short, abrupt, non‐purposeful movements (often disappear during sleep)
Grimacing
Bibasilar rales, aortic insufficiency or mitral regurgition murmurs, S3 gallop
Rheumatic Fever
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Slide 22JSOMTC, SWMG(A)
Rheumatic Fever
Erythema Marginatum
Slide 23JSOMTC, SWMG(A)
Rheumatic Fever
Laboratory findings
ESR >120 mm/h
WBC 12,000 – 20,000
ECG – prolonged PR interval
CXR may show cardiomegaly
ASO titer
Slide 24JSOMTC, SWMG(A)
Diagnosis requires the following:
Two major criteria or
One major and two minor criteria
Jones Criteria (Rheumatic Fever)
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Slide 25JSOMTC, SWMG(A)
Major criteria
Polyarthritis
Chorea
Carditis
Erythema Migrans
Sub Q nodules
Evidence of recent GABS (+ culture)
Minor criteria
Arthralgia
Fever
Elevated ESR
Prolonged PR interval
Jones Criteria (Rheumatic Fever)
Slide 26JSOMTC, SWMG(A)
Rheumatic Fever
Differential diagnosis
Polyarthritis:
• Gonococcal arthritis
• Subacute bacterial endocarditis
• Lyme disease
• Reiter’s syndrome
Carditis:
• Viral myocarditis
• Pericarditis
Slide 27JSOMTC, SWMG(A)
Management
New recommendation (2012) by Infectious Disease Society of America to only treat pharyngitis patients with a positive test for GABS
Rapid Strep to become part of MES
Primary: Benzathine Penicillin or oral PCN VK
Alternate: Clindamycin or Azithromycin
ASA or NSAID
Rheumatic Fever
10
Slide 28JSOMTC, SWMG(A)
Patient education
Relapsing condition
• Prophylaxis treatment before procedures
Bedrest until afebrile
Diet regular
Medications: expect tinnitus with high dose aspirin
Rheumatic Fever
Slide 29JSOMTC, SWMG(A)
Rheumatic Fever
Complication of untreated strep throat
Presentation: young patient (5 – 20 y/o)
Most common clinical manifestations
Poly arthritis (painful migratory arthritis)
Chorea (spastic involuntary movements)
Carditis (rubs/murmurs/gallop)
Jones criteria used for diagnosis
Slide 30JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
of Bacterial Meningitis
11
Slide 31JSOMTC, SWMG(A)
Caused byGram‐negative Aerobic Cocci
Slide 32JSOMTC, SWMG(A)
Meningococcal Meningitis(Neisseria Meningitidis)
Slide 33JSOMTC, SWMG(A)
Meningococcal Meningitis
Types
Neisseria meningiditis ‐ most common etiology for large, periodic epidemics
Strep. pneumoniae ‐ most often cause of community acquired infection
H. influenza ‐ decreased incidence with childhood vaccination programs
12
Slide 34JSOMTC, SWMG(A)
Meningococcal Meningitis
Characteristics
High fever, headache, and stiff neck
Infection has rapid onset / progression
Prompt diagnosis and treatment critical towards reduction of morbidity
Slide 35JSOMTC, SWMG(A)
Slide 36JSOMTC, SWMG(A)
Meningococcal Meningitis
Symptoms
Initial
• High fever
• Headache
• Stiff neck
•Malaise
• Photophobia
• Arthralgias/myalgias
Advanced
• Delirium
• Nausea / vomiting
• Skin rash
• Dizziness
• Seizures
• Coma
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Slide 37JSOMTC, SWMG(A)
Meningococcal Meningitis
History
How fast did your symptoms progress?
Have you been exposed to others who have been ill or had meningitis?
Have you had meningitis in the past?
Does it hurt to bend your neck or touch your chin to your chest?
Vaccinations against meningitis?
Travel to “meningitis belt”?
Recently done “The Haj”?
