INFECTIOUS DISEASE Medical Knowledge 1.

Define the common infectious illnesses causing fever in hospitalized patients, including the most likely organisms causing infection of specific sites. This includes pneumonia, urinary tract, intra-abdominal, diabetic foot ulcers, cellulitis, endocarditis, meningitis, septicemia, and C diff. 2. Define the differential diagnosis for fever in the neutropenic host and asplenic. 3. Outline the major factors to consider in choosing antibiotics, including spectrum of coverage, penetration, side effects. 4. Discuss the epidemiology of pneumonia in adults, including the concepts of community-acquired, hospital-acquired, healthcare-associated and aspiration types. 5. Define the host substrate (healthy, smoker, alcoholic, healthcare-associated, hospital acquired) and how it can help differentiate between various infecting organisms in pneumonias 6. Define the therapy of pneumonia caused by the most common organisms; discuss empiric therapy of common clinical syndromes including community acquired, healthcare-associated pneumonia and hospital acquired pneumonia. Patient Care 1. Evaluate a patient for a possible infection using a carefully-obtained history and physical exam, placing emphasis on epidemiological data; e.g. age, underlying health, risk factors for HIV, recent travel, whether health care associated pneumonia, and a ROS and PE of common sites for infection. 2. Order and interpret appropriate laboratory studies: CBC, cultures, renal and liver function tests, urinalysis, CXR, CSF etc. 3. Choose appropriate antibiotics or make the decision to withhold antibiotics in the appropriate setting 4. Initiate an appropriate diagnostic workup. Problem 1. Listed below are various clinical syndromes. In each, identify: Clinical Syndrome Community-acquired pneumonia in a patient with COPD Hospitalized-acquired pneumonia < 5 days before pneumonia develops Healthcare-associated pneumonia / Hospital acquired pneumonia > 5 days Most likely pathogens H influenza, Moraxella catarrhalis, S. Pneumoniae (upper respiratory big 3 for otitis, sinusitis) Severe COPD- pseudamonus , aerobic GNR (e.colic enterobactor, klebsiella) Gram negatives (not pseudomonas) pneumococcus, H flu, moraxella, plus legionella and staph depending on risk factors Resistant gram negatives including pseudomonas and depending on the hospital additional coverage for MRSA Reasonable initial empiric antibiotic agents Pseudomona, stapholycoccal or anaerobic coverage Floroquinolone or beta lactam + macrolide Get atypicals and typicals Ceftriaxone, ampicillin-sulbactam, levofloxacin, moxifloxacin or ertapenem Antipseudomonal B-lactam; defepime, ceftazidime, pipercillin/tazobactam, ticarcillin-clavulanic, meropenem, doripenem, or aztreonam PLUS One of the following: ciprofloxacin, levofloxacin, gentamicin, tobramycin, or amikacin PLUS Therapy for MRSA is suspected

Aspiration pneumonia in an alcoholic

S. pneumo, Klebsiella, staph Aspriaotn- anaerobes

Splenectomized patient with fever Neutropenic patient with a fever, no apparent source IVDA with fever and pleuretic chest pain (R side endocarditis) Nursing home patient with UTI + Foley

Pneumococcus, H influenza, meningococcus (encapsulated organisms) No need to answer but all regimens get pseudomonas

S aureus

Anti Staph penicillin (dicloxaccilin, methicillin) or Vanco + aminoglycoside

Diabetic foot ulcer (malodorous)

Enteric pathogens (eg, Escherichiacoli) are most commonly responsible, but Pseudomonas species, Enterococcus species, Staphylococcus aureus, coagulase-negative staphylococci, Enterobacter species, and yeast also are known to cause infection. Proteus and Pseudomonas species are the organisms most commonly associated with biofilm growth on catheters. caused by the same organisms as those in healthy hosts, namely group A streptococci and Staphylococcus aureus. In unusual epidemiologic circumstances, however, organisms such as Pasteurella multocida (eg, from dog or cat bites or scratches) may be noted and should always be considered. Group B streptococcal cellulitis is uncommon in healthy hosts but not uncommon in patients with diabetes. In diabetic individuals, group B streptococci may cause urinary tract infections and catheter-associated bacteriuria in addition to cellulitis, skin and/or soft-tissue infections, and chronic

Bacterial meningitis

osteomyelitis. 6-60 is N meningitides, enterovirus, S. pneumo or HSV 60+- S pneumo, GNRs, Listeria, N. Meningitidis

Cellulitis requiring Hospitalization Intra-abdominal infections (diverticulitis, cholecystitis) Infectious Diarrhea

