6/28/2011

Sepsis

• SIRS –systemic response • PIRO severity staging – Temp >38C (<36C) • TLR 4 –LPS (Gm‐) – HR >90bpm, RR >20bpm • TLR 2 –PGN, LTA (Gm+) Infectious Diseases (PaCO2<32mmHg) – WBC >12k or >10% bands • Fever, , DIC, ARDS, azotemia, olyguria, • Sepsis = SIRS + Infection cellulitis, purpura, GI HIHIM 409 • Severe Sepsis = Sepsis + bleeding, jaundice Organ Dysfunction • Procalcitonin diagnostic? • Septic Shock = Sepsis + • Tx: ATB, supportive, Hypotension Activated Protein C (Xigris)

Fever / Hyperthermia Bioterrorism

Anthrax (Cutaneous) Botulism (Inhalation) Fever Hyperthermia Bacillus antracis Bacillus antracis • Hypothalamic setpoint • Hypothalamic setpoint • Direct contact with spores • Inhaled spores, no person‐ shifted up by PGE2 unchanged • Jet black lesions (eschars) to‐person transmission stimulating EP‐3 • Does not respond to NSAIDS on skin within 7‐10d • Incubation: 1w to 2 months • Pyogenic cytokines • Heat stroke, • Incubation 1d • Mediastinal widening, • , drugs, PE, DVT, hyperthyroidism, atropine, pleural effusion, infiltrates C. difficile, fungal infection, ecstasy, malignant • Tx: Cipro or Doxy q 60d • Initial symptoms improve, MI, NG tubes, IV catheters hyperthermia, serotonin • Vaccine: attenuated Ag abrupt onset of fever/ARDS, syndrome shock/death within 24‐36h • Tx: Penicillin or Cipro/Doxy

Bioterrorism Bioterrorism

Anthrax (GI) Botulism Bacillus antracis Clostridium botulinum • Ingested spores, no person‐ • Most poisonous toxin on • Rice‐water diarrhea, • Affects horses, mules, to‐person transmission earth dehydration, shock donkeys • N/V, severe abd pain, • Not contagious, spread by • Incubation 12h‐5d • Enters cut skin, mucous bloody diarrhea, possibly aerosol/food • Food/water spread membranes, inhalation mediastinal widening, • 12‐72 h incubation rebound tenderness, ascites • N/V, diff see, swallow, speak • Incubation: 1‐7d • Muscle weakness/paralysis

• Tx: Penicillin or Cipro/Doxy

1 6/28/2011

Bioterrorism Bioterrorism

Plague Smallpox Yrsinia pestis Variola major • “Black Death”, infected • Nonspecific febrile • Officially eradicated • One of most infectious • Bubonic –1‐10 cm buboes on syndrome, pneumonia bacteria in world skin w/ edema, flu‐like • Incubation 10‐14d symptoms w/ abd pain • Hepatitis, endocarditis, • High fever, HA, backache, • Tick/insect bites • Septicemic ‐ secondary granulomatous • septicemia, thromboses in vomiting, rash on palm/sole Incubation 10‐14d acral v. leading to necrosis complications • Highly contagious • Fever, chills, HA, cough, • Penumonic – acute fulminant • Tx: Doxycycline 14‐21d • lethargy, skin ulcers, lymph‐ symptoms, nearly 100% No tx, vaccine within 3‐5d mortality rate adenopahty • Tx: Streptomycin or Doxycycline

Bioterrorism Bioterrorism

GB Sarin VX Ricin • Binary weapon –two non‐ • 1000x more toxic than GB • Waste leftover from lethal reagents mix to form • Persists in soil for 6d processing castor beans sarin gas • Binary weapon • V/D, dehydration, • Inhibit ACHe, phosphonate • Inhibits ACHe, phosphonate hypotension, hallucinations, esters, light brown oil esters, light brown oil seizures, hematuria, • multiple organ dysfunction If mild: dim vision, • If severe: stop breathing, salivation, chest tightness paralysis, seizures, LOC • No tx available • Tx: Atropine and 2PAMCl

