Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
.pdf
If head CT is required, do not hold antibiotics. Send blood cultures and then start antibiotics.
Further Management Plan/Results
CCS NOTE
All body fluid infections such as urine, CSF, ascites, pleural effusion, and joint fluid
are initially diagnosed based on cell count. Cultures are never available at the time a
treatment decision must be made.
Because of this patient’s severe symptoms combined with a high CSF WBC count that
is most likely neutrophils, empiric therapy must be started before knowing the culture
results. Ceftriaxone, with vancomycin, should be used until the culture results are
known.
Discussion
There is no predetermined length of treatment; that will depend on the clinical response and
whether the CSF clears of organisms. Listeria is a consideration in neonates or patients age
>50, or patients with diabetes, lymphoma, HIV, and in steroid use. Remember that Listeria is
resistant to all cephalosporins. Add penicillin or ampicillin to empiric ceftriaxone if the patient
is immunocompromised and you suspect Listeria.
Although viral meningitis can give neutrophilic predominance in the CSF in the first 24 hours,
it usually has a much lower total WBC count compared with bacterial meningitis. Viral
meningitis generally gives hundreds of cells, whereas bacterial can give thousands. The Gram
Start empiric antibiotics
51
stain is only 60–80% sensitive in the detection of the pathogen in bacterial meningitis, so the
negative stain does not rule out a bacterial etiology. Without a specific organism seen, the
patient should receive coverage for the most common organisms. Add vancomycin to the
empiric ceftriaxone until culture results are known.
S. pneumoniae and Neisseria meningitis are most common in this patient’s age group. Listeria
does not need to be covered empirically unless the patient is an infant or otherwise
immunocompromised with cancer (lymphoma most common) or steroid use. Ceftriaxone is
excellent empiric coverage until the culture results of the CSF are known. Vancomycin is
always added.
In the United States, 25,000 cases of bacterial meningitis occur each year; 70% of cases occur
in children age <5 years.
The most common complication from bacterial meningitis is hearing loss. Mental retardation,
cerebral palsy, seizures, and language problems may also occur.
Follow-up Management and Prevention
In adult meningitis, H. influenzae accounts for only 1–3% of cases, due to the introduction
of the haemophilus B vaccine.
S. pneumoniae is the most common cause of meningitis in children beyond the neonatal
period, as well as in adults.
In the neonatal period, gram-negative bacilli and group B streptococci are the most common
causes of meningitis.
Initial empiric therapy is ceftriaxone and vancomycin until results of the sensitivities
are known
1.
If organism is penicillin-sensitive, change the antibiotic to penicillin or ampicillin
2.
Corticosteroid (dexamethasone) therapy is now considered standard empiric therapy
for most cases of bacterial meningitis; benefits are greatest in patients with
52
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Final Diagnosis
Pneumococcal meningitis
CLINICAL PEARL
Other types of meningitis to consider are:
Cryptococcal Meningitis
pneumococcal meningitis, resulting in decreased morbidity (deafness) and mortality
Dexamethasone should be given immediately before, or with, the first dose of
antibiotic and continued for 4 days
Steroids can be discontinued if etiology of meningitis turns out to be non-
pneumococcal
Repeat lumbar puncture after a few days to ensure that infection has cleared, necessary
only if prompt clinical resolution does not occur
3.
Examine for otitis, mastoiditis, sinusitis to try to identify the origin of the meningitis4.
For brain abscess, do surgical drainage PLUS empiric coverage with metronidazole
AND ceftriaxone with or without vancomycin (polymicrobial, including anaerobes,
most importantly, B. fragilis)
5.
For post-neurosurgical or post-head traumatic patients, give vancomycin PLUS
cefepime or meropenem or ceftazidime to cover MRSA and pseudomonas
6.
History of HIV with <100 CD4 cells. India ink positive in 50–70%, antigen test
positive in >90%
More gradual in onset, less severe
Initial therapy with amphotericin, then lifelong fluconazole
53
Rocky Mountain Spotted Fever
Lyme Disease
Rash on wrists and ankles that moves toward the body
Confirm with serology specific for Rickettsia; treat with doxycycline until results of
testing are known
Endemic area such as the Northeast; history of rash
Diagnose with positive enzyme-linked immunosorbent assay or Western blot; treat
with ceftriaxone
54
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Case 5
Chief Complaint
“My belly is swollen, and it hurts.”
History and Physical Examination
A 59-year-old woman comes to the emergency room with 2 days of increasing abdominal
pain and distension. She has a history of alcoholism and biopsy-proven cirrhosis of the
liver. Her ascites had been controlled in the past with a low-sodium diet and
spironolactone, but she has been noncompliant with her medications recently.
Vital signs are T 38.4 C (101.1 F), BP 105/70 mm Hg, and pulse 120/min. Physical
examination shows a few spider angiomata visible on the face. Her extremities have a 2+
pitting edema in the legs to the mid-thigh. Her abdomen is moderately distended with the
presence of a fluid wave; it is diffusely tender but soft. There is no guarding or rebound
tenderness. The liver and spleen are not palpable secondary to the ascites. There are
normal bowel sounds. The remainder of the physical examination is unremarkable.
Differential Diagnosis
Spontaneous bacterial peritonitis1.
Secondary peritonitis (bowel perforation)2.
Pancreatitis3.
Cholangitis4.
