‫ﺑﺳم ﷲ اﻟرﺣﻣن اﻟرﺣﯾم‬

Infectious
Diseases
Hana faroug
MCP,BCPS 1
 Agenda
• RTI (Pneumonia, Influenza, sinusitis)
• UTIs
• Skin and Soft Tissue Infections
• Diabetic foot infections
• Osteomyelitis
• CNS Infections
• Endocarditis
• Peritonitis / Intra-abdominal Infections
• Clostridium difficile Infection
• Surgical Prophylaxis 2
1- RESPIRATORY
TRACT
INFECTIONS
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❖ Pneumonia :
▪ Pneumonia is the most common cause of death

attributable to ID and the seventh most common cause

of death in the USA.

▪ Hospital-acquired pneumonia (HAP) is the second most

common nosocomial infection.

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❖ Mortality rates :

– a. CAP without hospitalization: < 1%

– b. CAP with hospitalization: About 14%
– c. Nosocomial: About 33%–50%

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❖ Community-Acquired Pneumonia
Definition:
➢ Acute infection of the pulmonary parenchyma,
accompanied by the presence of an acute infiltrate
consistent with pneumonia on chest radiograph or
auscultatory findings.
• Pts must also NOT have any of the following
characteristics:

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1. ≥2 days hospitalization in the past 90 days;

2. residence in a long-term care facility;

3. receipt of IV antibiotic therapy,

chemotherapy, or Wound care in the past 30
days;
4. attendance at a hospital or hemodialysis clinic.

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❖ Predictors of a complicated course of CAP:
a. Age > 65 years
b. Comorbid illness (DM, CHF, lung disease, RF,
liver disease)
c. High temperature: >101°F (38°C)
d. Bacteremia
e. Altered mental status
f. Immunosuppression (e.g., steroid use, cancer)
g. High-risk etiology (Staphylococcus aureus, Legionella,
gram-negative bacilli, anaerobic aspiration)
h. Multilobe involvement or pleural effusions

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❖ Symptoms of CAP :
• Elderly pts often have fewer and less severe findings
(mental status changes are common).
– a. Fever or hypothermia
– b. Rigors
– c. Sweats
– d. New cough with or without sputum (90%)
– e. Chest discomfort (50%)
– f. Onset of dyspnea (66%)
– g. Fatigue, myalgias, abdominal pain, anorexia, and
headache
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❖ Severity-of-illness scoring systems in CAP:
a. CURB-65

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b. PSI or PORT (predictive ability similar to CURB-65, but better in patients with
lower mortality risk)
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 CAP Therapy
• Treatment duration:
At least 5 days, with 48–72 hours
afebrile and no more than one sign of
clinical instability (elevated temperature,
heart rate, or respiratory rate; decreased
systolic blood pressure; or arterial
oxygen saturation) before therapy
discontinuation.

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 a. Empiric ttt of non-hospitalized pts
Outpatient ≤1
❑ Previously healthy / No antibiotics in 3 months:
1. Macrolide (clarithromycin or azithromycin)
2. Doxycycline

❑ Comorbidities / Antibiotics in 3 months:

1. Respiratory Fluoroquinolone (levo- 750mg, moxi-, gemi-)

2. Macrolide (or doxycycline) + high-dose amoxicillin (1g TID)

or amoxicillin/clavulanate (2g BID) or cephalosporin

(ceftriaxone, cefuroxime, cefpodoxime)
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Empiric ttt of hospitalized pts ē moderately severe
pneumonia
Inpatient =2-3 “regular floor”

❑ Moderately severe :
1. Respiratory Fluoroquinolone (levo- 750mg, moxi-,gemi)

2. Macrolide (or doxycycline) plus Ampicillin,

ceftriaxone, or cefotaxime (ertapenem in select pts)

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 Empiric ttt of hospitalized pts ē severe
pneumonia (Inpatient ≥4 “ICU”)
( may need to add other antibiotics if P.aeruginosa
or MRSA are suspected)

➢ either a respiratory fluoroquinolone or

azithromycin plus Ampicillin/sulbactam or
Ceftriaxone or Cefotaxime
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 Nosocomial Pneumonia
❑ 1. HAP :
▪ pneumonia that occurs ≥48 hours after admission and is not
incubating at the time of admission

❑ 2. Ventilator-associated pneumonia :
▪ pneumonia that arises > 48–72 hours after endotracheal
intubation