Bioterrorism Bioterrorism

• Needs Immediate Treatment, Suspect … • “Active” Research • “Secretly” Developing – Respiratory Symptoms – Algeria – China • Acute: Cyanide – Egypt – Russia – Also nerve agents, mustard, lewisite, phosgene, SEB – India • “Former” Programs • DlDelaye d: AhAnthrax, , TTlularem ia – Iran – Canada – Also Q Fever, SEB, ricin, mustard, lewisite, phosgene – Israel – France – Neurological Symptoms – N. Korea – Germany • Acute: Nerve agents – Pakistan – Japan – Also cyanide – Syria – S. Africa • Delayed: Botulism – Taiwan – UK, US – Also VEE‐CNS

2 6/28/2011

Immunocompromised Complement Deficiency

• Deficiencies in • Clues • Hereditary angioedema • DAF and CD59 – Complement – Recurrent Neisseria inf – C1 inhibitor deficiency – Paroxymal nocturnal – IG/B‐Cell – Recurrent pneumonia – Overactive complement hemoglobinuria – Phagocyte – Severe presentation – Minor stressors trigger • C1, C3, C4 deficiency – T‐cell – Pneumocystis jiroveci attacks – Recurrent pyogenic sinus – Burkholderia cepacia • C5‐9 Deficiency and respiratory infection – Non‐TB Mycobacteria – MAC lysis defect • C1q deficiency – Aspergillus – Neisseria bacteremia – 90% have SLE

Ig/B‐Cell Deficiency Neutrophil Deficiency

• (Bruton’s) X‐Linked • CVID • Neutropenia • Hereditary Cyclic N. Agammaglobulinema – Low Ig, normal B‐cell – Causes – AD, ELA2 mutation – Btk defect, no B‐cells, Ig – Recurrent sinus, • Blacks have lower counts – Multiple pyogenic respiratory infections – Predictable cycles infections – Chronic infections with • Chemotherapy patients – Aphtous stomatitis Giardia, Campylobacter • Post‐infection, sepsis – No live vaccines! – Tx: G‐CSF, sttideroids – Tx: IvIg – Tx: ATB, IVIg • Sulfa‐drugs, β‐lactams • • Hyper IgM Syndrome • IgA deficiency – Infections Chediak‐Higashi – X‐linked, normal B‐cell – Associated with CVID • Mucositis Syndrome – Low Ig but high IgM – Compensated by others • Ecthyma gangrenosum – AR, LYST mutation – Pneumocystis infections • Secondary Ig deficiencies • Disseminated candidiasis – Giant lysosomes, – T‐cells lack CD40L – Multiple myeloma, • Aspergillosis ineffective granulopoiesis leukemia, skin burns – Oculocutaneous albinism

Neutrophil Deficiency Spleen “Deficiency”

• Job’s Syndrome • CGD • Splenectomy • Decrease in circulating – Hyper IgE, impaired – Defective NADPH – Trauma, ITP, Hairy cell activated B‐cells (75%) chemotaxis oxidase, no respiratory leukemia, abscess • Risk of thalassemia > – STAT3 gene mutation burst, no killing • Hyposplenism hodgkins > sphero‐ – Facies, , skin – IfInfec tions with cattlalase – Autoimmune (Graves, cytosis > ITP > sepsis Hashimoto, SLE) abscesses, sinusitis positive organisms • Infections – Neoplasia (Hodgkin, – NBT test – S. Pneumoniae (mostly) • Myeloperoxidase (MPO) CML, Sezary) – , GNR, – Makes pus green – Amyloidosis Neisseria (less common) – Converts H2O2 to HOCl – Alcoholism, elderly, – Deficiency impairs this Crohn’s, Sickle cell

