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Common Infectious Disease
Cases Found in the ER
39th Semi-Annual Family/Internal Medicine Review Program
Monday, March 23, 2015 at 2:30pm - 2:55pm
Ji Hoon Baang MD FACP
Assistant Professor of Clinical Medicine
Section of Hospital Medicine
Temple University School of Medicine
Disclosures
• None to disclose
SORT evidence rating system
• A = consistent, good-quality patient-oriented
evidence
• B = inconsistent or limited- quality patientoriented evidence
• C = consensus, disease-oriented evidence,
usual practice, expert opinion, or case series.
http://www.aafp.org/dam/AAFP/documents/journals/afp/sortdef07.pdf
Case 1
• 35 year old man presents
to you with an enlarging
painful lesion that has
been progressively
getting worse these past
few days.
• You perform an I&D and
plan to discharge the
patient.
• Do you treat him?
Image from meded.uscf.edu
Placebo vs TMP/SMX in adults (n=212)
Schmitz G et al. Ann Emerg Med 2010
Placebo vs TMP/SMX in adults (n=212)
Baseline Characteristics
Schmitz G et al. Ann Emerg Med 2010
Placebo vs TMP/SMX in adults (n=212)
Results: Treatment Failure at 7 days
Schmitz G et al. Ann Emerg Med 2010
I&D alone vs. I&D with antibiotics
in patients with SSTIs
Rajendran P AAC 2007; Schmitz G Ann Emerg Med 2010; Duong M Ann Emerg Med 2009; Slides adapted from Catherine Liu MD
% of Participants Choosing Different Treatment
Options for the Management of SSTIs
Hammond SP et al. NEJM 2008
Oral MRSA Antibiotics
Dose
Coverage
Cons
Trimethoprim /
sulfamethoxazole
1~2T DS po q12hours
MSSA +++
MRSA +++
Strep –
Bad strep drug
Sulfa in it
Doxycycline
Minocycline
100mg po q12 hours
MSSA +++
MRSA +++
Strep +
GI side effects,Pill induc
ed esophagitis, phototox
icity
Clindamycin
450 ~ 600mg po q8hours
MSSA +++
MRSA ++
Strep +++
Misses some MRSA
C diff risk higher
Three times a day
Linezolid
600mg q12hours
MSSA +++
MRSA +++
Strep +++
Expensive
Thrombocytopenia / neu
rotpathy / retinopathy (w
ith long term use, wks)
Key Recommendation for Practice
(Evidence Level A)
There is little evidence that giving
antibiotics adds benefit after an I&D of
an abscess
“You’ve treated most of the infection
once you drained an abscess. The
antibiotics is really for the surrounding
cellulitis”
Case 2
• 54 year old man with COPD presents to
you with cough and a fever of 102 that
started yesterday. Also complaining of
myalgia and describes as if he “hit by a
car”. CXR is normal and lung exams
reveals no wheezing. An NP swab for
influenza is done which is negative.
• Do I treat him?
Flu (H1N1) Clinical Characteristics
Clinical Symptoms
No./ Total No (%)
Fever
371/394 (94%)
Cough
365/397 (92%)
Sore Throat
242/367 (66%)
Diarrhea
82/323 (25%)
Vomitting
74/295 (25%)
NEJM 2009
How good is the rapid flu test?
Influenza can be ruled in but not ruled out through the
use of the rapid flu test due to it’s low sensitivity.
Chartrand C et al. Annals 2012
CDC Recommendation
• All hospitalized patients and all high-risk patients (either
hospitalized or outpatient) with suspected influenza
should be treated as soon as possible with one of three
available influenza antiviral medications.
• This should be done without waiting for confirmatory
influenza testing.
• While antiviral drugs work best when given early (within
48 hours), therapeutic benefit has been observed even
when treatment is initiated later.
http://emergency.cdc.gov/HAN/han00375.asp
Key Recommendation for Practice
(Evidence Level A)
A rapid flu test cannot rule out influenza and
should not deter you from initiating treatment if
your clinical suspicion is high.
“Just treat if you think the patient has the flu.
Don’t wait for the test results because it won’t
matter.”
