Infectious Diseases for Finals

By Jessica Shearer

Syllabus

Infection in surgical patient Severe Sepsis HIV Measles Rubella Whooping cough Malaria Febrile traveller Hospital acquired infection including C. difficile Infectious mononucleosis Pyrexia of unknown origin Influenza Mumps Chicken pox Infective gastroenteritis

Outline
Infection in surgical patient- case study
Hospital acquired infection- C. diff & MRSA Pyrexia of unknown origin

Infectious diseases slideshow

A case to whet the appetite..

Case Study
Middle of busy surgical night shift. You are the

only FY1 around and all of your seniors are in theatre.

Bleep: Doctor come quickly, Mr Darcy is MEWS-

ing a 6 and looks dreadful

58 year old male. Known COPD. Bowel Ca

2/7 post op open right hemicolectomy. No

intra-op complications.
Nurses cant tell you anymore details

Case Study
BP 85/90, Temp 38oC, HR 101 bpm, RR 24, Sats

85% on 2L NC, UO >200mls

Desaturating when taken off O2. Using a PCAS.
OE Looks Bad: Sweaty, drowsy, c/o pain around

wound site, crackles on chest, erythema around wound, calves SNT

What are you going to do??

10 point Masterplan for septic patient

1.

Stop panicking and think: Likely post-op sepsis 2o chest/urine/intra-abdo

O2 15L Non re-breathe (be careful with COPD patients!)

2.

3.
4. 5.

ABG
IV access x2 large bore ACF Bloods and cultures-FBC, U&E, LFT, CRP, clotting, lactate, amylase Fluid challenge- Volplex 500mls and assess response, repeat if necessary AGGRESSIVE FLUIDS +++ IV antibiotics STAT-broad spectrum and regular paracetamol IV

6.

7. 8.

SEPTIC SIX Blood cultures Urinary catheter Fluid challenge

Antibiotics Lactate measurement (ABG)

Oxygen

Empirical Antibiotics
Infection Appropriate antibiotic (Intravenous)

Cellulitis/skin infection
Urosepsis/acute pyelonephritis

Flucloxacillin 1g/6h
Co-amoxiclav 1.2g TDS + Gentamicin 5mg/kg (as a stat dose)

Severe CAP
Intra-abdominal sepsis Sepsis unknown cause Meningitis

Amoxicillin 1.2g TDS + Clarithromycin 500mg BD

Cefuroxime 1.5mg TDS + Metronidazole 500mg TDS Either Cef +Met or IV Tazocin 4.5g TDS Ceftriaxone 4g Stat then 2g/24h for 10/7

Hospital Acquired Infections..

Hospital acquired infection- C. difficile

Anaerobic Gram positive spore forming bacilli.

Spores are resistant to exposure to air, drying and

heat, alcohol and stomach acid, chemical disinfectants..

Major cause of diarrhoea. Mainly affects over 65

year olds

Associated with antibiotic use and environmental

C. difficile- Risk Factors

Elderly (over 65 years)
Long length of hospital stay

Recent use of antibiotics, especially broad spectrum e.g.

cephalosporins
Recent surgery, especially GI Serious underlying disease/illness and

immunocompromised patients
Prolonged use of PPI i.e. omeprazole, lansoprazole Drugs that suppress motility e.g. loperamide.

C. difficile- Symptoms & diagnosis

Explosive watery foul smelling diarrhoea
Abdominal cramping Occasional vomiting Ranges from mild self limiting diarrhoea to severe

psuedomembraneous colitis
Diagnosis made on presence of C. diff toxins A &

B in diarrhoeal stool samples.

C. difficile- Range of severity

Mild disease: 3 or fewer type 5-7 stolls per day and normal

Moderate disease: 3-5 stools per day & a raised WCC that is still <15

Severe disease: WCC>15 or a temperature of >38.5 or acute rising serum creatinine (e.g.>50% increase above baseline) or evidence of severe colitis (abdominal or radiological signs).

Complicated disease: hypotension or partial ileus or CT evidence of severe disease

Life threatening disease: complete ileus or toxic megacolon

SIGHT
Suspect case may be infective Isolate the patient in side room Gloves & aprons
Hand wash with soap and water Test stool for toxin

C. difficile- Treatment
Mild and moderate disease: oral Metronidazole 400mg

8 hourly for 10-14 days

Severe disease: oral Vancomycin 125mg 6 hourly for 10

-14 days
Complicated disease (including pseudomembranous

colitis): oral Vancomycin up to 500mg 6 hourly for 10-14 days plus Metronidazole IV 500mg 6 hourly for 10- 14 day
Oral route of vancomycin should be used whenever

possible with C. diff infection but can give IV vancomycin in systemic infection with poor oral absorption.

Hospital acquired infection- MRSA

S. aureus is a common skin commensal, found on skin &

nose of 1/3 healthy people (colonisation)

MRSA is a variety of Staphylococcus which has

developed resistance to common antibiotics.

Causes infection, especially when opportunity for bacteria

to enter body e.g. wounds, invasive devices, procedures.

Range from minor ailments to bacteraemia, UTI,

pneumonia and septicaemia

Spreads via skin to skin contact and indirectly through

inanimate objects e.g. door handles

MRSA-Treatment
Treatment of patients colonised with MRSA is:
Chlorhexadine 4% washes OD for 5/7 Mupirocin nasal ointment 2% applied to

nostrils TDS for 5/7

If MRSA bacteraemia suspected, treatment needs

discussing with microbiology, but usually IV vancomycin or linezolid

Pyrexia of unknown origin

Connective tissue disease (22%): RA, PR, Stills disease, GCA, SLE, PAN, Kawasaki disease

Other: Drugs, PE, Stroke, Crohns or UC, Sarcoid/amyloid, factitious

PUO: fever >38.3 for > 3/52 of undetermined cause after routine investigations

Infection (23%): Abscess/empyema, rheumatic fever, odd bacteria, granulomas, parasites, fungi, HIV, TB, typhoid

Tumour (20%): Lymphoma, malignancy (GI, RCC)

Pyrexia of unknown origin

Do all usual preliminary investigations (lots of blood

cultures)
Re-take history and thorough examination Further investigations e.g. LP, CT chest/abdo, serology Consider starting treatment for TB, endocarditis/trial of

aspirin or steroids
Think outside the box!

Infectious diseases Slideshow

Measles
RNA paramyxovirus
Transmitted via respiratory droplets

Low fever, cough, coryza, conjunctivitis

Kopliks spot-grain of salt opposite lower molar

Isolate and supportive treatment

Slight increase in cases-people not having MMR vaccine

Can get post-infective encephalomyelitis and subacute

sclerosing panencephalitis (4-10 years after, slow neurological degeneration, in those who have it as toddlers)

Rubella
RNA virus
Vaccinated in MMR so uncomon

Transmitted via respiratory droplets or placenta

Coryzal illness, cervical lymphadenopathy,

maculopapular rash (begins on face, spreads to trunk), splenomegaly

Supportive treatment

Malaria
Caused by 4 different species of protozoa, most common

is Plasmodium falciparum
Transmitted by the bite of the female anopheline

mosquito. Sporozoites taken up by liver where they mature

When maturation complete, released into bloodstread

and infect RBC. Haemolyse and release cytokines which cause malaria symptoms
Rigors, sweats, general malaise, D&V, anaemia, jaundice
Treatment with Quinine

Conclusion
Whistle stop tour of some infectious diseases you might

have neglected
Hopefully didnt bore you to death Good Luck!

Thanks!!