3 6/28/2011

T‐Cell Deficiency Food Safety

• DiGeorge’s • Wiskott‐Aldrich • Milk pasteurization: 72C for 15s or 63C for 30m – Deletion 22q11.2 – WASP protein – No T‐cells, hypocalcemia, – Pyogenic infections, • Botulism spores: kill with high heat + acidic velocardiofacial defects purpura, eczema • Preservatives: weak acids, nitrites, sulfites, spices • SCID – High IgA, IgE, low IgM – Combined B/T‐cell • Infections • RditiRadiation: γ‐iditiirradiation for spices, meats deficiency, lymphopenia, – Mycobacteria, norcardia, • Survival: Cold –Listeria; Chlorine – Giardia, hypogammaglobulinemia legionella, cryptococcus, – ADA, PNP, RAG1/2, Jak3 histoplasma, Cryptosporidum cysts; Anything home processed gene deficiencies pneumocystis, herpesvirus, • Outbreaks: Listeria (microwaved hot dogs), • CD4 T‐cell Deficiency cryptosporidium, toxoplasma Cyclospora (raspberries), Salmonella, ETEC – HIV, <300 CD4+/mL

Tuberculosis Mycobacterium tuberculosis, bovis, africanum Mycobacterium tuberculosis, bovis, africanum • Acid‐fast, aerobic non‐motile bacillus, reduce • Infected aerosolized droplets, milk (M. bovis), nitrates, produce niacin, slow growing replicates in middle/lower lobes alveolar • BACTEC blood culture, DAT tests using PCR space, Rasmussen’s aneurysm (pulmonary a.), • PPD (Mantoux) is killed tuberculin, positive if >15 mm, indicates prior infection (LTBI), need CXR pleural effusion, sputum with PMNs • Risks: (normal) 1st year: 3‐4%, lifetime: 5‐15% • Spread to hilar lymph nodes in macrophages (HIV infected) 1st year: 40%, +10% every year • • Tx: test susceptibility, give multiple drugs Reactivate in upper lobes, cavities form INH + RIF + ETH (+ PZA), INH prophylaxis, • Can disseminate through blood (military TB), hepatotoxicity skin lesions, HA, abd pain, osteomyelitis

Leprosy AIDS Mycobacterium leprae HIV infection

Lepromatous Tuberculoid Leprosy • Lenti‐ retrovirus, persistent viremia, infects T‐cells and macrophages (CD4 + CCR5/CXCR4) • Poor T 1 response • Strong T 1 response H H • CD4 >500 asymptomatic, 200‐500 increased • Large # of bacteria in tissue • Small # of bacteria • thrush, shingles, <200 opportunistic infections, Infectious, non self‐limiting • Self‐limiting <50 MAI, CMV • Tx: rifampicin (monthly) • Form granulomas and dapsone (daily) ‐ FREE CD4 drops 10/month on average • Transmitted by breast milk (acute), blood, semen • Thickened peripheral nerves Risk: blood 95%, pregnancy 20‐33%, MSM 10%, needlestick 1 in 300 (1 in 2400 with therapy) • Loss of sensation, lesions, peripheral nerve damage, Acute infection “mono”‐like w/ rash, ulcers, and hair loss, disfigurement w/o tonsil hypertrophy and exudate.

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AIDS HIV infection • Presents with unexplained anemia, leukopenia, • Gm‐ diplococci recurrent pneumococcal , Kaposi’s sarcoma, thrush, wasting, STD, fever • Infect columnar/cuboidal epi, PMN response, • Screen: ELISA, Confirm: Western Blot, Viral Load: pharynx, anorectal, conjunctivitis PCR, Severity: CD4 Count • SdSpread via sex and perillinatally • HAART Treatment: NRTI (AZT, 3TC), NNRTI • Dysuria w/o frequency or urgency, pain, (nevirapine, efavirenz), protease inhibitors discharge, cervicitis (PID complication) (ritonavir, nelfinavir) • Opportunistic Infections: CMV, MAC, PCP, • Dx by culturing swab for diplococci Toxoplasmosis, Cryptococcosis, Candida, PML • Tx with Ceftriaxone IM/cefixime PO

