23. Infectious Disease II Flashcards

1
Q

Pre-operative abx administration timing

A

Infuse abx (e.g. cefazolin or cefuroxime) within 60 min before first incision

If quinolone or vancomycin, start infusion 120 min before first incision

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2
Q

In what situations would additional doses of abx be administered during a surgery (intra-operative)?

A

Longer surgeries (>4hr)
Major blood loss

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3
Q

T/F: Abx are often continued up to 48 hours after surgery

A

False - abx are usually not needed post-operatively; if used, discontinue after 24 hours

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4
Q

Perioperative abx selection: ____ is preferred for most surgeries to prevent MSSA and streptococcal infections. ___ is an alternative if the patient has a beta-lactam allergy

A

Cefazolin (or cefuroxime) is preferred
Clindamycin is an alternative

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5
Q

Perioperative abx selection: In GI surgeries, ppx abx regimen needs to cover skin flora plus ___ and ___

A

Broad GN and anaerobic

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6
Q

Perioperative abx selection: ____ should be included if MRSA colonization or risk is present. This is also an alternative (instead of clindamycin) if the patient has a beta-lactam allergy.

A

Vancomycin

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7
Q

Perioperative abx selection: Which abx would you recommend for cardiac or vascular procedures? What if they have beta-lactam allergy?

A

Cefazolin or cefuroxime
Beta-lactam allergy: clindamycin or vancomycin

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8
Q

Perioperative abx selection: Which abx would you recommend for orthopedic (e.g. joint replacement, hip fracture repair) surgery? What if they have beta-lactam allergy?

A

Cefazolin
Beta-lactam allergy: clindamycin or vancomycin

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9
Q

Perioperative abx selection: What abx would you recommend for GI (e.g. appendectomy, colorectal surgery) surgery? What if they have beta-lactam allergy?

A

Cefazolin + metronidazole, cefotetan, cefoxitin, or amp/sulb
Beta-lactam allergy: clindamycin or metronidazole + aminoglycoside or quinolone

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10
Q

S/sx of meningitis

A

Fever, HA, nuchal rigidity (stiff neck), altered mental status
Others:L chills, vomiting, seizures, rash, and photophobia

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11
Q

How is meningitis diagnosed?

A

Lumbar puncture (LP), sample of CSF is collected and analyzed
Higher CSF pressure during LP procedure is a sign of possible infection

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12
Q

T/F: Meningitis is mostly caused by bacterial infections but can be d/t viral or fungi

A

False - mostly caused by VIRAL but can be d/t bacterial or fungi

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13
Q

Which bacteria most commonly cause meningitis?

A

Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae

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14
Q

The risk of meningitis d/t ___ is higher in which patient populations?

A

Listeria monocytogenes
Neonates
Pts age>50
Immunocompromised pts

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15
Q

____, administered 15-20 min prior to or with the first abx dose can prevent neurological complications (e.g. hearing loss) and death from pneumococcal meningitis.

A

Dexamethasone
Adult dosing: 0.15mg/kg (rounded to nearest 10 mg) IV q6hr for 4 days
If S. pneumoniae is not the cause of meningitis, dexamethasone can be d/c

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16
Q

Meningitis: Empiric Treatment: Coverage

A

Streptococcus pneumoniae and Neisseria meningitidis for most adults
Add Listeria monocytogenes coverage in neonates, age >50yo, and immunocompromised pts
Add vancomycin in pts ≥12 month old for double coverage of Streptococcus pneumoniae

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17
Q

Meningitis: Empiric Treatment: Age <1 month (neonate): Treatment Regimen

A

Ampicillin (Listeria coverage) + (Cefotaxime or Gentamicin)
Note: CANNOT use ceftriaxone - biliary sludging and kernicterus in neonates

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18
Q

Meningitis: Empiric Treatment: Treatment Regimen: 1 month to 50 yo

A

(Ceftriaxone or cefotaxime) + Vancomycin

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19
Q

Meningitis: Empiric Treatment: Treatment Regimen: Age >50 or immunocompromised

A

Ampicillin (for Listeria coverage) + (Ceftriaxone or cefotaxime) + Vancomycin

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20
Q

____ can cause biliary sludging and kernicterus in neonates. Do NOT use in neonates.

A

Ceftriaxone

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21
Q

Meningitis: Empiric Treatment: Treatment Regimen: Beta-lactam allergy

A

Quinolone (e.g. moxifloxacin) + vancomycin ± SMX/TMP (for Listeria coverage); obtain ID consult

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22
Q

S/sx of acute otitis media (AOM)

A

Bulging tympanic (eardrum) membranes, otorrhea (middle ear effusion/fluid), otalgia (ear pain), fever, crying and tugging/rubbing ears

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23
Q

T/F: Most AOM is viral and abx will be ineffective

A

True

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24
Q

AOM bacterial infection is typically caused by ____

A

S. pneumoniae, H. influenzae, Moraxella catarrhalis

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25
Q

When is observation for 2-3 days recommended for AOM?

