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16.09.2015, admin
The initial steps in the evaluation and management of a patient with infection are similar to those taken when treating all emergencies.
To determine the etiology of a patient’s infection, a careful history and physical examination must be obtained. Further clues, including onset, progression of symptoms, and associated events, may help differentiate between etiologic agents.
The patient’s past medical history can be critical in defining which organisms are more likely to be causing the infection. Another factor to consider is where the infection was acquired, because hospital-acquired organisms tend to be more resistant to antibiotics than those coming from the community. Physical ExaminationThe physical exam may give valuable diagnostic information, especially regarding the site of infection, which, as previously mentioned, is one of the most important hints as to the possible etiologic agent. Pulse oximetry, long regarded as the “fifth vital sign,” has the appeal of an objective and inexpensive way to assess breathing and oxygenation.
When evaluating a patient, the physician must pay close attention to the patient’s mental status.
The chemistry panel can occasionally offer clues to the etiology of an infection, as in the case of an elderly patient with cough, fever, hyponatremia, and elevated liver function tests (LFTs), possibly indicating Legionella pneumonia. Though an elevated WBC is associated with infection, its predictive value for bacterial disease has proven to be low.27,28 Serious bacterial illnesses may present with a normal WBC count, and WBC count elevations are often due to causes other than bacteria, such as viral infections. When managing patients with respiratory infections, a physician must decide whether to obtain a pulse oximetry measurement alone or to draw an arterial blood gas. A urinalysis is not necessary to diagnose a UTI in women ages 18-65 who present with symptoms of UTI, such as dysuria, frequency, and urgency, and who have no complicating factors.38 Complicating factors include diabetes, pregnancy, mmunosupression, underlying urinary tract disease or renal calculi, recent medical intervention (hospitalization or catheterization), recurrent UTIs, or failure of therapy.
Urinary dipstick testing has replaced urinalysis in many centers, because of its low cost, speed, and convenience. The cerebral spinal fluid (CSF) should be evaluated for cell count, glucose, protein, culture, and Gram stain on all patients.
The acute phase reactants are proteins produced by hepatocytes and other cell types in response to infection, inflammation, and tissue injury. Another acute phase reactant that is currently under investigation is serum procalcitonin (PCT). When performing radiologic studies in the ED, the physician must judiciously choose the modality that offers the highest yield. In a few instances, the Gram stain can be useful, mainly to identify bacteria in those body fluids that are normally sterile.8 In the ED setting, that usually means either the CSF, urine, or abscesses. Sputum Gram staining in community-acquired pneumonia is generally not useful and not recommended.
There is some controversy around when to prescribe antibiotics for pharyngitis, as well as when to obtain throat cultures or rapid strep antigen detection testing (RADT). The identity of an infectious organism usually cannot be known with certainty in the ED, as culture results take days to come back.
Get full access to all EB Medicine articles published 3 years (or more) ago, including evidence-based, peer-reviewed diagnosis and treatment recommendations. Illness is an almost inevitable hazard of being alive, at some point we all suffer from malaise of one sort or another, fortunately the human immune system is remarkably efficient at combating these and restoring us to full health, except for bacteria, so we list the most common bacterial infections, forewarned is forearmed.
The human body coexists with many trillions of bacteria that live on the surface of our skin, inside our digestive system, in fact throughout the body, and whilst most are beneficial or at worst harmless, there are a few bacteria that have the potential to cause serious illness. The biggest cause of death from bacterial infection is tuberculosis, a disease that kills 2 million men, women, and children every year around the globe ,and which is spread from person to person by sneezing, or thru saliva, and affects the lungs, but then spreading thru the bloodsystem to other organs. Another very common bacterial infection, particularly in the developed world is Chlamydia, a sexually transmitted disease that seems to occur most frequently amongst 15 to 19 year old women, and is fully preventable by following safe sex procedures, but has no noticeable symptoms and requires a urine test or pelvic examination by a gynecologist. Amongst the sexually transmitted diseases caused by bacterial infections is another very common ailment, gonorrhea, which in contrast to Chlamydia is very obvious when it strikes, exhibiting localized pelvic pain, itching and irritation, painful urination, and a thick green or yellow discharge, and in women, can also produce bleeding between periods. Less well known, but every bit as common are the many skin irritations that can be caused by bacterial infection, ranging from redness and slight swelling of Impetigo, to the pus filled blisters and pimples of folliculitis.
