Bacterial Infections

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Bacterial Infection
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Bacterial Infections

• Diphtheria
• Pertussis
• Tetanus
• Botulism
• Pneumococcemia
• Meningococcemia
• Kawasaki Disease
• Toxic Shock Syndrome

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Diphtheria --- definition

• Localized infection by C. diphtheriae occurs at
  various sites of the respiratory tract or the
  skin ---- endotoxin
• Respiratory tract diphtheria
• faucial (pharyngeal or tonsillar), nasal, and
  laryngeal (tracheobronchial) types, named for the
  primary location-----greatest toxicity
• Cutaneous diphtheria
• may be a primary skin infection or may occur as a
  secondary infection of a preexisting
  wound-----least toxicity

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Diphtheria

• S/S
• Sore throat
• Fever
• Dysphagia
• Diphtheritic membrane
• Muscle weakness
• Cardiac dysfunction

• Complication
• Airway obstruction (membrane formation edema)
• Congestive heart failure
• Cardiac conduction disturbances
• Muscle paralysis

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Diphtheria

• Ancillary Evaluation
• CBC\DC, EKG
• Specimen culture on Loefflers or tellurite media
• The diphtheritic membrane

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Diphtheria --- D/D

• Streptococcal or viral pharyngitis
• Tonsillitis
• Vincents angina
• Acute epiglottis
• Mononucleosis

• Laryngitis
• Bronchitis
• Tracheitis
• Monilial infection
• Rhinitis

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Diphtheria --- treatment

• Goal
• Limit the activity of already produced toxin
• Elimination of future toxin production by
  terminating the growth of C. diphtheriae

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Diphtheria --- treatment

• Equine serum diphtheria antitoxin
• Antibiotics ( for 14 days )
• Erythromycin -- 40-50mg/kg/day (up to 2gm) iv, po
• Aq. Crystalline penicillin 100,000150,000
  U/kg/d in 4 divided dose
• Vigorous cleansing --- cutaneous lesion

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Pertussis --- definition

• Pertussis means violent cough
• the hallmark of the disease.
• Whooping cough
• progressive, repetitive, and severe episodes of
  coughing
• followed by a forceful inspiration, which creates
  the characteristic whooping sound.

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Pertussis

• Age pediatric (most less than 1 y/o)
• Season Jun to Sep
• Incubation 710 days
• Route airborn droplet
• Organism Bordetella Genus
• Medium Bordet-Gengou medium (7 days)
• Mechanism toxin-mediated

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Pertussis --- clinical finding

• Catarrhal phase
• Nonspecific
• Highest infectivity
• Paroxysmal phase
• Paroxysm of coughing 40-50 times/d
• Whoop sudden, forceful inhalation
• Convalescent phase
• Residual cough and last for weeks to months

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Pertussis --- complication

• Major complications
• Pneumonia
• CNS sequelae
• Otitis media
• Complications related to the paroxysm of coughing

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Pertussis --- D/D

• URI and any of the following
• (1) a history of exposure
• (2) a severe persistent cough
• (3) posttussive vomiting
• (4) leukolymphocytosis
• Acute viral URI,Pneumonias, bronchiolitis, cystic
  fibrosis, tuberculosis, exacerbation of chronic
  obstructive pulmonary disease, and foreign bodies
  of the respiratory tract

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Pertussis --- treatment

• Goal
• Supportive oxygenation
• Suctioning
• Maintenance of hydration and nutrition
• Avoidance of respiratory irritants
• Erythromycin
• Drug of choice
• 50mg/kg/day (max 2gm) in 4 divided doses

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Tetanus --- definition

• a neurologic syndrome caused by the neurotoxin
  produced by the C. tetani organism
• acute onset of hypertonia or painful muscular
  contractions
• usually of the muscles of the jaw and neck
  without other apparent medical cause as reported
  by a health care professional

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Tetanus

• Portals
• puncture wounds, laceration, abrasion
• Exotoxins
• Tetanospasmin
• Interfere releasing of inhibitory
  neurotransmitters
• Tetanolysin
• Nonconvulsive neurotoxin

