Diagnosis and Treatment of Common Infectious Diseases

Angela Heithaus, MD, PSInternal Medicine

Seattle Healing Arts Center

GiocondaGioconda

20 YO non-pregnant UW female student 20 YO non-pregnant UW female student sexually active 3 x week with 1 partner sexually active 3 x week with 1 partner over past 6 months (he is over past 6 months (he is asymptomatic), no prior medical history asymptomatic), no prior medical history including STDincluding STD

C/O: pain on urination x 3 days with C/O: pain on urination x 3 days with increased frequency and urgency, some increased frequency and urgency, some suprapubic pain, no: blood, back pain, suprapubic pain, no: blood, back pain, vaginal d/c, fevervaginal d/c, fever

EpidemiologyEpidemiology

First 10 years of life:First 10 years of life: Girls 3% Girls 3% Boys 1.1%Boys 1.1% Teen girls 0.5 episodes/yearTeen girls 0.5 episodes/year Adult women 50-60% at least 1 Adult women 50-60% at least 1

episode/life timeepisode/life time Young, sexually active women 0.5 Young, sexually active women 0.5

episodes/ person yearepisodes/ person year Post-menopausal women 0.07% episodes Post-menopausal women 0.07% episodes

per person per yearper person per year

UTIUTI

UNCOMPLICATEDUNCOMPLICATED Healthy, young, non-Healthy, young, non-

pregnant femalepregnant female

COMPLICATEDCOMPLICATED Everything else: men, Everything else: men,

recurrent UTI, pyelo, recurrent UTI, pyelo, in-dwelling catheters, in-dwelling catheters, pregnant, diabeticpregnant, diabetic

Increased risk of Increased risk of failing therapyfailing therapy

MicrobiologyMicrobiology

80-85% Escherichia coli 80-85% Escherichia coli Staphylococcus saprophyticus, Proteus Staphylococcus saprophyticus, Proteus

mirabilis, enterococcimirabilis, enterococci Chlamydia-(acute urethral syndrome)Chlamydia-(acute urethral syndrome)

Negative standard culture Negative standard culture

Diagnosis in Uncomplicated UTIDiagnosis in Uncomplicated UTI PExPEx

Nl tempNl temp No costovertebral angle tendernessNo costovertebral angle tenderness

Clinical CriteriaClinical Criteria Dipstick: leukocyte esterase (pyuria) and nitrite Dipstick: leukocyte esterase (pyuria) and nitrite

(Enterobacteriaceae)(Enterobacteriaceae)75-96% sensitivity; 94-98% 75-96% sensitivity; 94-98%

specificity for specificity for detecting >10 detecting >10 leukocytes per HPFleukocytes per HPF

Evaluation of mid stream urine (unspun) for pyuria Evaluation of mid stream urine (unspun) for pyuria is most valuable laboratory diagnostic testis most valuable laboratory diagnostic test(abnl: 10 or more leukocytes per microL)(abnl: 10 or more leukocytes per microL)

Selected Oral AB Regimens for Selected Oral AB Regimens for Use in Uncomplicated UTIUse in Uncomplicated UTI

DrugDrug Dose, IntervalsDose, Intervals DurationDuration

CiprofloxacinCiprofloxacin 100-250 mg q12 hrs 100-250 mg q12 hrs (500 mg q24)(500 mg q24)

3 days3 days

LevofloxacinLevofloxacin 250 mg q24 hrs250 mg q24 hrs 3 days3 days

Trimethoprim-Trimethoprim-sulfamethoxazolesulfamethoxazole

160/800 mg q12 hrs160/800 mg q12 hrs 3 days3 days

TrimethoprimTrimethoprim 100 mg q12 hrs100 mg q12 hrs 3 days3 days

Amoxicillin/Amoxicillin/

ClavulanateClavulanate500 mg q 12 hrs500 mg q 12 hrs 7 days7 days

Giovanni Battista MorgagniGiovanni Battista Morgagni

22 YO M C/O (not: homeless, recently 22 YO M C/O (not: homeless, recently incarcerated, IDU, in military, on athletic incarcerated, IDU, in military, on athletic team or have family member with team or have family member with infection):infection): Local pain, swelling, rednessLocal pain, swelling, redness ? Drainage? Drainage ? Hit something a while ago? Hit something a while ago Denies: fever, chillsDenies: fever, chills

