This document provides information on approaching and evaluating patients with potential infectious diseases. It discusses taking an exposure and social history, performing a physical exam focusing on vital signs, lymph nodes, skin, and foreign bodies. Diagnostic testing options are outlined including lab tests, imaging, and pathogen-specific tests. Empirical antibiotic therapy is recommended for common infections like pneumonia based on presentation. Community-acquired pneumonia causes are discussed. Hospital-acquired pneumonia treatment typically involves antibiotics until culture results are available. Infective endocarditis typically involves bacterial vegetation on heart valves.

1. INFECTIOUS
DISEASES
G.ERIC MD4

2. APPROACH TO THE PATIENT:
Infectious Disease
HISTORYThe history is critical for developing a
focused differential diagnosis and for guiding
the physical exam and initial diagnostic
testing. In general, these aspects focus on two
areas:

3. Exposure History • History of infections or
exposure to drug-resistant
microbes Knowledge about a patient’s previous
infections, with the
associated microbial susceptibility profiles, is
very helpful in determining
possible etiologic agents. Specifically, knowing
whether a
patient has a history of infection

4. Social history Although the social history taken
by physicians is
often limited to inquiries about a patient’s alcohol
and tobacco use, a
complete social history can offer a number of
clues to the underlying
diagnosis.

5.  Dietary habits As certain pathogens are
associated with specific
 dietary habits, inquiring about a patient’s diet
can provide insight
 into possible exposures

6. Animal exposures Because animals are often
important vectors of
infectious diseases, patients should be asked
about exposures to
any animals, including contact with their own
pets, visits to petting
zoos, or random encounters

7. Travel history Attention should be paid to both
international and
domestic travel.

8. Host-Specific Factors Because many
opportunistic infections (e.g.,
with Pneumocystis jirovecii, Aspergillus species,
or JC virus) affect
only immunocompromised patients, it is of vital
importance to
determine the immune status of the patient

9. PHYSICAL EXAMINATION
Similar to the history, a thorough physical
examination is crucial
in evaluating patients with an infectious disease

10. Vital Signs Given that elevations in temperature
are often a hallmark
of infection, paying close attention to the
temperature may
be of value in diagnosing an infectious disease.
Lymphatics There are ~600 lymph nodes
throughout the body, and
infections are an important cause of
lymphadenopathy.

11. Skin The fact that many infections have
cutaneous manifestations
gives the skin examination particular importance
in the evaluation
of patients

12. Foreign Bodies As previously mentioned, many
infections are
caused by members of the indigenous
microbiota.

13. DIAGNOSTIC TESTING
Laboratory and radiologic testing has advanced
greatly over the
past few decades and has become an important
component in the
evaluation of patients. The dramatic increase in the
number of serologic
diagnostics, antigen tests, and molecular
diagnostics available
to the physician has, in fact, revolutionized medical
care.

14. CONT…..
White Blood Cell (WBC) Count Elevations in the
WBC count are
often associated with infection, though many
viral infections are
associated with leukopenia.

15. CONT……
Inflammatory Markers The erythrocyte
sedimentation rate (ESR)
and the C-reactive protein (CRP) level are indirect
and direct
measures of the acute-phase response,
respectively, that can be
used to assess a patient’s general level of
inflammation
Analysis of Cerebrospinal Fluid (CSF)
Assessment of CSF is critical
for patients with suspected meningitis or
encephalitis.

16. Cultures The mainstays of infectious disease
diagnosis include
the culture of infected tissue (e.g., surgical
specimens) or fluid
(e.g., blood, urine, sputum, purulence from a
wound).

17. Pathogen-Specific Testing Numerous pathogen-
specific tests (e.g.,
serology, antigen testing, PCR testing) are
commercially available,
and many hospitals now offer some of these
tests in-house
to facilitate rapid turnaround that ultimately
enhances patient
care

18. Radiology Imaging provides an important
adjunct to the physical
examination, allowing evaluation for
lymphadenopathy in regions
that are not externally accessible (e.g.,
mediastinum, intraabdominal
sites), assessment of internal organs for
evidence of infection, and
facilitation of image-guided percutaneous
sampling of deep spaces.

19. TREATMENT
Physicians often must balance the need for
empirical antibiotic
treatment with the patient’s clinical condition. When
clinically
feasible, it is best to obtain relevant samples (e.g.,
blood, CSF, tissue,
purulent exudate) for culture prior to the
administration of antibiotics,
as antibiotic treatment often makes subsequent
diagnosis
more difficult

20. NORMAL Bacterial
Meningits
Viral
Meningitis
Fungal
Meningitis
Parasitic
Meningiti
s
Tuberculo
us
Meningiti
s
Encephali
tis
WBC
count
(per μL)
<5 >1000 25–500 40–600 150–
2000
25–100 50–500
Gram’s
stain
Negative Positive
(in >60%
of cases)
Negative Rarely
positive
Negative OCCASIO
NALLY
POSITIVE
Negative
Glucose
(mg/dL)
40–85 <40 normal ↓ to
normal
normal <50 in
75% of
cases
normal
Protein
(mg/dL)
15–45 >100 20–80 150–300 50–200 100–200 50–100
Common
causes
— Streptoco
ccus
pneumoni
ae,
Neisseria
meningitidi
s
Enterovir
uses
Candida,
Cryptococ
cus, and
Aspergillu
s spp.
Angiostrong
ylus
cantonensis,
Gnathostom
a
spinigerum,
Baylisascari
s procyonis
Mycobacte
rium
tuberculosi
s
Herpesviru
ses,
enteroviru
ses,
influenza
virus,
rabies

21. Initial Empirical Antibiotic Therapy for Common Infecti ous Disease
Presentations
Clinical
Syndrome
Common Etiologies Antibiotic(s)
Septic shock Staphylococcus aureus,
Streptococcus pneumoniae,
enteric gramnegative
bacilli
Vancomycin, 15 mg/kg
q12hb;
plus
A broad-spectrum
antipseudomonal β-
lactam
(piperacillin-tazobactam,
4.5 g q6h;
imipenem, 1 g q8h;
meropenem, 1 g q8h; or
cefepime,
1–2 g q8–12h
Meningitis S. pneumoniae, Neisseria
meningitidis
Vancomycin, 15 mg/kg
q12hb;
plus
Ceftriaxone, 2 g q12h
CNS abscess Streptococcus spp.,
Staphylococcus spp.,
anaerobes, gramnegative
bacilli
Vancomycin, 15 mg/kg
q12hb;
plus
Ceftriaxone, 2 g q12h;
plus

22. Pneumonia
DEFINITION Pneumonia is an infection of the pulmonary
parenchyma.
PATHOPHYSIOLOGYPneumonia results from the
proliferation of microbial pathogens at the alveolar level
and the host’s response to those pathogens.
Microorganisms gain access to the lower respiratory
tract in several ways. The most common is by
aspiration from the oropharynx. Small-volume
aspiration occurs frequently during sleep (especially in
the elderly) and in patients with decreased levels of
consciousness. Many pathogens are inhaled as
contaminated droplets. Rarely,pneumonia occurs via
hematogenous spread (e.g., from tricuspid

23. CONT…
Mechanical factors are critically important in host
defense. The hairs and turbinates of the nares
capture larger inhaled particles before they reach
the lower respiratory tract. The branching
architecture of the tracheobronchial tree traps
microbes on the airway lining, where mucociliary
clearance and local antibacterial factors either clear
or kill the potential pathogen. The gag reflex and the
cough mechanism offer critical protection from
aspiration. In addition, the normal flora adhering to
mucosal cells of the oropharynx, whose
components are remarkably constant, prevents
pathogenic bacteria from binding and thereby
decreases the risk of pneumonia caused by these
more virulent bacteria. Even erythrocytes
can cross the alveolar-capillary membrane, with

24. CONT….
The host inflammatory response, rather than
proliferation of microorganisms, triggers the clinical
syndrome of pneumonia. The release of inflammatory
mediators, such as interleukin 1 and tumor necrosis
factor, results in fever. Chemokines, such as
interleukin 8 and granulocyte colony-stimulating
factor, stimulate the release of neutrophils and their
attraction to the lung, producing both peripheral
leukocytosis and increased purulent secretions.
Inflammatory mediators released by macrophages
and the newly recruited neutrophils create an alveolar
capillary leak equivalent to that seen in the acute
respiratory distress syndrome, although in pneumonia
this leak is localized (at least initially).

26. COMMUNITY-ACQUIRED PNEUMONIA
ETIOLOGY
ETIOLOGY Newly identified pathogens include
metapneumoviruses, the coronaviruses responsible for
severe acute respiratory syndrome (SARS) and Middle
East respiratory syndrome, and community-acquired
strains of methicillin-resistant Staphylococcus aureus
(MRSA). Although Streptococcus pneumoniae is most
common, other organisms also must be considered in
light of the patient’s risk factors and severity of illness.
Separation of potential agents into either “typical”
bacterial pathogens or “atypical” organisms may be
helpful. The former category includes S. pneumoniae,
Haemophilus influenzae, and (in selected patients) S.
aureus and gram-negative bacilli such as Klebsiella
pneumoniae and Pseudomonas aeruginosa. The
“atypical” organisms include Mycoplasma pneumoniae,
Chlamydia pneumoniae, and Legionella species (in
inpatients) as well as respiratory viruses such as

27. Risk factors for CAP include alcoholism, asthma,
immunosuppression, institutionalization, and
an age of ≥70 years. In the elderly, factors such
as decreased cough and gag reflexes as well
as reduced antibody and Toll-like receptor
responses increase the likelihood of
pneumonia. Risk factors for pneumococcal
pneumonia include dementia, seizure
disorders, heart failure, cerebrovascular
disease, alcoholism, tobacco smoking, chronic
obstructive pulmonary disease, and HIV
infection.

28. CLINICAL MANIFESTATIONS
The patient is frequently febrile with tachycardia or may have a
history of chills and/or sweats. Cough may be either
nonproductive or productive of mucoid, purulent, or blood-tinged
sputum. Gross hemoptysis is suggestive of CA-MRSA
pneumonia. Depending on severity, the patient may be able to
speak in full sentences or may be very short of breath. If the
pleura is involved, the patient may experience pleuritic chest
pain. Up to 20% of patients may have gastrointestinal symptoms
such as nausea, vomiting, and/or diarrhea. Other symptoms may
include fatigue, headache, myalgias, and arthralgias. Findings on
physical examination vary with the degree of pulmonary
consolidation and the presence or absence of a significant pleural
effusion. An increased respiratory rate and use of accessory
muscles of respiration are common. Palpation may reveal
increased or decreased

29. Cont…..
tactile fremitus, and the percussion note can vary
from dull to flat, reflecting underlying consolidated
lung and pleural fluid, respectively. Crackles,
bronchial breath sounds, and possibly a pleural
friction rub may be heard on auscultation. The
clinical presentation may not be so obvious in the
elderly, who may initially display new-onset or
worsening confusion and few other
manifestations. Severely ill patients may have
septic shock and evidence of organ failure.

30. Cont…
DIAGNOSIS When confronted with possible CAP, the
physician must ask two
questions: Is this pneumonia, and, if so, what is the
likely etiology? The former question is typically
answered by clinical and radiographic methods,
whereas the latter requires the aid of laboratory
techniques. Clinical Diagnosis The differential
diagnosis includes both infectious and noninfectious
entities such as acute bronchitis, acute
exacerbations of chronic bronchitis, heart failure,
pulmonary embolism, hypersensitivity pneumonitis,
and radiation pneumonitis. The importance of a
careful history cannot be overemphasized. For
example, known cardiac disease may suggest
worsening pulmonary edema, while underlying
carcinoma may suggest lung injury secondary to
irradiation.