Chlamydia Chlamydia C. trachomatis, psittaci, pneumoniae C. trachomatis, psittaci, pneumoniae

• Intracellular membrane‐bound inclusions LGV (STD) Urethritis • Dx with culture, DFA (MicroTrak), ELISA, • Endemic in Africa/SE Asia/ • NGU India/S. America annual screen sexually active women <25 yo • 7‐14d incubation • Painless ulcer (heals) to • Dyy,suria, scant discharge • Tx Azihithromyc in x 1 or Doxycycline bid x 7d, lymphadenopathy (scars) to • Complications ulceration of genetalia abstinence x 7d after treatment – PID, ectopic pregnancy • Tx: Doxycycline po bid x 21d – Reiter’s syndrome ()

Bacterial Vaginosis Trichomonas Vaginalis Gardnerella or Mobiluncus • Flagellated motile protozoa • Mild to moderate thin, gray, adherent vaginal • Yellow, purulent, frothy, foul‐smelling vaginal discharge with odor, itch discharge, itch, dysuria, lower abd pain • Clue cells (squamous cells stippled with • Tx: Metronidazo le ((kok in pregnancy) bacteria) • +Whiff test (fishy smell in KOH) • Tx: Flagyl/Clindamycin (+Metronidazole in pregnant women)

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Herpes Simplex HSV‐1/2 Treponema pallidum • Vesicular lesions, grouped, painful ulcers • 1⁰ ‐ localized painless chancres (ulcerated, non‐ tender, hard, smooth clean base) • Incubation 6 days, primary disease lasts 3wks • 2⁰ (25% untreated) –3‐6 wks after chancre, • Recurrence in 90% of patients generalized rash on palms/soles, condylomata lata (flat warts), minimally pruritic • Dx by Tzanck smear (Wright stain) showing • Latency –High Ab titers, 30% progress to 3⁰ multinucleated giant cells • 3⁰ ‐ “gummas” (granulomatous lesions) • Tx: Acyclovir neurosyphilis: general paresis (insanity), tabes dorsalis (demyelination of posterior columns ‐ sensation), Argyll Robertson pupil (non‐reactive to light), gun‐barrel sight

Syphilis Treponema pallidum H. ducreyi • Congenital: affects muscle, skin, bones; saber • Painful ulcer/ragged edges, painful inguinal shins, saddle nose, Hutchinson’s teeth lymphadenopathy • Often associated with HIV infection • Dx: non‐specific VDRL, RPR (i(negative in 1⁰, 3⁰), • Incubibation 4‐7d specific FTA‐ABS test (confirmatory) • Tx: Azithromycin x 1 or Ceftriaxone IM x 1 • Tx: (1⁰, 2⁰) Benzathine – Penicillin G IM x 1 (late latent) Benzathine PCN G q week x 3 (neurosyphilis) IV PCN G q 4h

Donovanosis TORCH Syndrome • Painless destructive ulcers • Mother asymtomatic but baby has: small size, hepatosplenomegaly, rash (thrombocytopenia), • No lymphadenopathy CNS defects (encephalitis, seizures), jaundice

• Tx: Doxycycline (+aminoglycoside) • Toxoplasma • Other (syphilis, HIV) • Rubella • CMV • HSV

6 6/28/2011

TORCH Syndrome TORCH Syndrome

Toxoplasmosis Other (syphilis) Other (HIV) Rubella • Detect IgG for previous • Test all pregnant mothers • Reduce transmission by • Vaccinate mother infection, positive immunity • If positive, treat monther – Anti‐HIV therapy (zidovudine) • Highest risk when mother • If not immune: monitor for with penicillin, if allergic to during pregnancy and at birth infected in 1st trimester, no IgM (acute), avoid PCN then desensitize – Give ifinfan t antire trov ira l risk after 16 weeks therapy for 16 weeks undercooked meat, garden • Infected babies commonly – Cesarean delivery • Infected infant has patent soil, wash fruits and show bone lesions, screen – No breast feeding ductus arteriosus vegetables, handwashing CSF for neurosyphilis • Treat infected infants aggressively

