!"#$%&' )"%*+,- .

/-$"0 &#1
!&$2"$"%34"'&$"1 5#6"78+#-


nuala !. Meyer Mu MS lCC
AsslsLanL rofessor of Medlclne
ulmonary, Allergy, and Crlucal Care Medlclne
unlverslLy of ennsylvanla erelman School of Medlclne

9:-7'+-,%"
8esearch supporL by nlP and ClaxoSmlLhkllne

;<="78*"-
SelecL Lhe approprlaLe dlagnosls and LreaLmenL for
lmporLanL CnS lnfecuons presenung Lo Lhe lCu
ApproprlaLely dlagnosls caLheLer-relaLed
bloodsLream lnfecuon (C88Sl)
SelecL whlch caLheLers need Lo be removed
ldenufy besL-pracuce facLors Lo decrease Lhe rlsk of
caLheLer-relaLed lnfecuons
!&-" >
A 19 yo college sLudenL ls broughL Lo Lhe Lu by frlends aer
feellng poorly and Lhen appearlng Lo pass ouL whlle sLudylng.
She c/o sore LhroaL for 2 days, a moderaLe headache, and
generallzed myalglas and faugue. Whlle ln Lhe Lu, she develops
hypoLenslon, lncreased leLhargy, fever, and a purpurlc rash
scauered over her Lrunk and legs. L ls performed and reveals
cloudy uld wlLh Lhe followlng gram sLaln. Cerlaxone,
vancomycln, and dexameLhasone are glven.

