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year 4 CDM 2 > Case 12: osteomyelitis, septic arthritis, pneumonia > Flashcards

Case 12: osteomyelitis, septic arthritis, pneumonia Flashcards

1
Q

Assessing diabetic ulcers

A

‘Probe to bone test’ a sterile metal instrument is used to probe the ulcer, with the detection of a hard and gritty surface suggesting osteomyelitis. This may guide the need for further investigation such as imaging or biopsy.

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2
Q

Osteomyelitis- investigations

A
  • Blood tests: raised WCC, CRP and PV (Plasma viscosity), Blood cultures positive in half of cases
  • X-ray: soft tissue swelling, osteopaenia, bone destruction, periosteal reaction, endosteal scalloping and new bone apposition. Often normal for the first two weeks of infection.
  • MRI: first line, initially bone marrow oedema
  • High resolution CT
  • Bone biopsy: to identify causative organism, not done if radiological evidence (gold standard)
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3
Q

Osteomyelitis antibiotics

A
  • Flucloxacillin (clindamycin if penicillin allergic), possibly with fusidic acid or rifampicin for the first two weeks
  • If MRSA: vancomycin or teicoplanin
  • If the affected bone is completely removed a short duration of antibiotics may be sufficient
  • Otherwise at least 6 weeks of treatment, usually parental via PICC is needed
  • Chronic osteomyelitis may require 3 months of antibiotics
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4
Q

Osteomyelitis surgery

A
  • Any infected necrotic bone should be removed
  • Urgent surgical debridement: necrotising soft tissue infection, secondary systemic infection from osteomyelitis. Drain pus and remove sequestra (dead bone)
  • Post surgery: soft tissue envelope can help healing
  • Orthopaedic hardware: seek secondary opinion
  • Prosthetic joins may need revision surgery
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5
Q

Septic arthritis: clinical features

A
  • Red, hot, swollen joint.
  • Painful and reduced range of movement- in both active and passive movement
  • Will cause Tachycardia and a fever.
  • Usually single join affected
  • Can have intraarticular effusion
  • Knee most common
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6
Q

How elderly patients present with septic arthritis

A
  • Elderly patients tend to present as afebrile and systemically well.
  • WCC may be normal in 50%.
  • More likely to present with non-specific symptoms such as worsening cognitive impairment, confusion and more frequent falls.
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7
Q

Septic arthritis- medical emergency

A

Regard a hot, swollen, acutely painful joint with restriction of movement as septic arthritis until proven otherwise.

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8
Q

Risk factors for septic arthritis

A
  • RA and SLE
  • Diabetes
  • Immunosuppression
  • Kidney failure
  • Joint replacement
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9
Q

How may gonococcal arthritis present

A
  • May present as either:
  • Septic arthritis (typically milder than S aureus) OR
  • Arthritis dermatitis syndrome (triad of rash, tenosynovitis and migratory polyarthritis affecting upper limbs)typically follows mucosal infection
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10
Q

Septic arthritis: how pathogens are spread

A
  • Direct injury: injury to a joint with skin break or infected neighbouring bone (infection spreads into joint)
  • Haematogenous: infection in other organs and spreads to joint via blood stream. Examples: abscess and wounds, Septicaemia, Gonorrhoea

Bacterial toxins destroy cartilage and cause progressive joint destruction

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11
Q

Septic arthritis: pathogensand risk factors

A
  • Neisseria gonorrhoea: most common in young sexually active individuals
  • Staph aureus: most common cause in adults

Risk factors
- Prosthetic joints
- Invasive joint procedures i.e. steroid injections, arthroscopy
- IV drug use
- Immunosuppression, chronic skin cancer

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12
Q

Septic arthritis: risk factors

A
  • Established joint disease
  • Recent joint injection/sugery
  • Immunosuppression- diabetes, alcoholism
  • IVDU
  • Prosthetic joints
  • UTI, indwelling catheter, recent abdominal surgery
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13
Q

