Infectious Disease



Infectious Disease





7-A. Fever of Unknown Origin in the United States38.3°C daily for 2 to 3 weeks, with cause undiagnosed despite 1 week of intensive studies in hospital.” class=HASTIP>1


Infection

Bacterial



  • Bacterial endocarditis


  • Sinusitis


  • Osteomyelitis


  • Intravascular catheter infections


  • Bronchiectasis


  • Relapsing mastoiditis


  • Dental abscess


  • Bartonella (cat scratch disease)


  • Upper abdominal sources



    • Cholangitis


    • Cholecystitis


    • Empyema of the gallbladder


    • Subphrenic, pancreatic, hepatic, and splenic abscesses


  • Lower abdominal sources



    • Appendicitis


    • Appendiceal abscess


    • Diverticulitis


    • Pelvic inflammatory disease or abscess


    • Perirectal abscess


    • Peritonitis



    • Mesenteric lymphadenitis


    • Septic pelvic thrombophlebitis


  • Genitourinary sources



    • Perinephric, intrarenal abscess


    • Prostatic abscess


    • Pyelonephritis


    • Tubo-ovarian abscess


    • Suppurative thrombophlebitis


    • Ureteral obstruction


    • Renal tuberculosis


  • Acute rheumatic fever


  • Bacteremia without primary focus, especially:



    • Meningococcemia


    • Gonococcemia


    • Salmonellosis


    • Listeriosis


    • Brucellosis


    • Ehrlichiosis


    • Borreliosis


    • Yersiniosis


    • Tularemia


    • Leptospirosis


    • Nocardiosis


    • Actinomycosis


  • Tuberculosis (TB), especially Mycobacterium tuberculosis (extrapulmonary, miliary, renal, TB meningitis), Mycobacterium avium complex, Mycobacterium kansasii


  • Viral, especially Epstein-Barr virus (EBV) (infectious mononucleosis), hepatitis, Coxsackie B, cytomegalovirus (CMV), human immunodeficiency virus (HIV), parvovirus B19, dengue, human herpes virus 6 (HHV6)


  • Chlamydial, Rickettsia (especially Q fever, psittacosis), Anaplasma, Ehrlichia, Rocky Mountain spotted fever


  • Parasitic, protozoan, especially:



    • Amebiasis


    • Malaria


    • Trichinosis


    • Toxoplasmosis


    • Pneumocystis carinii (jiroveci)



    • Babesiosis


    • Chagas disease


    • Strongyloides


  • Fungal, especially:



    • Candidiasis


    • Aspergillus


    • Histoplasmosis


    • Blastomycosis


    • Cryptococcosis


    • Coccidiomycosis


    • Sporotrichosis


    • Mucormycosis


Malignancy

Leukemia, lymphoma, especially Hodgkin disease

Solid tumor, especially carcinoma of:



  • Kidney (especially hypernephroma)


  • Lung


  • Pancreas


  • Liver (especially hepatoma)


  • Colon

Metastatic carcinoma (especially to liver, central nervous system)

Carcinomatosis

Myelodysplastic syndrome

Atrial myxoma


Collagen-Vascular Disease

Systemic lupus erythematosus (SLE)

Rheumatoid arthritis

Rheumatic fever

Adult Still disease

Polyarteritis nodosa, hypersensitivity vasculitis

Wegener granulomatosis

Temporal arteritis

Cryoglobulinemia

Churg-Strauss vasculitis

Takayasu arteritis

Familial Mediterranean fever

Pseudogout

Behçet disease



Drugs

Antibiotics, especially:



  • Penicillins


  • Cephalosporins


  • Sulfonamides


  • Amphotericin B


  • Quinolones


  • TB therapy, especially isoniazid (INH)

Allopurinol

Phenytoin

Barbiturates

Procainamide

Quinidine

Nonsteroidal anti-inflammatory therapy

Antineoplastic therapy

Interferon

H2 blockers

Methyldopa


Other

Pulmonary emboli, multiple

Thrombophlebitis

Sarcoidosis

Hepatitis (alcoholic or granulomatous)

