by mtoom


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What percentage of dog and cat bites get infected?
Cat 80%
Dog 5%
What is the most common pathogen in cat and dog bites?
  • Cat bite: Pastuerella multocida
  • Dog bite: Pastuerella canis
What is the treatment for animal bites?
Amoxicillin-clavulanate
What is a clenched fist injury?
What is the risk of infection for clenched fist injury? What is the plan of action?

It is a reverse bite injury (punching someone's teeth)
  • Risk: very high (septic joint, osteomyelitis)
  • Plan of action: IV antibiotics and imaging 
When is tetanus vaccine indicated?
  • Minor wound and no vaccine in 10 years
  • Major wound and no vaccine in 5 years
When is tetanus Ig indicated?
  • Major wound and not at least 3 doses of vaccine
What days is rabies vaccine required?
0, 3, 7 and 14
What do you think first (2) when you have lymphadenopathy? Some more rare causes (3)?
  • Infection
  • Malignancy

More rare:

  • Cyst
  • Sarcoidosis
  • Kawasaki's disease 
Some other causes of lymphadenopathy?
  • GAS (S. pyogenes)
  • S. aureus
  • HIV, CMV, EBV
  • Toxoplasma
  • Mycobacterium (Tuberculosis, Atypical)
  • Bartonella henselae (cat scratch disease)
  • Sporotrichosis, histoplasma, francisella, bacillus anthacis, borrelia burgdorferi, yersina pestis, nocardia
What causes cat scratch disease?
Bartonella henselae via cat bite, scratch or cat flea bite
Describe the symptoms, diagnosis (3) and treatment (1) of Cat Scratch Disease?
Symptoms
  • Local lymphadenitis with/without cutaneous legion
  • Skin lesion several days after exposure that lasts 1-3 weeks
  • Atypical: liver, spleen, ocular, neurological, MSK, FUO
Diagnosis
  • Serology (IFA), blood culture, tissue PCR
Treatment
  • Azithromycin 
What are the 2 classic syndromes of Disseminated Gonococcal infection?
  • 1. Triad: Tenosynovitis, polyarthritis, dermatitis
  • 2. Purulent arthritis

Cervicitis/urethritis is not common, most cases associated with asymptomatic genital infection
How do you diagnose a disseminated gonococcal infection?
Blood, skin and synovial fluid cultures are often (-)
  • Diagnosis: Cervical and urethral swabs are often (+) 
What is the treatment for Disseminated Gonococcal infection?
Cefotaxime + Doxycycline

For purulent arthritis: IV therapy & joint aspiration

For Triad presentation: Possible to switch to oral after 24-48 hours
What is septic arthritis?
Inflammation of a joint due to a bacterial or fungal infection.
How do you get septic arthritis (4) from most to least common?
From most to least common:
  • Hematogenous spread
  • Trauma/bite
  • Post-surgery
  • Direct spread from osteomyelitis 
What is the clinical triad (3) for septic arthritis?
  • Fever
  • Pain
  • Decreased range of motion
What are the main organisms (2) are responsible for septic arthritis? (from most to least common)
  • S. aureus (most common)
  • Strep (2nd most common)
     
  • Gram negatives/TB/fungal (less common)
What are some risk factors for septic arthritis (6)?
  • Age >80
  • Pre-existing joint disease
  • Diabetes
  • Recent joint surgery/infection
  • Prosthetic joint
  • IVDU
How do you diagnose septic arthritis (2)? What test must also be ordered?
  • Synovial fluid: 50,000 WBCs, gram stain/culture (+)
  • Blood cultures positive in 50% of Pts
  • Also order: X-ray to rule out associated osteomyelitis
What is the treatment for septic arthritis (2)?
  • IV antibiotics (by gram stain, x4 weeks), cover Staph.
  • Joint aspiration, surgical drainage in hip or prosthetic infection
What is Ludwig's angina?
Cellulitis of bilateral sublingual/submandibular spaces
What is the cause of Ludwig's angina?
Almost always caused by oral infection
  • 2nd and 3rd molars most common
  • 80% of patients report recent dental work or tooth pain
  • Other risks: immune compromise, tongue piercing, mandibular fracture 
What are 4 main items for management of Ludwig's angina?
  • Monitor/protect airway (1/3 require intubation)
  • Antibiotics (IV)
  • Surgical evaluation
  • CT scan to evaluate abscess and extend of spread
Describe antibiotic regimines (2) [2,3] for Ludwig's angina? What are the organisms? (name 3)
Polymicrobial: Strep, gram(+) anaerobes, Bacteroides
  • Penicillin G, 24 million units daily
    or
  • Clindamycin IV 600-900 IV q8h
    and 
  • Metronidazole (1gm, 500mg q6h)
Immunocompromised (atypical organisms: Pseudomonas, E.coli, Clostridium, Candida)
  • All of:
  • Piperacillin-Tazobactam 3.375g q6h
  • Ampicillin-Sulbactam 3g q6h
  • Ticarcillin-Clavulanate 3.1g q6h
What is Nikolsky's sign?
Skin reddens, fluid collects underneath, and skin rubs off, leaving raw red base
What is impetigo? What is the bullous kind?
An acute contagious staphylococcal or streptococcal skin disease characterized by vesicles, pustules, and yellowish crusts.

