Common InfectionsCommon Infectionsin the in the

Emergency DepartmentEmergency Department

Kevin G. Rodgers, MDKevin G. Rodgers, MD

Emergency MedicineEmergency Medicine

19 year old female presents c/o a 19 year old female presents c/o a sore throat, fever, malaise, and sore throat, fever, malaise, and swollen glands for 36 hours. Her swollen glands for 36 hours. Her PMH is significant for asthma PMH is significant for asthma for which she uses 2 inhalers.for which she uses 2 inhalers.

Case #1Case #1

What other history and PE would you like?What other history and PE would you like?

Case #1Case #1What is pertinent Hx and PE in this patient?What is pertinent Hx and PE in this patient?

–DDx?DDx?

–Centor Criteria?Centor Criteria?

–Complications?Complications?

Case #3 - PharyngitisCase #3 - Pharyngitis• Divide patients according to clinical suspicionDivide patients according to clinical suspicion

– Above Treatment ThresholdAbove Treatment Threshold

– Above Diagnostic ThresholdAbove Diagnostic Threshold

– Below Diagnostic ThresholdBelow Diagnostic Threshold

JAMA, Rational Clinical Exam: Does this patientJAMA, Rational Clinical Exam: Does this patienthave Strep throat? JAMA 284:22, 2000have Strep throat? JAMA 284:22, 2000

Exudate, fever, LNs, no URI, correct age Exudate, fever, LNs, no URI, correct age →treat→treat

Has 1-4 criteria Has 1-4 criteria →obtain rapid strep→obtain rapid strep

No exudate / shotty LN / low grade fever / URI sxsNo exudate / shotty LN / low grade fever / URI sxs

• Treat with PCN (PO or IM) or macrolidesTreat with PCN (PO or IM) or macrolides

• Tell patients that ABX will not typically Tell patients that ABX will not typically alter the duration of illness (maximum of 8 alter the duration of illness (maximum of 8 hours shorter if seen in the 1hours shorter if seen in the 1stst 24 hours) 24 hours)

• Tell patients that the full course must be Tell patients that the full course must be taken to prevent Rheumatic fevertaken to prevent Rheumatic fever

• Consider dexamethasone for severe STConsider dexamethasone for severe ST

Case #1 - PharyngitisCase #1 - Pharyngitis

Arch Pediatr Adolesc Med. 2005;159:278-282

Case #2Case #2

32 year old female with a history 32 year old female with a history of sinusitis presents c/o green of sinusitis presents c/o green nasal discharge and sinus pain x nasal discharge and sinus pain x 2 days. She is currently on nasal 2 days. She is currently on nasal steroids and Claritin. steroids and Claritin.

What percentage of patients presenting to the EDWhat percentage of patients presenting to the ED have sinusitis and how would you diagnose it?have sinusitis and how would you diagnose it?

Case #2-Acute SinusitisCase #2-Acute Sinusitis• Less than 5-10% of patients presenting to the Less than 5-10% of patients presenting to the

ED have actual bacterial sinusitis; most have ED have actual bacterial sinusitis; most have rhinosinusitis (viral, chemical, allergic or self-rhinosinusitis (viral, chemical, allergic or self-limited bacterial infection requiring no ABX)limited bacterial infection requiring no ABX)

• Clinical Diagnosis: fever, persistent purulent Clinical Diagnosis: fever, persistent purulent nasal discharge, sinus tenderness to percussion, nasal discharge, sinus tenderness to percussion, facial pain / maxillary toothache and symptom facial pain / maxillary toothache and symptom duration > 4-7 daysduration > 4-7 days

2004 ATBS Consensus Guidelines2004 ATBS Consensus Guidelines

Case #2-Acute SinusitisCase #2-Acute Sinusitis• CT scan ????CT scan ????

• Treatment????Treatment????

