How do we diagnose acute CAP? What are the ways to treat patients with CAP? Professor Ivan Hung (Hong Kong) presents his answers in his 2015 Pneumonia Lectures.
Learn more on www.waidid.org
Pneumonia - Community Acquired Pneumonia (CAP)Arshia Nozari
An overview to Community Acquired Pneumonia; It's Pathophysiology, Etiology, Epidemiology, Diagnosis and Treatment according to Harrison's Internal Medicine, 20th Edition (2018).
Pneumonia - Community Acquired Pneumonia (CAP)Arshia Nozari
An overview to Community Acquired Pneumonia; It's Pathophysiology, Etiology, Epidemiology, Diagnosis and Treatment according to Harrison's Internal Medicine, 20th Edition (2018).
Pneumonia Symposia presented at Hôpital Sacré Coeur in Milot, Haiti, 2011.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
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Diagnosis & Mangement of Community-Acquired Pneumonia, Hospital Acquired Pneu...Riaz Rahman
Clinical overview of Community Acquired Pneumonia, Hospital Acquired Pneumonia, Aspiration Pneumonia. Covers pathophysiology, clinical management, prevention, risk stratification (pneumonia severity index), prognostic factors, complications. Includes case studies, comprehension questions. Given at Jackson Park Medical Center on 12/1/2013. Includes references.
Pneumonia Symposia presented at Hôpital Sacré Coeur in Milot, Haiti, 2011.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
Do Not Forget To Visit Our Pages On Facebook on the following Links:
https://www.facebook.com/groups/569435236444761/
AND
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Diagnosis & Mangement of Community-Acquired Pneumonia, Hospital Acquired Pneu...Riaz Rahman
Clinical overview of Community Acquired Pneumonia, Hospital Acquired Pneumonia, Aspiration Pneumonia. Covers pathophysiology, clinical management, prevention, risk stratification (pneumonia severity index), prognostic factors, complications. Includes case studies, comprehension questions. Given at Jackson Park Medical Center on 12/1/2013. Includes references.
case presentation on PULMONARY TUBERCULOSISrohithadurga
CASE PRESENTATION ON PULMONARY TUBERCULOSIS INCLUDES patient demographics, chief complaints, past medical and medication history, personal habits, on examination, laboratory investigations, diagnosis, treatment.
disease information includes definition, etiology, clinical presentation, pathophysiology, diagnostic tests, treatment classification, patient counselling, life style modifications.
Designing vaccines for specific populations and germs - Slides by Professor E...WAidid
The presentation given by Professor Susanna Esposito at ECCMID 2019. A view on vaccines recommendations, combined vaccinations and impact of vaccination practices in the eradication of major infectious diseases.
To learn more, please visit www.waidid.org
Influenza vaccination and prevention of antimicrobial resistance - Slides by ...WAidid
The lecture presented by Professor Susanna Esposito at AMR 2019 on influenza vaccination and abuse of available antimicrobials.
To learn more, please visit www.waidid.org.
POINT-of-IMPACT testing. A European perspective - Bert NiestersWAidid
At SoGat meeting 2019 Bert Niesters - Professor in Molecular Diagnostic in Clinical Virology, Medical Molecular Microbiologist at University Medical Center Groningen, Department of Medical Microbiology, Division of Clinical Viroloy, The Netherlands - has talked about the developing trends in molecular diagnostics and the impact on the Laboratory.
To learn more, please visit www.waidid.org!
Measles and its prevention - Slideset by professor EdwardsWAidid
In this study Professor Kathryn M. Edwards (Sarah H. Sell and Cornelius Vanderbilt Professor - Division of Pediatric Infectious Diseases - Vanderbilt University Medical Center) provides an update on measles and its prevention.
To learn more, please visit www.waidid.org!
Is the use of antibiotics necessary in the treatment of diarrhoea?WAidid
Slide set presented by professors Per Ashorn (Finland) and Miguel O'Ryan (Chile) at the International Pediatric Association Congress in Panamá City, on March 18th.
To learn more, please visit www.waidid.org!