Bullous: Blister larger than 1cm, filled with clear fluid
Describe the organisms for Non-bullous versus Bullous impetigo?
Non-bullous
  • S. aureus > Group A Strep (S. pyogenes)
Bullous
  • Toxin-producing S. aureus
Describe the epidemiology for Non-bullous versus Bullous impetigo?
Non-bullous
  • Highly infectious
  • School age children
  • Auto-infection possible
Bullous
  • Neonates > Children > Adults 
Describe the diagnosis for Non-bullous versus Bullous impetigo?
Non-bullous: Clincal

Bullous impetigo: Clincal, Blood cultures, Sept eval.
Describe the Treatment for Non-bullous versus Bullous impetigo?
Non-bullous: Topical antibiotic

Bullous impetigo: Oral or IV antibiotic
  • Cloxacillin
  • Vancomycin (if risk of MSRA)
What are complications for non-bullous versus bullous impetigo?
Non-bullous impetigo: Rare

Bullous impetigo: Dehydration, sepsis
What organisms to think about for Human Bites?
They are polymicrobial
  • Viridens strep (100%)
  • Bacteroides (82%)
  • S. epidermidis (53%)
  • Corynebacterium (41%)
What does the Ankle-brachial Index (ABI) help with?
Assessment of Peripheral Vascular Disease (PVD)
What is a Charcot joint?
A weight-bearing joint that has undergone progressive degeneration with bony destruction, resorption and deformity.
What 3 levels do you assess a diabetic foot at?
  • Whole patient (signs of systemic illness, social supports)
  • Affected limb/foot (Anything that impairs healing including Charcot joint, edema, calluses, Peripheral vascular disease)
  • The infection
What will you see with infection in a diabetic foot (2)?
  • Inflammation
    +/- Purulent drainage
Describe the PEDIS/IDSA scale for diabetic foot (from 1 to 4)
  • 1 (uninfected) = no infection
  • 2 (mild) = infection of subQ tissue only
  • 3 (moderate) = infection deeper than subQ, or erythema >2cm
  • 4 (severe) = infection with SIRS
Which diabetic foot patients need to be hospitalized? How do you know?
Trust in the IDSA scale.

Hospitalize patients when:
  • Severe infection
  • Moderate infection with poor social support
  • Failing outpatient management 
When is a surgical consult for diabetic foot required?
Suspicion of deep space infection or necrotizing fasciitis
What 2 things are needed to manage diabetic foot infection?
  • Imaging
  • Wound culture
Why is imaging needed? What modality(s) are used?

  • XRay (osteomyelitis, bony deformity, foreign bodies or soft tissue gas)
    If osteo is unclear, do an MRI

When do you culture a chronically infected diabetic foot wound? What is proper procedure?
  • Culture if chronically infected, or recent antibiotics
  • Steps:
    1. Clean/debride
    2. Scrape ulcer base
    3. Aspirate purulent secretions
    4. Send for Gram stain, aerobic/anaerobic culture 
What 2 organisms do you need to cover for a diabetic foot infection? What are 4 other concerns for prescribing antibiotics?
  • Strep
    or
  • Staph

Other concerns:
  • Risk of MRSA: Empiric MRSA coverage required
  • Antibiotics in last month: Gram(-) Rods must be covered
  • Risk (warm climate, bare feet, water): Cover pseudomonas
  • Severe infection: Requires IV therapy and anaerobic coverage
What is Cellulitis?
Localized or diffuse inflammation of connective tissue, with severe inflammation of dermal and subcutaneous layers of the skin.
Describe the pathophysiology of Cellulitis.
A break in the skin allows skin flora to invade the dermis or subQ tissue, which can lead to bacteremia.

What are the 2 causative organisms for Cellulitis?
Causative organisms
  • Strep
    or
  • Staph
Describe the symptoms in simple and severe Cellulitis.
Simple/Localized
  • No systemic
  • WBC normal
  • Lymphadenopathy/Lymphangitis
Severe
  • Systemic symptoms
  • Bullae, hemorrhaging, swelling 
Where does Cellulitis present? (name 3 places in likeliness of presentation)
Lower extremities > upper extremities > face
How do you manage cellulitis? (5)
  • X-ray if trauma or foreign body
  • Ultrasound if abcess/DVT
  • Draw a line around to track spread
  • Give Antibiotics (Mild: Outpatient & oral, Severe: admit & IV), analgesics
  • Elevate foot

Needle aspirations/Blood cultures not necessary
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