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EM Clerkship Exam > Infections in the ED > Flashcards

Infections in the ED Flashcards

1
Q

SIRS criteria: SIRS is met when two or more of the following are met:

A
  1. temp over 38 or under 35
  2. heart rate over 90
  3. respiratory rate over 20 breaths/min or pa CO2 is <32
  4. WBC over 12,000 cells/mm3 or over 10% bands.

Sirs does not always mean the patient is septic, other conditions could include viral illness, stimulant overdose, alcohol withdrawal, trauma, burns, and pancreatitis.

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2
Q

Definition of sepsis

A

the presence of both SIRS AND infection (identified or probable)

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3
Q

severe sepsis definition

A

sepsis with organ dysfunction. Severe sepsis has a much higher mortality rate versus non severe sepsis.

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4
Q

examples of organ dysfunction in the context of sepsis

A
  1. sepsis induced hypotension
  2. elevated lactate >2mmol. 3mmol/L suggests septic shock
  3. altered mental status
  4. reduced urine output
  5. acute lung injury or ARDs
  6. acute kidney injury
  7. elevated bilirubin
  8. low platelets, coagulopathy, or DIC
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5
Q

definition of septic shock

A

Severe sepsis along with hemodynamic collapse, characterized by persistent hypotension
(Systolic BP <90 mmHg or Mean arterial pressure (MAP) < 70 mmHg) DESPITE fluid
resuscitation, or requirement of vasopressor medications. Septic shock is the most severe
sepsis syndrome and often requires ICU care.

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6
Q

Assessment of hemodynamic status

A
  • heart rate
  • hypotension/BP
  • signs of poor perfusion (cap refil, cool feeling skin, mottling, or signs of organ dysfunction)
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7
Q

aspects of initial resuscitation in sepsis

A
  1. administer antibiotics targeted at the suspected infeciton site within the first hour of presentation. Give broad spectrum if source of infection is uknown
  2. within the first three hours,
    - measure lactate
    - obtain 2 sets of blood cultures
    - rapid administration of IV fluids
    - reassess

Most important principles of hemodynamic resuscitation:
- RAPID initial assessment
- Start IV fluids ASAP
- Frequent reassessment of response to treatment (normalization of heart
rate, blood pressure, O2 sat, respiratory rate, temperature, urine output, lactate
levels)

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8
Q

Pathophys and definition of asymptomatic bacteriuria

A

refers to the presence of bacteria in the bladder in
the absence of symptoms. It is present in 10% of pregnant women, 40% of nursing home
residents, and 100% of patients with indwelling catheters for more than one month. It is
defined as the presence of more than >10^5 CFUs/mL of a urinary pathogen on microscopy
or a positive urine culture. In general, it does not require treatment except in pregnant
women and in those about to receive an invasive urologic procedure.

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9
Q

Pathophys and definition of urethritis and cystitis

A

colloquially described as UTIs; they refer to
infection of the urethra and bladder, but NOT the ureters and kidneys. They are common in
women after sexual intercourse and have a high (25%) spontaneous cure rate, with about
1% going on to bypass the urethral valves into the kidneys to produce pyelonephritis.

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10
Q

pathophysiology and definition of pyelonephritis

A

upper urinary tract infection, is infection of the renal parenchyma and
pelvicalyceal system. Clinically, it is differentiated from cystitis usually by the presence of
flank pain, costovertebral angle tenderness, and systemic symptoms such as fever, nausea,
and vomiting. Rare complications of pyelonephritis include acute bacterial nephritis, renal
abscess, or emphysematous pyelonephritis.

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11
Q

complicated vs uncomplicated UTI

A

Textbooks sometimes qualify UTIs as complicated or
uncomplicated - this refers to whether risk factors for an adverse outcome are present.
Traditional risk factors include simply being male or having pyelonephritis. In clinical
practice, these definitions are not very helpful as they do not necessarily guide management.
For exam purposes, it may be helpful to be aware of the below list. The most important risk
factor from this table is likely a prior history of instrumentation, surgery, or a significant
anatomical or functional deficit.
Risk factors for complicated UTI: Male sex, anatomical abnormality, recurrence, advanced
age, nursing home resident, neonatal age group, immunocompromise, pregnancy, advanced
neurological disease, suspicion or history of resistant organism

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12
Q

Risk factors for complicated UTI

A

: Male sex, anatomical abnormality, recurrence, advanced
age, nursing home resident, neonatal age group, immunocompromise, pregnancy, advanced
neurological disease, suspicion or history of resistant organism

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13
Q

most common bugs for UTIs

A
  1. E coli +/- ESBL >80%
  2. Klebsiella +/- ESBL >5-20%
  3. proteus
  4. enterobacter
  5. pseudomonas
  6. chlamydia trachomatis <5%
  7. Staphylococcus saprophyticus
  8. mycobacterium tuberculosis (in context of HIV)
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14
Q

ideal urine specimens

A

mid-stream, clean catch, or a catheter sample.