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❑ 3. Health care–associated pneumonia :
▪ pneumonia developing in a pt who was :
1. hospitalized in an acute care hospital for ≥ 2 days within
90 days of the infection;
2. who resided in a nursing home or long-term care facility;
3. who received recent IV antibiotic therapy, IV
chemotherapy, or wound care within the past 30 days of
the current infection.
4. who attended a hospital or hemodialysis clinic
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 HAP

Early onset (< 5 days) and Late onset (≥5) or risk

*(no RF (MDR factors for MDR organisms

Treatment duration:
Efforts should be made to decrease therapy duration to as
short as 7 or 8 days.
(14 days for pneumonia secondary to P. aeruginosa or
Acinetobacter). 20
❑ Risk factors for MDR organisms :
i. Antibiotic therapy within the past 90 days
ii. Hospitalization of 5 days or more
iii. High resistance in community or hospital unit
iv. Risk factors for health care–associated pneumonia
(a) Hospitalization for ≥ 2 days in the preceding 90 days
(b) Residence in a nursing home or extended care facility
(c) Home infusion therapy (including antibiotics)
(d) Chronic dialysis within 30 days
(e) Home wound care
(f) Family member with MDR pathogen
v. Immunosuppressive disease and/or therapy 21
Early onset (< 5 days) and no risk factors for MDR
organisms

i. Third-generation cephalosporin (ceftriaxone)

ii. Fluoroquinolone (levo, moxi, cipro)

iii. Ampicillin/sulbactam

iv. Ertapenem

Common organisms include :

Streptococcus pneumoniae, (MSSA),
H. influenzae,
E.coli, K. pneumoniae, Enterobacter spp., and Proteus spp.
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 Late onset (5 days or longer) or risk factors for
MDR organisms
i. aminoglycoside or fluoroquinolone (cipro, levo) plus

Ceftazidime or cefepime

ii. aminoglycoside or fluoroquinolone (cipro,levo) plus

Imipenem, meropenem, or doripenem

iii. aminoglycoside or fluoroquinolone (cipro, levo) plus

Piperacillin/tazobactam
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❑Common organisms include :
▪ those listed above for early onset plus Pseudomonas aeruginosa,
K. pneumoniae (extended-spectrum β-lactamase +ve),
Acinetobacter spp., MRSA, and Legionella pneumophila

iv. Vancomycin or linezolid should be added to the above

regimens only if MRSA risk factors :
▪(e.g., history of MRSA infection/colonization,
▪recent hospitalization or
▪antibiotic use,
▪presence of invasive health care devices) are present or
▪ there is a high incidence locally (> 10%–15%).
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jm

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1. Characteristics of influenza infection :
a. Epidemic with significant mortality
b. Epidemics begin abruptly → peak in 2–3 weeks → resolve in 5–6
weeks
c. Occurs almost exclusively in the winter months (December–April)
d. Average overall attack rates of 10%–20%
e. Mortality greatest in those > 65 years (especially with heart and lung
disease): > 80% of deaths caused by influenza are from this age
group (20,000 deaths a year in the United
States).

2. Is it a cold or the flu?

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 Pathophysiology

a. Type A:
i. Influenza further grouped by variations in
hemagglutinin and neuraminidase (e.g., H1N1,
H3N2)
ii. Changes through antigenic drift or shift
(a) Drift: Annual, gradual change caused by
mutations, substitutions, and deletions
(b) Shift: Less common dramatic change leading to
pandemics
iii. Causes epidemics every 1–3 years

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Type B:
i. Type B influenza carries one form of
hemagglutinin and one form of
neuraminidase, both of which are less likely to
mutate than the hemagglutinin and
neuraminidase of type A influenza.
ii. Changes through antigenic drift (minor
mutations from year to year); when enough
drifts occur, an epidemic is likely.
iii. Causes epidemics every 5 years

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❑ ttt indicated in pts with confirmed or suspected
influenza + the following conditions :
(use only the neuraminidase inhibitors)
i. Hospitalized pts
ii. Severe, complicated, or progressive illness
iii. High risk of influenza complications:
1. Pts < 2 years or ≥ 65 years
2. Pts with chronic disease states: Pulmonary (including
asthma), cardiovascular (except HTN alone), renal,
hepatic, hematologic (including sickle cell disease),
metabolic disorders (including DM ), or neurologic and
neurodevelopment conditions
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 3. Immnosupppressed patients
4. Pregnant women
5. Pts < 19 years who are receiving long-term aspirin
therapy
6. American Indians/Alaska Natives
7. Pts who are morbidly obese
8. Residents of nursing homes and other long-term care
facilities

iv. ttt may be considered for those without risk factors

according to clinical judgment (must initiate within
48 hours)