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Tetanus --- tetanus type

• Generalized tetanus
• Fully developed state of skeletal muscle
  hypertonicity ( Trismus Sardonic smile)
• Local tetanus
• Persistent muscle rigidity near the site of
  bacterial inoculation
• Cephalic tetanus
• Trismus and paralysis of one or more cranial
  nerves (CN VII)
• Neonatal tetanus
• Form of generalized tetanus occur in neonates
• Lucid consciousness

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Tetanus --- complication

• Muscle hypertonicity
• Sympathetic hyperactivity
• Acute respiratory failure asphyxia CV
  complication musculo-skeletal complication
  rhabdomyolysis hyperthermia psychologic trauma
  after trauma etc.
• Mortality function of
• Incubation period
• Severity of illness
• Age
• Medical treatment

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Tetanus --- D/D

• Acute abdomen
• Black widow spider bite
• Dental abscess
• Dislocated mandible
• Dystonic reaction
• Encephalitis
• Head trauma
• Hyperventilation syndrome
• Hypocalcemia
• Meningitis
• Peritonsillar abscess

• Progressive fluctuating muscular rigidity
  (stiff-man syndrome)
• Psychogenic
• Rabies
• Sepsis
• Subarachnoid hemorrhage
• Status epilepticus
• Strychnine poisoning
• Temporomandibular joint syndrome

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Tetanus --- treatment

• Goal
• Aggressive supportive care
• Administration of antitoxin
• Elimination of toxin production
• Active immunization

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Tetanus --- treatment

• Benzodiazepine
• Nondepolarizing neuromuscular blocking agent
• Dantrolene
• Muscle relaxant without CNS activity
• Hydration and electrolytes balance
• MgSO4 autonomic dysfunction
• TCP bradydysrhythmia
• Narcotics
• Barbiturate

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Tetanus --- treatment

• TIG (human tetanus immuno-globulin)
• neutralizes any circulating extraneuronal toxin
  or toxin present at the site of production
• 3,00010,000 U IM
• T ½ 25 days Protective antibody level 4872
  hrs
• Tetanus toxoid
• PCN G Erythromycin Metronidazole

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Botulism --- definition

• paralytic illness caused by neurotoxins produced
  by Clostridium botulinum
• Types
• (1) food-borne botulism
• (2) infant botulism
• (3) wound botulism
• (4) unclassified botulism.

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Botulism

• Infantile botulism
• The most common form
• Less than 1 y/o
• Ingestion of spores within honey or corn syrup
• Avoid feeding honey to any child lt 12 m/o

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Botulism

• Microorganism C. botulinum
• Neurotoxin mediated
• Mechanism block presynaptic acetylcholine
  release
• Botulinum toxin the most potent biologic toxins
  heat labile

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Botulism --- clinical finding

• Clinical diagnosis
• Cranial N ? Symmetric descending muscular
  weakness (upper and lower extremities and
  respiratory muscle)
• Alert afebril
• Ocular sign and decreased secretion
• Upper gt Lower Proximal gt distal
• Intact sensory
• Major cause of death respiratory failure

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Botulism --- ancillary test

• Electromyography
• a decreased amplitude of the compound muscle
  action potential in response to a supramaximal
  stimulus and facilitation of the muscle action
  potential with repetitive nerve stimulation
• Botulinus toxin

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Botulism --- D/D

• Illness related with paralysis
• Guillain-Barre syndrome
• MG
• Eaton-Lambert syndrome
• poliomyelitis
• Toxins
• Anticholinergics
• Organophosphate insecticides
• Neuromuscular blocker
• Aminoglycoside
• Heavy metal
• shellfish

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Botulism --- treatment

• Supportive care
• Mechanical ventilation VC lt 30
• Saline enemas and cathartics
• Avoid Mg and precipitating agents (GM)
• Antitoxin
• ABE trivalent preparation
• Only neutralize circulating toxin

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Pneumococcemia

• Definition
• Presence of Streptococcus. pneumoniae in the
  blood
• Most cases community acquired
• Peak incidence winter
• High risk
• chronic respiratory or cardiovascular disease,
  chronic alcohol abuse, cirrhosis, diabetes
  mellitus, absent or functionally impaired spleen
  ( splenectomy or sickle cell disease), chronic
  renal failure, nephrotic syndrome, organ
  transplantation, lymphoma, Hodgkins disease,
  multiple myeloma, and AIDS