Common bacterial infections of the skin are rarely treated quickly, many people suffer from pimples and blotches that aren’t caused by bacteria and incorrectly assume more of the same.
Many treatments for common bacterial infections are becoming less effective with every year that passes, the bacterium itself are evolving and developing resistance to antibiotic medications, and unfortunately with every evolution scientists are forced to play catch up, some even suggesting we may run out of options soon. Bacterial infections often times appear without any warning and begin as red spots on skin or tiny red dots on skin. Tiny red dots on skin or red spots on skin in a circular pattern with a blister like appearance are usually ringworm. Be sure to use shower shoes in locker rooms, around pool decks and while using public showers. Eczema, easily confused with Psoriasis, is an inflammatory skin disorder that causes the skin to be dry and cracked. Environmental factors can play a major role in the frequency, as well as the severity, of eczema outbreaks.
Minimize contact with water, especially hot water, as it tends to strip the skin of natural oils.
When eczema outbreaks occur, use an anti-itch healing cream, such as a topical steroid with 1% hydrocortisone. Contact dermatitis is considered a type of eczema and is triggered by the skin coming in physical contact with something that produces an allergic reaction or severely irritates the skin. The fastest way to prevent contact dermatitis is to avoid contact with known triggers that cause you to break out.
The basics come first: intubate sick, hypoxemic, and septic patients, if needed, and provideoxygen and circulatory support when indicated.


Bacteriologic statistics help identify the organism most likely to cause infection in a given patient at a given site (“specific organisms like specific sites”). For example, a patient with pneumonia who recently had a seizure disorder may have aspirated elevating anaerobes on the list of suspects.
Asplenic patients, or “functionally asplenic” patients, like those with sickle cell disease, would be prone to infection with encapsulated organisms. It is important to know the patterns of resistance for both hospital- and community-acquired organisms in your area. For example, a child with a bullous skin lesion probably has infection, while a young, healthy woman with costovertebral angle tenderness probably has pyelonephritis. The standard first goal of emergency medicine is an aggressive approach to correct abnormal vitals. The tympanic thermometer has been shown to be poorly sensitive for fever compared to the rectal. As long as its limitations are kept in mind (ie, its dependence on tissue perfusion, ambient temperature, skin color, presence of nail polish), it is an excellent tool that gives more information than respiratory rate alone. Additionally, the chemistry panel may show the hydration status, renal function, and acid-base status of the patient. Obtaining a WBC may be helpful when following a known abnormality or looking for an expected effect, such as drug-induced leukopenia.
As previously mentioned, the pulse oximeter has often been labeled the “fifth vital sign,” since it can give a good estimation of a patient’s respiratory status.
However, if the physician prefers to evaluate uncomplicated patients via urinalysis, a urine culture is not warranted. Although the finding of pyuria on urinalysis is very sensitive (95.8% sensitivity), it is not very specific (71%). More specific studies, such as viral cultures, VDRL, and cryptococcal antigen should be obtained, if clinically indicated.45 Currently, many physicians order a head CT in patients with suspected meningitis before proceeding to an LP, in order to screen for any intracranial abnormalities that may lead to brain herniation secondary to removing CSF. These reactants are quite nonspecific and nonsensitive for identifying individual disease entities.
