504 Clin Med VII - Syndromes

What is sepsis?

What is septic shock?

How does treatment differ?

Sepsis: Life threatening organ dysfunction caused by dysregulated host response to infection.

Shock: Sepsis with metabolic/circulatory abnormalities.

Treated similarly but shock requires vasopressors.

Sepsis/Septic Shock: Etiology (3)

1) Pneumonia (MCC)

2) Intra-abdominal

3) GU infections

Sepsis/Septic Shock: Etiology

Gram Positive (2)

Gram Negative (3)

Positive: S. aureus and S. pneumoniae (nasopharynx)

Negative: E. coli, Klebsiella, Pseudomonas aeruginosa (GU/GI)

Sepsis/Septic Shock: Risk Factors (2)

1) Chronic Disease (HIV/COPD/Cancer)

2) Immunosuppression

What are the 3 defining characteristics of septic shock?

1) Sepsis

2) Need for vasopressors to keep MAP >65

3) Lactate >2 even with fluids

3 factors for progressing from infection to organ dysfunction?

1) Load/virulence of infection

2) Comorbidities

3) Genetics (ability to respond)

Pro-inflammatory reactions in sepsis cause what? What about anti-inflammatory reactions?

Pro-Inflammatory: Tissue damage

Anti-Inflammatory: Susceptibility to 2nd infection

Sepsis/Septic Shock: Clinical Presentation

Cardiovascular

Respiratory

BP: Hypotension (High SVR)

O2: Hypoxemia

Sepsis/Septic Shock: Clinical Presentation (SVR/CO)

Early Shock

Post-Volume

Early Shock: High SVR, low CO

Post-Volume: Low SVR, high CO

How does a patient in septic shock respond to volume resuscitation?

Remain hypotensive.

Sepsis/Septic Shock: Clinical Presentation

Renal

CNS

Renal: Oliguria, azotemia (high BUN)

CNS: Delirium (due to inflammation)

What might be a necessary treatment due to chronic renal issues in septic shock?

Hemodialysis.

What two studies will you want to order if you see delirium or CNS issues in septic shock? What do you expect if CNS issues are due to sepsis?

CT: No focal lesions

EEG: No encephalopathy

Sepsis/Septic Shock: Dx

CBC (WBC/Platelets)

Lactate

Bilirubin

BUN/Cr

CBC: Thrombocytopenia, leukocytosis/penia with left shift

Lactate: Elevated >2.0

Bilirubin: Elevated

BUN/Cr: Elevated

Sepsis/Septic Shock: Dx

CXR (ARDS)

Dense infiltrates (non-cardiac origin)

What do you want to order within the 1st hour of sepsis diagnosis to help guide your treatment?

Blood cultures -> gram stain.

What is the SOFA score? What does it tell you?

What does a score of greater than 2 mean?

SOFA: Sequential Organ Failure Assessment (ICU)

- Tells us if/when organ function is impaired

- 10% death increase

What is the qSOFA score? What does it tell us? How does the point system work? What does a score above 2 mean?

qSOFA:

- Tells us risk of sepsis outside the ICU

- 10% death increase

What are the 3 qSOFA criteria?

RR > 22

sBP < 100mmHg

Altered mental status

Sepsis/Septic Shock: Tx

Fluids

Fluids:

- Volume resuscitation

- IV crystalloid (30mL/kg/3hr)

What is the goal MAP with fluid treatment? What is the main goal of using fluids aside from gaining pressure?

MAP > 65

Goal = normalize lactate.

Sepsis/Septic Shock: Tx

Antibiotics

Empiric Antibiotics (broad):

- Start within 1hr before culture results

- Pip/Taz, cefepime, meropenem, imipenem/cil

When would you want to throw in MRSA to the empiric treatment?

Hx of MRSA or possible abscess.

Sepsis/Septic Shock: Tx

Vasopressors

NE -> increase BP.

Avoid dopamine.

What will you do to the patient in order to administer pressors?

Central and arterial line.

Why would you want to add in a steroid such as hydrocortisone? Why can it be bad?

Reduce systemic inflammation, but must consider that it can worsen bacterial infections.

Sepsis/Septic Shock: Prognosis

Mortality Rate

Complications

MR: 20%

Complications: Lasting neuro symptoms, low quality of life

Sepsis/Septic Shock: Prevention (3)

1) Avoid unnecessary abx

2) Limit indwelling catheters

3) Adhere to infection control protocols

Fever of Unknown Origin: Etiology (3)

1) Cancer

2) Infection

3) Autoimmune - SLE

Fever of Unknown Origin: Diagnostic Requirements

Illness Length

Temperature

Immune Status

Diagnosis Progress

Illness Length: >3 weeks

Temperature: >100.9 (2x)

Immune Status: Immunocompetent

Diagnosis Progress: 3x visits/days w/ no confirmed diagnosis

How would you define neutropenic fever of unknown origin?

