Deep Dive #6: Bacteriuria and the Elderly

Author: Heidi Wald, MD, MSPH 

Associate Professor of Medicine – University of Colorado School of Medicine, Physician Advisor – Colorado Hospital Association

Dr. Heidi Wald explains common misconceptions of UTI’s in elderly patients and provides tips on how to properly identify them.

References:

Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici  Antibiotics for asymptomatic bacteriuria  Cochrane Collaborative Online Publication Date: April 2015.

Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.

Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015.

D’Agata ELoeb MB, and Mitchell.  Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070.

Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

Podcast #254: Myths About Antibiotic Course Length

Author: Chris Holmes, M.D.

Educational Pearls

  • There’s little/no data about the necessary length of an antibiotic course, nor has it proven that stopping a course of antibiotics early selects for the most resistant bugs.
  • There’s little incentive for drug companies to fund this type of study.
  • Pro-calcitonin levels have been used in some settings to distinguish if an infection has resolved or not, but this may not be feasible in an outpatient setting.

References: Llewelyn, Martin J et al. The antibiotic course has had its day. 2017. BMJ

Podcast #244: Fever in Sepsis

Author: Nick Hatch, M.D.

Educational Pearls

  • A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes.
  • Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively.

References: Paul J Young,  Rinaldo Bellomo. Fever in Sepsis: is it cool to be hot?. 2014. Critical Care

Podcast #240: Pott’s Puffy Tumor

Author: Suzanne Chilton, M.D.

Educational Pearls

  • Pott’s puffy tumor is a subperiosteal abscess of the frontal bone that arises from hematologic spread or direct infection via the frontal sinuses. The primary symptom is facial swelling.
  • It is much more common in children and adolescents.
  • Treatment involves removal of the frontal bone, reconstructive surgery, and 6-8 weeks of IV antibiotics.

References: Grewal HS, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill! The American Journal of Case Reports. 2012;13:133-136. doi:10.12659/AJCR.883236.

Podcast #219: History of Sepsis

 

Author: Chris Holmes, M.D.

Educational Pearls

  • “Sepo’ is a term from Homer (author of The Iliad and The Odyssey), and means “I rot”.
  • Hippocrates in 400 BC identified sepsis as a “dangerous decay within the body”.
  • Galen in 200 AD believed pus was “laudable”.
  • The Greeks and Romans used the term “myasma” to describe the smell of swamp and rotting flesh.
  • Dr. Emmanuel Rivers in Detroit did one of the the first big studies about sepsis and was an advocate for goal-directed therapy.
  • Now, Vitamin C cocktails are in use, but new sepsis treatments should be investigated carefully before implementation.

References: Funk, Duane J. et al. Sepsis and Septic Shock: A History. Critical Care Clinics , Volume 25 , Issue 1 , 83 – 101

Podcast #195: How to Properly Inject Heroin

Author: Don Stader, M.D

Educational Pearls:

  • It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing.
  • Hepatitis, HIV and infection are possible complications of improper IV drug use
  • The first step of heroin use is to dissolve the solid heroin in water using heat – a spoon and lighter are often used for this step. Next, the heroin is drawn into the syringe through a filter (cotton is often used).
  • Heroin concentration often varies widely – counsel patients to test their heroin first.
  • Sterility of the needle, water, cooker, cotton and syringe is paramount. Refer patients to a needle exchange program where they can get clean supplies.
  • Hepatitis C can live outside the body for 4 days – NEVER share ANY supplies.
  • Sterile procedure is important – needles should not be licked.

References: http://drugsense.org/flyers/10_tips_for_safer_use.pdf

 

Podcast #188: Monoarthritis

Author: Peter Bakes M.D.

Educational Pearls:

  • Some common causes of monoarticular arthritis include: crystal arthropathies (gout and pseudogout), infection (septic joint), reactive arthritis and acute presentations of chronic arthritides.
  • Lyme disease usually presents with a targetoid lesion associated with constitutional symptoms
  • The common triad of symptoms associated with reactive arthritis (aka Reiter’s Syndrome) consists of conjunctivitis, urethritis, and arthritis
  • Reactive arthritis commonly presents with a history of  a GU infection (often chlamydia) or GI infection (Shigella, Campylobacter, Yersinia, Salmonella). It is more common in men and those between 20 and 40 years old.
  • Treatment for reactive arthritis is usually supportive.

References: www.emedicine.medscape.com/article/331347-overview

Podcast #187: Mumps

Run Time: 4 minutes

Author: Gretchen Hinson M.D.

Educational Pearls:

  • The key imaging of a mumps patient is “chipmunk cheeks” or parotitis.
  • The swelling can extend almost to the ears and can be extremely painful – in about 25% of cases the swelling is unilateral.
  • Other organs can be involved as well including: testicles, ovaries, breast tissue, other salivary glands, and the brain/spinal cord.
  • Mumps is transmitted through droplets in the air.
  • Two immunizations will get you 88% probability immunity and one immunization will get you 78% probability of immunity. Yet, immunity can wane and there can be viral strains not covered by the immunization.
  • Mumps outbreaks are common in the winter season because of close quarters.
  • You can test for Mumps using an IGM blood test, (more likely to see a spike in this if the patient is not vaccinated) Buckle swabs, & Urine test.

References: https://www.cdc.gov/mumps/index.html

Podcast #169: Lyme Disease

bd9fdb03-4845-4c2d-b1fc-f4bcd1253d7cRun Time:  7 minutes

Author: Greg Burcham M.D.

Educational Pearls:

  • Case presentation: A 48 year-old male cyclist travels to new england for a race. Afterwards he is sore, tired and fatigued, but 1 week later back in Colorado he is still sore, tired, and fatigued, and he also noticed a rash that started after a few days. The patient presents to the ED after a syncope with HR in the low 40s.
  • This patient has Lyme Disease. Hallmarked by the rash that he has, known as erythema migrans – a migrating red rash.
  • Symptoms usually present 1-2 weeks after a tick bite, and generally start as nonspecific – fever, myalgias, headache, arthralgias, malaise. 80% of patients present with the rash that starts as a small red lesion that enlarges with a bright red border.
  • A smaller percentage of patient get early disseminated disease. The most concerning complications are cardiac – Atrioventricular Block, bradycardia, and syncope – or a meningitis presentation.
  • Late disseminated findings include chronic joint and muscle arthralgias, seizures, paresthesias, memory and cognitive changes. Amy Tan – author of The Joy Luck Club – has chronic lyme and she loses memory if she is off her antibiotics for any period of time.
  • Lyme Disease is increasing by more than 10% per year for several years due to the destruction of habitat of predators, leading to mice population explosion, and global warming.
  • Each stage of the tick life cycle require a blood meal – larva to nymph to adult. Normally larva find it hard to get a blood meal in the fall after they hatch in the late summer. The larva go dormant until spring when they are able to find a blood meal and eventually become adults so the life cycle can start over on an annual basis.
  • As the climate has warmed a higher percentage of larvae are feeding earlier in the year, with a greater frequency in the New England area.
  • The bacteria that causes Lyme Disease needs time to replicate in the host, but due to asynchronous feeding between the mice and ticks there is a higher concentration of the bacteria in both the mice and the ticks.

Link to Podcast: http://medicalminute.madewithopinion.com/lyme-disease/

References: http://rstb.royalsocietypublishing.org/content/370/1665/20140051

https://www.cdc.gov/lyme/