Mega Treatment Part 2 - NO ENDOCARDITIS

Diverticulitis, Cholecystitis, Cholangitis, Hepatic Abscess

Right Upper

Diverticulitis and Splenic Abscess

Left Upper

Diverticulitis

Left Lower

Diverticulitis and Appendicitis

Right Lower

T/F I-Abdominal Abscesses are accessible via Antibiotics

NO

Patient presents with an abscess that has epigastric pain shifting to right lower. Patient is an adult with high perforation risk, cancer risk above forty.

You manage this with antibiotics AND?

Laparoscopic Appendectomy

Patient presents with Biliary Infections

CHOLANGITIS - bile duct infected

CHOLECYSTITIS- gall bladder infected

CHOLELITHASIS- just a kidney stone that can lead to infection

Manifests as Right Upper Pain. Management?

ECRP, Laparoscopic Cholecystectomy, Percutaneous Cholecystostomy tubes

Patient presents with left lower abdominal pain and N/V.

Management is antibiotics and hat management?

Precutaneous Drainage, Colon resection if unsuccessful

Patient coems in with right upper pain, N.V, caused by gallstone migration, alcohol and drugs. What treatment?

Antibiotics ONLY in necrotizing noninfectious and Percutaneous drainage

Pathogens that cause IAI typically in community setting

E. coli, Enterococcus (from COPD, cancer, transplant, operations)

Pathogens that cause IAI in healthcare

MRSA. Enterococcus, ESBL, Candida

What makes a patient high risk in IAI?

70+, Cancer, bad organs disease, hypoalbuminema, resistant

Diagnosis needs

1. Assess symptoms and physical exam

2. Imaging for..?

3.

free air then diagnostic laparotomy

Source control for Primary Peritonitis which can be diagnostic or therapeutic

Paracentisis

Source control for IA abscess

Drainage catheter

Good source control + no bacteremia for IAI = duration of therapy is

4 days

Don't use this medication in IAI because of E. coli resistance.

Ampicillin/Sulbactam and FQ

Don't use this medication in IAI because of Bacteroides resistance.

Moxifloxacin

Don't use this medication in IAI because of Fragilis resistance.

Cefotetan and Clindamycin

Treatment for Single agent community IAI low risk

Cefoxitin, Ertapenem, Moxifloxacin

Treatment for multiple agent community IAI- low risk

Cef anything + Metronidazole

Treatment for Single agent community IAI- high risk

Zosyn, Meropenem, Imi-Cilastatin

Treatment for multiple agent community IAI- high risk

Cefepime + Metronidazole/ Aztreonam + metronidazole + Vanco

Treatment for Single agent healthcare IAI

Zosyn, Meropenem, Imi-Cilastatin

Treatment for multiple agent healthcare IAI

Cefepime/Ceftazidime+ Metronidazole OR Aztreonam + Metronidazole + Vanco

Treatment for agent healthcare IAI except patient had a liver transplant

Dapto and Linezolid

Treatment for healthcare IAI except patient possibly has MRSA, AMPC, ESBL from failed treatment.

MRSA: vanco, dapto, linezolid

ESBL/AMPC: Ertapenem.Meropenem/Imi-Cila

AMPC: Cefepime + Metronidazole

CRE: Ceftazidime/Avibactam + Tigecycline

Treatment for healthcare IAI when P. Aeruginosa is there

Ceftolozane-Tazobactam + Ceftazidime-Avibactam

Treatment for healthcare IAI when Baumanni is there

Ampicililn/Sulbactam + Sulbactam/Durlobactam

Treatment for healthcare IAI except patient had GI perforation

cover for C. Albicans

echinocandins (micafungin) or fluconazole for less critically ill pts

Empiric Treatment for Catheter Infection (CAI) gram positive which should ALWAYS BE COVERED.

Vancomycin over Daptomycin

Empiric treatment for Gram -negative only super sick for Pseudomonas.

Cefepime, Meropenem, Zosyn

Empiric treatment for Fungal infection only if TPN, femoral catheter, stem cell, GI surgery

Echinofungin

Patient has bacteremia despite 72+, tunnel infection, pocket infetion, S. Aureus, any resistance, Fungi, cuti, Myco. What do I do w catheter?

remove

Most common way to get infection from catheter.

skin and hub via Staph, Strepto, Candida

Patient has uncomplicated short term catheter with S. Aureus. Treatment?