Are we running out of antibiotics? - Slideset by Professor EspositoWAidid
How does antibiotic resistance happen?
This work, edited by the professor Susanna Esposito, tries to answer this question underlining the importance of prescribing the right drug with the right dose and duration, to avoid any kind of abuse that may cause or increase antibiotic resistance.
To learn more please visit www.waidid.org
Mandatory vaccinations: the italian experience - Slideset by Professor EspositoWAidid
Every year 2.5 million lives are saved by vaccines. In this slideset Professor Susanna Esposito gives an overview on the vaccine coverage in Italy, including the latest laws on mandatory and recommended vaccines.
To learn more please visit www.waidid.org
Efficacy differences between PCV10 and PCV13 - Slideset by Professors Esposit...WAidid
This slideset edited by Professors Esposito, Palmu, De Wals and Sanders for the Second WAidid Congress present some studies that compare in different countries (including Finland, Sweden, Quebec and the Netherlands) efficacy differences between PCV10 and PCV13.
To learn more please visit www.waidid.org
Efficacy and safety of immunomodulators in pediatric age - Slideset by Profes...WAidid
«The first cause of recurrent infections in children is... childhood itself.» (J. Gary Wheeler)
Is it possibe to treat and prevent recurrent respiratory infections (RTIs) in pediatric age? Some studies have shown that immunostimulants/immunomodulators can reduce and prevent RTIs in children.
To learn more please visit www.waidid.org
The importance of pertussis booster vaccine doses throughout life - Slideset ...WAidid
Pertussis is still a worldwide problem: every year there are almost 20-50 million cases and 300.000 deaths.
The incidence is increasing especially between adults and adolescents, with consequences on infants. For this reason, the increasing of a vaccination strategy for adolescent and adult is needed...
To learn more, please visit www.waidid.org.
Vaccination in immunosuppressed adults - Slideset by professor Katie FlanaganWAidid
Immune compromised persons are generally at increased risk of morbidity and mortality from many vaccine preventable diseases, but since many vaccines, especially the live ones, are contraindicated in many immunocompromising situations, the degree of patients' impairment should be assessed each time in order to determine the best vaccination strategy...
To learn more, please visit www.waidid.org.
Potential advantages of booster containing PCV regimen - Professor Shabir MadhiWAidid
This slideset, realized by Professor Shabir Madhi on the occasion of the 11th ISPPD held in Melbourne last April, evaluates the potential advantages of booster containing PCV dosing schedule.
To learn more, visit www.waidid.org!
Lymphogranuloma venereum - Professor Ivan HungWAidid
In the following slides, professor Ivan Hung (WAidid board member) report a case of Lymphogranuloma Venereum and a short review of its possible source of infection, in order not to understimate the risk of infections, mainly in promiscuous behavioural context.
To learn more, visit www.waidid.org.
Bacterial and bacterial-like sepsis in children - Susanna Esposito WAidid
How to detect and prevent bacterial and bacterial-like sepsis in children and adolescents? Professor Susanna Esposito presents in this slideset data on epidemiology, etiology and mortality rates of pediatrical sepsis, and then discusses the possible treatment and the more efficient way of preventing the burden of pediatric sepsis.
To learn more, visit www.waidid.org.
Guidelines on the management of cystic fibrosis in the adult - Professor Fran...WAidid
Forecasts for 2025 in 16 European countries indicate that the number of cystic fibrosis patients will increase by 50% and the number of CF adults will increase by 75%. The transition from a child service to an adult service is crucial, that's why - suggests Professor Blasi (Milan, Italy) in his slideset - there's a strong need to supply a continuing medical education to healthcare workers dealing with CF and to rethink more adequate structures.
To learn more, please visit www.waidid.org!
Katie Flanagan - Malaria vaccines current status and challengesWAidid
Vaccines are considered the most cost-effective means of control, prevention, elimination, eradication of infectious diseases: for this reason, a malaria vaccine would greatly assist in the drive to eradicate malaria from the world. Professor Flanagan presents in this slideset the current status and challenges of developing malaria vaccines.
To learn more, visit www.waidid.org!
