(*)KeithT.Borg,MD,PhD,FACEP DivisionChiefofPediatricEmergencyMedicine; AssociateProfessorofPediatricsandMedicine, MedicalUniversityofSouthCarolina,Charleston, SouthCarolina AdvancedPracticeProvider Academy April14‐18 SanDiego,CA CommonInfectionsintheED Infectiousdiseasesarecommonlyseenintheemergency department.Thespeakerwilldiscusshowtoaccurately diagnoseandappropriatelytreatanumberofthese disordersincludingpharyngitis,URIs,influenza, pneumoniaUTIsandskinandsofttissueinfections. Objectives:  Discussthecommonsourcesoffeverandinfectionin EDpatients.  Explainhowtodifferentiatethevarietyofetiologies ininfectiousagentsfromviralbacterialandfungal.  Discusswhichpatientswithuncomplicatedsystemic infectionscanbemanagedasanoutpatient.  DiscussCMSguidelinesformanagementof pneumonia. Date:4/17/2014 Time:9:00AM‐9:30AM CourseNumber:TH‐49 (*)ConsultingFees:EventMedicalConverage,SMTMedical Solutions 4/24/2014 Common Infections in the Emergency Department Keith Borg MD, PhD MUSC Pediatric and Adult Emergency Medicine Darrel J. Morrison, MSN, RN, FNP-BC, CEN Common Infections in the ED • Discuss the common sources of fever and infection in ED patients • Explain how to differentiate the variety of etiologies in infections agents from viral, bacterial, and fungal • Discuss which patients with uncomplicated systemic infections can be managed as an outpatient • Discuss guidelines for management of pneumonia 1 4/24/2014 Common Infections in the ED • Pharyngitis • Upper respiratory infections (URI) • Influenza • Pneumonia • Urinary tract infections (UTI) • Skin and soft tissue infections (STI) Pharyngitis • • • • • • Epidemiology • Etiology One of the most common • Multiple pathogen conditions in ambulatory causes care • Bacterial 12 million visits per year • Viral Group A Strep accounts for 5-15 % of these visits 60% of patients are given antibiotics Systematic approach is much needed 2 4/24/2014 Etiology •Bacterial (<20%) • Group A streptococcus (GAS) • Group C streptococcus • Group G streptococcus • Chlamydiophia pneumoniae • Mycoplasms pneumonia • Corynebacterium diphtheriae • Neisseria gonorrheae • Treponema pallidum • Francisella tularensis • Viral (50%) • • • • • • • • • • • • Rhinovirus Adenovirus Influenza A and B Parainfluenza Coxsackieviurs Coronavirus Echovirus Herpes simplex virus Epstein barr virus HIV Cytomegalovirus Respiratory syncytial virus Group A streptococcus •Most important treatable cause •Centor Criteria • Exudate •~ 5 to 15% of sore throats are • Tender anterior cervical positive for GAS adenopathy • Fever history •Clinical features: • Absence of cough • Sore throat • Age • 3-14 years • Tonsillar exudate • 15-44 years • 45 years or older • Tender cervial adenitis • Fever •Testing • Cough and significant • Rapid antigen detection test rhinorrhea are generally • Throat culture absent 3 4/24/2014 Group A streptococcus • • • • Treatment goals Reduce duration and severity of symptoms Reduce incidence of suppurative complications Reduce incidence of nonsuppurative complications • Reduce transmission to close contacts Group A streptococcus • Treatment • Adults and kids (> 27 kg) Penicillin V 500mg bid or tid X 10d (drug of choice) Bicillin C-R 2.4 M units Bicillin L-A 1.2 M units Amoxicillin 875 mg bid or 500mg tid X 10d Cephalexin 500 mg bid X 10d • Kids (< 27 kg) • Penicillin V 250 mg bid or tid X 10d • Amoxicillin 50 mg/kg per day divided X 10d • Cephalexin 25 to 50 mg/kg per day divided bid X 10d • • • • • 4 4/24/2014 Group A streptococcus • For patient with severe allergies to beta-lactam antibiotics Azithromycin • Adults Z-pack • Kids 12 mg/kg