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Common Infections in the Emergency Department

Common Infections in the Emergency Department. Kevin G. Rodgers, MD Emergency Medicine. Case #1. 19 year old female presents c/o a sore throat, fever, malaise, and swollen glands for 36 hours. Her PMH is significant for asthma for which she uses 2 inhalers.

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Common Infections in the Emergency Department

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  1. Common Infectionsin the Emergency Department Kevin G. Rodgers, MD Emergency Medicine

  2. Case #1 19 year old female presents c/o a sore throat, fever, malaise, and swollen glands for 36 hours. Her PMH is significant for asthma for which she uses 2 inhalers. What other history and PE would you like?

  3. Case #1 • DDx? • Centor Criteria? • Complications? What is pertinent Hx and PE in this patient?

  4. Case #3 - Pharyngitis • Divide patients according to clinical suspicion • Above Treatment Threshold • Above Diagnostic Threshold • Below Diagnostic Threshold Exudate, fever, LNs, no URI, correct age →treat Has 1-4 criteria →obtain rapid strep No exudate / shotty LN / low grade fever / URI sxs JAMA, Rational Clinical Exam: Does this patienthave Strep throat? JAMA 284:22, 2000

  5. Case #1 - Pharyngitis • Treat with PCN (PO or IM) or macrolides • Tell patients that ABX will not typically alter the duration of illness (maximum of 8 hours shorter if seen in the 1st 24 hours) • Tell patients that the full course must be taken to prevent Rheumatic fever • Consider dexamethasone for severe ST Arch Pediatr Adolesc Med. 2005;159:278-282

  6. Case #2 32 year old female with a history of sinusitis presents c/o green nasal discharge and sinus pain x 2 days. She is currently on nasal steroids and Claritin. What percentage of patients presenting to the ED have sinusitis and how would you diagnose it?

  7. Case #2-Acute Sinusitis • Less than 5-10% of patients presenting to the ED have actual bacterial sinusitis; most have rhinosinusitis (viral, chemical, allergic or self-limited bacterial infection requiring no ABX) • Clinical Diagnosis: fever, persistent purulent nasal discharge, sinus tenderness to percussion, facial pain / maxillary toothache and symptom duration > 4-7 days 2004 ATBS Consensus Guidelines

  8. Case #2-Acute Sinusitis • CT scan ???? • Treatment???? • Medical I&DDecongestantsSaline nose drops Oxymetazoline TID x 3 daysFluidsVaporizer / Moist heatAntibiotics (10-14 days) – consider cost and compliance: ampicillin, TMP-SMX, 2nd generation cephalosporins, fluoroquinolones

  9. Case #2-Acute Sinusitis • Consider admission versus 24° F/U in patients with frontal/pansinusitis or immunocompromised • patients • Treatment for acute exacerbations of chronic sinusitis ? • Steroids???

  10. Case #3 A 27 year old male presents c/o malaise, frontal headache, low grade fever, myalgias and nausea. He just finished a 14 day course of antibiotics for sinusitis. He felt well for 24 hours when these symptoms began. At this point what is in your DDx?

  11. Case #3 – DDx Headache • Infectious • Meningitis, Encephalitis, Sinusitis, Brain / Tooth Abscess, Pharyngitis, Otitis / Mastoiditis, Cavernous Sinus Thrombosis • Vascular • SAH, ICH, CVA, Carotid/Vertebral Dissection, Migraine, Cluster, Arteritis • Mechanical / Structural • Tension, Tumor (pseudo), Glaucoma, TMJ • Traumatic / Toxin • SAH, SDH, EDH, Post-Concussive, CO, Withdrawal

  12. Case #3 • What is the pertinent history and PE • in this patient? • History according to the DDx especially defining the onset and intensity of headache and comparison to previous headaches plus infectious sources • Physical exam should include ??

  13. Complete neurological, mental status, HEENT and neck exams

  14. Case #3 • Exam reveals a diaphoretic, warm confused patient • VS: 116/88 – 114 – 24 – 101.4 • HEENT – unremarkable, no sinus tenderness or purulent discharge or other source of infection • Neck – supple without Kernig’s / Brudzinski’s • Neuro – non-focal, intact exam What would you like to do now?

  15. Case #3-Meningitis • Headache, fever, stiff neck in 66% of adults; also consider with AMS, seizures, signs of increased ICP, focal deficits and petechial rashes; infants, immunocompromised, partially treated and elderly may not have a fever or stiff neck • Maintain a high index of suspicion….if the idea of meningitis even enters your mind, do a LP! • Door to Antibiotic Time?

  16. Case #3-Meningitis • Send CSF for protein, glucose, gram stain, culture, cells, cryptococcal antigen, latex agglutination (if antibiotics given) and Herpes PCR if indicated • CT scan before LP if focal neurologic signs, signs of increased ICP or obtunded patient who can’t cooperate with a neurologic exam • Very young and old: Ampicillin and gentamicin +/- acyclovir; all others: ceftriaxone or cefotaxime +/- vancomycin • Steroids in adults? van de Beek D, de Gans J, McIntyre P, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev Issue 1. 2007

  17. Case #4 47 year old male smoker presents c/o a productive cough for 4 days. He denies fever, chills, chest pain or SOB. He does note some occasional purulent, blood tinged sputum but denies night sweats or weight loss. His PMH is significant for HTN. DDx? What would you like to do?

