infection symposium Flashcards
symptoms of sepsis
confusion or disorientation,
shortness of breath,
high heart rate,
fever, or shivering, or feeling very cold,
extreme pain or discomfort, and.
clammy or sweaty skin.
sepsis definition
life threatening organ dysfunction due to a dysregulated host response to infection
septic shock
sepsis with presisting hypotension that requires vasopressors to maintain the mean arterial pressure at less than 65mmHg and serum lactate concentration of >2mmoll
qSOFA for sepsis
resp rate >/= 22breaths/min
altered thoughts/confusion (GCS<15)
systolic BP </= 100mmHg
if score >/=2 need intervention ASAP (10% morbitiy risk as no sepsis pt)
baseline assume 0 (unless other comorbities - diabetes/CVD)
spred of infection RED FLAGS
6
- temp <36 or >37
- elevated respiratory rate >20breaths/min
- elevated or reduced HR (60-100bpm is norm)
- trisumus due to swelling
- swelling crossing midline
- dehydration - reduced urine output
sepsis 6
3 IN
* O2 15l -* prevent hypoxia*
* high volume fluids -* prevent hypovolemia and shock*
* IV antibiotics
3 OUT
* monitor urine output
* bloods for culturing, glucose, FBC, Us + Es, CRP, lactate
advantages of pus aspirate over pus swab
2
**Infected with oral mucosal flora – harder to interpret results **
Swelling – relive pressure as establish drainage at same time
**Larger sample **
key information on specimen request form
8
order of importance
- Clinician contact details (name, number) – know how to get in contact with you
- Dx/presumptive dx
- Investigation: culture and susceptibility testing
- Pt identifiers
- Clinical details
- Date/time taken
- Specimen details
- Site
key safety elements when submitting microbiological/pathological materials to clinical lab
specimen safety
4
Needle in sharps container – clinicians responsibly
* Remove needle safely over sharps bin – twist off
Syringe cap – red plastic to seal end of syringe, prevent it flowing out accidentally
Puts pts label around syringe so its ready to go
Fill in request form
Key safety elements when submitting microbiological or pathological materials to clinical laboratories
packaging requirements
3
Need 3 layers of packing
* First layer need something absorbent incase something spills or leaks from sample
* Needs to be compliant with UN3373 standard (legal requirement)
Secure
Labelled
gram stain for gram positive
purple
gram stain for gram negative
pink
what is A
neutrophil (pus has lots of dead neutrophils)
Polymorphor nuclear leukocyte
what is B
gram positive bacilli
what is C
gram negative cocci
clinical example of use of gram stain from pus of a dental abscess
Lab can identity type of bacteria present in the infection and as result as suitable antibiotics to which the bacteria is sensitive to can be prescribed (reduced AB resistance as pt is being correct AB)
* Informs empiric choice of AB
* Narrow down with signs/symptoms/history in SEPSIS case – start broad – when get testing back narrow down more
describe Gram stain of this isolate from an infection in dento-alveolar bone
What is the most likely identity?
What is the preferred antibiotic of choice to treat this micro-organism
Mix of gram pos cocci and gram neg
**Gram positive cocci – stap aureus looks like grapes
* **Cause abscess, can be found in angular cheilits, implantitis. Also cause bad abdo and skin infections etc **
Preferred antibiotics is flucloxacillin
* Resistant to amoxicillin, penicillin, metronidazole
preferred antibiotics for gram positive cocci
flucloxacillin
resistant to amoxicillin, penicillin, metronidazole
example gram positive cocci
staph aureus
looks like grapes
Gram stain of this isolate from an acute peri-apical abscess.
What is the most likely identity?
