Tutorial Topics in Infection for the Combined Infection Training Programme最新文献

{"title":"Cardiovascular Infections","authors":"R. Wani, Satya Das","doi":"10.1093/oso/9780198801740.003.0037","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0037","url":null,"abstract":"Infective endocarditis (IE) is inflammation of the endothelial lining of the heart valves due to infective causes. IE is a rare condition with an incidence rate of three to nine cases per 100,000 population with a male to female ratio of 2:1. The rate is higher in people with unrepaired cyanotic congenital heart disease, prosthetic heart valves and previous endocarditis. Other risk factors for IE include: rheumatic fever (now accounts for < 10% of IE cases in developed countries), degenerative conditions of heart valves, intravenous drug abuse, diabetes, and HIV infection. One third of the cases are now healthcare associated infection (HCAI), particularly with haemodialysis, cardiac surgery, implantable cardiac devices, intravascular lines, and urinary catheters. In the past decade Staphylococcus aureus has replaced viridans streptococci as the leading cause of IE, the rate of enterococcal (mostly E. faecalis) and Bartonella IE has increased, while that of culture negative endocarditis has decreased. Untreated IE is a uniformly fatal condition, but the mortality rate can be reduced to 5–40% with appropriate treatment. There are two important prerequisite steps to the development of IE: 1. A damaged endothelium due to high pressure gradient and turbulent blood flow around a heart valve or septal defect. Fibrin and platelet deposition occur on the roughened endothelium forming a non-infective thrombus or vegetation. 2. Bacteraemia due to endocarditis-prone organisms resulting from trauma to mucous membranes (e.g. oral cavity, urinary, and gastrointestinal tract) or other colonized tissue or foreign body, which is not cleared by host defence mechanisms. Micro-organisms then attach to the damaged endothelium through a specific ligand-receptor interaction (hence the predilection for certain organisms to cause endocarditis, e.g. viridans streptococci from the mouth), colonize the thrombus, and grow and multiply within it to give rise to a mature/infective vegetation, which is the pathological hallmark of IE. Virulent organisms, classically S. aureus, can apparently infect a healthy endocardium. Damage to the endothelium results in valvular incompetence/regurgitation and symptoms and signs of heart failure and when severe, it is a potentially fatal condition that requires urgent valve surgery, even if the infection has fully responded to antimicrobial therapy.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121280743","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Bacteriology Diagnostic Methods","authors":"H. Dolphin, F. Ahmad","doi":"10.1093/oso/9780198801740.003.0015","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0015","url":null,"abstract":"This is summarized in Table 8.1. a) Microscopy— A cell count is performed on sterile fluids and CSF samples using the Neubauer chamber or a similar device. The number of white blood cells (WBC) and red blood cells seen under the microscope are reported as well as the differential WBC count (i.e. the number or percentage of lymphocytes and neutrophils in the sample). A Gram stain is then done and the presence of any organism reported. b) Culture samples are plated onto the appropriate media and streaked out for single colonies as shown. Blood agar is normally used; however, other media are used depending on the site of the specimen, e.g. chocolate agar is used if a fastidious organism is a potential pathogen such as Haemophilus sp.; anaerobic agar for anaerobes; selective agar such as MacConkey can be used on non-sterile specimens to differentiate between the colony types. Plates are incubated for eighteen to forty-eight hours at the correct conditions; most plates being CO2, others at O2 and anaerobically. c) Identification plates are examined for growth. Potentially significant isolates are identified either by MALDI-TOF MS, by API, or other biochemical tests. d) Sensitivities are performed on significant organisms by manual and automated methods. This is summarized in Table 8.2. Selective agar is necessary when isolating pathogens from faeces, although further confirmatory tests are needed. ● Black or colourless colonies on xylose lysine deoxycholate (XLD) or other chromogenic agar plates are tested with oxidase reagent. ● Oxidase negative isolates are identified by MALDI-TOF, API and or biochemically using triple-sugar iron (TSI) tubes. ● Serology is then performed on suspicious isolates and sent to a reference laboratory for confirmation. ● Campylobacter is confirmed by testing grey flat colonies on campylobacter agar with oxidase reagent. Oxidase positive samples are Gram stained and if ‘seagull’-shaped gram-negative bacteria are observed under the microscope, campylobacter is confirmed. The catalase test is a simple biochemical test to differentiate between Staphylococcus species and Streptococcus species, with the use of hydrogen peroxide (H2O2). It tests for the presence of the enzyme catalase which is found in Staphylococcus species.