  18. Case #4 • VS: 144/88 – 88 – 16 – 99.2° - 98% on RA • Gen: Non-toxic appearing, coughingLungs: CTA w/o rales, rhonchi, wheezesHeart: RRR w/o gallop, murmur, rubExtremities: no edema or calf tenderness Your orders?

  19. Case #4 – Acute Bronchitis • Most adults have viral bronchitis (NO ABX) and can be treated with inhaled -agonists (persistent cough is due to low level bronchospasm) +/- HC/APAP • It is recommended that smokers and patients with underlying lung disease receive antibiotics as ~ 20% may have bacterial bronchitis • Use antibiotics active against upper respiratory pathogens: macrolides, doxycycline, TMP-SMX, ampicillin x 5 days Cochrane Database Syst Rev. 2009

  20. Case #5 67 year old female presents c/o fever, chills, right-sided pleuritic chest pain and a productive cough for 3 days. Her PMH is significant for HTN, DJD, CHF and an MI 3 years ago. How is this patient different from the previous patient?

  21. Case #5 • VS: 162/92 – 126 – 36 – 102.7° - 91% RA • Gen: Toxic appearing patient in moderate respiratory distressLungs: CTA except rales at the left base Heart: Tachycardic w/o gallops, murmurs What is your workup and therapy?

  22. Case #5 - Pneumonia • Set up safety net: IV, O2, monitor • CXR and EKG (consider enzymes if CP, AMS, coexistent new onset CHF, DM) • Blood and sputum cultures (after saline neb) • CBC, CMP, +/- ABG ( oxygen saturations < 90% on RA or desaturation with exertion are reasons for admission regardless of PORT scores)

  23. Case #5 – Pneumonia Scoring • Age (males = years, females = age – 10) • Nursing home resident (10) • Comorbid Illness • Neoplastic Disease (30) • Liver Disease (20) • CHF (10) • Cerebrovascular Disease (10) • Renal Disease (10)

  24. Case #5 – Pneumonia Scoring • Physical exam findings • • AMS (20) • RR > 30 (20) • SBP < 90 (20) • • Temp <35° > 40° (15) • Pulse > 125 (10) • Laboratory or Radiographic findings • Arterial pH < 7.35 (30) • BUN>30 (20) • Na < 130 (20) • Glu>250 (10) • Hct < 30 (10) • PO2<60 (10) • Pleural Effusion (10) • >91 points = hospitalize, 71-90 = observation

  25. Case #5 - Pneumonia • Outpatient Therapy: • Healthy / no risk for DRSP: macrolide or doxycycline • Comorbidities or risk for DRSP: respiratory fluoroquinolone (moxi, gemi, levo) or -lactam (extended spectrum cephalosporin, Amp/Cl, high dose Amp) plus macrolide or doxycycline (ATS/IDSA) • Inpatient / Non-ICU Therapy: same as high risk • ICU Therapy: • -lactam + azithromycin or pulmonary fluoroquinolone • for Pseudomonas (NCAP/vent):piperacillin-tazobactam, cefepime, imipenem, or meropenem plus cipro/levo or azithro/ aminoglycoside

  26. Case #6 36 year old male presents c/o loose stools for 2 days and crampy abdominal pain. He is otherwise healthy and is on no medications. What historical and PE findings are important in this patient?

  27. Case #6 • Mexico • South America • Colorado • Day-care • Recent antibiotics • Shellfish • Fried-rice • HIV: another lecture by itself (call ID!) • PE: fecal blood, fever, hydration status, abdominal exam looking for other non-infectious causes

  28. DDx of Acute Diarrhea • Inflammatory bowel disease • Irritable bowel syndrome • Partial SBO / Colon cancer • Mesenteric ischemia • Ischemic colitis • Milk / food allergies • Sprue • Drugs / heavy metals / mushrooms • Carcinoid • Thyrotoxicosis / Addisonian crisis

  29. Case #6 –Workup / Therapy • IV versus PO rehydration if dehydrated • Rarely do you need labs in young healthy people or those with short duration of symptoms • Stool cultures only for surveillance purposes (poor sensitivity and expensive); O&P should be gotten by GI in F/U of chronic diarrhea • C. difficile toxin in patients with recent ABX or persistent symptoms; fecal leukocytes may be useful in equivocal cases

  30. Case #6 - Etiologies • Viral (50-70% of all cases) – supportive care • Invasive Bacteria: Campylobacter, Shigella, Salmonella, Yersinia, E. coli, +/-Vibrio – treat with ciprofloxacin or TMP-SMX as alternative • Toxin-Induced: E. coli, S. aureus, B. cereus, C. difficile, A. hydrophilis, Cholera – supportive care except C. difficile (metronidazole)

  31. Case #6 - Therapy • Most cases are self limited only requiring hydration • Anticholinergics (diphenhydramine) and anti- spasmotics (dicyclomine) for cramps if severe • For debilitating diarrhea use loperamide (use of diphenoxylate is associated with toxic megacolon) • Recent literature suggests that the incidence of worsening diarrhea due to lactose intolerance associated with milk product ingestion is rare

  32. Case #7 • 24 year old male prisoner presents with a spider bite he sustained 2 days ago

  33. Case #7 – A Rare Brown Recluse Bite

  34. MRSA

  35. Case #7 • Most of these are abscesses from the dreaded “MRSA” spider • Risk factors: prisoners, families with recurrent infections, athletes especially close contact sports, shelter dwellers, recurrent infections in an individual • Normal I&D, isolation if admitted • TMP/SMX, Clindamycin, Vancomycin

  36. Questions ?

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