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SEPSIS - MENINGITIS - MALARIA

SEPSIS - MENINGITIS - MALARIA. Pr. B. Vandercam Consultation Maladies Infectieuses et Tropicales Cliniques Universitaires St-Luc Octobre 2004 . Sepsis. Focus Absence of focus Purpura fulminans Community acquired sepsis immunocompentent adult Nosocomial sepsis immunocompetent adult

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SEPSIS - MENINGITIS - MALARIA

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  1. SEPSIS - MENINGITIS - MALARIA Pr. B. Vandercam Consultation Maladies Infectieuses et Tropicales Cliniques Universitaires St-Luc Octobre 2004

  2. Sepsis • Focus • Absence of focus • Purpura fulminans • Community acquired sepsis immunocompentent adult • Nosocomial sepsis immunocompetent adult • IV DU • Asplenic (anatomic or functional) • Neutropenia • Toxic shock syndrome

  3. Working definitions associated with sepsis and related disorders

  4. Source of infection • Anamnesis (pets, travel, household, …) • Physical examination (purpura, scar …) • Blood culture Urine culture RX thorax Echo (scan abdo) obstacle abscess collection Echo cardio

  5. Activated protein C (- 6 %) • Corticosteroids (low (HC 200-300 mg/day) - long (5-7d)) • Intensive insuline therapy (- 17%) • Volume resuscitation (- 15%)

  6. Prior medicare database analyses • MEEHAN T. Jama 1997; 278:2080 Mortality increased significantly with delay in first Abx dose > 8 hrs (registration to dose) • GLEASON PP. Arch Intern Med 1999, 159:2562 Mortality based on abx (OR) Cephalosporin 1.0 Cephalosporin + mac 0.76 Fluoroquinolone 0.64

  7. Method : review of Medicare database for patients > 65 yrs hospitalized with x-ray confirmed CAP • Period reviewed : July ’98 - March ’99 • Patients : 13 771 • PSI score : III - 47 % IV - 24 %

  8. Results

  9. Skin lesions and systemic infections

  10. Purpura fulminans : treatment • Cefotaxime 2 gr q 4 - 6 h or Ceftriaxone 2 gr q 12 h • Allergy Vanco 1 gr q 12 h + Aztreonam 2 gr q 6 h or Moxifloxacin 0,4 gr q 24 h or Levofloxacin 0,5 gr q 12 h

  11. Community acquired sepsis - immunocompetent adults • Infecting organisms • Enterobacteriacae • Staph aureus • Strept pneumoniae & spp • N. meningitidis • Bacteroides spp • Treatment • Cefotaxime or Ceftriaxone • Amoxi clav or cefurox + amino

  12. IVDU • Infecting organisms • Staph aureus • Exclude endocarditis • Previous antibiotherapy • Treatment Oxacilline 2 gr q 6 h or Vancomycine 1 gr q 12h + Genta 2,5 mg/kg q 12 h

  13. Asplenia • Overwhelming sepsis • Stand by therapy • Amoxi clav • Allergy, travel --> Moxifloxacin, Levofloxacin • Vaccination • Antibioprophylaxis

  14. Asplenia sepsis • Infecting organisms • S. pneumoniae • H. influenzae • N. meningitidis • Capnocytophaga spp • Treatment • Ceftriaxone or Cefotaxime

  15. Nosocomial *sepsis - immunocompetent adult • Infecting organisms • Enterobacteriacae • S. aureus • Strep pneumoniae • Bacteroïdes spp • P. aeruginosa • CNS * readmission - nursing home

  16. Nosocomial sepsis • Local epidemiology • Colonization • Previous antibiotherapy • IV line • Urinary catheter • Invasive procedure

  17. Treatment • Vancomycin ? • Cefotaxime or Ceftriaxone or Pip/tazo + amino • Ceftazidime or Cefepime or Carbapenem + amino

  18. Sepsis neutropenia • Infecting organisms • Strepto spp • CNS • S. aureus • Enterobacteriacae • P. aeruginosa • Colonization • Previous antibiotherapy

  19. Neutropenia « Low risk » Amoxi clav 2 gr q 6-8 h + Cipro 750 q 12 h OR Ceftriaxone 2 gr q 12 h + Amikacin 15-25 mg/kg q 24 h

  20. Neutropenia « High risk » • Ceftazidime 2 gr q 8 h • Cefepime 2 gr q 8 h • Pip/tazo 4 gr q 6 h • Imipenem 750 mg q 6 h • Meropenem 2 gr q 8 h + amino ???