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"62 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124286926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Geographical Pattern of Infectious Diseases and Infection Prevention for Travellers","authors":"Desmond Hsu, Zahir Osman Eltahir Babiker","doi":"10.1093/oso/9780198801740.003.0071","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0071","url":null,"abstract":"Infectious diseases are transmitted either directly from person to person via direct contact or droplet exposure, or indirectly through a vector organism (mosquito or tick) or a non-biological physical vehicle (soil or water). Vector-borne infectious diseases are highly influenced by climate factors such as temperature, precipitation, altitude, sunshine duration, and wind. Therefore, climate change is a major threat for the emergence and re-emergence of infectious diseases, e.g. re-emergence of dengue fever in some parts of southern Europe. The natural reservoirs of infectious diseases are either humans (anthroponoses) or animals (zoonoses). Population movement due to travel or civil unrest risks introducing non-immune populations to regions that are endemic for certain infectious diseases. By contrast, global trade contributes to the movement of animals or arthropods across the world and this poses a major risk for introducing infectious diseases to previously non-endemic settings, e.g. rats on board commercial ships and the global spread of hantaviruses; international trade in used car tyres and the risk of introducing flavivirus-infected mosquitoes into non-endemic settings; and the contribution of migratory birds to the introduction and the spread of West Nile virus in the United States. The unprecedented growth of international travel facilitates the swift movement of pathogens by travellers from one region to another. The main determinants of travel-related infections are destination country, activities undertaken during travel, and pre-existing morbidities. Therefore, the pre-travel consultation aims to assess potential health hazards associated with the trip, give advice on appropriate preventative measures, and educate the traveller about their own health. Attitudes towards seeking pre-travel health advice vary by the type of traveller. For example, those visiting friends and relatives (VFRs) in their country of origin are less likely to seek pre-travel health advice compared to tourists and therefore stand a higher chance of presenting with preventable infections such as malaria. The key aspects of a pre-travel consultation include: ● comprehensive risk assessment based on the demographic and clinical background of the traveller as well as the region of travel and itinerary.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"5 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117056719","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Different Types of Vaccines","authors":"C. Y. William Tong","doi":"10.1093/oso/9780198801740.003.0061","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0061","url":null,"abstract":"Vaccines can be classified according to their nature into the following types: ● Inactivated vaccines: ■ Whole organism; ■ Acellular extracts. ● Live attenuated vaccines. ● Toxoid vaccines. ● Subunit vaccines. ● Conjugate vaccines. ● DNA vaccines. ● Recombinant vector vaccines. Inactivation of the whole organism is the most basic form of vaccine produced by killing the micro-organism causing the disease using heat, chemical or radiation and presents all the antigens in the inactivated organism as a vaccine to induce immunity in the recipient. Other methods to produce an inactivated vaccine is by extracting acellular components of the organism through filtration. Examples of inactivated bacterial vaccines currently in use include: ● Anthrax—sterile filtrate from cultures of the Sterne strain of B. anthracis. ● Cholera—oral inactivated vaccine with 1mg of recombinant cholera toxin B (rCTB) in a liquid suspension of four strains of killed V. cholerae O1, representing subtypes Inaba and Ogawa and biotypes El Tor and classical. ● Pertussis—acellular vaccine has replaced previously used whole cell vaccine. ● Typhoid—purified Vi capsular polysaccharide from S. typhi; NB: the injectable, killed, whole-cell typhoid vaccine which contains heat-inactivated, phenol-preserved S. typhi organisms is no longer in use in the UK. Examples of inactivated viral vaccines currently in use in the UK include: ● Hepatitis A virus. ● Hepatitis E virus. ● Influenza A and B viruses. ● Japanese encephalitis virus. ● Polio viruses 1, 2, and 3 (IPV). ● Rabies virus. ● Tick-borne encephalitis virus. ● Bacterial vaccines: Bacillus Calmette-Guerin (BCG) vaccine is a live attenuated vaccine against tuberculosis derived from a Mycobacterium bovis strain. The oral typhoid vaccine contains a live attenuated strain of S. typhi (Ty21a) in an enteric-coated capsule. ● Viral vaccines: The measles, mumps, and rubella (MMR) vaccine contain live attenuated strains of measles, mumps, and rubella viruses, which are cultured separately and mixed before being lyophilized. Oral polio vaccine (OPV) against polio viruses 1, 2, and 3—OPV contains live attenuated strains of poliomyelitis virus types 1, 2, and 3 grown in cell cultures.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"22 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121308332","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Basic Immunology","authors":"J. Lambourne, R. Buchanan","doi":"10.1093/oso/9780198801740.003.0012","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0012","url":null,"abstract":"There are four major components of the immune system. These include: 1. mechanical barriers to pathogen entry. 