A

If symptoms are non-severe: otalgia <48 hrs, no otorrhea, temp <102.2ºF (39ºC) and:
Age 6-23 months: only in 1 ear
Age ≥2 years: in one or both ears

If no improvement or worsens, use abx

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26
Q

Observation is not an option for children age ____ and abx should be prescribed

A

<6 months

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27
Q

AOM: First-line treatment

A

High-dose amoxicillin 90mg/kg/day, divided into 2 doses OR
Amox/clav 90mg/kg/day, divided into 2 doses (preferred if pts received amoxicillin in the past 30 days)

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28
Q

AOM: Non-severe penicillin allergy

A

2nd or 3rd gen cephalosporin
Cefidinr, cefuroxime, cefpodoxime, or ceftriaxone

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29
Q

AOM: If treatment fails (not improved after 2-3 days)

A

Amox/clav 90mg/kg/day, divided in 2 doses (if initial treatment was amoxicillin) OR
ceftriaxone 50 mg/kg IM daily for 3 days

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30
Q

Patient complains of sneezing, runny nose, mild sore throat, cough, and congestion. Should they get abx?

A

No. This patient most likely has common cold (caused by respiratory viruses like rhinovirus, seasonal coronavirus) and generally resolves in a few days.
Recommend symptomatic care

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31
Q

Patient complains of sudden onset of fever, chills, fatigue, myalgia, dry cough, sore throat, and HA. Should they get abx?

A

This patient most likely has influenza virus.
Anti-infective care is recommended if suspected or confirmed infection AND (symptoms <48 hrs, severe illness (e.g. hospitalized), OR symptoms plus risk factors for influenza complications)
Recommend symptomatic care with or without antiviral

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32
Q

Patient complains of sore throat, fever, swollen lymph nodes, white patches (exudates) on the tonsils but no cough, runny nose, or congestion. What is their diagnosis?

A

Pharyngitis (“strep throat”) typically caused by respiratory viruses, Group A Streptococcus (S. pyogenes)
Take rapid antigen test before giving abx

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33
Q

Patient has a positive rapid antigen test for strep throat. What abx do you recommend?

A

Penicillin or amoxicillin
Mild PCN allergy: 1st or 2nd gen cephalosporin
Severe reaction to PCN: macrolide (clarithromycin, azithromycin) or clindamycin

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34
Q

Patient complains of nasal congestion, purulent nasal discharge, facial/ear/dental pain, HA, and fever. What is their diagnosis?

A

Acute sinusitis typically caused by respiratory viruses, S. pneumoniae, H. influenzae, M. catarrhalis

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35
Q

Patient is diagnosed with acute sinusitis. When should abx be considered?

A

≥10 days of persistent symptoms OR
≥ 3 days of severe symptoms (face pain, purulent nasal discharge, temp > 102ºF) OR
Worsening symptoms after initial improvement

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36
Q

Patient is diagnosed with acute sinusitis and symptoms have not improved for 11 days. When abx do you recommend?

A

Amox/clav OR
symptomatic care for up to 7 days, abx can be used when symptoms worsen or do not improve

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37
Q

What are some key defining features of acute bronchitis?

A

Cough lasting 1-3 weeks, chest wall tenderness, wheezing and/or rhonchi
Usually preceded by an upper respiratory tract virus, such as rhinovirus, coronavirus, or influenza virus
Chest X-ray findings are typically normal (rules out other causes of acute cough like pneumonia, COPD exacerbation) and cultures are not routinely performed

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38
Q

Acute bronchitis is typically caused by viral infections. While rare, what are some bacterial causes?

A

S. pneumoniae, H. influenzae, or atypical pathogens (e.g. Mycoplasma pneumoniae)

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39
Q

Patient is diagnosed with acute bronchitis. What is your abx recommendation?

A

Abx not recommended. Symptoms are generally self-limiting and can be managed with supportive care

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40
Q

Pertussis or “whooping cough” acute bronchitis caused by _____, characterized by forceful coughs followed by an inspiratory “whoop” sound

A

Bordatella pertussis

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41
Q

How do you confirm dx of pertussis?

A

Nasopharyngeal swab culture or PCR test for B. pertussis

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42
Q

Pertussis is highly contagious and should be treated with ___

A

macrolides (azithromycin, clarithromycin)

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43
Q

What are the 3 cardinal symptoms of COPD exacerbation?

A

Increaed dyspnea
Increased sputum volume
Increased sputum purulence

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44
Q

What causes COPD exacerbations?

A

Viral infections
Bacterial infections (e.g. H. influenzae, M. catarrhalis, S. pneumoniae)
Environmental pollution or an unknown cause

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45
Q

Supportive treatment (e.g. oxygen, systemic steroids, inhaled bronchodilators) are often adequate but abx is recommended if which criteria are met?

A

All 3 cardinal symptoms (increased dyspnea, sputum volume, sputum purulence) OR
Increased sputum purulence + 1 additional symptom OR
Mechanically ventilated

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46
Q

If abx is used for COPD exacerbation, what are the preferred abx?

A

Amox/clav
Others: azithromycin, doxycycline, respiratory FQ

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47
Q

S/sx of community-acquired pneumonia (CAP)

A

SOB, fever, cough with purulent sputum, pleuritic chest pain, rales (crackling lung sounds), tachypnea (increased respiratory rate), and decreased breath sounds
Gold standard dx test chest x-ray with “infiltrates”, “opacities” or “consolidations”

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48
Q

Which bacteria can cause CAP?

