Infectious Diseases (ID) #

Sepsis #

First thing to go: lactate, Cr
First thing to get better: lactate

Protocol:

1. Blood Cx (+ sputum, etc.)
2. Lactate (± procal)
3. Bolus 30mL/kg
4. Antiboitics
5. Recheck lactate

CAP (Community Acquired Pneumonia) #

Treat for 5 days, 7 if HAP/VAP

Antibiotics #

Denver Health Antibiogram
Children’s Hospital Bug Watch

Coverage #

Classes #

MRSA #

• Cellulitis is usually strep
  • Unless purulent, then more likely MRSA
• MRSA PNA is very unlikely

Pseudomonas #

IV:

• Zosyn (pip-tazo)
• Imapenum (ertapenum does not cover pseudo)
• Cipro
• Cefepime

PO:

• Cipro/Levo

Bugs #

Stenotrophomonas maltophilia #

• Cousin of pseudomonas
• Nasty
• Only suceptable to bactrim

Influenza #

Martality rate generally 0.1%

• Xofluza (baloxavir), 40mg for 40-80kg, 80mg for >=80kg, single dose
  • 48 hours to significantly reduced viral shedding ([Paper](’/literature/xofluza info on flu treatment.pdf’))
  • Different mechanism than tamiflu
• Tamiflu
  • approx 2 day reduction in duration
  • 4 days of viral shedding afterwards

COVID-19, SARS-CoV-2 (novel coronavirus) #

Novel virus out of Wuhan China (early paper). Mortality rate initailly between 1.4% (published from Guan cohort) and 2%. Likely undercounts asymptomatic patients, so could be considerably lower. No case reports in kids <15yo. Severe disease more likely in older patients.

Signs/Symptoms #

• Cough (≈86%)

• Fever (≈48%)

• Dyspnea (after 6 days)

• Respiratory distress (after 10 days)

• Body aches?

• Low WBCs (aroudn 1k)

• CRP >10mg/L

• Ground glass opacities bilaterally on chest CT

Transmission #

• Large droplet, only to about 6 feet
  • Plain surgical masks can protect from this
• Wash hands!
  • Stop touching your fave (surgical masks also probably help with this)
• N95’s probably not necessary (used to protect against airborne transmission)

Treatment #

• Supportive
• Remdesivir?

Legionella #

• Gram negative
• Found in contaminated water/soil
  • Common on cruise ships, grocery store sprayers
• Presents with: ↑Temp, ↓HR, N/V/D, hypoNa (affects JGA → ↓ aldosterone)

Dengue Fever #

• Classic: “pain behind eyes”
• HA, +F, +myalgias

Chikungunya #

• Fever + arthralgas, HA, fever, rash

Fusobacerium Necrophorum (anaerobe) #

• Can be a nasty pathogen (pretty virulent for an anaerobe)
• Causes septic thrombophlebitis
  • Lemiere’s Syndrome (septic thrombophlebitis of the jugular vein)

Fever #

• Fever of Unknown Origin
  • Must be: >38.3, >3 weeks, >1 week inpatient
  • hard to call, semantics
• Fever w/o localizing signs
• Fever w/ localizing signs

Special populations:

• Peds
  • almost always viral
  • 88% resolve
• Neutropenic
  • First bacteria
  • Fungal (>7 days)
• AIDS/Immunosuppressed
  • Mycobacerium
    • Usually MAC

Etiologies:

• Infection: 16%
• Rheum: 22%
• Malignancy: 7%
• Unknown: 51%

Initial Workup #

• History & Physical
  • Ask about travel within last year
    • TB, typhoid, ameoba
• CBC w/ diff
• Blood cx
• CMP
  • +/- hepatitis workup
• UA
• CXR

Subsequent Workup #

• Sed rate/CRP
• LDH
• TB
• HIV
• RF
• CK
• heterophile Ab (mono)
• ANA
• SPEP
• CT C/A/P
• LP (if neuro/AMS s/sx)
• ?Malaria
  • Thick and thin smear
• Biopsy anything you can

Notable Drug-Drug Interactions #

• Warfarin + Bactrim
• SSRI/TCA + Linezolid
• Fluoroquinolone + cations (Ca+, etc.)

Pearls #

• Levoquin side effect => neuropathy
• Fluoroquinalones can be a cause of AMS
• Less renal toxicity with Vanc/cefepine than with Vanc/Zosyn (3-5x risk)
• Urinalysis sensitivities
• Do not treat asymptomatic UTIs!
• Highly bioavailable abx (>90%):
  • doxy, levofloxicin, flagyl, linezolid, clinda, azithromycin
• Azithromycin monotherapy not good for almost anything
• Daptomycin doesn’t work in the lungs (gets inactivated)