Medical I&DMedical I&D DecongestantsDecongestantsSaline nose drops Saline nose drops Oxymetazoline TID x 3 daysOxymetazoline TID x 3 daysFluidsFluidsVaporizer / Moist heatVaporizer / Moist heat

AntibioticsAntibiotics (10-14 days) – consider cost and compliance: (10-14 days) – consider cost and compliance: ampicillin, TMP-SMX, 2nd generation cephalosporins, ampicillin, TMP-SMX, 2nd generation cephalosporins, fluoroquinolonesfluoroquinolones

Case #2-Acute SinusitisCase #2-Acute Sinusitis• Consider admission versus 24Consider admission versus 24° F/U in patients ° F/U in patients with frontal/pansinusitis or immunocompromised with frontal/pansinusitis or immunocompromised patientspatients

• Treatment for acute exacerbationsTreatment for acute exacerbations of chronic sinusitis ? of chronic sinusitis ?

• Steroids???Steroids???

Case #3Case #3

A 27 year old male presents c/o A 27 year old male presents c/o malaise, frontal headache, low malaise, frontal headache, low grade fever, myalgias and nausea. grade fever, myalgias and nausea. He just finished a 14 day course of He just finished a 14 day course of antibiotics for sinusitis. He felt well antibiotics for sinusitis. He felt well for 24 hours when these symptoms for 24 hours when these symptoms began. began.

At this point what is in your DDx?At this point what is in your DDx?

Case #3 – DDx HeadacheCase #3 – DDx Headache•InfectiousInfectious

Meningitis, Encephalitis, Sinusitis, Brain / Tooth Meningitis, Encephalitis, Sinusitis, Brain / Tooth Abscess, Pharyngitis, Otitis / Mastoiditis, Cavernous Abscess, Pharyngitis, Otitis / Mastoiditis, Cavernous Sinus ThrombosisSinus Thrombosis

•VascularVascular

SAH, ICH, CVA, Carotid/Vertebral Dissection, SAH, ICH, CVA, Carotid/Vertebral Dissection, Migraine, Cluster, ArteritisMigraine, Cluster, Arteritis

•Mechanical / StructuralMechanical / Structural

Tension, Tumor (pseudo), Glaucoma, TMJTension, Tumor (pseudo), Glaucoma, TMJ

•Traumatic / ToxinTraumatic / Toxin

SAH, SDH, EDH, Post-Concussive, CO, WithdrawalSAH, SDH, EDH, Post-Concussive, CO, Withdrawal

Case #3Case #3

– History according to the DDx especially History according to the DDx especially defining the onset and intensity of defining the onset and intensity of headache and comparison to previous headache and comparison to previous headaches plus infectious sourcesheadaches plus infectious sources

– Physical exam should include ?? Physical exam should include ??

•What is the pertinent history and PE What is the pertinent history and PE

in this patient?in this patient?

Complete neurological, Complete neurological, mental status, HEENT mental status, HEENT and neck examsand neck exams

Case #3Case #3• Exam reveals a diaphoretic, warm confused Exam reveals a diaphoretic, warm confused

patientpatient

• VS: 116/88 – 114 – 24 – 101.4VS: 116/88 – 114 – 24 – 101.4

• HEENT – unremarkable, no sinus tenderness HEENT – unremarkable, no sinus tenderness or purulent discharge or other source of or purulent discharge or other source of infectioninfection

• Neck – supple without Kernig’s / Brudzinski’sNeck – supple without Kernig’s / Brudzinski’s

• Neuro – non-focal, intact examNeuro – non-focal, intact exam

What would you like to do now?What would you like to do now?

Case #3-MeningitisCase #3-Meningitis

• Headache, fever, stiff neck in 66% of adults; Headache, fever, stiff neck in 66% of adults; also consider with AMS, seizures, signs of also consider with AMS, seizures, signs of increased ICP, focal deficits and petechial increased ICP, focal deficits and petechial rashes; infants, immunocompromised, partially rashes; infants, immunocompromised, partially treated and elderly may not have a fever or stiff treated and elderly may not have a fever or stiff neckneck

• Maintain a high index of suspicion….if the idea Maintain a high index of suspicion….if the idea of meningitis even enters your mind, do a LP!of meningitis even enters your mind, do a LP!

• Door to Antibiotic Time?Door to Antibiotic Time?

