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Diagnosis and Treatment of Common Infectious Diseases

Diagnosis and Treatment of Common Infectious Diseases. Angela Heithaus, MD, PS Internal Medicine Seattle Healing Arts Center. Gioconda.

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Diagnosis and Treatment of Common Infectious Diseases

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  1. Diagnosis and Treatment of Common Infectious Diseases Angela Heithaus, MD, PS Internal Medicine Seattle Healing Arts Center

  2. Gioconda • 20 YO non-pregnant UW female student sexually active 3 x week with 1 partner over past 6 months (he is asymptomatic), no prior medical history including STD • C/O: pain on urination x 3 days with increased frequency and urgency, some suprapubic pain, no: blood, back pain, vaginal d/c, fever

  3. Epidemiology • First 10 years of life: • Girls 3% Boys 1.1% • Teen girls 0.5 episodes/year • Adult women 50-60% at least 1 episode/life time • Young, sexually active women 0.5 episodes/ person year • Post-menopausal women 0.07% episodes per person per year

  4. UNCOMPLICATED Healthy, young, non-pregnant female COMPLICATED Everything else: men, recurrent UTI, pyelo, in-dwelling catheters, pregnant, diabetic Increased risk of failing therapy UTI

  5. Microbiology • 80-85% Escherichia coli • Staphylococcus saprophyticus, Proteus mirabilis, enterococci • Chlamydia-(acute urethral syndrome) • Negative standard culture

  6. Diagnosis in Uncomplicated UTI • PEx • Nl temp • No costovertebral angle tenderness • Clinical Criteria • Dipstick: leukocyte esterase (pyuria) and nitrite (Enterobacteriaceae) 75-96% sensitivity; 94-98% specificity for detecting >10 leukocytes per HPF • Evaluation of mid stream urine (unspun) for pyuria is most valuable laboratory diagnostic test (abnl: 10 or more leukocytes per microL)

  7. Selected Oral AB Regimens for Use in Uncomplicated UTI

  8. Giovanni Battista Morgagni • 22 YO M C/O (not: homeless, recently incarcerated, IDU, in military, on athletic team or have family member with infection): • Local pain, swelling, redness • ? Drainage • ? Hit something a while ago • Denies: fever, chills

  9. Skin and Soft Tissue Infections • Cellulitis • Most common skin infection leading to hospitalization • Superficial, spreading infection involving subcutaneous tissue • Other Common Skin Infections • Impetigo, Folliculitis, Furuncles, and Carbuncles • Abscess

  10. Impetigo, Folliculitis, Furuncle, Carbuncle • Impetigo: superficial vesiculopustular skin infection occurring prominently on exposed areas of the face and extremities • FFC: arise from hair follicle • Staph Aureus • Rarely require hospitalization • Respond to local measures • Recurrence may be prevented by decreasing staph aureus skin carriage

  11. Abscess • Localized accumulation of polymorphonuclear leukocytes with tissue necrosis involving the dermis and subcutaneous tissue • Large numbers of microorganisms are typically present in the purulent material • Infection begins from tracking in from the skin surface

  12. Microbiology • Most common microorgansim: Staph Aureus • Increased incidence of community-associated infections due to: methicillin-resistant S. Aureus (CA-MRSA) • Urban ER: 61/119 MRSA isolated • An average of more than 3 organisms; anaerobic in 1/3 of cases (1/2 IDU)

  13. Management • Incision, Drainage and culture • Fluctuant or has ‘pointed’ • Culture ?MRSA • Bacteremia and Antibiotic Prophylaxis • AHA guidelines for those high risk for EC and who have hardware (oxacillin, cefazolin, vanco) • Oral Antibiotic Therapy • Not ready for I&D, cellulitis, fever, high-risk features • Community Associated MRSA • Awareness of the local antimicrobial susceptibility patterns of community S. aureus isolates

  14. Oral Antibiotic Therapy • Oral, peri-rectal, vulvovaginal abscesses • Amoxicillin-clavulanate 875/125 mg BID • Clindamycin 150 mg QID • PLUS Ciprofloxacin 500 mg BID

