Infections of the compromisedhostYear 3 Semester 22007/08 BatchFaculty of MedicineUniversity of PeradeniyaSri Lanka
Following topics will be discussed. 1. Chronic diarrhoea in post transplanted patient 2. Haemorrhagic Chicken Pox 3. Sepsis in a baby born to a mother with PROM 4. HIV/Leishmaniasis co-infection 5. HIV-AIDS associated opportunistic infections of the respiratory system 6. Post oesophagectomy patient developing fever on 3rd day post operative in ICU 7. A patient with a history of mitral valve replacement developing fever after 7 months of surgery. 8. A paraplegic patient on long term indwelling catheter 9. Non healing foot ulcer in diabetic patient
Breached defenses Reasons for breach• Innate immunity- breach • IV Drug abuse in the skin • Blood transfusion• Adaptive immunity- • Sexual transmission ? breach in CMI4.HIV/Leishmaniasis co-infection Mechanism of breach HIV Leishmaniasis • • CD4+ T cell loss T cell depletion n Co - infection • Further reduction in T cell count • Increase viral replication by parasites AIDS
• ELISA for Anti HIV Ab For HIV • Western blot (serum) Diagnosis • PCR – Viral RNA • Microscopy (blood & BM) For Leishmaniasis • Immunochromotographic test • Anti-leishmanial drugs: Amphotericin B Na antimonyManagement oral Miltefosine • HIV drugs : HAART • Prevention of IV drug abusePrevention • Safe blood transfusion • Control of parasites
5.HIV-AIDS associated opportunistic infections of the respiratory system.Infectious Diseases Bacterial pneumonia,Pneumocystis jiroveci pneumonia,Other fungal pneumonia,Mycobacterium tuberculosis need for prompt treatment.History & Examination geographic location BACTERIAL MYCOBACTERI FUNGAL VIRAL/ AL PARASITCImmunology Pneumocystis Streptococcus Mycobacterium Cytomegalovir CD4+ cell count pneumoniae tuberculosis jirovecii s Haemophilus MycobacteriumLaboratory Tests species kansasii White blood cell count, Pseudomonas Mycobacterium Histoplasma Serum lactate dehydrogenase,aeruginosa avium complex capsulatum Arterial blood gas Staphylococcus Coccidioides aureus immitisChest Radiograph/CT/MRI Aspergillus Klebsiella speciesBronchoscopy pneumoniae (esp. fumigatus
Serology orPulmonary Pleural Important Blood Sputum BAL Disease Fluid Other Sites Cultures HIV-associated neoplasms or other disorders. Finally, HIV-infected persons may have preexisting pulmonary disease (e.g., asthma), pulmonary disease unrelated to their HIV infection (e.g., pulmonary embolism) may develop and be the cause of their symptoms.
6.Post oesophagectomy patient developing fever on 3rd day post operative in ICUCommon Breech oforganisms defenceGram –ve Breech of Common •Mucociliar bacilli y defence organismsGram +ve escalator, cocci •reflux Normal skin flora closure ofS. aureus glottis ET tube/ CVP •Coagulase -veFungi •CMI & HI ventilator line skin staphylococcusViral s •Candida Cannula •S. aureus•E.coli including MRSA•Candidaspp. • damage•Klebsiella to mucosa, Normal skin•Pseudomon •Flushing floraas spp. mechanis Urinary Surgica •S. Aureus m•Enterobacter •Direct cathete l skin •C. Diphtheriaespp. access to r incision •Candida•Citerobacter bladder site •Cryptococcus•Proteus Gut flora •anerobes
Specimens Management 1. Hx & clinical examination1. Blood for culture and ABST2. Urine for culture and ABST 2. Fever chart maintanance3. CVP line tip culture 3. Investigate for aetiological4. Sputum –if difficult to agents & manage accordingly. obtain,transtrachial aspirate & bronchoscopic biopsy Wound infection – proper wound5. Incision site pus for culture cleaning & proper antibiotics6. Drain fluid UTI - remove catheter do not catheterised unless essential aseptic procedures Prevention antibiotic only on evidence of 1. Aseptic surgical procedures infection 2. Minimise drains,catheters & Respiratory tract infection IV lines post operatively Proper antibiotic usage and 3. Avoid pre-operative chest antibiotics, physiotherapy 4. Give peri operative AB s CVP line and Cannula site 5. Minimize pre-op infection hospitalization 6. Eliminate nasal colonization of S. Aureus
