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If you want three opinions, then ask two infectious disease doctors. ---KBA
Microorganisms
Antibiotic
Its 1am and the nurse on Lakeside 65 just called you because Mrs. Price has a T of 101.5 . . . What do you do?
Textbook
Elevation in the bodys thermoregulatory set point. T >101 (38.3) at any time T >100.4 (38.0) for greater than one hour
IDSA guidelines
Fever
As always, this is the #1 priority when you are called about a patient. Go see the patient. Why are they admitted? Have they been febrile? What do they look like? Are there any signs or symptoms consistent with infectious or non-infectious causes of fever? When in doubt---GO SEE THE PATIENT!
Medications
Transfusion reaction Neuroleptic malignant syndrome Serotonin Syndrome Connective tissue disease Malignancy Hyperthyroidism Hematoma
Fever
2) Write Orders
Blood cultures Urinalysis, urine cultures CXR Other tests based on your history and exam
Sepsis
Fever or hypothermia T >38 or <36 Tachycardia HR >90 Tachypnea RR >20, or PaCO2 <32 WBC >12,000, <4000 or Bands >10%
Types of sepsis
Severe sepsis
Sepsis associated with organ dysfunction Sepsis with hypotension despite adequate fluid resuscitation
Septic shock
Treatment
Antibiotics
73 yo male h/o HF, CKD, CAD who presents with fevers, productive cough x2 days. On exam, patient is febrile to 101. Breathing is mildly labored with RR 28, HR 106, pulse ox 92% RA. Has crackles at the right lower lung field. Labs: wbc 13.5, Hct 34, plt 175. Na 134, BUN 35. What do you think? What studies would you like?
Initial Investigation
CXR Sputum culture Blood culture Consider ABG if respiratory distress or hypoxia Consider legionella or pneumococcal antigen if history indicates. None of the above should delay antibiotic treatment! Antibiotics should be given within 4 hours of initial evaluation!
Risk Factors?
Age COPD/chronic lung disease Renal insufficiency Heart failure CAD DM Malignancy Chronic neurological disease Chronic liver disease
Fever (may be absent in the elderly or immunocompromised) Cough Sputum production Dyspnea Pleuritic chest pain GI Sx: nausea, vomiting, diarrhea Mental status changes Tachycardia Tachypnea Leukocytosis or leukopenia Infiltrate on CXR - remember that an infiltrate may not appear in a hypovolemic patient!
IV therapy, chemotherapy, or wound care in the last 30 days. Resident of a nursing home/long term care facility Hospitalized >2 days in the last 90 days Attended HD in the last 30 days. Occurs >48 hours after admissions Not present on admission Occurs >48 hours after intubation
Typical
Atypical
CAP: treatment
Respiratory fluoroquinolone
Moxifloxacin
OR.
Beta-lactam + macrolide
Ceftriaxone + azithromycin
83 yo man with h/o CKD, COPD, Alzheimers who presents from his nursing home with mental status changes. T 102, HR 135, BP 86/40, RR 40 On exam, patient has right lower lobe rhonchi. What is the diagnosis? What are the potential bugs?
HCAP/HAP/VAP: Treatment
Hint: go through past microcan help you identify any MDRO immediately! Broad spectrum Abx:
Anti-pseudomonal cephalosporin or beta lactam/beta lactamase inhibitor cefepime or zosyn + Vancomycin +/Aminoglycoside
44 yo female with h/o HTN complaining of 2 days of dysuria and subjective fever. On exam, temperature is 99.7, HR 68, BP 120/64. Abdominal exam notable for suprapubic tenderness. UA - +LE, +nitrates, 4+ bacteria, >100 wbc Any thoughts?
Leukocyte esterase - release from leukocytes Nitrite - produced when bacteria convert nitrates to nitrites WBC - pyuria is defined as
Uncomplicated
Usually a female without recurrent infections Bugs: E coli (85%), S. saprophyticus Rx: Bactrim, cipro, nitrofurantoin Can treat for 3 days
Complicated
Forgein bodies: Catheter, calculi, tumors Anatomic problem: residual urine, neurogenic bladder, BPH Male Pregnant Recurrent infection Diabetes Bugs: Enterococci, Klebsiella, Proteus Did this bug come from the community or is it hospital associated? Rx: zosyn, cipro Treat for 7 days, followup culture
So what about
82 yo man with COPD, CAD, h/o CVA, chronic foley that your cointern admitted for falls. UA is positive and urine culture is growing Gram negative bacilli. What do you do?
60 yo man with pancreatic cancer who received chemotherapy through his MediPort 8 days ago is being admitted with fever. T 101.8, HR 94, RR 18, BP 101/64. Exam unremarkable. WBC 0.8 with 50% neutrophils What do you think?
Neutropenic Fever
Neutropenia
Absolute neutrophil count <500 Nadir typically reached at day 7-10 single temperature of >38.3C (101F), or a sustained temperature >38C (100.4F) for more than one hour
Neutropenic Fever
Initial Workup
2 sets of blood cultures one off the line, one peripheral Urine cultures Sputum cultures CXR
Push the dose: zosyn 4.5 grams 6h, vanco 1gram q12, goal trough 15-20 Consider adding an aminoglycoside. Remember: these people do not have an immune system!!!
Do you suspect viral infection (HSV?, VZV?)? Do you suspect fungal infection (thrush)?
The micro lab calls you and tells you that a patient on Carpenter has a blood culture growing gram positive cocci in clusters What do you do?
Go see the patient! Read the chart! Consider giving dose of vancomycin and redrawing blood cultures. Drop a short note describing your medical decision making in the chart and discuss with the primary team in the morning.
While pre-rounding.
Your patient that you are treating for HCAP tells you that they had 5 watery bowel movements last night. What do you think?
Clostridium difficile
Most common infectious cause of healthcare associated diarrhea in the United States. 3.4 8.4 cases per 1000 admissions
Diagnosis
Antibiotics
Age Proton Pump Inhibitor GI surgery LOS >7 days Feeding via NG tube Admission to ICU
Treatment C. Difficile
Stop the offending antibiotic! Oral metronidazole 500mg q8 Oral vancomycin 125mg q6 Contact precautions! Avoid anti-motility agents.
Helpful Hints/Suggestions
AKA things that make your life easier
Page 5 suggested empiric antibiotics based on organ system Page 179 renal dosing
Vancomycin
When you write the order for vancomycin, order a trough before the 4th dose. Just do it