31. Clinical Diagnosis The differential diagnosis
includes both infectious and noninfectious
entities such as acute bronchitis, acute
exacerbations of chronic bronchitis, heart failure,
pulmonary embolism, hypersensitivity
pneumonitis, and radiation pneumonitis. The
importance of a careful history cannot be
overemphasized. For example, known cardiac
disease may suggest worsening pulmonary
edema, while underlying carcinoma may suggest
lung injury secondary to irradiation.

32. cont….
Etiologic Diagnosis The etiology of pneumonia
usually cannot be determined solely on the basis
of clinical presentation. Gram’s Stain and
Culture of Sputum The main purpose of the
sputum Gram’s stain is to ensure that a sample
is suitable for culture. However, Gram’s staining
may also identify certain pathogens (e.g., S.
pneumoniae, S. aureus, and gram-negative
bacteria) by their characteristic appearance.
 Blood Cultures
 Urinary Antigen Tests Two commercially
available tests detect pneumococcal and

33. Cont….
 Polymerase Chain Reaction
 Serology
 Biomarkers A number of substances can
serve as markers of severe
inflammation. The two currently in use are C-
reactive protein (CRP)
and procalcitonin (PCT).

34. PROGNOSIS
The prognosis of CAP depends on the patient’s
age, comorbidities, and site of treatment
(inpatient or outpatient). Young patients
without comorbidity do well and usually
recover fully after ~2 weeks. Older patients
and those with comorbid conditions can take
several weeks longer to recover fully
 PREVENTION
 The main preventive measure is vaccination

35. Treatment of Typical Community Acquired Pneumonia
Condition Treatment Duration
Mild pneumonia (treated
on out-patient basis)
Amoxicillin (PO) 500–
1000 mg every 8 hours
Or Erythromycin 500 mg
(PO) every 8 hours
5 days
5 days
Severe pneumonia (in-
patient)
Ceftriaxone 1g IV every
12 hours
5 to 7 days

36. Condition treatment duration
Atypical pneumonias Erythromycin (PO) 500 mg every 6
hours
7 to 10 days
PCP Co-trimoxazole (PO) 1920 mg
every 6 hours PLUS Folic acid if
cytopenic Alternatively in sulphur
allergy: S: Clindamycin 450–600
mg (PO) every 6 hours
21 days
Staphylococcus aureus
Pneumonia
Cloxacillin (IV) 1 to 2mg every 6
hours Or S: *Clindamycin (IV/PO)
600mg every 6 to 8 hours
14 days
14 days
Klebsiella Pneumonia Chloramphenicol (IV) 500 mg every
6 hours +/- OR A: Gentamicin (IV) 4
to 5 mg/kg/24 hrs in 2 divided
10 to 14 days
10 to 14 days

37.  Hospital Acquired Pneumonia This is defined
as pneumonia that occurs 48 hours or more
after hospital admission but that was not
incubating at the time of admission
 Pharmacological treatment Empirical
treatment until bacteriology available A:
Ampicillin (IV) 1g every 6 hours for 7 to 10
days AND A: Gentamicin (IV) 4 to 5mg/kg/day
in 2 divided doses 7–10 days OR S:
Sulbactam (IV) 500mg once daily for 7 days

38. Infective Endocarditis
The prototypic lesion of infective endocarditis, the vegetation
(is a mass of platelets, fibrin, microcolonies of
microorganisms,
and scant inflammatory cells. Infection most commonly
involves heart valves but may also occur on the low-pressure
side
of a ventricular septal defect, on mural endocardium damaged
by
aberrant jets of blood or foreign bodies, or on intracardiac
devices
 themselves. The analogous process involving arteriovenous
shunts,
 arterio-arterial shunts (patent ductus arteriosus), or a
coarctation of
 the aorta is called infective endarteritis.

39. Vegetations (arrows) due to viridans streptococcal
endocarditis involving the mitral valve.

40. Endocarditis can be classified according to the
temporal evolution of disease, the site of
infection, the cause of infection, or the
predisposing risk factor (e.g., injection drug use).
Acute endocarditis is a hectically febrile illness
that rapidly damages cardiac structures, seeds
extracardiac sites, and, if untreated, progresses
to death within weeks. Subacute endocarditis
follows an indolent course; causes structural
cardiac damage only slowly, if at all; rarely
metastasizes; and is gradually progressive
unless complicated by a major embolic event or

41. ETIOLOGY
Although many species of bacteria and fungi cause
sporadic episodes of endocarditis, a few bacterial
species cause the majority of cases The oral cavity,
skin, and upper respiratory tract are the respective
primary portals for viridans streptococci, staphylococci,
and HACEK organisms (Haemophilus species,
Aggregatibacter aphrophilus, A.
actinomycetemcomitans, Cardiobacterium species,
Eikenella species, and Kingella species). Prosthetic
valve endocarditis (PVE) arising within 2 months of
valve surgery is generally nosocomial, the result of
intraoperative contaminationof the prosthesis or a
bacteremic postoperative complication.

42. PATHOGENESIS
The undamaged endothelium is resistant to infection by most
bacteria and to thrombus formation. Endothelial injury (e.g., at the
site of impact of high-velocity blood jets or on the low-pressure
side of a cardiac structural lesion) allows either direct infection by
virulent organisms or the development of a platelet-fibrin
thrombus—a condition called nonbacterial thrombotic endocarditis
(NBTE). This thrombus serves as a site of bacterial attachment
during transient bacteremia. The cardiac conditions most
commonly resulting in NBTE are mitral regurgitation, aortic
stenosis, aortic regurgitation, ventricular septal defects, and
complex congenital heart disease. NBTE also arises as a result of
a hypercoagulable state; this gives rise to marantic endocarditis
(uninfected vegetations seen in patients with malignancy and
chronic diseases) and to bland vegetations complicating systemic
lupus erythematosus and the antiphospholipid
antibody syndrome. Organisms that cause endocarditis enter the
bloodstream from mucosal surfaces, the skin, or sites of focal
infection. Fibrin deposition combines with platelet aggregation and
microorganism proliferation to generate an infected vegetation.
Organisms deep in vegetations are metabolically inactive
(nongrowing) and relatively resistant to killing by antimicrobial
agents. Proliferating surface organisms are shed into the
bloodstream continuously.

43. Cont….
The organisms that commonly cause endocarditis
have surface adhesin molecules, collectively
called microbial surface components recognizing
adhesin matrix molecules. The clinical
manifestations of endocarditis—other than
constitutional symptoms, which probably result
from cytokine production— arise from damage to
intracardiac structures; embolization of
vegetation fragments, leading to infection or
infarction of remote tissues; hematogenous
infection of sites during bacteremia; and tissue
injury due to the deposition of circulating
immune complexes or immune responses to

44. Clinical and Laborat ory Feat ures of Infecti ve
Endocarditis
 Fever
 Chills and sweats
 Anorexia, weight loss, malaise
 Myalgias, arthralgias
 Back pain
 Heart murmur
 New/worsened regurgitant murmur
 Arterial emboli
 Splenomegaly
 Clubbing
 Neurologic manifestations
 Peripheral manifestations (Osler’s nodes, subungual
 hemorrhages, Janeway lesions, Roth’s spots
 Petechiae
 Laboratory manifestations
 Anemia
 Leukocytosis
 Microscopic hematuria
 Elevated erythrocyte sedimentation rate
 Elevated C-reactive protein level
 Rheumatoid factor
 Circulating immune complexes
 Decreased serum complement

46. The Modified Duke Criteria for the Clinical Diagnosis of
Infecti ve Endocarditis a
Major Criteria
1. Positive blood culture Typical microorganism for infective
endocarditis from two separate blood
cultures
Viridans streptococci, Streptococcus gallolyticus, HACEK group
organisms,
Staphylococcus aureus,
2. Evidence of endocardial involvement
Positive echocardiogramb
Oscillating intracardiac mass on valve or supporting structures or in
the
path of regurgitant jets or in implanted material, in the absence of an
alternative anatomic explanation, or
Abscess, or
New partial dehiscence of prosthetic valve,

47. Cont…..
Minor Criteria
1. Predisposition: predisposing heart conditionsc or injection drug
use
2. Fever ≥38.0°C (≥100.4°F)
3. Vascular phenomena: major arterial emboli, septic pulmonary
infarcts,
mycotic aneurysm, intracranial hemorrhage, conjunctival
hemorrhages,
Janeway lesions
4. Immunologic phenomena: glomerulonephritis, Osler’s nodes,
Roth’s spots,
rheumatoid factor
5. Microbiologic evidence: positive blood culture but not meeting
major criterion,
as noted previously,d or serologic evidence of active infection with
an organism consistent with infective endocarditis

48. TREATMENT Infective
Endocarditis
ANTIMICROBIAL THERAPY
To cure endocarditis, all bacteria in the vegetation must be killed.
However, it is difficult to eradicate these bacteria because local
host defenses are deficient and because the bacteria are largely
nongrowing and metabolically inactive and thus are less easily
killed by antibiotics. Accordingly, therapy must be bactericidal
and
prolonged. Antibiotics are generally given parenterally to achieve
serum concentrations that, through passive diffusion, result in
effective
concentrations in the depths of the vegetation.

49. Treatment for native valves
Antibiotics Dosage & Route* Duration
Benzyl Penicillin G or 18–24milllion
Units/24hoursIVI,4
hourly in
4–6weeks
Ceftriaxone 2g IV daily 4–6weeks
Plus cloxacillin 2g IV 6 hourly 4–6weeks
plus, gentamicin ** 1–1.5mg/kg IV every 8
hours
4–6weeks

50. Cont….
Methicillin–Resistant
Staphylococci
Anaerobes (MRSA) add
vancomycin
30mg/kg/24hours IV in two equally
divided dose, not to exceed 2gm/24
hours unless serum levels are monitored
4–6
weeks

51. Prosthetic valve empirical treatment
antibiotics Dosage & Route* duration
Benzyl Penicillin G (X–
Pen) or
18 –24 milllion Units/24 hours IVI, 4
hourly in equally divided dose
6 – 8
weeks
Ceftriaxone 2mg once daily IVI >6 weeks
plus cloxacillin 2g IVI 6 hourly >6 weeks
plus, rifampicin 300 –600mg every 8 hourly >6 weeks
and gentamicin** 1mg/kg IVI every 8 hours 2 weeks

52.  Infective Endocarditis Prophylaxis Antibiotic
prophylaxis should be considered for patients at
highest risk for IE: Patients with any prosthetic
valve, including a trans catheter valve, or those in
whom any prosthetic material was used for
cardiac valve repair. Patients with a previous
episode of IE. Patients with Congenital Heart
Disease (CHD): (a) Any type of cyanotic CHD.
 (b) Any type of CHD repaired with a prosthetic
material, whether place surgically or by
percutaneous techniques, up to 6 months after the
procedure or lifelong if residual shunt or valvular
regurgitation remains.

53.  Prophylaxis of Endocarditis Infective To reduce
the risk of bacterial endocarditis, antibiotic
prophylaxis should be given to patients
undergoing dental procedures requiring
manipulation of the gingival or periapical
region of the teeth or perforation of the oral
mucosa.