Strep or staph

HSV encephatlitis- IV acycloivir CMV- Iv gancyclovir +/- foscarnet 3 mos-60: empiric treatment Vanco + ceftriaxone or cefotaxime >60 yrs ampicillin + vanco + ceft or cefotaxime Cephalexin, dicocloccillin Use clindamycin or TMP-SMX if MRSA is suspected

E coli, klebsiella, streptococcus, proteus, and enterobacter species; the anaerobes most Rotavirus, Norwalk virus

Healthcare-associated pneumonia is defined as a patient with extensive healthcare exposure, including: Intravenous therapy, wound care or intravenous chemotherapy within 30 days Nursing home resident Hospitalization 2 or more days within the last 90 days Hemodialysis patient within 30 days Problem 2 An 87-year-old man is hospitalized for a community acquired pneumonia. He is treated with azithromycin and ceftriaxone. Because of hypotension he goes to the ICU, and develops acute kidney injury requiring dialysis. On day 10 his white count starts to increase with a left shift. What would be some possibilities for the increasing WBC? Pleural effusion Empyema Hospital acquired pneumonia Abscess Sepsis Aspirated Urine Lung Central line septic phlebitis Wound C diff- increasing WBC without any obvious source

COMPLEX ACID BASE DISTURBANCES Medical Knowledge 1. If there is an increased anion gap be able to utilize the delta anion gap/delta bicarbonate to determine if there is also an additional disturbance such as a non anion gap acidosis of metabolic alkalosis. 2. To know the differential diagnosis for anion gap acidosis, non anion gap acidosis, metabolic alkalosis, respiratory acidosis (acute and chronic) and respiratory alkalosis (acute and chronic) In order to interpret these acid base abnormalities you need to review the concept of delta anion gap/delta bicarbonate. A good resource is the link below with the acid base conference. You can also read about this concept in UptoDate and other resources. Acid Base Online Tutorial: http://fitsweb.uchc.edu/student/selectives/TimurGraham/Delta_Ratio.html Interpret the following ABG: Utilize a normal pH as 7.38 7.42, pC02 40 mm Hg, and bicarbonate 25 meq/L Normal anion gap 10 1. Room air pH 7.32 p02 90 pC02 32 HC03 16 Anion gap 22 Low ph ; low O2, low pCO2, low bicarb, high anion gap Anion gap Metabolic acidosis with respiratory compensation Acute 1.5x16 = 25 + 8 -/+ 2 = 30-34 for expected pCO2- appropriately compensated respiratory (if pCO2 is lower- 26---lower than expected- also has a primary respiratory alkalosis) has overcompensated --- seen in SEPSIS or liver failure If not as low as expected- also has primary respiratory acidosis

22-12/ 25-16 10/9 1 to 2; Pure Anion Gap Acidosis Lactic acidosis: average value 1.6 DKA more likely to have a ratio closer to 1 due to urine ketone loss

2. 40% oxygen pH 7.20 p02 50 pC02 60 HC03 24 Anion gap 17 Acidemia, low O2, high pCO2, nl bicarb/low Respiratory acidosis with compensation with Elevated anion gap 17-12 / 25-24 5/1 = 5 High AG acidosis and a concurrent metabolic alkalosis or a pre-existing compensated respiratory acidosis Compensation for a chronic respiratory acidosis Severe sleep apnea

In order to check for respiratory compensation you use the Winters equation. This formula is only applicable for respiratory compensation for a metabolic acidosis. The expected pCO2 = 1.5 HCO3 + 8 +/- 2 If the patients pCO2 is within the expected range then the comment is appropriate respiratory compensation or secondary respiratory alkalosis. In this case expected pCO2 is 1.5 (14) + 8 +/- 2 ie 27-31 so this patient has a compensated respiratory alkalosis. If the pCO2 had been lower than 27 then it would be a primary respiratory alkalosis ie overcompensated If greater than 31 then inadequate compensation ie primary respiratory acidosis

The Delta Ratio (/) The delta ratio is sometimes used in the assessment of elevated anion gap metabolic acidosis to determine if a mixed acid base disorder is present. Delta ratio = Anion gap/ [HCO3-] or anion gap/ [HCO3-] Delta Delta = Measured anion gap Normal anion gap Delta del Normal [HCO3-] Measured [HCO3-] Delta Delta = (AG 12) Delta delaaa(24 - [HCO3-])

Delta ratio
< 0.4 <1 1 to 2

Assessment Guidelines
Hyperchloremic normal anion gap acidosis High AG & normal AG acidosis Pure Anion Gap Acidosis Lactic acidosis: average value 1.6 DKA more likely to have a ratio closer to 1 due to urine ketone loss High AG acidosis and a concurrent metabolic alkalosis or a pre-existing compensated respiratory acidosis

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