A

S. pneumoniae, H. influenzae, M. pnuemoniae, and possibly C. pneumoniae

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49
Q

____ is not used for CAP because it is not a respiratory FQ since it does not reliably cover S. pneumoniae

A

Ciprofloxacin

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50
Q

Typical duration of treatment for CAP is ___

A

5-7 days

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51
Q

Recommended outpatient empiric regimen for CAP patients who are healthy (no comorbidities)

A

Amox high dose (1g TID) OR
doxycycline OR
macrolide (azithromycin or clarithromycin) if local pneumococcal resistance is <25%

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52
Q

Recommended outpatient empiric regimen for CAP patients who are high risk with comorbidities

A

Beta-lactam + macrolide or doxycline:
- amox/clav or cephalosporin (e.g. cefpodoxime, cefuroxime)
OR
Respiratory FQ monotherapy: Moxifloxacin or levofloxacin

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53
Q

Recommended inpatient empiric regimen for nonsevere CAP

A

Beta-lactam + macrolide or doxycycline
- Preferred beta-lactam: ceftriaxone, cefotaxime, ceftaroline, or amp/sulb
OR
Respiratory FQ monotherapy: moxifloxacin or levofloxacin

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54
Q

Recommended inpatient empiric regimen for severe CAP (in ICU)

A

Beta-lactam + macrolide
OR
Beta-lactam + respiratory FQ (do NOT use quinolone monotherapy)

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55
Q

Recommended inpatient abx for MRSA coverage (prior respiratory isolation or positive nasal swab)

A

Vancomycin or linezolid

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56
Q

Recommended inpatient abx for Pseudomonas coverage (prior respiratory isolation)

A

Pip/tazo, cefepime, fetazidime, imipenem/cilastin, or meropenem

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57
Q

Recommended inpatient abx for previous hospitalization and use of parenteral abx in the past 90 days

A

Use regimen that covers both MRSA and Pseudomonas

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58
Q

What is the difference between hospital-acquired pneumonia (HAP) vs ventilator-associated pneumonia (VAP)?

A

HAP = onset > 48 hours after hospital admission
VAP = onset > 48 hours after start of mechanical ventilation - can be reduced by proper hand-washing, elevating head of the bed ≥30 degrees, weaning off ventilator asap, removing NG tubes when possible, and d/c unnecessary stress ulcer ppx (e.g. PPI)

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59
Q

What are common pathogens in HAP and VAP?

A

Nosocomial pathogens
Increased risk for MRSA, MDR GN rods including P. aeruginosa, Acinetobacter spp. Enterobater spp., E. coli, and Klebsiella spp.

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60
Q

HAP and VAP empiric regimen base

A

Pseudomonas and MSSA coverage - examples: cefepime, pip/tazo, levofloxacin

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61
Q

HAP and VAP add on regimen if risk for MRSA (IV abx use in past 90 days, MRSA prevalence in hospital unit is >20% or unknown, prior MRSA infection or positive MRSA nasal swab)

A

Vancomycin or linezolid
Example regimens:
cefepime + vancomycin
Meropenem + linezolid
Aztreonam + vancomycin

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62
Q

HAP and VAP regimen if risk for MDR GN pathogens (IV abx use in past 90 days, prevalence of GN resistance in hospital unit is >10% or unknown, ≥ 5 days prior to the onset of VAP)

A

Use 2 abx for Pseudomonas
Examples:
Pip/tazo + ciprofloxacin + vancomycin
Cefepime + gentamicin + linezolid

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63
Q

Abx for pseudomonas list used in HAP or VAP

A

Do NOT use 2 beta-lactams together
Beta-lactams: pip/tazo, cefepime, ceftazidime, imipenem/cilastatin, meropenem
Levofloxacin or ciprofloxacin
Aztreonam
Aminoglycosides (typically tobramycin) - always used in combo with other antipseudomonal drug

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64
Q

Tuberculosis (TB) is caused by _____ (an aerobic, non-spore forming bacillus)

A

Mycobacterium tuberculosis

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65
Q

With latent disease, the immune system is able to contain the infection and the patient lacks symptoms. Active pulmonary TB is transmitted by _____ and is highly contagious.

A

aerosolized droplets (e.g. sneezing, coughing, talking)

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66
Q

S/sx of TB

A

cough/hemoptysis (coughing up blood), purulent sputum, fever, night sweats, and unintentional weight loss

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67
Q

Your patient has active pulmonary TB. What is required of the patient and the healthcare workers?

A

Patient needs to be in isolation in a single negative-pressure room
Healthcare workers need to wear respiratory mask (N95)

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68
Q

How is latent TB diagnosed?

A

Tuberculin skin test (TST), also called purified protein derivative (PPD) test, or an interferon-gamma release assay (IGRA) blood test

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69
Q

In which patients can a false-positive TB test occur?

A

Those who received BCG vaccine

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70
Q

Dx of latent TB: Criteria for positive TST results: ≥5 mm induration

A

Close contacts of recent active TB cases
HIV infection
Immunosuppression (e.g. transplant, chemotherapy)

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71
Q

Dx of latent TB: Criteria for positive TST results: ≥10 mm induration

A

Immigrants from high burden countries
clinical risk (e.g. IV drug uses, DM)
Residents/employees of “high-risk” congregate settings (e.g. prisons, healthcare facilities, homeless shelters)

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72
Q

Dx of latent TB: Criteria for positive TST result1s: ≥5 mm induration

A

Patients with no risk factors

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73
Q

Latent TB treatment options

A

Isoniazid and rifapentine once weekly x 12 weeks via directly observed therapy (DOT) or self-administered. do NOT use this regimen for pregnant patients

Isoniazid with rifampin daily for 3 months

Rifampin 600mg daily for 4 months

Isoniazid 300mg daily for 6 or 9 months - may be preferred in HIV positive patients taking antiretroviral therapy (lower risk of DDIs); if used, take for 9 months

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74
Q

M. tuberculosis (MTB) is an ___ (AFB). AFB smear can detect but it is not specific to MTB. Definitive dx must be made with PCR or sputum culture results. Final culture and susceptibility results can take up to ___

A

Acid-fast bacilli
6 weeks (slow-growing organism)

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75
Q

Active TB treatment is divided into 2 phases: ___ and ____

A

intensive and continuation

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76
Q

TB intensive phase regimen consists of 4 drugs for 2 months. What are they?

