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SEPSIS - MENINGITIS - MALARIA. Pr. B. Vandercam Consultation Maladies Infectieuses et Tropicales Cliniques Universitaires St-Luc Octobre 2004 . Sepsis. Focus Absence of focus Purpura fulminans Community acquired sepsis immunocompentent adult Nosocomial sepsis immunocompetent adult

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sepsis meningitis malaria

SEPSIS - MENINGITIS - MALARIA

Pr. B. Vandercam

Consultation Maladies Infectieuses et Tropicales

Cliniques Universitaires St-Luc

Octobre 2004

sepsis
Sepsis
  • Focus
  • Absence of focus
    • Purpura fulminans
    • Community acquired sepsis immunocompentent adult
    • Nosocomial sepsis immunocompetent adult
    • IV DU
    • Asplenic (anatomic or functional)
    • Neutropenia
    • Toxic shock syndrome
source of infection
Source of infection
  • Anamnesis (pets, travel, household, …)
  • Physical examination (purpura, scar …)
  • Blood culture

Urine culture

RX thorax

Echo (scan abdo) obstacle abscess collection

Echo cardio

slide5
Activated protein C (- 6 %)
  • Corticosteroids (low (HC 200-300 mg/day) - long (5-7d))
  • Intensive insuline therapy (- 17%)
  • Volume resuscitation (- 15%)
prior medicare database analyses
Prior medicare database analyses
  • MEEHAN T. Jama 1997; 278:2080 Mortality increased significantly with delay in first Abx dose > 8 hrs (registration to dose)
  • GLEASON PP. Arch Intern Med 1999, 159:2562 Mortality based on abx (OR)

Cephalosporin 1.0

Cephalosporin + mac 0.76

Fluoroquinolone 0.64

slide7
Method : review of Medicare database for patients > 65 yrs hospitalized with x-ray confirmed CAP
  • Period reviewed : July ’98 - March ’99
  • Patients : 13 771
  • PSI score : III - 47 % IV - 24 %
purpura fulminans treatment
Purpura fulminans : treatment
  • Cefotaxime 2 gr q 4 - 6 h

or Ceftriaxone 2 gr q 12 h

  • Allergy

Vanco 1 gr q 12 h + Aztreonam 2 gr q 6 h or Moxifloxacin 0,4 gr q 24 h or Levofloxacin 0,5 gr q 12 h

community acquired sepsis immunocompetent adults
Community acquired sepsis - immunocompetent adults
  • Infecting organisms
    • Enterobacteriacae
    • Staph aureus
    • Strept pneumoniae & spp
    • N. meningitidis
    • Bacteroides spp
  • Treatment
    • Cefotaxime or Ceftriaxone
    • Amoxi clav or cefurox + amino
slide12
IVDU
  • Infecting organisms
    • Staph aureus
  • Exclude endocarditis
  • Previous antibiotherapy
  • Treatment

Oxacilline 2 gr q 6 h or Vancomycine 1 gr q 12h +

Genta 2,5 mg/kg q 12 h

asplenia
Asplenia
  • Overwhelming sepsis
  • Stand by therapy
    • Amoxi clav
    • Allergy, travel --> Moxifloxacin, Levofloxacin
    • Vaccination
  • Antibioprophylaxis
asplenia sepsis
Asplenia sepsis
  • Infecting organisms
    • S. pneumoniae
    • H. influenzae
    • N. meningitidis
    • Capnocytophaga spp
  • Treatment
    • Ceftriaxone or Cefotaxime
nosocomial sepsis immunocompetent adult
Nosocomial *sepsis - immunocompetent adult
  • Infecting organisms
    • Enterobacteriacae
    • S. aureus
    • Strep pneumoniae
    • Bacteroïdes spp
    • P. aeruginosa
    • CNS

* readmission - nursing home

nosocomial sepsis
Nosocomial sepsis
  • Local epidemiology
  • Colonization
  • Previous antibiotherapy
  • IV line
  • Urinary catheter
  • Invasive procedure
treatment
Treatment
  • Vancomycin ?
  • Cefotaxime or Ceftriaxone or Pip/tazo

+ amino

  • Ceftazidime or Cefepime or Carbapenem + amino
sepsis neutropenia
Sepsis neutropenia
  • Infecting organisms
    • Strepto spp
    • CNS
    • S. aureus
    • Enterobacteriacae
    • P. aeruginosa
  • Colonization
  • Previous antibiotherapy
neutropenia low risk
Neutropenia « Low risk »

Amoxi clav 2 gr q 6-8 h +

Cipro 750 q 12 h OR

Ceftriaxone 2 gr q 12 h +

Amikacin 15-25 mg/kg q 24 h

neutropenia high risk
Neutropenia « High risk »
  • Ceftazidime 2 gr q 8 h
  • Cefepime 2 gr q 8 h
  • Pip/tazo 4 gr q 6 h
  • Imipenem 750 mg q 6 h
  • Meropenem 2 gr q 8 h