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❑ Adamantanes:
i. Amantadine (Symmetrel); rimantadine (Flumadine)

ii. Inhibits viral uncoating and release of viral nucleic acid by

inhibiting M2 protein
(a) Effective only against influenza A virus.
(b) Not recommended for treatment because of current universal
resistance in influenza A

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❑ Neuraminidase inhibitors :
i. Oseltamivir (Tamiflu), Zanamivir
(Relenza)
ii. Inhibit neuraminidase; symptoms
resolve 1–1.5 days sooner
iii. Adverse effects :

(a) Oseltamivir:
Gl (nausea and vomiting)
(b) Zanamivir:

Bronchospasm, cough
(not recommended in pts with
asthma or COPD)
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• iv. Dose
• (a) Oseltamivir: 75 mg orally BID daily for 5 days;
decrease dose to 75 mg/day orally in pts with crcl
< 30 mL/minute

• (b) Zanamivir: Two inhalations (5 mg/inhalation)

BID daily for 5 days

Oseltamivir should be initiated only within 48 hours of

symptom onset.

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5. Prevention :

a. Chemoprophylaxis only for influenza-related

complications in individuals at very high risk (e.g., severely
immunosuppressed pts) who cannot be protected by the
vaccine when a high risk of exposure exists.

b. Amantadine, rimantadine:
▪ Not recommended for prevention because of current
universal resistance

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❑ Neuraminidase inhibitors :

➢ i. Oseltamivir (Tamiflu)

(a) Oseltamivir administered 75

mg/day orally for 6 weeks during
peak influenza season showed 74%
protective efficacy (as prophylaxis
in unvaccinated individuals).

(b) Begin oseltamivir 75 mg/day orally

within 2 days of close contact with
an infected individual, and continue
for no more than 10 days.

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➢ ii. Zanamivir (Relenza)
(a) Zanamivir 10 mg/day through
inhalation for 4 weeks during peak
influenza season showed 67%
protective efficacy (as prophylaxis in
unvaccinated individuals).

(b) Begin zanamivir 10 mg/day within 5

days of community outbreak and
continue for 4 weeks during peak
influenza season.

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Immunizations Related to the Respiratory
Tract

1. Pneumococcal vaccine.

2. Influenza vaccine.

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 Pneumococcal vaccines
Pneumococcal polysaccharide vaccine (PPSV23)
i. PPSV contains 23 purified capsular polysaccharide
antigens of S. pneumoniae.
iii. Antibody levels remain elevated for at least 5 years.

Pneumococcal conjugate vaccine (PCV13)

i. PCV contains 13 purified capsular polysaccharide
antigens of S. pneumoniae conjugated to a carrier
protein.
ii. The 13 capsular types are all in PPSV23 except for
one.

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Pneumococcal Vaccine Recommendations :
(all recommendations are for PPSV23 except where noted)

(13+23)

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 (13+23)

(13+23)
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 Influenza vaccine

❑Recommendations :
i. Everyone > 6 months →→→should receive the vaccine
annually.
ii. Children < 9 years →→→ should receive two doses, at least
1 month apart, the first season they receive the vaccine.
iv. Administer yearly in September or October.

• In adults the Centers for Disease Control and

Prevention (CDC) currently does not recommend
one vaccine over any other.
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 Definition and etiology
• a. Inflammation of the mucosal
lining of the nasal passage and
paranasal sinuses lasting up to
4 weeks
• b. Many different causes,
including viruses, bacteria, and
fungi.
• c. Viruses account for > 90% of
cases, whereas bacteria
account for < 10%.
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 Diagnosis
Presence of at least two major symptoms or one
major and two or more minor symptoms

(Bad breath)

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b. Viral or bacterial?

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S.C. is a 46-year-old woman who presents to the clinic
with purulent nasal discharge, nasal and facial
congestions, headaches, fever, and dental pain. Her
symptoms began about 10 days ago, improved after
about 4 days, and then worsened again a few days
later.
Which is the best empiric therapy for S.C.?
A. Cefpodoxime 200 mg twice daily.
B. Clindamycin 300 mg oral four times daily.
C. Amoxicillin/clavulanate 875 mg/125 mg every12 hours.
D. No antibiotic therapy needed because this is a
typical viral infection.

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52
 URINARY TRACT INFECTIONS
1. Most common bacterial infection in
humans: 7 million office visits per year; 1
million hospitalizations.

2. Many women (15%–20%) will have a urinary tract

infection (UTI) during their lifetime.

