1. Emergencies in Infection Reşat ÖZARAS, MD, Prof. rozaras@yahoo.com

2. Sepsis

3. Definitions American College of Chest Physicians Society of Critical Care Medicine 1992 Systemic Inflammatory Response Syndrome 2 or more Fever > 38°C or < 36°C Heart rate > 90 /min. Respiratory rate> 20 /min. or PC O 2 <32 mmHg Leukocyte > 12.000/mm 3, 10%

4. Definitions Systemic Inflammatory Response Syndrome 2 or more Temperature > 38°C or < 36°C Tachycardia > 90 /min. Tachypnea> 20 /min. or PC O 2 <32 mmHg Leukocyte > 12.000/mm 3, 10%

5. Temperature Tachycardia Tachypnea Leukocyte 3T1L

6. SIRS Infection Multiple Trauma Hemorrhagic shock Pancreatitis Ischemia Burn

7. SEPSIS SIRS + Documented infection (Clinical, radiological, microbiological, histological)

8. SEVERE SEPSIS Organ disfunction, Hipoperfusion abnormalities or Hipotension Lactic acidosis Oliguria Mental changes ARDS, DIC, RF SysBP 40 mmHg decrease from baseline SysBP

9. SEPTIC SHOCK Despite replacing adequate fluid (>1 L) hypotension (> 1 hour) + Hypoperfusion abnormalities

10. Skin and Soft Tissue Infections

11. Impetigo Frequent in children Etiology ; S.pyogenes**, S.aureus (<10%)

12. Erysipelas and Cellulitis Erysipelas; involves skin and subcutaneous tissue Cellulitis; involvement of dermis, subcutaneous tissue, and deeper soft tissues Etiology: S.pyogenes, rarely S.aureus Treatment: amox/clav, cefazolin

16. Gaseous gangrene Necrotic tissues and foreign substance- containing wounds Subcutaneous tissue necrosis and gas formation within tissues Etiology; Clostridia, staphylococci, E.coli, Proteus, Pseudomonas, anaerobs.

18. Treatment Surgery Antibiotics: –Ceftriaxone+metronidazole –Piperacillin/tazobactam –Carbapenem

19. Necrotising fasciitis (Streptococcal gangrene) Immunosuppresives, diabetics,alcoholics, IV drug users, peripheral vascular disorders,… Necrosis of subcutaneous tissue and fascia Etiology; Group A streptococci S.aureus and gram(-) bacilli and anaerobs

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24. Meningococcemia

25. Endocarditis

26. IE: Clinical classification Acute IE Main etiology: S. aureus Mortality without treatment: 100% within 2 mo. Subacute/chronic IE Main etiology: Viridans streptococci Mortality without treatment: 100% within 1 y.

27. Prosthetic valve endocarditis: Epidemiology Early Prosthetic valve endocarditis (< 2 mo.) Hospital acquired Intermediate prosthetic valve endocarditis (2-12 mo.) Hospital/community acquired Late prosthetic valve endocarditis (>12 mo.) Community acquired

29. Treatment MSSA –Sulbactam/ampicillin MRSA –Vancomycin

30. Bacterial Meningitis

31. Approach to a patient with presumed diagnosis of meningitis Decide within 30 min. Clinical evaluation Admission Acute (1 day-1 week) Subacute (1 week-1 month) Chronic (> 1 month) Clues from history and PE General condition of the patient Immune status of the patient

35. LP must not be done if Absolute:Skin inf. Papilledema, focal neurological findings, Relative:Suspect mass Spinal cord tumor Spinal epidural abscess Tendency to bleed, low platelets

36. Meningococci in CSF

37. Pneumococci in CSF

38. CSF Findings Etiology LEUKOCYTE S (/MM 3 ) CELL TYPEGLUCOSE(MG/DL ) PROTEIN(MG/DL Viral 50–1000Mononuclear>45<200 Bacterial 1000– 5000 Neutrophylic<40100–500 Tuberculous 50–300Mononuclear<4550–300

39. Empirical Treatment of Meningitis Clinical SituationProbable Bacteria Treatment Community AcquiredS. pneumoniae Ceftriaxone N. meningitidis 2 x 2 grams [Listeria] + [H. influenzae]Ampicillin 6x2 grams +Dexamethasone amp 4 x 8 mg, 4 days

40. Urinary Tract Inf

41. –Acute pyelonephritis : fever+costovertebral angle tenderness; back pain+/- dysuria, frequency –Cystitis : dysuria, frequency, urgency, suprapubical tenderness

42. Anatomical Classification Upper UTI –Acute pyelonephritis, chronic pyelonephritis, renal abscess Lower UTI –Cystitis Genital system inf. –Prostatitis, epididymitis, orchitis

43. Definitions –Bacteriuria : > 100.000/ml bacteria/urine –Complicated UTI: Anatomical or physiological –Relapse: Recurrence of the same infection with the same pathogen

44. UTI

45. Acute Pyelonephritis Chills, fever Flank pain, abdominal pain, back pain Nausea, vomiting Hypotension(  ) Tenderness on costovertebral angle Symptoms of cystitis –Urgency –Frequency –Dysuria –Suprapubic tenderness

46. Diagnosis History, PE Urine analysis Gram’s staining Culture ESR, CBC, CRP

47. Perinephritic abscess

48. Treatment Hospital/community –Quinolones? –Ceftriaxone

49. Pneumonia

50. Outpatient settings Inpatient settings –Ward –Intensive Care

51. Work-up History (standard+ antibiotics use, risk faktors) PE, vital signs (standard+ severity signs) Basic Lab (CRP, CBC, ALT, bilirubins, creatinine, Na, LDH) Sputum exam. Plain chest X-ray

54. Risk factors COPD, Cystic F, bronchiectasis DM Heart failure Renal failure Cerebrovasculer D. Cancer >65 y Immune def. Care units Alcoholism Severity Factors Tachypnea Fever Hypotension Confusion Cyanosis Leukocytosis Hypoxia Hyponatremia Radiological f (multilobar) Sepsis

55. Diagnosis 1-Acute fever 2-Cough, sputum/ dyspnea 3-Chest auscultation findings 4-Chest X-ray 5-CBC and CRP 6-Gram’s staining and culture of sputum

56. Etiology S. pneumoniae (pneumococci) H. influenzae Moraxella catarrhalis Mycoplasma pneumoniae Chlamydia pneumoniae Legionella pneumophila

57. Treatment: Outpatient I-without risk factors Macrolide or doxycycline II- with risk factors New generation quinolones or Amoxicillin/clavulonate + macrolide

58. Treatment: Inpatient Ceftriaxone + macrolide or Beta-lactam / beta-laktamase inhibitor + macrolide or FQ

59. Septic arthritis Usually one joint Knee, hip, shoulder,..

60. Risk factors Systemical immunity problems Trauma Rheumatic disorders

61. Etiology Staph Strep Gram (-) H. influenzae

62. Treatment Surgery (drainage, debridement …) Antibiotics (parenteral) –Sulbactam/ampicillin –Cefazolin

63. Conclusion Be aware of sepsis

64. 3T1L