Diagnosing septic arthritis

A
  • Blood cultures (may be negative)
  • Synovial fluid analysis (joint aspirate)
  • Gram stain will show inflammatory effusion with neutrophil predominance plus or minus gram negative diplococci
  • Culture & sensitivity testing
  • NAAT PCR (if available and validated for synovial fluids)
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14
Q

Septic arthritis: Investigations

A
  • Bedside: Obs, urine dip, ECG, CXR (for haematogenous spread infection)
  • Bloods: FBC, U&E, LFT, CRP, Lactate, Coag, culture, ESR
  • Imaging: X-ray is not diagnostic is useful to see baseline joint condition. May see increased synovial fluid or bone destruction
  • Joint arthrocentesis/aspiration: for synovial fluid analysis, gram staining and culture prior to antibiotics
  • WCC >100,000 suggests diagnosis is highly likely
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15
Q

Septic arthritis: management

A
  • IV ABX: for 4-6 weeks (initially IV for 2 weeks)
  • Analgesia
  • May require joint washout with surgeons
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16
Q

Septic arthritis: Arthrocentesis

A
  • Contraindications: overlying skin infection, anti-coagulation, low platelets
  • Aspirate to dryness
  • Look at colour, viscosity and clarity of the joint aspirate
  • Send for: gram stain, WCC, microscopy, culture, polarising microscopy (for crystals)
  • Negative synovial culture does not exclude septic arthritis
  • Once done give IV antibiotics, immobilise the joint and analgesia
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17
Q

Aspirate in septic arthritis

A

The aspirate will look thick, yellow and turbid. It will return as ‘positively birefringent rhomboid shaped crystals under polarised light microscopy.’

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18
Q

The Kocher criteria for the diagnosis of septic arthritis

A
  • fever>38.5 degrees C
  • non-weight bearing
  • raised ESR
  • raised WCC
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19
Q

Management of septic arthritis

A
  • Septic six protocol
  • Admit to hospital for IV antibiotics and joint drainage
  • Infection in aprosthetic jointwarrants urgent referral to orthopaedics, and should be managed in theatre: This includes surgical arthrocentesis and washout.
  • Infection in a native joint can be treated with joint aspiration and empirical antibiotic management
  • Prosthetic joint surgery: DAIR procedure (Debridement, Antibiotics and Implant Retention)
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20
Q

Antibiotics in septic arthritis

A
  • Flucloxacillin 2g QD
  • gonococcal arthritis: ceftriaxone or Cefotaxime
  • Antibiotics are typically continued IV for 2 weeks, before switching to PO if the patient is improving.
  • Joint aspirate before starting antibiotics
  • Start antibiotics oncecultures are taken
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21
Q

Septic arthritis complications: complications

A
  • Joint damage
  • Osteomyelitis: if suspected MRI
  • Sepsis
22
Q

Chronic periprosthetic joint infection

A
  • Delayed months - years
  • Biofilm maturity: mature
  • Clinical features: chronic pain, loosening of the prosthesis, sinus tract (fistula)
  • Organism: Coagulase negative staph
  • Treatment: complex removal of prosthesis. Exchange in 1, 2 or 3 stage
23
Q

Types of URTI

A
  • Rhinitis/ Rhino-sinusitis: runny nose, congestion, tender sinuses
  • Pharyngitis/ tonsillitis: sore throat, tonsillar discharge..
  • Epiglottitis: stridor, drooling, loss of voice
  • Laryngitis/ laryngotracheitis: hoarse voice, cough
  • Otitis media (AOM) and Otitis externa (OE)
24
Q

EBV- glandular fever

A
  • Triad of: sore throat, pyrexia and lymphadenopathy
  • Can also get Splenomegaly, Hepatitis, Haemolytic anaemia and jaundice
  • Can get a Maculopapular rash with Amoxicillin
  • Diagnosed with monospot test
25
Q