1he pauenL's rlsk for morLallLy ls mosL sLrongly lnuenced by:
A. uurauon of sympLoms before presenLauon
8. 8ecelpL of dexameLhasone
C. 1lme Lo anublouc admlnlsLrauon
u. Absence of one or more of Lhe classlc Lrlad of sympLoms (fever,
nuchal rlgldlLy, and menLal sLaLus changes)
L. Age on presenLauon
CuC.gov
?7,$" @&7$"%:&' A"#:#B:8-
Classlc Lrlad: lLvL8, headache, and neck suness
More lnsldlous ln elderly, dlabeucs, pauenLs wlLh cardlo-
pulmonary dlsease, and lmmunocompromlsed hosLs
urpura fulmlnans / peLechlal rash: esp n. menlngludls
MorbldlLy and morLallLy ls hlgh
lnl1lA1L 1PL8A? ASA / wlLhln 1 hour of presenLauon when
Lhe dlagnosls ls suspecLed
LvLn ll L lS uLLA?Lu
uelay > 6 hours assoclaLed wlLh morLallLy: Cdds 8auo 8.4
1ry Lo geL blood culLures pre-anubloucs
@&7$"%:&' A"#:#B:8-C D8+'+B/
!"#$%& %($)*+ 61
Menlngococcus 16
Croup 8 SLrep 14 , Croup A sLrep ln skull fracLures
,& -) 7
./0"$#/1 2
vacclnes
P. u has decreased dramaucally slnce Plb vacclne
neumonla vacclnes eecuve buL many seroLypes
Menlngococcal vacclne mlsses seroLype 8, ~30 cases
nosocomlal menlnglus (neurosurgery / devlces):
Cover M8SA, Coag negauve sLaph, enLerlc Cn8
(seudomonas)
Lumbar puncLure / CSl examlnauon
Cram sLaln / culLure, cell cL, glucose, proLeln, appearance
Cram sLaln ~80 sensluve, CulLure may be hlgher
More sensluve Lhan cell counL
Conslder Ag Lesung esp lf gram sLaln negauve
8acLeremla ls common, draw blood culLures
uo noL need all elemenLs of classlc Lrlad
Plghly llkely (>99) lf any of Lhe followlng ln CSl:
Clucose < 34, roLeln > 200, W8C>2000, Mn>1180
@&7$"%:&' A"#:#B:8-C 9:&B#+-:-
.$%"E E#",0+#:&"
CuC.gov
)":--"%:& 0"#:#B:81:-C F) 1:E'+7+77: G:-$"%:& 0+#+7/$+B"#"-
4+'" +6 H"&1 !I <"6+%" GJ
CbLaln a C1 lf:
local neurologlc slgns or apllledema
PlsLory of CnS abnormallues (LhaL could cloud neuro exam)
Age > 60
lmmunocompromlsed
Lven lf C1 ls negauve, avold L / LreaL emplrlcally lf:
8apldly decllnlng neuro exam
Clascow coma scale < 11
Any bralnsLem slgns
D0E:%:7 I2"%&E/ K&%:"- </ ?B"
lor adulLs and chlldren >2 monLhs of age,
Cover pneumococcus, menlngococcus
vanco + cerlaxone +/- amplclllln (for ./0"$#/1)
lf neurosurglcal or devlce-assoclaLed menlnglus
Cover for M8SA, M8SL, and seudomonas aeruglnosa
vanco + ceazldlme (or ceplme)
lf Cn allergy
Can subsuLuLe vanco and 8lfampln for pneumococcus
AzLreonam or uoroqulnolone (moxl, clpro) for Cn8s
1M/SMx for ./0"$#/1
neonaLes
Cover for C8S, 0"#$%"+2+22/, Cn8s, and ./0"$#/1
Amp + cefoLaxlme +/- Amlnoglycoslde
!+%87+-$"%+:1- 6+% ?7,$" A"#:#B:8-
8auonale: lnammauon causes hearlng loss /declLs
Luropean Lrlal: 301 pauenLs wlLh sLrongly suspecLed
bacLerlal menlnglus (cloudy CSl, + CS, or >1000 wbc)
8andomlzed Lo lv decadron 10 mg q6h vs placebo x 4d
SLerold group reduced morLallLy (88 0.48), compllcauons
(0.39)
LecL mosL pronounced ln S. pneumonlae and Lhose wlLh
Clascow Coma Scale < 11
ueveloplng world, resulLs less compelllng
Clve sLerolds emplrlcally, conunue lf S. pneumonlae
!2%+#:7 A"#:#B:8- L.M N O PQ-R
lmmunocompromlsed +/- approprlaLe Lravel hlsLory
lungal: CrypLococcus, hlsLo/blasLo/coccldlo
MycobacLerlal: 18
8acLerlal: nocardla/Acuno/LlsLerla/lranclcella/8rucellosls
SplrocheLal: Lyme dlsease, Syphllls, lepLosprla
araslLes: SLrongyloldes, 1oxo, SchlsLo, Cysucercosls, Amoeba
vlral: Plv, P1Lv1, CMv, L8v, vZv/PSv
non-lnfecuous:
CranulomaLous dlsease (Sarcold), vascullus (8ehceLs, SLL)
neoplasuc dlsease, drugs (nSAlus)
!&-" S
A 26 yo male farm worker presenLs wlLh new onseL selzures,
decreased menLal sLaLus (CCS 12), and a low grade fever. Pe ls
orlglnally from Mexlco buL has been ln Lhe unlLed SLaLes for 6
years, wlLhouL recenL Lravel. Pead C1 reveals one cysL wlLh
enhancemenL, and muluple non-enhanclng cysLs. 1here ls no
evldence of hydrocephalus. Whlch of Lhe followlng ls Lhe mosL
approprlaLe LreaLmenL for Lhls pauenL?

A. lmmedlaLe neurosurgery Lo evacuaLe Lhe enhanclng cysL
8. Albendazole
C. Albendazole and meLhylprednlsolone
u. Albendazole, meLhylprednlsolone, and phenyLoln
L. Lorazepam

