Brain pus

Having pus in your brain is a problem no matter how you cut it, but finding it in there can be a challenge.  While the classic triad is usually fever, headache and a focal neuro deficit, this isn’t always present.  Dave Traficante (@davetraf) just published a pretty cool case of bifrontal brain abscesses in the International Journal of Emergency Medicine of a gentlemen with this very problem.  Interestingly, he didn’t have any focal neuro deficits, but he did have a very flat affect and could care less of the pus accumulating in his brain which coincided with the frontal lobe location of his abscesses. Check it out here.

BOGO on TOAs

Lower abdominal pain in women can be challenging diagnostic dilemma in the Emergency Department. We had a case of a 50-year-old woman that had been previously seen by her PMD 3 days prior and diagnosed with a “small kidney stone” without any imaging, but did get the ever-reliable percocet prescription. Needless to say, she came to the ED because her pain wasn’t getting any better and now she was having increasing lower abdominal pain with high fevers. In the ED she was febrile (T: 104.5) and tachycardic (HR: 120s), but her BP was normal. She ended up having a WBC: 17k/mm3, bands: 20% and a pretty nasty UTI. Her pain persisted and we ended up doing a CT abd/pelvis with contrast to see if she had anything brewing. From the images below you can see that she had bilateral tubo-ovarian abscesses causing bilateral hydronephrosis seen on CT and confirmed with ultrasound. She was started on ampicillin, clindamycin and gentamicin and her abscesses were drained with CT guidance, yielding 400cc of thick, brown, purulent fluid. Yum

Figure 1 Figure 2

Up to one half of all cases of tubo-ovarian abscesses occur in patients with a history of pelvic inflammatory disease (PID). The theoretical etiology of tubo-ovarian abscesses is thought to revolve around an ascending infection arising in the lower reproductive tract, into the uterus and subsequently the fallopian tubes and ovaries. While Neisseria gonorrhea and Chlamydia trachomatis are commonly associated with PID, TOAs are typically polymicrobial and rarely grow either chlamydia or gonorrhea when cultured. As with most pelvic pathology, ultrasound remains the initial diagnostic modality of choice for tubo-ovarian abscesses to best visualize the upper reproductive tract. Ultrasound remains very specific (86-98%), whereas the sensitivity ranges between 56-93%. There is evidence however that computed tomography of the pelvis with contrast may provide better sensitivity than ultrasound in evaluation of TOAs. In the Emergency Department, a triple coverage antibiotic regimen (i.e. ampicillin/clindamycin/gentamicin) should be initiated despite whether the patient is going to need surgical exploration, percutaneous abscess drainage or conservative management. If the patient’s clinical status has either worsened or not improved after 48-72 hours the gynecologist will likely proceed with minimally invasive drainage procedures that have become more readily available, similar to our case.

Post by: Terrance McGovern DO, MPH (@drtmcg13)

Top 10 Infectious Disease Updates

I recently gave an “ID Updates” lecture at AAEM’s Scientific Assembly in Las Vegas, February 2016. Here are the top 10 pearls from my lecture. Some may be review, some more cutting edge. Enjoy!

  1. Use ultrasound to help guide diagnosis and management of suspected skin and soft tissue abscesses

The literature is mixed on this one but it makes sense to use ultrasound. Ultrasound seems to increase your diagnostic sensitivity and may affect management, especially in those “gray zone cases”. If you are feeling ambitious, use ultrasound after I & D to assess the success of your I & D. Plus, it’s pretty easy to do!

Alsaawi, A et al. European Journal of EM. 2016.

 

  1. Although guidelines still recommend solely I & D as the treatment of choice for simple skin and soft tissue abscesses, maybe antibiotics are not so bad!

A recent trial from Talan et al. from NEJM supports the use of antibiotics in skin and soft tissue abscesses. Antibiotics increased clinical cure and decreased complications. The knock on this trial is the included patients would have received antibiotics anyway based on disease severity; nonetheless, antibiotics benefitted patients with little harm.

Talan D et al. New England Journal of Medicine. 2016.

 

  1. First line treatment for suspected sexually transmitted infections (cervicitis, urethritis) is dual therapy Ceftriaxone 250 mg IM and Azithromycin 1 gram po.

Cefixime used to be a first line alternative (instead of Ceftriaxone), however, it is no longer with increasing resistance patterns. Bottom line—give dual therapy! Consider challenging patients who have a PCN allergy with Ceftriaxone. If you’re not going to give dual therapy with Ceftriaxone/Azithromycin, the reason better be good!

www.cdc.gov

 

  1. Newest GI recommendations state that antibiotics probably do not reduce symptom duration for uncomplicated CT proven diverticulitis.

Yes, I said it—no antibiotics for acute uncomplicated diverticulitis! Certainly, we would like to see more literature in this area, but the literature we do have show antibiotics do not improve symptoms. Antibiotics may however decrease complications, as per the guidelines. I’d like to see more here, but check out the references and see for yourself.

Strate L et al. Gastroenterology. 2015.

 

  1. Non-operative management of appendicitis is an option.

We’re not here yet in the U.S. but they are in Europe. In the newest Lancet study, 73% of patients who received non-operative management did not require an appendectomy out to one year. Those that failed non-operative management did not have complications of sepsis, abscess, or rupture compared to the operative group. The theory for non-operative management is not all appendicitis is an obstructive process that requires removal; some may respond to medical therapy.

Salminen P et al. JAMA. 2015.

 

  1. Timing of antibiotics does not reduce mortality from severe sepsis/septic shock.

CMS dictates we administer antibiotics within 3 hours of diagnosing severe sepsis/septic shock in the ED. It’s a core measure we need to meet. But it does not reduce mortality per a recent systematic review from Critical Care. Timing of antibiotics may be important, but antibiotic selection is probably more important.

Sterling S et al. Critical Care Medicine. 2015.

 

  1. Irrigation pressures do not matter in the management of open fractures.

In the OR, whether patients with open fractures get very low pressure, low pressure, or high pressure irrigation, re-op rates are the same!

The Flow Investigators. New England Journal of Medicine. 2015.

 

  1. Consider use of corticosteroids in inpatients with pneumonia.

Adjunctive prednisone in pneumonia reduced inpatient stay.

Angela Blum C et al. Lancet. 2015.

 

  1. It is thought that Strep sp. are the predominant organisms in cellulitis. But maybe not!

If Bactrim works as well as Clinda, Strep may not be the king organism in undifferentiated skin and soft tissue infections. Check out the reference.

Miller L et al. New England Journal of Medicine. 2015.

 

  1. Respect lactate!

We know lactate is not specific. But in the setting of infection or suspected sepsis, respect it if it is positive, even if in the intermediate range. Intermediate level lactates had a 30 day mortality of 15%.

Singh M et al. Annals of EM. In Press.

Post by: Nilesh Patel, DO (@nnpatel1291