Transcript Common Infections in the Emergency Department

Common Infections
in the
Emergency Department
Kevin G. Rodgers, MD
Emergency Medicine
Case #1
19 year old female presents c/o a
sore throat, fever, malaise, and
swollen glands for 36 hours. Her
PMH is significant for asthma
for which she uses 2 inhalers.
What other history and PE would you like?
Case #1
What is pertinent Hx and PE in this patient?
–DDx?
–Centor Criteria?
–Complications?
Case #3 - Pharyngitis
• Divide patients according to clinical suspicion
– Above Treatment Threshold
Exudate, fever, LNs, no URI, correct age →treat
– Above Diagnostic Threshold
Has 1-4 criteria →obtain rapid strep
– Below Diagnostic Threshold
No exudate / shotty LN / low grade fever / URI sxs
JAMA, Rational Clinical Exam: Does this patient
have Strep throat? JAMA 284:22, 2000
Case #1 - Pharyngitis
• Treat with PCN (PO or IM) or macrolides
• Tell patients that ABX will not typically
alter the duration of illness (maximum of 8
hours shorter if seen in the 1st 24 hours)
• Tell patients that the full course must be
taken to prevent Rheumatic fever
• Consider dexamethasone for severe ST
Arch Pediatr Adolesc Med. 2005;159:278-282
Case #2
32 year old female with a history
of sinusitis presents c/o green
nasal discharge and sinus pain x
2 days. She is currently on nasal
steroids and Claritin.
What percentage of patients presenting to the ED
have sinusitis and how would you diagnose it?
Case #2-Acute Sinusitis
• Less than 5-10% of patients presenting to the
ED have actual bacterial sinusitis; most have
rhinosinusitis (viral, chemical, allergic or selflimited bacterial infection requiring no ABX)
• Clinical Diagnosis: fever, persistent purulent
nasal discharge, sinus tenderness to percussion,
facial pain / maxillary toothache and symptom
duration > 4-7 days
2004 ATBS Consensus Guidelines
Case #2-Acute Sinusitis
• CT scan ????
• Treatment????
Medical I&D
Decongestants
Saline nose drops
Oxymetazoline TID x 3 days
Fluids
Vaporizer / Moist heat
Antibiotics (10-14 days) – consider cost and compliance:
ampicillin, TMP-SMX, 2nd generation cephalosporins,
fluoroquinolones
Case #2-Acute Sinusitis
• Consider admission versus 24° F/U in patients
with frontal/pansinusitis or immunocompromised
patients
• Treatment for acute exacerbations
of chronic sinusitis ?
• Steroids???
Case #3
A 27 year old male presents c/o
malaise, frontal headache, low
grade fever, myalgias and nausea.
He just finished a 14 day course of
antibiotics for sinusitis. He felt well
for 24 hours when these symptoms
began.
At this point what is in your DDx?
Case #3 – DDx Headache
•Infectious
Meningitis, Encephalitis, Sinusitis, Brain / Tooth
Abscess, Pharyngitis, Otitis / Mastoiditis, Cavernous
Sinus Thrombosis
•Vascular
SAH, ICH, CVA, Carotid/Vertebral Dissection,
Migraine, Cluster, Arteritis
•Mechanical / Structural
Tension, Tumor (pseudo), Glaucoma, TMJ
•Traumatic / Toxin
SAH, SDH, EDH, Post-Concussive, CO, Withdrawal
Case #3
•What is the pertinent history and PE
in this patient?
– History according to the DDx especially
defining the onset and intensity of
headache and comparison to previous
headaches plus infectious sources
– Physical exam should include ??
Complete neurological,
mental status, HEENT
and neck exams
Case #3
• Exam reveals a diaphoretic, warm confused
patient
• VS: 116/88 – 114 – 24 – 101.4
• HEENT – unremarkable, no sinus tenderness
or purulent discharge or other source of
infection
• Neck – supple without Kernig’s / Brudzinski’s
• Neuro – non-focal, intact exam
What would you like to do now?
Case #3-Meningitis
• Headache, fever, stiff neck in 66% of adults;
also consider with AMS, seizures, signs of
increased ICP, focal deficits and petechial
rashes; infants, immunocompromised, partially
treated and elderly may not have a fever or stiff
neck
• Maintain a high index of suspicion….if the idea
of meningitis even enters your mind, do a LP!
• Door to Antibiotic Time?
Case #3-Meningitis
• Send CSF for protein, glucose, gram stain, culture,
cells, cryptococcal antigen, latex agglutination (if
antibiotics given) and Herpes PCR if indicated
• CT scan before LP if focal neurologic signs, signs of
increased ICP or obtunded patient who can’t
cooperate with a neurologic exam
• Very young and old: Ampicillin and gentamicin +/acyclovir; all others: ceftriaxone or cefotaxime +/vancomycin
• Steroids in adults?
van de Beek D, de Gans J, McIntyre P, et al.
Corticosteroids for acute bacterial meningitis.
Cochrane Database Syst Rev Issue 1. 2007
Case #4
47 year old male smoker presents c/o
a productive cough for 4 days. He
denies fever, chills, chest pain or SOB.
He does note some occasional purulent,
blood tinged sputum but denies night
sweats or weight loss. His PMH is
significant for HTN.
DDx? What would you like to do?
Case #4
• VS: 144/88 – 88 – 16 – 99.2° - 98% on RA
• Gen: Non-toxic appearing, coughing
Lungs: CTA w/o rales, rhonchi, wheezes
Heart: RRR w/o gallop, murmur, rub
Extremities: no edema or calf tenderness
Your orders?