New perspectives in the treatment of multidrug-resistant tuberculosis - Profe...WAidid
The slideset offers an overview of MDR-TB: the epidemiology, the efficacy of the available treatments, and the new perspectives in the management of the pathology.
The slideset underlines, moreover, the existence of a free cost online instrument developed by ERS together with WHO to help clinician from all Europe to manage difficult-to-treat TB cases: TB Consilium.
Indicators of acute otitis media severity - Prof. Tal MaromWAidid
The slideset of professor Marom investigates the possibility and ways to establish the severity of AOM and focuses on the differences between pneumococcal vs non-pneumococcal AOM.
FInd more on www.waidid.org
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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Diagnosis and Management of Acute Community Acquired Pneumonia - Professor Ivan Hung
1. Diagnosis and Management of Acute
Community Acquired Pneumonia
Dr. Ivan Hung
MBChB (Bristol), MD (HK), FRCP (Lon, Edin), PDipID (HK)
Clinical Associate Professor
Honorary Consultant
Department of Medicine, QMH
The University of Hong Kong
5. National Institute for Health and Clinical Excellence: Guidance; 2008 Jul
Antibiotics ….when?
6. Key
laboratory
tests
for
diagnosis
of
acute
community
acquired
pneumonia
• 1.
Blood
culture
• 2.
Sputum/ETA/BAL
for
gram
stain,
bacterial
culture
(fungal
&
AFB
smear
&
culture,
PCP
smear,
parasiBc
ova)
• 3.
Pleural
fluid
for
gram
stain,
bacterial
culture
(fungal/AFB
smear
&
culture)
• 4.
NPA
or
T/S
(sputum,
ETA,
BAL)
for
respiratory
virus
anBgens
(animal
-‐
camel
/
poultry
exposure
in
endemic
areas:
RT-‐PCR
for
MERS-‐CoV
/
H7N9)
• 5.
Urine
for
pneumococcal
anBgenuria
• 6.
Urine
for
legionella
pneumophila
serogroup
1
anBgenuria
7.
8.
9. No. of infected cells: determining test sensitivity
Swabs inserted: sampling posterior pharyngeal
wall / level of ear lobes
Specimens with high viral load
Timing of specimen taking: viral load usually highest
within the first 48 hours after onset of disease
10. Aspirate and swab in
Viral transport medium,
Stored at 4 (<24hr) or
-70(>24hr) degree Celsius
11. Epidemic curve of staff with influenza like illness in AE department
Clinical attack rate: 46% (17 infected / 37 staff)
M:F = 9:6
Infected doctor = 9 (50%, 9/18)
Infected frontline nurse = 5 (45%, 5/11)
Infected senior nurse = 2 (33%, 2/6)
Infected supporting staff = 1 (50%, 1/2)
Clinical symptoms:
Sneeze: 9
Nasal drip: 6
Fever: 3
Cough: 11
Sputum: 8
Sore-throat: 11
Headache: 3
Lethargy: 6
Risk factor for infection:
Lack of vaccination (p=0.051)
Infected case: none received vaccine
Non-infected case: 4 (25%)received vaccine
12. Case
1
• F/27;
Japanese
• History
of
pepBc
ulcer
disease
and
leh
ovarian
cyst
• Fever
&
cough
for
2
days
– Given
oral
cefuroxime
by
private
pracBBoner.
No
improvement
• TOCC
– Came
back
from
Japan
~2
weeks
before
symptom
onset
– Works
in
office
buildings
– No
contact
with
paBents
with
influenza-‐like-‐
illness
– No
clustering
• A&E
(day
2
aher
symptom
onset)
– Temp
39.5°C
– BP
107/65
– Pulse
130
Day
2
a&er
symptom
onset
(A&E)
13. Case
1
• Diagnosis
(A&E):
– community
acquired
pneumonia
• AnBbioBcs:
– AugmenBn
1g
bd
po
– Azithromycin
500mg
daily
po
• Persistent
fever
• AdmiKed
5
days
aher
symptom
onset
• Switched
to
– IV
AugmenBn
1.2g
q8h
– oral
Azithromycin
500mg
daily
Day
5
a&er
symptom
onset
(admission)
14. Case
1
• Sputum
culture:
– WBC:
3+,
commensals
• NPA:
– negaBve
for
respiratory
viruses
by
direct
immunofluorescence
• Blood
culture:
– no
growth
(taken
aher
3
days
of
AugmenBn
/
Azithromycin)
Day
7
a&er
symptom
onset
(hospitalized)
15. • Persistent
fever
without
clinical/
radiological
improvement
despite
6
days
of
AugmenBn
&
Azithromycin
• OpBons?