Causes of URTI

A
  • Viruses: Rhinovirus, Coronavirus, Influenza, RSV, adenovirus, EBV
  • Bacteria: Group A streptocous (Tonsilitis), S.pneumonia, HIB
  • Other: Candida, Toxoplasma
  • Vaccinated againsy: HIB, Corynebacterium diphtheriae, Bordatella pertusis
  • Upper respiratory tract ends at the Larynx
  • Ranges from common cold to Epiglottitis
26
Q

Modified Centor score: for tonsilitis

A
  • Tender/swollen anterior cervical nodes (+1)
  • Cough absent (+1)
  • Exudate or tonsil swelling (+1)
  • Temperature >38 (+1)
  • Prescribe antibiotics if score >3 (Phenoxymethylpenicillin- erythromycin if penicillin allergic)
27
Q

Tonsilitis

A
  • Complication: Peri-tonsilar abscess (have to drain)
  • Acute onset of sore throat, fever, dysphagia
28
Q

Diptheria

A
  • Children receive vaccine in first year of life
  • Associated with travel or immigrants
  • Grey plaque in the mouth
  • Fever, sore throat, swollen neck
  • Bulls neck appearance or skin lesions
  • Management: antibiotics, anti-toxin, notifiable disease
29
Q

Epiglottitis

A
  • Particularly affects children
  • Caused by Haemophilia Influenza B (HIB)
  • Fever, sore throat, drooling , stridor
  • Do not agitate the patient (bloods, oral cavity examination, keep child with their carer if you can)
  • Airway support vital- ENT/anaesthetics
  • Antibiotics
30
Q

Bronchitis

A
  • Common
  • Characterised by bronchial inflammation with viral infection
  • Presents with cough, sputum, and evidence of upper airway infection
  • Absence of abnormalities on CXR distinguishes acute bronchitis from pneumonia
  • Usually caused by viral infection, usually not dangerous, generally gets better without antibiotics, seldom needs admission to hospital
  • Resolves within 3 weeks
31
Q

Pneumonia history

A

Pleuritic chest pain, productive cough, fever, SOB, Possible confusion

32
Q

Pneumonia risk factors

A
  • Aged under 5 or over 65-years-old
  • Smoking cigarettes
  • Recent viral respiratory tract infection
  • Chronic respiratory diseases:e.g. cystic fibrosis and COPD
  • Immunosuppression:e.g. cytotoxic drug therapy and HIV
  • Patients at risk of aspiration:e.g. those with neurological diseases such as Parkinson’s disease or those with oesophageal obstruction
  • IV drug users
  • Other non-respiratory co-morbidities:e.g. diabetes and cardiovascular disease
33
Q

Pneumonia examination

A
  • Tachypnoea, tachycardia, hypoxia
  • Fever, confusion
  • Decreased chest expansion on affected side
  • Dullness to percuss on affected side
  • Bronchial breath sounds on affected side
  • Crackles on affected side
  • Increased vocal resonance on affected side
34
Q

Pneumonia symptoms

A
  • Pleuritic pain (unilateral)
  • Dry cough, then purulent
  • Shallow rapid breathing
  • Possible confusion
  • Loss of appetite, low energy and fatigue
  • Probable preceding viral infection
  • Rapidly more ill, temp up to 39.5 degrees
35
Q

Causes of viral and community pneumonia

A

Causes of community acquired pneumoniae: S.pneumoniae, H.influenzae (COPD)

Viral pneumonia: Influenza virus (most common viral), RSV (common in infants and elderly)

36
Q

Causes of hospital acquired pneumonia

A

E.coli, S.aureus, Klebsiella pneumoniae (alcoholics and impaired swallow), Pseudomonas aeruginosa (cystic fibrosis or immunocompromised)

37
Q

Community vs Hospital acquired pneumonia

A
  • hospital-acquired pneumonia (HAP): pneumonia that occurs ≥ 48 hours after admission
  • ventilator-associated pneumonia (VAP): pneumonia that develops ≥48 hours after endotracheal intubation
38
Q