54. Infections of the Skin, Muscles,
and Soft Tissues
Skin and soft tissue infections occur in all races, all
ethnic
groups, and all geographic locations, although some
have
unique geographic niches. In modern times, the
frequency and
severity of some skin and soft tissue infections have
increased for several
reasons. First, microbes are rapidly disseminated
throughout the
world via efficient air travel, acquiring genes for
virulence factors and
antibiotic resistance

55. ANATOMIC RELATIONSHIPS: CLUES TO THE DIAGNOSIS OF SOFT
TISSUE INFECTIONS
Protection against infection of the epidermis depends on the mechanical
barrier afforded by the stratum corneum, since the epidermis itself is devoid
of blood vessels. Disruption of this layer by burns or bites, abrasions,
foreign bodies, primary dermatologic disorders (e.g., herpes simplex,
varicella, ecthyma gangrenosum), surgery, or vascular or pressure ulcer
allows penetration of bacteria to the deeper structures. Similarly, the hair
follicle can serve as a portal either for components of the normal flora (e.g.,
Staphylococcus) or for extrinsic Bacteria. Intracellular infection of the
squamous epithelium with vesicle formation may arise from cutaneous
inoculation, as in infection with herpes simplex virus (HSV) type 1; from the
dermal capillary plexus, as in varicella and infections due to other viruses
associated with viremia; or from cutaneous nerve roots, as in herpes zoster.
Bacteria infecting the epidermis, such as Streptococcus pyogenes, may be
translocated laterally to deeper structures via lymphatics, an event that
results in the rapid superficial spread of erysipelas. Later, engorgement or
obstruction of lymphatics causes flaccid edema of the epidermis, another
characteristic of erysipelas.

56. cont….
The rich plexus of capillaries beneath the dermal
papillae provides nutrition to the stratum
germinativum, and physiologic responses of this
plexus produce important clinical signs and
symptoms. For example, infective vasculitis of
the plexus results in petechiae, Osler’s nodes,
Janeway lesions, and palpable purpura, which, if
present, are important clues to the existence of
endocarditis. In addition,
metastatic infection within this plexus can result in
cutaneous manifestations of disseminated fungal
infection gonococcal infection, Salmonella
infection, Pseudomonas
Infection,meningococcemia and staphylococcal
infection

57. Cont….
The plexus also provides bacteria with access to the
circulation, thereby facilitating local spread or
bacteremia. Amplification of these physiologic
mechanisms by excessive levels of cytokines or
bacterial toxins causes leukostasis, venous
occlusion, and pitting edema. Edema with purple
bullae, ecchymosis, and cutaneous anesthesia
suggests loss of vascular integrity and necessitates
exploration of the deeper structures for evidence of
necrotizing fasciitis or myonecrosis. An early
diagnosis requires a high level of suspicion in
instances of unexplained fever and of pain and
tenderness in the soft tissue, even in the absence
of acute cutaneous inflammation

58. INFECTIONS ASSOCIATED WITH
VESICLES
Vesicle formation due to infection is caused by viral
proliferation within the epidermis. In varicella and
variola, viremia precedes the onset of a diffuse
centripetal rash that progresses from macules to
vesicles, then to pustules, and finally to scabs over
the course of 1–2 weeks. Vesicles of varicella have
a “dewdrop” appearance and develop in crops
randomly about the trunk, extremities, and face over
3–4 days. Herpes zoster occurs in a single
dermatome; the appearance of vesicles is preceded
by pain for several days. Zoster may occur in
persons of any age but is most common among
immunosuppressed individuals and elderly patients,
whereas most cases of varicella occur in young
children

59. CELLULITIS Cellulitis is an acute inflammatory condition of
the skin that is characterized by localized pain, erythema,
swelling, and heat. It may be caused by indigenous flora
colonizing the skin and appendages (e.g., S. aureus and
S. pyogenes) or by a wide variety of exogenous bacteria.
Bacteria may gain access to the epidermis through
cracks in the skin, abrasions, cuts, burns, insect bites,
surgical incisions, and IV catheters. Cellulitis caused by
S. aureus spreads from a central localized infection,
such as an abscess, folliculitis, or an infected foreign
bodyMRSA is rapidly replacing methicillin-sensitive S.
aureus (MSSA) as a cause of cellulitis in both inpatient
and outpatient settings. Cellulitis caused by MSSA or
MRSA is usually associated with a focal infection, such
as a furuncle, a carbuncle, a surgical wound, or an
abscesslevels of IgE (Job’s syndrome) and among nasal
carriers of staphylococci. Cellulitis caused by
Streptococcus agalactiae (group B Streptococcus) occurs
primarily in elderly patients and those with diabetes

60. ERYSIPELAS Erysipelas is due to S. pyogenes and is
characterized by an abrupt onset of fiery-red
swelling of the face or extremities.
NECROTIZING FASCIITISNecrotizing fasciitis,
formerly called streptococcal gangrene, may be
associated with group A Streptococcus or mixed
aerobic– anaerobic bacteria or may occur as a
component of gas gangrene caused by Clostridium
perfringensSwelling then develops and is followed
by brawny edema and tenderness. With
progression, dark-red induration of the epidermis
appears, along with bullae filled with blue or purple
fluid. Later the skin becomes friable and takes on a
bluish, maroon, or black color. By this stage,

61. MYOSITIS AND
MYONECROSISMuscle involvement can occur with viral infection
(e.g., influenza, dengue, or coxsackievirus B
infection) or parasitic invasion (e.g.,
trichinellosis, cysticercosis, or toxoplasmosis).
Although myalgia develops in most of these
infections, severe muscle pain is the hallmark
of pleurodynia (coxsackievirus B), trichinellosis,
and bacterial infection. Acute rhabdomyolysis
predictably occurs with clostridial and
streptococcal myositis but may also be
associated with influenza virus, echovirus,
coxsackievirus, Epstein-Barr virus, and
Legionella infections. Pyomyositis is usually
due to S. aureus, is common in tropical areas,

62. Cont….
DIAGNOSISOther crucial considerations in
narrowing the differential diagnosis are the
temporal progression of the lesions as well as
the patient’s travel history, animal exposure or
bite history, age, underlying disease status,
and lifestyle. However, even the astute clinician
may find it challenging to diagnose all
infections of the soft tissues by history and
inspection alone. Soft tissue radiography,
CTand MRI may be useful in determining the
depth of infection and should be performed
when the patient has rapidly progressing
lesions or evidence of a systemicinflammatory

63. TREATMENT Infections of the Skin,Muscles,
and Soft Tissues
Furuncles, carbuncles, and abscesses caused by MRSA
and MSSA
are common, and their treatment depends upon the size
of the
lesion. Furuncles <2.5 cm in diameter are usually
treated with moist
heat. Those that are larger (4.5 cm of erythema and
induration)
require surgical drainage, and the occurrence of these
larger lesions
in association with fever, chills, or leukocytosis requires
both drainage
and antibiotic treatment.

64. Condition Primary Treatment
Cellulitis (staphylococcal Nafcillin or oxacillin, 2 g IV
Herpes simplex (primary genital Acyclovir, 400 mg PO tid for 10 days
Necrotizing fasciitis (group A
streptococcalb
Clindamycin, 600–900 mg IVplus plus
Penicillin G, 4 million units IV
Animal bite (prophylaxis or early infection)a Amoxicillin/clavulanate,
875/125 mg PO bid
Animal bitea (established infection)
Ampicillin/sulbactam, 1.5–3 g IV q6h
Ampicillin/sulbactam, 1.5–3 g IV q6h
Herpes simplex (primary genital) Acyclovir, 800 mg PO 5 times daily for
7–10 days
MRSA skin infectiond Vancomycin, 1 g IV q12h

65.  Pharmacological Treatment Adults: B:
Flucloxacillin 250mg + Amoxycillin 250mg PO
6 hourly for 14 days OR A: Erythromycin 500
mg PO 6 hourly for 14 days; Children: B:
Cloxacillin25 mg/kg (IV) 6 hourly for 14 days
OR A: Erythromycin 10 mg/kg 6 hourly for 14
days

66. Lesion Infectious Agent
Vesicles
Small pox
Chickenpox
Shingles (herpes zoster)
Molluscum contagiosum
Rickettsialpox
Cold sores, herpetic whitlow,
herpes gladiatorum
Blistering distal dactylitis
Hand-foot-and-mouth disease
Variola virus
Varicella-zoster virus
Varicella-zoster virus
Molluscum contagiosum poxvirus
Rickettsia akari
Herpes simplex virus
Staphylococcus aureus
Coxsackievirus A16
Bullae
Staphylococcal scalded-skin
syndrome
Necrotizing fasciitis
Gas gangrene
Halophilic vibrio
S. aureus
S. pyogenes, Clostridium spp., mixed
aerobes and anaerobes
Clostridium spp.
Halophilic vibrio Vibrio vulnificus

67. Crusted lesions
Bullous impetigo/ecthyma
Impetigo contagiosa
Ringworm
Sporotrichosis
Histoplasmosis
Coccidioidomycosis
Blastomycosis
Cutaneous leishmaniasis
Cutaneous tuberculosis
Nocardiosis
Folliculitis
Furunculosis
Hot-tub folliculitis
Swimmer’s itch
Acne vulgaris
S. Aureus
S. Pyogenes
Superficial dermatophyte fungi
Sporothrix schenckii
Histoplasma capsulatum
Coccidioides immitis
Blastomyces dermatitidis
Leishmania spp.
Mycobacterium tuberculosis
Nocardia asteroides
S. Aureus
Pseudomonas aeruginosa
Schistosoma spp
Propionibacterium acnes

68. Ulcers with or without eschars
Anthrax
Ulceroglandular tularemia
Bubonic plague
Buruli ulcer
Leprosy
Cutaneous tuberculosis
Chancroid
Primary syphilis
Erysipelas
Cellulitis
Necrotizing fasciitis
Streptococcal gangrene
Fournier’s gangrene
Staphylococcal necrotizing fasciitis
Myositis and myonecrosis
Pyomyositis
Streptococcal necrotizing myositis
Gas gangrene
Nonclostridial (crepitant) myositis
Synergistic nonclostridial anaerobic
myonecrosis
Bacillus anthracis
Francisella tularensis
Yersinia pestis
Mycobacterium ulcerans
M. Leprae
M. Tuberculosis
Haemophilus ducreyi
T. pallidum
S. Pyogenes
Staphylococcus spp.,
S. Pyogenes
Mixed aerobic and anaerobic
Methicillin-resistant S. aureus
S. Aureus
S. Pyogenes
Clostridium spp.
Mixed aerobic and anaerobic
Mixed aerobic and anaerobic

69. Infectious Arthritis
Although Staphylococcus aureus, Neisseria
gonorrhoeae, and other bacteria are the most
common causes of infectious arthritis, various
mycobacteria, spirochetes, fungi, and viruses also
infect joints. Acute bacterial infection typically
involves a single joint or a few joints. Subacute or
chronic monarthritis or oligoarthritis suggests
mycobacterial or fungal infection; episodic
inflammation is seen in syphilis, Lyme disease, and
the reactive arthritis that follows enteric infections
and chlamydial urethritis. Acute polyarticular
inflammation occurs as an immunologic reaction
during the course of endocarditis, rheumatic fever,
disseminated neisserial infection, and acute
hepatitis B. Bacteria and viruses occasionally infect
multiple joints, the former most commonly in
persons with rheumatoid arthritis.