Remove and ABX 14 days

Patient has uncomplicated short term catheter with CoNS. Treatment?

Remove and treat 5-7 days OR keep and 10-14 days

Patient has uncomplicated short term catheter with Gram-, Candida, Enterococcus. Treatment?

Remove for 7-14 days

Patient has uncomplicated long term catheter with S. Aureus. Treatment?

remove and treat 4-6 weeks

Patient has uncomplicated long term catheter with ConS and Enterococcus. Treatment?

may retain cathether ABX + ALT for 10-14 days

remove when clinical status gets bad

Patient has uncomplicated long term catheter with Gram- Treatment?

Remove 7-14 days or Salvage

Patient has a tunnel infection/local abscess on catheter. Complicated infection. What to do?

remove and treat 7-10 days

Patient has a septic thrombosis, OM, endocarditis on catheter. Complicated infection. What to do?

remove and treat 4-6 weeks

Sepsis is typically caused by

Staph, Strept, Entero

Sepsis caused by gram negative particularly____ is very very bad.

pseudomonas

Late damage anti-inflammatory agents.

IL1, 4,10, 13, Type II IL-1, Epinephrine, TGF B, TNF A, Leukotriene B4, lipopolysaccharide binding protein

What's SIC?

SIC: sepsis induced coagulopathy scoring system determined by low platelet, INR high, SOFA high

List the cascade sepsis thing

Infection and Trauma

Intermediate to cytokine activation

Mediators

Complement activation + immune system dysregulation _ complement activation

SIRs

Sepsis

Severe Sepsis

Septic Shock

Despite resuscitation, need vasopressors

MODS

Death

Definition of Sepsis

qSOFA above 2 or change in 2 of total SOFA + Infection

Despite adequate resuscitation,

Need Vasopressors for MAP > ___ or Lactate is above ___

65, 2

Prompt Diagnosis for Sepsis how?

Prehospital screening

Code Sepsis

Use microbiologic cultures w 2 blood culture sets for anaerobic and aerobic

Use pathogen specific rapid diagnostic or candida markers

Bundle of Care for 1 hour first two steps

Measure Lactate >2 and get blood cultures

Bundle of care for 1 hour 3rd and 4th steps

give 30 ml/kg crystalloid OR lactate > 4mmol

apply vasopressors if hypotensive to maintain MAP above 65

In general just give antibiotics within one hour, 3 hours if shock is absent and sepsis is ____

possible

Treatment for Sepsis

IS MRSA typical?

only in high risk

Don't treat inflammatory noninfectious sepsis. In general, just give (drug class) and don't give combination unless serious bacteremia/sepsis without shock or neutropenic sepsis.

B-lactams

Duration of treatment for Sepsis

7-14 days depending on extremities

Treating Sepsis from Community Acquired UTI

Ceftriaxone, Cipro, Levo OR B-lactam/Inhibitor and AG

Treating Sepsis from Healthcare UTI

Ceftazidime ± AG OR cipro or B-L/BLI/AG

Treating Sepsis from Respiratory Community Acquired

Ceftriaxone + Azithromycin OR levofloxacin or moxifloxacin

Treating Sepsis from Respiratory Hospital Acquired

Ceftazidime/Cefepime + AG OR Ciprofloxacin OR B-lactam/I + AG

Treating Sepsis from Intrabdominal infections from community

B-Lactam/B-Li + AG Or cipro OR metronidazole OR ertapenem

Treating Sepsis from IAI hospital acquired

B=Lactam/I + AGs OR Carbapenem OR cipro and metronidazole

Patient present with really bad sepsis. You already have the diagnosis. what do you do first?

Crystalloid LR or Plasmalyte -- follow up diuretics

Fluid resuscitation doesn't work for sepsis

Now what?

Vasoactive (NE first, then Vasopressin, then Epinephrine, Then Dobutamine if cardiac dysfunction)

Vasopressors don't work for sepsis. Now what?

try low dose IV corticosteroids hydrocortisone/fludrocortisone. 200 mg as a continuous infusion

Strat glucose therapy in sepsis if

glucose above 180 and possibly bicarbonate for metabolic acidosis <7.2

Should I do VTE prophylaxis for sepsis?

