Emergencies in Infection

Emergencies in Infection

Reşat ÖZARAS, MD, [email protected]

Sepsis

Definitions American College of Chest PhysiciansSociety of Critical Care Medicine 1992

Systemic Inflammatory Response Syndrome

2 or more • Fever > 38°C or < 36°C • Heart rate > 90 /min.

• Respiratory rate> 20 /min. or PCO2<32 mmHg

• Leukocyte > 12.000/mm3, < 4000/mm3 or stabs > 10%

Definitions

Systemic Inflammatory Response Syndrome

2 or more • Temperature > 38°C or < 36°C • Tachycardia > 90 /min.

• Tachypnea> 20 /min. or PCO2<32 mmHg

• Leukocyte > 12.000/mm3, < 4000/mm3 or stabs > 10%

• Temperature

• Tachycardia

• Tachypnea

• Leukocyte

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SIRS

Infection

Multiple Trauma Hemorrhagic shock

Pancreatitis Ischemia

Burn

SEPSIS

SIRS

+ Documented infection

(Clinical, radiological, microbiological, histological)

SEVERE SEPSISSEVERE SEPSIS

Organ disfunction,

Hipoperfusion abnormalities or Hipotension

Lactic acidosis Oliguria

Mental changes

Lactic acidosis Oliguria

Mental changes

ARDS, DIC, RFARDS, DIC, RF

SysBP < 90 mm Hg or >40 mmHg decrease from baseline SysBP

SysBP < 90 mm Hg or >40 mmHg decrease from baseline SysBP

SEPTIC SHOCK

Despite replacing adequate fluid (>1 L)

hypotension (> 1 hour)

+

Hypoperfusion abnormalities

Skin and Soft Tissue Infections

Impetigo

• Frequent in children• Etiology ; S.pyogenes**, S.aureus (<10%)

Erysipelas and Cellulitis

• Erysipelas; involves skin and subcutaneous tissue

• Cellulitis; involvement of dermis, subcutaneous tissue, and deeper soft tissues

• Etiology: S.pyogenes, rarely S.aureus• Treatment: amox/clav, cefazolin

Gaseous gangrene

• Necrotic tissues and foreign substance-containing wounds

• Subcutaneous tissue necrosis and gas formation within tissues

• Etiology; Clostridia, staphylococci, E.coli, Proteus, Pseudomonas, anaerobs.

Treatment

• Surgery

• Antibiotics: – Ceftriaxone+metronidazole– Piperacillin/tazobactam– Carbapenem

Necrotising fasciitis(Streptococcal gangrene)

• Immunosuppresives, diabetics,alcoholics, IV drug users, peripheral vascular disorders,…

• Necrosis of subcutaneous tissue and fascia Etiology;

• Group A streptococci • S.aureus and gram(-) bacilli and anaerobs

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Meningococcemia

Endocarditis

IE: Clinical classification

Acute IE

Main etiology: S. aureus

Mortality without treatment: 100% within 2 mo.

Subacute/chronic IE

Main etiology: Viridans streptococci

Mortality without treatment: 100% within 1 y.

Prosthetic valve endocarditis: Epidemiology

• Early Prosthetic valve endocarditis (< 2 mo.)

Hospital acquired• Intermediate prosthetic valve endocarditis (2-12

mo.)

Hospital/community acquired• Late prosthetic valve endocarditis (>12 mo.)

Community acquired

Treatment

• MSSA– Sulbactam/ampicillin

• MRSA– Vancomycin

Bacterial Meningitis

Approach to a patient with presumed diagnosis of meningitis

Decide within 30 min.

Clinical evaluation

Admission Acute (1 day-1 week)

Subacute (1 week-1 month) Chronic (> 1 month) Clues from history and PE

General condition of the patient

Immune status of the patient

LP must not be done if

Absolute: Skin inf.

Papilledema, focal neurological findings,

Relative: Suspect mass

Spinal cord tumor

Spinal epidural abscess

Tendency to bleed, low platelets

Meningococci in CSF

Pneumococci in CSF

CSF Findings

Etiology LEUKOCYTES (/MM3)

CELL TYPE GLUCOSE(MG/DL)

PROTEIN(MG/DL

Viral 50–1000 Mononuclear >45 <200

Bacterial 1000–5000

Neutrophylic <40 100–500

Tuberculous 50–300 Mononuclear <45 50–300

Empirical Treatment of Meningitis

Clinical Situation Probable Bacteria Treatment

Community Acquired S. pneumoniae Ceftriaxone

N. meningitidis 2 x 2 grams

[Listeria] +

[H. influenzae] Ampicillin 6x2 grams

+Dexamethasone amp 4 x 8 mg, 4 days

Urinary Tract Inf

– Acute pyelonephritis : fever+costovertebral angle tenderness; back pain+/- dysuria, frequency

– Cystitis : dysuria, frequency, urgency, suprapubical tenderness

Definitions

– Bacteriuria : > 100.000/ml bacteria/urine– Complicated UTI: Anatomical or physiological – Relapse: Recurrence of the same infection with

the same pathogen

UTI

Acute Pyelonephritis

• Chills, fever• Flank pain, abdominal pain, back pain• Nausea, vomiting• Hypotension()• Tenderness on costovertebral angle• Symptoms of cystitis

– Urgency – Frequency– Dysuria– Suprapubic tenderness

Diagnosis

• History, PE• Urine analysis• Gram’s staining• Culture• ESR, CBC, CRP

Perinephritic abscess

Treatment

• Hospital/community– Quinolones?– Ceftriaxone

Pneumonia

• Outpatient settings

• Inpatient settings– Ward– Intensive Care

Work-up

• History (standard+ antibiotics use, risk faktors)

• PE, vital signs (standard+ severity signs)

• Basic Lab (CRP, CBC, ALT, bilirubins, creatinine, Na, LDH)

• Sputum exam.

• Plain chest X-ray

• Risk factors COPD, Cystic F,

bronchiectasisDMHeart failureRenal failureCerebrovasculer D.Cancer>65 yImmune def.Care unitsAlcoholism

• Severity FactorsTachypneaFever HypotensionConfusion Cyanosis

LeukocytosisHypoxiaHyponatremiaRadiological f (multilobar)Sepsis

Diagnosis

1-Acute fever

2-Cough, sputum/ dyspnea

3-Chest auscultation findings

4-Chest X-ray

5-CBC and CRP

6-Gram’s staining and culture of sputum

Etiology

• S. pneumoniae (pneumococci)

• H. influenzae

• Moraxella catarrhalis

• Mycoplasma pneumoniae

• Chlamydia pneumoniae

• Legionella pneumophila

Treatment: Outpatient

I-without risk factors

Macrolide or doxycycline

II- with risk factors

New generation quinolones

or

Amoxicillin/clavulonate + macrolide

Treatment: Inpatient

Ceftriaxone + macrolide

or

Beta-lactam / beta-laktamase inhibitor + macrolide

or

FQ

Septic arthritis

• Usually one joint

•Knee, hip, shoulder,..

Risk factors

• Systemical immunity problems

• Trauma

• Rheumatic disorders

Etiology

• Staph

• Strep

• Gram (-)

• H. influenzae

Treatment

• Surgery (drainage, debridement …)

• Antibiotics (parenteral)– Sulbactam/ampicillin– Cefazolin

Conclusion

• Be aware of sepsis

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