Normal Cardiac

MAP, HR, CO, CI,PCWP SVR, CVP

Map

HR

CO

CI

PCWP

SVR

CVP

ADHF Cardiac

MAP, HR, CO, CI,PCWP SVR, CVP

MAP 60-80

HR 70-90

CO 2-4

CI 1.3-2

PCWP 18-30

SVR 1500-3000

CVP 6-15

Sepsis Cardiac

MAP, HR, CO, CI,PCWP SVR, CVP

MAP 60-80

HR 90-100

CO 5-8

CI 3.5-4

PCWP 5-8

SVR 300-800

CVP 2-6

TBW (total body water)

men

women

men= 60% of LBW

Women=

50% of LBW

Intravascular Vol Depletion

HR,SBP, BUN/Creat ratio

hr >100

SBP < 80

BUN/CREAT RATIO >10:1

Orthostatic bp changes

Daily fluid requirements

Formula to calculate Na replacement to 120

Women: 0.5*LBW*(12-Na)

Men: 0.5*LBW*(120-Na)

HCAP -Early onset and no risk factors for multi drug resistant organisms

(four)

3rd generation cephalosporin (cefotaxime or ceftriaxone)

Resp. fluoroquinolone

Unasyn

Ertapenem

Treatment duration-try to keep 7-8 days, 14 for P. aeruginosa

Imipenem, meropenem, doripenem with

  aminoglycosie or resp fluorquinolone

Zosyn with

  aminoglycoside or resp fluorquinolone

Vanco or Linezold added only if:

  1. hx of mrsa infection

  2. recent hospital or abx use

  3. presece of invasive heath care devices

Treatment duration-try to keep 7-8 days, 14 for P. aeruginosa

W=0.5*LBW*(140-NA)

M=0.5*LBW*(140-NA)

Replace 25-50% in 1st 24hrs, max

8-12meq/L in 24hrs.

CAP Organism's-common

(six)

Unidentifiable 40-60%

M. pneumoniae  13-37

S. pneumoniae    9-20

H. influenze        3-10

C. pneumoniae   1-17

Legionella Pneumoniae 0.7-13

Virues

S. aureus

Moraxella catarrhalis

Pneumoncystis pneumonia

anaerobes

gm neg bacilli (e.g. K pneumoniae)

HCAP Organism

(nine)

S. aureus

Pseudomonas 

Enterobacter sp.

Klebsiella pneumoniae

candida

Acinetobacter sp.

Serratia marcescens

E. coli

S. pneumoniae

CAP-Out patient empiric treatment

Healthy, no abx in last 3 months

Macrolide (clarithromycin or azith for suspected H. influ)

or

Doxycycliine

Treatment duration-at least 5 days, with 48-72 hrs afeb and no more than one sign of clinical instability before therapy discontinuation.

CAP-Out patient empiric treatment

with comorbid conditions

Respiratory Flouroquinolone or

Macrolide/Doxy with 

      1. High dose amox

      2. Augmentin

      3. cephalosporin (ceftriax,ceurox,cefpodoxime)

Treatment duration-at least 5 days, with 48-72 hrs afeb and no more than one sign of clinical instability before therapy discontinuation.

Respiratory fluoroquinolone

or

Macrolide/doxy with

1.ampicillin

2.ceftriaxone or cefotaxime

3.ertapenem

Treatment duration-at least 5 days, with 48-72 hrs afeb and no more than one sign of clinical instability before therapy discontinuation.

Influenza prevention Meds and doses

(4)

Amanadine and Rimantadine:

**Use only if testing shows increased susceptibility**

Oseltamvir: 75-150mg/ day x6 weeks, begin within 2 days of close contact with infected person x at least 7 days.

Zanamivir :10mg inhaled daily x4 weeks

Unasyn,ceftriaxone,cefotaxime with

respiratory fluoroquinolone or azith

May need to add other abx for P. aeruginosa or MRSA

Treatment duration-at least 5 days, with 48-72 hrs afeb and no more than one sign of clinical instability before therapy discontinuation.

1. If patient received vaccine >/= 5 years previously and was less than 65.

2. After 5 years for anyone >/=2 with functional or anatomic asplenia

3.After 5 years for anyone >/= 2 that is immunocompromised.

Influenza Vaccine-types

(two)

Injection-inactivated virus

Inhalation-live attenuated (flumist)

Influenza Treatment meds and doses

(four)-

Amantidine:not recommended only effective with influ A

100mg bid for 3-7 days

Decrease for renal function

   amantidine > rimantadine

side effects: cns, gi, peripheral edema,orthostatic hypotension

**Use only if testing shows increased susceptibility**

Oseltamivir 

75mg bid x5 days

75mg qday x5 for crcl <30

Side effects-gi

Zanamivir

2 inhalations (10m) bid x5 days

Side effect-bronchospams,cough

E.coli                                 31

P. aeruginosa                    10

other gm neg bacilli          10

K. pneumoniae                   9

S. aureus                            6

P. mirailis                           5

Enterococcus                      2

fungal                               14 

Frequency, dysuria, hematuria

subpubic pain

costovertabral angle tenderness-flank pain

fever,chills

increased wbc's

nausea,vomiting

elderly-mental satus changes,abdom pain, decreased eating/drinking

Acute Cellulitis

symptoms

acute spreading infec-deep dermis and subcut fat

non-elevated rashp-poorly defined margins

previous minor trauma

warmth,pain,edema

often impaired lymphatic drainage

Acute cellulitis

organisms

usually S. pyogenes

occasionally S. aureus

Acute cellulitis

treatment primary and alternative

anti-staphylococcal pcn

(nafcillin,oxacillin or dicloxacillin)