Case #3-MeningitisCase #3-Meningitis• Send CSF for protein, glucose, gram stain, culture, Send CSF for protein, glucose, gram stain, culture,

cells, cryptococcal antigen, latex agglutination (if cells, cryptococcal antigen, latex agglutination (if antibiotics given) and Herpes PCR if indicatedantibiotics given) and Herpes PCR if indicated

• CT scan before LP if focal neurologic signs, signs of CT scan before LP if focal neurologic signs, signs of increased ICP or obtunded patient who can’t increased ICP or obtunded patient who can’t cooperate with a neurologic examcooperate with a neurologic exam

• Very young and old: Ampicillin and gentamicin +/- Very young and old: Ampicillin and gentamicin +/- acyclovir; all others: ceftriaxone or cefotaxime +/- acyclovir; all others: ceftriaxone or cefotaxime +/- vancomycinvancomycin

• Steroids in adults?Steroids in adults?van de Beek D, de Gans J, McIntyre P, et al.Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev Issue 1. 2007

Case #4Case #4

47 year old male smoker presents c/o 47 year old male smoker presents c/o

a productive cough for 4 days. He a productive cough for 4 days. He denies fever, chills, chest pain or SOB. denies fever, chills, chest pain or SOB. He does note some occasional purulent, He does note some occasional purulent, blood tinged sputum but denies night blood tinged sputum but denies night sweats or weight loss. His PMH is sweats or weight loss. His PMH is significant for HTN.significant for HTN.

DDx? What would you like to do?DDx? What would you like to do?

Case #4Case #4• VS: 144/88 – 88 – 16 – 99.2VS: 144/88 – 88 – 16 – 99.2° - 98% on RA° - 98% on RA

• Gen: Non-toxic appearing, coughingGen: Non-toxic appearing, coughingLungs: CTA w/o rales, rhonchi, wheezesLungs: CTA w/o rales, rhonchi, wheezesHeart: RRR w/o gallop, murmur, rubHeart: RRR w/o gallop, murmur, rubExtremities: no edema or calf tendernessExtremities: no edema or calf tenderness

Your orders?Your orders?

• Most adults have viral bronchitis (NO ABX) and can Most adults have viral bronchitis (NO ABX) and can be treated with inhaled be treated with inhaled -agonists (persistent cough -agonists (persistent cough is due to low level bronchospasm) +/- HC/APAP is due to low level bronchospasm) +/- HC/APAP

• It is recommended that smokers and patients with It is recommended that smokers and patients with underlying lung disease receive antibiotics as ~ 20% underlying lung disease receive antibiotics as ~ 20% may have bacterial bronchitismay have bacterial bronchitis

• Use antibiotics active against upper respiratory Use antibiotics active against upper respiratory pathogens: macrolides, doxycycline, TMP-SMX, pathogens: macrolides, doxycycline, TMP-SMX, ampicillin x ampicillin x 5 days5 days

Case #4 – Acute BronchitisCase #4 – Acute Bronchitis

Cochrane Database Syst Rev. 2009Cochrane Database Syst Rev. 2009

Case #5Case #5

67 year old female presents c/o 67 year old female presents c/o fever, chills, right-sided pleuritic fever, chills, right-sided pleuritic chest pain and a productive cough chest pain and a productive cough for 3 days. Her PMH is significant for 3 days. Her PMH is significant for HTN, DJD, CHF and an MI 3 for HTN, DJD, CHF and an MI 3 years ago.years ago.

How is this patient different from How is this patient different from the previous patient?the previous patient?

Case #5Case #5• VS: 162/92 – 126 – 36 – 102.7VS: 162/92 – 126 – 36 – 102.7° - 91% RA° - 91% RA

• Gen: Toxic appearing patient in moderateGen: Toxic appearing patient in moderate respiratory distress respiratory distressLungs: CTA except rales at the left baseLungs: CTA except rales at the left baseHeart: Tachycardic w/o gallops, murmursHeart: Tachycardic w/o gallops, murmurs

What is your workup and therapy?What is your workup and therapy?