This aminopeptide is identical to the precursor of calcitonin, but it has no hormonal activity. For example, Waters view x-rays to diagnose sinusitis are only 68% sensitive and 87% specific for maxillary sinusitis. In 2002, the Infectious Diseases Society of America (IDSA) developed a practice guideline for the diagnosis and management of group A streptococcal pharyngitis.60 They recommend that, if the clinical suspicion for strep throat is low — based on the absence of fever, anterior cervical adenopathy, and palatal petechiae — symptomatic treatment is all that is required. Blood cultures should be performed in patients who are immunosuppressed (eg, HIV, malignancies), have sickle cell disease, are steroid-dependent, or are admitted from a nursing home. Bacterial infections left untreated are a common cause of death in many countries, yet in most cases early intervention is successful. People most at risk from contracting this common bacterial infection are close family and friends, although extremely close proximity, such as is found in tribal villages and slum communities are equally at risk. Gonorrhea however isn’t just restricted sexually active adults, newborn infants can contract the disease from an infected mother, which if not treated at birth can quickly lead to blindness.
Left untreated many skin infections cause long term scarring, and in some cases may spread thru contact with eyes, mouth, nostrils, and open cuts to the bloodstream. By the time an accurate diagnosis is made the infection has reached a stage where antibiotics are required, yet may not have been required if proper identification had been done in it’s early stages.
This is probably the most compelling reason of them all for treating bacterial infection in it’s early stages rather than later. Then gently apply an antiseptic healing ointment or a topical antibiotic directly to the site of infection.
These types of infection typically develop in between the toes, the groin region, under the breasts, in the folds of skin or in areas covered by diapers in babies. It is quite easy to come in contact with the fungus that causes these types of infections, especially in warm damp areas like pool decks, locker rooms, public showers or workout areas.
It is often red and itchy and primarily affects the elbow and knees, the back of the arms, the hands and the eyelids.
Fluctuating temperatures and a dry climate, or skin contact with latex gloves or perfumes are known triggers. Pat dry the skin and then apply an emollient, such as Aquaphor, which helps the skin to retain moisture. Luckily, unlike many forms of eczema and psoriasis, contact dermatitis can be completely cured in most instances.
When dealing with a current bout of contact dermatitis, try to identify the trigger source so you can avoid it in the future. In such a host, Haemophilus influenzae and pneumococcus can cause overwhelming sepsis in a very short time. Occasionally, there will be special physical findings that point to a specific etiology, as for example the erythema migrans rash characteristic of Lyme disease. One study followed 171 elderly patients admitted to a hospital with a presenting diagnosis of delirium and found that the most common cause of delirium was infection (34%), particularly pneumonia and urinary tract infections.26 For more details pertaining to the physical exam, please consult Table 6. Both a urinalysis and a urine culture are recommended in patients with complicating factors, and in patients with pyelonephritis.39 Children diagnosed with UTI may initially have a negative urinalysis but positive urine cultures. The presence of bacteria on microscopic examination is less sensitive (40-70%), but is more specific (85-95%). C-reactive protein (CRP) concentrations “increase with acute invasive infections, which parallel the severity of the inflammation or tissue injury.”51 However, the CRP is an expensive test that may not be available at all institutions. PCT is usually found in the thyroid gland only, but during bacterial infection it is found in serum.53 One study has shown that procalcitonin levels are significantly increased in cases of severe bacterial infection and sepsis,54 while viral infections and localized inflammatory responses present with low levels.


Symptoms such as coryza, absence of fever, diarrhea, and conjunctivitis point to a viral etiology. Obviously, blood cultures should be drawn in patients who may be septic or may have infective endocarditis or bacterial meningitis. Be sure to change your bandages frequently and see your doctor if the infection gets worse.
These areas of the body are usually covered or clothed, creating a warm, dark and moist environment that is conducive to fungal infection. Studies indicate that 17-20% of children under the age of 12 months are affected by eczema. Persons with eczema should resist scratching the affected areas, as this will only make the condition worse.
The hallmark of contact dermatitis is intense itching associated with welts or a blistering rash. Even though a thorough history usually leads to a correct diagnosis, it can at times be misleading.
Though the clinical presentation can be useful, it might sometimes be atypical or even misleading, especially in the very young, the elderly, and the immunosuppressed.
