3/15/2017 Cases in Infectious Diseases NO DISCLOSURES Richard A. Jacobs, M.D., PhD. Case Records of the Massachusetts General Hospital Case Presentation A 22 yr old comes to the office complaining of the acute onset of unilateral weakness • Periventricular heterotopia due to an FLNA of the right side of his face. mutation and congenital alveolar dysplasia. Your diagnosis is Bell’s Palsy. N Engl J Med 2017; 376:562‐574 1 3/15/2017 What is Your Therapy? Etiology of Facial Nerve Palsy 100% • 50% are idiopathic (Bell’s Palsy) 1. Prednisolone • Herpes Simplex/Varicella Zoster (Geniculate 2. Acyclovir ganglion) – Direct invasion v. immunologic/inflammatory 3. Prednisolone + • Lyme disease (most common cause of bilateral FN acyclovir palsy) 4. Nothing • Other infections—CMV, EBV,HIV • Non‐infectious—Diabetes, sarcoid, tumors, 1 trauma Therapy of Bell’s Palsy Therapy of Bell’s Palsy • 839 patients enrolled within 72 hours of • Quite controversial onset of symptoms • Because of the association with herpes viruses – Placebo + placebo (206) the use of acyclovir has been felt to be – Prednisilone (60mg X 5 days then reduced beneficial by 10 mg/day) + placebo (210) • – Valacyclovir (1000mg TID X 7 Days) + Two well done prospective, randomized, placebo (207) controlled, blinded studies have been done – Valacyclovir X7 Days + prednisolone X10 Days (206) Lancet Neurol 2008;7:993‐1000 2 3/15/2017 Therapy of Bell’s Palsy Prednisilone Prednisilone • Case closed on therapy??? NO!! + valacyclovir Placebo • Other less powered studies and subgroup Valacyclovir analyses suggest that acyclovir might be + placebo beneficial in the most severe cases – Minimal or no movement of facial muscles and inability to close the eye Take Home Points Case Presentation • 57 yo male with polycystic kidney disease, • Early treatment (within 72 hours of gout, HTN and hyperlipidemia onset) recommended • Underwent bilateral nephrectomies and renal • For most cases prednisolone for 10 days transplant (CMV D +/R‐). Required ATG post‐ is adequate transplant • For severe cases (complete or near • Immunosuppression—mycophenolate 360 mg complete paralysis) prednisolone for 10 BID, tacrolimus 7 mg BID and prednisone 5 mg days + valacyclovir 1000mg TID for 7 days is recommended QD; prophylactic ganciclovir 3 3/15/2017 Case Presentation (cont) Case Presentation (cont) • Shortly after transplant sustained an “injury” • P&SH to his (R) ankle resulting in pain and swelling – Lives in Oakland, CA • About 2 months post‐transplant, at a routine – No travel clinic visit his ankle was warm, red, tender and – No unusual food/animal exposures swollen. • BCs X 2 neg • • WBC‐ 12.5 (4.0‐11.0), CRP‐72 (<6.3) and xray Urine culture‐100,000 CFU of MRSA showed an effusion • Aspiration – Bloody fluid with 102,000 WBCs & 96% PMNs • Admitted for evaluation – Negative for crystals Case Presentation (cont) Case Presentation (cont) • Cultures/stains from aspiration and OR were • The following day he was taken to the OR for I&D all negative for bacteria, fungus and AFB – Chronic appearing inflammation with friable synovium • About one week later, because of failure to • WORKING DIAGNOSIS—transient S. aureus improve, an MRI‐c/w with intraosseous abscesses bacteremia from septic (R) ankle with S. aureus bacteriuria. • Back to the OR – • Started on vancomycin & ceftriaxone pending No gross purulence cultures – “cystic void” in the calcaneus and talus that were opened 4 3/15/2017 Case Presentation (cont) What is your diagnosis? • Cultures for: 1. Gout – Bacteria 2. S. aureus – Fungus 3. Yeast infection (candida) – AFB 4. Mold infection • Additional specialized tests (aspergillus/rhizopus) 5. AFB‐MTb or NTM • 1 week later a diagnosis was made 6. Other University of Washington Molecular Diagnostic Laboratory Can submit tissue, paraffin blocks or sterile fluid DNA sequencing for: UREAPLASMA UREALYTICUM Bacteria (16S ribosomal RNA) Yeast (26S ribosomal RNA) Moulds (28S ribosomal RNA) http://depts.washington.edu/molmicdx/mdx/te sts/bctseq.shtml 5 3/15/2017 Culture Negative Septic Arthritis Culture Negative Septic Arthritis • Prior antibiotics • Sensitivity of the test ( ≈90%) • Reactive arthritis • Lyme disease (Borrelia spp.) – Following diarrhea • Fastidious organisms • Salmonella, Shigella, Campylobacter, Yersinia, C. difficile – Brucella – Coxiella (Q fever) – Following urogenital infections – Legionella • Chlamydia trachomatis – Bartonella – Whipple’s disease – Mycoplasma (immunoglobulin deficiency) Case Presentation Should Prophylaxis Be Given? 