Flashcards in Articles Deck (76)
Loading flashcards...
1
Power-Pulsed Lavage article
- Significantly reduces the amount of bacteria
-if it does not hurt go ahead and use it.
2
Patzakis article
-Foot divided into three sections for puncture wounds
-Highest to lowest for development of osteomyelitis:
Zone 1> Zone 2> Zone 3
3
Nail puncture through a rubber soled shoe
- Unsuccessful treatment group more likely to have received antibiotics in the community
-Unsuccessful treatment group waited longer to go to ED
-Gram + bacteria (cover staph)
-Gram - bacteria (cover pseudo)
4
Plantar puncture wounds in Children
Time of presentation:
Day of injury:
-prophylactic tetanus
-cleansing of puncture
-x-ray or sonography
24-36 hours after injury
-hospitalize for parenteral antibiotics
-perform surgery
1 week after injury
-retained foreign body must be removed
-osteomyelitis
Later symptoms
-deeper infections present
5
Hawthorn fragment in a child's foot
-MRI may not be the best mode of visualization, use an ultrasound
6
Definition of SIRS
SIRS= more than one of the following:
-temp extremes
-high HR
-High Resp
-High WBC
7
Definition of sepsis
SIRS+infection
8
Severe sepsis
Sepsis+ organ dysfunction, hypoperfusion abnormality, or sepsis induced hypotension
9
Septic shock
-a subset of severe sepsis
-sepsis induced hypotension
10
MODS
-a continuum where the organ fail to maintain homeostasis
11
Types of fevers (5)
-infection: most common cause
-cytokine-mediated fevers
-central fevers:harm to the thermoregulatory regions of brain
-fever of unknown origin
-drug fever
12
Postoperative fevers (5)
-Day 1: Systemic Inflammatory response syndrome
-Day 2-3: respiratory causes
-Day 3-5: Urinary tract infection
-Day 4-7: wound infection, DVT and acute gout
Day 5-8: drug fever
13
Surgical management of diabetic foot infections
-broad spectrum antibiotics should be prescribed
-need a stepwise approach when it comes to these patients
14
Performing serum inflammatory markers for the diagnosis and follow up of patients with osteo
Inflammatory markers are: CRP, ESR, White blood cells, Procalcitonin.
- They will decline after initiation of antibiotic treatment
-ESR is the best marker used to monitor the response to therapy in patients with osteo. ESR declines in soft tissue infections not osteo
-Using inflammatory markers, particularly ESR with observation will go a long way
15
Acute Phase reactants predict risk of amputations in diabetic foot infections
- post treatment CRP level is a strong predictor of treatment failure and amputation risk in patients with diabetic foot ulcers
16
Value of WBC with differential in acute diabetic foot infection
- diagnosis of infection is made primarily on the basis of clinical signs
-a normal WBC and white cell differential should not deter the physician from taking appropriate action.
17
Angiograms: what do they visualize (3)
-distribution of disease
-length and severity of diseased segments
-demonstrate inflow and outflow vessels
18
Types of angiograms
-Computed tomography angiogram (CTA)
-Magnetic Resonance Angiogram (MRA)
-Digital subtraction Arteriography (DSA)
19
Computed Tomography Angiogram
-IV iodine rich contrast injected.
-CT scanning used
A rapid exam but not good for renal disease and becomes shadowed due to calcification.
20
Magnetic resonance angiogram
Does not require IV contrast (but if it does will use Gadolinium)
-This is a more expensive exam than the rest however gives you a very clear picture
21
Digital Subtraction arteriography
Gold standard
- Will give a superior resolution with lower doses of contrast in real time.
-However will have much higher exposure to radiation
22
CO2
-used as a negative contrast agent in DSA by displacing the blood.
