Diagnosis and Treatment of

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Diagnosis and Treatment of Common Infectious
Diseases
Angela Heithaus, MD, PS Internal Medicine Seattle
Healing Arts Center
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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 on urination x 3 days with increased
  frequency and urgency, some suprapubic pain, no
  blood, back pain, vaginal d/c, fever

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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/
  person year
• Post-menopausal women 0.07 episodes per person
  per year

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UTI

• UNCOMPLICATED
• Healthy, young, non-pregnant female

• COMPLICATED
• Everything else men, recurrent UTI, pyelo,
  in-dwelling catheters, pregnant, diabetic
• Increased risk of failing therapy

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Microbiology

• 80-85 Escherichia coli
• Staphylococcus saprophyticus, Proteus mirabilis,
  enterococci
• Chlamydia-(acute urethral syndrome)
• Negative standard culture

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Diagnosis in Uncomplicated UTI

• PEx
• Nl temp
• No costovertebral angle tenderness
• Clinical Criteria
• Dipstick leukocyte esterase (pyuria) and nitrite
  (Enterobacteriaceae)
• 75-96 sensitivity 94-98 specificity for
  detecting gt10 leukocytes per HPF
• Evaluation of mid stream urine (unspun) for
  pyuria is most valuable laboratory diagnostic
  test
• (abnl 10 or more leukocytes per microL)

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Selected Oral AB Regimens for Use in
Uncomplicated UTI
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Giovanni Battista Morgagni

• 22 YO M C/O (not homeless, 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

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Skin and Soft Tissue Infections

• Cellulitis
• Most common skin infection leading to
  hospitalization
• Superficial, spreading infection involving
  subcutaneous tissue
• Other Common Skin Infections
• Impetigo, Folliculitis, Furuncles, and Carbuncles
• Abscess

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Impetigo, Folliculitis, Furuncle, Carbuncle

• Impetigo superficial vesiculopustular skin
  infection occurring prominently on exposed areas
  of the face and extremities
• FFC arise from hair follicle
• Staph Aureus
• Rarely require hospitalization
• Respond to local measures
• Recurrence may be prevented by decreasing staph
  aureus skin carriage

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Abscess

• Localized accumulation of polymorphonuclear
  leukocytes with tissue necrosis involving the
  dermis and subcutaneous tissue
• Large numbers of microorganisms are typically
  present in the purulent material
• Infection begins from tracking in from the skin
  surface

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Microbiology

• Most common microorgansim Staph Aureus
• Increased incidence of community-associated
  infections due to methicillin-resistant S.
  Aureus (CA-MRSA)
• Urban ER 61/119 MRSA isolated
• An average of more than 3 organisms anaerobic in
  1/3 of cases (1/2 IDU)

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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, vanco)
• Oral Antibiotic Therapy
• Not ready for ID, cellulitis, fever, high-risk
  features
• Community Associated MRSA
• Awareness of the local antimicrobial
  susceptibility patterns of community S. aureus
  isolates

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Oral Antibiotic Therapy
Oral, peri-rectal, vulvovaginal abscesses
Amoxicillin-clavulanate 875/125 mg BID
Clindamycin 150 mg QID
PLUS Ciprofloxacin 500 mg BID

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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

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Acute Bronchitis

• Over 90 are viral
• Approximately 60 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

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Usual Suspects
Coronavirus (types 1-3) Rhinovirus Influenza A
and B Parainfluenza Respiratory syncytial virus
Human metapneumovirus
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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

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Other Suspects

• Mycoplasma pneumoniae
• Chlamydophila (formerly Chlamydia) pneumoniae
• Bordetella pertussis (severe paroxysmal cough)

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To Shoot or Not to Shoot

• Pneumonitis vs Acute Bronchitis
• Abnl vital signs
• temp gt 38 C (100.4 F)
• Pulse gt 100/min
• RR gt24
• Crackles on exam

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Chronic CoughThink

• Postnasal drip syndrome
• Asthma
• Gastroesophageal reflux

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Beatrice

• 28 YO otherwise healthy female 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

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Acute Sinusitis

• Almost all cases viral in etiology
• Rhinovirus, 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 chronic
  sinus disease

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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
  bacterial sinusitis in adults
• Annual incidence of acute community-acquired
  bacterial sinusitis is approximately 20 million
  cases

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Comparison of Contemporary Guidelines for the
Diagnosis of Acute Community Acquired Bacterial
Sinusitis

• CDC
• Maxillary pain or tenderness in face or teeth
  rhinorrhea, no improvement x 7 days
• Severe sxs
• Plain films not needed

• Sinus Allergy Health Partnership
• Persistant sxs after 10 days or worsening after
  5-7 days
• Nasal drainage, congestion, d/c facial
  pressure/pain hyposmia/anosmia fever cough
  ear sxs
• Plain films, CT, MRI not needed

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Treatment of Viral Rhinosinusitisin Adults

• At first sign of a cold
• Sustained release 1st generation antihistamine
  (chlorpheniramine, brompheniramine, clemastine),
  PLUS NSAID (ibuprofen, naproxen)
• Continue 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

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Comparison Guidelines for the Treatment of ACA
Bacterial Sinusitis

• CDC
• Only those meeting 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 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

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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

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