100% • The dentist of your 45 year old female patient with MVP and moderate mitral 1.Yes regurgitation calls wanting to know if she needs antibiotic prophylaxis for a root 2.No canal and which one. 1 6 3/15/2017 Prophylaxis for Endocarditis Prophylaxis for Endocarditis • Paradigm shift in recommendations – Lack of published data showing benefit • Original AHA Guidelines in 1997 – Transient bacteremia occurs commonly as a result of normal daily activities • Major revision by AHA in 2007 with several • Brushing and flossing—20%‐68% updates, the most recent in 2014 (J Am Coll • Toothpick—20%‐40% Cardiol. 2014;63(22):e57) • Chewing food—7%‐51% – Endocarditis is more likely to occur from frequent bacteremias associated with daily activities than from bacteremias caused by dental, GI or GU procedures Prophylaxis for Endocarditis High Risk Procedures DENTAL PROCEDURES • Prophylaxis recommended ONLY for: Manipulation of the gingivial tissue: HIGH RISK PROCEDURES ROUTINE DENTAL CLEANING In TOOTH EXTRACTION HIGH RISK INDIVIDUALS Manipulation of the periapical region of the tooth: ROOT CANAL 7 3/15/2017 High Risk Procedures High Risk Procedures RESPIRATORY PROCEDURES SKIN & MUSCULOSKELETAL PROCEDURES Violation of the respiratory mucosa Drainage of an abscess TONSILLECTOMY/ADNOIDECTOMY antibiotics directed at S. aureus and Group A BRONCHOSCOPY WITH BIOPSY streptococcus Drainage of infected material DRAINAGE OF AN EMPYEMA Procedures for Which Endocarditis Conditions of Highest Risk Prophylaxis is NOT Recommended • Included • Not included • GI PROCEDURES – Prosthetic heart valves – Bicuspid aortic valve – Risk of bacteremia low even with biopsy (2%‐5%) – Prior endocarditis – Acquired aortic or mitral valve disease and organisms involved rarely cause endocarditis – Cyanotic heart disease • Unrepaired • MVP with regurgitation • GU PROCEDURES • Partially repaired • Prior valve repair – Risk of bacteremia high with bacteriuria • Repaired within last 6 – Hypertrophic months cardiomyopathy with – TREAT BACTERIURIA BEFORE PROCEDURE – Heart transplant with latent or resting “valvulopathy” obstruction 8 3/15/2017 Back to the Patient Recommended Regimens ( Single Dose 30‐60 min Before Procedure) • She had a high risk procedure—root canal Situation Agent Adult Dose • BUT did NOT have a high risk heart Oral regimen Amoxicillin 2 g Allergic to Cephalexin or 2 g condition—MVP with regurgitation penicillin or Clindamycin 600 mg ampicillin or (minor allergy) Azithromycin/ 500 mg Clarithromycin NO PROHYLAXIS INDICATED Allergic to Clindamycin 600 mg penicillin or or ampicillin Azithromycin/ 500 mg (anaphylaxis, Clarithromycin angioedema or urticaria Case Presentation Should Prophylaxis Be Given? 100% • The dentist of your 65 year old patient who is 9 months s/p total hip 1. Yes arthroplasty calls wanting to know if prophylaxis should be given for a root 2. No canal 1 9 3/15/2017 Dental Prophylaxis for Prosthetic Dental Prophylaxis for Prosthetic Joints Joints—2013 Guidelines • GOOD NEWS • Area of controversy for years between the ADA, AAOS and IDSA – 2004 AAOS & ADA recommendation prophylaxis if joint placed within past 2 years – 2009 AAOS recommends prophylaxis for all prosthetic joints regardless of when placed – Promise of collaboration with joint guidelines – 2013 AAOS & ADA propose new guidelines Dental Prophylaxis for Prosthetic Dental Prophylaxis for Prosthetic Joints—2013 Guidelines Joints—2013 Guidelines • GOOD NEWS • GOOD NEWS – The practitioner might consider discontinuing the – The practitioner might consider discontinuing the practice of routinely prescribing prophylactic practice of routinely prescribing prophylactic antibiotics for patients with hip and knee antibiotics for patients with hip and knee prosthetic joint implants undergoing dental prosthetic joint implants undergoing dental procedures. procedures. • BAD NEWS 10 3/15/2017 Dental Prophylaxis for Prosthetic Dental Prophylaxis for Prosthetic Joints—2013 Guidelines Joints—2013 Guidelines • GOOD NEWS • GOOD NEWS – The practitioner might consider discontinuing the – The practitioner might consider discontinuing the practice of routinely prescribing prophylactic practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic antibiotics for patients with hip and knee joint implants undergoing dental procedures. prosthetic joint implants undergoing dental • BAD NEWS—> Grade of Recommendation is procedures. Limited • BAD NEWS—> Grade of Recommendation is • Practitioners should be cautious in deciding Limited whether to follow a recommendation classified as Limited What TO DO?? ADA Recommendations • In 2014 the ADA Council on Scientific Affairs • Disconnect between organisms causing PJIs convened an expert panel to clarify the 2013 and mouth flora ADA/AAOS confusing recommendations – Late infections almost always due to skin flora (S. epi, P. acnes, corynebacterium spp) not streptococci found in the mouth • Bacteremias common as a result of everyday activities • Best study cited in the