70. APPROACH TO THE PATIENT:
Infectious Arthritis
Aspiration of synovial fluid—an essential element in the
evaluation
of potentially infected joints—can be performed without
difficulty in most cases by the insertion of a large-bore
needle
into the site of maximal fluctuance or tenderness or by the
route
of easiest access. Ultrasonography or fluoroscopy may be
used
to guide aspiration of difficult-to-localize effusions of the hip
and, occasionally, the shoulder and other joints. Normal
synovial
fluid contains <180 cells (predominantly mononuclear cells)
per

71. ACUTE BACTERIAL ARTHRITIS
PATHOGENESIS Bacteria enter the joint from the
bloodstream; from a contiguous site of infection in
bone or soft tissue; or by direct inoculation during
surgery, injection, animal or human bite, or trauma.
In hematogenous infection, bacteria escape from
synovial capillaries, which have no limiting basement
membrane, and within hours provoke neutrophilic
infiltration of the synovium. Neutrophils and bacteria
enter the joint space; later, bacteria adhere to
articular cartilage. Degradation of cartilage begins
within 48 h as a result of increased intraarticular
pressure, release of proteases and cytokines from
chondrocytes and synovial macrophages, and
invasion of the cartilage by bacteria and

72. Acute septic arthritis of the sternoclavicular joint.
A man in his forties with a history of cirrhosis presented with a new
onset of fever and lower neck pain. He had no history of IV drug
use or previous catheter placement. Jaundice and a painful swollen
area over his left sternoclavicular joint were evident on physical
examination. Cultures of blood drawn at admission grew group B
Streptococcus. The patient recovered after treatment with IV penicillin

73. Septic arthritis Surgical drainage B:
Cloxacillin or S:
Clindamycin as for acute
osteomyelitis
6 days 7 days
Gonococcal arthritis A: Benzyl penicillin (IV)
2.5–5 MU 6 hourly or (if
penicillin resistant) S:
Kanamycin (IM) 2 g
once daily

74. Osteomyelitis
Osteomyelitis, an infection of bone, can be caused by
various microorganisms that arrive at bone through
different routes. Spontaneous hematogenous
osteomyelitis may occur in otherwise healthy
individuals, whereas local microbial spread mainly
affects either individuals who have underlying
disease (e.g., vascular insufficiency) or patients who
have compromised skin or other tissue barriers, with
consequent exposure of bone. The latter situation
typically follows surgery involving bone, such as
sternotomy or orthopedic repair.
Osteomyelitis Osteomyelitis is an infection of the bone,
and is most common in children under 12 years.
Staphylococci are the most frequent responsible
organisms. Salmonella osteomyelitis infection is a
common complication of sickle cell disease.
Tuberculosis osteomyelitis occurs in association with

75. cont…..
Any of three mechanisms can underlie osteomyelitis: (1)
hematogenous spread; (2) spread from a contiguous
site following surgery; and (3) secondary infection in
the setting of vascular insufficiency or concomitant
neuropathy. Hematogenous osteomyelitis in adults
typically involves the vertebral column. In only about
half of patients can a primary focus be detected. The
most common primary foci of infection are the urinary
tract, skin/soft tissue, intravascular catheterizationsites,
and the endocardium. Spread from a contiguous
source follows either bone trauma or surgical
intervention. Wound infection leading to osteomyelitis
typically occurs after cardiovascular intervention
involving the sternum, orthopedic repair, or prosthetic
joint insertion. Osteomyelitis secondary to vascular
insufficiency or peripheral neupathy.

76. Cont……
Whereas acute osteomyelitis can generally be treated
with antibiotics alone, antibiotic treatment for chronic
osteomyelitis should be combined with debridement
surgery. Acute hematogenous or contiguous
osteomyelitis evolves over a short period—i.e., a
few days or weeks. In contrast, subacute or chronic
osteomyelitis lasts for weeks or months before
treatment is started. Typical examples of a subacute
course are vertebral osteomyelitis due to
tuberculosis or brucellosis and delayed
implantassociated infections caused mainly by low-
virulence microorganisms (coagulase-negative
staphylococci, Propionibacterium acnes). Chronic
osteomyelitis develops when insufficient therapy
leads to persistence or recurrence, most often after
sternal, mandibular, or foot infection

77. Cont……
Classification by location distinguishes among
cases in the long bones, the vertebral column,
and the periarticular bones. Long bones are
generally involved after hematogenous seeding
in children or contiguous spread following trauma
or surgery. The risk of vertebral osteomyelitis in
adults increases with age. Periarticular
osteomyelitis, which complicates septic arthritis
that has not been adequately treated, is
especially common in periprosthetic joint
infection.

78. VERTEBRAL OSTEOMYELITIS
PATHOGENESIS
Vertebral osteomyelitis, also referred to as disk-space
infection, septic
diskitis, spondylodiskitis, or spinal osteomyelitis, is the most
common
manifestation of hematogenous bone infection in adults.
This
designation reflects a pathogenic process leading to
involvement of
the adjacent vertebrae and the corresponding intervertebral
disk. In
adults, the disk is avascular. Microorganisms invade via the
segmental
arterial circulation in adjacent endplates and then spread
into the
disk. Alternative routes of infection are retrograde seeding

79. CLINICAL MANIFESTATIONS
The signs and symptoms of vertebral osteomyelitis are nonspecific.
Only about half of patients develop fever >38°C (100.4°F), perhaps
because analgesic drugs are frequently used by these patients.
Back pain is the leading initial symptom (>85% of cases). The
location of the pain corresponds to the site of infection: the cervical
spine in ~10% of cases, the thoracic spine in 30%, and the lumbar
spine in 60%. One exception is involvement at the thoracic level in
two-thirds of cases of tuberculous osteomyelitis and at the lumbar
level in only one-third. This difference is due to direct mycobacterial
spread via pleural or mediastinal lymph nodes in pulmonary
tuberculosis. Neurologic deficits, such as radiculopathy, weakness,
or sensory loss, are observed in about one-third of cases of
vertebral osteomyelitis

80. Acute osteomyelitis Surgical drainage
(recommended in all cases
presenting with history > 24
hours) B: Cloxacillin (IV) 1–
2 g 6 hourly Or S:
Clindamycin (IV) 600 mg 8
hourly.
6 weeks or stop at 3 weeks
if X-ray normal
Chronic osteomyelitis Surgery. Antibioticsnot
generallyrecommended
Osteomyelitis in patient with
sickle cell anemia
Ampicillin (IV) 2 g 6 hourly
Plus B: Cloxacillin (IV) 1–2
g 6 hourly Plus B:
Chloramphenicol (IV) 500
mg 6 hourly (if salmonella is
suspected
5 to 12 weeks 6 to 12
weeks 2 to 3 weeks

81. OSTEOMYELITIS IN LONG BONES
PATHOGENESIS
Osteomyelitis in long bones is a consequence of
hematogenous seeding,
exogenous contamination during trauma (open
fracture), or perioperative
contamination during orthopedic repairs.

82. FOOT OSTEOMYELITIS
PATHOGENESIS
Osteomyelitis of the foot usually occurs in patients with
diabetes,
peripheral arterial insufficiency, or peripheral neuropathy
and after
foot surgery. These entities are often linked to each
other, especially
in diabetic patients with late complications. However, foot
osteomyelitis
is also seen in patients with isolated peripheral
neuropathy and
can manifest as implant-associated osteomyelitis in
patients without
comorbidity due to a deep wound infection after foot

83. Neuropathic joint disease (Charcot foot) complicated
by chronic foot osteomyelitis in a 78-year old woman with
diabetes mellitus complicated by severe neuropathy.

84. Intraabdominal Infections and
Abscesses
Intraperitoneal infections generally arise because a normal anatomic
barrier is disrupted. This disruption may occur when the appendix, a
diverticulum, or an ulcer ruptures; when the bowel wall is weakened
by ischemia, tumor, or inflammation (e.g., in inflammatory bowel
disease); or with adjacent inflammatory processes, such as
pancreatitis or pelvic inflammatory disease, in which enzymes (in the
former case) or organisms (in the latter) may leak into the peritoneal
cavity. Whatever the inciting event, once inflammation develops and
organisms usually contained within the bowel or another organ enter
the normally sterile peritoneal space, a predictable series of events
takes place. Intraabdominal infections occur in two stages: peritonitis
and—if the patient survives this stage and goes untreated—abscess
formation. The types of microorganisms predominating in each stage
of infection are responsible for the pathogenesis of disease.

85. PERITONITIS
Peritonitis is a life-threatening event that is often accompanied by
bacteremia and sepsis syndrome. The peritoneal cavity is large but
is divided into compartments. The upper and lower peritoneal
cavities are divided by the transverse mesocolon; the greater
omentum extends from the transverse mesocolon and from the
lower pole of the stomach to line the lower peritoneal cavity. The
pancreas, duodenum, and ascending and descending colon are
located in the anterior retroperitoneal space; the kidneys, ureters,
and adrenals are found in the posterior retroperitoneal space. The
other organs, including liver, stomach, gallbladder, spleen, jejunum,
ileum, transverse and sigmoid colon, cecum, and appendix, are
within the peritoneal cavity. The cavity is lined with a serous
membrane that can serve as a conduit for fluids—a property
exploited in peritoneal dialysisA small amount of serous fluid is
normally present in the peritoneal space, with a protein content
(consisting mainly of albumin) of <30 g/L and <300 white blood cells
(WBCs, generally mononuclear cells) per microliter. In bacterial
infections, leukocyte recruitment into the infected peritoneal cavity
consists of an early influx of polymorphonuclear leukocytes (PMNs)
and a prolonged subsequent phase of mononuclear cell migration.
The phenotype of the infiltrating leukocytes during the course of
inflammation is regulated primarily by

86. PRIMARY (SPONTANEOUS) BACTERIAL PERITONITIS
Peritonitis is either primary (without an apparent source of
contamination)
or secondary. The types of organisms found and the clinical
presentations of these two processes are different. In adults,
primary
bacterial peritonitis (PBP) occurs most commonly in
conjunction with
cirrhosis of the liver (frequently the result of alcoholism).
However, the
disease has been reported in adults with metastatic
malignant disease,
postnecrotic cirrhosis, chronic active hepatitis, acute viral
hepatitis,
congestive heart failure, systemic lupus erythematosus, and
lymphedema

87. Pneumoperitoneum. Free air under the diaphragm
on an upright chest film suggests the presence of a bowel perforation
and associated peritonitis

88. SECONDARY PERITONITIS Secondary
peritonitis develops when bacteria
contaminate the peritoneum as a result of
spillage from an intraabdominal viscus. The
organisms found almost always constitute a
mixed flora in which facultative gram-negative
bacilli and anaerobes predominate, especially
when the contaminating source is colonic.

89. Treatment for PBP is directed at the isolate from blood or
peritoneal
fluid. Gram’s staining of peritoneal fluid often gives negative
results
in PBP. Therefore, until culture results become available,
therapy
should cover gram-negative aerobic bacilli and gram-positive
cocci.
Third-generation cephalosporins such as cefotaxime (2 g q8h,
administered IV) provide reasonable initial coverage in
moderately
ill patients. Broad-spectrum antibiotics, such as penicillin/
β-lactamase inhibitor combinations (e.g.,
piperacillin/tazobactam,
3.375 g q6h IV for adults with normal renal function) or
ceftriaxone

90. Treatment for secondary peritonitis includes early
administration of
antibiotics aimed particularly at aerobic gram-negative bacilli
and
anaerobes (see below). Mild to moderate disease can be
treated with
many drugs covering these organisms, including broad-
spectrum
penicillin/β-lactamase inhibitor combinations (e.g.,
ticarcillin/clavulanate,
3.1 g q4–6h IV), cefoxitin (2 g q4–6h IV), or a combination
of either a fluoroquinolone (e.g., levofloxacin, 750 mg q24h
IV) or
a third-generation cephalosporin (e.g., ceftriaxone, 2 g q24h

91. INTRAPERITONEAL ABSCESSES
Abscess formation is common in untreated
peritonitis if overt gramnegative
sepsis either does not develop or develops but is
not fatal. In
experimental models of abscess formation, mixed
aerobic and anaerobic
organisms have been implanted intraperitoneally.
Without therapy
directed at anaerobes, animals develop
intraabdominal abscesses

92. Clinical Presentation Of all intraabdominal abscesses, 74% are
intraperitoneal
or retroperitoneal and are not visceral. Most intraperitoneal
abscesses result from fecal spillage from a colonic source, such as
an
inflamed appendix. Abscesses can also arise from other
processes.
They usually form within weeks of the development of peritonitis
and
may be found in a variety of locations from omentum to mesentery,
pelvis to psoas muscles, and subphrenic space to a visceral organ
such
as the liver, where they may develop either on the surface of the
organ
or within it. Periappendiceal and diverticular abscesses occur
commonly.
Diverticular abscesses are least likely to rupture.