Case #4 – Acute Bronchitis
• Most adults have viral bronchitis (NO ABX) and can
be treated with inhaled -agonists (persistent cough
is due to low level bronchospasm) +/- HC/APAP
• It is recommended that smokers and patients with
underlying lung disease receive antibiotics as ~ 20%
may have bacterial bronchitis
• Use antibiotics active against upper respiratory
pathogens: macrolides, doxycycline, TMP-SMX,
ampicillin x 5 days
Cochrane Database Syst Rev. 2009
Case #5
67 year old female presents c/o
fever, chills, right-sided pleuritic
chest pain and a productive cough
for 3 days. Her PMH is significant
for HTN, DJD, CHF and an MI 3
years ago.
How is this patient different from
the previous patient?
Case #5
• VS: 162/92 – 126 – 36 – 102.7° - 91% RA
• Gen: Toxic appearing patient in moderate
respiratory distress
Lungs: CTA except rales at the left base
Heart: Tachycardic w/o gallops, murmurs
What is your workup and therapy?
Case #5 - Pneumonia
• Set up safety net: IV, O2, monitor
• CXR and EKG (consider enzymes if CP, AMS,
coexistent new onset CHF, DM)
• Blood and sputum cultures (after saline neb)
• CBC, CMP, +/- ABG ( oxygen saturations <
90% on RA or desaturation with exertion are
reasons for admission regardless of PORT
scores)
Case #5 – Pneumonia Scoring
• Age (males = years, females = age – 10)
• Nursing home resident (10)
• Comorbid Illness
– Neoplastic Disease (30)
– Liver Disease (20)
– CHF (10)
– Cerebrovascular Disease (10)
– Renal Disease (10)
Case #5 – Pneumonia Scoring
• Physical exam findings
• AMS (20)
• RR > 30 (20)
• SBP < 90 (20)
• Temp <35° > 40° (15)
• Pulse > 125 (10)
• Laboratory or Radiographic findings
• Arterial pH < 7.35 (30)
• BUN>30 (20)
• Na < 130 (20)
• Glu>250 (10)
• Hct < 30 (10)
• PO2<60 (10)
• Pleural Effusion (10)
• >91 points = hospitalize, 71-90 = observation
Case #5 - Pneumonia
• Outpatient Therapy:
– Healthy / no risk for DRSP: macrolide or doxycycline
– Comorbidities or risk for DRSP: respiratory
fluoroquinolone (moxi, gemi, levo) or -lactam
(extended spectrum cephalosporin, Amp/Cl, high dose
Amp) plus macrolide or doxycycline (ATS/IDSA)
• Inpatient / Non-ICU Therapy: same as high risk
• ICU Therapy:
– -lactam + azithromycin or pulmonary fluoroquinolone
– for Pseudomonas (NCAP/vent): piperacillin-tazobactam,
cefepime, imipenem, or meropenem plus cipro/levo or azithro/
aminoglycoside
Case #6
36 year old male presents c/o loose
stools for 2 days and crampy
abdominal pain. He is otherwise
healthy and is on no medications.
What historical and PE findings are
important in this patient?
Case #6
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Mexico
South America
Colorado
Day-care
Recent antibiotics
Shellfish
Fried-rice
HIV: another lecture by itself (call ID!)
PE: fecal blood, fever, hydration status,
abdominal exam looking for other non-infectious
causes
DDx of Acute Diarrhea
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Inflammatory bowel disease
Irritable bowel syndrome
Partial SBO / Colon cancer
Mesenteric ischemia
Ischemic colitis
Milk / food allergies
Sprue
Drugs / heavy metals / mushrooms
Carcinoid
Thyrotoxicosis / Addisonian crisis
Case #6 –Workup / Therapy
• IV versus PO rehydration if dehydrated
• Rarely do you need labs in young healthy people
or those with short duration of symptoms
• Stool cultures only for surveillance purposes
(poor sensitivity and expensive); O&P should be
gotten by GI in F/U of chronic diarrhea
• C. difficile toxin in patients with recent ABX or
persistent symptoms; fecal leukocytes may be
useful in equivocal cases
Case #6 - Etiologies
• Viral (50-70% of all cases) – supportive care
• Invasive Bacteria: Campylobacter, Shigella,
Salmonella, Yersinia, E. coli, +/-Vibrio – treat
with ciprofloxacin or TMP-SMX as alternative
• Toxin-Induced: E. coli, S. aureus, B. cereus, C.
difficile, A. hydrophilis, Cholera – supportive
care except C. difficile (metronidazole)
Case #6 - Therapy
• Most cases are self limited only requiring
hydration
• Anticholinergics (diphenhydramine) and antispasmotics (dicyclomine) for cramps if severe
• For debilitating diarrhea use loperamide (use of
diphenoxylate is associated with toxic megacolon)
• Recent literature suggests that the incidence of
worsening diarrhea due to lactose intolerance
associated with milk product ingestion is rare
Case #7
• 24 year old male prisoner presents with a
spider bite he sustained 2 days ago
Case #7 – A Rare Brown Recluse Bite
MRSA
Case #7
• Most of these are abscesses from the dreaded
“MRSA” spider
• Risk factors: prisoners, families with
recurrent infections, athletes especially close
contact sports, shelter dwellers, recurrent
infections in an individual
• Normal I&D, isolation if admitted
• TMP/SMX, Clindamycin, Vancomycin
Questions ?