INFECTIONS IN ACCIDENT INFECTIONS IN ACCIDENT AND EMERGENCYAND EMERGENCY

http://www.tcd.ie/Clinical_Microbiology/Notes on :

Contents of LectureContents of Lecture

Number of Possible Clinical Cases presenting to A/E

Meningitis Animal/Human Bites Tetanus Trauma/Wounds Peritonitis Severe Pneumonia Measles

Each Case FormatEach Case Format

Clinical PresentationDifferential DiagnosesInvestigations-including

biochemistry,haematology,radiology, Microbiology etc

Management

Case OneCase One 15 year old girl presents to A/E by ambulance from G.P

practice, Letter stated she had presented there that day with 1 day

history of headache , feeling generally unwell (No past medical history), G.P had noted non-blanching rash on back of patient, She has administer 4 megaunits of Benzyl Penicillin I/m, called Ambulance

On presentation to A/E, girl was confused /disorientated, photophobic, BP: 80/50 mmHg, Pulse Rate 140 regular, Temperature 35º C (hypothermic) (patient cold), Rash noted on thighs and back– non-blanching

Rash Of Meningococcaemia

Case OneCase One

What to do?Diagnosis

Clinical ExaminationClinical Examination

Of Note:GCS: 12Photophobic, Pupils reacting, Fundoscopy

impossible, nuchal rigidityMild cyanosis

DexamethasoneDexamethasone

Additional studies have shown the benefit of using DEXAMETHASONE 0.15mg/KG 6 hourly2-4 days (give with or before ANTIBIOTIC)

11. FURTHER CONSULTATION: early phone consultation with relevant specialists is desirable, cosider tertiary centre referral

12. COAGULATION13. FURTHER MANAGEMENT14. LP: if meningitis suspected and no

contraindications do when haemodynamically stable( usually day 2-3)

15. NOTIFY public health and initiate CHEMOPROPHYLAXIS if necessary

KEY POINTKEY POINT

The speed with which meningococcal infection is recognised and treated is critical to achieving a successful outcome and clinical suspicion alone mandates treatment

Action-STATAction-STAT Recovery Position, Oxygen given, Assistance requested Large gauge cannulas x 2 for access Blood taken for FBC, U/E, Coag ,Glucose, Group and

Cross match and Blood Cultures, EDTA (FBC) bottle taken for Neisseria meningitidis PCR

Cefotaxime 2 g I/v given ( also give with or before Dexamethasone 0.15mg/KG 6 hourly2-4 days)

Intravenous fluids given 2L Hartmanns STAT Urinary Catheter placed in situ Anaesthetist on call and Microbiologist called

UREGENTLY

ActionAction

Skin Scrapings taken for Gram stain to see Gram negative diplococci consistent with diagnosis

Patient transferred to Intensive Care within 15 minutes

Any additonal specimensAny additonal specimens

Cerebrospinal Fluid –Lumbar puncture depending on Platelets and Coagulation Screen and if hemodynaically stable

Clotted blood sample for OMP for Neisseria meningitidis also

INTRACELLUALR GRAM NEGATIVE DIPLOCOCCI , GRAM STAIN OF SKIN SCRAPINGS

Taken in A/E and seen on gram stain 10 minutes later In Microbiology Lab

Gram Stain of positive Blood culture , which became

Positive night of admission

Gram Negative diploccocci

DiagnosisDiagnosisMeningococcal SepticaemiaMeningococcal Septicaemia

OutcomeOutcome

Patients survived no loss of limbs or cognitive function but significant areas of skin affected remain painful until replaced by normal skin

Rehabiliation took months

See handout cards

ANIMAL/HUMAN BITESANIMAL/HUMAN BITES

Case 2 HistoryCase 2 History

28 year old gentleman presents 1 hour after (at 4 a.m) with human bite to right hand sustained during a fist fight with his brother outside a nightclub

He complains of a painful 2nd and 3rd metacarpal joint

They have now made -up

On examinationOn examination

There is a 1 x 1 cm rugged abrasion with the indentation of teeth on either side overlying the 1st metacarpal joint on the right hand

All movements of hand appear intact- no evidence of tendon damage

Otherwise there are no injuries to the rest of the body

No significant medical history

No known allergies No history or risk of

HIV/Hepatitis in brother

Action Action

The wound is cleaned ,irrigated with bethadine and debrided (if required)-It is extremely important that this is throughly carried out

X-ray of Right hand is carried out to outrule fracture – no fracture seen

Co-amoxiclav is prescribed for 5 days

Patient is asked to return for follow-up with G.P

Human BiteHuman Bite

Organisms found in Infected Organisms found in Infected Human bitesHuman bites

Usually polymicrobial/mixed due to mixed nature of dental flora

Viridans Streptococci- 100%

Staph. Epidermidis 53%

Corynebacteriium spp. 41%

Staph aureus 29% Eikenella spp. 15% Bacteroides spp. 82% Peptostreptococcus

spp. 26% Therefore therapy

must have both aerobic and anaerobic cover

Dog Bites-OrganismsDog Bites-Organisms

Pasteurella multocida Staph aureus Bacteroides spp. Fusobacterium spp. Capnocytophaga spp (N.B in asplenic

individuals) In endemic areas query rabies?? With bites consider tetanus prophylaxis

Case Three Case Three

Case ThreeCase Three

A 72 year old man presents unable to move her jaw, leg muscle spasms and a history of a leg laceration sustained in the garden from a rose bush thorn four days earlier.

Diagnosis?

On ExaminationOn Examination

The man has trismus and a 5x6x2 cm avulsion of the skin on the anterior tibial aspect with black necrotic tissue 2x3x2 cm on the medical aspect of wound.