Pen  G if definitively streptococcal

Alternative:

clinda

B-lactam inhibitor combo

first-gen cephalosporin

vanco or liinzolid for mrsa

5-10 days may worsen when treatment begins

Erysipelas

symptoms

acute spreading infect primarly superficial dermis

usually infants and elderly

most common on legs and feet

warmth,erythema and pain

edge of infect elevated with sharp margins

blood cultures usually not positive

Erysipelas

organisms

usually group a streptococus

occasionally group G,C,B strep

Erysipelas

treatment

Pen G

Clinda

7-10 days

Necrotizing fascitis

symptoms

involves subcut fat and superficial fascia

significant systemic symptoms

Necrotizing fascitis

treatment

surgical debridement most important

abx not curative

b-lactamase inhib plus clinda plus cipro

carbapenems,cefotaxime plus clinda or metronidazole

high dose iv pen g plus clinda for streptococcal

Necrotizing fascitis

organisims

S. pyognes

mixed infect with facultative and anaerobic bacteria

shingles vaccine

who gets treatment

Zostavax

one dose all adults 60 or older regardless of chicken pox or zoster hx

not for active herpes zoster or post-herpetic neuralgia

diabetic foot  Infection

organisms

usually polymicrobial

s.aureus

streptococcus

enterococcus

proteus

e. coli

klebsiella

enterobacter

P.aeruginosa

bacteroides

peptococcus

Diabetic Foot infections

therapy-shallow non-limb threatening

treat like cellulitis

penicillanase-resistant pcn

first gen cephalosporin ect.

Diabetic Foot infections

deep, limb-threatening

amp/sulbactam

ticarcillin/clavulanate

piperacillin/tazobactam

ertapenem

quinaolone plus clinda/metronidazole

cefoxitin

3rd gen cephalosporin plus clinda or metronid

treat for 1-2 weeks if skin/soft tissue

treat for -12 weeks if osteomyelitis

Diabetic Foot infections

topical treatment

Becaplermin (regranex)

recombinan human platelet-derived growth factor

increases prod of cells that repair wounds and form granulation tissue

oseomyelitis

Hematogenous spread

Definition

oseomyelitis

Hematogenous spread

patient population

children less than 16 

femur,tibia,humerus

adults

vertebrae

oseomyelitis

Hematogenous spread

predisposing factors

bacteremia (iv cath, skin

infec, uri)

sickle cell anemia

oseomyelitis

Hematogenous spread

common pathogens

usually monomicrobial

children: S.aureus 60%-90%

  s. epidermidis

  s. Pyogenes

  S. pneumoniae

  H.influenzea

  P. aeruginosa

  enterobacter

  e. coli (all < 5%)

Adults:

   s. aureus

  gm neg bacilli

Sickle cell anemia:

  salmonella 7%

  s. pneumoniae

IV drug users:

  p. aeruginosa

oseomyelitis

Contiguous spread

Definition

oseomyelitis

Contiguous spread

Patient population

Adults 25-50 

femur,tibia skull

oseomyelitis

Contiguous spread

predisposing factors

open reduction of fractures

gunshot wound

dental/sinus infections

sof tissue infections

oseomyelitis

Contiguous spread

common pathogens

usually mixed infections

s. aureus 60%

s. epidermidis

streptococus

gm neg bacilli

 p. aeruginosa (foot punctures)

 proteus

 klebsiella

 e.coli

Anaerobic (human bites, decubitus ulcers) 

oseomyelitis

Vascular Insuff

Definition

oseomyelitis

Vascular Insuff

patient population

oseomyelitis

Vascular Insuff

predisposing factors

diabetes

pvd

post-CAB (sternum)

oseomyelitis

Vascular Insuff

common pathogens

S. aureus

S. epidermidis

streptococcus

gm neg bacilli

anaerobic-bateroides

Infected prosthesis:

  s. aureus

  s. epidermidis

oseomyelitis

 lab test

elevated wbc

elevated erythroecyte sed rate

elevated c-reactive protein

oseomyelitis

diagnostic tests

radiographic test-post results lag behind infec 

radionuclide imaging-pos as soon as 24hr-48 hr        after infect begins

MRI, CT

oseomyelitis

Emperic therapy

Neonates <1month

Nafcillin plus cefotaxime

Nafcillin plus aminoglycoside

oseomyelitis

Emperic therapy

infants 1-36 months

cefuroxime

ceftriaxone

nafcillin plus cefotaxime

oseomyelitis

Emperic therapy

Peds >3 years

nafcillin

cefazolin

clindamycin

oseomyelitis

Emperic therapy

Adults

Nafcillin or cefazolin or vanco

choose additional abx on basis of patient specific charaterisics

sickle cell:

nafcillin plus amp

prosthetic joint: 

  vanco plus rifampin

  nafcillin plus rifampin

duration acute = 4-6 weeks

            chronic = 6-8 weeks iv, then 3-12months                               oral

oseomyelitis

criteria for oral therapy

adherence

id organisim is highly susceptible to oral abx

c-reactive protein <2

adequate surgical debridment