Case #5 - PneumoniaCase #5 - Pneumonia• Set up safety net: IV, O2, monitorSet up safety net: IV, O2, monitor

• CXR and EKG (consider enzymes if CP, AMS, CXR and EKG (consider enzymes if CP, AMS, coexistent new onset CHF, DM)coexistent new onset CHF, DM)

• Blood and sputum cultures (after saline neb)Blood and sputum cultures (after saline neb)

• CBC, CMP, +/- ABG ( oxygen saturations < CBC, CMP, +/- ABG ( oxygen saturations < 90% on RA or desaturation with exertion are 90% on RA or desaturation with exertion are reasons for admission regardless of PORT reasons for admission regardless of PORT scores)scores)

• Age (males = years, females = age – 10)Age (males = years, females = age – 10)

• Nursing home resident (10)Nursing home resident (10)

• Comorbid IllnessComorbid Illness– Neoplastic Disease (30)Neoplastic Disease (30)

– Liver Disease (20)Liver Disease (20)

– CHF (10)CHF (10)

– Cerebrovascular Disease (10)Cerebrovascular Disease (10)

– Renal Disease (10)Renal Disease (10)

Case #5 – Pneumonia ScoringCase #5 – Pneumonia Scoring

• Physical exam findingsPhysical exam findings

•• AMS (20)AMS (20) • • RR > 30 (20) RR > 30 (20) •• SBP < 90 (20) SBP < 90 (20)

• • Temp <35° > 40° (15) Temp <35° > 40° (15) •• Pulse > 125 (10) Pulse > 125 (10)

• Laboratory or Radiographic findingsLaboratory or Radiographic findings

• Arterial pH < 7.35 (30)Arterial pH < 7.35 (30) • BUN>30 (20)• BUN>30 (20)

• Na < 130 (20)Na < 130 (20) • Glu>250 (10) • Glu>250 (10)

• Hct < 30 (10)Hct < 30 (10) • PO2<60 (10) • PO2<60 (10)

• Pleural Effusion (10)Pleural Effusion (10)

• >91 points = hospitalize, 71-90 = observation>91 points = hospitalize, 71-90 = observation

Case #5 – Pneumonia ScoringCase #5 – Pneumonia Scoring

Case #5 - PneumoniaCase #5 - Pneumonia• Outpatient Therapy: Outpatient Therapy:

– Healthy / no risk for DRSP: macrolide or doxycycline Healthy / no risk for DRSP: macrolide or doxycycline – Comorbidities or risk for DRSP: respiratory Comorbidities or risk for DRSP: respiratory

fluoroquinolone (moxi, gemi, levo) or fluoroquinolone (moxi, gemi, levo) or -lactam -lactam (extended spectrum cephalosporin, Amp/Cl, high dose (extended spectrum cephalosporin, Amp/Cl, high dose Amp) plus macrolide or doxycycline (ATS/IDSA)Amp) plus macrolide or doxycycline (ATS/IDSA)

• Inpatient / Non-ICU Therapy: same as high riskInpatient / Non-ICU Therapy: same as high risk

• ICU Therapy: ICU Therapy: -lactam + azithromycin or pulmonary fluoroquinolone-lactam + azithromycin or pulmonary fluoroquinolone– for for Pseudomonas (NCAP/vent):Pseudomonas (NCAP/vent): piperacillin-tazobactam, piperacillin-tazobactam,

cefepime, imipenem, or meropenem plus cipro/levo or azithro/ cefepime, imipenem, or meropenem plus cipro/levo or azithro/ aminoglycosideaminoglycoside

36 year old male presents c/o 36 year old male presents c/o loose stools for 2 days and crampy loose stools for 2 days and crampy abdominal pain. He is otherwise abdominal pain. He is otherwise healthy and is on no medications.healthy and is on no medications.

Case #6Case #6

What historical and PE findings areWhat historical and PE findings are important in this patient?important in this patient?