TORCH Syndrome Other Congenital

CMV HSV • GBS – Perinatal infection (50%), anogenital screening • Dangerous if mother not • Perinatal infection by immune before pregnancy reactivated herpes lesions – Concern in newborn (meningitis), infant (sepsis) • If mother not immune, 40% • Reduce transmission by • VSV transmission Cesarean section – Primary infection during pregnancy very serious, especially during first 20 weeks (later is mild) • 15% infected infants have • Can treat mother with – VZV Ig given within 96h of exposure, no vaccine neurological symptoms acyclovir around birth time – (hearing loss, MR) to reduce transmission Fetal infection results in short limbs, skin scars, CNS • Education, handwashing, no • Treat infected infants with • B19 vaccine antiviral therapy – Most maternal infections do not lead to fetal infection – Infant symptoms: death, anemia w/ blueberry rash

Endocarditis Endocarditis

• Infection of the endocardial surface or valves NVE PVE • Surface disrupted, platelets/fibrin deposit on • Native Valve Endocarditis • Prosthetic Valve Endocarditis exposed collagen forming sterile thrombus, • Viridans strep most • Coagulase negative Staph common (followed by S. most common in early PVE transient bacteremia infect sterile thrombus aureus, Strep, Entero) • Late PVE similar to NVE but on low pressure side (Venturi effect), • If culture negative, can be coag neg staph still common thrombus grows, Ab cannot clear infection HACEK, intracellular • Platelets still deposit pathogens, fungi • Once established, require ATB to cure • Infection of surgical site leads to ring abscess • Two types, native or prosthetic valve endoc.

7 6/28/2011

Endocarditis Endocarditis

• Fever + murmur, persistent bacteremia • Dx: Duke –microbes on valve OR 2 major OR • Insidious onset of non‐specific symptoms 1 major & 3 minor OR 5 minor • Tx: IV Bactericidal for >4 weeks • History of heart disease, dental work (Viridans) IV PCN + aminoglycoside • SllSmall red lilesions on pall/lms/soles, Janeway are (Culture‐neg) IV Ceftriaxone non‐tender, Osler’s is tender (MRSA) Vancomycin + Gentamycin + Rifampin • Roth spots –retinal hemorrhage w/ central pallor (Entero) Ampicillin + Gentamycin (Fungi) Amphotericin B + SURGERY • Splinter hemorrhages under nails (2+ embolic event) SURGERY • Anemia, elevated ESR, TEE echo • Prophylaxis: Amoxicillin

Respiratory Diseases Respiratory Diseases

Typical Pneumonia Atypical Pneumonia Rhinitis Influenza Streptococcus pneumoniae Mycoplasma pneumoniae • Rhinovirus, parainfluenza, • Leading infectious cause of • Rusty sputum, unilobar • Dry cough, myringitis RSV, coronavirus, others death in US • Aspirated into alveolar • Inhaled, attaches to • Rhinorrhea, little cellular • Type A shifts H+N antigens space, fills with fluid and respiratory cell, bronchitis damage, self‐limiting easily, B less so PMN, then fills with blood infiltrated by plasma cells, • Symptoms peak days 3‐4, • Vaccine: 2 A strains, 1 B (2‐3d), then fill with fibrin, lasts 2‐6 wks persist 1‐2 weeks • Amantadine resistance is then resolve w/o scarring • Similar to Chlamydophila • Late August to early spring, prevalent • Asplenic, sickle‐cell, • Unusual over age 40 unrelated to temp agammaglobulinemia at risk • IgM cold agglutinins • Vaccine has 23 serotypes