2. the innate immune system. 3. the adaptive immune system. 4. the lymphoid organs. Mechanical barriers include skin and mucous membranes and tight junctions between epithelial cells prevent pathogen entry. Breaches can be iatrogenic, for example, IV lines, surgical wounds, and mucositis, and are a large source of healthcare- associated infections. The innate immune system provides the first internal line of defence, as well as initiating and shaping the adaptive immune response. The innate system comprises a range of responses: phagocytosis by neutrophils and macrophages (guided in part by the adaptive immune system), the complement cascade, and the release of antimicrobial peptides by epithelial cells (e.g. defensins, cathelicidin). The adaptive immune system includes both humoral (antibody- mediated) and cell-mediated responses. It is capable of greater diversity and specificity than the innate immune system, and can develop memory to pathogens and provide increased protection on re-exposure. Immune cells are divided into myeloid cells (neutrophils, eosinophils, basophils, mast cells, and monocytes/macrophages) and lymphoid cells (B, T, and NK cells). These all originate in the bone marrow from pluripotent haematopoietic stem cells. The lymphoid organs include the spleen, the lymph nodes, and mucosal-associated lymphoid tissues—which respond to antigens in the blood, tissues, and epithelial surfaces respectively. The three main ‘professional’ phagocytes are macrophages, dendritic cells, and neutrophils. They are similar with respect to how they recognize pathogens, but differ in their principal location and effector functions. Phagocytes express an array of Pattern Recognition Receptors (PRRs) e.g. Toll-like receptors and lectins (proteins that bind carbohydrates). PRRs recognize Pathogen- Associated Molecular Patterns (PAMPs)— elements which are conserved across species, such as cell-surface glycoproteins and nucleic acid sequences. Though limited in number, PRRs have evolved to recognize a huge array of pathogens. Binding of PRRs to PAMPs enhances phagocytosis. Macrophages are tissue-resident phagocytes, initiating and co-ordinating the local immune response. The cytokines and chemokines they produce cause vasodilation and alter the expression of endothelial cell adhesion factors, recruiting circulating immune cells.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"43 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125701977","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outpatient Parenteral Antimicrobial Treatment (OPAT)","authors":"M. Melzer","doi":"10.1093/oso/9780198801740.003.0058","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0058","url":null,"abstract":"Outpatient parenteral antimicrobial therapy (OPAT) is the provision of intravenous (IV) antibiotics to patients in the community or an ambulatory care setting. It was first used to treat children with cystic fibrosis in the 1970s but did not become part of adult services in the UK until the 1990s. OPAT facilitates hospital admission avoidance and decreased lengths of inpatient stay. It is associated with high levels of patient satisfaction. Recent clinical guidelines on the provision of OPAT services in the UK and US have recently been published Skin and soft tissue infections (SSTIs), in particular lower limb cellulitis, are the commonest medical conditions referred to OPAT services. Patients are typically treated for three to five days with IV antibiotics but patients with lymphoedema or underlying skin conditions typically require longer courses. Increasingly, multidrug-resistant urinary tract infections (UTIs) may be treated in the community with IV antibiotics, although oral options such as fosfomycin are now available. Patients with bone and joint infection invariably require prolonged parenteral antibiotic courses, whether this be vertebral osteomyelitis or native or prosthetic joint infection. Other less common examples, where careful patient selection is required, include infected diabetic foot ulcers (with or without osteomyelitis), infective endocarditis, empyema, liver, and tubo-ovarian and brain abscesses. Patients are recruited on the basis of clinical syndromes (e.g. lower limb cellulitis) or laboratory referral (e.g. multidrug-resistant UTIs). Active recruitment (e.g. attendance at acute assessment unit board rounds or orthopaedic multidisciplinary teams, MDTs) compared to passive recruitment (waiting for clinical referrals) increases the yield of patients. The suitability of a patient to receive treatment out of hospital or in an ambulatory care setting needs careful assessment and is dependent upon age, comorbidities, and severity of infection. OPAT also requires patients to engage actively and reliably with therapy. Therefore, IV drug users and patients with serious mental health problems are generally not suitable. Commonly used antibiotics are those given once daily as these reduce nursing time, although some nursing teams can administer IV antibiotics up to three times per day. It is imperative to take a drug allergy history and seek an alternative class of antibiotics when a patient complains of severe penicillin allergy.