1. Start
Meropenem
2. Start
Doxycycline
3. Start
TB
treatment
(HREZ)
4. Start
oseltamivir
5. ConBnue
with
current
treatment
Oral
AugmenBn/
IV
AugmenBn
Oral
Azithromycin
0
1
2
3
4
5
6
7
8
16. • Persistent
fever
without
clinical/
radiological
improvement
despite
6
days
of
AugmenBn
&
Azithromycin
• OpBons?
1. Start
Meropenem
2. Start
Doxycycline
3. Start
TB
treatment
(HREZ)
4. Start
oseltamivir
5. ConBnue
with
current
treatment
• Given
piperacillin-‐tazobactam
&
doxyccycline
– Rapid
resoluBon
of
symptoms
• Ix:
– NPA
PCR
for
Mycoplasma
pneumoniae:
posiBve
– Mycoplasma
pneumoniae
serology
• <10
(D5)
à
1280
(D21)
• Macrolide
resistance
marker
found:
A2063G
mutaBon
Oral
AugmenBn/
IV
AugmenBn
Oral
Azithromycin
0
1
2
3
4
5
6
7
8
20. MRMP
rate
in
the
world
• China:
70%-‐90%
• Taiwan:
23%
• Japan:
87.1%
(children)
• US:
up
to
18%
• Europe:
up
to
26%
Clin
Infect
Dis.
2012;
55(12):1642–9
Pediatr
Pulmonol.
2012
Nov
20.
doi:
10.1002/ppul.22706.
MMWR
Morb
Mortal
Wkly
Rep.
2012
Oct
19;61:834-‐8
J
AnBmicrob
Chemother.
2011
Apr;66(4):734-‐7.
Hong Kong
Lung
DC
et
al.
Hong
Kong
Med
J.
2011
Oct;17(5):407-‐9.
Clinical implications:
• Longer
Bme
to
resoluBon
of
fever
• More
persistent
symptoms/signs
• Longer
duraBon
of
anBbioBcs
• Higher
bacterial
load
21. Rapid
effecBveness
of
tetracyclines
Tetracyclines
be>er
than
quinolone
Clin
Infect
Dis.
2012;
55(12):1642–9
22. Case
2
• M/30
months
• Good
past
health
• All
vaccinaBons
up-‐to-‐date,
received
a
dose
of
pneumococcal
conjugate
vaccine
(private
pracBBoner)
• Travelled
to
Singapore
31/3
–
8/4,
– Transit
at
Vietnam
on
31/3
(3h
at
departure
hall)
– Mosquito
bite
on
5/4
• 6/4:
Fever
to
40℃
with
occasional
dry
cough
• 8/4:
Given
ventolin
for
symptom
at
HKSH
outpaBent
• 10/4:
persistent
fever,
no
symptom
improvement
à
AdmiKed
to
HKSH
– started
on
AugmenBn
9/4 13/4
WCC 11.87 2.66
ANC 5.54 0.48
Lym 4.08 1.38
Aty
Lym -‐ 5%
Plt 285 183
25. Transferred
to
QMH
18/4
18/4
CT
thorax
at
HKSH
– ConsolidaBve
changes
at
RML
and
RLL
with
associated
loss
of
volume.
