1. Acute confusion Lent term year 2

2. The case 75 year old lady who has been a bit confused over the last year Found by her neighbour on the bathroom floor Admitted as an emergency

4. assessment Very confused and uncooperative T 36, P100, b.p.110/60 Not further examination possible

5. Differential diagnosis?

6. DD for acute confusion Metabolic/endocrine Structural Circulation Infection

7. Metabolic/endocrine >Drugs/toxins (eg alcohol) >Liver, renal, respiratory failure >Electrolyte disturbance (glucose, Na, Ca) >Hypothermia +Hypothyroidism +Porphyria

8. structural >Space Occupying Lesion (SOL) >Head injury >Raised intracranial pressure >Post-ictal

9. circulation >Haemorrhage >Ischaemia >Hypotension >Vasculitis

10. Non-cranial >Meningitis >Encephalitis >Non cranial infection eg respiratory, UTI/generalised sepsis

11. Investigations?

12. investigations U&Es, FBC, TSH, Ca, Blood gases LFTs glucose ?drug toxicity CRP Urine microscopy CXR ECG ?lumbar puncture ?cranial imaging

13. In this case: Hb 13g/dl WC 10 x10 9 dl/l Na 135 K 4.2 U 10mMol/l Ca 2.2 mMol/l LFTs normal ECG sinus tachycardia Urine microscopy: >200 wcc/mm 3 CSU sent (MSU not obtainable)

14. Treat as UTI whilst awaiting culture and sensitivity, but how?

15. Factors to consider when choosing an antibiotic

16. Choosing an antibiotic Most likely organism Sensitivity: may need broad spectrum How ill is the patient? Likely route/dose/frequency/length of course Recent or concurrent antibiotics Other medication Other illness e.g renal function Price/local policies

17. Problems with antibiotics Side effects Achieving therapeutic dose (may need to measure) Toxicity Teratogenicity Allergy Compliance/concordance Resistance: inate or acquired Opportunistic infection

18. Some favourite examples 1.Bowel surgery 2.Community acquired chest infection 3.UTI 4.Chlamydial infection See the BNF or http://www.globalrph.com/bugs2.htm http://www.globalrph.com/bugs2.htm IF IN DOUBT CONSULT YOUR MICROBIOLOGIST

19. Bowel surgery Broad spectrum against Gram –ve cocci and anaerobic organisms No substitute for antiseptic technique and antiseptics Consider: cephalosporin/metronidazole/gentamicin

20. Community-acquired chest infection ?haemophilus influenzae, streptococcus pneumoniae Broad spectrum E.g.: Augmentin, Cefotaxime, Ceftizoxime, Ceftriaxone, Azithromycin, Clarithromycin, TMP-SMX, Oral 3rd generation Cephalosporins

21. Urinary tract infection Usually bowel organisms (G-ve) Amoxycillin, cephalosporins, gentamicin

22. Chlamydial infection Azithromycin, Doxycycline Erythromycin But don’t forget to look for other concurrent STD and treat the partner