Case #6Case #6• Mexico Mexico • South America South America • ColoradoColorado• Day-careDay-care• Recent antibioticsRecent antibiotics• Shellfish Shellfish • Fried-rice Fried-rice • HIV: another lecture by itself (call ID!)HIV: another lecture by itself (call ID!)• PE: fecal blood, fever, hydration status, PE: fecal blood, fever, hydration status,

abdominal exam looking for other non-infectious abdominal exam looking for other non-infectious causescauses

• Inflammatory bowel diseaseInflammatory bowel disease• Irritable bowel syndromeIrritable bowel syndrome• Partial SBO / Colon cancerPartial SBO / Colon cancer• Mesenteric ischemiaMesenteric ischemia• Ischemic colitisIschemic colitis• Milk / food allergiesMilk / food allergies• SprueSprue• Drugs / heavy metals / mushroomsDrugs / heavy metals / mushrooms• CarcinoidCarcinoid• Thyrotoxicosis / Addisonian crisisThyrotoxicosis / Addisonian crisis

DDx of Acute DiarrheaDDx of Acute Diarrhea

• IV versus PO rehydration if dehydratedIV versus PO rehydration if dehydrated

• Rarely do you need labs in young healthy people Rarely do you need labs in young healthy people or those with short duration of symptomsor those with short duration of symptoms

• Stool cultures only for surveillance purposes Stool cultures only for surveillance purposes (poor sensitivity and expensive); O&P should be (poor sensitivity and expensive); O&P should be gotten by GI in F/U of chronic diarrheagotten by GI in F/U of chronic diarrhea

• C. difficile toxin in patients with recent ABX or C. difficile toxin in patients with recent ABX or persistent symptoms; fecal leukocytes may be persistent symptoms; fecal leukocytes may be useful in equivocal casesuseful in equivocal cases

Case #6 –Workup / TherapyCase #6 –Workup / Therapy

• Viral (50-70% of all cases) – Viral (50-70% of all cases) – supportive caresupportive care

• Invasive Bacteria: Campylobacter, Shigella, Invasive Bacteria: Campylobacter, Shigella, Salmonella, Yersinia, E. coli, +/-Vibrio – Salmonella, Yersinia, E. coli, +/-Vibrio – treat treat with ciprofloxacin or TMP-SMX as alternativewith ciprofloxacin or TMP-SMX as alternative

• Toxin-Induced: E. coli, S. aureus, B. cereus, C. Toxin-Induced: E. coli, S. aureus, B. cereus, C. difficile, A. hydrophilis, Cholera – difficile, A. hydrophilis, Cholera – supportive supportive care except C. difficile (metronidazole)care except C. difficile (metronidazole)

Case #6 - EtiologiesCase #6 - Etiologies

• Most cases are self limited only requiring Most cases are self limited only requiring hydrationhydration

• Anticholinergics (diphenhydramine) and anti- Anticholinergics (diphenhydramine) and anti- spasmotics (dicyclomine) for cramps if severespasmotics (dicyclomine) for cramps if severe

• For debilitating diarrhea use loperamide (use of For debilitating diarrhea use loperamide (use of diphenoxylate is associated with toxic megacolon)diphenoxylate is associated with toxic megacolon)

• Recent literature suggests that the incidence of Recent literature suggests that the incidence of worsening diarrhea due to lactose intolerance worsening diarrhea due to lactose intolerance associated with milk product ingestion is rareassociated with milk product ingestion is rare

Case #6 - TherapyCase #6 - Therapy

CaseCase #7 #7

• 24 year old male prisoner presents with a spider bite he sustained 2 days ago

Case #7 – A Rare Brown Recluse Bite Case #7 – A Rare Brown Recluse Bite

MRSAMRSA

Case #7Case #7• Most of these are abscesses from the dreaded Most of these are abscesses from the dreaded

“MRSA” spider“MRSA” spider

• Risk factors: prisoners, families with Risk factors: prisoners, families with recurrent infections, athletes especially close recurrent infections, athletes especially close contact sports, shelter dwellers, recurrent contact sports, shelter dwellers, recurrent infections in an individualinfections in an individual

• Normal I&D, isolation if admittedNormal I&D, isolation if admitted

• TMP/SMX, Clindamycin, VancomycinTMP/SMX, Clindamycin, Vancomycin

Questions ?Questions ?