+ amino ???

toxic shock syndrome
Toxic shock syndrome
  • Infecting organisms
    • Strepto A, B, C,
    • Staph aureus
  • Treatment
    • Cefazoline 2 gr q 8 h + Clindamycine 600 mg q 8 h
clinical diagnosis
Clinical diagnosis
  • Fever sensitivity 85%
  • Menigism 70%
  • Altered mental status 60%
  • Kernig

Sensitivity 5%

Specificity 95%

Poser la question = y répondre

case presentation
Case presentation
  • 25-year-old man
  • 2-day history of severe headache, fever, neck stiffness
  • 38,3 °C
  • No rash
  • Normal mental status and neurologic examination
  • Pain on neck flexion but able to flex his neck fully
  • No Kernig and Brudzinski signs
contraindications of lumbar puncture
Contraindications of lumbar puncture
  • Known or suspected space-occupying lesions with mass effect

 LP deferred until CT scan

  • Severe uncorrected coagulopathy (INR > 1.5)
  • Trombocytopenia (platelet count < 50 000/mm³)
  • Infection at the puncture site (decubitus ulcer)

- Glasgow < 13

- Shock

when should a computerized tomography scan precede a lumbar puncture
When should a computerized tomography scan precede a lumbar puncture ?
  • Age over 60 years
  • Immunocompromised state
  • History of primary neurologic disease, head trauma, neurosurgery
  • History of seizure within the past week
  • Altered mental status, cilated or poorly reactive pupils, occular palsy and focal neurologic abnormalities
  • Papilledema, bradycardia, irregular respiration
  • History of cancer
  • Suspicion of brain abscess (endocarditis, bacteremia …)

Empiric anti infective therapy without delay

csf examination
CSF examination
  • Gram stain - Ziehl - Ink
  • Culture (bacteria, fungi, brucella, nocardia …)
  • Bacterial antigens
    • if antibiotherapy
    • Gram or culture negative
  • PCR virus + BK
  • Blood culture 60 % + in acute bacterial meningitis
slide28
Purpura, petechia  N. meningitidis
  • Cellulitis face  S. aureus

H. influ

  • VRS, VRI  S. pneumoniae

H. influ

  • Parotitis  Mumps
  • Endocarditis  S. aureus
  • Septic arthritis  S. pneumoniae S. aureus
  • Pregnancy  Listeria
acute meningitis treatment
Acute meningitis treatment
  • IV line - blood cultures
  • AB + dexa 10 mg within 30 min(*)
  • LP if no contraindication
  • Chest x-ray
  • Delta scan if needed

(*) S. pneumoniae : 4 h

N. meningitidis : 2 h LCR

antibiotherapy
Antibiotherapy
  • Listeria : ampi or CTX
  • S. pneumoniae : peni i 10% cef 3 i 1%
  • H. influ :  vaccination
antibiotherapy dosage
Antibiotherapy dosage

Penetration - bactericide - CMI

  • Cefotax 2 gr -(4 gr) q 4h (ratio 25%)
  • Ceftriaxone 2 gr q 12h (ratio 15 - 30%)
  • Ampi 2 gr q 4h (ratio 10 - 15%)
  • Cefepime (ratio 10%)
  • Ceftazidime (ratio 20 - 40%)
  • Cotrimoxazole (ratio 30 - 35%)
antibiotic therapy in meningitis
Antibiotic therapy in meningitis
  • IV from the beginning to the end …
  • Standard therapy
    • 7 days for N. meningitidis
    • 10 - 14 days for S. pneumoniae
    • (14) - 21 days for L. monocytogenes
meningitis child 3 months adults 50 yrs
Meningitis : child > 3 months - adults < 50 yrs
  • Infecting organisms
    • S. pneumoniae
    • N. meningitidis
    • H. influ
    • L. monocytogenes
  • Treatment
    • Cefotaxime + ampicilline
    • Ceftriaxone + ampicilline
meningitis alcoohol adults 50 yrs cellular immune deficiency debilitating illness
Meningitis : alcoohol - adults < 50 yrs Cellular immune deficiency - Debilitating illness
  • Infecting organisms
    • S. pneumoniae
    • L. monocytogenes
    • N. meningitidis
    • Gram negative bacilli
  • Treatment
    • Cefotaxime + ampicilline
    • Ceftriaxone + ampicilline
meningitis hiv aids
Meningitis : HIV /AIDS
  • Infecting organisms
    • C. neoformans
    • S. pneumoniae
    • M. tuberculosis
    • L. monocytogenes
    • T. pallidum
    • N. meningitidis
    • HIV
meningitis cerebrospinal fluid shunt
Meningitis : cerebrospinal fluid shunt
  • Infecting organisms
    • Coag neg staph
    • S. aureus
    • Diphteroids
    • Enterobacteriaceae
  • Treatment
    • Vancomycin + cefta
meningitis after cranial or spinal trauma
Meningitis : after cranial or spinal trauma
  • Infecting organisms
    • S. pneumoniae
    • H. influ
  • Treatment
    • Cefotaxime or Ceftriaxone
meningitis after cranial or spinal trauma 4 days
Meningitis after cranial or spinal trauma (> 4 days)
  • Infecting organisms
    • Enterobacteriaceae
    • S. aureus
    • P. aeruginosa
    • S. pneumoniae
  • Treatment
    • Vancomycin + ceftazidime
people on the move demographics year 2003
People on the move: demographics year 2003
  • 175 million persons live outside of their country of origin (2,9%) of the world\'s population
  • Population of concern to UNHCR: 21,6 million
  • Refugees 11,7 million
  • Internally displaced persons: 20-30 million
  • Rural to urban migration: 20-30 million/year
  • 1-2 million migrate permanently every year
  • 700 million tourist arrivals/year
malaria risk pyramid for 1 month of travel without chemoprophylaxis
Malaria risk pyramid for 1 month of travel without chemoprophylaxis
  • Oceania 1:5
  • Africa 1:50
  • South Asia 1:250
  • Southeast Asia 1:2500
  • South America 1:5000
  • Mexico and Central America 1:10 000