– Early
change
of
necroBzing
pneumonia
has
to
be
considered
– Moderate
right
pleural
effusion
with
no
mediasBnal
shih
– Prominent
pre-‐carinal
LN
up
to
0.6x1.3cm
9/4 13/4 18/4
WCC 11.87 2.66 11.68
ANC 5.54 0.48 3.62
Lym 4.08 1.38 7.48
Atyp
lym 5%
Plt 285 183 566
Day
13
a&er
symptom
onset
(Day
2
a&er
admission
to
QMH)
26. 18/4:
Blood culture: sterile
MSU: no growth
NPA x respiratory virus IF: negative
ASOT <100
Legionella antigen: negative
Melioidosis serology: T/F
EMU, Gastric aspirate: AFB smear negative
US-guided pleural drainage:
Right pleural effusion with internal echoes and
incomplete septation, measuring <1cm in thickness,
with thickest part 1.4cm
Fluid appearance: Turbid
pH 7.0, fluid protein 56.0
LDH 606, TCC 6925, neutrophil 70%
AFB smear negative, TB-PCR
Gram stain: no organisms seen
Bacterial culture: sterile
Antibiotics:
Augmentin 10-13/4, Cefepime 13-18/4
Fortum, Vancomycin, Azithromycin 18/4
Case
3
What further investigations could be
done?
33. • Cross-‐reacBvity
reported
in:
– Streptococcus
viridans,
Enterococcus
faecalis
(PF)
Porcel
et
al.
Chest.
2007;131:1442-‐1447
– Streptococcus
oralis
(CSF)
Alonso-‐
Tarrés
C
et
al.
Lancet.
(2001)13;358(9289):
1273-‐4.
– Streptococcus
sanguis,
S
miNs
(PF)
Flores
et
al,
Eur
J
Pediatr
(2010)
169:581-‐584
– Streptococcus
oralis
– Streptococcus
salivarius
(PF)
Ploton
et
al.
Pathol
Biol.(2006)54:498-‐501
34. Pros
Easy to perform
Less affected by antibiotics treatment
Bedside test
Rapid
Cons
Antibiotics susceptibility cannot be done
Serotyping not possible
Cost ($1500 for 12)
Cross-reactivity
35. Case
3
• Elderly
male,
NS/social
drinker,
• PH:
hypertension
X
30yr,
DM
for
15
yr
now
on
insulin,
mild
coronary
artery
disease
(LAD),
hyperlipidemia,
gout
• Chronic
renal
failure
on
CAPD
• Acute
onset
of
fever
and
shortness
of
breath
for
1
day,
given
two
doses
of
ciproxfloxacin
250mg
q12h
by
family
physician.
He
had
no
bowel
moBon
for
one
day.
• Referred
to
QMH
with
worsening
of
symptoms
• Drug
list:
– Cadura
1mg
bd
– Adalat
GITS
90mg
bd
– Betaloc
75mg
bd
– Hydralazine
75mg
tds
– Lipitor
20mg
nocte
– CaCO3
2000/1000mg
bd
with
meals
– Renagel
1200mg
bd
– Lanthanum
carbonate
500mg
bd
– Mircera
50
micrograms
q10days
– Lasix
120mg
daily
– Natrilix
SR
1
tab
daily
– NaHCO3
900mg
daily
– CarBa
100mg
daily
– ForBfer
1
tab
daily
36. Case
3
• PaBent
given
IV
AugmenBn
1.2
gm
q12h
aher
blood
culture
by
nephrologist
• Though
no
coffee
ground
or
melena,
upper
endoscopy
by
gastroenterologist
because
Hb
dropped
from
11
(last
blood
checking
at
OPD)
to
7
• Endoscopy
aborted
because
of
desaturaBon
to
70%;
RR
30/min.