  21. Toxic shock syndrome • Infecting organisms • Strepto A, B, C, • Staph aureus • Treatment • Cefazoline 2 gr q 8 h + Clindamycine 600 mg q 8 h

  22. Clinical diagnosis • Fever sensitivity 85% • Menigism 70% • Altered mental status 60% • Kernig Sensitivity 5% Specificity 95% Poser la question = y répondre

  23. Case presentation • 25-year-old man • 2-day history of severe headache, fever, neck stiffness • 38,3 °C • No rash • Normal mental status and neurologic examination • Pain on neck flexion but able to flex his neck fully • No Kernig and Brudzinski signs

  24. Contraindications of lumbar puncture • Known or suspected space-occupying lesions with mass effect  LP deferred until CT scan • Severe uncorrected coagulopathy (INR > 1.5) • Trombocytopenia (platelet count < 50 000/mm³) • Infection at the puncture site (decubitus ulcer) - Glasgow < 13 - Shock

  25. When should a computerized tomography scan precede a lumbar puncture ? • Age over 60 years • Immunocompromised state • History of primary neurologic disease, head trauma, neurosurgery • History of seizure within the past week • Altered mental status, cilated or poorly reactive pupils, occular palsy and focal neurologic abnormalities • Papilledema, bradycardia, irregular respiration • History of cancer • Suspicion of brain abscess (endocarditis, bacteremia …) Empiric anti infective therapy without delay

  26. CSF examination • Gram stain - Ziehl - Ink • Culture (bacteria, fungi, brucella, nocardia …) • Bacterial antigens • if antibiotherapy • Gram or culture negative • PCR virus + BK • Blood culture 60 % + in acute bacterial meningitis

  27. CSF characteristics in selected neurologic conditions

  28. Purpura, petechia  N. meningitidis • Cellulitis face  S. aureus H. influ • VRS, VRI  S. pneumoniae H. influ • Parotitis  Mumps • Endocarditis  S. aureus • Septic arthritis  S. pneumoniae S. aureus • Pregnancy  Listeria

  29. Acute meningitis treatment • IV line - blood cultures • AB + dexa 10 mg within 30 min(*) • LP if no contraindication • Chest x-ray • Delta scan if needed (*) S. pneumoniae : 4 h N. meningitidis : 2 h LCR

  30. Antibiotherapy • Listeria : ampi or CTX • S. pneumoniae : peni i 10% cef 3 i 1% • H. influ :  vaccination

  31. Antibiotherapy dosage Penetration - bactericide - CMI • Cefotax 2 gr -(4 gr) q 4h (ratio 25%) • Ceftriaxone 2 gr q 12h (ratio 15 - 30%) • Ampi 2 gr q 4h (ratio 10 - 15%) • Cefepime (ratio 10%) • Ceftazidime (ratio 20 - 40%) • Cotrimoxazole (ratio 30 - 35%)

  32. Antibiotic therapy in meningitis • IV from the beginning to the end … • Standard therapy • 7 days for N. meningitidis • 10 - 14 days for S. pneumoniae • (14) - 21 days for L. monocytogenes

  33. Meningitis : child > 3 months - adults < 50 yrs • Infecting organisms • S. pneumoniae • N. meningitidis • H. influ • L. monocytogenes • Treatment • Cefotaxime + ampicilline • Ceftriaxone + ampicilline

  34. Meningitis : alcoohol - adults < 50 yrs Cellular immune deficiency - Debilitating illness • Infecting organisms • S. pneumoniae • L. monocytogenes • N. meningitidis • Gram negative bacilli • Treatment • Cefotaxime + ampicilline • Ceftriaxone + ampicilline

  35. Meningitis : HIV /AIDS • Infecting organisms • C. neoformans • S. pneumoniae • M. tuberculosis • L. monocytogenes • T. pallidum • N. meningitidis • HIV

  36. Meningitis : cerebrospinal fluid shunt • Infecting organisms • Coag neg staph • S. aureus • Diphteroids • Enterobacteriaceae • Treatment • Vancomycin + cefta

  37. Meningitis : after cranial or spinal trauma • Infecting organisms • S. pneumoniae • H. influ • Treatment • Cefotaxime or Ceftriaxone

  38. Meningitis after cranial or spinal trauma (> 4 days) • Infecting organisms • Enterobacteriaceae • S. aureus • P. aeruginosa • S. pneumoniae • Treatment • Vancomycin + ceftazidime

  39. People on the move: demographics year 2003 • 175 million persons live outside of their country of origin (2,9%) of the world's population • Population of concern to UNHCR: 21,6 million • Refugees 11,7 million • Internally displaced persons: 20-30 million • Rural to urban migration: 20-30 million/year • 1-2 million migrate permanently every year • 700 million tourist arrivals/year

  40. Malaria risk pyramid for 1 month of travel without chemoprophylaxis • Oceania 1:5 • Africa 1:50 • South Asia 1:250 • Southeast Asia 1:2500 • South America 1:5000 • Mexico and Central America 1:10 000 01643

  41. Délai d’apparition de malaria selon espèce Schwartz NEJM 2003; 349, 1510

  42. Malaria en Belgique Institut de Santé Publique-Louis Pasteur

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