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1
Q

mechanisms of abx resistance

A

may be intrinsic
evoked or evolved
- inactivation - enzyme production e.g. beta lactamase
- target site modification - structural changes to bacterial components e.g. ribosomes
- decreased cell wall permeability - structural changes
- active expulsion - efflux pumps

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2
Q

common resistant organisms

A

MRSA: sensitive to vanc / teic
C.diff
VRE: linezolid, tigeycline
ESBL (e.coli / klebsiella): carbapenem
Carbapenemase producing enterobacteracae CPE
Pseudomonas: piptaz, quinolones, carbapenems

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3
Q

antimicrobial stewardship

A

infection control, judicious abx management
optimise drug choice, timing, dose and duration to eradicate infection and reduce negative effects of antimicrobials (nosocomial infection, resistant organisms)

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4
Q

strategies in antimicrobial stewardship

A
  • involvement of microbiologist
  • cultures prior to starting
  • isolating patients with resistance organisms
  • formulary restriction
  • optimisation - de-escalation, short courses, enteral conversion
  • restrictive antibiotic strategies
  • dose optimisation - avoid subtherapeutic doses
  • education and training

PCT for de-escalation

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5
Q

bactericidal activity of antibiotics

A

Minimum inhibitory concentration MIC - concentration of antimicrobial required to completely inhibit visible growth
time-dependent killing - bactericidal when concentration above MIC consistently
concentration dependent killing - bactericidal when peak concentration above a certain level
AUC / MIC - concentration and time dependent killing effects

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6
Q

SDD

A

selective decontamination digestive tract
SDD reduce overall mortality by 6%

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7
Q

Pyrexia in critical care

A
  • infection responsible for 73% pyrexia
  • < 72hrs likely to be non-infectious post SAH or elective surgery
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8
Q

Systematic consideration of sources

A

A - dental abscesses, tonsilitis, sinusitis
B - Pneumonia, tracheitis, empyema
C - IE
D - meningitis, encephalitis, cerebral abscess
E - cellulitis, nec fas, septic arthritis, ifnected pressure sore
F - UTI, pyelonephritis
G - cholecytisits, peritonitis, diverticulitis, appendicitis
GU - PID, epidymo-orchitis, prostatitis

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9
Q

considerations invesitgating PUO

A
  • fever - onset, severity, course
  • systemic sx - weight loss, night sweats, skin lesions
  • vaccination
  • unwell contacts
  • activities - travel, country, alcohol, drugs, animals
  • relevant diseases - HIV, malignancy, sickle cell
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10
Q

considerations of managing bacterial infection

A
  • suspected source - broad, narrow spectrum, tissue penetration
  • duration in hospital
  • previous cultures
  • positive cultures
  • toxin production
  • severity of illness - septic, stable
  • extracorporeal circuits
  • route of adminsitration
  • guidelines / micro advice
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11
Q

stopping abx

A

individualised
clinical improvement - e.g. improved gas exchange, resolving pyrxexia
prolonged courses indicated in some situations - IE, osteomyeletis
biomakers

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12
Q

Common viruses in critical care

A

orthomyxoviridae - infuenza ABC
Coronaviridae - SARS, MERS, covid-19
Herpesviridae - HSV, VZV, CMV, EBV
paramyxoviridae - RSV, measles, mumps
flaviviridae - dengue
filoviridae - ebola

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13
Q

virus classification

A

DNA or RNA surrounded by protein capsid. capsid helical, icosahedral or complex. some have outer envelope or are naked
RNA
- icosahedral naked - picornavirus. enveloped - flavivirus
- helical enveloped - coronavirus, orthomyxovirus
- complex -retrovirus
DNA
- icosahedral naked - parvovirus
- icosahedral enveleoped - herpes

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14
Q

challenges of fungal infections in critical care

A
  • insidious presentation - hard to diagnose
  • prolonged courses of treatment
  • significant side effects of treatment
  • high mortality
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15
Q

types of fungal infections

A

moulds : aspergillus
yeasts : candida, cryptococcosis
dimorphic : histoplasma

primary: immunocompetent patients. abundant spores and some innate virulence
secondary : opportunistic, less innate virulence but cause disease in immune impaired