Atypical pneumonias

A
  • symptoms may be subacute or less severe hence the term ‘walking pneumonia’
  • absence of lobar consolidation on chest x-ray
  • not detectable on Gram stain
  • lack of response to penicillin antibiotics
  • Examples: Legionella pneumonia, Mycoplasma pneumonia
39
Q

Pneumonia investigations

A
  • Bedside: Obs
  • Bloods: FBC, U&Es, CRP, blood/sputum culture
  • Imaging: CXR - look for areas of opacification (consolidation)
  • CURB65 score
40
Q

CURB-65 scoring system: mortality rate in hospital

A
  • Confusion (AMTS<=8)
  • Raised blood urea nitrogen >=7 mmol/L
  • Respiratory rate >30
  • Blood pressure <60 diastolic or <90 systolic
  • Age >=65
  • Score 0-1 = low risk
  • Score 2 = moderate risk
  • Score 3-5 = high risk
41
Q

CRB65 score (mortality risk in GP)

A
  • Confusion [AMTS 8 or less]
  • Raised respiratory rate [30 or more]
  • Low BP [DBP <60mmHg or SBP <90mmHg]
  • Aged 65 or more
  • Stratified for risk or death:
  • 0: low risk [<1% mortality]
  • 1 or 2: intermediate risk [1-10% mortality
  • 3 or 4: high risk [>10% mortality
42
Q

Atypical pneumonias

A

Legionella, often found in air conditioning units at hotels. Tested from urine sample. May test for HIV at same time.

43
Q

Pneumonia management CAP

A
  • Maintain airway, support breathing, high flow O2 if needed
  • Antibiotics asap (adjust after microbiology results) PO:
  • Low risk patient: Amoxicillin (or doxycycline if pen allergic)
  • Moderate risk patient: Amoxicillin + Clarythromycin
  • High risk patient: Co-amoxiclav + Clarythromycin
44
Q

How to manage pneumonia of differing severity

A
  • Low risk: home based care, antibiotics for 5 days
  • Medium or high severity: hospitalisation with 5-7 days of antibiotics
  • If CURB-65 score 4-5 consider ICU
45
Q

HAP

A
  • Organisms similar to CAP but in addition S.aureus and gram negative
  • Usually bacterial
  • Significant cause of death in ICU and lengthens hospital stays
46
Q

Pneumonia management HAP

A
  • Maintain airway, support breathing, high flow O2 if needed
  • Antibiotics asap (adjust after microbiology results):
  • Low/moderate risk patient: Co-amoxiclav PO
  • High risk patient/severe infection: Piperacillin or ceftazidine or cetriaxone IV

6 weeks after the initial pneumonia presentation you do a chest x-ray to make sure there isn’t a tumour hidden by the consolidation

47
Q

Discharge after pneumonia

A

NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings:

  • temperature higher than 37.5°C
  • respiratory rate 24 breaths per minute or more
  • heart rate over 100 beats per minute
  • systolic blood pressure 90 mmHg or less
  • oxygen saturation under 90% on room air
  • abnormal mental status
  • inability to eat without assistance.
48
Q

Natural history of pneumonia

A
  • 1 week – fever resolved
  • 4 weeks – chest pain & sputum production substantially reduced
  • 6 weeks – cough & breathlessness substantially reduced
  • 3 months – most resolved but fatigue may be present
  • 6 months - most people back to normal
49
Q

Brain abscess

A
  • A focal, infectious, intra-cerebral collection of pus, encapsulated within a well-vascularised wall
  • Originate from contiguous spread of infection from sinusitis, otitis media, or dental infections; haematogenous spread from distant sources (e.g., endocarditis, pulmonary infections); or direct inoculation from trauma or neurosurgical procedures.
  • Risk factors include immunocompromised states, congenital heart disease (right-to-left shunts), chronic otitis and sinusitis, and intravenous drug use.
50
Q

Progress of brain abscess

A
  • early/initial cerebritis (1-3 days)
  • late cerebritis (4-9 days)
  • early capsule formation (10-13 days)
  • late capsule formation (14 days onwards)

year 4 CDM 2 (39 decks)

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