Skin and Soft Tissue InfectionsSkin and Soft Tissue Infections CellulitisCellulitis

Most common skin infection leading to Most common skin infection leading to hospitalizationhospitalization

Superficial, spreading infection involving Superficial, spreading infection involving subcutaneous tissuesubcutaneous tissue

Other Common Skin InfectionsOther Common Skin Infections Impetigo, Folliculitis, Furuncles, and Impetigo, Folliculitis, Furuncles, and

CarbunclesCarbuncles

AbscessAbscess

Impetigo, Folliculitis, Furuncle, Impetigo, Folliculitis, Furuncle, CarbuncleCarbuncle

Impetigo: superficial vesiculopustular skin Impetigo: superficial vesiculopustular skin infection occurring prominently on infection occurring prominently on exposed areas of the face and extremities exposed areas of the face and extremities

FFC: arise from hair follicleFFC: arise from hair follicle Staph AureusStaph Aureus Rarely require hospitalizationRarely require hospitalization Respond to local measuresRespond to local measures Recurrence may be prevented by decreasing Recurrence may be prevented by decreasing

staph aureus skin carriagestaph aureus skin carriage

AbscessAbscess

Localized accumulation of Localized accumulation of polymorphonuclear leukocytes with tissue polymorphonuclear leukocytes with tissue necrosis involving the dermis and necrosis involving the dermis and subcutaneous tissue subcutaneous tissue

Large numbers of microorganisms are Large numbers of microorganisms are typically present in the purulent material typically present in the purulent material

Infection begins from tracking in from the Infection begins from tracking in from the skin surfaceskin surface

MicrobiologyMicrobiology

Most common microorgansim: Staph Most common microorgansim: Staph AureusAureus

Increased incidence of community-Increased incidence of community-associated infections due to: methicillin-associated infections due to: methicillin-resistant S. Aureus (CA-MRSA)resistant S. Aureus (CA-MRSA)

Urban ER: 61/119 MRSA isolatedUrban ER: 61/119 MRSA isolated An average of more than 3 organisms; An average of more than 3 organisms;

anaerobic in 1/3 of cases (1/2 IDU)anaerobic in 1/3 of cases (1/2 IDU)

ManagementManagement Incision, Drainage and cultureIncision, Drainage and culture

Fluctuant or has ‘pointed’Fluctuant or has ‘pointed’ Culture ?MRSACulture ?MRSA

Bacteremia and Antibiotic ProphylaxisBacteremia and Antibiotic Prophylaxis AHA guidelines for those high risk for EC and who AHA guidelines for those high risk for EC and who

have hardware (oxacillin, cefazolin, vanco)have hardware (oxacillin, cefazolin, vanco) Oral Antibiotic TherapyOral Antibiotic Therapy

Not ready for I&D, cellulitis, fever, high-risk featuresNot ready for I&D, cellulitis, fever, high-risk features Community Associated MRSACommunity Associated MRSA

Awareness of the local antimicrobial susceptibility Awareness of the local antimicrobial susceptibility patterns of community S. aureus isolates patterns of community S. aureus isolates

Oral Antibiotic TherapyOral Antibiotic Therapy

DrugDrug Dosage, intervalDosage, interval

DicloxacillinDicloxacillin 500 mg qid500 mg qid

CephalexinCephalexin 250 mg qid250 mg qid

Clindamycin Clindamycin 150-450 mg qid150-450 mg qid

AzithromycinAzithromycin 500 mg x 1, 250 mg qd500 mg x 1, 250 mg qd

Oral, peri-rectal, vulvovaginal abscesses

Amoxicillin-clavulanate 875/125 mg BID Amoxicillin-clavulanate 875/125 mg BID Clindamycin 150 mg QID Clindamycin 150 mg QID PLUS Ciprofloxacin 500 mg BID PLUS Ciprofloxacin 500 mg BID