Respiratory Diseases Acute Bacterial Meningitis

• S. pneumoniae • Stiff neck, Kernig’s sign Aspiration Pneumonia – vaccine covers most types (leg extension resisted • Chronic, foul sputum • N. meningitidis when supine), • Polymicrobial anaerobic, – B cause half infections Brudzinski’s sign (neck flex causes flex) microaerophilic aspirated – vaccine does not have B into lung • H. influenzae • Dx: CNS leukocytosis, positive culture • Alcoholics, seizures, – type b vaccine • • Tx: Ceftriaxone (+Vanco if tracheoesophageal fistula L. monocytogenes community acquired) are risk factors – neonates + elderly (+ampicillin if immuno‐ • Tx: Clindamycin PO x 3wks • <4w GBS, <18y H.flu, 18‐ compromised) 50y S.pneu, >50y L.mono + Dexamethasone

8 6/28/2011

Acute Viral Meningitis Chronic Meningitis

• Enterovirus • Mucosal to viremia to • Fungal • Chronic symptoms with – Kids > 2 wks old BBB crossing to – CSF glucose normal, gradual neurologic – Summer months subarachnoid space to protein >60, WBC <500 decline – CSF to inflammation Hand‐foot‐mouth • Tuberculosis • Dx: history, PE, LP disease, herpangina • Dx: LP <1000, mostly – CSF protein >>100 • HSV‐2 lymphocytes • Tx: most likely diagnosis – AFB smear, +culture – Aseptic meningitis • Tx: (enterov) nothing – Genital warts (HSV‐2) acyclovir • HIV (HIV) HAART – Aseptic meningitis

Intracranial Abscess Viral Encephalitis

• Frontal: sinus, teeth • Neurologic deficit • Non‐treatable • Altered mental status, Temporal: ear, jaw, sinus • 1‐3d: early cerebritis – EEEV, WEEV, VEEV, St. decrease LOC, seizures Cerebellum: ear, jaw 4‐9d: late cerebritis Louis Encephalitis, West • Enter brain via blood, – Strep, GNR, Bacteroides, 10‐13d: early capsule Nile, Polio, Rabies, HIV, retrograde transport, S. aureus, Fusobacter >14d: late capsule Measles exposed CN‐I • MCA: blood, lung, heart • Dx: MRI/CT c contrast – Staph, Strep, Fusobacter, • Dx: EEG, MRI, LP/PCR • Tx: Surgical drainage, • Treatable Actinomyces, Anaerobes • Tx: Acyclovir if treatable manage ICP, culture – HSV‐1/2, VZV • Beneath wound Metronidazole + ceph + – Clostridium, Staph, Strep naf/vanco

Subdural Empyema Epidural Abscess

• Bacteriology • Altered mental status, Intracranial Spinal – Strep, Staph, focal neuro signs, • Mainly S. aureus (60‐90%) S. pneumoniae, seizures, like rapidly • Intracranial epidural abscess • H. influenzae, expanding mass lesion spills over into subdural Abscess covers 4‐5 vertebra anerobes, GNR but can extend entire length • space – UllUsually polibillymicrobial Reach via emissary • Focal pain, radiculopathy, vessels or osteomyelitis • 81% associated with increasing paralysis subdural empyema, similar • Dx: MRI • Bacteria enter space by • Inflammatory Source bacteriology, diagnositic, osteomyelitis or • Tx: Burr holes, – 50‐80% frontal/ethmoid treatment hematogenous craniotomy, manage ICP – 10‐20% mastoid/AOM • Dx: MRI, myelogram Metronidazole + – 5% hematogenous • Tx: Surgical drainage Ceftriaxone + Naf/Vanco Metro + 3rd gen ceph + Vanco