01643

malaria en belgique
Malaria en Belgique

Institut de Santé Publique-Louis Pasteur

who dies from travelers malaria
Who dies from travelers’ malaria ?

USA & Canada (n = 21) Total (%)

No chemo 21 100

Dealy seeking care 1 5

Missed by MD 13 62

Lab misdiagnosis 9 43

Mistreatment 11 52

MMWR July 20, 2001 & 1999; 48:SS-1 Kain K et al. CMAJ 2001, 164:654-659

contribution de certaines anomalies biologiques au diagnostic de la malaria
Contribution de certaines anomalies biologiques au diagnostic de la malaria
  • Thrombopénie : 60-85%

Si de plus GB  N : VPP : 77%VPN : 92%

  • Leucopénie ou GB N : quasi-constante
  • CRP: 100% (mais très peu spécifique)

Précoce

Très élevé // à parasitémie et à évolution

 VPN très bonne (probable) si CRP N

  •  LDH : (très) sensible : 83-100%

peu spécifique : 60%

  •  haptoglobine :  90% des cas

VPN élevée de taux N

Intérêt potentiel couplé à CRP

malaria p falciparum
Malaria à P. falciparum

Règles: Vu la provenance essentiellement africaine des souches isolées en Belgique

Hospitaliser si:

  • patient non immun
  • patient immun avec > 2% GR+ et/ou critères de gravité

Préférer un traitement à base de quinine (5j ± 2j)si malaria sévère(+ doxycycline)

slide60
La parasitémie peut augmenter durant les premières 24h de traitement

(action sur points limités du cycle qui continue à évoluer "malgré" le traitement)

 Résistance R3 est déterminée à 48h (où diminution de 75% doit être obtenue)

  • La température peut persister pendant 72-96h sans signification péjorative
  • Si haute suspicion de malaria, et GE (-) :

répéter 3 - 4 x sur 48h

traitement de la malaria p falciparum s v re
Traitement de la malaria à P. falciparum sévère
  • Bihydrochlorate de quinine
    • 500 mg IV (dans 250ml glucosé ED) en 4h/ 3x/j pdt 3-7j
    • 10 mg/kg (soit 8mg/kg de quinine base) 3x/j chez enfant

N.B.: si origine S. Est Asiatique (ou si malaria sévère ?)

dose charge : 20 mg/kg (donc 1 seule fois)

ou (dès que possible/début si pas V /peu critères gravité)

  • Sulfate de quinine: 500 mg per os 3x/j pdt 3-7 jours
slide62
+

Doxycycline 200 mg/j puis 100 mg/j pdt 6 j

ou

Clindamycine 600 mg 3-4x/jour pdt 3-7 j

(par exemple, si grossesse)

malaria treatment
Malaria treatment

P. falciparum (zone A) - P. vivax, P. ovale (*)

  • Day 1 : nivaquine 600 mg + 300 mg
  • Day 2 : 300 mg
  • Day 3 : 300 mg

(*) Primaquine 15 mg q 24 h x 14 days

malaria treatment1
Malaria treatment

P. falciparum

  • Malarone P.O 4 x 3 days (food, milky drink)
  • Quinine sulfate 500 mg q 8 h x 3-7 days

+ Doxy 100 mg q 12h x 7 days

  • Quinine I.V. 10-20 mg/kg over 4 h in 5% dextrose

Quinine I.V. 10 mg/kg over 4 h q 8 h

+ Doxy 100 mg q 12h or Clinda 10 mg/kg q 8h

  • Qt ! Halofantrine ! Mefloquine 2 weeks
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