Galileo GalileiGalileo Galilei

40 YO otherwise healthy, non-smoker C M 40 YO otherwise healthy, non-smoker C M presents C/O:presents C/O: dry cough x 2 weeksdry cough x 2 weeks clear sputum production and fatigueclear sputum production and fatigue

Denies: pharyngitis, fever, chillsDenies: pharyngitis, fever, chills Vitals: Nl temp, RR, PVitals: Nl temp, RR, P

Acute BronchitisAcute Bronchitis

Over 90% are viralOver 90% are viral Approximately 60% of patients seeking Approximately 60% of patients seeking

medical care are given antibioticsmedical care are given antibiotics One of the most common causes of One of the most common causes of

antibiotic abuseantibiotic abuse ACP and CDC state Pertussis is only form ACP and CDC state Pertussis is only form

that should be treatedthat should be treated

Usual SuspectsUsual Suspects

Coronavirus (types 1-3) Coronavirus (types 1-3) RhinovirusRhinovirusInfluenza A and B Influenza A and B ParainfluenzaParainfluenzaRespiratory syncytial virus Respiratory syncytial virus Human metapneumovirus Human metapneumovirus

InfluenzaInfluenza

Cough, purulent sputum, fever, and Cough, purulent sputum, fever, and constitutional complaints during the constitutional complaints during the influenza seasoninfluenza season

AmantadineAmantadine, , rimantadinerimantadine, or , or neuraminidase inhibitorsneuraminidase inhibitors

Must be given within 48 hours of symptom Must be given within 48 hours of symptom onset for demonstrable benefitonset for demonstrable benefit

Other SuspectsOther Suspects

Mycoplasma pneumoniae Mycoplasma pneumoniae Chlamydophila (formerly Chlamydia) Chlamydophila (formerly Chlamydia)

pneumoniae pneumoniae Bordetella pertussis (severe paroxysmal Bordetella pertussis (severe paroxysmal

cough)cough)

To Shoot or Not to ShootTo Shoot or Not to Shoot

Pneumonitis vs Acute BronchitisPneumonitis vs Acute Bronchitis

Abnl vital signs:Abnl vital signs:

temp > 38 C (100.4 F)temp > 38 C (100.4 F)

Pulse > 100/minPulse > 100/min

RR >24RR >24

Crackles on examCrackles on exam

Chronic CoughChronic CoughThink…Think…

Postnasal drip syndrome Postnasal drip syndrome Asthma Asthma Gastroesophageal reflux Gastroesophageal reflux

BeatriceBeatrice

28 YO otherwise healthy female who C/O:28 YO otherwise healthy female who C/O: nasal congestion, purulent nasal nasal congestion, purulent nasal

discharge, maxillary tooth discomfort, discharge, maxillary tooth discomfort, hyposmia, and facial pain or pressure that hyposmia, and facial pain or pressure that is worse when bending forward, is worse when bending forward, headache, fever (nonacute), halitosis, headache, fever (nonacute), halitosis, fatigue, cough, ear pain, and ear fullnessfatigue, cough, ear pain, and ear fullness

Acute SinusitisAcute Sinusitis Almost all cases viral in etiology Almost all cases viral in etiology

Rhinovirus, parainfluenza, and influenza virusRhinovirus, parainfluenza, and influenza virus Usually resolves in 7-10 daysUsually resolves in 7-10 days

2% complicated by acute bacterial sinusitis2% complicated by acute bacterial sinusitis Streptococcus pneumoniae and Haemophilus Streptococcus pneumoniae and Haemophilus

influenzaeinfluenzae Self-limited, 75% resolve without tx in 1 monthSelf-limited, 75% resolve without tx in 1 month Morbidity can include intracranial and orbital Morbidity can include intracranial and orbital

complications and of possibly developing chronic complications and of possibly developing chronic sinus disease sinus disease

How many get it?How many get it?