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"160 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123102167","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Host-Parasite (Microbe) Relationship","authors":"C. Rosmarin","doi":"10.1093/oso/9780198801740.003.0011","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0011","url":null,"abstract":"No and yes. The skin, oropharynx, upper airways, gastrointestinal tract, and lower female genital tract are full of bacteria, with the highest concentration being in the colon and in dental plaque. Overall, humans are made up of slightly more bacterial cells than human cells; about 40 versus 30 trillion respectively. Although much less prominent, fungi and viruses are also present. In addition to these endogenous microbes, humans come into contact with numerous others on a daily basis—they are inhaled, ingested with food and drink, and picked up on the skin from the environment. Some of these remain in and on the human body for periods of time, while others slough off or die. In contrast to this, there are certain areas of the body where microbial agents are not expected to occur under normal circumstances. These are called sterile sites and include: major organs and their surrounding fluids and capsules; blood and body fluids other than faeces and saliva (yes, including urine!); bone, bone marrow, and joint fluid; subcutaneous tissue, fat, muscle, and tendons; the lower respiratory tract; and some of the genital tract. Microbes only enter these protected sterile sites through various breaches in physical and immunological defences. Again— no and yes. This is a question that has posed much debate over the centuries and seems to evolve as understanding of both humans and microbes expands. Early understanding of infectious diseases was based on the idea that the microbe was an aggressor and the host a passive victim. Currently there is a better understanding of the relationship between microbe and host, which is more of a dance than a war. In order to express an understanding of the relationships between host humans and microbes, a language is required that describes this confusing and complex interaction, especially considering that knowledge in this field is still evolving. The bacteria that reside in or on human bodies on a semi- permanent basis are called normal flora, or indigenous microbiome. Each person has a relatively unique set of fairly stable microbes likely determined by early experience, and continued exposures and diets.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"41 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131743636","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Use of Antimicrobials and Toxicity","authors":"A. Sefton","doi":"10.1093/oso/9780198801740.003.0054","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0054","url":null,"abstract":"Broad-spectrum antibacterial agents kill most bacteria including gram-positive rods and cocci, gram-negative rods and cocci, and often anaerobes too. Narrow-spectrum agents kill a narrow range of microbes, e.g. benzylpenicillin is mainly active against gram-positive cocci. By and large a narrow-spectrum antimicrobial is less likely to disrupt a patient’s normal flora than a broad-spectrum agent. Hence, if the likely organism is causing an infection it is best to give a narrow-spectrum antimicrobial to treat that specific organism. If a patient presents ‘septic’ and the source of infection is unknown, relevant cultures should be taken followed by broad-spectrum antimicrobial cover. This can later be modified either when the source of infection is found or as a result of microbiology culture results. ● Agents mostly active against gram-positive bacteria include: ■ Penicillin (Also active against Neisseria spp.). ■ Fusidic acid. ■ Macrolides (Also active against Legionella, Campylobacter, Bordetella spp.). ■ Clindamycin. ■ Glycopeptides. ■ Oxazolidinones. ■ Streptogramins. ● Agents mainly active against gram-negative bacteria include: ■ Polymyxin. ■ Trimethoprim. ■ Aminoglycosides (also active against staphylococci and show synergy when combined with beta-lactams against/glycopeptides against streptococci). ■ Monobactams. ■ Temocillin. ● Broad-spectrum antimicrobials include: ■ Beta-lactam plus beta-lactamase inhibitor combinations. ■ Cephalosporins. ■ Carbapenems. ■ Chloramphenicol, Tetracyclines/Glycyclines. A bactericidal agent is a compound that actively kills multiplying bacteria. A bacteriostatic compound inhibits the growth of bacteria. Whether or not an antimicrobial is bactericidal or bacteriostatic depends on a variety of things, including the type of agent, its concentration, and the organism it is being used to treat. It is especially important to try and use a bactericidal agent if the patient’s immune system is impaired or the infection is at a site where it is difficult for the immune system to access, e.g. the heart valves in bacterial endocarditis, the meninges in meningitis. Examples of each are given here: ● Bactericidal agents include beta-lactams, glycopeptides, fluoroquinolones, and aminoglycosides. ● Bacteriostatic agents include macrolides, clindamycin, tetracyclines, trimethoprim, and sulphonamides. The therapeutic index of a drug is the ration of the concentration of drug likely to be toxic to the patient divided by the concentration of drug likely to be clinically effective.