What is the preferred antibiotic of choice to treat this micro-organism
Gram positive cocci – all in chain
Strep angiosus
*Phenoxymethylpenicillin – used for strep
full name for penV
Phenoxymethylpenicillin
Phenoxymethylpenicillin used for
streptococcus angiosus
flucloxacillin used for
staphylcoccus aureus
WHO definition of antibiotic resistance
“Antimicrobial resistance occurs when microorganisms such as bacteria, viruses, fungi and parasites change in ways that render the medications used to cure the infections they cause ineffective”
describe this chart used to measure antibiotic reistance in the lab
MIC = Minimal Inhibitory Concentration
A - sensitive
B – breakpoint
C – resistant
European Committee on Antimicrobial Susceptibility Test (EUCAST)
antibiotic resistnace clinically defined as
When infection is highly unlikely to respond even to maximum doses of antibiotics
3 examples of clinical factors that influence the penetration of antibiotics to the site of infection
- biofilm disruption
- pus collection
3.site of infection
oral black pigmenting anaerobe e.g.
Prevotella Intermedia
most common type of resistance mechanism for beta-lactams in BPA’s. Choose from;
Enzymatic inactivation (Beta-lactamase)
why is Pen V not the first line beta-lactam for the management of dento-alveolar infections
Equally effective as Amoxicillin but less harmful to resident flora
*
Narrower spectrum so less harm to gut flora etc – but still only when needs to be prescribed*
Which of the following micro-organisms from dental infections are usually susceptible to metronidazole
a. Streptococcus anginosus
b. Staphylococcus aureus
c. Peptostreptococcus micros
d. Actinomyces israellii
e. Streptococcus mutans
Anaerobic Bacterial Infections (GRAM NEGATIVE)
c. Peptostreptococcus micros
and prevotella intermedia
Strict Anaerobes Only
Which of the following mechanisms is likely to result in metronidazole resistance
a.Enzymatic inactivation
b.Modified target
c.Decreased uptake
d.Increase efflux
e. All of the above
e. All of the above
anticrobial strewardship is
a coordinated program that promotes the appropriate use of antimicrobials (inc antibiotics), improves pt outcomes, reduced microbials resistance and decreases the spread of infections caused by multi-drug resistant organisms
pus sampling role in antimicrobial stewardship
Prescribing antibiotics that would be ineffective for that infection
* Contributing to resistance
* Reduce pt success outcome
* Inc risk of spreading infection
barriers in GDP to pus sampling
- Time
- Money
- Lack of equipment
- Lack of clinical knowledge on how to sample and transport sample
what to do when someone presents with a large swelling
(infection spreading)
Quick assess- ABCDE – breathing, able to walk/sit, understand
* Hot potato voice– raise tongue and FOM, see less of oropharynx, unable to speak properly
Then
History – when dd it start, how long, change rapidly – how quickly
Medical – allergies, RED FLAGS - immunocompromised, diabetic (esp if not well controlled – worse quicker and poor healing – check HbA1c value 48mmol/mol) and renal problems or bleeding disorders
SH – live alone, smoking (don’t heal well, exacerbate everything in the mouth), alcohol,
and E/O and I/O
E/O assessment for spread of infection focus
asymmetry,
swelling (palpate – site, shape, size (use ruler)- fixed, firm, heat, obstructing eye or lower mandible),
lymphadenopathy – check all, **can you feel border of mandible, **
check jaw opening (guarding - scared and/or painful; get them to open to max opening even if its painful; place fingers on their incisal edges – will feel hard to open more; if just owww – not true trismus; true trismus if submasseteric swelling)
I/O assessment for spread of infection focus
any sign obvious sources of infection
quick survey,
able to do any TTP/mobility checks,
any sinus,
loss of sulcus depth – swelling gone into space and able to incise it,
check tongue position and FOM – need to be able to palpate – if unilateral take finger on FOM on unaffected and then affect – should be soft, not raised or not lumpy – will feel more than see,
check oropharynx and uvular– warn pt will depress tongue (deviation)
Hot potato voice– raise tongue and FOM, see less of oropharynx, unable to speak properly
special investigations for spread of infection?