Diverticulitis5.
55
Initial Management
Setting: emergency department
Initial Diagnostic Plan Results
CBC WBC 14,500/mm
3
with 77%
polymorphonuclear leukocytes, platelets
118,000/mm
3
Prothrombin time 14.7 seconds (normal: <13 seconds)
Albumin 2.7 g/dL (normal: 3.5–5 g/dL)
AST/ALT Normal
Abdominal x-ray No obstruction, no air-fluid levels
Chest x-ray No infiltrates, no air under the diaphragm
Assessment
The ascites that accumulates from alcoholic cirrhosis is especially predisposed to spontaneous
peritonitis. Spontaneous peritonitis presumably occurs from hematologic seeding in the
absence of perforation of an abdominal organ or trauma, such as a knife wound. Although this
patient’s complaints (pain and distension) and physical exam (fever, tenderness) are clearly
indicative of peritonitis, these findings do not have to be present for spontaneous bacterial
peritonitis to occur. Ultimately, the only certain diagnostic method is a paracentesis of the
ascitic fluid. Patients may also present with hepatic encephalopathy.
A paracentesis must be performed in new-onset ascites even in the absence of symptoms
because spontaneous bacterial peritonitis can still be present. Criteria for diagnosis are a
polymorphonuclear leukocyte count of >250/mm
3
or total WBC count >500/mm
3
in the ascitic
56
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
fluid. The elevation of the prothrombin time and the decreased albumin are indicative of the
decreased synthetic function of the liver with far advanced cirrhosis. The transaminases are
normal because eventually the liver becomes so destroyed that the transaminases return to
normal. If the ascitic fluid had very low glucose (<50 mg/dL), very high LDH or neutrophil
count >10,000 or is polymicrobial, secondary peritonitis should be suspected and imaging
should be done.
CLINICAL PEARL
The Gram stain is relatively specific if it is positive, but it lacks sensitivity and cannot
exclude infection if it is negative. This is also true for the culture of the paracentesis
fluid.
Further Diagnostic Plan Results
Paracentesis WBC count 750/mm
3
with 90%
polymorphonuclear leukocytes
Culture yields E. coli
Fluid albumin 2.2 mg/dL
Treatment Plan
Antibiotics for gram-negative bacilli and S. pneumoniae (cefotaxime or ceftriaxone) plus
infusion of IV albumin; in this case we know the cause is E. coli, but most cases are culture-
negative, thus the need to cover S. pneumoniae with cephalosporins
Diuretics and repeated abdominal paracenteses to remove larger volumes of fluid if patient
becomes uncomfortable or respiratory function is compromised
57
Discussion
Although spontaneous bacterial peritonitis implies that all abdominal organs are intact, the
most common organisms are the bowel flora. Most often it is caused by a single agent.
Polymicrobial infections generally indicate perforation of a viscus. Aerobic gram-negative
bacilli (Enterobacteriaceae) such as E. coli are the most common. Gram positives such as S.
pneumoniae, group A streptococci (pyogenes), and enterococci are also common. It is caused
by translocation of enteric bacteria across the bowel wall.
Studies have shown that giving IV albumin infusion on days 1 and 3 of antibiotic treatment
increases the effective arterial circulating volume and renal perfusion, thus decreasing the
incidence of hepatorenal syndrome and improving mortality.
IV cefotaxime has evolved as the drug of choice, however. Cefotaxime will cover E. coli as
well as S. pneumoniae. Anaerobes are rarely the causative organism in spontaneous bacterial
peritonitis. When a specific organism is identified, as with this patient, the choice depends
upon the specific sensitivities of the organism.
Prevention
Around 70% of patients who survive spontaneous bacterial peritonitis will have another
episode within 1 year. Oral norfloxacin, ciprofloxacin, and trimethoprim-sulfamethoxazole
have been shown to reduce the rate of recurrent infections to <20%. Therefore, any patient with
a history or spontaneous bacterial peritonitis should take one of these agents for prophylaxis
indefinitely.
When patients with cirrhosis have bleeding esophageal varices, they are at an increased risk of
developing spontaneous bacterial peritonitis. Studies show that giving these patients
ceftriaxone or ciprofloxacin for 1 week during the bleed reduces the risk. Therefore, during a
variceal bleed, patients with cirrhosis should receive antibiotics, even if they do not have
clinically apparent ascites.
58
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Final Diagnosis
Spontaneous bacterial peritonitis
59
Case 6
Chief Complaint
“I’m here to see what medications I need.”
History and Physical Examination
A 47-year-old woman who has recently found that she is HIV-positive comes to your
office for an initial evaluation. She has always been healthy and took the test only because
an old boyfriend died of AIDS. She has no other medical problems and is currently on no
medications.
Her only tests done so far are CD4 (T-cell) count 47 cells/mL (normal 600–1,200
cells/mL), polymerase chain reaction-RNA viral load 180,000 (normal <50 to >750,000),
and PPD skin test with 8 mm in duration. She has no symptoms. Her last Pap smear was 4
years ago. Vital signs and examination, including pelvic examination, are normal.
Initial Management
Setting: outpatient
Diagnostic/Therapeutic Plan
Rapid plasma reagin or venereal disease; normal research laboratory tests for syphilis
Toxoplasmosis antibody test
CBC
60
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Соседние файлы в папке Библиотека им академика М.И. Перельмана