A

Rifampin, isoniazid, pyrazinamide, and ethambutol daily or x5/week
(RIPE therapy)

Note: 4 drugs for 2 months

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77
Q

TB continuation phase (typically ____ months) treatment can be scaled back to 2 drugs (commonly ___ and ___) based on drug susceptibility of the isolate

A

4 months (may be extended to 7 months in select cases (e.g. sputum culture remains positive after 2 months of treatment, or if intensive phase treatment did not include pyrazinamide)

rifampin and isoniazid daily, 5x/week or 3x/week

Note: 2 drugs for 4 months

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78
Q

T/F: Latent TB is when a patient shows no symptoms but is still contagious

A

False - patient shows no symptoms and is not contagious, treated with 1 or 2 drugs for 3-4 months (preferably)

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79
Q

Contraindications for rifampin (Rifadin)

A

Do not use with protease inhibitors

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80
Q

Side effects for rifampin (Rifadin)

A

Increased LFTs, hemolytic anemia (detected with positive Coombs test), flu-like syndrome, GI upset, rash/pruritus
Orange-red discoloration of body secretions (saliva, urine, sweat, tears); can stain contact lenses, clothing, and bedsheets

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81
Q

Rifampin has many DDIs; ___ has fewer DDIs and can replace rifampin in some cases (e.g. HIV patients taking protease inhibitors), thought a DDI screen is still needed

A

Rifabutin

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82
Q

You should also take ____ when taking isoniazid to decrease risk of ____

A

pyridoxine (vit B6) 25-50mg PO daily
decrease risk of isoniazid associated peripheral neuropathy

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83
Q

Boxed warning for isoniazid

A

severe and fatal hepatitis

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84
Q

Contraindications for isoniazid

A

Active liver disease, previous serious adverse reaction to isoniazid

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85
Q

Warnings for isoniazid

A

Peripheral neuropathy (higher risk in pts predisposed to neuropathy (e.g. DM, HIV, renal failure, alcohol use disorder, elderly, malnourished)
Pyridoxine (vit B6) supplementation recommended for these patients and patients who are pregnant or breastfeeding

86
Q

Side effects for isoniazid

A

Increased LFTs (usually asymptomatic)
Drug induced lupus erythematosus (DILE), hemolytic anemia (detected with positive Coombs test), agranulocytosis, aplastic anemia, hyperglycemia, headache, GI upset, pancreatitis, SJS/DRESS, optic neuritis

87
Q

Contraindications for pyrazinamide

A

Acute gout, severe hepatic damage

88
Q

Side effects for pyrazinamide

A

Increased LFTs, hyperuricemia/gout, GI upset, malaise, arthralgia, myalgia, rash

89
Q

Contraindications for ethambutol (Myambutol)

A

Optic neuritis (risk vs benefit decision)
Do NOT use in young children, unconscious patient or any patient who cannot discern and report visual changes

90
Q

Side effects for ethambutol (Myambutol)

A

Increased LFTs, optic neuritis (dose-related), confusion, hallucinations

decreased visual acuity, partial loss of vision/blind spot and/or color blindness (usually reversible), rash, HA, N/V

91
Q

Rifampin is a potent (inducer/inhibitor) of CYP___ and p-gp (others: 1A2, 2C8, 2C9, 2C19)

A

Potent inducer
CYP 3A4 and Pgp
Can decrease conc and therapeutic effect of many other drugs

92
Q

Rifampin can decrease serum conc of which drugs?

A

Protease inhibitors (substitute rifabutin)
Warfarin (very large drop in INR is common, requires increased dose of warfarin)
Oral contraceptives (decreased efficacy; requires additional backup contraceptive methods)

93
Q

It is recommended to NOT use rifampin with certain anticoagulants. What are they?

A

Apixaban, rivaroxaban, edoxaban, or dabigatran

94
Q

RIPE Therapy for TB: Monitoring Infection

A

Sputum sample (for culture), symptoms, and chest x-ray (are lungs clear or clearing up?)

95
Q

RIPE Therapy for TB: Drug Specific Key Points: All RIPE drugs

A

Increased LFTs, including total bilirubin - monitor

96
Q

RIPE Therapy for TB: Drug Specific Key Points: Rifampin

A

Orange bodily secretions
strong CYP450 inducer (can use rifabutin if unacceptable DDIs
Flu-like symptoms

97
Q

RIPE Therapy for TB: Drug Specific Key Points: Isoniazid

A

Peripheral neuropathy: give with pyridoxine (vitamin B6) 25-50 mg PO daily
Monitor for symptoms of DILE

98
Q

RIPE Therapy for TB: Drug Specific Key Points: Rifampin and Isoniazid

A

Risk for hemolytic anemia (identified with positive Coombs test)

99
Q

RIPE Therapy for TB: Drug Specific Key Points: Prazinamide

A

Increased uric acid - do not use with acute gout

100
Q

RIPE Therapy for TB: Drug Specific Key Points: Ethambutol

A

Visual damage (requires baseline and monthly vision exams)
Confusion/hallucinations

101
Q

Infective endocarditis is dx using the Modified Duke Criteria, which includes ___ and ___

A

echocardiogram and positive blood cultures

102
Q

3 Most common species of organisms that cause infective endocarditis are ___,___, and ____

A

staphylococci
Streptococci
Enterococci

103
Q

Infective endocarditis empiric treatment often includes __ and __

A

vancoymycin
ceftriaxone

104
Q

____ is added to the infective endocarditis antimicrobial regimen for synergy when the infection is more difficult to eradicate, such as with prosthetic valve infections or when treating more resistant organisms

A

Gentamicin

105
Q

What is the typical duration for infective endocarditis treatment?