- a great alternative for patients with renal failure or contrast allergy
23
Echocardiograms
-2 types and what are they used for
TTE and TEE
-TTE is a noninvasive procedure , however it may be blocked by body tissues, or scarring
-TEE is much less common and much more invasive. Usually only occurs when good visualization can not be obtained with TTE
24
Tech 99
-binds directly to calcium hydroxyapatite to form soluble salts via osteoblasts
-High sensitivity for low specificity:
---osteomyelitis
---recent surgery
---arthritis
---bone tumors
---fracture
--- ischemic necrosis of bone
25
Gallium-67-
-identifies acute inflammation and infection
through:
---direct bacterial uptake
---phagocytosis of bacterial cells by phagocytes
---direct leukocyte labelling
Sensitive but not specific for acute osteo will also pick up:
--infection
--fractures
-- inflammation
--trauma
--neoplasms
--gout
26
Indium-111
-WBC are isolated from patient's blood and labelled with Indium-111 and reinjected into patient
-Highly sensitive and specific for acute soft tissue and osseous infections
27
Ceretec Scan
Tc-99 labelled WBC
-High sensitivity for acute soft tissue and osseous infections
-Higher specificity for acute osteomyelitis than in In-111
-easier and less radiation than Indium-111, which allows more radioactive material to be used and increased anatomical contrast
28
SPECT/CT
-single photon emisssion CT
-Detects radio-labelled markers and creates an image
-Shows level of biological activity as well
29
What will acute osteomyelitis show on:
-Tc-99m Scan
-Ga-67 scan
-Indium scan
-Ceretec scan
-Tc 99:
---Phase 1: +
---Phase II:++
---Phase III:+++
-Ga-67 scan: positive focal uptake
-Indium Scan: Positive
-Ceretec scan: Positive
30
What will Inactive Chronic osteo show on:
-Tc-99m Scan
-Ga-67 scan
-Indium scan
-Ceretec scan
-Tc-99m Scan
---Phase I: +/-
---Phase II: +
---Phase III: +++
-Ga-67: negative
-Indium: Negative
-Ceretec scan: Negative
31
What will acute cellulitis show on:
-Tc-99m Scan
-Ga-67 scan
-Indium scan
-Ceretec scan
Tc-99m Scan:
---Phase I:+++
---Phase II: ++
---Phase III: +
-Ga-67: Positive diffuse uptake
-Indium: Positibe
Ceretec Scan: Negative
32
Charcot joint:
-Tc-99m Scan
-Ga-67 scan
-Indium scan
-Ceretec scan
Tc-99m Scan:
---Phase I: +/-
---Phase II: +/-
---Phase III: +++
---Phase IV: ++/+++
-Ga-67: Negative
-Indium scan: Negative
-Ceretec scan: Negative
33
Positive Ceretec signifies?
acute osteomyelitis
34
Positive Indium indicates?
either acute osteomyelitis or acute cellulitis
35
Positive Ga-67 scan signifies?
-Positive focal uptake signifies: acute osteomyelitis
-Positive diffuse uptake signifies: acute cellulitis
36
Identifying the incidence and risk factors for reamputation among patients who underwent foot amputation article:
-Risks associated with reamputation
-Higher level amputations
-Longer hospitalization
-Insulin-dependent diabetes
-Gangrene on admission
37
Acute Kidney Injury definition
-abrupt and usually reversible decline in the GFR or decreased urine output within 7 days
-increase in creatinine of .3mg/dL within 48 hours
-50 percent increase in creatinine within 7 days
- decrease in urine volume to <3mL/kg over six hours
Will result in an elevation of BUN, creatinine
38
AKI diagnosis: How to make it
-UA w/ microscopy
-BMP
-Serum and urine protein electrophoresis
-renal ultrasound
39
AKI treatment (4) things
-determine the cause
-remove any active insults
-minimize new injury
-identify the complications
40
Probing to bone in infected pedal ulcers article conclusion
-in hospitalized diabetic patients with limb-threatening infection, palpable bone at the ulcer base by Probe to bone test was significantly associated with underlying osteo.
41
Probe to bone test in a diaetic foot osteo in a clinical setting
-in a clinical setting the PTB test is better used to exclude osteo
-in a hospital setting the PTB test is more helpful in diagnosing osteo
42
Efficacy of MRI in diagnosing diabetic foot osteo in the presence of ischemia
-preoperative MRI effective in diagnosis of neuropathic ulcers
-Preoperative MRI less effective in diagnosis of ischemic ulcers
43
Statistical reliability of bone biopsy for the diagnosis of diabetic foot osteomyelitis article
-results suggest limited reliability of the histopathologic analysis of bone
-histopathologic bone biopsy should not be sonsidered the "standard" of diabetic foot osteo
44
Does this patient with diabetes have osteo of the lower extremity article
-osteo of the foot causes significant morbidity in patients with diabetes
-using the criteria of an ulcer that measures more than 2cm, positive PTB, an ESR greater than 70mm/h, an abnormal x-ray and MRI, along with a detailed history can help improve diagnostic accuracy and improve patient outcomes
45
Primary non surgical management of osteo of the foot in diabetics article
-urgent surgery is indicated in some patients, however non-surgical management of those without limb-threatening infection is associated with a high rate of apparent remission
46
Outcome of diabetic foot osteo treated non-surgically
-Bone culture based antibiotic therapy is an independent factor predictive of remission in diabetic patients with osteo of the foot
-there is also a possible negative effect of nonbone-based antibiotic therapy for osteo of the diabetic foot
47
Rate of residual osteo after partial amp in diabetic patients
-after debridement and irrigation it is recommended to routinely obtain bone margin cultures
- residual osteo has a statistical significant association with poor outcomes
48
Reasons for prophylactic use of antibiotics
-Following wounds
-For surgery
-For prophylaxis against bacterial endocarditis in patient with compromised heart valve
-Dental patients
49
Antibiotics used for prophylaxis (8)
- cefazolin
-cefuroxime
-Ceftriaxone
-Vancomycin
-Clindamycin
-Ciprofloxacin
-Levofloxacin
-Teicoplanin
50
Cefazolin
-use in Lower extremity
-Half life
-coverage
-Doseage
-most frequently used for lower extremity
-longest half-life of any 1st generation cephalosporin
-spectrum: anti-staphylococcal and gram negative
Dosing: 1-2g IV or IM before surgery
51
Cefuroxime
-what type of surgery is it used
-comparison to ancef
-usually used in cardiothoracic surgery
-may have better anti-staph than Cefazolin
52
Ceftriaxone
-half life
-spectrum
-longest half life of any cephalosporin
-relative lack of anti-staph activity
53
Vancomycin
-when is it used
-dosing
-used in penicillin or cephalosporin allergic patients or high MRSA expected areas
-1g IV 12hours.... slow infusion over 1 hour
54
Clindamycin
Use?
