emergencies in infection
DESCRIPTION
Emergencies in Infection. Reşat ÖZARAS, MD, Prof. [email protected]. Sepsis. Definitions American College of Chest Physicians Society of Critical Care Medicine 1992. Systemic Inflammatory Response Syndrome 2 or more Fever > 38°C or < 36°C Heart rate > 90 /min. - PowerPoint PPT PresentationTRANSCRIPT
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Sepsis
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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%
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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%
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• Temperature
• Tachycardia
• Tachypnea
• Leukocyte
3T1L
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SIRS
Infection
Multiple Trauma Hemorrhagic shock
Pancreatitis Ischemia
Burn
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SEPSIS
SIRS
+ Documented infection
(Clinical, radiological, microbiological, histological)
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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
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SEPTIC SHOCK
Despite replacing adequate fluid (>1 L)
hypotension (> 1 hour)
+
Hypoperfusion abnormalities
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Skin and Soft Tissue Infections
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Impetigo
• Frequent in children• Etiology ; S.pyogenes**, S.aureus (<10%)
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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
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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.
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Treatment
• Surgery
• Antibiotics: – Ceftriaxone+metronidazole– Piperacillin/tazobactam– Carbapenem
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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
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Endocarditis
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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.
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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
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Treatment
• MSSA– Sulbactam/ampicillin
• MRSA– Vancomycin
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Bacterial Meningitis
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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
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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
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Meningococci in CSF
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Pneumococci in CSF
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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
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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
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Urinary Tract Inf
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– Acute pyelonephritis : fever+costovertebral angle tenderness; back pain+/- dysuria, frequency
– Cystitis : dysuria, frequency, urgency, suprapubical tenderness
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Definitions
– Bacteriuria : > 100.000/ml bacteria/urine– Complicated UTI: Anatomical or physiological – Relapse: Recurrence of the same infection with
the same pathogen
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UTI
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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
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Diagnosis
• History, PE• Urine analysis• Gram’s staining• Culture• ESR, CBC, CRP
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Perinephritic abscess
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Treatment
• Hospital/community– Quinolones?– Ceftriaxone
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Pneumonia
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• Outpatient settings
• Inpatient settings– Ward– Intensive Care
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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
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• Risk factors COPD, Cystic F,
bronchiectasisDMHeart failureRenal failureCerebrovasculer D.Cancer>65 yImmune def.Care unitsAlcoholism
• Severity FactorsTachypneaFever HypotensionConfusion Cyanosis
LeukocytosisHypoxiaHyponatremiaRadiological f (multilobar)Sepsis
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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
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Etiology
• S. pneumoniae (pneumococci)
• H. influenzae
• Moraxella catarrhalis
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Legionella pneumophila
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Treatment: Outpatient
I-without risk factors
Macrolide or doxycycline
II- with risk factors
New generation quinolones
or
Amoxicillin/clavulonate + macrolide
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Treatment: Inpatient
Ceftriaxone + macrolide
or
Beta-lactam / beta-laktamase inhibitor + macrolide
or
FQ
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Septic arthritis
• Usually one joint
•Knee, hip, shoulder,..
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Risk factors
• Systemical immunity problems
• Trauma
• Rheumatic disorders
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Etiology
• Staph
• Strep
• Gram (-)
• H. influenzae
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Treatment
• Surgery (drainage, debridement …)
• Antibiotics (parenteral)– Sulbactam/ampicillin– Cefazolin
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Conclusion
• Be aware of sepsis
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3T1L