@%&:# ?<-7"--
local collecuon wlLhln braln parenchyma
Slngle - Lyplcally from dlrecL exLenslon (slnus, ouus) or
Muluple - Lyplcally hemaLogenous spread
Peadache, oen unllaLeral, +/- focal slgns (Cn palsy)
lever 43, Selzures 23, papllledema or Cn palsles - laLe
L CCn18AlnulCA1Lu ll lCCAL PA or CnS llnulnC
uralnage recommended lf > 2.3 cm or Lhlck capsule
Send gram sLaln, aeroblc and anaeroblc culLures, Al8
sLaln/culLure, fungal sLaln/culLure
@%&:# ?<-7"-- T D8+'+B/ &#1 I%"&$0"#$
Mlxed lnfecuons common (~30)
SLrepLococcl (up Lo 70) and anaerobes (20-40,
lncl 8acLeroldes) - frequenLly ln mlxed lnfecuons
S. aureus: usually slngle lsolaLe, Lrauma, endocardlus
Cram negauve: nosocomlal, lmmunocompromlsed
Lmplrlc Lherapy:
vancomycln, llagyl, 3
rd
gen Cephalosporln (Cerlaxone)
Ceplme/Ceazldlme lf neurosurgery or lmmunocomp'd
SLerolds lf cerebral edema or mass eecL
U,#B&' ?<-7"--
lnvaslve molds ln profound
neuLropenla
Asperglllus more common,
buL mucor recognlzed
Mucor ls lnherenLly reslsLanL
Lo vorlconazole
Llpld amphoLerlcln 8 (+/-
caspofungln) whlle conrm
Lhe agenL.
Conslder surglcal debrldemenL
.,<1,%&' D0E/"0&
lnfecuon spreads Lo Lhe subdural space, usually as
compllcauon of menlnglus, slnuslus, ouus, masLoldlus
Conslder when menlngeal slgns + lncreased lC
M8l superlor Lo C1
8acLerlology slmllar Lo braln abscess
SLrepLococcl, anaerobes, sLaph, gram negauves
neurosurglcal emergency: musL draln +/- decompress
vanco, MeLronldazole, 3
rd
Cenerauon Cephalosporln

!&-" V
39 yo female wlLh a hlsLory of chronlc back paln s/p monLhly
glucocorucold L1 ln[ecuons presenLs c/o low grade fever,
lncreased back paln, and rlghL leg weakness. She has no
hlsLory of splnal or neurosurgery. She ls dlabeuc wlLh
adequaLe glucose conLrol (PbA1c = 3.9). Cn exam, she has
focal Lenderness aL L2, dlmlnlshed sLrengLh ln her rlghL LL,
and lnLacL recLal Lone. She ls febrlle Lo 100.7 l. Whlch ls Lhe
mosL approprlaLe course of acuon?
A. Crder a splnal x-ray
8. Crder a splnal M8l and consulL neurosurgery
C. erform a lumbar puncLure
u. lace a lCC llne and lnluaLe anubloucs (vanco, cerlaxone)
L. Crder physlcal Lherapy and re-evaluaLe ln 4 weeks

DE:1,%&' ?<-7"--
Splnal Lpldural abscesses accounL for 90 of leslons
8ack paln/ splnal paln, fever, neurologlc slgns = Lrlad
lever uncommon buL helpful lf presenL = danger slgn
uux lncludes neoplasuc lnvolvemenL of Lhecal sac
8lsk facLors: lvuA, uM, splnal procedures or epldural anesLh
aralysls can become permanenL wlLhln 24 hours
Coal = early dlagnosls, dralnage
Medlcal Lherapy alone may be approprlaLe lf neuro sx mlld
Cnce paralysls presenL > 24h, surgery unllkely Lo regaln
neurologlc funcuon 8u1 may be necessary Lo clear lnfecuon
DE:1,%&' ?<-7"-- 3 A&#&B"0"#$
Common paLhogens = SLaph aureus/M8SA > 60,
gram negauves, SLrepLococcl, Coag negauve sLaph
Lmplrlc coverage
vancomycln
3
rd
generauon cephalosporln (cover seudomonas lf
nosocomlal)
MeLronldazole for anaerobes
AsplraLe abscess, blood culLures. L yleld ls low
lnvolve neurosurgery early lf neurologlcal ndlngs
uurauon of Lherapy 6-8 weeks, Lallor Lo cllnlcal course
!&-" O
A prevlously healLhy 72 yo man ls broughL Lo Lhe Lu durlng
summer wlLh fever, leLhargy, and slurred speech for 3 days.
Pe has no neck suness. M8l ls normal. An L ls performed,
and Lhe CSl has 143 W8Cs, wlLh a lymphocyLe predomlnance.
?ou sLarL hlgh-dose lv acyclovlr (ACv), buL Lhe PSv and vZv
C8s are negauve. ?ou nexL sLep would be:

