Lightning Lecture – Syphilis by Landon Pehle

• Treponema pallidum
• “The Great Imitator”
• Stages
  • Primary – painless chancre
  • Secondary – rash, lymphadenophty, condyloma lata
  • Tertiary – meningitis, aortitis, aneurysms, argyll robertson pupil
  • Congenital syphilis 
• Testing
  • PRP/VDRL (1st line screening)
  • FTA-ABS (specific testing)
  • Darkfield microscopy
• USPSTF recommends screening in high risk groups
• LP in neurologic, ocular, latent syphilis, HIV coinfection
• Treatment
  • Penicillin G
    • Jarisch-Herxheiner reaction
    • Desensitization

Lightning Lecture – Botulism by Madison Wilson

• Clostridium botulinum
  • Spores
  • Found in soil, water
  • Anareobic
• DDX for MG, GBS, tick paralysis, hypothyroid
  • Botulism with no CNS effects
• Workup
  • Neutralization assay is gold standard
  • CT head
  • Basic lab work
  • LP
• CDC algorithm for initiating treatment
  • Equine derived antitoxin
• Admit to ICU
  • Airway watch, NG tube, foley catheter
  • Recovery is slow
• Infantile botulism
  • pH is higher in GI tract, easier for spores to colonize and release in large intestine
  • Flaccid paralysis, loss of head control, respiratory failure, loss of reflexes
  • Human based botulism IG
• Wound botulism
  • In vivo toxin 
  • Treat with debridement, penicillin, and antitoxin
• Inhalation botulism
  • Aerosol for bioterrorism

Infectious Recommendations from Pharmacy – Dr. Hannah Moore

• Sepsis
  • 30CC/kilo fluids
  • Empiric antibiotic therapy
    • Assess risk factors
    • Previous + micro
      • Previous resistance?
    • MRSA – Vanc (IV), Doxy (PO)
    • Pseudomonas – Zosyn (IV), Cefepime (IV), Cipro/Levaquin (PO)
  • Bacterial meningitis
    • S pneumo, N meningitides, listeria, GBS, H influenza, HSV, VZV
    • CSF findings – bacterial vs viral vs fungal
    • Empiric therapy
      • Ceftriaxone, vanc, ampicillin, acyclovir
    • Steroids
      • Early treatment with decadron improvs outcomes wacute bacterial meningitis 
      • 10mg Q6
  • Bacterial PNA
    • S pneumo, N meningitides, listeria, GBS, H influenza, mycoplasma, chlamydia
    • Outpatient therapy
      • No comorbidities – amoxicillin or doxy, or macrolide
      • Comorbities – augmentin or cephalosporin and macrolide or doxy or respiratory fluoroquinolone
    • Inpatient therapy
      • Non severe vs severe
        • See IDSA guidelines, multiple therapy options given patients history, severity
  • Intraabdominal infections
    • Classifications – uncomplicated vs complicated
    • E coli, proteus, bacteroids, kleibsiella, bacteroides
    • Empiric therapy
      • Based on severity (mild to high risk)
        • See IDSA guidelines, usually recommending combination therapy with flagyl
  • UTI
    • Classifications – uncomplicated vs complicated
    • Asymptomatic bacteriuria
      • Treat pregnant women, patient undergoing urologic procedures, patient with kidney transplant w/n 3 months
    • E coli, klebsiella, proteus, pseudomonas, enterococcus, staph, enterobacter
    • Empiric therapy
      • See IDSA guidelines
  • Skin/soft tissue infections
    • Staph, strep, clostridial, aeromonas
    • See IDSA guidelines
  • Hypersensitivty reactions
    • Type 1 – IgE, anaphylaxis
    • Type 4 – T cell mediated, SJS/TEN
    • Penicillin desensitization in the ED

Sepsis – Dr Hugh Shoff

• Hospital scoring
• Patient safety measures and trends

Infective endocarditis – Dr Jarred Thomas

• Most common site of infection – tricuspid valve
• Most common bacteria – S aureus
• Highest risk factor – previous IE
• Average age of infection is now increasing
  • Current high risk: MRSA, prosthetic valves, ESRD, IV drug use
• Acute vs subacute
• Systemic issues from IE based on left vs right side infection
• Blood cultures
  • Ideally three sets as well as fungal culture
  • Do not obtain from port site
• Treatment
  • Abx
  • Surgery
• Valvular conditions that needs PPX as established by AHA 2021 Guidelines