daily X 5d • Clarithromycin • Adults 250 mg bid X 10d • Kids 7.5 mg/kg/dose bid X 10d • Clindamycin • Adults28 to 70 kg: 20 mg/kg/day orally divided tid X 10d > 70 kg: 450 to 600 mg orally tid X 10d • Kids 20 mg/kg per day orally divided tid X 10d • Pharyngitis • Symptomatic treatment • Topical/Local therapies • Magic Mouthwash • Lozenges • Sucrets • Cepacol • Chloraseptic • Throat sprays • Analgesics • IDSA recommends ASA or NSAIDs • Glucocorticoids • IDSA recommends against the use of glucocorticoids in patients with strep pharyngitis • Document no PTA, Ludwigs or other abscess 5 4/24/2014 Upper Respiratory Infections • • • • • • • • • • Definition Infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and bronchi Common cold Pharyngitis • > 7 million visits/yr Sinusitis • ~20 million visits/yr Tracheobronchitis • ~12 million visits/yr Epidemiology Occur mostly during winter months Close contacts Person to person contact/droplet Upper Respiratory Infections • Etiology • Viruses Rhinovirus Parainfluenza virus Coronavirus Adenovirus Respiratory syncytial virus Coxsackie virus Influenza • Bacteria • Pharyngitis- previously discussed • Rhinosinusitis- S. pneumoniae, H. Influenzae, M. Catarrhalis • Tracheobronchitis- B. pertussis, B. parapertussis, M. Pneumoniae, C. Pneumoniae • • • • • • • 6 4/24/2014 Upper Respiratory Infections • Clinical features • • • • • • • Coryza Nasal congestion Sneezing Sore throat Low grade fever Inflamed nasal mucosa Cough • • • Productive Color is not reliable! Non-Productive Upper Respiratory Infections • Testing • • • • • • • • • Diagnostic testing have very limited utility with URIs Exceptions Pharyngitis Influenza RSV (infants) Epiglottitis Pharyngeal abscess Mastoiditis Pneumonia 7 4/24/2014 Upper Respiratory Infections • Symptomatic treatment • Complications • • • • Push fluids Antipyretics/Analgesics Avoid systemic steroids Intranasal steroids have virtually no immediate effect • Antibiotics generally not needed • Antitussive • Codeine not shown to be significantly effective • Antihistamines • Decongestants • • • • • Acute rhinosinusitis Lower respiratory tract disease Acute otitis media Acute bacterial tracheobronchitis Asthma exacerbation Influenza • Introduction • • • • • • Acute respiratory illness Influenza A or B virus Occurs in outbreaks and epidemics worldwide Mainly during winter months Associated with increased morbidity and mortality CDC tracks influenza virus throughout the world • http://www.cdc.gov/flu/weekly/summary.htm 8 4/24/2014 Influenza • Clinical features of uncomplicated influenza • • • • • • • • Abrupt onset of fever Headache Myalgias Malaise Weakness Sneezing Nonproductive cough Symptoms gradually improve after 2-5 days with residual symptoms lasting up to 1-2 weeks Influenza • Testing • Rapid antigen tests • Polymerase Chain Reaction (PCR) • Who to test? • Test only patients if the result will influence management decisions 9 4/24/2014 Influenza • Groups at high risk of influenza complications • • • • • • • • • • • • • • Children < 2 years Adults > 65 years of age COPD / Asthma CVD CKD CLD SCD DM Immunosuppresion Pregnant women Morbidly obese Residents of LTCF Children < 19 on ASA therapy Native Americans and Alaskan Natives Influenza • Treatment • Neuraminidase inhibitors • Active against influenza A & B • Zanamivir (inhaled) • Oseltamivir (oral) • Adamantanes • Active against influenza A • Amantadine • Rimantadine 10 4/24/2014 Influenza • Benefits of therapy • Shorten the duration of influenza symptoms • 1 to 3 days • Benefit is greatest when given earlier in course of illness • Decreased severity and incidence of complications of influenza • Decreased the duration of hospitalization in patient with severe influenza • Decreased influenza associated mortality Influenza • Whom to treat with antiviral therapy? • Groups at high risk as previously stated • Illness requiring hospitalization • Progressive, severe, or complicated illness 11 4/24/2014 Pneumonia • Epidemiology • CDC combines PNA with influenza for morbidity & mortality data • PNA & influenza = 8th leading causes of death in the US (2005) • Age-adjusted death rate = 21.8 per 100,000 • Mortality rate: 7.3% out-Pt, 12% In-Pt, 40% ICU • Death rates increase with comorbidity and age Risk Factors • Aspiration risk • Swallowing and esophageal motility disorders • Stroke • Nasogastric tube • Intubation • Sz and syncope • Bacteremia risk • Indwelling vascular lines • Intrathoracic devices • Debilitation • • • • Alcoholism Extremes of age Neoplasia Immunosuppresion • Chronic diseases • • • • • • Diabetes Renal failure Liver failure Valvular heart disease Congestive heart failure Pulmonary disorders • COPD • Chest wall disorders • Skeletal muscle disorders • Bronchial obstruction • Bronchoscopy • Viral lung infections 12 4/24/2014 Pneumonia • Clinical features • Cough • Fever • Sputum production • Pleuritic chest pain • Rales • Bronchial breath sounds • Hemoptysis • GI symptoms • Dyspnea • Older patients may have atypical symptoms Pneumonia Labs •CBC •CMP •Blood cultures •Sputum culture •Legionella UAT •Pneumococcal UAT Radiology •CXR • Gold standard •CT scan 13 4/24/2014 Pneumonia • Outpatient vs Admission • Scoring criteria to assess for severity of disease can be used to identify patients with CAP, who may be candidates for outpt managemtent • CURB-65 criteria (confusion, uremia, RR, low BP, age 65 yrs or greater) • Pneumonia Severity Index Pneumonia •Outpatient Treatment • Previously healthy and no use of antimicrobials within the previous 3 months • Macrolide • Doxycycline • Presence of comorbidities or use of antimicrobials in the past 3 months • Respiratory fluoroquinolone • • Organisms • • • • Strep pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydophilia pneumonia Moxi-, levo-, gemi- • Beta lactam plus macrolide • Areas with high macrolide resistant Strep pneumoniae • Respiratory fluoroquinolone 14 4/24/2014 Pneumonia • Inpatient (non-ICU) Treatment • • Respiratory fluoroquinolone • Moxi-, levo-, gemi- • Organisms • • • • • • Strep pneumoniae Mycoplasma pneumoniae Chlamydophia pneumoniae Haemophilus influenzae Legionella species Aspiration Beta lactam plus macrolide Pneumonia • Inpatient (ICU) Treatment • • • IV Beta lactam plus either IV macrolide or IV respiratory fluoroquinolone Risk of pseudomonas • An antipneumococcal, antipseudomonal b-lactam (piperacillin- tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750 mg) • Or The above b-lactam plus an aminoglycoside and azithromycin • Or The above b-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for above b-lactam) 15 4/24/2014 Pneumonia in Children • Clinical features: • Infants: non-specific manifestations • Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx, cough, respiratory distress • Older children: more specific • Fever, cough, chest pain, tachypnea, tachycardia, grunting, nasal flaring, retracting. Cyanosis usually very late. • Signs/Physical exam • RR > 60 for all ages • Hypoxia • Rales, wheezes, crackles, coarse breath sounds Pneumonia in Children • Organisms: • 0-4 wks: GBS, GN enterics, Listeria • 4-12 wks: C. trachomatis, GBS, GN enterics, Listeria, viral (RSV/parainfluenza), B. pertussis • 3 mos-4 yrs: Viral, S. pneumo, H. influenza, M. catarrhalis, Grp A Strep, Mycoplasma • > 5yrs: Mycoplasma (5-15yrs), C. pneumo, S. pneumo, viral 16 4/24/2014 Pneumonia in the Elderly • • • • Prevention important Presentation can be subtle Antibiotic choice in CAP is same as other adults Healthcare associated pneumonia • Consider S. aureus (skin wounds) and GN bacteria (aspiration) Pneumonia in Immunocompromised Pts • • • Smokers, alcoholics, bedridden, immunocompromised, elderly Common still common • S. pneumo • Mycoplasma Pneumocystis Carinii Pneumonia • P. jirovecii • Fever, dyspnea, non-prod cough (triad 50%), insidious onset in AIDS, acute in other immunocompromised Pts • CXR: bilateral interstitial infiltrates • Steroids for hypoxia • TMP-SMZ still first line 17 4/24/2014 Urinary Tract Infection • Lower • Urethritis • Cystitis • Upper • Pyelonephritis • Intrarenal and perinephric abscess Etiology •Gram neg. bacteria • E. coli = 80% of uncomp. acute UTI • Proteus – assoc. with stones • Klebsiella – assoc. with stones • Enterobacter • Serratia • Pseudomonas •Gram pos. cocci • Staphylococcus saprophyticus 10-15 % acute sx UTI in young females • Enterococci – occas. in acute uncomp. cystitis • Staphylococcus aureus – assoc. with renal stones, instrumentation, increased susp. of bacteremic kidney infection 18 4/24/2014 Etiology • Urethritis from chlamydia, gonorrhea, HSV – acute sx female with sterile pyuria • Ureaplasma urealyticum • Candida or other fungal species – commonly assoc. with cath. or DM • Mycobacteria Pathogenesis • Usually ascent of bacteria from urethra to bladder to kidney • Vaginal introitus, distal urethra colonized by normal flora • Gram negative bacilli from bowel may colonize at introitus, periurethra 19 4/24/2014 Predisposing conditions to UTI • Female • Short urethra, proximity to anus, termination beneath labia • Sexual activity • Pregnancy • 2-3% have UTI in preg, 20-30% with asx bacteriuria  may lead to pyelo • Increased risk of pyelo = decreased ureteral tone, decreased ureteral peristalsis, temp. incomp of vesicoureteral valves Predisposing conditions to UTI • Neurogenic bladder dysfunction or bladder diverticulum (incomplete emptying) • Age - Postmenopausal women with uterine or bladder prolapse (incomplete emptying), lack of estrogen, decreased normal flora, concomitant medical conditions such as DM • Vesicoureteral reflux • Bacterial virulence • Genetics • Change in urine nutrients, DM, gout 20 4/24/2014 Urethritis • Acute dysuria, frequency • Often need to suspect sexually transmitted pathogens esp. if sx more than 2 days, no hematuria, no suprapubic pain, new sexual partner, cervicitis Cystitis • • • • • Sx: frequency, dysuria, urgency, suprapubic pain Cloudy, malodorous urine (nonspec.) Leukocyte esterase positive = pyuria Nitrite positive (but not always) WBC (2-5 with sx) and bacteria on urine microscopy 21 4/24/2014 Pyelonephritis • Fever • Chills, N/V, diarrhea, tachycardia, myalgias • CVAT or tenderness with deep abdominal tenderness • Possibly signs of Gram neg. sepsis Pyelonephritis • Leukocytosis • Pyuria with leukocyte casts, and bacteria and hematuria on microscopy • Complications: sepsis, papillary necrosis, ureteral obstruction, abscess, decreased renal function if scarring from chronic infection, in pregnancy – may increase incidence of preterm labor 22 4/24/2014 Catheter-Associated Urinary Tract Infections • 10-15% of hosp. patients with indwelling catheter develop bacteriuria • Risk of infection is 3-5% per day of catheterization • UTI after one-time bladder cath approx. 