Together with central venous pressure, it should be one of the most closely monitored parameters in patients presenting to the ED in early sepsis. On the other hand, relative bradycardia in a hypotensive or febrile patient can sometimes give a clue to the specific etiology of an infection (eg, salmonella sepsis). Although arterial blood gas measurements cannot discriminate between viral and bacterial infections, they may aid in the detection of hypoxemia in patients with community-acquired pneumonia.
However, the presence of positive leukocyte esterase and nitrate has a much higher correlation of culture-proven UTI.41 Those UTIs caused by gram-positive organisms will not be nitratepositive. Following these recommendations would significantly reduce the number of unnecessary head CTs currently ordered. Currently, the only disease entities studied in the context of evaluating CRP and ESR utility in the ED setting are pelvic inflammatory disease (PID), appendicitis, and septic arthritis. If there is suspicion for group A strep, either a throat culture or rapid antigen detection test can be performed. When the skin is broken, as in the case of a wound or a picked scab or even the site of a ruptured pimple, bacteria is able to penetrate the skin and begin to fester and multiply. Skin that is red, cracking and peeling or even blistering are sure signs of a fungal infection. Many will outgrow their condition by early adolescence, but recurrence in adulthood is common.
Other triggers include poison ivy, latex, cleaning fluids, detergents and formaldehyde in nail polish. It is of utmost importance to start antibiotics as soon as possible, as this may be a lifesaving action.
Your hospital laboratory will often be able to provide you with the sensitivities of the most common organisms. One study evaluated 1009 febrile infants for sepsis and found that the sensitivity of the absolute band count was significantly superior to the total WBC in predicting outcome.34 Another study looked at the absolute band count in infants = 60 days of age with fever (rectal temperature = 38? C) who were at low risk for serious bacterial infection according to the Rochester criteria. In a prospective cohort study of 2267 patients, hypoxemia was most associated in patients older than 30 years who had chronic obstructive pulmonary disease (COPD), respiratory rate greater than 24, altered mental status, and involvement of greater than one lobe on chest x-ray.
Once there is a clinical suspicion for meningitis, blood cultures and an LP must be performed immediately, and antibiotic therapy should be started without delay to help prevent adverse outcomes. However, in low-risk patients with a low ESR, one may choose to observe the patient closely. One study of patients admitted to an ED in China found that PCT is no better marker for infection than CRP.55 Further study of this reactant is clearly warranted is identical to the precursor of calcitonin, but it has no hormonal activity.
However, many RADTs are significantly less sensitive than the throat culture; therefore, the IDSA recommends follow-up of a negative RADT with a throat culture in adolescents and children. Initially, the bacteria affects the wound and surrounding tissue, but can rapidly begins to spread throughout your entire body if left untreated. They found that the absolute band count varied widely from laboratory to laboratory.35 The recommendation is that, if the absolute band count is to be relied upon, then the physician should be aware of the laboratory’s definition of segmented neutrophils, since this varies so greatly.
Blood cultures should be drawn before antibiotics are begun, since 47-77% of patients with bacterial meningitis have positive growth on blood cultures.47-49 Once antibiotics are given, an LP should be performed as soon as possible since CSF sterilization can occur rapidly. In short, the ESR has a low utility in the ED, but it may be used to distinguish high-risk from low-risk patients. Testing should be conducted in children who have had contact with individuals with confirmed strep throat in the prior 2 weeks.
Common signs of bacterial infections can include red spots on skin, tiny red dots on skin, red blotches on skin, heat, inflammation and possibly bleeding. One retrospective study examined the rate at which parenteral antibiotic petreatment in a pediatric population sterilizes CSF cultures and found that there was complete sterilization of meningococcus (Neisseria meningitidis) within 2 hours and the beginning of sterilization of pneumococcus by 4 hours of therapy.50 An adequate culture can help guide antibiotic therapy and may also rule out bacterial meningitis.
Children should not be treated for group A streptococcal pharyngitis in the absence of a positive test.
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