Infectious Disease

Question 1

-What are physcial exam changes, vital sign changes, or lab abnormalities that present in sepsis and septic shock?

Answer 1

• Physical exam-delayed cap refill, AMS, cool mottled extremities
• Vital sign-fever, tachycardia, tachypnea, hypoxia, hypotension
• Lab-any sign of end organ damage as in elevated creatinine, hyperbili or elevated LFTs, elevated INR, abnormal leukocyte count (high or low) or band neutrophilia >10%

Question 2

What are the SIRS criteria and how should you use them?

Answer 2

• systemic inflammatory response syndrome criteria, these are a clue that something is wrong. If a patient is suspected of having an infection and has atleast 2 SIRS criteria, presume sepsis until proven otherwise
• 4 Criteria:
  1) fever or hypothermia
  2) tachycaria or bradycardia
  3) tachypnea or requiring mechanical ventilation
  4) abnormal leukocyte count (high or low) or band neutrophilia >10

Question 3

What is the “sepsis bundle” to always remember for any suspected septic patient?

Answer 3

-Culture, bolus, and antibiotics within the first hour of arrival

Question 4

What labwork should be obtained in patients with suspected sepsis vs septic shock?

Answer 4

-blood+urine culture, CBC w/diff, loaded gas, POCT glucose, BMP+Hepatic panel, Coags, type and cross

Question 5

• How should fluids be administered during septic shock?

- When should you consider using a vasoactive medication?

Answer 5

• Give up to 60 mL/kg of NS boluses within the first hour and start D10NS at maintenance.
• Fluid boluses of 20/kg should be given until evidence of fluid overload or shock reversal occurs.
• At 40mL/kg you should consider starting a vasoactive medication to acheive perfusion and consider giving blood if Hgb is <10mg/dL

Question 6

How should antibiotics be administered during sepsis vs septic shock?

Answer 6

• give broad spectrum vanc+rocephin
• Add clinda if there is evidence of toxic shock
• Replace rocephin with cefepime if patient is immunocompromised
• Replace rocephin with zosyn vs meropenem if there is a suspected GI source
• Replace rocephin with meropenem if there is a documented penicillin allergy

Question 7

• When should you consider giving pressors in sepsis vs septic shock?
• What pressors should you use?
• how are these medications dosed?

Answer 7

• if you’ve given at least 1x 20mL/kg (but usually at 40mL/kg) NS bolus and there is no clinical change
• For WARM shock (flash cap refill+bounding pulses, cardiac dysfxn likely 2/2 decreased vascular tone) give norepinephrine
• For COLD shock (delayed cap refill, diminished pulses, skin mottling, cardiac dysfxn likely 2/2 preload vs afterload vs contractility defect) give epinephrine
• Both are dosed as 0.05-0.1 mcg/kg/min and during shock can be given through a PIV

Question 8

• During sepsis vs septic shock, when should you consider hydrocortisone?
• What dosing should you use?

Answer 8

• Any shock refractory to pressors
• For younger than toddlers give 50mg IV
• For toddlers and up give 100mg IV

Question 9

• During sepsis vs septic shock when should you consider intubation?
• What drugs would you use for RSI?

Answer 9

• Consider for anyone undergoing respiratory distress refractory to NIPPV
• For sedative use ketamine+atropine
• For paralytic use succinylcholine, or rocuronium if succinylcholine is contraindicated

Question 10

When should you consider giving tamiflu?

Answer 10

• Flu positive patient <2yo whose symptoms began <48 hours ago
• Consider giving to those >2yo or >/=48 duration of symptoms if patient is medically fragile or pt with severe symptoms

Question 11

• What are the 3 Cs of early measles?
• What oral manifestation may be present?
• What is the rash of measles?

Answer 11

• Conjunctivitis, coryza, cough
• Koplic spots, white spots along the buccal mucosa
• Morbilliform rash-“eggs on the head” looks like erythematous and macular leasions

Question 12

What is the causative agent and 2 forms of meningococcemia?

Answer 12

• neisseria meningitidis

- septic form (worse prognosis) and meningitic form

Question 13

What is the presentation of meningococcemia?

Answer 13

3mo-5yo vs adolescent with history of URI sxs that decompensated and now has lethargy, HA, fever, vomiting, purpuric rash over the trunk and sepsis

Question 14

What complications can happen with meningococcemia and what workup should be done if it is suspected?

Answer 14

• adrenal hemorrhage (waterhouse freiderichson syndrome), DIC, sepsis
• WU-culture the lesions, csf, blood. Gram stain will show gram - diplococci

Question 15

How should meningococcemia be managed?

Answer 15

• Tx with rocephin+vanc, tx complications of hypoglycemia, thrombocytopenia, anemia, hypotension
• All providers will need prophylaxis

Question 16

What organisms commonly cause meningitis in the following age groups?

• 0-28 days
• 1-3 months
• > 3mos

Answer 16

• 0-28 days-GBS, E. Coli, listeria, HSV
• 1-3 months-GBS, E coli, Hib, S pneumo, neisseria
• > 3mos-S pneumo, neisseria

Question 17

What are signs and symptoms that should clue you into the possibility of necrotizing fasciitis?

