What are 5 causes of ALT >1000
- Vascular (shock liver, portal venous thrombosis, Budd Chiari)
- Toxic (ie. acetaminophen)
- Viral (hep, CMV, EBV, HSV)
- Metabolic (autoimmune, Wilson’s, acute fatty liver of pregnancy)
- Lymphoma
Name 8 complications of fulminant hepatic failure
- Hepatic encephalopathy
- Cerebral edema
- Coagulopathy
- Metabolic acidosis (lactate)
- Hepatorenal syndrome
- Electrolyte abnormalities (hypoK, hypoNa)
- Hypoglycemia
- Increased risk of infection
What are 3 options for treatment of hepatic encephalopathy?
- Lactulose
- Metronidazole
- Dietary protein restriction
Improves symptoms
None are proven to improve mortality
Define spontaneous bacterial peritonitis (lab values for peritoneal fluid analysis)
PMNs >250 x 10^6
WBC > 500 x 10^6
What are initial physiologic goals in a patient with severe TBI?
- Avoid hypoxemia (PaO2 80-120 mmHg)
- Normocarbia (PaCO2 35-40 mmHg)
- Avoid hypotension (MAP >65)
- CPP 60-70
- Normal temperature (35.5-37 celcius)
- Normoglycemia (5-8 mmol/L)
What are 5 anti-pseudomonal antibiotics
- Piperacillin-Tazobactam
- Meropenem, imipenem
- Ciprofloxacin
- Gentamycin, tobramycin
- Ceftazadime
What antibiotics cover against MRSA?
Hospital acquired: vancomycin, linezolid
Community acquired: clindamycin, tetracycline, doxycycline, TMP-SMX (variable resistance)
With fungemia, where to suspect other infections?
- Endocarditis
- Line/indwelling catheter infections
- Opthalmic (get ophtho consult)
What are 5 common cell mediated immune dysfunction categories?
- Malignancy
- Diabetes
- Immunosuppression
- Third trimester pregnancy
- Cirrhosis
Why are steroids added in treatment of meningitis?
What is the typical dose?
When should you time the delivery of steroids?
- Decreases overwhelming cytokine response as a result of bacterial cell wall lysis from bacteriocidal antibiotics
This cytokine release in response to bacterial wall debris is thought responsible for inflammation and swelling - Dexamethasone 10 mg IV q6h x 4 days
- Before or at time of first dose of antibiotics
What antibiotic coverage is needed for Listeria monocytogenes?
Ampicillin (not covered by 3rd generation cephalosporins)
What bacteria should you consider in asplenic patients?
Encapsulated
S. pneumoniae, H. influenza, N. meningidites, Klebsiella, S. aureus
How does the spleen play a role in humoral immunity? (3 mechanisms)
- Filter for bacteria with antibodies
- Reservoir for B-lymphocytes, which are activated into plasma cells to make more antibodies
- Alternate complement pathway housed in spleen
If a patient has cell mediated immune deficiency, what type of bacteria causes problems? Give 3 examples
Intracellular organisms
Listeria
Legionella
Salmonella
What type of bacteria is Stenotrophomonas maltophilia? What types of patients do we see with it?
Gram negative, aerobic (closely related to pseudomonas)
Opportunistic - adheres like biofilm
Hospitalized (ICU), immunocompromised
Treatment options for Stenotrophomonas?
TMP-SMX
Intrinsically resistant to beta-lactams, aminoglycosides, carbapenems, fluoroquinolones
7 causes of high fever (T>38.9)
- Infection
- Drug fever
- Transfusion reaction
- Extensive tissue necrosis
- Neuroleptic malignant syndrome
- Heat stroke
- Toxic (salicylates, thyrotoxicosis, sympathomimetics etc)
How long to treat ventilator associated pneumonia? - relevant trial?
8 days, consider longer if Pseudomonas
RCT: 8 days vs. 15 days
French multicentre RCT, n = 401
similar mortality, morbidity and recurrent infections
What should you consider in patients on broad spectrum antibiotics >1 week who develop fever/sepsis picture?
Fungal super-infection
7 Causes of antibiotic failure
- Wrong diagnosis (non-infectious)
- Wrong dose
- Inadequate drug penetration (abscess, BBB, foreign body)
- Inadequate empiric coverage and incorrect spectrum
- Superinfection
- Drug interactions leading to antibiotic inactivation
- Unusual pathogens (Rickettsia, Chlamydia, parasites)
What are 4 classes of risk factors that predispose patients to aspiration?
- Altered level of consciousness
- Dysphagia
- Neurological disorders
- Mechanical disruption of barrier mechanisms
Diagnostic criteria of Streptococcal Toxic Shock Syndrome?
- Isolation of Group A Strep from normally sterile site (blood, CSF, pleural, peritoneal fluid, tissue biopsy, surgical wound)
- Hypotension (SBP <5th percentile peds)
2 or more of the following:
A. Renal dysfunction
B. Coagulopathy
C. Liver dysfunction
D. ARDS
E. Erythematous macular rash, may desquamate
F. Soft tissue necrosis (nec fasc, myositis, gangrene)
Diagnostic criteria of Staphylococcus Toxic Shock Syndrome
- Fever > 38.9 degrees celclius
- Hypotension sBP /= 15
a. Orthostatic syncope or dizziness - Rash – diffuse macular erythroderma
- Desquamation – 1-2 weeks after onset of illness, esp. palms and soles
- Multisystem involvement (3+)
a. GI: vomiting/diarrhea at onset of illness
b. MSK: severe myalgias, CK elevation >2x ULN
c. Mucous membranes: vaginal, oropharyngea or conjunctival hyperemia
d. Renal: BUN or Cr >2x ULN or pyuria
e. Hepatic: bilirubin or transaminases >2x ULN
f. Hematologic: platelets <100,000/microL
g. CNS: disorientation or alterations in consciousness without focal neuro signs in absence of fever and hypotension - Negative results on the following tests
a. Blood, CSF, throat for another pathogen, blood may be + for S. aureus
b. Serologic tests for RMSF, leptospirosis or measles
DDx abrupt onset shock in previously well individual
Staph TSS Gram negative sepsis Typhoid fever Rocky Mountain spotted fever Meningococcemia Strep pneumo infection Heat stroke
