infection symposium

Question 1

symptoms of sepsis

Answer 1

confusion or disorientation,
shortness of breath,
high heart rate,
fever, or shivering, or feeling very cold,
extreme pain or discomfort, and.
clammy or sweaty skin.

Question 2

sepsis definition

Answer 2

life threatening organ dysfunction due to a dysregulated host response to infection

Question 3

septic shock

Answer 3

sepsis with presisting hypotension that requires vasopressors to maintain the mean arterial pressure at less than 65mmHg and serum lactate concentration of >2mmoll

Question 4

qSOFA for sepsis

Answer 4

resp rate >/= 22breaths/min
altered thoughts/confusion (GCS<15)
systolic BP </= 100mmHg

if score >/=2 need intervention ASAP (10% morbitiy risk as no sepsis pt)

baseline assume 0 (unless other comorbities - diabetes/CVD)

Question 5

spred of infection RED FLAGS

6

Answer 5

• temp <36 or >37
• elevated respiratory rate >20breaths/min
• elevated or reduced HR (60-100bpm is norm)
• trisumus due to swelling
• swelling crossing midline
• dehydration - reduced urine output

Question 6

sepsis 6

Answer 6

3 IN
* O2 15l -* prevent hypoxia*
* high volume fluids -* prevent hypovolemia and shock*
* IV antibiotics

3 OUT
* monitor urine output
* bloods for culturing, glucose, FBC, Us + Es, CRP, lactate

Question 7

advantages of pus aspirate over pus swab

2

Answer 7

**Infected with oral mucosal flora – harder to interpret results **

Swelling – relive pressure as establish drainage at same time

**Larger sample **

Question 8

key information on specimen request form

8
order of importance

Answer 8

• Clinician contact details (name, number) – know how to get in contact with you
• Dx/presumptive dx
• Investigation: culture and susceptibility testing
• Pt identifiers
• Clinical details
• Date/time taken
• Specimen details
• Site

Question 9

key safety elements when submitting microbiological/pathological materials to clinical lab

specimen safety

4

Answer 9

Needle in sharps container – clinicians responsibly
* Remove needle safely over sharps bin – twist off

Syringe cap – red plastic to seal end of syringe, prevent it flowing out accidentally

Puts pts label around syringe so its ready to go

Fill in request form

Question 10

Key safety elements when submitting microbiological or pathological materials to clinical laboratories

packaging requirements

3

Answer 10

Need 3 layers of packing
* First layer need something absorbent incase something spills or leaks from sample
* Needs to be compliant with UN3373 standard (legal requirement)

Secure

Labelled

Question 11

gram stain for gram positive

Answer 11

purple

Question 12

gram stain for gram negative

Answer 12

pink

Question 13

what is A

Answer 13

neutrophil (pus has lots of dead neutrophils)

Polymorphor nuclear leukocyte

Question 14

what is B

Answer 14

gram positive bacilli

Question 15

what is C

Answer 15

gram negative cocci

Question 16

clinical example of use of gram stain from pus of a dental abscess

Answer 16

Lab can identity type of bacteria present in the infection and as result as suitable antibiotics to which the bacteria is sensitive to can be prescribed (reduced AB resistance as pt is being correct AB)
* Informs empiric choice of AB
* Narrow down with signs/symptoms/history in SEPSIS case – start broad – when get testing back narrow down more

Question 17

describe Gram stain of this isolate from an infection in dento-alveolar bone
What is the most likely identity?
What is the preferred antibiotic of choice to treat this micro-organism

Answer 17

Mix of gram pos cocci and gram neg

**Gram positive cocci – stap aureus looks like grapes
* **Cause abscess, can be found in angular cheilits, implantitis. Also cause bad abdo and skin infections etc **

Preferred antibiotics is flucloxacillin
* Resistant to amoxicillin, penicillin, metronidazole

Question 18

preferred antibiotics for gram positive cocci

Answer 18

flucloxacillin

resistant to amoxicillin, penicillin, metronidazole

Question 19

example gram positive cocci

Answer 19

staph aureus

looks like grapes

Question 20

Gram stain of this isolate from an acute peri-apical abscess.
What is the most likely identity?
What is the preferred antibiotic of choice to treat this micro-organism

Answer 20

Gram positive cocci – all in chain

Strep angiosus
*Phenoxymethylpenicillin – used for strep

Question 21

full name for penV

Answer 21

Phenoxymethylpenicillin

Question 22

Phenoxymethylpenicillin used for

Answer 22

streptococcus angiosus

Question 23

flucloxacillin used for

Answer 23

staphylcoccus aureus

Question 24

WHO definition of antibiotic resistance

Answer 24

“Antimicrobial resistance occurs when microorganisms such as bacteria, viruses, fungi and parasites change in ways that render the medications used to cure the infections they cause ineffective”