Inflammatory bowel disease

Whipple disease

Thyroiditis

Pheochromocytoma

Thyrotoxicosis

Myelofibrosis

Serum sickness

Hemolytic states

Trauma with hematoma in closed spaces (especially perisplenic, perihepatic, perivesicular)

Dissecting aneurysm

Periodic fever (especially familial Mediterranean fever)

Sarcoidosis

Gout

Addison disease

Adrenal insufficiency

Weber-Christian disease

Cyclic neutropenia

Cat scratch fever


Kikuchi disease

Postpericardiotomy syndrome

Factitious fever

Habitual hyperthermia



References

1. Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases. Medicine. 1961;40:1.

2. Petersdorf RG. Fever of unknown origin: an old friend revisited (editorial). Arch Intern Med. 1992;152:21.

3. Gleckman R, Crowley M, Esposito A. Fever of unknown origin: a view from the community hospital. Am J Med Sci. 1977; 274:21-25.

4. Brusch JL, Weinstein L. Fever of unknown origin. Med Clin North Am. 1988;72:1247-1261.

5. Gorbach SL, Bartlett JG, Blacklow NR. Infectious Diseases. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:1568, 1577.

6. Mandell GL, Bennett JE, Dolin R. Principles and Practices of Infectious Diseases. 6th ed. Philadelphia: Elsevier Churchill Livingstone; 2005:718-727, 1568-1578.

7. Amin K, Kauffman CA. Fever of unknown origin. Postgrad Med. 2003;114:69-75.

8. Cunha BA. Fever of unknown origin. Infect Dis Clin North Am. 1996;10:111-128.

9. Tal S, Guller V, Gurevich A, Levi S. Fever of unknown origin in the elderly. J Intern Med. 2002;252:295-304.

10. Larson EB, Featherstone HJ, Petersdorf RG. Fever of undetermined origin: diagnosis and follow-up of 105 cases 1970-1980. Medicine. 1982;61:269-292.



7-B. Most Common Organisms Causing Specific Infections



























































































































































































































































































































































































































































Infection

Organisms


Skin and soft tissue


Cellulitis

Orbital

Streptococcus pneumoniae [including penicillin-resistant S. pneumoniae (PRSP)], Haemophilus influenzae, group A streptococci (macrolide/erythromycin resistance reported), Moraxella catarrhalis, Staphylococcus aureus [including methicillin-resistant S. aureus (MRSA)]

Nondiabetic—extremities

Group A > B, C, G streptococci, S. aureus (including MRSA)

Diabetic—extremities

Streptococci (groups A, C, G), S. aureus, Escherichia coli, Proteus spp., Klebsiella spp., Enterobacter spp., Pseudomonas aeruginosa, Enterococcus spp., Clostridia spp.


Necrotizing fasciitis

Streptococci (groups A, C, G), Clostridia spp. + Enterobacteriaceae, MRSA


Burns

S. aureus (including MRSA), streptococci, Enterobacter spp., Staphylococcus epidermidis, P. aeruginosa, fungi, herpes simplex virus (HSV)


Wounds

Traumatic

Polymicrobial: S. aureus (including MRSA), group A and anaerobic streptococci, Enterobacteriaceae, Clostridium perfringens, Clostridium tetani

Water exposure

P. aeruginosa, Aeromonas spp.

Salt water exposure

Vibrio vulnificus, Vibrio damsela

Postoperative


Nongenitourinary, nongynecologic, nongastrointestinal

S. aureus (including MRSA), S. epidermidis, group A streptococci, Enterobacteriaceae


Genitourinary, gynecologic, gastrointestinal

S. aureus (including MRSA), S. epidermidis, group A, B, C streptococci, Enterobacteriaceae, Enterococcus spp. [including vancomycin-resistant Enterococcus (VRE)], Bacteroides spp., Clostridium spp.


Decubiti

Polymicrobial

Streptococci (anaerobic and groups A, C, G), Enterococcus spp. (including VRE), S. aureus (including MRSA), Enterobacteriaceae, Pseudomonas spp., Bacteroides spp.