3. From 1–50 years of age, UTIs occur predominantly

in women; after 50, men are affected because
ofprostate problems.

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Incidence of Urinary Tract Infections
by Organism

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 Clinical Presentation
• Lower UTI: ( Cystitis )
(older adults may have only nonspecific symptoms,
such as mental status changes ,abdominal pain, and
decreased eating or drinking)
a. Dysuria
b. Frequent urination
c. Urgency
d. Occasionally, gross hematuria
e. Occasionally, foul-smelling urine
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• Upper UTI: (Pyelonephritis )
(older adults may have only nonspecific symptoms,
such as mental status changes, abdominal pain, and
decreased eating or drinking)
a. Frequency, dysuria, hematuria
b. Suprapubic pain
c. Costovertebral angle tenderness; flank pain
d. Fever, chills
e. Elevated WBC
f. Nausea, vomiting

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Factors associated with or used to define
complicated UTI
a. Male sex
b. Hospital acquired
c. Pregnancy
d. Anatomic abnormality of the urinary tract
e. Childhood UTIs
f. Recent antimicrobial use
g. Indwelling urinary catheter
h. Recent urinary tract instrumentation
i. Immunosuppression
J. DM
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❑ Recurrent cystitis :

➢ a. Relapse:
Infection with the same organism within 14 days
of discontinuing antibiotics for the preceding UTI.

➢ b. Reinfection:
Infection with a completely different
organism—most common cause of recurrent
cystitis

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 Therapy
❑ 1. Uncomplicated cystitis :
a. Recommended therapy :
i. Trimethoprim/sulfamethoxazole →→ Duration:
3days
ii. Nitrofurantoin →→ Duration: 5 days
iii. Fosfomycin →→ Duration: One dose
b. Alternatives :
i. Fluoroquinolones – Duration: 3 days
ii. β-Lactams – Duration: 3–7 days

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❑ 2. Uncomplicated pyelonephritis :

Outpatient therapy :

(if pt is not immunocompromised or does not have N/V)

– i. Trimethoprim/sulfamethoxazole – Duration: 14 days
– ii. Fluoroquinolone – Duration: 5–7 days
– iii. β-Lactam – Duration: 10–14 days (less effective than first two
options)
Uropathogen resistance > 10%

Use initial dose of an IV , long-acting β-lactam (e.g., ceftriaxone) or

once-daily aminoglycoside.

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❑ 3. Complicated UTIs :
Inpatient therapy

i. Fluoroquinolone
ii. Aminoglycoside
iii. Extended-spectrum β-lactam
Therapy duration:
5–14 days (5 days with levofloxacin)

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❑ 4. Pregnancy :
• (pregnant women should be screened for bacteriuria
and treated, even if asymptomatic)
• a. Seven-day treatment regimen
i. Amoxicillin
ii. Nitrofurantoin b. Antibiotics to avoid
(avoid after 38 weeks’ gestation
i. Fluoroquinolones
and during labor and delivery)
ii. Tetracyclines
iii. Cephalexin iii. Aminoglycosides
iv. Trimethoprim/sulfamethoxazole
(used frequently but avoidance
recommended, especially (late 3d
trimester)
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Recurrent cystitis :
a. Relapse
i. Assess for pharmacologic reason for treatment failure.
ii. Longer treatment (for 2–6 weeks,depending on length of
initial course.

b. Reinfection :
i. If pt has two or fewer UTIs in 1 year,→→→→→ use
pt-initiated therapy for symptomatic episodes (3-day
treatment regimens).

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ii. If pt has ≥ 3 UTIs in 1 year and they are
temporally related to sexual activity, →→→→→
use post-intercourse prophylaxis with:
• trimethoprim/sulfamethoxazole single strength.
• cephalexin 250 mg.
• nitrofurantoin 50–100 mg.

iii. If pt has ≥ 3 UTIs in 1 year that are not related to

sexual activity, →→→→→ use daily or three
times/week prophylaxis with:
• trimethoprim 100 mg.
• trimethoprim/sulfamethoxazole single strength.
• cephalexin 250 mg, or nitrofurantoin 50–100 mg

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 Catheter-related UTIs
a. Short-term indwelling catheters :
▪Preventive antimicrobial therapy is not recommended (resistance)

▪ Asymptomatic pts ē bacteriuria →→→ should not be treated

▪ Symptomatic + bacteriuria →→→ should be treated with (7 days if

symptoms Resolve) (10–14 days of if delayed response)
(both durations whether or not catheter removed).

▪Treat for 5 days ē levofloxacin if the patient is not severely ill.

