Infectious Diseases
Pete Johnston
Outcomes
Act Conditions:
Infection in surgical patients
Infectious mononucleosis Severe Sepsis Pyrexia of unknown origin Gastroenteritis Hospital acquired infection
Case one
Its 3am on Lincoln Wing. Youre asked to see a patient with a temperature of 39.6C
BG: 54 y/o man. 5 days post Hartmanns for perforated diverticulum.
T39.6C, HR 150, BP 130/75, RR 28. Urine output anybodys guess! Are they septic???
What is Sepsis?
Suspected or known source + two or more of: 1) Temp < 36C or > 38C 2) HR > 90 3) RR > 20 4) WCC <4.0 x 109 or > 12.0 x 109
Wheres it coming from???
0-24 hours (ish) Post-op pyrexia C. 48 hours chest, atelectasis Day 3-5 UTI, HAP. Day 5-7 wound infection > 1 week: deeper source: wound dehisce & Intravenous Lines
abdominal collections.
Dont forget: DVT + PE cause pyrexia.
What to do.
1) Assessment.
Chest, abdomen, lines, legs, wounds.
2) Investigations.
Bloods, paired cultures, wound swabs, urinalysis, CXR, ABG.
3) Treatment
Oxygen, fluids (20mls / kg), antibiotics.
Empirical antibiotics
According to local guidelines HAP: IV co-amoxiclav (<5 days) Piperacillin-tazobactam (> 5 days) Line: Vancomycin Urosepsis: piperacillin-tazobactam. Intra-abdo: cefuroxime-metronidazole (< 65 yrs), piperacillin-tazobactam (> 65 years)
Infectious mononucleosis
Infectious mononucleosis
Signs: lymphadenopathy, mild splenomegaly, swollen tonsils +/- exudate. Symptoms: malaise, fever, sore throat. Important differentials: tonsillitis, lymphoma / leukaemia, head and neck cancers.
Investigations
FBC: lymphocytosis with atypical cells (resembling monocytes). Monospot or Paul-Bunnel test. IgG = previous infection; IgM = current infection.
Management
Abstinence from alcohol as long as symptoms persist Avoid contact sports for @ 3 weeks DO NOT give amoxicillin / ampicillin!!!
Pyrexia of unknown origin.
Fever > 38.1C on several occasions over at least three weeks.
AND
No clear diagnosis after at least one week of investigations
Causes
V: vascular I: inflammatory T: trauma A: autoimmune M: metabolic
I: iatrogenic
N: neoplastic D: degenerative
Infective Causes
Abscesses: (liver, sub-phrenic, pelvic, peri-nephric) Empyema: gallbladder, lung. Travel History: malaria, schistosomiasis, TB. HIV seroconversion
Autoimmune
Polymyalgia rheumatica / giant cell arteritis Rheumatoid arthritis Vasculitides: polyarteritis nodosa Hyperthyroidism
Neoplastic
Lymphoma Leukaemia (Occasionally) solid tumours, e.g. renal cell, GI.
Investigations
1st Line:
routine bloods inc. ESR, LFTs, TFTs Blood cultures HIV test Sputum (+ AAFB) Stool MC+S CXR
Investigations
2nd Line
Rheumatoid factor, CCP, ANA, ANCA Lumbar puncture Echocardiogram CT
Investigations
Third Line
Liver biopsy Exploratory laparotomy Bronchoscopy
Infectious Gastroenteritis
Dysentery Shighella Amoebic (entamoeba hystolitica) (Salmonella) (E. coli) Diarrhoea Norovirus Campylobacter jejuni Salmonella E. coli Clostridium difficile Rice Water Vibriae cholera
Pseudomembranous Colitis
Differentiating mil-moderate disease (metronidazole 400 mg TDS 10-14 days) from severe (vancomycin 125 mg QDS 10-14 days) WCC >15 x 109 / L acutely rising blood creatinine (e.g. >50% increase above baseline) temperature >38.5C evidence of severe colitis (abdominal signs, radiology).
Points to take away
Define SIRS / sepsis Likely sources of infection by site and by timing Key facts that are good MCQ-fodder!