Bites—dog

Streptococcus viridans, Pasteurella multocida, S. aureus (including MRSA), Eikenella corrodens, Bacteroides spp., Fusobacterium spp., eugonic fermenter-4 (EF-4), S. epidermidis, Capnocytophagia spp., dysgonic fermenter-2 (DF-2)


Bites—cat

P. multocida, S. aureus, Bartonella henselae (cat scratch disease), B. henselae and Bartonella quintana both (bacillary angiomatosis, peliosis hepatitis), B. quintana only (trench fever)


Bites—human

S. viridans, S. epidermidis, S. aureus, E. corrodens, Peptostreptococcus spp., Bacteroides spp., Haemophilus parainfluenzae, Peptococcus spp., Fusobacterium spp., Corynebacterium spp.


Bites—tick

Borrelia burgdorferi (Lyme disease), Ehrlichia chaffeensis (human monocytic ehrlichiosis), Anaplasma (Ehrlichia) phagocytophilia (human granulocytic ehrlichiosis), Rickettsia rickettsii (Rocky Mountain spotted fever), Babesia microti (babesiosis), Borrelia recurrentis (relapsing fever), Rickettsia conorii (spotted fever, especially boutonneuse fever), Francisella tularemia (rare)


Respiratory Infections


Sinusitis

Acute

S. pneumoniae (including PRSP), H. influenzae, M. catarrhalis, group A streptococci, S. aureus (including MRSA), mixed anaerobes, viruses

Chronic

Acute plus Bacteroides spp., Prevotella, Peptostreptococcus, Fusobacterium, P. aeruginosa

Diabetic

Acute plus P. aeruginosa, Rhizopus spp. (Mucoraceae), Aspergillus sp.

Neutropenic

Acute plus Aspergillus spp. (especially fumigatus)


Pharyngitis

Acute

Streptococci (groups A, C, G), viruses (especially Coxsackievirus, EBV, enterocytophatogenic human orphan virus, enterovirus, HSV I-II, HIV, HHV6), Corynebacterium diphtheriae, Mycoplasma pneumoniae, Neisseria gonorrhoeae, Candida albicans, Chlamydia pneumoniae

Neutropenic

Acute pharyngitis, especially C. albicans, HSV I-II, CMV


Bronchitis

Acute

Viral, M. pneumoniae, C. pneumoniae, H. influenzae, S. pneumoniae, M. catarrhalis, Bordetella pertussis


Lung abscess

Bacteroides spp., Fusobacterium spp., Peptostreptococcus spp., Prevotella spp., microaerophilic streptococci, S. viridans


Aspiration pneumonia

Streptococcus spp., Bacteroides spp., Fusobacterium spp., Peptostreptococcus spp., M. catarrhalis, E. corrodens, Nocardia spp.


Health care-acquired aspiration pneumonia

Aspiration pneumonia, plus S. aureus (including MRSA), Enterobacteriaceae, Candida spp., Legionella spp., Stenotrophomonas spp.


Pneumonia

Community-acquired pneumonia (CAP) without coexistent disease, <60 years

S. pneumoniae (including PRSP), M. pneumoniae, respiratory viruses, especially influenzae, parainfluenzae, adenovirus, respiratory syncytial virus (RSV), H. influenzae, Legionella spp., C. pneumoniae, Chlamydia psittaci

Postinfluenza pneumonia

S. pneumoniae, H. influenzae, S. aureus (including MRSA) (rare)

CAP with coexistent disease, >60 yearsa

S. pneumoniae, M. pneumoniae, respiratory viruses, especially influenzae, H. influenzae, C. pneumoniae, Legionella spp., Klebsiella pneumoniae, M. catarrhalis, anaerobic bacteria if aspiration (see Aspiration pneumonia), M. tuberculosis, fungi


Important exposure history for CAP

Actinomyces israelii (especially in aspiration of poor dentition)



S. pneumoniae (including PRSP), H. influenzae, M. catarrhalis: chronic obstructive pulmonary disease



S. pneumoniae (including PRSP), anaerobes, K. pneumoniae: alcohol use/abuse



S. aureus (including MRSA) 2/2 hematogenous spread: intravenous drug users



P. aeruginosa, H. influenzae, S. pneumoniae (including PRSP), Aspergillus, M. avium complex: bronchiectasis



Coxiella burnetii: Q fever (livestock exposure or unpasteurized milk exposure)