A. Change acyclovlr Lo valacyclovlr
8. lnluaLe amphoLerlcln and ucyLoslne
C. 8epeaL lumbar puncLure and check ollgoclonal bands
u. lnluaLe dexameLhasone 10 mg lv q6h
L. Check CSl for WesL nlle vlrus anubody
K:%&' D#7"E2&':8-
Lncephallus causes abnormal braln funcuon - MSA,
alLered moLor, sensory, behavlor, personallLy, speech, or
movemenL
usually vlral: PSv>WesL nlle >LnLero >varlcella zosLer
8arely: adenovlrus, lnuenza, MM8, rables
lmmunocompromlsed: CMv, L8v, PPv6, !C vlrus
Plv - encephallus or encephalopaLhy (ML)
Conslder non-lnfecuous (lymphoma, vascullus)
Conslder chronlc menlnglus, 8lckeuslal dlsease

H.K D#7"E2&':8-
MosL common cause of encephallus (3-10 of cases)
PSv-1 more common ln adulLs, PSv-2 ln neonaLes
1yplcal M8l = edema or hemorrhage ln Lhe Lemporal lobes
Abnormal ln Lhe vasL ma[orlLy of pauenLs
Larly LreaLmenL lmproves prognosls
MorLallLy 13 , morbldlLy 30
1reaL wlLh hlgh-dose lv ACv for 14-21 days
C8 ls posluve ln 96-98 of cases
May be negauve ln Lhe rsL 48
o
lf euology unknown, repeaL CSl aer 1-3 days of Lherapy
?%<+%*:%&' D#7"E2&':8-W "-E X)K
8elauvely rare unul Wnv emerged ~1999
1yplcal hosL > age 30, or lmmunocompromlsed
CSl lgM and lgC anubody uLers helpful Lhough may
cross-reacL beLween vlruses
no LreaLmenL ls avallable
SLudles of lln-!2b and rlbavlrln have been dlsappolnung
Supporuve care
Wnv morLallLy ~10, morbldlLy lncludes cognluve
lmpalrmenL, funcuonal lmpalrmenL, depresslon
!&-" YC
A 31 yo woman wlLh a h/o lvuu and skln popplng wlLh heroln
presenLs complalnlng of blurry vlslon, dlmculLy speaklng, and
weakness. Cn exam you noLe an alerL menLal sLaLus wlLh
bllaLeral pLosls, dysarLhrla, and hyporeexlc upper exLremlues
wlLh 2/3 proxlmal and dlsLal upper exLremlLy sLrengLh. She
has 2 abscesses on her upper Lhlghs. Per A8C on room alr ls
7.21/62/89. ln addluon Lo supporung her breaLhlng, whlch ls
Lhe approprlaLe LreaLmenL?
A. lnLravenous lmmunoglobulln (lvlg)
8. vancomycln
C. enlclllln C and MeLronldazole
u. enlclllln C, MeLronldazole, uebrldemenL, and anuLoxln
L. enlclllln C, MeLronldazole, and anuLoxln

Z#,-,&' )"%*+,- ./-$"0 5#6"78+#-
Wound 8oLullsm: ClosLrldlum boLullnum
CuLbreaks ln lv drug abusers
uescendlng symmeLrlcal accld paralysls, cranlal nerve palsles
1reaL wlLh en C +/or MeLronldazole, 7-valenL anuLoxln
(uCP)
uebrlde wounds lf abscess, Mechanlcal venulauon as needed
1eLanus: ClosLrldlum LeLanl
~8 days followlng a peneLraung skln wound ln non-vacclnaLed
alnful muscle spasms, Lrlsmus, dysphagla, apnea
8x: MeLronldazole/en C, debrlde, LeLanus lC, *&77:#&$"
A&/ %"[,:%" O3\ P""Q- +6 -,EE+%8*" 7&%"
!&-" \
Whlch of Lhe followlng besL descrlbes Lhe llkellhood of
rlsk for developlng a caLheLer-relaLed blood sLream
lnfecuon (C88Sl)?