Get xrays if you can – compare with old if possible
Measure HR, temp, o2 sats, BP (internal better than external) – use right cuff for pt size
Normal
* 36 degrees +/- degree
* 60-100bpm (whats normal for them – children higher than adults)
* 120/80, 60-90 (systolic/diastolic)
* 95-100 O2 sats (COPD – carbon diox driven so will be lower)*
normal values for
temp
HR
BP
O2 sats
- 36 degrees +/- degree
- 60-100bpm (whats normal for them – children higher than adults)
- 120/80, 60-90 (systolic/diastolic)
- 95-100 O2 sats (COPD – carbon diox driven so will be lower)*
maxillary spread of infection
- canine space (high risk for eye involvement) – will look like blistered eye or puffy eye;
- palatal space
manidbular spread of infectin
buccal
submental
submasseteric
sublingual
SIRS
serious inflammatory response syndrome
(used to assess SEPSIS)
4 components of SIRS
- tachycardia (heart rate >90 beats/min),
- tachypnea (respiratory rate >20 breaths/min),
- fever or hypothermia (temperature >38 or <36 °C),
- leukocytosis, leukopenia, or bandemia (white blood cells >1,200/mm3, <4,000/mm3 or bandemia ≥10%)
when to speak to maxfax
maintaining airway and breathing ok but couple of worrying signs - phone
* Know where the closest is, have their number ask for Maxillofacial on call SHO – can be on hold if they are operating
* Have a clear concise relevant history ready to present with temp and obvs
* They will give advice – ask you to do x, y, z or get them in (advise pt to not eat or drink anything on route)
get them to A&E if rapidly swelling that needs IV AB not oral; hard swelling over body of mandible – hard and trapped in facial spaces, needs draining, why feeling mandible imp; if they are high risk pt; showing any signs of sepsis – warranted as spreading
* If cant get them send to A&E with letter – with history and your details, best to try and get in touch with them
tell pt no eating or drinking till been triaged at hospital
Need maxfax for incision and drainage sometimes because **we cannot incise extraorally **– not safe because could hit a major blood vessel,
Cross midline – get ambulance
if localised intraorally swelling what should GDP do
incise to bone approx 1cm, be careful of mental foramen and nerves
* clear liquid first, then yellow pus - scoop out with Howarth’s, can rinse with saline too
leave to drain (don’t suture)
analgesia advice and come back in 5days
2 most common dental infections
Dental abscess
Pericoronitis
abscess of upper 6
spread options
5
Out socket
Buccal space
Maxillary sinus
Palate
Infraorbital
abscess of lower 3rd molar
spread options
4
Submasseteric
Submental
Sublingual
Pharyngeal spaces – esp lateral pharyngeal concerns – as compromised airway
abscess of canine
spread options
canine space, cavernous sinus thrombosis
concern – as spread to brain risk
basic steps in management of infection in GDP
6
History
Examination
Resuscitative ABC and supportive tx
Special investigations
**Remove source of infection +/- I&D of swelling **
possible antibiotics
key history questions for infection
When did it start – rapid progressively, or slower over weeks
If they can open their mouth
Are they in pain
Have they had any recent dental issues or dental work
Changes to medical history – allergies, medications, red flag illnesses
Quick dental and social history
Alcohol and blood clotting?
cellulitis swelling telltale
hard
fluctuant swelling inficates
fresh swelling, more able to drain
optiosn for removing source of infection
3
XLA
RCT/Pulp extirpate
incision and drain
why may not be able to get a pt numb
abscess suppuration is acidic, LA is weak bases, pKa process means it will not work
*Mepivacaine is plain so slight differ pH properties – maybe worth trying
Or just I&D and hopefully next time will be able to get numb as some suppuration escape
*
do you stitch over I&D
no
tell pt will have blood and pus escaping from it and will be able to definitive tx hopefully when they come back in
factors to consider when determining severity of infectino
Onset
progression
history
trismus
systemic symptoms
Pt factors e.g. diabetic or on steroids
when to use antibiotics
- Local measures failed- XLA and area still swollen on review
- Pt is systemically unwell – determined by pt obs
- Cellulitis present - hard shiny swelling
- Infection spreading rapidly
3 key red flags for A&E and maxfax
Significant trimsus, FOM swelling or diff breathing
things to warn pt off when pulp extirpate in emergency setting
Advice guarded prognosis –
* will need to assess restorablity of teeth once all the dental caries removed
* large abscess could reduce RCT success,
need pt to come back for more tx