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15
Q

T/F presence of WBCs provide some amount of accuracy for UTI diagnosis

A

FALSE. Bacteria, leukocyte esterase, nitrites are higher in sensitivity and specificity

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16
Q

Accuracy values (sens and spec) of markers that would indicate a positive urine culture

A
  1. bacteria (95% sensitive, 60% specific)
  2. leukocyte esterase (75% sensitive, 50% specific)
  3. nitrates (50% sensitive, 90% specific)
17
Q

DDx for dysuria

A 
UTI
STI
Vaginitis/cervicitis (trichomonas, yeast)
Urethritis from UTI
Allergy/chemical irritation
Bladder/urethral cancer
Kidney stones
Urethral strictures/prolapse
Fistulae
Urethral foreign body
Urethral diverticulum
Cystocele
Chronic cystitis or urethritis
18
Q

phenazopyridine

A

a local anesthetic on the lining of the urinary tract.

19
Q

common treatments for uncomplicated cystitis

A
  • nitrofurantoin
  • fosfomycin
  • TMP-SMX
  • cephlex
20
Q

5P’s of the suspected STI history

A
  • partners: how many, which gender
  • prevention of pregnancy: what types of BC if any are bieing used
  • Protection: what types of protection of STIs
  • practices: oral/vaginal/anal sex or other practices
  • past history of STI
21
Q

most common presenting syndrome of

STIs.

A

Urethritis/cervicitis or mucopurulent cervicitis is the most common presenting syndrome of
STIs. It refers to inflammation of the urethra or cervix, and often presents with pain, burning,
urethral or vaginal discharge, or dysuria (which is why it should be considered along with
UTI, especially in men in whom UTIs are less common). The most common etiologies are
chlamydia and gonorrhea, and patients should be empirically treated for both.

22
Q

Pelvic Inflammatory disease (PID) usually results from untreated ___ and represents a spreading infection to the pelvic organs. It sometimes presents as abdominal or pelvic pain.
It is differentiated from cervicitis by more significant abdominal or pelvic pain, as well as the
physical finding of “___ sign”, or severe cervical motion tenderness.

A

Pelvic Inflammatory disease (PID) usually results from untreated cervicitis and represents a
spreading infection to the pelvic organs. It sometimes presents as abdominal or pelvic pain.
It is differentiated from cervicitis by more significant abdominal or pelvic pain, as well as the
physical finding of “chandelier’s sign”, or severe cervical motion tenderness.

23
Q

Disseminated gonococcemia

A

are syndrome of gonorrhea spreading systemically,
causing symptoms of rash, arthralgias, septic arthritis, fever, or general malaise.
Gonococcemia should be added to the differential of patients with rashes and monoarthritis.
Gonococcus can also cause a throat infection if there is a history of oral sex in those
presenting with a sore throat.

24
Q

which reflex is lost in epididymo-orchitis?

A

cremasteric reflex is lost
Epididymo-orchitis is inflammation of the testes or the epididymis specifically. In younger
men or those at risk, this is usually caused by chlamydia or gonorrhea. Young men often
present with the complaint of testicular pain or swelling: a consideration for tumour/mass as
well as torsion should be made. The cremasteric reflex is often lost in those with
epididymitis. An ultrasound will often show evidence of epididymitis, but this can often be
diagnosed clinically with tenderness right at the epididymis. In older men, urinary pathogens
like E. coli are more common.

25
Q

general treatment for chlamydia

A

azithromycin or doxycycline

26
Q

gonorrhea treatment

A

ceftriaxone 250mg IM single dose

27
Q

herpes simplex I or II

A

acyclovir or valacyclovir

28
Q

CURB 65 criteria for pneumonia

A

determines morbidity risk/change of pneumonia

  • confusion
  • uremia
  • respiratory rate high >30
  • low Bp
  • age over 65

EM Clerkship Exam (1 decks)

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