Acute Meningitis Reşat ÖZARAS, MD , Prof. Infection Dept. rozaras@yahoo
Emergencies in Infection Reşat ÖZARAS, MD, Prof. [email protected].
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Transcript of Emergencies in Infection Reşat ÖZARAS, MD, Prof. [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
3T1L
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
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
3T1L