Slide 38JSOMTC, SWMG(A)
Meningococcal Meningitis
Objective: Signs
Fever to 104oF or 40oC
Cervical meningismus
Prostration
Toxic appearance
Slide 39JSOMTC, SWMG(A)
Meningococcal Meningitis
Hemorrhagic petechial skin lesions
Possible papilledema due to increased ICP
Eponyms / classic signs
Meningeal signs
Brudzinsky sign
Kernig’s sign
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Slide 40JSOMTC, SWMG(A)
Slide 41JSOMTC, SWMG(A)
Meningococcal Meningitis Brudzinsky ‐ flexion of head / neck onto chest causes increase of pain of nuchal or spinal regions / patient will tend to flex the leg / knee
Kernig's ‐ extension of leg / knee with patient in supine position – this movement is limited by spasm of hamstring which also causes pain
Slide 42JSOMTC, SWMG(A)
Lab: WBC Count ‐ Leukocytosis
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Slide 43JSOMTC, SWMG(A)
Lab: Gram‐negative Cocci
Slide 44JSOMTC, SWMG(A)
Meningococcal Meningitis
CSF analysis
Bacterial form ‐ elev WBC (over 10000) PML* predom., decreased glucose, increased protein
Viral form ‐ WBC decreased (below 1000 ), less than 50% PML’s, nl glucose, nl protein
Slide 45JSOMTC, SWMG(A)
Meningococcal Meningitis
Assessment ‐ DDX
Rickettsial infection
Dengue
Leptospirosis
Cerebral malaria
Malignancy
Severe viral or bacterial sepsis
Subdural/epidural hematoma
Stroke
Toxin (e.g., drugs, ETOH, etc.)
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Slide 46JSOMTC, SWMG(A)
Meningococcal Meningitis
Plan (Empiric Treatment)
Availability of certain procedures may be limited in the field
Begin antibiotics as soon as possible
Empiric choices: penicillin or ampicillin
Ceftriaxone (Rocephin) or cefotaxime (3rd generation cephalosporin)
Plus vancomycin in adults to cover possibility of penicillin resistant Strep. pneumoniae
Slide 47JSOMTC, SWMG(A)
Meningococcal Meningitis
Plan (cont.)
Evacuate immediately
Airway support/oxygen (intubate as needed)
Fluid hydration with IV NS or LR
Control fever with Tylenol
Consider steroids (Decadron)
Respiratory isolation x 24h
Intimate contacts: prophylaxis
Slide 48JSOMTC, SWMG(A)
Meningococcal Meningitis
Prevention
Isolation
Medications
• Ciprofloxacin 500mg PO single dose
• Ceftriaxone 250 mg IM single dose
Vaccine
Elimination of carrier
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Slide 49JSOMTC, SWMG(A)
Meningococcal Meningitis
Treatment
High index of suspicion
High fever, headache, stiff neck
Rapid progression of symptoms (hours)
Administration of broad‐spectrum antibiotics should not await the results of diagnostic tests
Slide 50JSOMTC, SWMG(A)
The Etiology, Signs and Symptoms, Diagnostic Tests, and Management
Action: Communicate knowledge of “Bacterial Infections”
Condition: Given a lecture in a classroom environment
Standard: Receive a minimum score of 75% on the written exam IAW course standards
Slide 179JSOMTC, SWMG(A)
Agenda
Identify Group A B‐Hemolytic Streptococcusand the diseases it can cause
Communicate the etiology, signs and symptoms, the Jones Criteria, diagnostic tests, and management of rheumatic fever
Communicate the etiology, signs and symptoms, diagnostic tests, and management of bacterial meningitis
Slide 180JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of anthrax, to include: pneumonic, G.I., and cutaneous forms
Communicate the etiology, signs and symptoms, diagnostic tests, and management of brucellosis
61
Slide 181JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of tularemia
Communicate the etiology, signs and symptoms, diagnostic tests, and management of typhoid
Communicate the etiology, signs and symptoms, diagnostic tests, and management of cholera
Slide 182JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the three forms of plague
Communicate the etiology, signs and symptoms, diagnostic tests, and management of the four kinds of tetanus, to include: generalized, neonatal, local, and cephalic tetanus
Slide 183JSOMTC, SWMG(A)
Agenda
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Clostridium perfringensinfections
Communicate the etiology, signs and symptoms, diagnostic tests, and management of Bartonella bacterial diseases, to include: Cat Scratch Disease, Trench Fever, and Oroya Fever
62
Slide 184JSOMTC, SWMG(A)
Reason
The regions that SOF personnel deploy to are among the most disease ridden‐places on the planet. Preventative measures combined with maintaining a high index of suspicion will result in more combat ready forces on the battlefield accomplishing the mission.