He had run water over this at the time and bandaged it up himself but did not clean the wound throughly when it happen or seek advice

He never had a course of tetanus vaccination He is allergic to penicillin

Laceration with escharLaceration with eschar

TRISMUS

Tetanus ProphylaxisTetanus Prophylaxis

DiagnosisDiagnosis

Tetanus due to Clostridium tetani exotoxin-GABA antagonist- results in blocking of the inhibitory pulses to motor neurones, acts at myoneural junction of skeletal junction and neuronal membranes in the spinal cord

Treatment (not prophylaxis)Treatment (not prophylaxis)

Supportive therapy for muscle spasm- in this case ventilation and sedation required

Human Tetanus ImmunoglobulinTetanus toxoid vaccination (Td)Metronidazole 500 mg 6 hourly I/v for 10

daysCleaning, Irrigation and Debridement of

wound Immediate

OutcomeOutcome

Patient remained ventilated for a number of weeks

Wound required subsequent skin grafting

KEY POINTKEY POINTCLEAN, IRRIGATE, DEBRIDE CLEAN, IRRIGATE, DEBRIDE ALL WOUNDS IMMEDIATELY ALL WOUNDS IMMEDIATELY

AND THROUGHLYAND THROUGHLYVACCINATION AVAILABLE VACCINATION AVAILABLE

Case 4Case 4

Patient presents complaining of Patient presents complaining of

Severe abdominal pain for 6 hoursEpisodes of vomitingHad noted some change in bowel habit over

the past 8 months

Case 4Case 4On Examination: T: 39.5oC Pulse: 95/min Tender in right lower quadrant of abdomen Rebound tenderness Absent bowel sounds Admit!!

Investigations: Blood Cultures FBC, U&E, ESR, CRP,Coag screen, Group and Hold X Ray abdomen(PFA)

Likely DiagnosisLikely Diagnosis

‘Acute Abdomen’

DiiferentialAppendicitisPeritonitis secondary to perforated ulcer,

large bowel neoplasm, diverticulitis, etc.

Likely DiagnosisLikely DiagnosisPFA

Likely DiagnosisLikely DiagnosisPFA

Likely OrganismsLikely Organisms

Site No of organisms (cfu/g)

Organisms

Stomach 103 Lactobacilli, streptococci, yeasts

Small Intestine

103-109 As stomach + clostridia, enterobacteriaceae, enterococci

Large Intestine

108-1012 Mostly anaerobes, and aerobic gram negatives and Enterococci

SurgerySurgery Taken to theatre for laparotomy Discover tumour in descending colon which has

perforated and has an associated abscess and peritonitis

Tumour removed with some difficulty, some pus spilled into peritoneum

section of colon removed and colostomy put in situ Pus sent for Culture and Sensitivity Antibiotics: IV Co-Amoxiclav+ Ciprofloxacin+

Metronidazole

Blood Cultures E. coli:

– S – Gentamicin, cefuroxime, ciprofloxacin– S Ampicillin, cephradine

Bacteroides fragilis– S – metronidazole

Swabs at surgery as above + enterococci spp. S Ampicillin

Admitted to ICU, improves over next few weeks but develops MRSA colonisation

CASE 5CASE 5

Case 5Case 5

Katie, 2 year oldPC: fever 38oC, Cough,HPC: x 4/7O/E: difficult to examine, irritable, noticed

white spots in mouth, some chest signsInv: FBC, U& E, CRP, ESR, CXR, swab

from lesions to microbiology

Later in the day, you notice Later in the day, you notice a rash appearing…a rash appearing…

Measles!!Measles!!

No Tx in children, supportive therapy

IsolateNotify to public healthVaccination is preventative

Case 6Case 6

Case 6Case 6

Brian, 63

•PC: ache and discharge from site of old fracture repair

•HPC: RTA 3/12 ago, femur fractured and screws inserted, wound infected with E. coli treated with Co-amoxyclav for 3/52

Case 6Case 6

PMHx: At time of RTA also had -

• subdural haematoma treated with burr hole

• 4 fractured ribs

• lacerated spleen requiring splenectomy

• Developed MRSA pneumonia in ICU

Case 6Case 6

• Social Hx: retired barrister, ex smoker, lost wife in same RTA

• Presently not an any antibiotics, no allergies

• O/E: T 38.5oC, pus from very tender tibial wound, nil else

Case 6Case 6

• Inv:

- FBC, U&E, CRP, ESR,

- X ray femur

- pus sent for culture and sensitivity

Would you admit this patient?

Tx: MRSA screen Surgery to (ORTHOPODS)

– Remove old screws– Debride infected and dead tissue– Send Tissue and Bone for culture

and Sensitivity– Consider repair(Orthopods)

IV antibiotics as per tissue result probably needs 2 agents IV for ~ 4/52, followed by oral antibiotics

Community Acquired Community Acquired PneumoniaPneumonia

Case 7Case 7

Presentation Presentation

72 year old previously fit gent retiredFamily have noted that he was distracted

over the past 4 days and forget his routine G.P appointment for Vit .B 12 injection

He is also catching his breath a lot

On examination-CURBOn examination-CURB

Confusion ( doesn`t know the day of the week or month)

RR 34 breaths per minutesBP 130/70 mmHgUrea has come back from the lab at 13

mmol/ L

Chest X-RAYChest X-RAY

Decision Decision

Do you admit this patient?What tests would you send to the

microbiology lab?What therapy do you choose?

KEY POINT KEY POINT USE CURB-65 TO ACCESS :USE CURB-65 TO ACCESS :DETERMINES WHETHER TO DETERMINES WHETHER TO

ADMIT PATIENT AND ADMIT PATIENT AND THERAPYTHERAPY