93. VISCERAL ABSCESSES
Liver Abscesses The liver is the organ most subject to
the development
of abscesses. In one study of 540 intraabdominal
abscesses, 26% were
visceral. Liver abscesses made up 13% of the total
number, or 48% of all
visceral abscesses. Liver abscesses may be solitary
or multiple; they may
arise from hematogenous spread of bacteria or from
local spread from
contiguous sites of infection within the peritoneal
cavity.

94. Fever is the most common presenting sign of liver abscess.
Some
patients, particularly those with associated disease of the biliary
tract,
have symptoms and signs localized to the right upper quadrant,
including pain, guarding, punch tenderness, and even rebound
tenderness.
Nonspecific symptoms, such as chills, anorexia, weight loss,
nausea,
and vomiting, may also develop. Only 50% of patients with liver
abscesses, however, have hepatomegaly, right-upper-quadrant
tenderness,
or jaundice; thus, one-half of patients have no symptoms or
signs
to direct attention to the liver.

95. Acute Infectious DiarrhealDiseases
and Bacterial Food Poisoning
INOCULUM SIZE The number of microorganisms that
must be ingested to cause disease varies
considerably from species to species. For Shigella,
enterohemorrhagic Escherichia coli, Giardia lamblia,
or Entamoeba, as few as 10–100 bacteria or cysts
can produce infection, while 105−108 Vibrio cholerae
organisms must be ingested to cause disease. The
infective dose of Salmonella varies widely, depending
on the species, host, and food vehicle. The ability of
organisms to overcome host defenses has important
implications for transmission; Shigella,
enterohemorrhagic E. coli, Entamoeba, and Giardia
can spread by person-to-person contact, whereas
under some circumstances Salmonella may have to
grow in food for several hours before reaching
an effective infectious dose.

96. ADHERENCE
Many organisms must adhere to the gastrointestinal mucosa as an initial
step in the pathogenic process; thus, organisms that can compete with
the normal bowel flora and colonize the mucosa have an important
advantage in causing disease. Specific cell-surface proteins involved
in attachment of bacteria to intestinal cells are important virulence
determinants. V. cholerae, for example, adheres to the brush border
of small-intestinal enterocytes via specific surface adhesins, including
the toxin-coregulated pilus and other accessory colonization factors.
Enterotoxigenic E. coli, which causes watery diarrhea, produces an
adherence protein called colonization factor antigen that is necessary for
colonization of the upper small intestine by the organism prior to the
production of enterotoxin. Enteropathogenic E. coli, an agent of diarrhea
in young children, and enterohemorrhagic E. coli, which causes
hemorrhagic colitis and the hemolytic-uremic syndrome, produce virulence
determinants that allow these organisms to attach to and efface the
brush border of the intestinal epithelium.

97. TOXIN PRODUCTIONThe production of one or
more exotoxins is important in the pathogenesis
of numerous enteric organisms. Such toxins
include enterotoxins, which cause watery
diarrhea by acting directly on secretory
mechanisms in the intestinal mucosa;
cytotoxins, which cause destruction of mucosal
cells and associated inflammatory diarrhea; and
neurotoxins, which act directly on the central or
peripheral nervous system.Neurotoxins are
usually produced by bacteria outside the host
and therefore cause symptoms soon after
ingestion. Included are the staphylococcal and
Bacillus cereus toxins, which act on the central

98. INVASION
Dysentery may result not only from the production of cytotoxins but
also from bacterial invasion and destruction of intestinal mucosal cells.
Infections due to Shigella and enteroinvasive E. coli are
characterized by the organisms’ invasion of mucosal epithelial cells,
intraepithelial multiplication, and subsequent spread to adjacent
cells. Salmonella causes inflammatory diarrhea by invasion of the
bowel mucosa but generally is not associated with the destruction
of enterocytes or the full clinical syndrome of dysentery. Salmonella
typhi and Yersinia enterocolitica can penetrate intact intestinal
mucosa, multiply intracellularly in Peyer’s patches and intestinal
lymph nodes, and then disseminate through the bloodstream to
cause enteric fever, a syndrome characterized by fever, headache,
relative bradycardia, abdominal pain, splenomegaly,and leukopenia.

99. HOST DEFENSESGiven the enormous number
of microorganisms ingested with every meal,
the normal host must combat a constant influx
of potential enteric pathogens. Studies of
infections in patients with alterations in
defense mechanisms have led to a greater
understanding of the variety of ways in which
the normal host can protect itself against
disease.

100. INTESTINAL MICROBIOTA
The large numbers of bacteria that normally inhabit
the intestine (the intestinal microbiota) act as an
important host defense mechanism, preventing
colonization by potential enteric pathogens. Persons
with fewer intestinal bacteria, such as infants who
have not yet developed normal enteric colonization
or patients receiving antibiotics, are at significantly
greater risk of developing infections with enteric
pathogens. The composition of the intestinal
microbiota is as important as the number of
organisms present. More than 99% of the normal
colonic microbiota is made up of anaerobic bacteria,
and the acidic pH and volatile fatty acids produced
by these organisms appear to be critical elements in
resistance

101. GASTRIC ACID The acidic pH of the stomach is
an important barrier to enteric pathogens, and
an increased frequency of infections due to
Salmonella, G. lamblia, and a variety of
helminths has been reported among patients
who have undergone gastric surgery or are
achlorhydric for some other reason.
Neutralization of gastric acid with antacids,
proton pump inhibitors, or H2 blockers—a
common practice in the management of
hospitalized patients—similarly increases the
risk of enteric colonization. In addition, some
microorganisms can survive the extreme acidity

102. INTESTINAL MOTILITY Normal peristalsis is the
major mechanism for clearance of bacteria from
the proximal small intestine. When intestinal
motility is impaired (e.g., by treatment with opiates
or other antimotility drugs, anatomic
abnormalities, or hypomotility states), the
frequency of bacterial overgrowth and infection of
the small bowel with enteric pathogens is
increased. Some patients whose treatment for
Shigella infection consists of diphenoxylate
hydrochloride with atropine (Lomotil) experience
prolonged fever and shedding of organisms, while
patients treated with opiates for mild Salmonella
gastroenteritis have a higher frequency of

103. IMMUNITY Both cellular immune responses and
antibody production play important roles in
protection from enteric infections. Humoral
immunity to enteric pathogens consists of
systemic IgG and IgM as well as secretory IgA.
The mucosal immune system may be the first
line of defense against many gastrointestinal
pathogens.

104. APPROACH TO THE PATIENT:
Infectious Diarrhea or Bacterial Food Poisoning
HISTORY
The answers to questions with high discriminating value can
quickly narrow the range of potential causes of diarrhea and help
determine whether treatment is needed.
PHYSICAL EXAMINATION
The examination of patients for signs of dehydration provides
essential information about the severity of the diarrheal illness and
the need for rapid therapy. Mild dehydration is indicated by thirst,
dry mouth, decreased axillary sweat, decreased urine output, and
slight weight loss. Signs of moderate dehydration include an orthostatic
fall in blood pressure, skin tenting, and sunken eyes (or, in
infants, a sunken fontanelle). Signs of severe dehydration include
lethargy, obtundation, feeble pulse, hypotension, and frank shock

105. Gastrointestinal Path ogens Causing Acute Diarrhea
Mechanism Location illness Stool
Findings
Examples of
Pathogens
Involved
Noninflammat
ory
(enterotoxin
Proximal
small
bowel
Watery
diarrhea
No fecal
leukocytes;
mild or
no increase in
fecal
lactoferrin
V.cholerae,
E.coliClostridi
um
perfringens,
Bacillus
cereus,S.
aureus
rotavirus,
norovirus
Cyclospora
spp.,
microsporidia

106. CONT…..
Inflammatory
(invasion or
cytotoxin
Colon or distal
small bowel
Dysentery or
inflammatory
diarrhea
Fecal
polymorphonu
clear
leukocytes;
substantial
increase in
fecal lactoferrin
Shigella spp.,
Salmonella spp.,
Campylobacter
jejuni,
enterohemorrhagi
c
E. coli,
enteroinvasive E.
coli, Yersinia
enterocolitica,
Listeria
monocytogenes,
Vibrio
parahaemolyticus,
Clostridium
difficile, A.
hydrophila, P.
shigelloides,
Entamoeba
histolytica,
Klebsiella oxytoca

107. CONT……
Penetrating Distal small
bowel
Enteric fever Fecal
mononuclear
leukocytes
Salmonella
typhi, Y.
enterocolitic
a

108. The mainstay of treatment is adequate rehydration. The
treatment
of cholera and other dehydrating diarrheal diseases was
revolutionized by the promotion of oral rehydration
solution (ORS),
the efficacy of which depends on the fact that glucose-
facilitated
absorption of sodium and water in the small intestine
remains
intact in the presence of cholera toxin.
Patients who are severely dehydrated or in
whom vomiting precludes the use of oral therapy should
receive IV
solutions such as Ringer’s lactate.

109. Clostridium difficile Infection, Including
Pseudomembranous Colitis
DEFINITION Clostridium difficile infection (CDI) is a
unique colonic disease that is acquired most often in
association with antimicrobial use and the consequent
disruption of the normal colonic microbiota. The most
commonly diagnosed diarrheal illness acquired in the
hospital, CDI results from the ingestion of spores of C.
difficile that vegetate, multiply, and secrete toxins,
causing diarrhea and pseudomembranous colitis (PMC)
in the most severe cases. Clindamycin, ampicillin, and
cephalosporins were the first antibiotics associated with
CDI. The second- and third-generation cephalosporins,
particularly cefotaxime, ceftriaxone, cefuroxime, and
ceftazidime, are frequently responsible for this
condition, and the fluoroquinolones (ciprofloxacin,
levofloxacin, and moxifloxacin) are the most recent drug
class to be implicated in hospital outbreaks.

110. Autopsy specimen showing confluent pseudomembranes
covering the cecum of a patient with pseudomembranous
colitis. Note the sparing of the terminal ileum (arrow).

111. PATHOLOGY AND PATHOGENESIS Spores of
toxigenic C. difficile are ingested, survive gastric
acidity, germinate in the small bowel, and colonize
the lower intestinal tract, where they elaborate two
large toxins: toxin A (an enterotoxin) and toxin B
(a cytotoxin). These toxins initiate processes
resulting in the disruption of epithelial-cell barrier
function, diarrhea, and pseudomembrane
formation. Toxin A is a potent neutrophil
chemoattractant, and both toxins glucosylate the
guanosine triphosphate (GTP)–binding proteins of
the Rho subfamily that regulate the actin cell
cytoskeleton.

