1. More infectious disease Bugs and drugs FP style

2. Sore throat l 46 yo male 2 day h/o sore throat. Throughout the day yesterday the soreness worsened and he had trouble eating dinner because of pain. Today his fever was 103.5 and he looks well in your office except for erythema in pharynx without exudate.

3. Now what l Differential diagnosis? l What is the best test to evaluate this patient? l What is the appropriate therapy?

4. Differential and don’t miss diagnoses l Viral l mono l mycoplasma pneumoniae l foreign body l epiglottitis l para or retropharyngeal abscess l Diptheria l acute HIV l gonococcal pharyngitis l GAS pharyngitis (rare ~10%)

5. GAS pharyngitis l Pre-test prob is less than 10% l empiric therapy based on clinical decision making is relatively expensive and lacks sensitivity and specificity l strategies using rapid tests, culture or observation are more cost effective l rapid strep used in our clinic >95% sensitive, >90%sensitive l Reason to treat is to prevent rheumatic fever l treatment Pen V or Erythro for 10 days l ann int medicine 2003;139:113

6. What about carriers l If asymptomatic: no culture, no treatment l just say no

7. What about repeat strep l Symptomatic with multiple positive cultures or rapid strep tests l treat with Clindamycin or AM/CL and consider adding rifampin

8. Adult epiglottitis l If concerned need ENT or ability to visualize epiglottis (direct laryngoscopy) l cherry-red, swollen l onset more insidious, appear less toxic than kids l BUGS l S pneumoniae l H influenzae or parainfluenzae l GAS

9. Therapy for epiglottitis l Antibiotics 2nd or 3rd generation cephalosporin l Obs in ICU l Steroids show no proven benefit

10. C. Diphtheriae l Does occur in immunized individuals l grayish membrane in pharynx is diagnostic l need antitoxin and Pen G or erythro

11. Gonococci l History l usually exudative but can present as diffuse erythema l use ceftriaxone and treat for chlamydia also (azithro or doxy)

12. NEXT l A 7 yo boy was playing in the street and stepped on a nail. He has a puncture wound that goes through his tennis shoe. The wound is over the third metatarsal phalangeal area and there is localized swelling and little erythema.

13. Doctor? l Should prophylactic antibiotics be given? l If he presented one week later with obvious cellulitis and pain, what then?

14. DATA l Incidence of infection in puncture wounds is not well defined but is estimated in ER literature as 5-15% and is easily treatable l Low incidence of osteomyelitis <2% l Conservative treatment based on ER data which showed that pain at 48 hour mark is most sensitive indicator of infection

15. Compassionate Conservative Management l Lather, rinse, repeat l non-weight bearing X 24 hours l telephone F/U at 48 hours l no antibiotics

16. Bugs l Staph Aureus (be cautious for MRSA) l GAS l Clostridium perfringens or tetani l pseudomonas l If soft tissue/cellulitis use AM/Cl, erythro, clinda or fluoroquinolone

17. NEXT l 48 yo teacher, IVDU with fever, pain R arm and decreased ROM R shoulder, SOB and chest pain. l T 39.5 P 125 2/6 SEM l CXR no infiltrates

18. Questions? l At what school is this patient employed? l Differential? l What antibiotic?

19. What about MRSA? l Community acquired MRSA has been reported in most states l It is common among IVDU, prison inmates, military, native americans, sports teams, HIV infected, homosexual men, ENT patients, children

20. Community acquired MRSA l IS susceptible to many antibiotics l Lack the hospital-associated risk factors l Has unique molecular properties which differ from hospital strains

21. At Saint Joes 2003 data l MSSA at Joes is 100% (409 ISOLATES) susceptible to Augmentin l MRSA Rate in 2003 =37% l (235 isolates) 88% susceptible to Gentamycin, 100% to Vanco

22. Second line agents for MRSA l Doxycycline 10% resistance little data l TMP/SMX 20% l Clindamycin 40% l Fluoroquinolones >50% l Macrolides 50-80% l Rifampin ~5% rapid resistance if not used in combo

23. Not FDA approved l Synercid $130/day IV only, poorly tolerated l Zyvox $100/day IV and po l Cubicin only for specific genotype