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Rapidly Fatal Infections

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Rapidly Fatal Infections Eric D. Katz, MD, FACEP Program Director Vice-Chair for Education Remember, the thicker the fatpad, the faster it spreads. – PowerPoint PPT presentation

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Title: Rapidly Fatal Infections


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

2
Youve 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
  1. Understand how our diagnoses of infectious
    disease may advance over the next few years
  2. Understand 3 rapidly fatal infections
  3. Understand clinically useful tips to identify
    rapidly fatal infections from non-threatening
    diseases

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

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
Fourniers 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
Fourniers 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 Fourniers
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. lt 3 hours preferable, but definitely lt 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
  1. Sharply demarcated erythema
  2. Pain out of proportion to exam
  3. Central anesthesia
  4. Rapid spread
  5. 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 lt1yo or gt55yo
  • 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
  1. Long prodrome followed by rapid neurologic
    deficits especially speech
  2. Acyclovir for meningitis patients
  3. Watch for cerebral edema and SIADH

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

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
  • Listeria monocytogenes

38
What do we all know?
  • Rapidly fatal especially if untreated
  • a. Increase mortality with agegt60, seizures, and
    severe AMS
  • Treatment should proceed LP

39
First controversy
  • CT before LP or just LP?
  • Definitely CT if
  • a. gt60
  • 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 gt1month, they get vanco
  • Supported by AAP, IDSA

44
Some quick abx facts
  • lt1 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
  1. Treat early and with low suspicion
  2. Consider skipping CTs in VERY selected patients
  3. Consider a loading dose of decadron
  4. Vanco with 3rd generation cephalosporin for gt1
    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
  1. Necrotizing Fasciitis Pain/Fever OOP or
    anesthesia
  2. Encephalitis Get acyclovir early in suspected
    CNS infection
  3. Meningitis steroids, early abx

51
Thank you!
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