Dose:
-useful in implant surgery
-great substitute for vancomcin in beta-lactam allergic patients
-dosing 600-900 mg IV
55
Ciprofloxacin
use:
activity:
very versatile but not used as likely in prophylaxis for lower extremity surgery
-mediocre anti-staphylococcal activity
56
Levofloxacin
coverage:
half life:
Oral vs. IV
-better staph and strep coverage than Cipro
-longer half life
-oral dosing achievable levels are similar as parenteral
57
Joint aspiration:
Uses
----diagnosis vs therapy
Diagnostic:
-used in the evaluation for septic joint
-also used in the confirmation of gouty arthritis
Therapeutic
-injection with steroids for inflammatory condition
-drain effusion to relieve pressure
58
Aspiration of the ankle:
-approaches
Medial approach:
-more common
-leg kept at 90 degrees, insert needle between TA and medial malleolus.
Lateral approach: less common
-between lateral to EDL
59
Aspiration of the MTPJ
steps:
-distract the toe with gentle plantarflexion
-insert needle perpendicularly and into joint space medially
-avoid extensors
60
Synovial fluid analysis
WBC count to keep in mind
<2000WBC/mm3 is noninflammatory
>2000 WBC/mm3 is inflammatory or septic
61
Synovial fluid analysis table
LOOK AT STEVEN's tables
62
Late hematogenous infection of the 1 MTPJ
- It is more common for late hematogenous infections to come from knee and hip replacements.
-This case occured in 1st MTPJ due to misdiagnosis and the administration of steroids
63
Acute hematogenous osteo
-Labs to receive
CBC
ESR and CRP
Blood cultures
64
Acute Hematogenous osteo
Unique infecting organisms in:
-newborns
-children
Newborns: Group B strep
Children: H. influenzae
65
Acute hematogenous osteo treatment options (3)
-Incision and drainage
-cultures
-antibiotics that are tailored toward the infection
66
Pathogens isolated from deep soft tissue and bone in patients with diabetic foot infections
-main finding
Most of the time bone and soft tissue cultures differed
67
Minimum Inhibitory Concentration
-definition
Is the lowest concentration of a chemical which prevents visible growth of a bacterium overnight
68
Minimum Inhibitory Concentration
-Clinical use
used to confirm resistance and to determine in vitro activity of new antimicrobials
69
Minimum Inhibitory concentration
-Interpretation
-antimicrobials with the smallest MIC are the most effective
70
Minimum Inhibitory concentrations
-Breakpoint
-chosen concentration of an antibiotic which defines whether a species of bacteria is susceptible or resistant
-If the MIC is smaller than the susceptibility breakpoint then the bacteria is considered to be susceptible to the antibiotic
71
The role of polymethylmethacrylate antibiotic loaded cement-article
-Three big antibiotics are:
*tobramycin
*gentamycin
*vancomycin
-PMMA provides local delivery of high concentrations that do not depend on vascular support or have systemic toxicity complications
72
Infection control issues
-active surveillance cultures: definition
-Decolonization: definition
Active surveillance cultures:
-universal or targeted microbiological screening cultures for patients admitted to a hospital
-used to try and help control infections
Decolonization:
-a process used in infection control that destroys a resistant organism before it can cause infection and spread by using topical antibiotics and antiseptics
73
C. difficile
Diagnosis
Treatment:
Diagnosis:
-C. difficile infection requires demonstration of C.dif toxins or detection of toxigenic C.dif organisms
-Findings of pseudomembranous colitis are highly suggestive of C.diff
Treatment:
-discontinuation of inciting antibiotic
-Vanc: 125 mg QID PO
-Metronidazole: 500mg QID PO
74
Hospital acquired MRSA
-Buzzwords:
Treatment:
-Older patients
-In a care facility
-With chronic wounds
- Multiple recent antibiotic exposure
-treated: Vanco, Zyvox and Cubicin
75
Community acquired MRSA
-Buzzwords:
Treatment
-Younger patients
-Contain genes: USA300, PVL, SCC mec IV, and cycolytic peptides
Treatment:
-TMP/SMX (bactrim)
-Minocycline and doxycycline
76