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Pneumococcemia --- Clinical findings

• Range from a minor febrile illness to
  life-threatening septic shock
• Otitis media, pneumonia, meningitis etc.
• End-organ damage MODS
• OPSI (overwhelming postsplenectomy infection)
• Septic shock, adrenal hemorrhage, and DIC

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Pneumococcemia --- treatment

• Goal
• Stabilization of life-threatening conditions
• Eradication of the infection
• Treatment of predisposing or coexisting
  conditions

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Pneumococcemia --- treatment

• Regimens
• PCN G 612 million U/day divided in Q4h iv
• Meningitis case
• 24 million U/d child 250,000 U/kg/24hrs divided
  Q4h iv
• Ceftriaxone and cefotaxime
• Penicillin resistance
• Mean inhibitory concentration (MIC) gt 0.1u/ml
• High-level resistance MIC gt 2.0u/ml
• Ceftriaxone 100mg/kg iv, followed by 100 mg/kg
  divided in Q12h (max 4gm)
• Cefotaxime 200mg/kg/d divided in Q6h iv (Max
  12gm)

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Pneumococcemia --- vaccination

• Pneumococcal vaccine 23 valent vaccine
• Immunocompetent adults with chronic illnesses or
  those 65 years of age or older
• Immunocompromised adults
• Adults and children older than 2 years with
  asymptomatic HIV infections
• Children older than 2 years with chronic illness
• Persons living in special environments or social
  settings with an identified increased risk

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Meningococcemia --- definition

• presence of N. meningitidis in the blood
• Waterhouse-Friderichsen syndrome (Fulminant
  meningococcemia)
• extreme severity and rapid clinical
  deterioration, including vasomotor collapse and
  shock.
• Chronic meningococcemia
• fever, rash, joint symptoms lasting longer than a
  week, and a blood culture positive for N.
  meningitidis

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Meningococcemia --- Clinical findings

• Fever, rash, meningitis- small portion on initial
  visit
• Fever and petechiae or purpura (60)
• Rash
• Petechiae and maculopapular
• Trunk and extremities (pressure point)

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Meningococcemia --- complication

• Target organ
• Heart, CNS, skin, mucous and serous membranes,
  and adrenal glands
• Most common abnormality
• Myocarditis associated with acute CHF

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Meningococcemia

• Poor prognostic indicators
• Seizures on presentation
• Hypothermia
• WBC lt 500/mm3
• Platelet count lt 100,000/mm3
• Development of purpura fulminans
• Onset of petechiae within 12 hours of admission
• Absence of meningitis
• Presence of shock
• Low sedimentation rate
• Hyperpyrexia
• Extremes of age

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Meningococcemia

• Clinical finding
• Blood culture
• Antigen detection test
• Grams stain
• peripheral blood buffy coat specimen or petechial
  scraping
• CSF ICP elevated, protein increased, glucose
  decreased

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Meningococcemia ---- D/D

• Viral exanthems
• Rocky Mountain spotted fever
• Typhus
• Typhoid fever
• Endocarditis
• Vasculitis syndromes (polyarteritis nodosa and
• Henoch-Schönlein purpura)
• Toxic shock syndrome
• Acute rheumatic fever

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Meningococcemia --- treatment

• PCN G
• Adult24,000,000 U/d divided in Q24hr iv
• Child 250,000 U/kg/d divided in Q24hr iv or
  ampicillin 200400mg/kg/d divided in 4/d
• Alternatives
• Cefotaxime
• Ceftriaxone
• Above two S. pneumoniae, H. influenza
• CSP rapid sterilization
• Lower incidence of hearing loss
• chloramphenicol
• Dexamethasone 0.15mg/kg 1520min before
  antibiotics (infant and child)
• Plasmapheresis

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Meningococcemia --- prophylaxis

• Rifampin
• 10 mg/kg (up to 600mg) po Q12h 4 dose
• Infant lt 1m/o 5 mg/kg
• Urine discoloration
• Contact lenses staining
• Ceftriaxone IM
• Ciproflaxin po
• Meningococcal vaccine