Brucella spp.: cattle, swine, goat exposure



Francisella tularensis: rabbit, tick, and deerfly exposure



Pseudomonas pseudomallei: melioidosis (Southeast Asia travel, exposure)



Salmonella spp.: raw, undercooked eggs, poultry, raw cookie batter, melon, tomatoes



Coccidioides immitis: inhalation of spores in Southwest United States



Histoplasma capsulatum: inhalation of organisms from bird droppings (bats, chickens, starlings)



Blastomyces dermatitidis: inhalation of organisms from contaminated soil



Yersinia pestis: rat flea, infected close human contact exposure



Legionella spp.: inhalation of organisms from contaminated water supply systems, contaminated soil



M. pneumoniae: high incidence in closed populations (i.e., boarding schools, college dormitories, military recruit camps)


Health care-acquired pneumonia (with or without mechanical ventilation)

Aerobic gram-negative bacilli [Enterobacter aerogenes, cloacae, P. aeruginosa, Burkholderia cepacia, S. pneumoniae (including PRSP), K. pneumoniae, Klebsiella oxytoca, Acinetobacter calcoaceticus var. anitratum or lwoffi, S. aureus (including MRSA), Legionella spp.]


Neutropenia and health care-acquired pneumonia (with or without mechanical ventilation)

See Health care-acquired pneumonia, plus fungi [C. albicans, Aspergillus spp. (especially fumigatus, flavus)]


Pneumonia

Immunocompromised host

S. pneumoniae, S. aureus (including MRSA), aerobic gram-negative bacilli, Legionella spp., Nocardia spp. (especially with steroid use, malignancy, lymphoma, HIV), Cryptococcus neoformans (inhalation of organisms from pigeon droppings in soil, HIV, malignancy, diabetes mellitus, steroid use, chemotherapy), Aspergillus spp. (inhalation of organisms from soil or air, malignancy, especially neutropenia, steroid use, posttransplant, chemotherapy), phycomycetes: leukemia and lymphoma, Toxoplasma gondii [ingestion of raw or rare meat, cat feces containing cysts of T. gondii (e.g., litter or sandbox exposure)]



Viruses [especially influenza, HSV, CMV, varicella-zoster virus (VZV), adenovirus, M. tuberculosis]



Fungi (especially Candida spp., Aspergillus spp.)


Pneumonia with associated bioterrorism exposure

Bacillus anthracis (anthrax)


F. tularensis (tularemia)

Potential organisms/manifestations

Clostridium botulinum (botulism)

Y. pestis (plague)



Hemorrhagic fever viruses (Ebola/Marburg)



Variola major virus (smallpox)



Hantavirus



Pandemic influenza



Severe acute respiratory syndrome (SARS): Coronavirus


HIV infection

See HIV, Pulmonary section (7-F)

Meningitis

S. pneumoniae (including PRSP), Neisseria meningitidis, enterovirus, H. influenzae (rare), EBV, HIV, HSV II, VZV, CMV, mumps, West Nile virus, Eastern equine, Western equine, St. Louis virus, California virus, rabies virus, lymphocytic choriomeningitis, B. burgdorferi, Ehrlichia spp.


Young, elderly, and immunocompromised

S. pneumoniae (including PRSP), Listeria monocytogenes, gram-negative bacilli, C. neoformans, H. influenzae (rare since H. influenzae type b vaccine), leptospirosis, cerebral malaria, trichinosis, rickettsiae, mycobacteria, amebiasis, Mycoplasma, Treponema pallidum (syphilis)


Brain abscess

S. pneumoniae (including PRSP), streptococci, Bacteroides spp., Enterobacteriaceae, Propionibacterium acnes, S. aureus (including MRSA), Nocardia spp., L. monocytogenes


Otitis media

S. pneumoniae (including PRSP), H. influenzae, M. catarrhalis, group A streptococci, S. aureus, viruses, gram-negative bacilli


