More infectious disease

Bugs and drugs FP style

Sore throat

46 yo male 2 day h/o sore throat. Throughout the day yesterday the soreness worsened and he had trouble eating dinner because of pain. Today his fever was 103.5 and he looks well in your office except for erythema in pharynx without exudate.

Now what

Differential diagnosis? What is the best test to evaluate

this patient? What is the appropriate therapy?

Differential and don’t miss diagnoses

Viral mono mycoplasma pneumoniae foreign body epiglottitis para or retropharyngeal abscess Diptheria acute HIV gonococcal pharyngitis GAS pharyngitis (rare ~10%)

GAS pharyngitis

Pre-test prob is less than 10% empiric therapy based on clinical decision making is

relatively expensive and lacks sensitivity and specificity strategies using rapid tests, culture or observation are

more cost effective

rapid strep used in our clinic >95% sensitive, >90%sensitive

Reason to treat is to prevent rheumatic fever treatment Pen V or Erythro for 10 days ann int medicine 2003;139:113

What about carriers

If asymptomatic: no culture, no treatment

just say no

What about repeat strep

Symptomatic with multiple positive cultures or rapid strep tests

treat with Clindamycin or AM/CL and consider adding rifampin

Adult epiglottitis

If concerned need ENT or ability to visualize epiglottis (direct laryngoscopy)

cherry-red, swollen onset more insidious, appear less toxic than

kids BUGS S pneumoniae H influenzae or parainfluenzae GAS

Therapy for epiglottitis

Antibiotics 2nd or 3rd generation cephalosporin

Obs in ICU Steroids show no proven benefit

C. Diphtheriae

Does occur in immunized individuals

grayish membrane in pharynx is diagnostic

need antitoxin and Pen G or erythro

Gonococci

History usually exudative but can present

as diffuse erythema

use ceftriaxone and treat for chlamydia also (azithro or doxy)

NEXT

A 7 yo boy was playing in the street and stepped on a nail. He has a puncture wound that goes through his tennis shoe. The wound is over the third metatarsal phalangeal area and there is localized swelling and little erythema.

Doctor?

Should prophylactic antibiotics be given?

If he presented one week later with obvious cellulitis and pain, what then?

DATA

Incidence of infection in puncture wounds is not well defined but is estimated in ER literature as 5-15% and is easily treatable

Low incidence of osteomyelitis <2% Conservative treatment based on ER

data which showed that pain at 48 hour mark is most sensitive indicator of infection

Compassionate Conservative Management

Lather, rinse, repeat non-weight bearing X 24 hours telephone F/U at 48 hours no antibiotics

Bugs

Staph Aureus (be cautious for MRSA) GAS Clostridium perfringens or tetani pseudomonas

If soft tissue/cellulitis use AM/Cl, erythro, clinda or fluoroquinolone

NEXT

48 yo teacher, IVDU with fever, pain R arm and decreased ROM R shoulder, SOB and chest pain.

T 39.5 P 125 2/6 SEM CXR no infiltrates

Questions?

At what school is this patient employed?

Differential? What antibiotic?

What about MRSA?

Community acquired MRSA has been reported in most states

It is common among IVDU, prison inmates, military, native americans, sports teams, HIV infected, homosexual men, ENT patients, children

Community acquired MRSA

IS susceptible to many antibiotics Lack the hospital-associated risk

factors Has unique molecular properties

which differ from hospital strains

At Saint Joes 2003 data

MSSA at Joes is 100% (409 ISOLATES) susceptible to Augmentin

MRSA Rate in 2003 =37% (235 isolates) 88% susceptible to

Gentamycin, 100% to Vanco

Second line agents for MRSA

Doxycycline 10% resistance little data

TMP/SMX 20% Clindamycin 40% Fluoroquinolones >50% Macrolides 50-80% Rifampin ~5% rapid resistance if not

used in combo

Not FDA approved

Synercid $130/day IV only, poorly tolerated

Zyvox $100/day IV and po Cubicin only for specific genotype