A

4-6 weeks of IV abx treatment (may be longer if prosthetic valves and/or more resistant organisms involved)

106
Q

Duration of gentamicin synergy (if used for infective endocarditis treatment) is ___, depending on the organism being treated when the presence or absence of a prosthetic valve

A

2-6 weeks

107
Q

What is target peak and trough levels of gentamicin when used for synergy in infective endocarditis treatment?

A

Peak 3-4 mcg/mL
Trough <1 mcg/mL

108
Q

Infective Endocarditis Treatment: Preferred abx regimen: Viridans group streptococci present

A

PCN or CTX (± gentamicin)
If beta-lactam allergy: vancomycin monotherapy

109
Q

Infective Endocarditis Treatment: Preferred abx regimen: MSSA present

A

Nafcillin or cefazolin (+ gentamicin and rifampin if prosthetic valve)
If beta-lactam allergy: vancomycin (+ gentamicin and rifampin if prosthetic valve)
Note: daptomycin monotherapy is alt for MSSA IE when pt has beta-lactam allergy and no prosthetic valve

110
Q

Infective Endocarditis Treatment: Preferred abx regimen: MRSA present

A

Vancomycin (+gentamicin and rifampin if prosthetic valve)

111
Q

Infective Endocarditis Treatment: Preferred abx regimen: Enterococci

A

For both native and prosthetic valve IE: PCN or ampicillin + gentamicin or ampicillin + high-dose CTX
If beta-lactam allergy: vancomycin + gentamicin
If VRE: daptomycin or linezolid

112
Q

Which patients are at high risk for infective endocarditis and require dental ppx?

A

Dental work needed, such as root canal +
Select cardiac conditions, including:
- Prosthetic heart valve or heart valve repaired with artificial material
Hx of endocarditis
Heart transplant with abnormal heart valve function
Certain congenial heart defects including heart/heart valve disease

113
Q

Adult regimen for IE dental ppx: First line

A

Amoxicillin 2 grams PO single dose 30-60 min before dental procedure

114
Q

Adult regimen for IE dental ppx: NPO

A

Ampicillin 2g IM/IV OR Cefazolin or CTX 1g IM/IV

115
Q

Adult regimen for IE dental ppx: PCN allergy

A

Azithromycin or clarithromycin 500mg OR doxycycline 100mg

116
Q

Spontaneous bacterial peritonitis (SBP) is suspected if an ascitic fluid sample reveals ____

A

≥250 cells/mm3 PMNs (polymorphonuclear leukocytes)

117
Q

Empiric treatment for SBP first line

A

CTX for 5-7 days

118
Q

Alternative treatment for SBP if critically ill or at risk for MDR pathogens

A

Carbapenems (e.g. meropenem)

119
Q

Secondary PPX for SBP

A

SMX/TMP or a quinolone (e.g. ciprofloxacin)

120
Q

What are common intra-abdominal infections?

A

Appendicitis, cholecystitis (acute inflammation of gallbladder d/t obstruct stone), cholangitis (infection of common bile duct), secondary peritonitis (caused by ulceration, ischemia, obstruction, surgery), diverticulitis

121
Q

Intra-abdominal infections are usually polymicrobial so empiric abx treatment should target multiple pathogens including ___, ___, and ___

A

streptococci, enteric GN, and anerobes (e.g. B. fragilis)

122
Q

What increases risk of MDR pathogens?

A

Critically ill
Hospitalized > 48 hrs
abx in past 90 days

123
Q

If there is a risk of MDR pathogens, coverage of __ and other resistant organisms may be necessary for intra-abdominal infections

A

pseudomonas

124
Q

Treatment options for intra-abdominal infections: Community-acquired (low risk)

A

Ertapenem
Moxifloxacin
(Cefuroxime, cefotaxime, or CTX) + metronidazole
(Ciprofloxacin or levofloxacin) + metronidazole

Covers: PEK, anaerobes, streptococci

125
Q

Treatment options for intra-abdominal infections: Risk for resistant or nosocomial pathogens

A

Carbapenem (except ertapenem)
Pip/tazo
(cefepime or ceftazidime) + metronidazole

Covers: PEK, Pseudomonas, Enterobacter, anaerobes, streptococci ± enterococci

126
Q

What are examples of superficial SSTIs

A

Impetigo, furuncle, carbuncle

127
Q

What is an example of infection that penetrate the subcutaneous tissues

A

Cellulitis

128
Q

SSTI classifications: Mild infection

A

Systemic signs abset

129
Q

SSTI classifications: Moderate infection

A

Systemic signs present (Temp >100.4ºF, HR >90, WBC > 12,000 or <4000 cell/mm3

130
Q

SSTI classifications: Sevefre infection

A

Systemic signs present
Signs of deeper infection (e.g. fluid-filled blisters, skin sloughing, hypotension, or evidence of organ dysfunction)
Patient is immunocompromised or failed oral abx + incision and drainage (for purulent infections)

131
Q

Patient comes in with a blister-like rash around their mouth that looks like honey-colored crust. What do they have and what do you recommend?