▪ Treat for 3 days in women ≤ 65 years who have their catheters

removed and who do not have upper urinary tract symptoms.
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b. Long-term indwelling catheters :
i. Virtually all pts will be bacteriuric with two to five
organisms.
ii. Asymptomatic pts→→→→→ should not be treated.
iii. Symptomatic pts →→→→→ should be treated (7 days)
to prevent resistance, and →→→→→ catheter
replacement may be indicated

❑NP from self ass:

▪If the pt was asymptomatic, →→ the catheter does not need to
be replaced.
▪ If she were symptomatic, →→ catheter replacement might be
indicated.
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 Prostatitis
a. Acute bacterial prostatitis
i. Primarily gram-negative organisms
ii. Therapy duration, 4 weeks
(a) TMP/SMZ
(b) Fluoroquinolones

b. Chronic bacterial prostatitis

i. Difficult to treat
ii. Therapy duration, 1–4 months
(a) TMP/SMZ
(b) Fluoroquinolones
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 Epididymitis
• a. > 35 years;
(enteric organisms)
Epididymitis is an
i. Therapy: inflammation of the coiled
duration: 10 days to 4 weeks tube (epididymis) at the
ii. Antibiotics: TMP/SMZ back of the testicle that
or fluoroquinolones stores and carries sperm.
• b. < 35 years;
(gonococcal or chlamydial)
i. Therapy:
duration: 10 days
ii. Antibiotics:
Ceftriaxone 250 mg IM once
plus doxycycline 100 mg BID
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69
 Skin & Soft
Tissue Infections

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 Cellulitis
Description :
a. involves the deep dermis and SC fat
b. Non-elevated and poorly defined
margins
c. Warmth, pain, erythema and edema,
and tender lymphadenopathy
d. Malaise, fever, and chills
e. Usually, patient has had previous
minor trauma, abrasions, ulcers, or
surgery (could be as little as tinea
infections, psoriasis, or eczema).
Usually S. pyogenes and occasionally
S. aureus (rarely other organisms)
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Treatment:
5–10 days (may extend therapy if infection has not
improved)
a. Antistaphylococcal penicillin.
(nafcillin, oxacillin, or dicloxacillin)
b. Penicillin G if definitively streptococcal.
Alternatives
i. Clindamycin
ii. β-Lactamase inhibitor combinations
iii. First-generation cephalosporin
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 Treat empirically for
MRSA if
1. Associated with
penetrating trauma,
esp. from illicit drug
use.
2. purulent drainage
3. Concurrent evidance of
MRSA infection else
where.

▪i. Outpatient :
Clindamycin,Trimethoprim/sulfamethoxazole (add β-lactam for
Streptococcus), doxycycline (add β-lactam for Streptococcus).

▪ii. Inpatient :
Vancomycin, linezolid, daptomycin, telavancin. 73
 Erysipelas
Description
a. involves the superficial dermis
c. Usually (infants & elderly)
d. Usually (legs and feet (facial
less common)
e. Warmth, erythema, and pain
f. Edge of infection is elevated
and sharply demarcated from
the surrounding tissue.

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 • Microorganism: Group A Streptococcus (S.
pyogenes), but occasionally, groups G, C, and
B are seen

❑Treatment:
5 days (may extend therapy if infection has not
improved)
1. Penicillin G
2. Clindamycin

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 Necrotizing Fasciitis
Description :
a. Acute, necrotizing cellulites that involve
the SC fat and superficial fascia
b. Infection extensively alters surrounding
tissue, leading to cutaneous anesthesia
or gangrene.
c. Very painful
d. Streptococcal infection: Either
spontaneous or attributable to varicella,
minor trauma (cuts, burns, and splinters),
surgical procedures, or mixed infection
(abdominal surgery or trauma)

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❑ Microorganisms :
• a. S. pyogenes
• b. Mixed infection with facultative and anaerobic bacteria

❑Treatment :
a. Surgical debridement: Most important therapy (repeated
debridement)
b. Antibiotics : are not curative; given in addition to surgery (if
used early, may be effective alone)
c. Empiric therapy:
Vancoycin or linezolide plus pipracillin\tazobactam or
carbapenem or ceftriaxone with metronidazole.

d. Streptococcal necrotizing fasciitis:

High-dose IV penicillin plus clindamycin
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Varicella-Zoster immunization
“Shingles vaccine ”

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 4. Diabetic
Foot Infections

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 Etiology
1. Neuropathy:
Motor and autonomic
a. Mechanical or thermal injuries lead to ulcerations
without patient knowledge.
b. Gait disturbances and foot deformities; maldistribution
of weight on the foot
c. Diminished sweating, causing dry, cracked skin
2. Vasculopathy:
Decreased lower limb perfusion
3. Immunologic defects:
Cellular and humoral
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 Therapy
✓ Preventive therapy:
a. Examine feet daily for calluses, blisters,
trauma, and so forth.
b. Wear properly fitting shoes.
c. No barefoot walking
d. Keep feet clean and dry.
e. Have toenails cut properly.