Beef with the Chiefs

Systemic infections – Dr Robin Lund

• Rocky mountain spotted fever
  • Highest mortality in children, males, most common in Midwest
  • Treatment – doxycycline
• Kawasaki Disease
  • CRASH symptoms
  • Kawasaki Disease Shock Syndrome
  • Treatment – IVIG, ASA
  • KD vs MISC
    • MISC more GI symptoms, usually older kids, higher inflammatory markers
• Meningits
  • Most likely in neonates – GBS
  • Most likely in other peds – Strep pneumo
  • Classic signs/symptoms
    • HA, fever, AMS, paradoxical irritability
  • Cannot exclude meningitis based on labs, CSF
  • Treatment – Abx, steroids
• Osteoarticular infections
  • Septic arthritis
    • More common in males, < 20 yo
    • Typically hematogenous spread
    • Erythema, edema, tenderness
  • Acute hematogenous osteomyelitis
    • More commonly in metaphysis
  • Typical pathogens – Staph, GABHS, S pneumo
  • Workup – Joint tap, blood cultures
  • Treatment – Abx

Acetaminophen Toxicity – Justin Arnold

• Acetaminophen in multiple combination drugs
• Adult dosing
  • Immediate release 325mg
  • Extra strength 500mg
  • Arthritis 650mg
  • Max 4g/day, 2.5g/day in liver failure patients
• MOA: don’t really know
  • Inhibition of COX, PGs
  • Reduction in pain signaling
• Single toxic dose – in a 24 hour period
  • Adults: 7.5g
  • Pediatrics: 150mg/kg
• 4 stages of toxicity
  • Stage 1 – Asx/mild symptoms (day 1)
  • Stage 2 – Liver toxicity (day 2,3)
  • Stage 3 – Liver failure (day 3,4)
  • Stage 4 – Recovery (day 4-10)
• Treatment – NAC
  • Goal to administer within 8 hours of ingestion
  • Possible anaphylactoid reactions
    • Most likely during 1 hour load
    • Treat as you would with anaphylaxis
    • Start again at half the rate
• Diagnosis
  • Need a tylenol level on every ingestion patient
  • Rumack-Matthew Nomogram
  • King’s College Criteria for prognosis/transplant need

Wellness Day 

• Wellness rotation and fellowship – Reach out to Dr Huecker and Dr Dennison if any questions

Lightning Lecture – Tuberculosis by Hannah Hudson-Knapp

• ⅓ world population infected
  • Special populations – pediatric, AIDS patients, 
• Infection types – Primary, latent, reactivation, miliary
• Evaluate with: Tuberculin skin test (PPD) -> PCR Sputum Assay (gold standard), IGRA, Acid-Fast stain
• Management
  • RIPE therapy
  • Modifications with pregnancy (RIE therapy)
  • Vit B6 prescribed with isoniazid (to decrease seizure risk)
• New vaccines currently in clinical trial
• Disposition
  • Admit
  • Louisvilleky.gov for health department information on patient cases

Lightning Lecture – Tetanus by Jonathan Mattingly

• Mortality rate 45%
• Clinical features
  • Type: Neonatal, local, generalized, cephalic
  • Grade I-IV presentations
  • Timeline: Incubation, acute, and convalescent phases
  • + Spatula test
  • Wound cultures often negative
• Management
  • TIG  directly into wound and IM, metronidazole or clindamycin

Teaching Strategies – Feedback Models by Matt Lyons

• One minute preceptor
  • Get a commitment
  • Probe for supporting evidence
  • Teach a brief principle
  • Reinforce what was done right
  • Correct errors
• Pendleton model
  • Ask, tell, ask, tell

Question Review – Metabolic, Nutrition, Endocrine by Nicole Harris

R2 Pathway – Sepsis by Makayla Campbell and Olivia Stanforth

• Sepsis definition – Life threatening organ dysfunction caused by dysregulated host response to infection
• Surviving sepsis Guidelines (2024)
  • Hour 1 Bundle: Lactic, blood cultures, broad spectrum abx, fluids, vasopressors (if needed)
    • Studies show benefit with LR vs NS
      • Special considerations – managing fluids in heart failure, cirrhotic patients
    • “Broad spectrum” antibiotics initiation = improvement in mortality
      • Special consideration – kidney injury (renally dosing abx)
    • Vasopressors
      • Norepinephrine first line, vasopressin second line/add on if needed
  • Special populations: Neutropenic fever, transplant recipients
• Refer to updated Sepsis Pathway on Room Niner

Image Review – by Dr Kahra Nix, Dr Jeff Baker, Dr Alex Bequer

• POCUS during cardiac arrest
  • CAN increase length of pulse checks, CAN decrease in hospital mortality
  • Use POCUS in PEA/asystole, also use after ROSC
    • Record clip 
    • 3 questions: Is there tamponade, RV strain, or cardiac activity? 
    • Do not delay for shocks
  • Can assess peripheral veins for DVT if concerned for PE