Question 25

describe this chart used to measure antibiotic reistance in the lab

Answer 25

MIC = Minimal Inhibitory Concentration A - sensitive B – breakpoint C – resistant

Question 26

European Committee on Antimicrobial Susceptibility Test (EUCAST) antibiotic resistnace clinically defined as

Answer 26

When infection is highly unlikely to respond even to maximum doses of antibiotics

Question 27

3 examples of clinical factors that influence the penetration of antibiotics to the site of infection

Answer 27

1. biofilm disruption 2. pus collection 3.site of infection

Question 28

oral black pigmenting anaerobe e.g.

Answer 28

Prevotella Intermedia

Question 29

most common type of resistance mechanism for beta-lactams in BPA’s. Choose from;

Answer 29

Enzymatic inactivation (Beta-lactamase)

Question 30

why is Pen V not the first line beta-lactam for the management of dento-alveolar infections

Answer 30

Equally effective as Amoxicillin but less harmful to resident flora * Narrower spectrum so less harm to gut flora etc – but still only when needs to be prescribed*

Question 31

Which of the following micro-organisms from dental infections are usually susceptible to metronidazole a. Streptococcus anginosus b. Staphylococcus aureus c. Peptostreptococcus micros d. Actinomyces israellii e. Streptococcus mutans

Answer 31

Anaerobic Bacterial Infections (GRAM NEGATIVE) c. Peptostreptococcus micros and prevotella intermedia | *Strict Anaerobes Only*

Question 32

Which of the following mechanisms is likely to result in metronidazole resistance a.Enzymatic inactivation b.Modified target c.Decreased uptake d.Increase efflux e. All of the above

Answer 32

e. All of the above

Question 33

anticrobial strewardship is

Answer 33

a coordinated program that promotes the appropriate use of antimicrobials (inc antibiotics), improves pt outcomes, reduced microbials resistance and decreases the spread of infections caused by multi-drug resistant organisms

Question 34

pus sampling role in antimicrobial stewardship

Answer 34

Prescribing antibiotics that would be ineffective for that infection * Contributing to resistance * Reduce pt success outcome * Inc risk of spreading infection

Question 35

barriers in GDP to pus sampling

Answer 35

* Time * Money * Lack of equipment * Lack of clinical knowledge on how to sample and transport sample

Question 36

what to do when someone presents with a large swelling (infection spreading)

Answer 36

Quick assess- ABCDE – breathing, able to walk/sit, understand * Hot potato voice– raise tongue and FOM, see less of oropharynx, unable to speak properly Then History – when dd it start, how long, change rapidly – how quickly Medical – allergies, RED FLAGS - immunocompromised, diabetic (esp if not well controlled – worse quicker and poor healing – check HbA1c value 48mmol/mol) and renal problems or bleeding disorders SH – live alone, smoking (don’t heal well, exacerbate everything in the mouth), alcohol, and E/O and I/O

Question 37

E/O assessment for spread of infection focus

Answer 37

asymmetry, swelling (palpate – site, shape, size (use ruler)- fixed, firm, heat, obstructing eye or lower mandible), lymphadenopathy – check all, **can you feel border of mandible, ** check jaw opening (guarding - scared and/or painful; get them to open to max opening even if its painful; place fingers on their incisal edges – will feel hard to open more; if just owww – not true trismus; true trismus if submasseteric swelling)

Question 38

I/O assessment for spread of infection focus

Answer 38

any sign obvious sources of infection quick survey, able to do any TTP/mobility checks, any sinus, loss of sulcus depth – swelling gone into space and able to incise it, check tongue position and FOM – need to be able to palpate – if unilateral take finger on FOM on unaffected and then affect – should be soft, not raised or not lumpy – will feel more than see, check oropharynx and uvular– warn pt will depress tongue (deviation) Hot potato voice– raise tongue and FOM, see less of oropharynx, unable to speak properly

Question 39

special investigations for spread of infection?