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 Antimicrobial therapy
✓ Polymicrobial (gm+ve, gm-ve & anaerobic)
a. Mild infections (and no antibiotics in the past month)
i. No MRSA risk factors:
• penicillinase-resistant penicillin,
• first-generation cephalosporin,
• fluoroquinolone,
• clindamycin
ii. MRSA risk factors:
• doxycycline
• trimethoprim/sulfamethoxazole
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• b. Moderate to severe infections
– Ampicillin/sulbactam
– Ertapenem
– Cefoxitin
– Third-generation cephalosporin
– Moxifloxacin alone or ciprofloxacin/levofloxacin
plus clindamycin
– Tigecycline

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 • If risk of P. aeruginosa use:
piperacillin/tazobactam, ceftazidime, cefepime, or
carbapenem.
✓ Risk factors
– patients soaking their feet,
– lack of response to nonpseudomonaltherapy,
– a severe infection.

• If risk of MRSA use:

vancomycin, linezolid, or daptomycin.
✓ Risk factors
– history of MRSA infection or colonization,
– high local prevalence of MRSA,
– a severeinfection.

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 Treatment duration

• 1–2 weeks for mild to moderate infections .

• 2–3 weeks for severe infections.

• Surgical Therapy:

1. Drainage and debridement (appropriate wound care) are

very important.
2. Amputation is often necessary; if infection is discovered
early, can maintain structural integrity of the foot.

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Therapy Length :
1. Acute osteomyelitis: 4–6 weeks
2. Chronic osteomyelitis: 6–8 weeks
of parenteral therapy and 3–12
months of oral therapy

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 ➢Prosthetic joint infections :
b. Debridement and retention of prosthesis or one-stage
exchange of prosthesis

i. Staphylococcal: Pathogen-specific IV therapy

plus rifampin 350–400 mg twice daily for 2–6 weeks,
followed by rifampin plus ciprofloxacin or levofloxacin
for 3 months (hip, elbow, shoulder, ankle prosthesis) or
6 months (knee prosthesis).
ii. Non-staphylococcal: Pathogen-specific IV (or
highly bioavailable oral) therapy for 4–6 weeks, followed by
indefinite oral suppression therapy.

93
b. Resection of prosthesis with/without planned
reimplantation or amputation:

i. Pathogen-specific IV (or highly bioavailable

oral) therapy for 4–6 weeks.

ii. Only 24–48 hours of antibiotic therapy after

amputation if all infected tissue is removed.

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6. (CNS) Infections

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“Meningitis”

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❑ Clinical Presentation :
1. Symptoms :
a. Fever, chills
b. Headache, backache, nuchal
rigidity, mental status
changes, photophobia
c. Nausea, vomiting, anorexia,
poor feeding habits (infants)
d. Petechiae/purpura (Neisseria
meningitidis meningitis)
2. Physical signs :
a. Brudzinski sign
b. Kernig sign
c. Bulging fontanel 99
❑Diagnosis :
1. History and physical examination
2. Lumbar puncture
(CSF stains/studies)
3. Laboratory findings
a. Increased WBC with a left shift
b. CSF Gram stain
c. CSF cultures (positive in 75%–80% of bacterial meningitis cases)
d. Blood cultures (±)
e. C-RP conc : High negative predictive value

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❑ Empiric Therapy :
▪ 1. Neonates < 1 month :
• a. Ampicillin plus aminoglycoside or
• b. Ampicillin plus cefotaxime
▪ 2. Infants (1–23 months):
Third-generation cephalosporin (cefotaxime or
ceftriaxone) plus vancomycin
▪ 3. Pediatrics and adults (2–50 years):
Third-generation cephalosporin (cefotaxime or
ceftriaxone) plus vancomycin

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 4. Older adults (≥ 50 years):
Third-generation cephalosporin (cefotaxime or
ceftriaxone) plus vancomycin plus ampicillin

5. Penetrating head trauma, post-neurosurgery, or CSF

shunt:
Vancomycin plus cefepime, ceftazidime, or
meropenem

NB from self ass :

Even if a patient is believed to have aseptic meningitis after analysis of
the CSF, antibiotics need to be given until CSF cultures are negative
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Therapy for Common Pathogens

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 Adjunctive Corticosteroid Therapy
1. Less hearing loss and other neurologic sequelae in
children with H. Influenzae meningitis
2. Improved outcomes, ↓mort. in adults with
S.pneumoniae meningitis.
3. May decrease antibiotic penetration.
Dose and administration :
▪ Give corticosteroids 10–20 minutes before or at same time as
antibiotics.
▪ Dexamethasone 0.15 mg/kg q6h for 2-4 day; 10-20 mins before or
at AB time.

