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Rapidly Fatal Infections

Rapidly Fatal Infections. Eric D. Katz, MD, FACEP Program Director Vice-Chair for Education. You’ve seen this patient…. 40 y.o. male Temp 39.0, BP 60/palp, HR 140 (ST) Multilobar pneumonia How do you treat him? Did I mention his immunocompromise? What if he has MRSA risks?

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Rapidly Fatal Infections

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  1. Rapidly Fatal Infections Eric D. Katz, MD, FACEP Program Director Vice-Chair for Education

  2. You’ve seen this patient… • 40 y.o. male • Temp 39.0, BP 60/palp, HR 140 (ST) • Multilobar pneumonia How do you treat him? Did I mention his immunocompromise? What if he has MRSA risks? This could easily be rapidly fatal

  3. You might have seen this patient • 40 y.o. male • Temp 39.0, BP 60/palp, HR 140 (ST) • Recent travel to Mexico • CXR shows diffuse interstitial process How do you treat him? Is this rapidly fatal?

  4. By the end of this lecture you will: • Understand how our diagnoses of infectious disease may advance over the next few years • Understand 3 rapidly fatal infections • Understand clinically useful tips to identify rapidly fatal infections from non-threatening diseases

  5. The future of managing infectious diseases Changing our diagnostic abilities

  6. Short incubation culture systems • Now on the market • Faster detection of infection and rapid susceptibility testing • Sensitivity variable • Poor detection of resistance

  7. Direct Antigen Testing • Available for legionella, hemophilus, strep and mycoplasma • Sensitivity and specificity are very variable • Use in clinical practice not defined • At best level 2C indication

  8. Proteonomics Assessment of upregulation and downregulation of several thousand proteins in different disease states. Role in clinical care not established.

  9. A Rapidly Fatal Infection First Case 52 yo DM male had minimal trauma to chest 4 days ago. Then developed spreading redness on chest wall, which has progressed to a painless lesion.

  10. Necrotizing Fasciitis • Usually in middle-aged patients • Young patients often infected after slight trauma • Rising incidence likely from more immunocompromised patients and injection drug users • DM, Cancer, EtOH, PVD, transplant, HIV, neutropenia

  11. Necrotizing Fasciitis • Begins as cellulitis, then progresses to involve fat, fascia and muscle • Bugs: Often polymicrobial. Very often with synergistic organisms Up to 70-80% Mortality rate

  12. Necrotizing Fasciitis - Detection • Early • May show mild superficial skin changes – sharp demarcation of erythema and very rapid spread • POOP • Late • Pain progresses to anesthesia • Extensive edema • Crepitus • Cyanosis

  13. Necrotizing Fasciitis - Early

  14. Necrotizing Fasciitis

  15. Fournier’s Gangrene • A variant of necrotizing fasciitis involving the perineum, perianal or genital areas • Ofter preceded by local infection, surgery, trauma or foreign body. • Differs from other NF • Older onset • Delay to seeking treatment (5 days)

  16. Fournier’s Gangrene

  17. Necrotizing Fasciitis - Odor X

  18. Necrotizing Fasciitis: Diagnostics • Find the gas! • XR: good PPV, poor NPV • Possible role for ultrasound • On CT, absence of tissue enhancement after IV contrast suggests necrosis • CT may help surgeons with planning

  19. Sub-cutaneous air on XR

  20. CT

  21. Necrotizing Fasciitis and Fournier’s

  22. Necrotizing Fasciitis - Treatment • Antibiotics • Coverage for GPC, GNR and clostridia • Some suggestions for clinda to decrease toxin A from clostridia • carbopenem + clinda • vancomycin + aminoglycoside + clinda • Fluid replacement/ shock managment • Surgery a. < 3 hours preferable, but definitely < 12

  23. Necrotizing Fasciitis - Outcomes • Very dependent to extent of involvement and time to diagnosis. • Mortality of 15-65% • Some suggestion of improvement with hyperbaric oxygen

  24. Necrotizing Fasciitis Take Home Points Sharply demarcated erythema Pain out of proportion to exam Central anesthesia Rapid spread Get the surgeon fast!