112. CLINICAL MANIFESTATIONS
Diarrhea is the most common manifestation caused by C.
difficile.
Stools are almost never grossly bloody and range from soft and
unformed to watery or mucoid in consistency, with a
characteristic
odor. Patients may have as many as 20 bowel movements per
day. Clinical and laboratory findings include fever in 28% of
cases, abdominal
pain in 22%, and leukocytosis in 50%. When adynamic ileus
(which
is seen on x-ray in ~20% of cases) results in cessation of stool
passage,
the diagnosis of CDI is frequently overlooked.

113. DIAGNOSIS
The diagnosis of CDI is based on a combination
of clinical criteria:
(1) diarrhea (≥3 unformed stools per 24 h for ≥2
days) with no other
recognized cause plus (2) toxin A or B detected
in the stool, toxinproducing
C. difficile detected in the stool by PCR or
culture, or
pseudomembranes seen in the colon

114. TREATMENT Clostridium difficile
Infection
PRIMARY CDI
When possible, discontinuation of any ongoing antimicrobial
administration
is recommended as the first step in treatment of CDI. Earlier
studies indicated that 15–23% of patients respond to this
simple
measure. General treatment guidelines include hydration
and the avoidance of antiperistaltic agents and opiates,
which
may mask symptoms and possibly worsen disease.
Nevertheless,
antiperistaltic agents have been used safely with
vancomycin or
metronidazole for mild to moderate CDI.

115. Urinary Tract Infections,
Pyelonephritis, and Prostatitis
 was the first tolerable and effective agent for
the treatment of UTI.
 Since the most common manifestation of UTI
is acute cystitis and
 since acute cystitis is far more prevalent
among women than among
 men, most clinical research on UTI has
involved women.

116. UTI may be asymptomatic (subclinical infection) or symptomatic (disease). Thus,
the term urinary tract infection encompasses a variety of clinical entities,
including asymptomatic bacteriuria (ASB), cystitis, prostatitis, and pyelonephritis.
The distinction between symptomatic UTI and ASB has major clinical
implications. Both UTI and ASB connote the presence of bacteria in the urinary
tract, usually accompanied by white blood cells and inflammatory cytokines in
the urine. However, ASB occurs in the absence of symptoms attributable to the
bacteria in the urinary tract and does not usually require treatment, while UTI has
more typically been assumed to imply symptomatic disease that warrants
antimicrobial therapy. Much of the literature concerning UTI, particularly catheter-
associated infection, does not differentiate between UTI and ASB. In this
chapter, the term UTI denotes symptomatic disease; cystitis, symptomatic
infection of the bladder; and pyelonephritis, symptomatic infection of the kidneys.
Uncomplicated UTI refers to acute cystitis or pyelonephritis in nonpregnant
outpatient women without anatomic abnormalities or instrumentation of the
urinary tract; the term complicated UTI encompasses all other types of UTI.
Recurrent UTI is not necessarily complicated; individual episodes can be
uncomplicated and treated as such. Catheter-associated bacteriuria can be
either symptomatic (CAUTI) or asymptomatic.

117. EPIDEMIOLOGY AND RISK FACTORS Except among infants and
the elderly, UTI occurs far more commonly in females than in
males. During the neonatal period, the incidence of UTI is slightly
higher among males than among females because male infants
more commonly have congenital urinary tract anomalies. After 50
years of age, obstruction from prostatic hypertrophy becomes
common in men, and the incidence of UTI is almost as high among
men as among women. Between 1 year and ~50 years of age, UTI
and recurrent UTI are predominantly diseases of females. The
prevalence of ASB is ~5% among women between ages 20 and 40
and may be as high as 40–50% among elderly women and men. As
many as 50–80% of women in the general population acquire
atleast one UTI during their lifetime—uncomplicated cystitis in most
cases. Recent use of a diaphragm with spermicide, frequent sexual
intercourse, and a history of UTI are independent risk factors for
acute cystitis. Cystitis is temporally related to recent sexual
intercourse in a dose-response manner, with an increased relative
risk ranging from 1.4 with one episode of intercourse to 4.8 with five
episodes of intercourse in the preceding week. In healthy
postmenopausal women, sexualactivity, diabetes mellitus, and
incontinence are risk factors for UTI.

118. Cont….
Many factors predisposing women to cystitis also increase
the risk of pyelonephritis. Factors independently
associated with pyelonephritis in young healthy women
include frequent sexual intercourse, a new sexual partner,
a UTI in the previous 12 months, a maternal history of
UTI, diabetes, and incontinence. The common risk factors
for cystitis and pyelonephritis are not surprising given that
pyelonephritis typically arises through the ascent of
bacteria from the bladder to the upper urinary tract.
However, pyelonephritis can occur without clear
antecedent cystitis. The majority of men with UTI have a
functional or anatomic abnormality of the urinary tract,
most commonly urinary obstruction secondary to prostatic
hypertrophy. That said, not all men with UTI have
detectable urinary abnormalities; this point is particularly
relevant for men ≤45 years of age. Lack of circumcision is
also associated with an increased risk of UTI because
Escherichia coli is more likely to colonize the glans and
prepuce and subsequently migrate into the urinary tract.

119. ETIOLOGY The uropathogens causing UTI vary by clinical
syndrome but are usually enteric gram-negative rods that
have migrated to the urinary tract. The susceptibility patterns
of these organisms vary by clinical syndrome and by
geography. the etiologic agents are highly predictable: E. coli
accounts for 75–90% of isolates; Staphylococcus
saprophyticus for 5–15% (with particularly frequent isolation
from younger women); and Klebsiella, Proteus, Enterococcus,
and Citrobacter species, along with other organisms, for 5–
10%. but other aerobic gram-negative rods, such as
Pseudomonasaeruginosa and Klebsiella, Proteus, Citrobacter,
Acinetobacter, and Morganella species, also are frequently
isolated. Gram-positive bacteria (e.g., enterococci and
Staphylococcus aureus) and yeasts are also important
pathogens in complicated UTI.

120. PATHOGENESIS
The urinary tract can be viewed as an anatomic unit united by a continuous
column of urine extending from the urethra to the kidneys. In the majority of
UTIs, bacteria establish infection by ascending from the urethra to the
bladder. Continuing ascent up the ureter to the kidney is the pathway for
most renal parenchymal infections. However, introduction of bacteria into
the bladder does not inevitably lead to sustained and symptomatic
infection. The interplay of host, pathogen, and environmental factors
determines whether tissue invasion and symptomatic infection will ensue.
For example, bacteria often enter the bladder after sexual intercourse, but
normal voiding and innate host defense mechanisms in the bladder
eliminate these organisms. Any foreign body in the urinary tract, such as a
urinary catheter or stone, provides an inert surface for bacterial
colonization. Abnormal micturition and/or significant residual urine volume
promotes true infection. In the simplest of terms, anything that increases
the likelihood of bacteria entering the bladder and staying there increases
the risk of UTI.

121. APPROACH TO THE PATIENT:
Clinical Syndromes
The most important issue to be addressed when a UTI is
suspected is the characterization of the clinical syndrome as
ASB, uncomplicated cystitis, pyelonephritis, prostatitis, or
complicated UTI. This information will shape the diagnostic and
therapeutic approach.
Asymptomatic Bacteriuria A diagnosis of ASB can be considered
only when the patient does not have local or systemic
symptoms referable to the urinary tract. The clinical
presentation is usually that of a patient who undergoes a
screening urine culture for a reason unrelated to the
genitourinary tract and is incidentally found to have bacteriuria.
Cystitis The typical symptoms of cystitis are dysuria, urinary
frequency, and urgency. Nocturia, hesitancy, suprapubic
discomfort, and gross hematuria are often noted as well.
Unilateral back or flank pain is generally an indication that the
upper urinary tract is involved. Fever also is an indication of
invasive infection of either the kidney
or the prostate.

122. Cont…..
Pyelonephritis
Mild pyelonephritis can present as low-grade
fever with or without
lower-back or costovertebral-angle pain, whereas
severe pyelonephritis
can manifest as high fever, rigors, nausea,
vomiting, and
flank and/or loin pain. Symptoms are generally
acute in onset, and
symptoms of cystitis may not be present. Fever
is the main feature
distinguishing cystitis and pyelonephritis.

123. Cont…..
Prostatitis
Prostatitis includes both infectious and noninfectious abnormalities
of the prostate gland. Infections can be acute or chronic, are
almost always bacterial in nature, and are far less common than
the noninfectious entity chronic pelvic pain syndrome (formerly
known as chronic prostatitis). Acute bacterial prostatitis presents as
dysuria, frequency, and pain in the prostatic pelvic or perineal area.
Fever and chills are usually present, and symptoms of bladder outlet
obstruction are common
Complicated UTI
Complicated UTI presents as a symptomatic episode of cystitis or
pyelonephritis in a man or woman with an anatomic predisposition
to infection, with a foreign body in the urinary tract, or with factors
predisposing to a delayed response to therapy

124. DIAGNOSTIC TOOLS History The diagnosis of any of the UTI syndromes
or ASB begins with a detailed history. The history given by the patient.
has a high predictive value in uncomplicated cystitis. A meta-analysis
evaluating the probability of acute UTI on the basis of history and
physical findings concluded that, in women presenting with at least one
symptom of UTI (dysuria, frequency, hematuria, or back pain) and
without complicating factors, the probability of acute cystitis or
pyelonephritis is 50%. If vaginal discharge and complicating factors are
absent and risk factors for UTI are present, then the probability of UTI is
close to 90%, and no laboratory evaluation is needed. Similarly, a
combination of dysuria and urinary frequency in the absence of vaginal
discharge increases the probability of UTI to 96%. Further laboratory
evaluation with dipstick testing or urine culture is not necessary in such
patients before the initiation of definitive therapy.

125. The Urine Dipstick Test, Urinalysis, and Urine Culture Useful
diagnostic
tools include the urine dipstick test and urinalysis, both of
which provide point-of-care information, and the urine
culture, which can retrospectively confirm a prior
diagnosis. Understanding the parameters of the dipstick
test is important in interpreting its results. Only members
of the family Enterobacteriaceae convert nitrate to nitrite,
and enough nitrite must accumulate in the urine to reach
the threshold of detection. If a woman with acute cystitis is
forcing fluids and voiding frequently, the dipstick test for
nitrite is less likely to be positive, even when E. coli is
present. The leukocyte esterase test detects this enzyme
in the host’s polymorphonuclear leukocytes in the urine,
whether the cells are intact or lysed. Many reviews have
attempted to describe the diagnostic accuracy of dipstick
testing. The bottom line for clinicians is that a urine
dipstick test can confirm the diagnosis of
uncomplicatedcystitis in a patient with a reasonably high

126. Cont…
The detection of bacteria in a urine culture is the
diagnostic “gold
standard” for UTI; unfortunately, however, culture
results do not
become available until 24 h after the patient’s
presentation. Identifying
specific organism(s) can require an additional 24
h.