ANC<500 (including all other criteria).

Fever of Unknown Origin: Diagnostic Criteria

Prolonged Fever

Episodic Fever

Prolonged: >6 months (granulomatous disease)

Episodic: Meet criteria, can go 2 weeks without fever

Fever of Unknown Origin: Clinical Findings

Behavior

Vitals

History

- Observe patient temp. taking

- Tachy, chills

- Social, travel, diet

What do you want to order for ALL patients with FUO? What are some other diagnostics worth ordering (3)?

- CXR all patients

- Cultures of sputum, blood, urine, CSF, stool

- Blood smears

- Imaging: CT, MRI

-> Keep looking until you find cause!

Fever of Unknown Origin: Tx

No empiric antibiotics/steroids until culture results come back.

What would you do if a patient with FUO was immunocompromised, exhibits signs of rapid decline, or has constitutional symptoms?

Admit.

Infectious Diarrhea: Etiology

Culprits (4)

1) Norovirus

2) C. diff

3) E. coli

4) Shigella (bloody)

Infectious Diarrhea: Length

Acute

Chronic

Acute: <14 days

Chronic: >14 days

Infectious Diarrhea: Quantity

Mild

Moderate

Severe

Mild: 3 or less daily

Moderate: 4 or more daily with local abdominal symptoms

Severe: 4 or more daily with systemic symptoms

Infectious Diarrhea: Clinical Presentation (Freq, Vol, blood)

Inflammatory

Non-Inflammatory

Inflammatory:

Frequent, bloody, low volume stool with urgency, fever

Non-Inflammatory:

Less frequent, watery, very high volume

How will infectious diarrhea look if a preformed toxin is consumed versus a toxin produced after ingestion?

Pre-Formed: 1-6 hr, no fever, vomiting, toxin detected in food

Post-Ingestion: 8-16 hr, cramping, less vomiting, toxin in stool

Infectious Diarrhea: Dx

Culture

Stool -> fecal leukocytes. Perform if symptoms lasting 3-4 days.

Infectious Diarrhea: Tx

Non-Pharmacological

Often self-limiting.

IV fluids and electrolytes.

Infectious Diarrhea: Tx

Pharmacological

If severe illness/dehydration or immunocompromised.

Fluoroquinolone or Azithromycin.

What do you want to avoid regarding infectious diarrhea treatment?

Loperamide (anti-motility).

Osteomyelitis: Etiology

MCC

S. aureus

Osteomyelitis: Pathogenesis (3)

Long Bones or Vertebrae:

1) Direct inoculation (fracture, surgery)

2) Invasion

3) Skin breakdown

Osteomyelitis: Complication + Presentation

Epidural abscess on vertebrae.

Radicular (radiating) back pain + fever.

Osteomyelitis: Clinical Presentation (3)

Local tenderness

Constitutional sxs

Back pain

Osteomyelitis: Dx

Cultures (2)

ESR/CRP

Culture: Blood -> if negative -> BM bx and culture

ESR/CRP: Elevated (follow course of tx)

Osteomyelitis: Dx

XR

CT

MRI

XR: Early findings normal, later see demineralization

CT: Localize abscess

MRI: Most specific

What is the best diagnostic tool because it is the most sensitive for osteomyelitis?

Bone scan w/ gallium.

Osteomyelitis: Tx

Pharmacological (2)

Duration

Cefazolin/Naficillin (MSSA) or Vanco (MRSA)

- 4 to 6 weeks

- IV preferred

What is required for osteomyelitis with extensive disease, epidural abscess or recurrent infection?

Surgical consult.

UTI: Etiology

MCC (Uncomplicated)

E. coli

UTI: Definitions

Unresolved

Persistent

Reinfection

Unresolved: never sterilized (non compliance, bacteria resistance, mixed infection and only treated one)

Persistent: initially sterilized but comes back

Reinfection: new infection, new pathogen

UTI: Pathogenesis

Ascending route up the urinary tract MCC.

Why are women more likely to get a UTI? In what situation would a male be likely to get one?

Female: Sex, short urethra, normal flora

Male: Uncircumcised

Acute Cystitis: Epidemiology and Etiology

Usually bacterial (UTI). Can also be viral or other pathogenesis.

Rare in adults.

Rare in men -> investigate pathology (renal stone, prostatitis, chronic urinary retention).

UTI: Clinical Presentation

- Urinary frequency/urgency

- Suprapubic pain

- Hematuria possible

- CVA tenderness

What do you want to rule out when working up a UTI?

PID, vulvovaginitis, urethritis, prostatitis.

UTI: Dx

Urine (2)

UA: Nitrites

Clean Catch Urine Culture: >100k

What imaging is indicated for men if presenting with UTI/acute cystitis?