  25. Specific Diseases Not to Miss Second Case • 14 yo male develops malaise, fever, headache, and nausea. 12 hours later he develops lethargy, confusion and delirium. • In your ED he complains of headache before he becomes aphasic and seizes.

  26. CT

  27. Encephalitis Cerebritis Meningitis

  28. Encephalitis - onset • Usually have a prodrome of • Fever • HA • N/V • Lethargy • Myalgias • Present with altered mental status and possibly focal neuro deficits • behavior and speech changes are common

  29. Encephalitis - usual suspects • HSV – reactivation • Arbovirus – ticks or mosquitoes • Rabies – mammal • VZV, CMV, Toxo – immunocompromised patients • Geography matters: SLE, EEE, WNE, JE, etc.

  30. So if you suspect it… • Start Acyclovir for HSV or VZV • WE FORGET THIS STEP VERY OFTEN • Low risk drug • Without treatment, HSV mortality 50-75% • With treatment, 30% mortality • Mortality higher in <1yo or >55yo • VZV potentially lethal in immunocompromised patients • Toxo and CMV are treatable but less aggressive

  31. The LP • Antivirals are OK before LP • PCR for HSV available • Specific 100%, sensitivity 75-98% • Viral serologies for arbovirus, SLE, JE, WNE • Toxo titers • Persistent RBC in CSF • Gram stain negative

  32. Clinically, watch for: • Cerebral edema a. possibly helped by lasix, dexamethasone, hyperventilation • Shock, hypoxia • Hyponatremia (SIADH) Imaging only helpful to evaluate safety of LP and look for other causes

  33. EncephalitisTake Home Points Long prodrome followed by rapid neurologic deficits – especially speech Acyclovir for meningitis patients Watch for cerebral edema and SIADH

  34. Differentiating our last case from the next one Case 3

  35. Specific Diseases Not To Miss Third Case 20 y.o. CF just arrived home from college and presents with headache for one day. Mom thought she was under stress until she got a fever and had AMS.

  36. While you are watching, her skin changes

  37. Meningitis • Common bacteria are evolving rapidly. • Most common in adults: • Strep pneumo • Neisseria meningitides • Listeriamonocytogenes

  38. What do we all know? • Rapidly fatal – especially if untreated a. Increase mortality with age>60, seizures, and severe AMS • Treatment should proceed LP

  39. First controversy • CT before LP or just LP? Definitely CT if a. >60 b. AMS c. abnormal neuro exam d. hx of cancer/immunocompromize e. papilledema

  40. Second controversy Corticosteroids? Early reports: no mortality benefit Later: decrease complications (especially hearing loss, brain damage, learning disabilities and retardation)

  41. Third Controversy • Who gets prophylaxis? • Members of the same house or daycare • Those with direct contact of oral secretions • Current Regimens • Cipro – 400mg PO once • Rifampin – 600mg PO q12 for 4 doses

  42. Antibiotic selection

  43. Why are we using vanco for everyone? • HiB vaccine shifted causative agent • Increasing prevalence of PCN and cephalosporin resistance • So… for everyone >1month, they get vanco • Supported by AAP, IDSA

  44. Some quick abx facts • <1 month – S. agalactae, E. coli, L. monocytogenes, Klebsiellas • no ceftriaxone • Amp + Cefotaxime, Amp + aminoglyc • HSV coverage

  45. Kids 1-23 months • S. pneumo, N. meningitides, H. infl, S. agalactae, E. coli • Easy coverage for all: • Vanc + 3rd gen cephalosporin

  46. 2-50 years old • S. pneumo, N. meningitides • Easy treatment • Vanc + 3rd gen cephalosporin

  47. 50+ S. pneumo, N. meningitidis, L. mono and aerobic GNB Vanc + 3rd gen cephalosporin If history of recent gram negative infection, change 3rd generation to cefipime

  48. Take home points: Meningitis Treat early and with low suspicion Consider skipping CT’s in VERY selected patients Consider a loading dose of decadron Vanco with 3rd generation cephalosporin for >1 month old

  49. So in summary Lots of rapidly fatal infections out there Most are detectable early Early treatment converts many of them to less fatal infections

  50. Take home points: • Necrotizing Fasciitis – Pain/Fever OOP or anesthesia • Encephalitis – Get acyclovir early in suspected CNS infection • Meningitis – steroids, early abx

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