Mastoiditis

S. pneumoniae (including PRSP), group A streptococci, S. aureus (including MRSA), H. influenzae, P. aeruginosa, anaerobes


Conjunctivitis

Viral (adenovirus 8 and 19), S. aureus (including MRSA), S. pneumoniae, H. influenzae, N. gonorrhoeae, Chlamydia trachomatis


Keratitis

S. aureus (including MRSA), S. epidermidis, S. pneumoniae, group A streptococci, gram-negative bacilli, P. aeruginosa, Acanthamoeba (contact lens users), L. monocytogenes (especially in diabetic patients), Hartmannella (soft contact lens users)


Vaginitis

Candida spp. (C. albicans >> Candida glabrata, Candida tropicalis), Trichomonas vaginalis, polymicrobial (especially Gardnerella vaginalis, Prevotella spp.), Mobiluncus, Mycoplasma hominis


Cervicitis, nonspecific urethritis

N. gonorrhoeae,b C. trachomatis, M. hominis, Ureaplasma, HSV, Mycoplasma genitalium


Pelvic inflammatory disease

N. gonorrhoeae,b C. trachomatis, Bacteroides spp., gram-negative bacilli, streptococci


Other urogenital sexually transmitted diseases

T. pallidum (syphilis), human papillomavirus (HPV) 6, 11, 16, 18 (anogenital warts), Haemophilus ducreyi (chancroid), C. trachomatis (lymphogranuloma venereum), Calymmatobacterium granulomatis (granuloma inguinale), HSV type II (genital herpes), Candida spp., group B streptococci, Gardnerella (balanitis), N. gonorrhoeae, C. trachomatis (proctitis)


Prostatitis

N. gonorrhoeae, C. trachomatis, gram-negative bacilli, P. aeruginosa (usually chronic in males >35 years of age), Enterococcus (including VRE),



M. Tuberculosis, mycoplasmas, ureaplasmas


Urinary tract infection

Cystitis

Enterobacteriaceae [especially E. coli, Enterococcus (including VRE), Staphylococcus saprophyticus, C. trachomatis]

Pyelonephritis

Enterobacteriaceae [especially E. coli, Klebsiella spp., Enterococcus spp. (including VRE), P. aeruginosa, Proteus mirabilis]


Perinephric abscess

Enterobacteriaceae [especially E. coli, Klebsiella spp., Enterococcus spp. (including VRE), P. aeruginosa, P. mirabilis, S. aureus (including MRSA), 2/2 hematogenous spread]


Sepsis, septic shock

Nonimmunocompromised host

S. viridans, S. pneumoniae (including PRSP), group B streptococci, S. aureus (including MRSA), S. epidermidis, E. coli, Enterococcus spp. (including VRE), Klebsiella spp., Proteus spp., P. aeruginosa, anaerobes, H. influenzae, N. meningitidis

Health care acquired

Enterobacteriaceae, Enterococcus spp. (including VRE), S. aureus (including MRSA), S. epidermidis, Candida spp., anaerobes

Immunocompromised host, neutropenia

Enterobacteriaceae (especially P. aeruginosa, E. coli, Klebsiella spp.), S. pneumoniae (including PRSP), S. viridans, coagulase-negative Staphylococcus, S. aureus (including MRSA), C. albicans, Aspergillus spp., VRE, L. monocytogenes, anaerobes, Fusobacterium spp. (see 7-C)

Postsplenectomy

S. pneumoniae (including PRSP), H. influenzae, N. meningitidis, B. microti, Capnocytophaga (DF-2)

Intravenous line infections, sepsis

Coagulase-negative Staphylococcus, S. aureus (including MRSA), Candida spp., Pseudomonas spp., Acinetobacter spp., Enterobacter spp.

