1、,Diagnosis and Treatment of Common Infectious Diseases,Angela Heithaus, MD, PS Internal Medicine Seattle Healing Arts Center,Gioconda,20 YO non-pregnant UW female student sexually active 3 x week with 1 partner over past 6 months (he is asymptomatic), no prior medical history including STD C/O: pain
2、 on urination x 3 days with increased frequency and urgency, some suprapubic pain, no: blood, back pain, vaginal d/c, fever,Epidemiology,First 10 years of life: Girls 3% Boys 1.1% Teen girls 0.5 episodes/year Adult women 50-60% at least 1 episode/life time Young, sexually active women 0.5 episodes/
3、person year Post-menopausal women 0.07% episodes per person per year,UTI,UNCOMPLICATED Healthy, young, non-pregnant female,COMPLICATED Everything else: men, recurrent UTI, pyelo, in-dwelling catheters, pregnant, diabetic Increased risk of failing therapy,Microbiology,80-85% Escherichia coli Staphylo
4、coccus saprophyticus, Proteus mirabilis, enterococci Chlamydia-(acute urethral syndrome) Negative standard culture,Diagnosis in Uncomplicated UTI,PEx Nl temp No costovertebral angle tenderness Clinical Criteria Dipstick: leukocyte esterase (pyuria) and nitrite (Enterobacteriaceae)75-96% sensitivity;
5、 94-98% specificity for detecting 10 leukocytes per HPF Evaluation of mid stream urine (unspun) for pyuria is most valuable laboratory diagnostic test(abnl: 10 or more leukocytes per microL),Selected Oral AB Regimens for Use in Uncomplicated UTI,Giovanni Battista Morgagni,22 YO M C/O (not: homeless,
6、 recently incarcerated, IDU, in military, on athletic team or have family member with infection): Local pain, swelling, redness ? Drainage ? Hit something a while ago Denies: fever, chills,Skin and Soft Tissue Infections,Cellulitis Most common skin infection leading to hospitalization Superficial, s
7、preading infection involving subcutaneous tissueOther Common Skin Infections Impetigo, Folliculitis, Furuncles, and CarbunclesAbscess,Impetigo, Folliculitis, Furuncle, Carbuncle,Impetigo: superficial vesiculopustular skin infection occurring prominently on exposed areas of the face and extremities F
8、FC: arise from hair follicle Staph Aureus Rarely require hospitalization Respond to local measures Recurrence may be prevented by decreasing staph aureus skin carriage,Abscess,Localized accumulation of polymorphonuclear leukocytes with tissue necrosis involving the dermis and subcutaneous tissue Lar
9、ge numbers of microorganisms are typically present in the purulent material Infection begins from tracking in from the skin surface,Microbiology,Most common microorgansim: Staph Aureus Increased incidence of community-associated infections due to: methicillin-resistant S. Aureus (CA-MRSA) Urban ER:
10、61/119 MRSA isolated An average of more than 3 organisms; anaerobic in 1/3 of cases (1/2 IDU),Management,Incision, Drainage and culture Fluctuant or has pointed Culture ?MRSA Bacteremia and Antibiotic Prophylaxis AHA guidelines for those high risk for EC and who have hardware (oxacillin, cefazolin,
11、vanco) Oral Antibiotic Therapy Not ready for I&D, cellulitis, fever, high-risk features Community Associated MRSA Awareness of the local antimicrobial susceptibility patterns of community S. aureus isolates,Oral Antibiotic Therapy,Oral, peri-rectal, vulvovaginal abscesses Amoxicillin-clavulanate 875
12、/125 mg BID Clindamycin 150 mg QID PLUS Ciprofloxacin 500 mg BID,Galileo Galilei,40 YO otherwise healthy, non-smoker C M presents C/O: dry cough x 2 weeks clear sputum production and fatigue Denies: pharyngitis, fever, chills Vitals: Nl temp, RR, P,Acute Bronchitis,Over 90% are viral Approximately 6
13、0% of patients seeking medical care are given antibiotics One of the most common causes of antibiotic abuse ACP and CDC state Pertussis is only form that should be treated,Usual Suspects,Coronavirus (types 1-3) Rhinovirus Influenza A and B Parainfluenza Respiratory syncytial virus Human metapneumovi
14、rus,Influenza,Cough, purulent sputum, fever, and constitutional complaints during the influenza season Amantadine, rimantadine, or neuraminidase inhibitors Must be given within 48 hours of symptom onset for demonstrable benefit,Other Suspects,Mycoplasma pneumoniae Chlamydophila (formerly Chlamydia)
15、pneumoniae Bordetella pertussis (severe paroxysmal cough),To Shoot or Not to Shoot,Pneumonitis vs Acute BronchitisAbnl vital signs:temp 38 C (100.4 F)Pulse 100/minRR 24Crackles on exam,Chronic Cough Think,Postnasal drip syndrome Asthma Gastroesophageal reflux,Beatrice,28 YO otherwise healthy female
16、who C/O: nasal congestion, purulent nasal discharge, maxillary tooth discomfort, hyposmia, and facial pain or pressure that is worse when bending forward, headache, fever (nonacute), halitosis, fatigue, cough, ear pain, and ear fullness,Acute Sinusitis,Almost all cases viral in etiology Rhinovirus,
17、parainfluenza, and influenza virus Usually resolves in 7-10 days 2% complicated by acute bacterial sinusitis Streptococcus pneumoniae and Haemophilus influenzae Self-limited, 75% resolve without tx in 1 month Morbidity can include intracranial and orbital complications and of possibly developing chr
18、onic sinus disease,How many get it?,Average adult has from 2-3 colds and influenza-like illnesses per year Average child six to 10 Represents approximately one billion acute respiratory illnesses annually Approximately 0.5 to 2 percent of colds and influenza-like illnesses are complicated by acute b
19、acterial sinusitis in adults Annual incidence of acute community-acquired bacterial sinusitis is approximately 20 million cases,Comparison of Contemporary Guidelines for the Diagnosis of Acute Community Acquired Bacterial Sinusitis,CDCMaxillary pain or tenderness in face or teeth + rhinorrhea, no im
20、provement x 7 days Severe sxsPlain films not needed,Sinus ear sxsPlain films, CT, MRI not needed,Treatment of Viral Rhinosinusitis in Adults,At first sign of a cold Sustained release 1st generation antihistamine (chlorpheniramine, brompheniramine, clemastine), PLUS NSAID (ibuprofen, naproxen) Contin
21、ue taking both q 12 hrs until sxs clear Add oral decongestant (pseudoephedrine) and/or a cough suppressant (dextromethrophan) If sxs persist and are no better or worse after 7-10 days, consider antibiotic therapy,Comparison Guidelines for the Treatment of ACA Bacterial Sinusitis,CDCOnly those meetin
22、g clinical dx criteria Narrow spectrum agents Amoxicillin 1.5-3.5 g/d Doxycycline 100mg BID TMP-SMX 1DS BID,Sinus & Allergy Health Partnership Mild disease, - AB 4-6 wks Amoxicillin Amoxicillin-Clavulanate Cefpodoxime Cefuroxime axetil Mild disease +AB or moderate disease AB in 4-6 wks Any of above
23、or Levofloxacin or gatifloxicin Moderate +AB in 4-6 wks Amoxicillin-Clavulanate or Levofloxacin or gatifloxicin or Combo tx with amoxicillin or clindamycin PLUS cefpodoxime or cefixime,Intranasal Steroids,Use is not recommended OK in treating chronic sinus disease Steroid therapy increases viral concentrations in nasal secretions in cases of viral rhinosinusitis,