127.  Pharmacological Treatment Acute
pyelonephritis A: Ciprofloxacin 500 mg (PO)
12 hourly for 7 days
 Uncomplicated cystitis Adults: A: Ciprofloxacin
500 mg (PO) as single dose Complicated
cystitis Adults: A: Ciprofloxacin 500 mg (PO)
12 hourly for 7 days For pregnant women and
adolescents: C: Amoxicillin/clavulanic acid
500/125 mg (PO) 12 hourly for 7 days

128. Sexually Transmitted Infections:
Worldwide, most adults acquire at least one sexually
transmitted infection (STI), and many remain at risk
for complications. Certain STIs, such as syphilis,
gonorrhea, HIV infection, hepatitis B, and chancroid,
are most concentrated within “core populations”
characterized by high rates of partner change,
multiple concurrent partners, or “dense,” highly
connected sexual networks—e.g., involving sex
workers and their clients, some men who have sex
with men (MSM), and persons involved in the use of
illicit drugs, particularly crack cocaine and
methamphetamine. Other STIs are distributed more
evenly throughout societies. For example, chlamydial
infections, genital infections with HPV, and genital
herpes can spread widely, even in relatively low-risk

129. URETHRITIS IN MEN Urethritis in men produces urethral discharge,
dysuria, or both, usually without frequency of urination. Causes
include Neisseria gonorrhoeae, C. trachomatis, Mycoplasma
genitalium, Ureaplasma urealyticum, Trichomonas vaginalis, HSV,
and adenovirus.
EPIDIDYMITIS Acute epididymitis, almost always unilateral, produces
pain, swelling, and tenderness of the epididymis, with or without
symptoms or signs of urethritis. This condition must be
differentiated from testicular torsion, tumor, and trauma. Torsion, a
surgical emergency, usually occurs in the second or third decade of
life and produces a sudden onset of pain.
URETHRITIS AND THE URETHRAL SYNDROME IN WOMEN C.
trachomatis, N. gonorrhoeae, and occasionally HSV cause
symptomatic urethritis—known as the urethral syndrome in
women—that is characterized by “internal” dysuria (usually without
urinary urgency or frequency), pyuria, and an absence of
Escherichia coli and other uropathogens at counts of ≥102/mL in
urine. In contrast, the dysuria associated with vulvar herpes or
vulvovaginal candidiasis (and perhaps with trichomoniasis) is often
described as “external,” being caused by painful contact of urine
with the inflamed or ulcerated labia orintroitus.

130. VULVOVAGINAL INFECTIONS Abnormal Vaginal Discharge If
directly questioned about vaginal discharge during routine
health checkups, many women acknowledge having nonspecific
symptoms of vaginal discharge that do not correlate with
objective signs of inflammation or with actual infection.
However, unsolicited reporting of abnormal vaginal discharge
does suggest bacterial vaginosis or trichomoniasis. Specifically,
an abnormally increased amount or an abnormal odor of the
discharge is associated with one or both of these conditions.
Cervical infection with N. gonorrhoeae or C. trachomatis does
not often cause an increased amount or abnormal odor of
discharge; however, when these pathogens cause cervicitis,
they—like T. vaginalis—often result in an increased number of
neutrophils in vaginal fluid, which thus takes on a yellow color.
Vulvar conditions such as genital herpes or vulvovaginal
candidiasis can cause vulvar pruritus, burning, irritation, or
lesions as well as external dysuria (as urine passes over the
inflamed vulva or areas of epithelial disruption) or vulvar
dyspareunia.

131. Diagnostic Feat ures and Management of Va ginal Infecti on
Feature Normal Vaginal
Examination
Vulvovaginal
Candidiasis
Trichomonal
Vaginitis
Bacterial
Vaginosis
Etiology
Typical
symptoms
Discharge
Amount
Color
pH of vaginal
fluid
Usual treatment
Uninfected;
lactobacilli
Predominant
None
Variable;
usually scant
Clear or
translucentUsu
ally ≤4.5
Candida
albicans
Vulvar itching
and/or
Irritation
Scant
White
Usually ≤4.5
Azole cream,
clotrimazole
(100-mg vaginal
tablet) once
daily for 7 days
Trichomonas
vaginalis
Profuse
discharge;
vulvar
Itching
Often profuse
White oyellow
Usually ≤5
Metronidazole
or tinidazole,
2 g orally
(single dose
Gardnerella
Vaginalis
Malodorous,
slightly
increased
Discharge
Moderate
White or gray
Usually >4.5
Metronidazole, 500
mg PO bid
for 7
daysClindamycin, 2%
cream, one
full applicator

132. Meningitis, Encephalitis, Brain
Abscess, and Empyema
Acute infections of the nervous system are among the
most important problems in medicine because early
recognition, efficient decision making, and rapid
institution of therapy can be lifesaving. These distinct
clinical syndromes include acute bacterial meningitis,
viral meningitis, encephalitis, focal infections such as
brain abscess and subdural empyema, and infectious
thrombophlebitis. Each may present with a nonspecific
prodrome of fever and headache, which in a previously
healthy individual may initially be thought to be benign,
until (with the exception of viral meningitis) altered
consciousness, focal neurologic signs, or seizures
appear. Key goals of early management are to
emergently distinguish between these conditions,
identify the responsible pathogen, and initiate

133. ACUTE BACTERIAL
MENINGITIS
DEFINITION Bacterial meningitis is an acute
purulent infection within the subarachnoid
space. It is associated with a CNS
inflammatory reaction that may result in
decreased consciousness, seizures, raised
intracranial pressure (ICP), and stroke. The
meninges, subarachnoid space, and brain
parenchyma are all frequently involved in the
inflammatory reaction (meningoencephalitis).

134. ETIOLOGY S. pneumoniae (is the most common
cause of meningitis in adults >20 years of age,
accounting for nearly half the reported cases (1.1
per 100,000 persons per year). There are a number
of predisposing conditions that increase the risk of
pneumococcal meningitis, the most important of
which is pneumococcal pneumonia, Staphylococcus
aureus, Haemophilus sp., and Enterobacteriaceae.
Meningitis complicating endocarditis may be due to
viridans streptococci, S. aureus, Streptococcus
bovis, the HACEK group (Haemophilus sp.,
Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella corrodens,
Kingella kingae), or enterococci.

135. Cont….
L. monocytogenes (is an increasingly important cause
of meningitis in neonates (<1 month of age),
pregnant women, individuals >60 years, and
immunocompromised individuals of all ages.
Infection is acquired by ingesting foods
contaminated by Listeria. Foodborne human listerial
infection has been reported from contaminated
coleslaw, milk, soft cheeses, and several types of
“ready-to-eat” foods, including delicatessen meat
and uncooked hotdogs. The frequency of H.
influenzae type b (Hib) meningitis in children has
declined dramatically since the introduction of the
Hib conjugate vaccine, although rare cases of Hib
meningitis in vaccinated children have been
reported. More frequently, H. influenzae causes
meningitis in unvaccinated children and older adults,

136. PATHOPHYSIOLOGY bacteria initially colonize the
nasopharynx by attaching to nasopharyngeal
epithelial cells. Bacteria are transported across
epithelial cells in membrane-bound vacuoles to the
intravascular space or invade the intravascular space
by creating separations in the apical tight junctions of
columnar epithelial cells. Bloodborne bacteria can
reach the intraventricular choroid plexus, directly
infect choroid plexus epithelial cells, and gain access
to the CSF. A critical event in the pathogenesis of
bacterial meningitis is the inflammatory reaction
induced by the invading bacteria. Many of the
neurologic manifestations and complications of
bacterial meningitis result from the immune response
to the invading pathogen rather than from direct
bacteriainduced tissue injury. As a result, neurologic
injury can progress even after the CSF has been
sterilized by antibiotic therapy. and complications of
bacterial meningitis result from the immune response
to the invading pathogen rather than from direct

137. CLINICAL PRESENTATION
The classic clinical triad of meningitis is fever, headache, and nuchal rigidity,
but the classic triad may not be present. A decreased level of consciousness
occurs in >75% of patients and can vary from lethargy to coma. Fever and
either headache, stiff neck, or an altered level of consciousness will be
present in nearly every patient with bacterial meningitis. Nausea, vomiting,
and photophobia are also common complaints. The classic clinical triad of
meningitis is fever, headache, and nuchal rigidity, but the classic triad may
not be present. A decreased level of consciousness occurs in >75% of
patients and can vary from lethargy to coma. Fever and either headache, stiff
neck, or an altered level of consciousness will be present in nearly every
patient with bacterial meningitis. Nausea, vomiting, and photophobia are also
common complaints. Focal seizures are usually due to focal arterial ischemia
or infarction, cortical venous thrombosis with hemorrhage, or focal edema.
Generalized seizure activity and status epilepticus may be due to
hyponatremia, cerebral anoxia, or, less commonly, the toxic effects of
antimicrobial agents. Signs of increased ICP include a deteriorating or
reduced level of consciousness, papilledema, dilated poorly reactive pupils,
sixth nerve palsies, decerebrate posturing, and the Cushing reflex
(bradycardia, hypertension, and irregular respirations). The most disastrous
complication of increased ICP is cerebral herniation. The incidence of
herniation in patients with bacterial meningitis has been reported to occur in
as few as 1% to as many as 8% of cases.

138. Cont,….
Specific clinical features may provide clues to the
diagnosis of individual
organisms and are discussed in more detail in specific
chapters
devoted to individual pathogens. The most important
of these clues is
the rash of meningococcemia, which begins as a
diffuse erythematous
maculopapular rash resembling a viral exanthem;
however, the skin
lesions of meningococcemia rapidly become
petechial. Petechiae are
found on the trunk and lower extremities, in the
mucous membranes
and conjunctiva, and occasionally on the palms and
soles.

139. DIAGNOSIS When bacterial meningitis is suspected,
blood cultures should be immediately obtained and
empirical antimicrobial and adjunctive
dexamethasone therapy initiated without delay
The diagnosis of bacterial meningitis is made by
examination of the CSF, The classic CSF
abnormalities in bacterial meningitis (Table 164-2)
are (1) polymorphonuclear (PMN) leukocytosis
(>100 cells/μL in 90%), (2) decreased glucose
concentration (<2.2 mmol/L [<40 mg/dL] and/ or
CSF/serum glucose ratio of <0.4 in ~60%), (3)
increased protein concentration (>0.45 g/L [>45
mg/dL] in 90%), and (4) increased opening
pressure (>180 mmH2O in 90%). CSF bacterial
cultures are positive in >80% of patients, and CSF
Gram’s stain demonstrates organisms in >60%.