2% • Gram neg. bacteremia most significant complication of cath-induced UTI • Greater antimicrobial resistance Diagnosis of UTI • • • • • • • History Physical exam Lab Urinalysis with micro • Leuk. Esterase pos. = pyuria • Nitrite positive • from urea producing bacteria (but not always) • Micro – WBC (even 2-5 in patient with sx) • Micro – Bacteria Urine culture when needed Sensitivities of culture for tailored antibiotic therapy May dx acute uncomp. cystitis based on hx, PE, and UA alone, no need for culture to treat 23 4/24/2014 Diagnosis • Urine culture • Once 105 colonies per mL considered standard for dx but misses up to 50% • Now, 102 to 104 accepted as significant if patient symptomatic • Needed in upper UTI, comp. UTI, and in failed treatment or reinfection • Sensitivities for better tailoring of tx Treatment • Uncomplicated cystitis in pregnant patient • Requires longer duration of treatment • 7-14 days • Cephalosporin, nitrofurantoin, augmentin, 24 4/24/2014 Pyelonephritis • Outpatient treatment • Uncomplicated, nonpregnant • Primary • Fluoroquinolone x 7 days • Alternate • Augmentin, TMP/SMX, or oral cephalosporin x 14 days Pyelonephritis • Inpatient treatment • Treat IV until patient is afebrile 24-48 hours. Then, complete 2 week course with PO meds • Use FQ or amp/gent or ceftriaxone or piperacillin • If no improvement on IV, consider imaging studies to look for abscess or obstruction • All pregnant patients with pyelo get inpatient tx, appropriate IV antibiotics immediately 25 4/24/2014 Treatment of Complicated UTI • Catheter related • Amp/gent or Zosyn or ticaricillin/clav or imipenem or meropenem x 2-3 weeks • Switch to PO FQ or TMP/SMX when possible • Rule out obstruction • Watch out for enterococci and pseudomonas UTIs in Children • Most infants >2 months can be managed outpt with close follow-up • Indications for hospitalization • Age < 2 months • Clinical urosepsis or potential bacteremia • Immunocompromised pt • Vomiting or inability to tolerate PO meds • Lack of adequate outpt follow-up • Failure to respond to outpt therapy 26 4/24/2014 UTIs in Children • Outpatient Imaging (RUS and VCUG) • Girls < 3 years with first UTI • Boys of an age with first UTI • Children of any age with febrile UTI • Children with recurrent UTI (if they have not been imaged previously) • First UTI in a child of any age with family hx of renal dx, abnormal voiding pattern, poor growth, htn, or abnormalities of urinary tract UTIs in Children • Treatment • Cefixime (Suprax) • 16 mg/kg per day PO in 2 div doses on day 1; then 8mg/kg PO qd • Cefdinir • 14 mg/kg per day PO div in 2 doses • Augmentin (resistance) • Keflex (resistance) • Bactrim (resistance) 27 4/24/2014 UTIs in Children • Duration of Therapy • < 2 yrs & febrile or recurrent UTIs • 10 days • >2 yrs & afebrile & without abnormalities of urinary tract & without hx of UTIs • 5 days UTIs in Men • Less common than in women • Considered complicated • Risk factors • Anal intercourse • Lack of circumcision • Clinical features • Dysuria • Frequency • Urgency • Suprapubic pain • Hematuria 28 4/24/2014 UTIs in Men • Testing • UA • Pyuria • Urine cx if UA positive • Differential diagnoses • Cystitis • Prostatitis • Pyelonephritis • Urethritis UTIs in Men • Treatment • Cystitis • Trimethoprim-sulfamethoxazole X 7 to 14 d • Avoid if resistance rates > 20% or if taken within the preceding 3 months • Fluoroquinolone X 7 to 14 d • Nitrofurantoin and beta-lactams should not be used in men 29 4/24/2014 Skin and Soft Tissue Infections • Impetigo • Erysipelas • Cellulitis • Abscess Impetigo • Bacteria • Beta hemolytic