Use in children with→→→ H. influenzae meningitis or in adults with

pneumococcal meningitis; however, may need to initiate before knowing
specific causative bacteria 106
Prophylaxis

107
108
109
 Brain Abscess
Pathophysiology :
• a. Direct extension or retrograde septic phlebitis
from otitis media, mastoiditis, sinusitis, and facial
cellulitis.
• b. Hematogenous: Particularly lung abscess or
infective endocarditis: 3%–20% have no
detectable focus.

110
• Signs and symptoms :
a. Expanding intracranial mass lesion: Focal
neurologic deficits
b. Headache
c. Fever
d. Seizures
e. Mortality is about 50%.

• Microbiology
a. Usually polymicrobial
b. Streptococcus spp. in 50%–60%
c. Anaerobes in about 40%

111
❑Therapy :
a. Incision and drainage: By craniotomy or
stereotaxic needle aspiration
b. Suggested empiric regimens based on source of
infection :
• Otitis media or mastoiditis:
Metronidazole plus third-generation cephalosporin
• Sinusitis:
Metronidazole plus third-generation cephalosporin
112
 • Dental sepsis:
Penicillin plus metronidazole
• Trauma or neurosurgery:
vancomycin plus third-generation cephalosporin.
• Lung abscess, empyema:
penicillin plus metronidazole plus sulfonamide.
• Unknown:
vancomycin plus metronidazole plus
third-generation cephalosporin.

✓ Corticosteroids if elevated intracranial pressure

113
 Case

• Prophylaxis ?? 114
B /Neisseria meningitidis/Rifampin or
ceftriaxone 115
7. Endocarditis

116
Endocarditis

117
Treatment Recommendation for Endocarditis

118
HACEK = Haemophilus, Actinobacillus Cardiobacterium,
Eikenella, Kingella
119
 7
1

2
3

4
5

120
121
• BV is scheduled to have a dental procedure (root
canal) performed next week. She has a history of
congenital heart disease. She is allergic to
penicillin (rash). Which one of the following
prophylaxis, if any, would you recommend?

(A) no prophylaxis is required

(B) amoxicillin 2 g, one hour before procedure
(C) clindamycin 600 mg, one hour before and six
hours after procedure
(D) clarithromycin 500 mg, one hour before
procedure
122
• BV is scheduled to have a dental procedure (root
canal) performed next week. She has a history of
congenital heart disease. She is allergic to
penicillin (rash). Which one of the following
prophylaxis, if any, would you recommend?

(A) no prophylaxis is required

(B) amoxicillin 2 g, one hour before procedure
(C) clindamycin 600 mg, one hour before and six
hours after procedure
(D) clarithromycin 500 mg, one hour before
procedure
123
124
 PERITONITIS AND INTRA-ABDOMINAL
INFECTIONS
Therapy:
Therapy or prophylaxis should be limited in:
a. Bowel injuries caused by trauma that are repaired
within 12 hours
b. Intraoperative contamination by enteric contents
c. Perforations of the stomach, duodenum, and proximal
jejunum.
d. Acute appendicitis without evidence of perforation,
abscess, or peritonitis.
(treat for less than 24 hours)
125
• Mild to moderate community-acquired infection
a. Cefoxitin
b. Cefazolin, cefuroxime, ceftriaxone, or cefotaxime plus
metronidazole
c. Ticarcillin/clavulanate
d. Ertapenem
e. Moxifloxacin
f. Ciprofloxacin or levofloxacin plus metronidazole
g. Tigecycline
• High-risk or severe community-acquired or health care–acquired
infection
a. Piperacillin/tazobactam
b. Ceftazidime or cefepime plus metronidazole
c. Imipenem/cilastatin, meropenem, or doripenem
d. Ciprofloxacin or levofloxacin plus metronidazole (not
for health care–acquired infections)
e. Aminoglycoside when extended-spectrum
β-lactamase–producing Enterobacteriaceae or P.
aeruginosa is of concern (health care–acquired
infections only)
f. Vancomycin for MRSA (health care–acquired infections
only)
126
Therapy duration: 4–7 days (unless source control is difficult)
Clostridium difficile Infection

127
128
129
130
MEDICAL AND SURGICAL
PROPHYLAXIS

131
MEDICAL/SURGICAL PROPHYLAXIS

132
✓ Antibiotics must be present in the tissues at the time of bacterial
contamination (incision) and throughout the operative period;
“on-call” dosing is not acceptable.

