Infections: Disease, Treatment Pathways And Case Studies Flashcards
Case Study(1) Mrs AB, 82 years, comes into the ward presenting with bilateral leg swelling redness of feet, ankles & lower calves. Past medical history is Type 2 diabetes, and several previous admission with diabetic mellitus over the last 6 months. Allergies: NKDA.
a. Interpret the findings on her chart: any alarm bells….
b. Write the drug chart for this patient: what other information do you need?
c. What do you suspect she has?
b)Confirming patient’s penicillin allergy status and what type of reaction they had. Confirm if patient is taking any OTC medicines, supplements, homeopathic medicines. Confirm regular medicines taken again to see if you are missing any from the records. Check the blood sugar levels on last admission and HbA1C control. Bring in diabetes management team. Add VTE prophylaxis due to her stay in hospital (think: Virchow’s triad include intravascular vessel wall damage, stasis of flow, and the presence of a hypercoagulable state). Check pain score. MRSA History
Do differentials to rule out any other causes such leg oedema.
c) Cellulitis
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d) What other factors should you be considering?
e) What is the likely causative organism of this infection?
f) What are the complications associated with cellulitis (insert image).
d) Diabetic: increased infection susceptibility and may have prolonged recovery from this infection due to compromised immune system. Athlete foot: fungus can be part of the infection causing worsening of symptom presentation
e) most common: Streptococcus pyogenes. Staphylococcus aureus. (Gram-positive)
f) Necrotizing fasciitis:destruction and rapidly progressive soft tissue infection that involves the deep subcutaneous tissues and fascia. Myositis — inflammation of muscle due to infection. Sepsis.
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g) How would you manage the patient? (Consider if they did have penicillin allergy)
g) Patient management involves:
Outline the area where the diffuse redness is monitor its reduction in size as indicator of treatment efficacy.
1. Prescribe high dose oral antibiotics:
Flucloxacillin 500-1000 mg QDS for 5-7 days. If patient is systemically unwell then IV then switch after 24-48 hr if symptoms get better.
Penicillin allergy: Clarithromycin 500 mg BD, Doxycline 200 mg First day, then 100 mg OD for 5-7 day.
2. Manage pain:
Mild-moderate: analgesics
Elevate leg and avoid compression garments during acute cellulitis.
3. Monitor
Treatment efficacy: 2-3 days assessing if local symptoms deteriorate (such as redness or swelling beyond the initial presentation).
No substantial improvement after 7 days: Assess adherence to treatment, and continue the first-line oral antibiotic for a further 7days.
Cellulitis is characterised by…
pain, warmth, swelling, and erythema. Blisters and bullae may form. Fever, malaise, nausea, and rigors may accompany or precede the skin changes.
Risk factors for cellulitis.
Risk factors include skin trauma, ulceration, and obesity.
How do you risk stratify an individual with cellulitis. What is the scores you’ll be concerned with….
Reminder: ELON MUSK
ERON ClassiFICATION = class II IIII IV you would handle in secondary care.
SEWs score >6= fluid and more frequent monitoring.
When choosing antibiotic for cellulitis what would you consider?
The severity of symptoms.
The site of infection (for example, near the eyes or nose).
The risk of uncommon pathogens (for example, from a penetrating injury, after exposure to water-borne organisms, or an infection acquired outside the UK).
Previous microbiological results from a swab.
The person’s meticillin-resistant Staphylococcus aureus (MRSA) status if known.
First line agent for cellulitis.
flucloxacillin 500–1000 mg four times daily for 5–7 days.
Second line agent for cellulitis if patient has penicillin allergy/Pregnancy.
Clarithromycin 500 mg twice daily for 5–7 days.
Doxycycline 200 mg on the first day then 100 mg once daily, for a total of 5–7 days.
Erythromycin (in pregnancy) 500 mg four times daily for 5–7 days.
Alternative choice of antibiotic for severe cellulitis?
Co-amoxiclav 500/125mg TDS for 7 days.
Antibiotic to be added if MRSA is suspected or confirmed with cellulitis.
Vancomycin
First-line H. pylori eradication regimens
proton pump inhibitor (PPI)
antibiotics (taking into account previous exposure to clarithromycin or metronidazole)
bismuth (a chelate)
Ensure the person is aware of the importance of compliance with the prescribed regimen.
NICE recommendation for first line H.pylori eradication regimens( consider allergies)
Lansoprazole 30 mg / omeprazole 20–40 mg
offer a 7-day triple therapy regimen of:
A PPI twice-daily and amoxicillin 1 g twice-daily and
Either clarithromycin 500 mg twice-daily or metronidazole 400 mg twice-daily.
If patient allergic to penicillin, offer a 7-day triple therapy regimen of:
A PPI twice-daily and clarithromycin 500 mg twice-daily and metronidazole 400 mg twice-daily.
Aims of H.pylori treatment
Treatment aims to eradicate H. pylori, reduce the risk of peptic ulcer disease, ulcer bleeding and gastric malignancy, and the recurrence of gastritis and peptic ulcers.
What are the three species responsible for pneumonia.
Str.pneumonia, H.influenza, Pseudomonas. aeruginosa.
For CAP what scoring system do you use and when is appropriate based on the scoring system to admit someone to hospital.
CRB-65: New onset confusion, Respiratory rate above 30 breaths/min, Blood pressure systolic of 90 mmHg or less or diastolic of 60 mmHg or less; and 65 years old or older.
CRB-65: 1-2 admit to hospital.
What self-care advice would you provide patient with CAP.
What is the first line agent for managing CAP.
What is the second line agent if amoxicillin is unsuitable for managing CAP.
What diagnosis do you use in a hospital setting.
CURB-65: Urea >7 mmol
First line agent for hospital acquired pneumonia (HAP)
What is the second line agent that can be given if patient has penicillin allergy in HAP Tx.
What is the first line IV choice antibiotics if severe symptoms of HAP have been noted in Tx.
What organism causes bacterial meningitis.
What are the signs of bacterial meningitis.
Triad: Fever, Stiff neck, Altered mental status (account for 41% cases).
Neisseria: rash as presentation (non-blanching rash: not turn white under finger).
*meningococcemia is leading cause of sudden death.
What are monitoring requirements for bacterial meningitis.
Reduction in non-blanching rash.
Temperature.
ECG monitioing
Pain management
Blood pressure.
Signs of sepsis.
What is the first line for managing bacterial meningitis for patient with no penicillin allergy.
What is the self-care measures you can counsel patient who have UTI.
What is the first line agent and second line agent for UTI.