Case 3
• A 75 year old woman comes to you with fever,
cough and myalgia. In your review of systems
she also notes “smelly urine”. A urinalysis shows
10 WBC / HPF and ++ bacteria. She denies any
urinary symptoms including dysuria, frequency
and urgency.
• Do you treat her?
How common is asymptotic bacteriuria
Nicolle LE et al. CID 2004
Asymptomatic bacteriuria in
sexually active woman
• Only 8 % of patients with significant bacteriuria developed a UTI
vs 1% in patients with insignificant bacteriuria.
• The risk of UTI persisted for 1 month.
Hooton TM et al. NEJM 2000
65 Asymptomatic bacteriuria episodes
Hooton TM et al. NEJM 2000
Host Factors play a significant role in the
development of bacteriuria
Hooton TM et al. NEJM 2000
Treating bacteriuria has
little impact after 1 year
Asscher AW et al. BMJ 1969
Antibiotics vs Placebo in
Diabetic Woman (n=105)
Harding GKM et al. NEJM 2002
Conclusion
• Association of asymptomatic bacteriuria with
symptomatic urinary infection is likely attributable to host
factors that promote both symptomatic an asymptomatic
urinary infection, rather than symptomatic infection being
attributable to asymptomatic bacteriuria.
• The treatment of asymptomatic bacteriuria neither
decreases the frequency of asymptomatic infection nor
prevents further episodes of asymptomatic bacteriuria
Key Recommendation for Practice
(Evidence Level A)
There is little evidence that treating
asymptomatic bacteriuria has an significant
long term and short term clinical impact except
in pregnant patients.
“Don’t treat a positive urine if the patient is not
complaining.”
Case 4
• A 25 year old woman presents
after being bitten by a cat last
night at a party about 1 hour
ago. She didn’t realize there
was a cat on the floor and
stepped on the cat which lead
to the bite. Her bite wound
looks like the picture.
• What do you do?
The Basics
• Good Wound Care
• Tetanus
• Rabies
• Antibiotics?
Oral Flora
• Oral flora
– Anaerobes
– Streptococcus spp, Staphylococcus spp
– Pasteurella multocida
• Not in humans
– Capnocytophaga canimorsis
• Mostly in dogs
– Eikenella corrodens
• Classic organism in human bites
• Skin flora
– Streptococcus spp, Staphylococcus spp
Dog Bite
Dog Bite
• Relatively low rate of infection (2%~5%)
• Routine antibiotic prophylaxis not indicated
• “High risk” patients and wounds likely need antibiotic
prophylaxis
– High wound: Wounds requiring primary closure, devitalized
tissue, hands and wrist bites, deep bites, bites to the genitals
– High risk patients: Diabetes, immunosuppressed patients,
cirrhosis and splenectomy
• “US free of canine rabies” (CDC 2007)
– Risk low but not gone (i.e. adoption of dogs not from the US)
– Most are from skunks, raccoons, bats and foxes
Cat Bite
http://gizmodo.com/5931500/why-cat-bites-are-pretty-much-the-worst-thing-ever
Cat Bite
• Relatively high infection rate: >50%
• More complications such as tenosynovitis,
osteomyelitis, septic arthritis
• Rabies: rare but not gone
• Antibiotic prophylaxis usually reccomended
Antibiotics
• Amoxicllin / clavulanic acid
– Excellent coverage of almost all oral flora
– A good head and neck drug
– 500mg PO TID, 875mg PO BID
• Doxycycline and metronidazole
– Alternative when allergic to PCN
• Moxifloxacin
– Some anaerobe resistance (up to 40%)
Key Recommendation for Practice
(Evidence Level B)
Give antibiotics prophylactically for every cat
bite case by case for dog bites.
“If a cat bites you treat ASAP, if a dog bites
you look at the wound and patient then
decide.”
Conclusion (Evidence Level)
• There is little evidence that giving antibiotics adds
benefit after an I&D of an abscess (A)
• A rapid flu test cannot rule out influenza and should
not deter you from initiating treatment if your clinical
suspicion is high. (A)
• There is little evidence that treating asymptomatic
bacteriuria has an significant long term and short
term clinical impact except in pregnant patients. (A)
• Give antibiotics prophylactically for every cat bite
case by case for dog bites. (B)
Thank you.