A

Impetigo
Use warm, wet compresses to help remove dried crusts

Limited localized lesions: Apply topical abx, typically mupirocin (alt: retapamulin (Altabax) and ozenoxacin (Xepi)

Numerous, extensive lesions: Cephalexin or dicloxacillin

132
Q

Define folliculitis

A

A superficial infection of hair follicles (looks like red pimples)

133
Q

Define furuncle (boil)

A

Purulent infection of hair follicle

134
Q

Define carbuncle

A

Group of infected furuncles

135
Q

What is the bacterial cause of folliculitis/furuncle/carbuncles

A

S. aureus, including community-acquired MRSA (CA-MRSA)

136
Q

Folliculitis and small furuncles may require only warm compresses to decrease inflammation and help with drainage. For larger furuncles and carbuncles, I&D ± abx may be required. What abx would you recommend?

A

SMX/TMP or Doxycycline

Covers: MSSA and MRSA

137
Q

What are s/sx of cellulitis

A

Mild symptoms: localized pain, swelling, redness, warmth
Often occurs on the legs, generally unilateral, can rapidly spread/expand

138
Q

What abx do you recommend for cellulitis infections?

A

Cephalexin
Others: dicloxacillin
Beta-lactam allergy: clindamycin
Duration: 5 days (longer if no improvement after 5 days)

139
Q

What is the bacterial cause of an abscess?

A

S. aureus, including CA-MRSA

140
Q

What abx do you recommend for abscess

A

SMX/TMP or doxycycline
Others: minocycline, clindamycin, linezolid (but more expensive)

Covers MSSA and MRSA
If cultures show MSSA, use cephalexin

141
Q

What abx do you recommend for severe purulent SSTI

A

MRSA coverage:
Vancomycin (goal trough 10-15)
Daptomycin
Linezolid

Others: ceftaroline, tedizolid, telavancin

Once clinically stable, can switch to PO abx

142
Q

What is necrotizing fascilitis

A

A life-threatening, fast-moving type of skin infection that rapidly destroys tissue and can quickly penetrate down to the muscle

Presentation: intense pain/tenderness over affected skin and udnerlying muscle (often out of proportion with clinical findings), skin discoloration, edema, systemic signs

Requires emergency treatment in a hospital

142
Q

What abx do you recommend for necrotizing fascilitis

A

Urgent surgical debridement

Broad empiric therapy:
Vancomycin or daptomycin + beta-lactam (pip/tazo, meropenem) + clindamycin (to suppress streptococcal toxin production

143
Q

Treatment of Mod-severe diabetic foot infections: No MRSA coverage needed

A

Amp/sulb
Pip/tazo
Carbapenem (meropenem, ertapenem)
Moxifloxacin
(CTX, cefepime, levofloxacin, ciprofloxacin) + metronidazole

Pseudomonas coverage: pip/tazo, meropenem, cefepime, levofloxacin, ciprofloxacin

144
Q

Treatment of Mod-severe diabetic foot infections: MRSA Coverage needed

A

Add vancomycin, daptomycin, or linezolid to empiric regimen

145
Q

What is the typical duration for moderate-severe diabetic foot infection treatment?

A

7-14 days

146
Q

What is the typical duration for more severe, deep tissue infection diabetic foot infection treatment?

A

2-4 weeks

147
Q

What is the typical duration for severe, limb-threatening or bone/joint infection diabetic foot infection treatment?

A

4-6 weeks

148
Q

What is the typical duration for osteomyelitis diabetic foot infection treatment?

A

Longer courses, may require chronic suppressive therapy

149
Q

S/sx of cystitis

A

Urgency and frequency, nocturia
Dysuria (painful urination, burning)
Suprapubic tenderness
Hematuria
Urinalysis: Pyuria (WBC >10 cells/mm3), bacteria, and positive leukocyte esterase and/or nitrates

150
Q

S/sx of pyelonephritis

A

Flank pain
Abd pain, N/V
Fever, chills, and malaise

151
Q

Most acute cystitis is caused by ___

A

E. coli

152
Q

Drugs of choice for acute uncomplicated cystitis

A

Nitrofuantoin (Macrobid) 100mg PO BID x 5 days (contraindicated if CrCl <60)
OR SMX/TMP DS 1 tab po BID x3 days (do NOT use if sulfa allergy or ≥ 20% e.coli resistance rate)
OR fosfomycin 3g x1 dose

153
Q

Alt options for acute uncomplicated cystitis

A

Beta-lactam (amox/clav or cephalosporin) x5-7 days
Ciprofloxacin or levofloxacin x 3 days *

*Quinolones: do NOT use in children, pregnant patients, those with seizures, neuropathy, or QT prolongation risk; watch for tendinitis/rupture and BG changes (esp in DM pts)

154
Q

Treatment options for acute uncomplicated cystitis in pregnant patients

A

Amoxicillin
Cephalexin
Beta-lactam allergy: Fosfomycin
Duration: 7 days

155
Q

Treatment options for Acute pyelonephritis, moderately ill outpatient if local quinolone resistance ≤ 10%