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"11 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121867530","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Bone and Joint Infections","authors":"J. Dave, R. Ghani","doi":"10.1093/oso/9780198801740.003.0039","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0039","url":null,"abstract":"Patients with bone and joint infections can present with native joint septic arthritis, osteomyelitis, or implant-associated bone and joint infections. Patients often present with an acute onset of hot, swollen, painful joint with restricted function in one or more joints over a couple of weeks. On examination the affected joint is painful with a limited range of movement, and fever is present. Risk factors for septic arthritis include an abnormal joint architecture due to pre-existing joint disease, e.g. patients with rheumatoid arthritis, or patients on haemodialysis, with diabetes mellitus, or older than 80 years of age. The differential diagnosis includes reactive arthritis, pre-patellar bursitis, gout, Lyme disease, brucellosis, and Whipples disease. Staphylococcus aureus is the most common cause of septic arthritis, followed by Group A streptococcus and other haemolytic streptococci including B, C and G. Gram-negative rods such as Escherichia coli are implicated in the elderly, immunosuppressed, or patients with comorbidities. Pseudomonas aeruginosa is implicated in intravenous (IV) drug users and patients post-surgery or intra-articular injections. Kingella kingae causes septic arthritis in children younger than four years of age. Neisseria gonorrhoeae, Neisseria meningitidis, and Salmonella species can also cause septic arthritis as part of a disseminated infection. Septic monoarthritis commonly occurs in patients with disseminated gonococcal infection. Blood cultures, white blood cell count, C reactive protein (CRP), electrolytes, and liver function tests are indicated. Serial CRP is useful in monitoring response to treatment. If there is a history of unprotected sexual intercourse, gonococcal testing is recommended. Brucella serology and Tropheryma whippei serology may be considered based on the clinical history. Joint fluid aspiration should be performed by a specialist within the hospital. Joint fluid aspirate is processed in the laboratory for microscopy, culture, and sensitivity. Gram stain can show an increase in neutrophils and presence of bacteria. The guidelines provided by the British Society for Rheumatology on the management of hot swollen joints in adults has provided advice for empirical treatment for suspected septic arthritis, but the local antibiotic policy should also be considered. Initial treatment is with intravenous flucloxacillin 2g four times daily, or 450– 600mg four times daily of intravenous clindamycin to cover S. aureus.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"9 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124910108","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sepsis—Recognition, Diagnosis, and Management in Adult Patients","authors":"M. Melzer","doi":"10.1093/oso/9780198801740.003.0032","DOIUrl":"https://doi.org/10.1093/oso/9780198801740.003.0032","url":null,"abstract":"Sepsis is defined as life- threatening organ dysfunction caused by a detrimental host response to infection. Septic shock is a subset of sepsis in which underlying circulatory and cellular abnormalities are profound enough to substantially increase mortality. Septic shock is characterized by: ● The need for vasopressors to maintain mean arterial pressure (MAP) > 65mmHg despite adequate volume resuscitation. ● A serum lactate > 2mmol/L In lay terms, it is hypoperfusion with evidence of metabolic derangement. The mortality for both criteria is ~40%, compared to 20–30% for a single item. Please also refer to: https:// www.nice.org.uk/ guidance/indevelopment/gid-cgwave0686 The old definitions of sepsis described a heterogeneous group of patients and did not discriminate between infectious and non- infectious causes such as pancreatitis and trauma. The new definitions also allow easier recognition, based on a combination of symptoms and signs. Key parameters include: decreased level of consciousness, rigors, severe myalgia, high or low temperature, pulse > 130/min, systolic blood pressure < 90mmHg, respiratory rate (RR) > 25/ min, creatinine > 170μmol/ L, platelets < 100 x 109/l and bilirubin > 33μmol/ L. The Clinical Quality Commission recommend that NHS trusts use the national early warning score (NEWS), and a score > 5 is an indication to consider moving a patient to critical care. SIRS is defined as any of the two following criteria: acutely altered mental state, temperature < 36°C or > 38°C, pulse > 90/ min, RR > 20/ min, WCC > 12 or < 4 x 109/L and hyperglycaemia in the absence of diabetes mellitus. In the former definitions (1991 and 2001), sepsis was defined as infection plus SIRS. SIRS, however, was not good at separating infected patients who died from those who recovered from infection. SIRS was often an appropriate reaction to infection and many hospitalized patients meet the SIRS criteria. Also, as many as one in eight patients admitted to critical care units with infection and new organ failure did not have two SIRS criteria required to fulfil the sepsis definition. SIRS is no longer part of the new definitions.","PeriodicalId":274779,"journal":{"name":"Tutorial Topics in Infection for the Combined Infection Training Programme","volume":"3 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126893783","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}