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16
Q

risk factors for fungal infection

A
  • icu admission
  • immunocompromised
  • respiratory compromise - CF, COPD
  • invasive procedures
  • broad spectrum antibiotics
  • gut contamination
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17
Q

invasive candidiasis

A

commonest fungal infection in ICU
usually superficial colonisation but candidaemia has high mortality
haematagenous spread - heart, liver, brain, eyes
echo / ophthalmology review
positive blood cultures need detailed assessment
fluconazole / anadilafungin treatment

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18
Q

aspergillus

A
  • invasive pulmonary aspergillosis
  • chronic cavitatory aspergillosis
  • extra pulmonary aspergillosis
  • allergic bronchopulmonary aspergillosis - steroids, antifungals
  • aspergilloma
  • angio- invasion e.g. massive haemoptysis
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19
Q

other fungal infections

A

PCP
- progressive dyspnoea, dry cough, exertion desaturation, air leaks
crpytococcus
- pulmonary cryptococcosis - infiltrative pneumonia
- meningoencephalitis - slow progressive
- relatively immune modulation - inflammation / immune reconstitution on treatment
mucormycosis
- disseminated infection, angio invasion, necrosis

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20
Q

fungal disease investigations

A
  • mc/s relevant fluid / tissue
  • beta d glucan - most infections
    invasive candidiasis
  • blood culture
  • serum mannan / anti-manna
  • fundoscopy
  • pcr
    aspergillosis
  • serum / bal galactomannan - relatively specific
  • CT chest - air crescent, halo sign
  • histology
    PCP
  • sputum / bal per
  • cxr / ct
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21
Q

anti fungal classes

A

polyenes - amphotericin b - cell wall damage . cryptococcosis
azoles - voriconazole (aspergillosis), fluconazole (candida)- inhibit cell wall synthesis.
echinocadins - inhibit b glucan synthesis - caspo / anadulofungin
flucytosine - incoproated in rna

22
Q

anti fungal side effects

A

fluconazole / voriconazole - liver, qtc, cytochrome p450
anidulafungin - liver
amphotericin - renal, eleectrolyte

23
Q

anti fungal prophylaxis

A
  • neutropenia
  • ALF
  • HIV
  • follow transplant
  • gi perforation
24
Q

nosocomial infection definition

A
  • infection after 48hrs admission
  • within 3 days of hospital discharge
  • within 30 days of an operation