9 6/28/2011

Nosocomial Precautions Nosocomial Risks and Numbers

• Standard: gloves, do not recap needles • Accidental contaminated needlestick – Infectious: blood, CSF, amniotic/vaginal fluid, semen – 1:300 HIV (therapy decrease risk 8‐fold) – Low Risk: saliva, sputum, urine, feces – 1:30 Hepatitis C • Surgery: double glove, cover shoes, (face shield) – 1:3 Hepatitis B (without therapy) • CttContact: gown (l(+gloves ) – VRE, MRSA, C. difficile • Bacterial drug resistance • Droplet: surgical mask – 63% S. aureus in hospitals are MRSA (2007) – Influenza, Mumps, Meningococcal Meningitis – 80% E. faecium in this area are VRE • Airborne: N‐95 mask (particles <5 microns) • Bacteruria occurs in 100% of patients with – TB, Chicken Pox indwelling urinary catheters after 30 days

UTIs UTIs

• We prevent UTIs by emptying bladder, valves, Lower UTI Upper UTI normal flora distally, lack glucose, Tamm‐Horsfall • Cystitis • Fever common symptom protein (prevent E. coli attachment) – Dysuria, frequency, urgency • Pyelonephritis • Lower UTI vs Upper UTI – Pyuria tested by urine dipstick – 85% E. coli, 15% entero – Hematuria, bacteruria – Dysuria, frequency, urgency – Lower UTI is the lower poles and the bladder, upper – Uncomplicated tx Cipro x 3d – Fever, CVA/flank tenderness, N/V UTI is the upper poles and the kidneys – Complicated tx Cipro x 7‐14d – “urosepsis” appear septic • Uncomplicated vs Complicated • Urethritis – Tx ampi + aminoglycoside x 14d – Usually due to STD • Renal Abscess – Uncomplicated is adult female who Is not pregnant • Prostatitis – Rare complication in DM with normal urinary tract anatomy/fxn – Avoid rectal exam if acute – Can be caused by S. aureus • E. coli most common cause of UTIs – Acute tx: TMP‐SMX x 14d – Dx CT/Ultrasound – Chronic difficult to treat – Tx anti‐staph PCN, cephalosporin

Cellulitis Other UTIs Staph. aureus | Strep. pyogenes

Catheter‐related UTI Pregnancy • Source: anterior nares • Source: nasopharynx • Most common nosocomial • 5% develop asymptomatic • Virulence: hemolytic • Virulence: M‐protein infection bacteruria toxin and leukocidin and hyaluronidase • Indwelling = Foley cath • Screened at 1st visit and 28th • Entry by infected oil gland, puncture, bite, rash • Mostly by E. coli, Proteus, week (or 16th week once) • High risk: poor lymph drainage, blood supply, Pseudomonas, Enterococci • Associated with premature neutropenia, hypogammaglobulinemia • Can lead to “urosepsis” labor, stillbirth, low infant • Tx: elevate extremity, local heat, ATB birth weights • Tx: change the catheter • Variants • Tx amoxicillin, TMP‐SMX, broad spectrum ATB x 3‐5d • Impetigo – confined to dermis with crusting cephalosporin to eradicate • Erysipelas – rapidly spreads, raised borders • Furuncles –local abscesses from infected gland • Carbuncle – several connected furuncles

10 6/28/2011

Skin and Soft Tissue Diseases Skin and Soft Tissue Infections

Synergistic Gangrene Toxin‐Cased Skin Inflammation Anthrax • Clostridium perfringens is • Toxic Shock Syndrome: • Bacillus anthracis, a soil • Gm‐ coccobacillus synergistic with GNR, S. – Staphylcoccus protein bacterium • Cat bites aureus causing cellulitis – Desquamation of skin of • Marked edema, necrosis • Pain/swelling at bite can hdhands, ftfeet, tongue • Necrosis of blood vessels, surrounding black ulcer spread to joints and bone – Hypotension, organ failure gangrene of subcutaneous • 20% fatal if untreated • Tx: opening bite, cleaning, • Scarlet Fever tissue, spreads rapidly • Common in underdevelopd PCN – Streptococcus toxin • Tx: Surgical removal world – Diffuse red rash • Scalded‐skin syndrome – Staphylococcal toxin – Dehydration, infection