  15. Galileo Galilei • 40 YO otherwise healthy, non-smoker C M presents C/O: • dry cough x 2 weeks • clear sputum production and fatigue • Denies: pharyngitis, fever, chills • Vitals: Nl temp, RR, P

  16. Acute Bronchitis • Over 90% are viral • Approximately 60% of patients seeking medical care are given antibiotics • One of the most common causes of antibiotic abuse • ACP and CDC state Pertussis is only form that should be treated

  17. Usual Suspects Coronavirus (types 1-3) Rhinovirus Influenza A and B Parainfluenza Respiratory syncytial virus Human metapneumovirus

  18. Influenza • Cough, purulent sputum, fever, and constitutional complaints during the influenza season • Amantadine, rimantadine, or neuraminidase inhibitors • Must be given within 48 hours of symptom onset for demonstrable benefit

  19. Other Suspects • Mycoplasma pneumoniae • Chlamydophila (formerly Chlamydia) pneumoniae • Bordetella pertussis (severe paroxysmal cough)

  20. To Shoot or Not to Shoot Pneumonitis vs Acute Bronchitis Abnl vital signs: temp > 38 C (100.4 F) Pulse > 100/min RR >24 Crackles on exam

  21. Chronic CoughThink… • Postnasal drip syndrome • Asthma • Gastroesophageal reflux

  22. Beatrice • 28 YO otherwise healthy female who C/O: • nasal congestion, purulent nasal discharge, maxillary tooth discomfort, hyposmia, and facial pain or pressure that is worse when bending forward, headache, fever (nonacute), halitosis, fatigue, cough, ear pain, and ear fullness

  23. Acute Sinusitis • Almost all cases viral in etiology • Rhinovirus, parainfluenza, and influenza virus • Usually resolves in 7-10 days • 2% complicated by acute bacterial sinusitis • Streptococcus pneumoniae and Haemophilus influenzae • Self-limited, 75% resolve without tx in 1 month • Morbidity can include intracranial and orbital complications and of possibly developing chronic sinus disease

  24. How many get it? • Average adult has from 2-3 colds and influenza-like illnesses per year • Average child six to 10 • Represents approximately one billion acute respiratory illnesses annually • Approximately 0.5 to 2 percent of colds and influenza-like illnesses are complicated by acute bacterial sinusitis in adults • Annual incidence of acute community-acquired bacterial sinusitis is approximately 20 million cases

  25. CDC Maxillary pain or tenderness in face or teeth + rhinorrhea, no improvement x 7 days Severe sxs Plain films not needed Sinus & Allergy Health Partnership Persistant sxs after 10 days or worsening after 5-7 days Nasal drainage, congestion, d/c; facial pressure/pain; hyposmia/anosmia; fever; cough; ear sxs Plain films, CT, MRI not needed Comparison of Contemporary Guidelines for the Diagnosis of Acute Community Acquired Bacterial Sinusitis

  26. Treatment of Viral Rhinosinusitisin Adults • At first sign of a cold • Sustained release 1st generation antihistamine (chlorpheniramine, brompheniramine, clemastine), PLUS NSAID (ibuprofen, naproxen) • Continue taking both q 12 hrs until sxs clear • Add oral decongestant (pseudoephedrine) and/or a cough suppressant (dextromethrophan) • If sxs persist and are no better or worse after 7-10 days, consider antibiotic therapy

  27. CDC Only those meeting clinical dx criteria Narrow spectrum agents Amoxicillin 1.5-3.5 g/d Doxycycline 100mg BID TMP-SMX 1DS BID Sinus & Allergy Health Partnership Mild disease, - AB 4-6 wks Amoxicillin Amoxicillin-Clavulanate Cefpodoxime Cefuroxime axetil Mild disease +AB or moderate disease – AB in 4-6 wks Any of above or Levofloxacin or gatifloxicin Moderate +AB in 4-6 wks Amoxicillin-Clavulanate or Levofloxacin or gatifloxicin or Combo tx with amoxicillin or clindamycin PLUS cefpodoxime or cefixime Comparison Guidelines for the Treatment of ACA Bacterial Sinusitis

  28. Intranasal Steroids • Use is not recommended • OK in treating chronic sinus disease • Steroid therapy increases viral concentrations in nasal secretions in cases of viral rhinosinusitis

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