US of abdomen.

CT if recurrent.

UTI: Tx

Female

Male

Adjuvant

Female: Fosfomycin, nitrofuratonin, tri/sulf

Male: Find underlying etiology

Adjuvant: Phenazopyridine (urinary analgiesic)

UTI: Complications

Pyelonephritis (WBC casts in urine).

Prostatitis in men.

UTI: Prevention (3)

Hydration - frequently empty bladder.

Prophylactic abx for post-menopausal women.

Minimize indwelling catheter use.

Endocarditis: Etiology

MCC

S. aureus

Endocarditis: Essentials of Diagnosis (5)

Fever

Pre-existing organic heart lesion

Positive blood cultures

Vegetation on echo.

Systemic emboli

Endocarditis: Risk Factors (2)

1) Valvular Disease

2) Congenital Defects

What bacteria commonly causes native valve, early prosthetic valve, or IVDU endocarditis? What about late prosthetic valve endocarditis?

S. aureus.

Strep.

Endocarditis: Clinical Presentation

Nails

Heart Sounds

Nails: Splinter hemorrhages

Heart: Changing regurgitant murmur (caused by valve/cardiac damage)

Endocarditis: Clinical Presentation

Eyes

Roth spots

Endocarditis: Clinical Presentation

Peripheral Lesions (3)

1) Osler Nodes (painful, on fingers/toes)

2) Janeway Lesions (painless, on soles/palms)

3) Petechiae-palate

Endocarditis: Dx

CXR

EKG

CXR: Pulmonary infiltrates

EKG: Conduction abnormalities

What are the two echocardiography studies for diagnosing endocarditis?

TTE - transthoracic (less sensitive)

TEE - transesophageal (more sensitive)

What is the Duke criteria used for diagnosing bacterial endocarditis?

2 major criteria

OR

1 major + 3 minor criteria

OR

5 minor criteria

Endocarditis: Dx

Cultures

Blood Culture: 3 sets

Does a negative blood culture rule out endocarditis?

No - transient bacteremia.

Endocarditis: Tx

Pharmacological

Empiric treatment for Staph, Strep, Enterococci:

Ceftriaxone + Vancomycin (2-4 weeks)

-> move to narrow regimen based on cultures.

How long do you treat prosthetic valve endocarditis?

6 weeks.

If someone has a prosthetic valve and is going for a dental or respiratory procedure, what should you do?

Antibiotic prophylaxis pre-procedural (Amoxicillin).

Meningitis: Etiology

Bacterial (4)

Can spread to CNS hematogenously from other infection sites. Massive inflammatory response to pathogen.

Bacterial:

S. pneumoniae (MCC)

N. meningitidis

GBS

Listeria

Meningitis: Clinical Presentation

- Headache

- Sensory disturbance

- Head/neck stiffness

- Fever

Meningitis: Clinical Presentation

Special Tests

Brudzinski's and Kernig's positive

Meningitis: Clinical Presentation

Elevated Intracranial Pressure (5)

Altered level of consciousness

Papilledema

Dilated, non-reactive pupils

Decerebrate posturing

Cushing reflex

Meningitis: Dx

Cultures

Imaging

Culture: Blood and CSF

Imaging: CT, MRI

What does CSF show in bacterial meningitis?

WBC elevated

Glucose low

Protein elevated

Bacterial Meningitis: Tx

Pharmacological (2)

Abx (Empiric - ampicillin + 3rd gen cephalosporin)

Dexamethosone

Neisseria meningitis:

Presentation

Tx

Prophylaxis

Presentation: Petechial rash, myalgia

Tx: Pen G or Vanco + ceftriaxone

Prophylaxis: Rifampin

Pneumococcal meningitis:

Presentation

Treatment

Presentation: Associated with sinus infection, head trauma, pneumonia; no rash

Treatment: Ceftriaxone + Vanco

When would you need to do a CT scan prior to a lumbar puncture? Why?

Abnormal neuro exam. Want to ensure no ICP before LP, can cause herniation.

Viral Meningitis: Etiology (2)

Herpes simplex

Enterovirus

What is the most important diagnostic for viral meningitis?

CSF PCR.

How will glucose and protein look in CSF of viral meningitis?

Normal.

How do you treat viral meningitis?

Acyclovir. Usually self-limited process.

Most likely also empiric antibiotic treatment because you cannot initially tell which it is. Taper as labs come back.

Encephalitis: Etiology

Inflammation of brain tissue (not meninges).

EBV, HIV, CMV, HSV.

Encephalitis: Clinical Presentation

Hallucinations, agitation, psychosis, seizures.

Encephalitis: Dx (3)

CSF -> PCR

CT/MRI/EEG

Brain bx

Encephalitis: Tx (2)

Acyclovir and anti-convulsants for seizures.

URI: Etiology

Viral. Easily transmitted.