Admit
to
ICU
by
intensivist;
• Had
diarrhea
7X
watery
in
24hr
aher
admission
• Consulted
microbiologist/ID
Day 4 after symptom onset
(admission)
37. Case
3
• Microbiology
&
ID:
– Temp:
39
C,
p
– BP
160/90,
RR
25/min
– P:
120/min,
irregular
(80
regular
aher
digoxin/amiodarone)
– SaO2:
70%
on
room
air;
95%
while
on
CPAP
– Slow
mentaBon,
pallor+,
facial
puffiness,
bilateral
ankle
edema,
scratch
mark+
– No
exit
site
erythema
or
tunnel
tract
/
abdominal
tenderness,
PD
fluid
clear;
– Decreased
air
entry
to
leh
posterior
chest;
coarse
inspiratory
crepitus
• Hb
7.5,
WBC
8.6,
N
7.4,
L
0.65,
Plt
160,
• Urea
36.2,
Cr
1299,
Na
135,
K
5.1,
A/G
28/33,
ALP
34,
ALT
13,
AST
28,
Ca
2.1,
PO4:
1.68
• LDH
405(221),
troponin
0.21
(N<0.5
AMI),
CPK
131
(355)
• RetrospecBve
quesBoning:
history
of
travel
to
a
Hotel
and
zoo
for
1
day(9
Dec)
in
Guangzhou
6
days
before
admission(18
Dec)
Day 5 after symptom onset
38. Case
3
• RecommendaBons:
1. Microbiological
workup
for
causes
of
acute
community
acquired
typical
&
atypical
pneumonia
with
history
of
zoonoBc
contact
in
a
uraemic
paBent
on
CAPD
2. Empirical
IV
levofloxacin
0.5
gm
q48h,
meropenem0.5gm
q24h,
one
dose
zanamivir
0.6
gm
Bll
anBgenuria
&
viral
PCR
back
3. Acute
leh
heart
failure:
draw
fluid
out
by
increased
PD
Day 6 after symptom onset
(LLZ consolidation despite
dialysis)
39. InvesBgaBons
&
what
to
do
next?
• Blood
culture:
negaBve
• Cold
aggluBnin:
negaBve
• Sputum
not
produced
Bll
day
4
aher
admission
(21
Dec)
• NPA
viral
anBgen
by
IF:
negaBve
(19
Dec)
• Resplex
II
RT-‐PCR
for
10(16)
viruses:
influenza
A(M,
pH1,
H3),
and
B,
adenovirus,
parainfluenza
1-‐3,
respiratory
syncyBal
virus
A
and
B,
human
metapneumovirus,
human
rhinovirus.
coronavirus
(229E,
OC43,
NL63,
HKU1),
coxsackie/echo
virus,
bocavirus
and
adenoviruses
(B,
E):
negaBve
• Urine
anBgen
EIA(Binax)
for
legionella
pneumophila
serogroup1
&
streptococcus
pneumoniae
C
polyssacharide:
negaBve
(20
Dec)
• Urinalysis:
proteinuria
100mg/dL;
glucose:
250mg/dL;
occult
blood:
small;
RBC:
<30/ul
• Stool
culture
&
clostridium
difficile
cytotoxin:
negaBve
• PD
fluid:
normal
cell
count
&
culture
negaBve
40. Recent
travel,
acute
CAP,
diarrhea:
Real-‐Bme
PCR
for
legionella
pnemophila
22
Dec
2011
NPA
on
Day
1
&
Sputum
sample
on
Day
4
are
posiBve;
Stop
meropenem
&
zanamivir;
ConBnue
levofloxacin
alone;
NoBfy
epidemiologists
of
CHP
Legionella antigenuria EIA: negative 2X; Early use of
ciprofloxacin? Renal failure & inability to concentrate
bacterial antigen?
41.
42. No
response
to
Beta-‐lactams;
Respond
to
Fluoroquinolones
Marcolides
Tetracyclines
by
2
to
3
days;
*
*
43.
44. Legionellosis
in
what
host
• Risk
factors
for
Legionnaires‘
disease
include
1.
increasing
age,
2.
smoking,
3.
male
sex,
4.
chronic
lung
disease,
5.
hematologic
malignancies,
6.
end-‐stage
renal
disease,
7.
lung
cancer,
8.
immunosuppression,
9.
diabetes
and
10.
HIV/AIDS
• Health
advice
to
paBents
with
immunosuppressed
condiBons:
1. eat
and
drink
boiled
items,
2. use
sterile
or
off-‐boiled
water
for
nebulizers,
3. rinse
mouth
with
off-‐boiled
water,
4. flush
iniBal
stream
and
avoid
nebulizaBon
5. consider
inline
bacterial
filter
in
very
immunosuppressed
hosts