140. DIFFERENTIAL DIAGNOSIS Viral meningoencephalitis,
and particularly herpes simplex virus (HSV) encephalitis,
can mimic the clinical presentation of bacterial
Meningitis. The typical CSF profile with viral CNS
infections is a lymphocytic pleocytosis with a normal
glucose concentration, in contrast to the PMN
pleocytosis and hypoglycorrhachia characteristic of
bacterial meningitis. The typical CSF profile with viral
CNS infections is a lymphocytic pleocytosis with a
normal glucose concentration, in contrast to the PMN
pleocytosis and hypoglycorrhachia characteristic of
bacterial meningitis. The disease may present acutely
with high fever, prostration, myalgia, headache, nausea,
and vomiting. Most patients develop a characteristic rash
within 96 h of the onset of symptoms. The rash is initially
a diffuse erythematous maculopapular rash that may be

141. CONT…..
Focal suppurative CNS infections (see below), including
subdural and epidural empyema and brain abscess, should
also be considered, especially when focal neurologic
findings are present. MRI should be performed promptly in
all patients with suspected meningitis who have focal
features, both to detect the intracranial infection and to
search for associated areas of infection in the sinuses or
mastoid bones. A number of noninfectious CNS disorders
can mimic bacterial meningitis. Subarachnoid hemorrhage
(SAH; the major consideration. Other possibilities include
chemical meningitis due to rupture of tumor contents into
the CSF (e.g., from a cystic glioma or craniopharyngioma
epidermoid or dermoid cyst); druginduced hypersensitivity
meningitis; carcinomatous or lymphomatous meningitis;
meningitis associated with inflammatory disorders such as
sarcoid, systemic lupus erythematosus (SLE), and Behcet’s
syndrome; pituitary apoplexy; and uveomeningitic
syndromes (Vogt-Koyanagi- Harada syndrome). On
occasion, subacutely evolving meningitisThe principal

142. TREATMENT Acute Bacterial
Meningitis
 Pharmacological Treatment I. Where the
organism is not known: Adults: B:
Chloramphenicol 1000mg IV 6 hourly for 14
days Plus A: Benzyl penicillin 5MU IV 6 hourly
for 14 days. OR A: Ceftriaxone IV 2 g 12
hourly for 14 days
 Supportive therapy Control of fever and
pain(refer fever and pain section) Control
convulsions( see section convulsions) If
unconscious, insert NGT for feeding and
urethral catheter

143.  Where the organism is known: Meningococcal
meningitis Adults & children >2yrs A: Ceftriaxone IM
100mg/kg as a single dose (divide into 2 injections if
needed & inject half-dose in each buttock)
 Haemophilus influenza meningitis Adults A:
Ceftriaxone IV 2g 12 hourly for 14 days OR
D:Cefotaxime 2g IV 6 hourly for 10 days OR B:
Chloramphenicol 1g IV 6 hourly for 7–10 days
 Children C: Ampicillin 50–100 mg/kg 6 hourly for 10
days OR B: Chloramphenicol 50 mg/kg 6 hourly for
10 days
 Pneumococcal meningitis A: Benzyl penicillin 5MU
IV 6 hourly for 14 days OR B: Ceftriaxone IV 2 g 12
hourly for 14 days OR D: Ceftriaxone + Salbactam
(IV) 1.5mg twice daily for 14 days OR D: Cefotaxime
2g IV 6 hourly for 10 days

144. PROGNOSIS Mortality rate is 3–7% for meningitis caused by
H. influenzae, N. meningitidis, or group B streptococci;
15% for that due to L. monocytogenes; and 20% for S.
pneumoniae. In general, the risk of death from bacterial
meningitis increases with (1) decreased level of
consciousness on admission, (2) onset of seizures within
24 h of admission, (3) signs of increased ICP, (4) young
age (infancy) and age >50, (5) the presence of comorbid
conditions including shock and/or the need for mechanical
ventilation, and (6) delay in the initiation of treatment.
Decreased CSF glucose concentration (<2.2 mmol/L [<40
mg/dL]) and markedly increased CSF protein concentration
(>3 g/L [> 300 mg/dL]) have been predictive of increased
mortality and poorer outcomes in some series. Moderate or
severe sequelae occur in ~25% of survivors, although the
exact incidence varies with the infecting organism.
Common sequelae include decreased intellectual function,
memory impairment, seizures, hearing loss and dizziness,
and gait disturbances.

145. VIRAL ENCEPHALITIS
DEFINITION
In contrast to viral meningitis, where the infectious
process and associated
inflammatory response are limited largely to the
meninges, in
encephalitis the brain parenchyma is also involved.
Many patients with
encephalitis also have evidence of associated
meningitis (meningoencephalitis)

146. CLINICAL MANIFESTATIONS In addition to the acute febrile
illness with evidence of meningealinvolvement
characteristic of meningitis, the patient with encephalitis
commonly has an altered level of consciousness
(confusion, behavioral abnormalities), or a depressed level
of consciousness ranging from mild lethargy to coma, and
evidence of either focal or diffuse neurologic signs and
symptoms. Patients with encephalitis may have
hallucinations, agitation, personality change, behavioral
disorders, and, at times, a frankly psychotic state. Focal or
generalized seizures occur in many patients with
encephalitis. The most commonly encountered focal
findings are aphasia, ataxia, upper or lower motor neuron
patterns of weakness, involuntary movements (e.g.,
myoclonic jerks, tremor), and cranial nerve deficits (e.g.,
ocular palsies, facial weakness). Involvement of the
hypothalamicpituitary axis may result in temperature
dysregulation, diabetes insipidus, or the development of
the syndrome of inappropriate secretionof antidiuretic
hormone (SIADH).

147.  ETIOLOGYThe most
 commonly identified viruses causing sporadic
cases of acute encephalitis
 in immunocompetent adults are herpesviruses
(HSV, VZV, EBV).
 Epidemics of encephalitis are caused by
arboviruses

148. LABORATORY DIAGNOSIS CSF Examination CSF
examination should be performed in all patients with
suspected viral encephalitis unless contraindicated by
the presenceof severely increased ICP. The
characteristic CSF profile is indistinguishable from
that of viral meningitis and typically consists of a
lymphocytic pleocytosis, a mildly elevated protein
concentration, and a normal glucose concentration. A
CSF pleocytosis (>5 cells/μL) occurs in >95% of
immunocompetent patients with documented viral
encephalitis. MRI, CT, and EEG Patients with
suspected encephalitis almost invariably undergo
neuroimaging studies and often EEG. These tests
help identify or exclude alternative diagnoses and
assist in the differentiation between a focal, as
opposed to a diffuse, encephalitic process. Focal
findings in a patient with encephalitis should always
raise the possibility

149.  CSF PCRCSF PCR has become the primary
diagnostic test for CNS infections
 caused by CMV, EBV, HHV-6, and
enteroviruses
 Serologic Studies and Antigen Detection
 MRI, CT, and EEG
 Brain Biopsy

150. TREATMENT Viral Encephalitis
 Supportive Therapy Manage it as for
unconscious patients (control seizures)
 Pharmacological Treatment B: Acyclovir
IV/Oral (10–15 mg/kg every 8 hourly for 14–21
days
 Basic management and supportive therapy
should include
 careful monitoring of ICP, fluid restriction,
avoidance of hypotonic
 intravenous solutions, and suppression of
fever

151. SUBACUTE MENINGITIS
CLINICAL MANIFESTATIONS
Patients with subacute meningitis typically have an
unrelenting headache, stiff neck, low-grade fever, and
lethargy for days to several weeks before they present
for evaluation. Cranial nerve abnormalities and night
sweats may be present
ETIOLOGY Common causative organisms include M.
tuberculosis, C. neoformans, H. capsulatum, C. immitis,
and T. pallidum. Initial infection with M. tuberculosis is
acquired by inhalation of aerosolized droplet nuclei.
Tuberculous meningitis in adults does not develop
acutely from hematogenous spread of tubercle bacilli to
the meninges. Rather, millet seed–sized (miliary)
tubercles form in the parenchyma of the brain during

152. CONT….
Fungal infections are typically acquired by the
inhalation of airborne fungal spores. The initial
pulmonary infection may be asymptomatic or
present with fever, cough, sputum production, and
chest pain. The pulmonary infection is often self-
limited. A localized pulmonary fungal infection can
then remain dormant in the lungs until there is an
abnormality in cell-mediated immunity that allows
the fungus to reactivate and disseminate to the
CNS. The most common pathogen causing fungal
meningitis is C. neoformans. This fungus is found
worldwide in soil and bird excreta. Syphilis is a
sexually transmitted disease that is manifest by the
appearance of a painless chancre at the site of
inoculation. T. pallidum invades the CNS early in

153. LABORATORY DIAGNOSIS The classic CSF
abnormalities in tuberculous meningitis are as follows: (1)
elevated opening pressure, (2) lymphocytic pleocytosis
(10–500 cells/μL), (3) elevated protein concentration in
the range of 1–5 g/L, and (4) decreased glucose
concentration in the range of 1.1–2.2 mmol/L (20–40
mg/dL). The combination of unrelenting headache, stiff
neck, fatigue, night sweats, and fever with a CSF
lymphocytic pleocytosis and a mildly decreased glucose
concentration is highly suspicious for tuberculous
meningitis. The last tube of fluid collected at LP is the
best tube to send for a smear for acid-fast bacilli (AFB).
PCR for the detection of M. tuberculosis DNA should be
sent on CSF if availablediagnosis of pulmonary
tuberculosis. The characteristic CSF abnormalities in
fungal meningitis are a mononuclear or lymphocytic
pleocytosis, an increased protein concentration, and a
decreased glucose concentration. There may be
eosinophils in the CSF in C. immitis meningitis. Large
volumes of CSF are often required to demonstrate the

154. TREATMENT Subacute
MeningitisInitial therapy is a combination of isoniazid (300 mg/d),
rifampin (10 mg/kg per day), pyrazinamide (30 mg/kg per day in
divided doses), ethambutol (15–25 mg/kg per day in divided
doses), and pyridoxine (50 mg/d). Dexamethasone therapy is
recommended for HIV-negative patients
with tuberculous meningitis. The dose is 12–16 mg/d for 3 weeks,
and then tapered over 3 weeks. Meningitis due to C. neoformans in
non-HIV, nontransplant
patients is treated with induction therapy with amphotericin B
(AmB) (0.7 mg/kg IV per day) plus flucytosine (100 mg/kg per day
in four divided doses) for at least 4 weeks. Patients with HIV
infection are treated with AmB or a lipid formulation
plus flucytosine for at least 2 weeks, followed by fluconazole
for a minimum of 8 weeks. Syphilitic meningitis is treated with
aqueous penicillin G in a
dose of 3–4 million units intravenously every 4 h for 10–14 days

155. BRAIN ABSCESS DEFINITION A brain abscess is
a focal, suppurative infection within the brain
parenchyma, typically surrounded by a
vascularized capsule.
ETIOLOGY A brain abscess may develop (1) by
direct spread from a contiguous cranial site of
infection, such as paranasal sinusitis, otitis media,
mastoiditis, or dental infection; (2) following head
trauma or a neurosurgical procedure; or (3) as a
result of hematogenous spread from a remote site
of infection. In up to 25% of cases, no obvious
primary source of infection is apparent
(cryptogenic brain abscess). Approximately one-
third of brain abscesses are associated with otitis

156. PATHOGENESIS AND HISTOPATHOLOGY
Results of experimental models of brain abscess
formation suggest that
for bacterial invasion of brain parenchyma to occur,
there must be
preexisting or concomitant areas of ischemia,
necrosis, or hypoxemia
in brain tissue. The intact brain parenchyma is
relatively resistant
to infection. Once bacteria have established
infection, brain abscess
frequently evolves through a series of stages,
influenced by the nature
of the infecting organism and by the

157. DIAGNOSIS
Diagnosis is made by neuroimaging studies. MRI
better than CT for demonstrating abscesses in the
early (cerebritis)
stages and is superior to CT for identifying
abscesses in the posterior
fossa. Cerebritis appears on MRI as an area of low-
signal intensity
on T1-weighted images with irregular
postgadolinium enhancement
and as an area of increased signal intensity on T2-
weighted images.

158. Pneumococcal brain abscess. Note that the abscess wall has hyperintense signal on the axial
T1-weighted magnetic resonance
imaging (MRI) (A, black arrow), hypointense signal on the axial proton density images (B, black
arrow), and enhances prominently after gadolinium
administration on the coronal T1-weighted image (C). The abscess is surrounded by a large
amount of vasogenic edema and has a small
“daughter” abscess (C, white arrow). (Courtesy of Joseph Lurito, MD; with permission.)

159. TREATMENT Brain Abscess
 Optimal therapy of brain abscesses involves a
combination of highdose
 parenteral antibiotics and neurosurgical
drainage. Empirical
 therapy of community-acquired brain abscess
in an immunocompetent
 patient typically includes a third- or fourth-
generation
 cephalosporin (e.g., cefotaxime, ceftriaxone, or
cefepime) and metronidazole

160. Humanity has but three great enemies: Fever,famine, and war; of
these by far the greatest,by far the most terrible, is fever.
—William Osler