7.A patient with a history of mitral valve replacement developing fever after 7 months of surgery.Breached defenses Bacteremia. •Absence of blood •Poor dental hygiene? supply. WITH •IV drug use? •Abnormal blood flow. •Soft tissue infection? •Occult source? Suspicious case of Prosthetic Valve Endocarditis Early (< than 60 days) • Staph aureus, Staph epidermidisBacterialendocarditis Late(>than 60 days) • Strep viridans 50%-70% (Streptococcus sanguis, Strep.oralis Strep. mitis) Rare causes: HACEK Group & Culture negative BE • Staph aureus 25%
Diagnosis ? History Examination > Splinter hemorrhages, Janeway lesions, Osler’s node, Rothspots. Investigations >Blood culture, FBC, ESR, CRP, Liver biochemistry, ECG,Echocardiography Blood culture •Blood samples should be taken prior to antibiotic use. •At least 3 sets of samples ( 6 bottles) •Under aseptic condition. •Do NOT use cannulaManagement • Start empirical antibiotic treatment • Change or continue antibiotics according to the patient’s response and culture results. • Decision about surgical intervention should be made after joint consultation between cardiologist and cardiothoracic surgeon.Prevention •Use prophylactic antibiotics prior to dental & surgical procedures. •Good dental hygiene. •Avoid risky behaviors such as i.v. drug abuse.
Case Summary: Mrs. X, year old paraplegic formonths on indwelling catheter presented with fever forday with chills and burning sensation in urethra.Pastmedical history, DM for yrs Symptoms and signs: Fever, Chills, Burning sensation of Urethra & Pubic area, Nausea, Headache, Mild lower back pain Problems Catheter Immunocompromised Paraplegic and its complications Female Old age
Diagnosis - Catheter associated complicated UTI COMMON ORGANISMS…MECHANISMS OF UTI… # E.coli• Mechanical trauma to urethra # Klebsiella• Introducing normal flora # Proteus & Candida• Bladder atonia - VU valve incompetence PREVENTION AND•Diabetis: reduse immunity MANAGEMENT…• Urine retention• Ascending infections Management… Predisposing factors COLLECTION , STORAGE & Antibiotics TRANSPORTATION OF URINE SPECIMEN FOR LAB Prevention… INVESTIGATIONS… Avoid catheterisation Minimum duration # UFR Intermittent catheterisation # Urine culture Aseptic conditions # FBC Closed, sterile drainage # Blood culture system # ABST Maintain gravity drainage Prophylactic antibiotics
NON HEALING FOOT ULCER IN DIABETIC PATIENTPathophysiology Defense How it is compromised Skin Trauma Reflexes(pain) Loss of sensation due to diabetic neuropathy Repair mechanisms Reduce blood supply by diabetic vasculopathy Immunity Alteration of cellular and humoral immunity Coordination Poor coordination due to reduced sensation ,poor vison ect.Organisms involvedPolymicrobial cause- mostly involvedStaphylococcus aureusgroup A beta haemolytic StreptococcusStaphylococcus epidermidis Pseudomonas aeruginosagram negative anaerobes Candida spp.Gram negative aerobes Clostridium perfringensEnterococcus
Assessment of vascular insufficiency- Bacterial cultures & Proper Hx & Ex peripheral pulses, Doppler U.S ABST- Laboratory testing- DIAGNOSIS WBC Radiological testing- count, ESR, glucos plain x-ray e, etc... MANAGEMENT Good diabetic control. Ulcer Mx - elevation, soft tissue support & antibiotics with appropriate wound management. Ulceration with deep tissue invasion-rest, elevation, antibiotics for secondary infection & protracted treatment with wound management. Mx of vascular insufficiency. ( Medical and Surgical ) If infection persists & leading to complication -amputation done PREVENTION Good diabetes control Foot care Educating the patient.