A

Cipro or levofloxacin x5-7 days

Concerns for quinolone adverse effects: SMX/TMP or beta-lactam (amox/clav, cefdinir, cefadroxil, cefpodoxime) x7-10 days

156
Q

Treatment options for Acute pyelonephritis, moderately ill outpatient if local quinolone resistance > 10%

A

CTX, ertapenem, or aminoglycoside extended-interval dose x1 + quinolone (cipro, levo) x5-7 days

Concerns for quinolone adverse effects: SMX/TMP or beta-lactam (amox/clav, cefdinir, cefadroxil, cefpodoxime) x7-10 days

157
Q

Treatment options for Acute pyelonephritis, severely ill hospitalized patient

A

Initial: CTX or quinolone (cipro, levo)

Concern for resistance: pip/tazo or a carbapenem (if ESBL-producing organism suspected)

Step-down according to culture + susceptibility
Duration 5-10 days depending on regimen and clinical response

158
Q

Do not use ____ for UTIs (does not reach high levels in the urine)

A

Moxifloxacin

159
Q

Acute pyelonephritis, risk for or documented pseudomonas infection, which abx to consider?

A

Pip/tazo or antipseudomonal carbapenem (meropenem, doripenem, imipenem/cilastatin)

160
Q

____ can help with dysuria (pain/burning with urination) but does not treat the infection

A

Phenazopyridine (Pyridium, Azo Urinary Pain Relief)

161
Q

Dosing for phenazopyridine

A

200 mg PO TID x2 days (max)
Take with 8 oz of water, with food to minimize stomach upset

162
Q

Contraindications for phenazopyridine

A

Do NOT use in renal impairment of liver disease

163
Q

Patient counseling points for phenazopyridine

A

Max duration: 2 days
Take with 8oz of water and with food to minimize stomach upset
Can cause red-orange coloring of the urine and other body fluids; contact lenses/clothes can be stained

164
Q

T/F: Bacteriuria alone indicates abx treatment in all patients

A

False - unless they are symptomatic you don’t give abx for just bacteriuria (exception pregnant pts regardless of symptoms

165
Q

Preferred treatment for bacteriuria in pregnant patients

A

Amoxicillin ± clavulanate or an oral cephalosporin
Beta-lactam allergy: nitrofurantoin, SMX/TMP, or fosfomycin (nitrofurantoin, SMX/TMP reserve when other options not available, avoid in 1st trimester if possible // avoid SMX/TMP in 3rd trimester if possible, can cause hyperbilirubinemia and kernicterus in newborn if used close to delivery)

166
Q

Which abx should be avoided in pregnant patients with bacteriuria

A

Quinolones (cartilage toxicity and arthropathies)

167
Q

S/sx C.diff infection

A

at least 3 watery stools per day
abdominal cramps
Fever
Elevated WBC count

168
Q

What are some risk factors of C. diff infection

A

Healthcare exposure, use of PPIs, advanced age, immunocompromised state, obesity, and previous CDI

169
Q

How to dx C. diff infection

A

Positive C. diff stool toxin or PCR

170
Q

Bezlotoxumab can be added on to a CDI regimen for high risk patients which include:

A

≥65 yo, immunocompromised status, severe presentation, and/or experiencing 2nd episode of CDI within past 6 months

171
Q

Treatment for CDI: 1st episode

A

Fidaxomicin 200mg PO BID x 10 days OR
Vancomycin 125 mg PO QID x 10 days OR
Metronidazole 500mg PO TID x 10 days (option only if non-severe and treatments above are not available)

172
Q

Treatment for CDI: 2nd episode

A

Fidaxomicin 200mg PO BID x 10 days OR
Vancomycin 125mg PO QID x 10 days + taper (normal course acceptable if metronidazole was used for 1st episode)

173
Q

Treatment for CDI: 3rd episode or subsequent episodes

A

Fidaxomicin 200mg PO BID x 10 days OR
Vancomycin 125mg PO QID x10 days + taper OR
Vancomycin 125mg PO QID x 10 days + rifaximin 400mg TID x20 days OR
Fecal microbiota transplantation

174
Q

Treatment for CDI: Fulminant/complicated disease (dx when sig systemic toxic effects such as hypotension, shock, ileus, or toxic megacolon)

A

Vancomycin 500mg PO/NG/PR QID + metronidazole 5400mg IV q8h

175
Q

S/sx of common STIs: chlamydia

A

Genital discharge or no symptoms

176
Q

S/sx of common STIs: gonorrhea

A

Genital discharge or no symptoms

177
Q

S/sx of common STIs: genital warts

A

single or multiple pink/skin-toned lesions

178
Q

S/sx of common STIs: latent syphilis

A

Asymptomatic

179
Q

S/sx of common STIs: primary syphilis

A

Painless, smooth genital sores (Chancre)

180
Q

S/sx of common STIs: bacterial vaginosis

A

vaginal discharge (clear, white or gray) that has a “fishy” odor and pH > 4.5; little o no pain

181
Q

S/sx of common STIs: Trichomoniasis

A

Yellow/green, frothy vaginal discharge with pH >4.5; soreness, pain with intercourse

182
Q

Treatment: Syphilis (primary, secondary, or early latent) drug of choice and dosing

A

Penicillin G benzathine (Bicillin L-A, do NOT sub with Bicillin C-R)
2.4 million units IM x1

