Big Bad Infections

Question 1

what are the general variables of SIRS?

Answer 1

temp > 100.9 or <96.8

HR > 90 or more than 2 SD above the normal value for age

tachypnea (RR > 20)

altered mental status

significant edema or positive fluid balance

hyperglycemia

Question 2

what are the inflammatory variables of SIRS?

Answer 2

leukocytosis or leukopenia

normal WBC with > 10% immature forms

plasma C-reactive protein more than 2 SD above normal value

plasma procalcitonin more than 2 SD above normal value

Question 3

sepsis = ____ + _____

Answer 3

sepsis = SIRS + infection (or possible infection)

Question 4

what is severe sepsis?

Answer 4

two or more SIRS criteria + infection AND

end organ damage

Question 5

in severe sepsis, end organ damage is defined by one of the following…

Answer 5

hypotension

renal failure

shock liver

coagulopathy

repiratory failure

elevated lactice acid > 2

Question 6

what is septic shock?

what is the lactate level?

Answer 6

severe hypoperfusion persisten in first hour AFTER aggressive fluid resuscitation

lactate level > 4

Question 7

what are the major Duke criteria for endocarditis?

Answer 7

positive blood cultures x2 w/ common offenders identified & no clear primary focuse

persistently + blood cultures after or during tx

TTE evidence of vegetation or good auscultaito of NEW valvular regurg

other imaging stating question of intracardiac abnormality

Question 8

what are the minor Duke criteria for endocarditis?

Answer 8

presence of valular heart disease

IV drug use

fever

unexplained vascular phenomenon (conjunctival hemorrhage, cutaneous petechiae, evidence of major or minor arterial emboli, intracranial hemorrhage)

Question 9

what should we do with any positive Duke criteria?

Answer 9

get an ID consult

Question 10

what is hematogenous osteomyelitis?

Answer 10

bacteremia leads to seeding of bacteria within bone

monomicrobial

blood & bone cultures should match

Question 11

what is continguous osteomyelitis?

Answer 11

bacteria seeds the bone from adjacent tissue

polymicrobial

blood cultures may or may not be positive

Question 12

what is DM associated continguous osteomyelitis?

Answer 12

presentation: slow insidious onset

frequently presents as skin disruptions that are very slow healing, non-healing or recurrent

Question 13

can DM associated contiguous osteomyelitis subacute or chronic?

Answer 13

subacute (days to weeks)

chronic (months to years)

Question 14

what should we think if we can “see bone and touch bone”

Answer 14

osteo

Question 15

what is the preferred imaging method for osteomyelitis?

Answer 15

MRI is prefffered

Question 16

what type of antibiotics should be started for osteomyelitis?

Answer 16

broad spectrum parenteral antibiotics

Question 17

what is the typical length of treatment for osteo?

what labs will be done weekly?

Answer 17

tx is 6 weeks

labs done weekly are CBC, CMP, CRP

Question 18

what is included in the CRB-65 scoring for pneumonia?

Answer 18

clinical symptoms of pneumonia plus

confusion (delirium) → 1 point

RR > 30 → 1 point

BP < 90 systolic or < 60 diastolic → 1 point

Question 19

how does the scoring of the CRB-65 influence how we manage pneumonia patients?

what is an automatic admission?

Answer 19

0-1 point → manage at home

> 1 point → inpatient management

hypoxia is an automatic admission

Question 20

almost all antibiotic use in pneumonia is ______

Answer 20

empiric

(very hard to get a good sputum culture)

Question 21

what are some adjunct treatments for pneumonia?

Answer 21

O2 if sats < 90%

nebulized inhalation treatment - albuterol or Duoneb

steroids? (not commonly used

Question 22

do we need to repeat imaging in patients with pneumonia?

Answer 22

not if clinical improvement has been observed

if we do need imaging, consider CT chest for empyema & lung abscess

Question 23

what are some factors associated with HCAP?

Answer 23

IV therapy, wound care, or chemo within prior 30 days

resident of a nursing home/long-term care facility

hospitalization for 2 or more days within the prior 90 days

pneumonia that occurs 48 hrs or more after admission

pneumonia that develops more than 48-72 hrs after intubation

Question 24

what is the length of treatment for HCAP?

Answer 24

7 days minimum

Question 25

in HCAP, when can we try to cange to PO equivalents?

Answer 25

only if excellent clinical response to IV therapy for 48-72 hours

Question 26

what is the triple antibiotic therapy for HCAP with MDR risk?

Answer 26

Zosyn

Flouroquinolone

Vanco

Question 27

what is aspiration pneumonia?

Answer 27

an inoculum deleterious to the lwoer airways by a direct toxic effect, stimulation of an inflammatory process form bacterial infection, or obstruction due to uncleared fluid or particulate matter

Question 28

with possible aspiration pneumonia, we must keep patients strict NPO until ______

Answer 28

until speech therapy can evaluate and recommend safe swallowing strategies

Question 29

what IV antibiotic should be used if hospitalization is needed for aspiration pneumonia?

what if oral therapy is preferred?

Answer 29

IV - clindamycin

PO- augmentin

Question 30

what are 3 take home points for pneumonia?

Answer 30

1. identify the type of pneumonia
2. appropriate empiric antibiotic
3. strict NPO until speech therapy can evaluated