1. Management of Common Infections Dr Chow Ting Soo Infectious Disease Unit Hospital Pulau Pinang

2. History- Basic info 42 year old lady Background medical history of Diabetes mellitus for many years, not on regular treatment Fever for 4 days Unwell, poor appetite, nausea, vomiting, In AE: T 39 degree C, BP 123/74, PR 104,

3. What further history would you like to ask?

4. Case history 42 year old lady, DM type 2, not on regular treatment Fever 4 days associated increasing urine frequency, pain on micturition and also increasing left loin pain, no passing out stone /sandy particles per urethra, no blood seen in the urine, never had history of instrumentations on urinary tract, no history of renal stone before, first admission to hospital, not seen any other doctor yet before this. (WHY is it important to ask these questions??)

5. Clinical examination Temp 38.5 PR 110 BP 123/74 What do you want to do next?

6. Case examination REF: 15 RR 24 Oxygen 98% room air CRT < 2 sec BP 124/74 PR 110 good volume, bounding, warm periphery Temp 38.5 GCS full, hydration fair, no neuro deficit Lungs clear CVS normal Abd: soft non tender, left loin renal angle tender renal punch positive Urine test : RBC numerous, PC +++, nitrate +, ketone –ve, urine pH 7.1 ( urine pH high > alkaline when bact infection present, nitrate also positive indicate UTI) FBC stat: TW 18, Hb 10, Plt 155, neutrophil 80% BUSE : na 135, K 3.5, BU 8, creatinine 140,

7. Diagnosis?

8. What investigations you would do next?

9. Case - Investigations LFT- albumin 30, ALT 58, Blood C+S – at least 2 bottles, 2X 10 cc aerobics sent and pending CXR- clear Urine C+S - pending VBG – HCO3 18 US KUB –mild left hydronephrosis, no stones seen, no hydroureter. Baseline ECG – normal ECG HbA1C – pending

10. Management

11. Starting antibiotic therapy: Is not as easy as ABC Which regime?

12. Answer? 1. Imipenem 2. Meropenem 3.pip/tazo 4 Cefipime 5 ceftriaxone 6 Unasyn or augmentin 7 ertapenem

13. What Constitutes Initial Appropriate Therapy?

14. List the class of antibiotic 1.? 2.? 3.? 4.? 5.? 6.? 7.?

15. So in this patient … Clinically sepsis, pyelonephritis, Not hypotensive, Not in shock, not severe sepsis, Community acquired Cultures taken Need to Cover e.coli, kleb, strep, with ??

16. Timing on administration of antibiotic

17. Treatment Duration?

18. Sepsis treatment is not just antibiotics alone! What else?