Average adult has from 2-3 colds and influenza-like Average adult has from 2-3 colds and influenza-like illnesses per year illnesses per year

Average child six to 10Average child six to 10 Represents approximately one billion acute respiratory Represents approximately one billion acute respiratory

illnesses annually illnesses annually Approximately 0.5 to 2 percent of colds and influenza-Approximately 0.5 to 2 percent of colds and influenza-

like illnesses are complicated by acute bacterial sinusitis like illnesses are complicated by acute bacterial sinusitis in adultsin adults

Annual incidence of acute community-acquired bacterial Annual incidence of acute community-acquired bacterial sinusitis is approximately 20 million casessinusitis is approximately 20 million cases

Comparison of Contemporary Guidelines for the Diagnosis Comparison of Contemporary Guidelines for the Diagnosis of Acute Community Acquired Bacterial Sinusitisof Acute Community Acquired Bacterial Sinusitis

CDCCDC

Maxillary pain or Maxillary pain or tenderness in face or tenderness in face or teeth + rhinorrhea, no teeth + rhinorrhea, no improvement x 7 daysimprovement x 7 days

Severe sxsSevere sxs

Plain films not neededPlain films not needed

Sinus & Allergy Health Sinus & Allergy Health PartnershipPartnership

Persistant sxs after 10 Persistant sxs after 10 days or worsening after days or worsening after 5-7 days5-7 days Nasal drainage, Nasal drainage,

congestion, d/c; facial congestion, d/c; facial pressure/pain; pressure/pain; hyposmia/anosmia; fever; hyposmia/anosmia; fever; cough; ear sxscough; ear sxs

Plain films, CT, MRI not Plain films, CT, MRI not neededneeded

Treatment of Viral RhinosinusitisTreatment of Viral Rhinosinusitisin Adultsin Adults

At first sign of a coldAt first sign of a cold Sustained release 1Sustained release 1stst generation antihistamine generation antihistamine

(chlorpheniramine, brompheniramine, (chlorpheniramine, brompheniramine, clemastine), PLUS NSAID (ibuprofen, clemastine), PLUS NSAID (ibuprofen, naproxen)naproxen)

Continue taking both q 12 hrs until sxs clearContinue taking both q 12 hrs until sxs clear Add oral decongestant (pseudoephedrine) Add oral decongestant (pseudoephedrine)

and/or a cough suppressant and/or a cough suppressant (dextromethrophan)(dextromethrophan)

If sxs persist and are no better or worse If sxs persist and are no better or worse after 7-10 days, consider antibiotic therapyafter 7-10 days, consider antibiotic therapy

Comparison Guidelines for the Treatment of ACA Comparison Guidelines for the Treatment of ACA Bacterial SinusitisBacterial Sinusitis

CDCCDC

Only those meeting clinical dx Only those meeting clinical dx criteriacriteria

Narrow spectrum agentsNarrow spectrum agents Amoxicillin 1.5-3.5 g/dAmoxicillin 1.5-3.5 g/d Doxycycline 100mg BIDDoxycycline 100mg BID TMP-SMX 1DS BIDTMP-SMX 1DS BID

Sinus & Allergy Health Sinus & Allergy Health PartnershipPartnership Mild disease, - AB 4-6 wksMild disease, - AB 4-6 wks

AmoxicillinAmoxicillin Amoxicillin-ClavulanateAmoxicillin-Clavulanate CefpodoximeCefpodoxime Cefuroxime axetilCefuroxime axetil

Mild disease +AB or moderate Mild disease +AB or moderate disease – AB in 4-6 wksdisease – AB in 4-6 wks Any of above orAny of above or Levofloxacin or gatifloxicinLevofloxacin or gatifloxicin

Moderate +AB in 4-6 wksModerate +AB in 4-6 wks Amoxicillin-Clavulanate orAmoxicillin-Clavulanate or Levofloxacin or gatifloxicin orLevofloxacin or gatifloxicin or Combo tx with amoxicillin or Combo tx with amoxicillin or

clindamycin PLUS cefpodoxime or clindamycin PLUS cefpodoxime or cefiximecefixime

Intranasal SteroidsIntranasal Steroids

Use is not recommended Use is not recommended OK in treating chronic sinus disease OK in treating chronic sinus disease Steroid therapy increases viral Steroid therapy increases viral

concentrations in nasal secretions in concentrations in nasal secretions in cases of viral rhinosinusitis cases of viral rhinosinusitis