Answer 39

Get xrays if you can – compare with old if possible Measure HR, temp, o2 sats, BP (internal better than external) – use right cuff for pt size Normal * 36 degrees +/- degree * 60-100bpm (whats normal for them – children higher than adults) * 120/80, 60-90 (systolic/diastolic) * 95-100 O2 sats (COPD – carbon diox driven so will be lower)*

Question 40

normal values for temp HR BP O2 sats

Answer 40

* 36 degrees +/- degree * 60-100bpm (whats normal for them – children higher than adults) * 120/80, 60-90 (systolic/diastolic) * 95-100 O2 sats (COPD – carbon diox driven so will be lower)*

Question 41

maxillary spread of infection

Answer 41

* canine space (high risk for eye involvement) – will look like blistered eye or puffy eye; * palatal space

Question 42

manidbular spread of infectin

Answer 42

buccal submental submasseteric sublingual

Question 43

SIRS

Answer 43

serious inflammatory response syndrome (used to assess SEPSIS)

Question 44

4 components of SIRS

Answer 44

* tachycardia (heart rate >90 beats/min), * tachypnea (respiratory rate >20 breaths/min), * fever or hypothermia (temperature >38 or <36 °C), * leukocytosis, leukopenia, or bandemia (white blood cells >1,200/mm3, <4,000/mm3 or bandemia ≥10%)

Question 45

when to speak to maxfax

Answer 45

maintaining airway and breathing ok but couple of worrying signs - phone * Know where the closest is, have their number ask for Maxillofacial on call SHO – can be on hold if they are operating * Have a clear concise relevant history ready to present with temp and obvs * They will give advice – ask you to do x, y, z or get them in (advise pt to not eat or drink anything on route) get them to A&E if rapidly swelling that needs IV AB not oral; hard swelling over body of mandible – hard and trapped in facial spaces, needs draining, why feeling mandible imp; if they are high risk pt; showing any signs of sepsis – warranted as spreading * If cant get them send to A&E with letter – with history and your details, best to try and get in touch with them tell pt no eating or drinking till been triaged at hospital Need maxfax for incision and drainage sometimes because **we cannot incise extraorally **– not safe because could hit a major blood vessel, Cross midline – get ambulance

Question 46

if localised intraorally swelling what should GDP do

Answer 46

incise to bone approx 1cm, *be careful of mental foramen and nerves* * clear liquid first, then yellow pus - scoop out with Howarth's, can rinse with saline too leave to drain (don't suture) analgesia advice and come back in 5days

Question 47

2 most common dental infections

Answer 47

Dental abscess Pericoronitis

Question 48

abscess of upper 6 spread options | 5

Answer 48

Out socket Buccal space Maxillary sinus Palate Infraorbital

Question 49

abscess of lower 3rd molar spread options | 4

Answer 49

Submasseteric Submental Sublingual Pharyngeal spaces – esp lateral pharyngeal concerns – as compromised airway

Question 50

abscess of canine spread options

Answer 50

canine space, cavernous sinus thrombosis concern – as spread to brain risk

Question 51

basic steps in management of infection in GDP | 6

Answer 51

History Examination Resuscitative ABC and supportive tx Special investigations **Remove source of infection +/- I&D of swelling ** *possible antibiotics*

Question 52

key history questions for infection

Answer 52

When did it start – rapid progressively, or slower over weeks If they can open their mouth Are they in pain Have they had any recent dental issues or dental work Changes to medical history – allergies, medications, red flag illnesses Quick dental and social history Alcohol and blood clotting?

Question 53

cellulitis swelling telltale

Answer 53

hard

Question 54

fluctuant swelling inficates

Answer 54

fresh swelling, more able to drain

Question 55

optiosn for removing source of infection | 3

Answer 55

XLA RCT/Pulp extirpate incision and drain

Question 56

why may not be able to get a pt numb

Answer 56

abscess suppuration is acidic, LA is weak bases, pKa process means it will not work *Mepivacaine is plain so slight differ pH properties – maybe worth trying Or just I&D and hopefully next time will be able to get numb as some suppuration escape *

Question 57

do you stitch over I&D

Answer 57

no tell pt will have blood and pus escaping from it and will be able to definitive tx hopefully when they come back in

Question 58

factors to consider when determining severity of infectino

Answer 58

Onset progression history trismus systemic symptoms Pt factors e.g. diabetic or on steroids

Question 59

when to use antibiotics

Answer 59

* Local measures failed- XLA and area still swollen on review * Pt is systemically unwell – determined by pt obs * Cellulitis present - hard shiny swelling * Infection spreading rapidly

Question 60

3 key red flags for A&E and maxfax

Answer 60

Significant trimsus, FOM swelling or diff breathing

Question 61

things to warn pt off when pulp extirpate in emergency setting

Answer 61

Advice guarded prognosis – * will need to assess restorablity of teeth once all the dental caries removed * large abscess could reduce RCT success, need pt to come back for more tx