common, preventable, increase mortality and morbidity

25
factors predisposing to nosocomial infection
patient - elderly - malnutiriton - alcohol - chronic lung disease - diabetes disease - surgery - trauma - burns treatments - invasive procedures - intubation, catheters, drains - transfusion - antimicrobials - immunosuppression - prolonged LOS
26
Nosocomial infection examples
Blood stream / central line associated / catheter related - CRBSI - bloodstream infection attributed to intravascular catheter (quantitative culture of tip or difference in growth between catheter and peripheral blood cultures). - CLABSI - lab confirmed BSI in patient with indwelling central line < 48 hrs prior to development of infection, unrelated to another infection - coagulase neg staph, staph aureus, candida Pneumonia - pseudomonas, staph aureus, enterobacter, klebsiella catheter associated UTI - pseudomonas, enterococci, E Coli Surgical site infections - staph, coagulase negative staph, enteroccoci
27
line infection prevention / managament
minimise insertion / evaluate need catheter type - abx impregnated, minimal lumens, dedicated PN site - subclavian > IJ > femoral ANTT on insertion optimum care - disinfect, flushes replacement - avoid routine management - catheter removal - sepsis, persistently positive cultures, persistent symptoms - precious lines may be treated medically
28
other factors preventing nosocomial infection
- hand hygiene - PPE - VAP bundles - Antimicrobial stewardship - line care
29
HIV
Human immunodeficiency virus retrovirus infecting CD4 T cells viral RNA transcribed into DNA by viral reverse transcriptase enzymes chronic progressive immune deficiency
30
HIV diagnosis
serological test HIV-1 p24 antigen may be positive from day 18 antibody test positive from 3 months
31
HIV stages
0 - early - CD4 count negative 1 - Acute - CD 4 > 500 2 - chronic - CD4 200-499 3 - AIDS - CD4 < 200 or OI
32
Opportunistic infections (AIDS defining)
Bacteria: mycoplasma - TB, MAC, recurrent pneumonia Fungal: PCP, oesophageal candidiasis, cryptococcus Viral: CMV retinitis, oesophagitis. HSV pneumonitis Parasitic: toxoplasmosis Neoplastic: Kaposi sarcoma
33
HIV presentations to critical care
- complications of disease - significant side effects of treatment - pathology not directly related sepsis and respiratory failure commonest, followed by CNS issues Severe opportunistic infections tend to occur in patients previously not known to have HIV or those with restricted access to HAART
34
HAART classifications
NRTIs: lamivudine, zidovudine, tenofovir NNRTI: efavirenz integrase inhibitors: raltegravir Protease inhibitors: lopinavir
35
HAART side effects
Most can cause hepatitis lactic acidosis: zidovudine AKI: tonofaviar TEN: tenofovir
36
Immune reconstitution inflammatory syndrome
IRIS inflammatory disorders associated with paradoxical worsening of infectious conditions following ART initiation worsening of treated condition or unmasking of OI resp failure - worsening of PCP HLH
37
management of ART
if already taking then continue where possible adjust doses according to organ failure commencing de novo individualised decision - immediate - severe acute OI - < 2 weeks other OI - delayed - T
38
PCP management
BAL, PCR, beta d glucan, CT for diagnosis mx septrin steroids if pao2 < 9
39
TB
AFB, MC/S, PCR tissue biopsy Mx RIPE 2 months then 9 months RI steroids if CNS
40
cerebral toxoplasmosis
altered mental state, seizures parasite IgG serology, CSF/blood PCR t.gondii pyrimethamine, sulphadizeine, leucovorin
41
HIV risk factors
- MSM - IVDU - Prisoners - Patients from areas of high prevalence - sex workers ICU testing - AIDS defining OI, indicator conditions - CAP, invasive pneumocococcal disease - GBS - unexplained fever, weight loss, chronic diarrhoea - malignant lymphoma - VZV, HBV, HCVm candidaemia
42
Malaria
life threatening tropical infection protozoa transmitted by mosquitoes plasmodium falciparum in nearly all serious illness Vivax / ovale / malaria less severe risk factors - travel to endemic areas - Africa, Asia, Latin America - mosquito bites - poor compliance with chemoprophylaxis
43
Malaria pathophysiology
life cycle depends on mosquito and humans 1. human liver stage - human bitten by mosquito, parasites travel to liver, mature into schizonts, hepatocytes rupture and merozoites are released in bloodstream 2. merozoites infect erythrocytes, multiple into trophozoites and onto schizonts. erythrocytes rupture - further merozoites into blood 3. mosquito stage - gametocytes in mosquito undergo sexual reproduction and produce eggs, release sporozoites into mosquito saliva
44
malaria diagnosis
suspicion, history presents 12-14 days after inoculation fever, altered mental state, seizures, jaundice blood film - thick and film microscopy - thick = organism - thin = quantified parasitaemias
45
severe malaria
B : pulmonary oedema, SPO2 < 92% C: Shock, SBP < 80 D : GCS < 11, seizures, glucose < 2.2 F : creat > 265 G : Bili > 50 H : Hb < 70 I : pataistaemia > 10%
46
malaria treatment
parenteral if paristaemia > 2% or jaundice anyone witht evidence of severe disease IV Artesunate 2.4mg/kg 12hrly 3 doses then daily Quinine if artesunate not available 20mg/kg then 10mg/kg Supportive Mx of complications - ARDS - Cerebral malaria - anti epileptics, airway control - AKI - RRT if required - Anaemia - restrictive transfusion - Coagulopathy - products as indicated
47
varicella zoster virus
mild fever, maculopapular rash, vesicular, scab 10-21 day incubation. infectious 2 days before rash until crusted complications - arthritis, secondary bacterial infection, pneumonitis, encephalitis, facial nerve palsy
48
Dengue fever
virus transmitted by mosquitoes 4-7 day incubation fever, headache, myalgia sever disease = dengue haemorrhage fever acute vascular permeability - hypoproteinaemia, hypovolaemia, effusions, dengue shock abnormal haemostats - haemorrhage, thrombocytopenia
49
Leptospirosis
leptospirosis spirochetes rodent , cattle, dog urine direct / mucosal contact 5-14 day incubation asymptomatic, flu like illness to MOD positive culture / pcr can cause vasculitis, renal, liver, myocarditis doxycycline / IV penicillin / cephalopsorins
50
Toxoplasmosis
protozoal infection T.gondii food, congenital, zoonotic (cat faeces) flu like illness, retinitis, lymphadenopathy pyrimethamine, sulphanmide
51

FFICM (14 decks)

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