Title: Rapidly Fatal Infections
1Rapidly Fatal Infections
- Eric D. Katz, MD, FACEP
- Program Director
- Vice-Chair for Education
2Youve 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
3You 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?
4By 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
5Changing our diagnostic abilities
- The future of managing infectious diseases
6Short incubation culture systems
- Now on the market
- Faster detection of infection and rapid
susceptibility testing - Sensitivity variable
- Poor detection of resistance
7Direct 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
8Proteonomics
- Assessment of upregulation and downregulation of
several thousand proteins in different disease
states. - Role in clinical care not established.
9A 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.
10Necrotizing 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
11Necrotizing 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
12Necrotizing 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
13Necrotizing Fasciitis - Early
14Necrotizing Fasciitis
15Fourniers 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)
16Fourniers Gangrene
17Necrotizing Fasciitis - Odor
X
18Necrotizing 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
19Sub-cutaneous air on XR
20CT
21Necrotizing Fasciitis and Fourniers
22Necrotizing 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
23Necrotizing Fasciitis - Outcomes
- Very dependent to extent of involvement and time
to diagnosis. - Mortality of 15-65
- Some suggestion of improvement with hyperbaric
oxygen
24Necrotizing Fasciitis Take Home Points
- Sharply demarcated erythema
- Pain out of proportion to exam
- Central anesthesia
- Rapid spread
- Get the surgeon fast!
25Specific 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.
26CT
27Cerebritis
Meningitis
28Encephalitis - 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
29Encephalitis - usual suspects
- HSV reactivation
- Arbovirus ticks or mosquitoes
- Rabies mammal
- VZV, CMV, Toxo immunocompromised patients
- Geography matters
- SLE, EEE, WNE, JE, etc.
30So 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
31The 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
32Clinically, 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
33EncephalitisTake Home Points
- Long prodrome followed by rapid neurologic
deficits especially speech - Acyclovir for meningitis patients
- Watch for cerebral edema and SIADH
34Case 3
- Differentiating our last case from the next one
35Specific 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.
36While you are watching, her skin changes
37Meningitis
- Common bacteria are evolving rapidly.
- Most common in adults
- Strep pneumo
- Neisseria meningitides
- Listeria monocytogenes
38What do we all know?
- Rapidly fatal especially if untreated
- a. Increase mortality with agegt60, seizures, and
severe AMS - Treatment should proceed LP
39First 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
40Second controversy
- Corticosteroids?
- Early reports no mortality benefit
- Later decrease complications (especially
hearing loss, brain damage, learning disabilities
and retardation)
41Third 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
42Antibiotic selection
43Why 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
44Some quick abx facts
- lt1 month S. agalactae, E. coli, L.
monocytogenes, Klebsiellas - no ceftriaxone
- Amp Cefotaxime, Amp aminoglyc
- HSV coverage
45Kids 1-23 months
- S. pneumo, N. meningitides, H. infl, S.
agalactae, E. coli - Easy coverage for all
- Vanc 3rd gen cephalosporin
462-50 years old
- S. pneumo, N. meningitides
- Easy treatment
- Vanc 3rd gen cephalosporin
4750
- 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
48Take home points Meningitis
- Treat early and with low suspicion
- Consider skipping CTs in VERY selected patients
- Consider a loading dose of decadron
- Vanco with 3rd generation cephalosporin for gt1
month old
49So in summary
- Lots of rapidly fatal infections out there
- Most are detectable early
- Early treatment converts many of them to less
fatal infections
50Take home points
- Necrotizing Fasciitis Pain/Fever OOP or
anesthesia - Encephalitis Get acyclovir early in suspected
CNS infection - Meningitis steroids, early abx
51Thank you!