Answer 17

• Patient with a soft tissue infection with pain out of proportion to exam, hemorrhagic bullae, edema, crepitus, erythema
• half of patients present without fever and half present without a clear portal of entry, so have a high index of suspicion

Question 18

What will workup show with nec fasciitis?

Answer 18

-leukocytosis, hyponatremia, xray/CT showing gas tracking in the soft tissue

Question 19

How should nec fasciitis be managed?

Answer 19

• If suspected immediate surgical consultation, time=tissue
• Mark the borders of involved tissue for comparison
• Tx with vanc, clinda (inactivate toxin), and zosyn

Question 20

• How should pneumonia be treated by age group?

- When should chlamydia pneumonia be considered?

Answer 20

• <5yo amox vs amp
• > 5yo add azithro
• if disease is severe broaden to vanc and rocephin
• if a stacatto cough is heard in a 3wk-3mo consider chlamydia pneumonia and add on azithro

Question 21

• What clinical criteria indicate admission for pneumonia?

- Which patients need PICU admission?

Answer 21

• admit anyone <6mos, hypoxia, febrile, tachypnic

- To PICU if sating <92% on >50% fiO2, apnic, exhaustion, AMS

Question 22

What is the presentation and management of Roseola?

Answer 22

• 3-4 days of high fevers and decreased PO intake, once the fever resolves a maculopapular rash spreads from the trunk to the extremities
• supportive care

Question 23

What are the centor criteria to consider strep pharyngitis as a ddx item?

Answer 23

• Tender cervical adenopathy
• High fevers
• Exudative pharyngitis
• Absence of cough

Question 24

How should a strep pharyngitis infection be treated?

Answer 24

Tx with oral penicillin vs IM, give azithro if questionable allergy history

Question 25

List potential complications of a strep infection.

Answer 25

- rheumatic fever - scarlet fever - strep toxic shock syndrome - glomerulonephritis

Question 26

- What is the clinical presentation of scarlet fever? - What is the treatment? - What anticipatory guidance should you tell parents about following treatment?

Answer 26

- erythematous sandpaper-like rash, pastia's lines (hypopigmented lines within skin creases), strawberry tongue - treat the same as strep pharyngitis with penicillin vs azithro if allergy hx - the skin will initially peel following treatment

Question 27

- How are the jones criteria used to diagnose rheumatic fever? - What are the major jones criteria? - What are the minor jones criteria?

Answer 27

- Dx of rheumatic fever is made if 2 major criteria are satisfied with hx of strep infxn or at least 2 minor criteria and 1 major criteria are met with history of a strep infection - Major criteria-carditis, sydenham's chorea, subQ nodules, arthritis, erythema marginatum (annular rash) - Minor criteria-fever, arthralgia, increased PR interval on EKG, elevated acute phase reactants (leukocytosis, CRP, ESR), family hx of rheumatic heart disease

Question 28

- What are the Kocher criteria? | - How are they useful prognostically?

Answer 28

- These are 4 criteria used to predict the probability that a patient has septic arthritis, the criteria are: 1) non-weight-bearing 2) fever >38.5C 3) ESR > 40 mm/hr 4) WBC >12k cells/mm3 - Prognostically, 1 criteria=3% probability, 2 criteria=40% criteria, 3 criteria=93% probability, and 4 criteria=99% probability.

Question 29

-How should you manage a patient you suspect of having a septic joint?

Answer 29

- Obtain CBC/ESR/ultrasound of the extremity | - Consult ortho for possible aspiration vs OR

Question 30

- What causes Dengue Fever? - What is the spectrum of illness of Dengue Fever? - What are sxs/PE findings? - How is it diagnosed? - What would you see on CBC+coags? - How is managed?

Answer 30

- Viral illness spread mosquito vector in an endemic region (travel travel travel) - Can present from mild febrile illness to frank hemorrhagic shock. - Sxs include fever, headache, arthralgia/myalgia, abdominal pain, NVD, petechial rash. On PE you may see tourniquet sign-petechial rash underlying blood pressure cuff or other evidence of spontaneous bleeding - Viral PCR can detect it but you will likely get a CBC+coags given the sxs which will show thrombocytopenia, elevated hematocrit, and elevated PTT - Manage shock/resuscitate as appropriate. There is no curative therapy-this patient needs supportive care and ICU admission for frequent labwork and serial monitoring

Question 31

How should you interpret urine culture results?

Answer 31

-Any bacterial growth of 50,000 or more CFU of a single organism in a catheterized urine sample is confirmatory of UTI. In a voided urine sample (bag or clean-catch), more than 100,000 CFU is considered significant; however, growth of more than one organism on the urine culture suggests contamination.

Question 32

- What common organism in septic arthritis should you always consider covering for? - Why? - What antibiotic would you use?

Answer 32

- Kingella kingae is a common cause of septic arthritis and osteomyelitis in infants and toddlers. - Kingella kingae is difficult to isolate on typical culture media; polymerase chain reaction assays improve the diagnostic yield significantly; if polymerase chain reaction is unavailable, coverage for Kingella should be considered in cases of culture-negative septic arthritis in children younger than 4 years. - Rocephin ftw! (Ampicillin-sulbactam or a first-, second-, or third-generation cephalosporin)