APPROACH TO PT WITH

INFECTIOUS DISEASE
Dr ALEX MOGERE
Consultant physician
History
• Not until the work of Louis Pasteur and Robert Koch in the late 19th
century was there credible evidence supporting the germ theory of
disease(that microorganisms are the direct cause of infections)
• the 20th century saw the elimination of smallpox, one of the great
scourges in the history of humanity.
• during the latter half of the century, several chronic diseases were
demonstrated to be directly/indirectly caused by infectious microbes; eg
associations of HP with PUD and gastric Ca, HPV with cervical Ca, and
hep B and C viruses with liver Ca
• ~16% of all malignancies are now known to be associated with an
infectious cause
Global hx
• Infectious diseases remain the second leading cause of death
worldwide.
• in 2010, 23% of all deaths w/wide were related to infectious diseases,
with rates >60% in most sub-Saharan African countries.
• understanding the local epidemiology of disease is critically important
in evaluating patients.
• HIV-infected adults represent 15–26% of the total population in
countries like Zimbabwe, Botswana, and Swaziland.
• drug-resistant TB is rampant throughout the former Soviet-bloc
countries, India, China, and SA.
Microbiota
• Normal, healthy humans are colonized with over 100 trillion bacteria
as well as countless viruses, fungi, and archaea; taken together, these
microorganisms outnumber human cells by 10–100 times
• The major reservoir of these microbes is the GIT, but very substantial
numbers of microbes live in the female genital tract, the oral cavity,
and the nasopharynx.
• microbial colonization might be highly relevant to the biology and
disease susceptibility of the host
• The commensal organisms provide the host with myriad benefits,
from aiding in metabolism to shaping the immune system.
Ct. Microbiota
• The vast majority of infections are caused by orgs that are part of the
normal flora (e.g., S. aureus, S. pneumoniae, P.aeruginosa), with
relatively few infections due to orgs that are strictly pathogens (e.g, N.
gonorrhoeae, rabies virus).
• Site specific knowledge of the indigenous flora may facilitate
appropriate interpretation of culture results, aid in selection of
empirical Abx Tx
When to consider infectious aetiology
• Infections have an infinite range of presentations, from acute life
threatening conditions (e.g., meningococcemia) to chronic diseases of
varying severity (e.g., H. pylori–associated PUD) to no symptoms at all
(e.g., latent M. TB)
History
• obtaining a complete and thorough Hx is paramount
• The Hx is critical for developing a focused DDX and for guiding the
physical exam and initial diagnostic testing
• obtain an exposure history that may identify microorganisms with
which the patient may have come into contact
• Obtain host-specific factors that may predispose to the development of
an infection.
• Obtain patient’s previous infections, with the associated microbial
susceptibility profiles
• obtainhistory of infection with drug-resistant organisms
Ct. history
• Obtain hx of exposure to drug resistant microbes (e.g., during a recent
stay in a hospital, nursing home, or long-term acute-care facility)
• a complete social history can offer a number of clues to the
underlying diagnosis.
• Dietary habits- certain pathogens are associated with specific dietary
habits,eg Shiga toxin–producing strains of Escherichia coli and
Toxoplasma gondii are associated with the consumption of raw or
undercooked meat
Ct History
• Pts should be asked about exposures to any animals, including contact
with their own pets, visits to petting zoos, or random encounters eg
dogs can carry ticks that serve as agents for the transmission of
several infectious diseases,
• Travel hx- obtain hx of both international and domestic travel.
• determine the immune status of the patient. Defects in the immune
system may be due to an underlying disease,drugs etc
Physical exam
• serial exams are critical since new findings may appear as the illness
progresses.
Temperature:
• Rectal temp. more accurately reflect the core body temp and are
0.4°C (0.7°F) and 0.8°C (1.4°F) higher than oral and axillary temps,
respectively.
• Fever-temperature ≥38.3°C (101°F).
• For every 1°C (1.8°F) increase in core temperature, the heart rate
typically rises by 15–20 beats/min.
Infectious causes of relative bradycardia
Ct . Physical exam
Lymphadenopathy
• infections are an important cause of lymphadenopathy
• There are ~600 lymph nodes throughout the body,
• with notation of the location, size (normal, <1 cm), presence or
absence of tenderness, and consistency (soft, firm, or shotty) and of
whether the nodes are matted
• 75% of pts with LN+ have localized findings, and the remaining 25%
have generalized lymphadenopathy
Ct physical exam
• Perform a complete skin exam, with attention to both front and back
• hospitalization of pts is often associated with breaches of the
epithelial barriers eg IV cannulae, surg. Drains etc
Diagnosis
• The tests should be viewed as adjuncts to the hx and p/e—not a replacement for them
• selection of initial tests should be based directly on the pt’s hx and p/e findings.
WBCs
• Leucocytosis is often associated with infection, though many viral infections are
associated with leukopenia
• It is important to assess the WBC differential -different classes of microbes are associated
with various leukocyte types.
• bacteria are associated with an increase in polymorphonuclear neutrophils, often with
elevated levels of earlier developmental forms such as bands;
• viruses are associated with an increase in lymphocytes; and
• certain parasites are associated with esinophilia.
• Check out the major infectious causes of esinophilia
Ct Diagnosis
Inflammatory markers
• ESR and the CRP level are indirect and direct measures of the acute-
phase response, respectively
• these markers can be followed serially over time to monitor disease
progress/resolution
• ESR changes relatively slowly, and its measurement more often than
weekly usually is not useful;
• CRP concentrations change rapidly, and daily measurements can be
useful in the appropriate context
Some Causes of extremely elevated
ESR(>100mm/hr)
CSF analysis
• An opening pressure should always be recorded, and
• fluid should routinely be sent for cell counts, Gram’s stain and culture,
and determination of glucose and protein levels.
• A CSF Gram’s stain typically requires >100000 bacteria/mL for reliable
positivity
CSF profiles for meningitis and encephalitis
Cultures
• Mainstays of infectious disease diagnosis
• include the culture of infected tissue
• Ideally, specimens are collected before the administration of
antimicrobial therapy;
Pathogen specific tests
• Serology,
• Antigen testing,
• PCR testing
Infection control
• You must consider what infection control methods are necessary to
prevent transmission of any possible infection to other people
• Persons exposed to certain pathogens (e.g., N. meningitidis, HIV,
Bacillus anthracis) should receive postexposure prophylaxis to prevent
disease acquisition
Infectious Disease(ID) consultation
• ID specialists provide other services (e.g., infection control,
antimicrobial stewardship, Mx of outpt ABx Tx, occupational exposure
programs) that have been shown to benefit pts.
(1) difficult-to diagnose patients with presumed infections,
(2) pts who are not responding to treatment as expected,
(3) pts with a complicated medical history (e.g., organ transplant
recipients, patients immunosuppressed due to autoimmune or
inflammatory conditions), and
(4) pts with “exotic” diseases (i.e., diseases that are not typically seen
within the region).
Initial empirical abx Tx for common
infections
Initial empirical abx Tx for common
infections
Initial empirical Abx Tx for common
infections