A. lemoral > Subclavlan > lnLernal [ugular
8. A caLheLer > venous > ArLerlal > Mldllne
C. non-Lunneled > 1unneled cued > 1unneled uncued
u. neuLropenla > MalnuLrluon > 8urns > Llderly
L. Mldllne > lCC > CenLral veln caLheLer > erlpheral lv
9"]#:8+#-C !4@.5
8acLeremla + no obvlous source when CvC ln place
90 llkely Lo be Lhe caLheLer
CuC denluon of C88Sl requlres
1. uocumenLauon of bacLeremla
2. Lvldence LhaL Lhe lnfecuon ls relaLed Lo Lhe caLheLer
A"$2+1+'+B/
CulLure up of CvC (or lnLroducer lf AC) only lf
suspecL lnfecuon
> 13 cfu on caLh up (roll plaLe" meLhod) LhaL correlaLes
wlLh perlpheral blood culLure lsolaLe cllnches C88Sl
lf no caLh up culLure, palred quanuLauve culLures,
perlpheral and caLheLer hub
CaLheLer culLure wlLh elLher 3x bacLerlal concenLrauon or
> 2 hours earller posluvlLy suggesLs Lhe caLheLer ls source*
*8Cs musL be drawn aL Lhe same ume and have Lhe exacL same
amounL of blood ln each boule
Mermel 34/( 5(6$2" 7/0 2009
!&$2"$"%- &#1 4:-Q +6 5#6"78+#
All shorL-Lerm CvC have a rlsk of C88Sl
lemoral vs neck llnes (l!/SC) remalns conLroverslal
Clder sLudles supporL j rlsk wlLh neck llne, posL-2003 do noL
Cne 8C1 femoral vs subclavlan: femoral 3-fold more lnfecuon
Lower rlsk assoclaLed wlLh
Mldllne caLheLers, Anublouc-lmpregnaLed caLheLers, 1unneled
caLheLers, orLs
lnfecuon rlsk lncreases wlLh longer durauon
Aer 3-4 days for perlpheral lv or AC, aer 6 days for CvC
Makl uC 819+ 34/( :#+2 2006, Safdar 3;$0" 2003, Marlk 3#/" 31#$ 8$< 2012
!&$2"$"%- &#1 4:-Q +6 5#6"78+#
1ype of CaLheLer 8lsk per 1000 caLheLer days
A caLheLer 3.7
non-Lunneled CvC 2.7
1unneled CvC 1.7
ArLerlal 1.7
Cued and Lunneled CvC 1.6
erlpheral CvC 1.1
erlpheral lv 0.3
Mldllne 0.2
no ad[usLmenL for severlLy of lllness
Makl uC 819+ 34/( :#+2 2006
J&8"#$ U&7$+%- &#1 4:-Q +6 !4@.5
8urns or loss of skln lnLegrlLy (S!S/1Lns)
neuLropenla or bone marrow LransplanLauon
CLher lmmunodeclency
MalnuLrluon
8ecelpL of 1n
revlous bacLeremla
Chronlc lllness
LxLremes of age
.+,%7"- +6 5#6"78+#
1. Skln colonlzauon
auenL's skln and healLhcare workers'
2. lnLralumlnal conLamlnauon
3. Seedlng from a dlsLanL slLe / hemaLogenous
4. lnfusaLe conLamlnauon
1hlnk of Lhls when an ouLbreak of slmllar bacLerla/fungus
Low rlsk pauenL develops a bloodsLream lnfecuon
ulagnose by culLurlng Lhe lnfusaLe lLself
A:7%+<:+'+B/ +6 !4@.5
SLaph 30 (CnS 30, SLaph aureus 20)
LnLerococcus 10, lncreaslngly v8L ln unlLed SLaLes
Candlda 10
Lsp 1n/hyperallmenLauon, lmpalred mucosal lnLegrlLy
Aeroblc Cn 20-30 (L. coll, klebslella, seudomonas,
LnLerobacLer, Serraua, AclneLobacLer)
seudomonas especlally followlng burns
Cns common ln neuLropenlc pauenLs
Conslder posslblllLy of lnfusaLe conLamlnauon lf > 1 pauenL
^,"-8+# _
Whlch of Lhe followlng sLaLemenLs regardlng
prevenuon of caLheLer-relaLed bloodsLream
lnfecuons ls nC1 18uL?
A. use of dally chlorhexldlne baLhlng for lCu pauenLs reduces
skln colonlzauon wlLh reslsLanL organlsms
8. Lxperlenced operaLors have fewer C88Sl aer CvC lnseruon
compared Lo lnexperlenced
C. Pand washlng ls unnecessary lf sLerlle gloves and gowns are
used
u. 1he use of a full body drape reduces Lhe rlsk of C88Sl
L. 1here ls no evldence LhaL cenLral venous caLheLers should be
rouunely replaced aer 7 days
9"7%"&-:#B 4:-Q +6 !4.@5C J%+*+#+-$ !2"7Q':-$
1. Pand washlng before sLerlle gloves
2. Chlorhexldlne skln preparauon - allow Lo dry
3. lull barrler precauuons, lncludlng full body drape
4. Avoldance of Lhe femoral slLe when posslble
3. 8emove caLheLers LhaL are noL needed
CuC 8ecommendauons 88=> >$2+** >$% 2002
rovonosL ? @(A4 B 8$< 2006
9"7%"&-:#B 4:-Q +6 !4.@5C
?11:8+#&' 7+#-:1"%&8+#-
ually chlorhexldlne baLhlng (Cllmo nL!M 2013)
LxL8lLnCLu CL8A1C8S for lnseruon and care
uedlcaLed venous access Leams reduce C88Sl rlsk
Auenuon Lo access polnLs, chlorhexldlne dlsk/sponge
Conslder anublouc lmpregnaLed caLheLers
Conslder heparln lock or heparln-bonded caLheLers
uecreased cloL seems Lo assoclaLe wlLh fewer C88Sl
8ouune replacemenL of CvC nC1 8LCCMMLnuLu
Powever, remove and replace non-sLerlle/emergency llnes
!&%" +6 $2" ?77"-- H,<C !9! 4"7-
use 70 alcohol / lodophor Lo clean ln[ecuon porLs pre-access
Access Lhe porL only wlLh sLerlle devlces
CPAnCL needleless componenLs as leasL as frequenLly as Lhe
admlnlsLrauon seL
Caps no more frequenLly Lhan every 72 hours
AdmlnsLrauon seLs /add-on devlces no more oen Lhan 72
hours
1ublng used for blood/ producLs or llplds aer 24 hours
Lnsure LhaL all componenLs of Lhe sysLem are compauble Lo
mlnlmlze leaks and breaks
Cap all sLopcocks when noL ln use
!&-" `
lor whlch of Lhe followlng pauenLs would lL be approprlaLe
Lo auempL Lo salvage raLher Lhan removlng Lhe caLheLer?