✓ Administering antibiotics earlier than immediately preoperatively

(within 60 minutes before incision or 60–120 minutes if using
vancomycin or a fluoroquinolone) is unnecessary.

✓Administering antibiotics Postoperatively is no more effective than

administering no prophylaxis.
133
✓ Redose if the surgery lasts longer than 4 hours (or more
than 2 half-lives of the antibiotic) or involves considerable
blood loss.
✓ Cardiac procedures may require 24 hours of antibiotics
postsurgery.

134
 Antibiotic Prophylaxis in Specific Surgical Procedures

1. Gastrointestinal:
a.Gastric/duodenal:
i. Because of acidity, little normal flora
iii. Indicated for morbid obesity, esophageal obstruction,
decreased gastric acidity, or decreased gastrointestinal motility.
iv. Recommendation: Cefazolin 2 g before induction
b. Biliary :
Indicated for high-risk patients:
(a) Acute cholecystitis
(b) Obstructive jaundice
(c) Common duct stones
(d) Age older than 70 years
iii. Recommendation: Cefazolin, cefoxitin, cefotetan, or ceftriaxone
2 g or ampicillin/sulbactam 3 g before induction
135
c. Appendectomy:
i. Acutely inflamed or normal appendix: Less
than 10% risk
ii. Evidence of perforation: More than 50% risk
(treatment necessary)
iii. If perforated appendix, treat for 3–7 days
iv. Recommendation: Cefoxitin or cefotetan 2 g
(or cefazolin plus metronidazole) before
induction

136
d. Colorectal :
coverage for aerobes and anaerobes has proved most
effective
Preoperative antibiotics:
• Cefoxitin or cefotetan 2 g (or cefazolin or ceftriaxone plus
metronidazole or ampicillin/sulbactam or ertapenem)
before induction or gentamicin/tobramycin 5 mg/kg and
clindamycin 900 mg–metronidazole 500 mg preinduction
with or without neomycin 1 g and erythromycin 1 g at 19,
18, and 9 hours before surgery or neomycin 2 g and
metronidazole 2 g at 13 and 9 hours before surgery.

137
 2- O&G:
a.Vaginal/abdominal hysterectomy: Cefazoline,cefoxitin ,
cefotetan 2 g or ampcillin\sulbactam before induction.
b. Cesarean section : Cefazolin 2 g after the cord is clamped.

3. Cardiothoracic:
a. Cardiac surgery :
Cefazolin or cefuroxime 2 g preinduction (plus intraoperative
doses), if MRSA OR hospitalized; vancomycin
b. Pulmonary resection :
(i.e., lobectomy and pneumonectomy). Cefazolin 2g
preinduction (or ampcillin\sulbactam or vancomycin)
c. Vascular surgery:
Cefazolin 2 g preinduction and every 8 hours for three doses; if
MRSA == vancomycin
138
4. Orthopedic:
Prophylaxis is indicated when surgery involves
prosthetic materials.
Cefazolin 2 g preinduction (or vancomycin)
5. Head and neck:
Cefazolin or cefuroxime 2 g plus metronidazole or A/S 3
g or clindamycin 900 mg preinduction
6. Urologic: “not recommended”
✓ +ve urine culture before surgery (should TT and then
operate).
✓ Unsuccessful, Cover for the infecting organism and
operate.

139
 Cases
• For Apartial colectomy. Which one of the
following would be the best surgical
prophylaxis regimen?

(A) cefazolin 1g prior to surgery

(B) cefazolin 1g prior to and for 48 hours after
surgery
(C) neomycin 1 g and erythromycin 1 g at 19,
18, and 9 hours before surgery
(D) cefotetan 2 g prior to surgery
140
 Cases
• For Apartial colectomy. Which one of the
following would be the best surgical
prophylaxis regimen?

(A) cefazolin 1g prior to surgery

(B) cefazolin 1g prior to and for 48 hours after
surgery
(C) neomycin 1 g and erythromycin 1 g at 19,
18, and 9 hours before surgery
(D) cefotetan 2 g prior to surgery
141
142