Infectious Diseases Update2008

1
Infectious Diseases Update-2008

• Things I Think I Think-2008
• MRSA, Immunizations, Viruses Other Than Rotavirus
• Blaise L. Congeni M.D.

2
Chief Complaint/HPI

• 7 yo WF presents with 6 days of fever and now
  cant walk, vomiting and not eating.
• SinceSunday 6 days of fever high as 103-104
• No pattern
• Motrin and Tylenol around the clock
• Was seen by PCP prior Tuesday viral
• Wednesday joint pain
• LgtR knee
• Shoulder, elbow
• Now wont walk, Mother is carrying

3
Physical Exam

• Vitals 113/67 Temp 38.2 P150 RR34 98
• Appearance Ill non toxic, WD, uncomfortable
• HEENT dry MMM, conj clear, Tms clear, No
  eyrthema or exudate, blue lips (gatorade)
• Skin no rashes
• Abd soft ND, NT
• Lung clear no GFR
• Car tachy, no murmur or rubs, pulses sym
• Extrem no joint erythema, no swelling reluctant
  to move the kness but able. Reflexes present
• Very tentative to move joints due to pain.

4
Labs

• Xrays of knees negative
• CBC
• Wbc 3.5 H/H 9.8/30 plt 153
• B45 S23 L19 AL6 M5 E2 ANC 3.2
• BMP
• Na 135 K 3.5 Cl 100 bicarb 26.6 BUN 11/.4 Glu
  106 Ca 8.9
• UA
• Yellow SG1.015 leucs/nit neg wbc 4-8 rbs 2-5
  ESR 40
• CRP 9.5
• CK 45
• Strep negative
• Flu negative
• Mono negative
• RF, ANA, ASO pending

5
Floor

• Initial vitals
• 114/42 39.0 124 1 liter O2 for sats 89
• Bolus 20cc/kg
• CXR negative
• Transferred to the ICU for possible septic shock
• 2100 labs
• CBC
• Wbc 4.9 H/H 9.9/28.4 plt 99
• B30 S35 L14 AL2 M19
• BMP
• Na 136K 6.2 Cl 106 bicarb 18.3 BUN 15/.06 Glu
  167
• Ca 8.6 protein 5.1 Alb 2.5 alt 78 ast 85 alk
  phos 234

6
12/15/2008 9 PM
7
12/1/5/2008 9PM
8
(No Transcript)
9
(No Transcript)
10
Severe Sepsis

• Isolation of S. aureus from a clinically
  important site
• Hypotension
• Respiratory distress syndrome or respiratory
  failure
• Plus involvement of CNS, liver, kidneys, muscle
  or skin or hemostasis or leukopenia or
  thrombocytopenia
• This syndrome is similar to TSS, but does not
  fulfill all the CDC criteria

Shulman, Ayoub. Peds, 1976. 5859-66.
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
Empiric Treatment of severe infections due to S.
aureus

• Vancomycin, linezolid, daptomycin-issues with
  each.
• Changing susceptibility of MRSA.
• Issues associated with recurrences.

15
Monitoring Vancomycin LevelsTroughs 10-15

• Severe infections, especially with bacteremia or
  meningitis associated with positive cultures.
• Persistently blood cultures
• Infections dues to MRSA associated with increased
  MICs.
• Infections associated with changes in renal
  function.
• When to consider alternative or additional agents

16
Principles of Decolonization

• When to consider surveillance cultures
• Where to apply topical therapy, soaps
• When to treat family members
• Mupiricin resistance 10-15
• Retapamulin effective against some strains of
  S. aureus resistant to mupiricin, approved 4/07
  for topical therapy of impetigo for MSSA, bid for
  5 days, not approved for intranasal application

17
Serotype 19AStreptococcus pneumoniae

• Penicillin, 8?g/mL Amoxicillin,8?g/mLTrimethopri
  m, gt32?g/mL Clarithromycin, gt32?g/mL
  Azithromycin, 32?g/mL Clindamycin,
  gt64?g/mLTetracycline., gt16?g/mL Cefprozil,
  gt16?g/mL, Cefuroxime, gt16?g/mL Cefpodoxime,
  gt16?g/mL, Cefdinir, gt16?g/mL Ceftriaxone,
  6?g/mL. This serotype 19A strain demonstrated
  suspectability to Telithromycin,
  0.5?g/mLVancomycin, 0.25?g/mL Rifampin
  lt0.12?g/mL Ciprofloxacin, 1?g/mL and
  Levofloxacin, 1?g/mL
• JAMA, October 17, 2007- Volume 298, No. 15

18
(No Transcript)
19
What I learned

• Timing is everything.
• Dont fight the tape.
• There is no rule against good fortune. Be
  grateful. (3 Gs- green, glad, grateful.)
• Surround yourself with people more capable than
  yourself. Blc-2007.

20
Case 2

• 13 year old male presents to ER
• Complaints of 2-3 week h/o hemoptysis,
  intermittent low grade fevers (approx 38C twice
  weekly), nasal congestion, and decreased appetite
• Prior episode of coughing blood occurred 2 weeks
  ago and described as bright red, 1-2 tsp, similar
  episode also occurred approx 5 months ago

21
Case 2

• Denies rash, vomiting, diarrhea, weight loss
• Moved to USA from the Russia (state of Georgia)
  approx 1 year ago
• Takes no medications
• No significant PMH, pt did receive a full
  physical and immunization updates prior to
  immigration, pt received a BCG vaccine in the
  past
• FMH positive for TB as a child in father
• No known current exposure to TB