183
Q

Treatment: Syphilis (primary, secondary, or early latent) beta-lactam allergy

A

Doxycycline 100mg PO BID x14 days

If pregnant, nonadherent with treatment, or unlikely to f/u, desensitize and treat with Bicillin L-A (PCN G benzathine)

184
Q

Dx syphilis

A

Positive non-treponemal test (rapid plasma reagin (RPR) or Venereal Disease Research Lab (VDRL) blood test) and treponemal assay

185
Q

Treatment: Syphilis (late latent or tertiary) drug of choice and dosing

A

Penicillin G benzathine 2.4 million units IM weekly x3 weeks (7.2 million units total)

186
Q

Treatment: Syphilis (late latent or tertiary) beta-lactam allergy

A

Doxycycline 100mg PO BID x28 days

If pregnant, nonadherent with treatment, or unlikely to f/u, desensitize and treat with Bicillin L-A (PCN G benzathine)

187
Q

Treatment: neurosyphilis

A

Penicillin G aqueous crystalline 3-4 million units IV q4h x10-14 days
Alt: Penicillin G procaine
Beta-lactam allergy: desensitization followed by administration of penicillin G aqueous IV

188
Q

Treatment: Gonorrhea drug of choice and dosing

A

CTX 500mg IM x1 (if ≥150kg, increase dose to 1g IM x1)
If chlamydia has not been excluded: add doxycycline

189
Q

Treatment: Gonorrhea drug of choice and dosing, pregnant pts

A

Same
CTX 500mg IM x1 (if ≥150kg, increase dose to 1g IM x1)
If chlamydia has not been excluded: add doxycycline

190
Q

Treatment: Gonorrhea alternatives

A

If CTX not available: cefixime 800mg PO x1
If cephalosporin allergy: gentamicin 240mg IM x1 + azithromycin 2g POx1

Note: CTX is most effective for pharyngeal infections

191
Q

Treatment: Chlamydia drug of choice, non-pregnant

A

Doxycycline 100mg PO BID x7 days

192
Q

Treatment: Chlamydia drug of choice, pregnant

A

Azithromycin 1g PO x1

193
Q

Treatment: Chlamydia alternatives

A

Erythromycin base 500mg PO QID x7 days OR
Levofloxacin 500mg PO daily x7 days

Pregnancy: amoxicillin 500mg PO TID x7 days

194
Q

Treatment: Bacterial vaignosis drug of choice and dosing

A

Metronidazole 500mg PO BID x7 days OR
Metronidazole 0.75% gel intravaginally daily x 5 days OR
Clindamycin 2% cream intravaginally at bedtime x 7 days

195
Q

Treatment: Bacterial vaginosis alternatives

A

Clindamycin 300mg PO BID x7 days (or clindamycin ovules 100mg intravaginally at bedtime x3 days) OR
tinidazole 2g PO daily x2 days (or 1 g PO daily x 5 days) OR
Secnidazole 2g PO x1 dose

196
Q

T/F: females with bacterial vaginosis should regularly clean their vaginas such as using a douche

A

False - females with bacterial vaginosis should NOT douche

197
Q

Treatment: Trichomoniasis drug of choice and dosing

A

Metronidazole
Females: 500mg PO BID x7 days
Males: 2g PO x1

198
Q

Treatment: Trichomoniasis, pregnant

A

Metronidazole (per package labeling contraindicated in 1st trimester but based on safety data CDC recommends safe in all trimesters)

199
Q

Treatment: Genital warts

A

Imiquimod cream (Aldara, Zyclara) apply topically to clean, dry, warty tissue and wash off in 6-10 hours
Apply 3x/week until cleared (or 16 weeks)

200
Q

T/F: Genital wart treatment is required even if asymptomatic

A

False - warts generally resolve spontaneously within 1 year

201
Q

____ vaccine reduces the risk of genital warts as well as cervical and other cancers

A

Gardasil

202
Q

Genital warts are often caused by ___ strains __ and __

A

HPV strains 6 and 11

203
Q

____ is the most common tickborne disease and most fatal of these illnesses in the US

A

Rocky Mountain spotted fever

204
Q

S/sx of Rocky Mountain spotted fever

A

fever, HA, muscle pain, followed 3-5 days later by an erythemateous petechia rash (pinpoint or splotchy red spots caused by bleeding into the dermis)

205
Q

Treatment: Rocky Mountain Spotted fever

A

Doxycycline 100mg PO/IV BID x5-7 days (drug of choice, even in pediatric patients)

206
Q

What bacteria causes Rocky Mountain Spotted Fever?

A

Rickettsia rickettsii
GN obligate intracellular bacteria

207
Q

Treatment: Lyme Disease

A

Doxycycline 100mg PO BID x10 days OR
Amoxicillin 500mg PO TID x14 days OR
Cefuroxime 500mg PO BID x14 days

208
Q

What bacteria causes lyme disease?

A

Borrelia burgdorferi, Borrelia mayonii
Spirochetes

209
Q

Treatment: Ehrlichiosis

A

Doxycycline 100mg PO/IV BID x7-14 days

210
Q

What bacteria causes ehrlichiosis?

A

Ehrlichia chaffeensis
Obligate intracellular bacteria

211
Q

How to tell between lyme disease vs ringworm

A

Lyme disease: bacterial
Lyme disease s/sx: “bull’s-eye” rash (round, red with central clearing as it expands), achy joints, fever

Ringworm: fungal infection (Tinea corporis)
Ringworm s/sx: 1+ reddish, raised rings, can be itchy