In immunocompromised hosts

Coagulase-negative Staphylococcus, S. aureus (including MRSA), Candida spp., Pseudomonas spp., Acinetobacter spp., Corynebacterium jeikeium (JK), Aspergillus spp., Enterococcus spp. (including VRE)


HIV

See 12-A


Toxic shock syndrome

S. aureus (toxin mediated), beta streptococci groups A, B, C, G, Clostridium sordelli


Gastroenteritis

Enteric viruses (especially rotaviruses, Norwalk virus), Shigella spp., Salmonella spp., C. jejuni, E. coli 0157:H7, Clostridium difficile, Entamoeba histolytica, Vibrio cholerae, Yersinia enterocolitica, L. monocytogenes, Vibrio parahaemolyticus, Giardia lamblia, Cyclospora spp., S. aureus, Bacillus cereus


HIV associated

See 12-G


Peritonitis

Secondary to bowel perforation

E. coli, Klebsiella spp., Enterobacter spp., Enterococcus spp. (including VRE), S. viridans, Bacteroides fragilis, P. aeruginosa, Clostridium spp., Peptostreptococcus spp.

Spontaneous bacterial peritonitis

S. pneumoniae (including PRSP), Enterobacteriaceae (especially E. coli), K. pneumoniae [extended spectrum beta-lactamase producers (ESBL)], Enterococcus spp. (including VRE), group A streptococci, anaerobes


Intra-abdominal abscess

E. coli, Klebsiella spp., Enterobacter spp., Enterococcus spp. (including VRE), streptococci, Bacteroides spp., S. aureus (including MRSA), Clostridium spp., Peptostreptococcus spp., Peptococcus spp.


Diverticulitis

Enterobacteriaceae (especially E. coli, Klebsiella spp., Proteus spp.), enterococci, B. fragilis, Peptostreptococcus spp., Clostridium spp.


Complicated appendicitis

E. coli, P. aeruginosa, Bacteroides spp., Peptostreptococcus spp., Peptococcus spp., alpha-hemolytic streptococci, Enterococcus spp. (including VRE)


Acute cholecystitis

E. coli, Klebsiella spp., Enterobacter spp., Enterococcus spp. (including VRE), Bacteroides spp., Fusobacterium spp., Clostridium spp.


Cholangitis

E. coli, Klebsiella spp., Enterococcus spp. (including VRE), Bacteroides spp., Clostridium spp.


Arthritis

Acute monoarticular

N. gonorrhoeae,b S. aureus (including MRSA), S. pneumoniae (including PRSP), B. burgdorferi

Acute polyarticular

N. gonorrhoeae,b S. aureus (including MRSA), B. burgdorferi, N. meningitidis, arthritis secondary to syphilis, parvovirus B19, rubella virus, EBV, HIV, hepatitis B

Chronic

Mycobacteria spp., fungi, Nocardia spp., Brucella spp.


Endocarditis

Native valve

S. viridans, S. aureus (including MRSA), Enterococcus spp. (including VRE), Streptococcus bovis, S. epidermidis, HACEK (H. parainfluenzae, Haemophilus aphrophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella), fungi, C. psittaci, C. burnetii, Brucella spp., Bartonella spp. (henselae/quintana)

Early prosthetic valve (<2 months postoperative)

S. epidermidis, S. aureus (including MRSA), streptococci, Enterobacteriaceae, diphtheroids, fungi

Late prosthetic valve (>2 months postoperative)

S. epidermidis, S. viridans, S. aureus (including MRSA), S. bovis, Enterobacteriaceae, Enterococcus spp. (including VRE), diphtheroids, fungi (Candida spp., Aspergillus spp.), P. acnes


Osteomyelitis

Acute

S. aureus (including MRSA), S. epidermidis, group A and B streptococci, E. coli, Salmonella spp. (usually with history of sickle cell disease, thalassemia, after iron chelation therapy), Klebsiella spp., Pseudomonas spp., S. Pneumoniae (including PRSP), M. tuberculosis

Chronic

S. aureus (including MRSA), Klebsiella spp., P. aeruginosa, Enterobacter spp.


a Coexisting disease: diabetes mellitus, ethanol use, chronic obstructive pulmonary disease, congenital hepatic fibrosis, cigarette use, malnutrition, chronic renal failure, liver disease, postsplenectomy.

b Note increased resistance of N. gonorrhoeae to fluoroquinolones.




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Jun 19, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Infectious Disease

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