streptococci • S. aureus • Clinical manifestations: • Begins painless, occasionally pruritis • Yellow / honey colored lesions (crusted) • Exposed ares of the body • Face • Extremities • Bullous or non bullous 30 4/24/2014 Erysipelas • Clinical features • Involves the upper dermis and superficial lymphatics • Erythematous lesions raised above the level of surrounding skin • Clear line of demarcation between involved and uninvolved tissue • Fever • Chills • Warmth • Most commonly on lower extremities Cellulitis • • • • Acute spreading infection of skin Extending more deeply than erysipelas Involving subcutaneous tissues Clinical features • Skin erythema • Edema • Warmth • With or without discharge • Fever, chills 31 4/24/2014 Abscess •Clinical features • Collection of pus within the dermis and deeper skin tissues • Painful • Tender • Fluctuant • Erythematous • Swelling • Warmth • Fever • Treatment • • Incision & Drainage Appropriate antibiotics according to clinical presentation Skin and Soft Tissue Infections • Differential diagnosis • Necrotizing fasciitis • Gas gangrene • Toxic shock syndrome • Bursitis • Osteomyelitis • Herpez zoster • Erythema migrans • Impetigo • Abscess • Insect bite • Gout • Dermatitis 32 4/24/2014 Skin and Soft Tissue Infections • Diagnosis • • • • • • • Clinical manifestations Lab testing Generally not needed Only if systemic toxicity, extensive skin involvement, underlying comorbidities, recurrent/persistent cellulitis Radiology Generally not needed Can assist in assessing for occult abscesses, distinguishing cellulitis from osteomyelitis, or assessing for the presence of gas. Skin and Soft Tissue Infections • Disposition • Outpatient • No systemic signs of infection • Good outpatient follow up • Able to take oral medications • Inpatient • Systemic signs of infection • Failed previous outpatient therapy • Significant co-morbid conditions 33 4/24/2014 References Baddour, L.M. (2013). Cellulitis and erysipelas. UpToDate. Retrieved from http://www.uptodate.com Baddour, L.M. (2014). Skin abscesses, furuncles, and carbuncles. UpToDate. Retrieved from http://www.uptodate.com Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter, E. R., Harrison, C., . . . Swanson, J. T. (2011). The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases, 53(7), e25-e76. doi: 10.1093/cid/cir531 Chow, A. W., Benninger, M. S., Brook, I., Brozek, J. L., Goldstein, E. J. C., Hicks, L. 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Acute uncomplicated cystitis and pyelonephritis in women. UpToDate. Retrieved from http://www.uptodate.com Hooton, T.M. and Gupta, K. (2013). Urinary tract infections and asymptomatic bacteriuria in pregnancy. UpToDate. Retrieved from http://www.uptodate.com Kalpana Gupta, Thomas M. Hooton, Kurt G. Naber, Björn Wullt, Richard Colgan, Loren G. Miller, Gregory J. Moran, Lindsay E. Nicolle, Raul Raz, Anthony J. Schaeffer, and David E. Soper International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases Clin Infect Dis. (2011) 52 (5): e103-e120. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG. 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Symptomatic treatment of acute pharyngitis in adults. UpToDate. Retrieved from http://www.uptodate.com Stevens, D. L., Bisno, A. L., Chambers, H. F., Everett, E. D., Dellinger, P., Goldstein, E. J. C., . . . Wade, J. C. (2005). Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. Clinical Infectious Diseases, 41(10), 1373-1406. doi: 10.1086/497143 Zachary, K. (2014). Treatment of seasonal influenza in adults. UpToDate. Retrieved from http://www.uptodate.com 34