HAI

Question 1

A 66 year old male presented with an acute coronary syndrome 2 days ago and had coronary stenting performed yesterday without complication. Nursing staff alert youth he developed a cough and myalgia overnight and now has a fever of 38.5. You are aware that other patients in the hospital have had similar febrile presentations. How would you manage this situation?

HAI - assessment

Answer 1

Impression
Given low grade fever, multiple other people implicated and only 1 day post-op and considering a viral LRTI/URTI. COVID high on DDX but also other viral including RSV, influenza, parainfluenza,etc.

5Ws of post-op fever;

• UTI
• Pneumonia, atelectasis
• Wound/lines +/- infection
• DVT/PE
• Pyrexial response (diagnosis of exclusion)

Goals

• Targeted Hx/Ex/Ix to determine likely aetiology of post-op fever
• appropriate definitive and supportive measures

Question 2

HAI - Assessment

Answer 2

Assessment
Ensure HD stability, rule out systemic signs of infection. MERT if shocked/severe respiratory symptoms

Ensure HD stability, rule out systemic signs of infection
A - Patent, maintaining.
B - SP02/RR monitoring. Supplemental as required. Sputum sample for MCS + aspirate for viral panel PCR, CXR to investigate Ddx
C - BP/ECG/HR monitoring. IV access if not already, send bloods: cultures, VBG, FBC, UEC, CRP. fluid resus pending HD status, empirical Abx if deemed septic or according to other likely focus of infection
D - GCS
E - looking for sites of infection: wounds, lines, uti, chest: conduct resp and abdo exams.

Question 3

HAI - Hx

Answer 3

History

• sx: cough, pain, productive, onset of sx, previous illness, sick contacts with other patients/visitors
• REDS: Chills, Rigors
• Risks: immunocompromised (steroids, DM, etc)
• PMHx: existing respiratory disease, ECOG, medications (corticosteroids), vaccination status
• SNAP

Question 4

HAI - Ex

Answer 4

Examination

• General appearance + vitals
• Systems review: resp, cardio, abdo, genitourinary examinations

Question 5

HAI - Ix

Answer 5

Investigations
- Septic screen (sputum, urine for PCR, cultures, CXR, culture of lines, etc)

• Bedside: ECG, VBG
• Bloods: FBC, CRP/ESR, UEC, LFT
• Imaging: Consider CT chest if indeterminate cause

Question 6

HAI - Mx

Answer 6

Management
Supportive
- antipyretics
- fluids
- isolation, single room. alert ward staff and label room with appropriate droplet/airborne precautions
- viral swabs for COVID, RSV, influenza, parainfluenza

Viral pneumonia - just supportive treatment

• antivirals (tamiflu - not very effective)
• fluids
• antipyretics

Bacterial HAP
- low: oral augmenting BD 7 days
- Severe: piptaz IV QID, add Gent + Vanc if in shock
o if in shock, need intubation, ICU referral

Aspiration pneumonia

• oral augmentin BD for 7 days
• IV Ceftriaxone