Skin and Soft Tissue Infections GI Infections

Lymphocutaneous Granulomas Lyme Disease • Transmission: Feces, Food, Fluids, Fingers, • Mycobacterium manium or • Borrelia burgdorferi Fomites, Fornication, Flies Sporothrix schenckii • Deer tick bite, expanding • Lactose+ (CSEEK) Citrobacter, Serratia, E. coli, • Painful papule can ulcerate, disc of redness clearing in spread along lymphatics center (bulls‐eye), lethargy, Enterobacter, Kleb • M. marinum: exposure to fever, can progress to • Lactose‐ (invas) Salmonella, Shigella, Yersinia fresh/brackish water arthritis and CNS symptoms • S. schenckii: exposure to • Tx: PCN, tetracycline • Lactose‐ (opportunistic) Proteus plants (rose thorns, hay) • Non‐motile Gm‐ rod: Shigella, Kleb, Yersinia • Tx: (fungus) Itraconazole (bac) rifampin+ethambutol

Vibrios Pathogenic E. coil

• Vibrio cholerae • Vibrio parahemolyticus • ETEC (‐toxigenic) • EHEC (‐hemorrhagic) – Cholera toxin: increase – Improperly cooked – Traveler’s diarrhea – Bloody diarrhea cAMP results in water seafood, oysters – Contaminated food/H2O – Fever, HUS (hemolytic loss and dehydration – GI year‐round, wound – Toxins cause diarrhea anemia, oliguric RF, – Rice water diarr hea, no ifinfec tions and • LT ↑cAMP, ST ↑cGMP throm bocy topen ia ) fever, no inflammation septicemia in summer • EPEC (‐pathgenic) – E. coli O157:H7 – Halophilic, Gulf Coast • – – Infant diarrhea Shiga‐like toxin, Stx – Spread via contaminated – Very virulent – – Burgers, apple juice food/water Effacing of microvilli, – Eating oysters can cause increased signal transd. – Do not give ATB sepsis – Oral/fecal, hands, foods • EAEC (‐adhesive)

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Invasive Enteric Pathogens Invasive Enteric Pathogens

• Shigella • Salmonella • Yersinia • Camphylobacter – S. dysenteriae – S. typhi (humans), – Y. enterocolitica and – Small Gm‐ commas (developing countries, choleraesuis (pigs), pseudotuberculosis – C. jejuni (most common US shiga toxin stops protein typhimurium (US) – Resist phagocytosis gastroenteritis, poultry, synthesis), sonnei (US), – ThidTyphoid fever – Blood transfusion disease unpasteurized milk, water) flexneri, boydii (grow at 4C) C. fetus (spread to blood) – Bacteria invade and C. upsaliensis (uncommon) – Resistant to acid – Belgian chocolates divide in macrophages – – Mimic appendicitis Damage jejunum mucosa, – 70% <15 yo kids – Carrier in gallbladder ulceration, self‐limited – Tx: Cipro, TMP‐SMX, third – Invade colon, multiply – – Tx (typhi) ampicillin, gen ceph Guillan‐Barre sequale intracellularly cefriaxone, bactrim

Helicobacter

• H. pylori • H. cinaedi – Spiral Gm‐ rods – Gastroenteritis, – Corkscrew motility septicemia, proctitis, – Urease production cellulitis, sepsis in ICH – – Pepp/tic/duodenal ulcers, Homosexual men gastritis, carcinoma, MALT – Tx amp and/or gent lymphoma • H. fennelliae – Fecal‐oral transmission – Gastroenteritis, – Dx ELISA, urease breath septicemia, proctitis test, silver stain, biopsy – Homosexual men – Tx proton pump inhibitor + – Tx amp and/or gent tetra + metro + bismuth

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