A. An AML pauenL wlLh neuLropenla, a new fever, and a Lender llne
slLe
8. A 40 yo female on 1n for malnuLrluon wlLh yeasL on 2 culLures
C. A man wlLh SLaph aureus growlng from blood 8 days posL-op from
an aoruc valve replacemenL
u. A sLable 62 yo female wlLh 3 days of bacLeremla (LnLerococcus
feacalls) and a prosLheuc mlLral valve
L. A CCu pauenL wlLh coagulase negauve sLaph growlng from 2
culLures, low grade fever, wlLh sLable vlLal slgns
I+ J,'' +% )+$ $+ J,''C .2+%$3$"%0 !K!
Severe sepsls or hemodynamlc lnsLablllLy
Lndocardlus or susplclon of meLasLauc lnfecuon
LryLhema, pus, or llne malfuncuon (cloL)
S. aureus, LnLerococcus, Cn, fungus, mycobacLerla
8aclllus, mlcrococcus, proplonobacLerla - hard Lo
eradlcaLe
Conslder sysLemlc + llne lock anubloucs lf CnS
erslsLenL bacLeremla > 72 hrs or deLerlorauon - pull

I+ J,'' +% )+$ $+ J,''C G+#B3$"%0 !K!
,#'"-- a
1unnel or ockeL lnfecuon
Pemodynamlc lnsLablllLy, severe sepsls, endocardlus
erslsLenL bacLeremla aer 72 hours
Crganlsm:
SLaphylococcus aureus
seudomonas aeruglnosa
Candlda / any fungl or MycobacLerla
8aclllus, roplonobacLer, Mlcrococcus - low vlrulence buL hard
Lo eradlcaLe
AuempL salvage lf enLerococcus , CnS, or gram negauve
LhaL lsn'L seudomonas
I%"&$0"#$
Lmplrlc: vancomycln
Conslder Cn or anufungal (echlnocandln) lf rlsk facLors
Conslder local blograms - v8L, vanco reslsLanL sLaph
1allor accordlng Lo organlsm
8emove Lhe llne and LreaL 10 - 14d once culLure neg
LxLend Lo 6 - 8 wks lf perslsLenL bacLeremla or
endocardlus
lf SLaph aureus, conslder 1LL aL 7 days Lo r/o endocardlus