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Kawasaki disease

• Mucocutaneous lymph node syndrome
• Acute vasculitis
• Age 80 lt 5 y/o
• Season spring and winter

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Kawasaki disease --- definition

• Fever lasting 5 days or more without another more
  reasonable explanation and at least four of the
  following criteria
• 1.Bilateral conjunctival injection
• 2.Mucous membrane changes
• injected or fissured lips, injected pharynx, or
  strawberry tongue
• 3.Extremity changes
• erythema of palms or soles, edema of the hands or
  feet, or generalized or periungual desquamation
• 4.Rash
• 5.Cervical lymphadenopathy ( LN gt 1.5 cm)

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Kawasaki disease
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Kawasaki disease
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Kawasaki disease
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Kawasaki disease

• Atypical Kawasaki disease
• Fever of unknown origin
• Less than four of the five criteria
• Coronary artery disease

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Kawasaki disease

• Acute phase (first 11 d)
• Vasculitis and perivasculitis
• Most common cause of death- myocarditis
• Subacute phase (1120 d)
• Aneurysm form
• Convalescent phase (2160 d)
• Chronic phase (61d)

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Kawasaki disease

• The most common cause of acquired pediatric heart
  disease in US
• All Kawasaki disease patient should have EKG and
  echocardiogram
• LAB WBC ? HB ? Plt ?

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Kawasaki disease --- D/D

• Measles
• Toxic shock syndrome
• Scarlet fever
• Leptospirosis
• Stevens-Johnson syndrome
• Staphylococcal scalded-skin syndrome

• Influenza
• Rocky Mountain spotted fever
• juvenile rheumatoid arthritis
• drug reaction
• other viral infections
• mercury toxicity

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Kawasaki disease --- treatment

• IVIG
• Antiinflammatory effect
• 2gm/kg iv infusion over 12 h
• High-dose aspirin
• Antiinflammatory antithrombolytic effect
• 80-100 mg/kg/day in four divided dose until
  afebril
• Then 3-5 mg/kg (max 80mg/d) Qd for 6-8 weeks

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Toxic Shock Syndrome --definition

• Fever
• BT gt 38.9 C (102 F)
• Rash
• diffuse macular erythroderma
• Desquamation
• 1 to 2 weeks after onset of illness, particularly
  of palms and soles
• Hypotension

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Toxic Shock Syndrome --definition

• Multisystem involvement 3 or more
• GI
• vomiting or diarrhea at onset of illness
• Muscular
• severe myalgia or creatine phosphokinase level at
  least twice the upper limit of normal for
  laboratory
• Mucous membrane
• vaginal, oropharyngeal, or conjunctival hyperemia
  
• Renal
• BUN or creatinine at least twice the upper limit
  of normal for laboratory or urinary sediment with
  pyuria (³5 leukocytes per high-power field) in
  the absence of urinary tract infection
• Hepatic
• total bilirubin, AST, ALT at least twice the
  upper limit of normal for laboratory
• Hematologic
• platelets lt100,000/mm3
• CNS
• disorientation or alterations in consciousness
  without focal neurologic signs when fever and
  hypotension are absent

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Toxic Shock Syndrome --- definition

• Negative results on the following tests, if
  obtained
• Blood, throat, or CSF cultures (blood culture may
  be positive for S. aureus)
• Rise in titer to Rocky Mountain spotted fever,
  leptospirosis, or rubeola

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Toxic Shock Syndrome

• Predominant in women 1534 y/o
• S. aureus
• Toxic shock syndrome toxin (TSST-1)
• Blood culture usually negative
• Clinical diagnosis

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Toxic Shock Syndrome --- D/D

• Streptococcal TSS
• Kawasaki disease
• Staphylococcal scalded-skin syndrome
• Scarlet fever
• Steven-Johnson syndrome
• Rocky Mountain spotted fever
• Leptospirosis
• Meningococcemia

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Toxic Shock Syndrome --- treatment

• Supportive treatment
• Adequate removal or debridement of the source of
  staphylococci
• Drug of choice
• Penicillinase-resistant synthetic penicillin
• First-generation cephalosporin
• Alternative Vancomycin or clindamycin

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The End