LMWH yes

Infection control for sepsis.

Which one do you use for intrabdominal abscess, thoracic empyema, septic arthritis

Drainage

Infection control for sepsis.

Which one do you use for necrosis?

Debridement

Infection control for sepsis.

Diverticulitis. What do you do?

Sigmoid Resection

Infection control for sepsis.

Gangrenous Cholecystitis, what do you do?

Cholecystectomy

Infection control for sepsis.

Clostridial myonecrosis, what do you do?

amputation

Abdominal pain, N/V/D, fever, 3-7 days.

Which viral gastroenteritis?

Rotavirus

Abdominal Cramps and myalgia, from environment, 2-3 days.

Which viral gastroenteritis?

Norovirus

Respiratory symptoms, fecal-oral, 7-9 days,

Which viral gastroenteritis?

Adenovirus

Patient presents with watery diarrhea and LEG CRAMPS. Which bacteria caused the diarrhea?

Vibrio Cholerae

Patient presents with bloody diarrhea from contaminated poultry and fever. Which bacteria caused the diarrhea?

Campylobacter

Patient has bloody diarrhea from animal contact. Risks: babies, 50+ w atherosclerosis, immunocompromised, prosthetic joints Which bacteria?

Nontyphoid salmonella

Patient has bloody + watery diarrhea 8-10 stools a day. Worst: seizures, rtoxic megacolon, perforated colon. Which bacteria?

Shigella

Which protozoan diarrhea?

Light colored fatty stools w bloating, abdominal cramps, belching, anorexia, malaise, flatulence, nausea

Chronic: Constipation, weight loss, lactose intolerance, vitamin deficiencies

Giardiasis

Which protozoan diarrhea?

Watery non bloody diarrhea w stomach pain, fever, JOINT PAIN, anorexia.

In immunocompromised: cholera-like watery diarrhea, malabsorption, respiratory or pancreatic dissemination

Cryptosporidiosis

Liver Amebiasis presentation

High fever, rigors, sweating, high WBC and ALT

Complication of C. Jejuni Diarrhea

Guillan Barre Syndrome

Patient presents with Slightly sunken eyes and decreased tears <2 seconds: moderate. Treatment?

ORS 50-100 mL/kg over 3-4 hours

Patient presents with Sunken orbits + lethargic- severe dehydration. Treatment?

LR/NS 20 ml/Kg until mental status improves then D5 ½ IV or ORS over 4 hours

Patient is actively diarrheaing and is under 10 kg. You want to replace their fluids, what is the treatment?

60-120 ml ORS

Patient is severely dehydrated and currently going through acidosis because of nonstop diarrhea. Treatment?

ORS via tube or D5 ½ w 20 mEq IV. Correct acidosis with LR

Treatment for ETEC or anything besides EHEC.

Ciprofloxacin 750 PO

Treatment for Vibrio Cholerae Diarrhea

Doxycycline 300 PO

Treatment for Campylobacter

Azithromycin 500 every day 3 days

Treatment for Salmonella

Ceftriaxone 2g, Ciprofloxacin 750 PO for 7-10 days

Treatment for Shigella

Azithromycin 500 mg PO every 24, Ceftriaxone 2g x 5, Cipro 750 q24 PO

Treatment for Yersinia

Bactrim x 7 days

Traveler's preferred Diarrhea treatment for severe

Azithromycin 1000 PO or 500 x 3 days

Traveler's diarrhea treatment (other than azithromycin)

Ciprofloxacin 750 or Leofloxacin 500 or Rifaximin 200 mg

Vaccines for Traveler's diarrhea

Rotavirus infants and Cholerae Typhoid

Patient presents with E. Coli, Shigella, Salmonnella. 6-72 hours incubation → bloody diarrhea, vomiting, cramping, loose stools

Protozoal: gradual onset w low grade symptoms 2-5 stools a day.

Patient has dysentery, what does he have and what treatment?

Traveler's Diarrhea and treat with Azithro 1000

Medications most likely to cause C. Diff Diarrhea

Clindamycin, 3GC/4GC, FQ, Carbapenem - High

Patient presents with 3+ watery stool, colitis, ileus, megacolon, High WBC and dehydration markers. What he have?

C. Diff diarrhea