Infection

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

Copyright 2007 Lippincott Williams & Wilkins

> Table of Contents > Medicine > Infection

Infection

A. See also

CNS Infections, p. 54.

B. Fever workup

• H&P: Pain, cough, shortness of breath, dysuria, diarrhea, new drugs. Vital signs; lung, cardiac, abdomen, mouth, skin, fundi,

• Tests: CBC, UA, urine culture, CXR; consider sputum culture, stool culture for C. difficile, wound culture, line tip culture throat swab, LP, shunt tap, ascites tap, induced sputum for TB, HIV test, echocardiogram . Drug fever and tumor fever = dx of exclusion.

  • Blood cultures: If T >101.5 F. If pt. has a central line, draw one off each port and one peripherally.

  • LP: If neurological signs, encephalopathy, severe HA, meningismus, recent brain trauma, or surgery. See Lumbar Puncture, p. 224; Cerebrospinal Fluid, p. 19.

C. Infection precautions

Refer to institutional policies for specifics. These lists are not complete.

• Contact: For pts. with certain skin and enteric infections.

  P.213

  
  

  • Use: Hand hygiene, glove, gown, dedicated equipment, private room or coinfected roommate.

  • Agents: Methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus (VRE), chickenpox or disseminated VZV, C. difficile, others.

• Droplet: Spread by large respiratory droplets when the pt. coughs, sneezes, talks.

  • Use: Hand hygiene, disposable surgical mask when within 3 feet of pt., private room.

  • Agents: Meningococcal infection, H. influenzae meningitis or respiratory infection, Mycoplasma pneumonia, rubella.

• Airborne: Spread by small droplets when the pt. breathes.

  • Use: Hand hygiene, fitted respirator, isolation room with negative pressure. Nonimmune personnel should avoid exposure to patient if possible.

  • Agents: Tuberculosis, chickenpox or disseminated VZV, measles, SARS, avian flu.

• Neutropenic precautions: If absolute neutrophil count <500 (where ANC = WBC %PMNs).

  • Inpts need: Positive pressure rooms to avoid infection, contact and droplet precautions, bleeding precautions if platelets <20, nystatin swish and swallow 10 cc qid.

  • Agents: HIV, bone marrow transplants, chemotherapy .

  • Infection and neutropenia: Does an HIV pt. with TB get a positive pressure room inside a negative pressure room?

D. Human immunodeficiency virus (HIV)

See also neurological consequences of HIV, p. 227.

• Protease inhibitors: Agenerase = amprenavir, Crixivan = indinavir, Invirase = saquinavir, Kaletra = lopinavir/ritonavir, Norvir = ritonavir, Viracept = nelfinavir.

• NRTIs: Nucleoside reverse transcriptase inhibitors. They may cause distal symmetric peripheral polyneuropathy. Hivid = ddC (zalcitabine), Videx = DDI (didanosine), Zerit = D4T (stavudine).

• NNRTIs: Nonnucleoside reverse transcriptase inhibitors. Epivir = 3TC (lamivudine), Rescriptor = delavirdine, Retrovir = AZT (zidovudine), Sustiva = efavirenz, Viramune = nevirapine.

• Secondary infections: Bacterial, pneumocystis, toxoplasmosis, fungal, mycobacterial, viral (PML, CMV, HSV, VZV), syphilis. .

  • Prophylactic Abx: Pts. should get azithromycin for Mycobacterium avium when CD4 <50, Bactrim for pneumocystis and toxoplasmosis when <200 and toxoplasmosis when <100, itraconazole for histoplasmosis in endemic areas when <100.

• Secondary neoplasms: Kaposi's sarcoma; lymphoma.

E. Antibiotic recommendations for adults

See also Abx resistance tables, p. 215. These are rough guidelines only. Revise Abx when culture data become available. Except when you must give Abx immediately, make sure all cultures have been taken before starting Abx. Not all febrile pts. need Abx.

P.214

Table 56. Empiric antibiotic recommendations. (MGH data, 2005. These guidelines are not useful outside the USA. Courtesy of David Hooper, MD.)

Suspected Cause	First Choice
Community-Acquired Pneumonia
H. flu, M. catarr. or unclear	Ceftriaxone IV macrolide
Aspiration/oral flora	Penicillin IV metronidazole
Strep. pneumoniae	Penicillin IV
Staph. aureus	Nafcillin
GNR, or recent hospital stay	Ceftriaxone or cefepime metronidazole
Sepsis Syndrome
Intra-abdominal/pelvic source	Ampicillin metronidazole levofloxacin
Urosepsis	Ampicillin gentamicin
Unknown source	Vancomycin ceftriaxone metronidazole
Neutropenic host with fever	Cefepime
Acute Bacterial Meningitis
Immunocompetent host	Ceftriaxone vancomycin
Immunocompromised host	Ceftriaxone ampicillin vancomycin
IVDA, head trauma/surgery	Nafcillin [ceftriaxone or ceftazidime]
Skin and SoftTissue Infection
No underlying dz	Nafcillin or cefazolin
Underlying dz (DM, IVDA )	Ampicillin-sulbactam or piperacillin-tazobactam
Urinary Tract Infection
Patients who need IV Abx	Ampicillin gentamicin
AcuteSeptic Arthritis
No underlying disease	Nafcillin or cefazolin
Prosthetic joint	Vancomycin gentamicin
Likely gonorrhea	Ceftriaxone

F. Remove foreign bodies

Change central lines, consider removal of bladder catheter, ventricular shunt .

G. Control fever

E.g., with acetaminophen; consider cooling blanket. Fever can worsen infarct size, strain the heart, and cause dehydration.

H. Fever and neutropenia

See Neutropenic precautions, p. 213.