ABIM 2015 - ID Flashcards
1
Q
What is the MAJOR cause of MENINGITIS which is transmitted via the FECAL-ORAL route and is most prevalent in the SUMMER and FALL?
A
ENTEROVIRUSES (viral meningitis has normal CSF stains and negative cultures) - most common cause of “ASEPTIC” meningitis in adults
2
Q
Due to VACCINATION, the FREQUENT MENINGITIS associated with this virus is now rarely seen?
A
MUMPS VIRUS (MMR vaccine) - LIVE VACCINE (also varicella and influenza)
3
Q
What is the SYNDROME of Benign RECURRENT LYMPHOCYTIC Meningitis (10 EPISODES lasting 2-5 DAYS with spontaneous recovery) caused by?
A
HSV-2
4
Q
SUDDEN onset of FEVER, HA, NUCHAL RIGIDITY and PHOTOPHOBIA for
A
VIRAL MENINGITIS
5
Q
What VIRAL MENINGITIS causes symptoms of VOMITING and SALIVARY gland enlargement (elevate serum AMYLASE) in 50% of cases?
A
MUMPS MENINGITIS
6
Q
UNLIKE PCR testing for Enterovirus, HSV-2 and MUMPS - caused viral (aseptic) meningitis, HOW is VIRAL MENINGITIS caused by the West Nile Virus DIAGNOSED?
A
West Nile Virus IgM Ab’s in the CSF
7
Q
How is MENINGITIS caused by ENTEROVIRUS, HSV-2 and MUMPS diagnosed?
A
PCR
8
Q
What is the normal CSF opening pressure?
A
50-200 mm H2O
9
Q
Which MENINGITIS type is MORE LIKELY to have a HIGH opening pressure?
A
BACTERIAL (200-500 mm H2O)
10
Q
What is the WBC (leukocyte count) in BACTERIAL MENINGITIS vs VIRAL MENINGITIS?
A
BACTERIAL >1000/µL (1000-5000/µL)
VIRAL
11
Q
What is the predominant leukocyte (WBC) seen in VIRAL MENINGITIS?
A
LYMPHOCYTE
12
Q
What is the typical change in GLUCOSE and PROTEIN seen in BACTERIAL MENINGITIS?
A
LOW GLUCOSE and HIGH PROTEIN
13
Q
Is protein elevated in VIRAL MENINGITIS?
A
YES, but lower than in bacterial (
14
Q
How is VIRAL MENINGITIS treated?
A
SUPPORTIVE ONLY
15
Q
What is the MOST COMMON cause of BACTERIAL MENINGITIS in the US at this time which usually presents after symptoms of OTITIS MEDIA, SINUSITIS, PNA, BASILAR SKULL FRACTURE with CSF LEAK, or in the IMMUNOCOMPROMISED?
A
Streptococcus pneumoniae
16
Q
This pathogen causes BACTERIAL MENINGITIS in children & young adults and in patients with COMPLEMENT DEFICIENCY?
A
Neisseria meningitidis
17
Q
This pathogen causes BACTERIAL MENINGITIS in neonates and adults >50 and in IMMUNOCOMPROMISED, those with DM, Kidney/Liver disease and those taking anti-TNF-α inhibitors?
A
Listeria monocytogenes
18
Q
Outbreaks of BACTERIAL MENINGITIS after eating CLOE SLAW, SOFT CHEESES, RAW VEGETABLES, ALFALFA TABLETS, CANTALOUPES, HOT DOGS, HAMBURGERS are caused by?
A
Listeria monocytogenes
19
Q
What BACTERIAL MENINGITIS affects mostly NEONATES and as such UNIVERSAL SCREENING of ALL PREGNANT WOMEN at 35-37 weeks for RECTOVAGINAL colonization with this bacteria and treatment with prophylaxis of CARRIERS is recommended?
A
Streptococcus agaLACTiae
20
Q
Patients who’ve had HEAD TRAUMA or NEUROSURGERY and older/immunocompromised and STRONGYLOIDES infection are prone to BACTERIAL MENINGITIS with these pathogens?
A
Gram NEGATIVE (E.coli, Klebsiella, Pseudomonas and Serratia)
21
Q
Another cause of BACTERIAL MENINGITIS with symptoms SIMILAR to those caused by Streptococcus pneumoniae that most commonly affects adults with REMOTE h/o HEAD TRAUMA or CSF LEAKS and in IMMUNOCOMPROMISED predisposing to RECURRENT BACTERIAL MENINGITIS is?
A
Haemophilus influenzae
22
Q
RECURRENT VIRAL MENINGITIS (RECURRENT LYMPHOCYTIC Meningitis) is most commonly caused by?
A
HSV-2
23
Q
RECURRENT BACTERIAL MENINGITIS is most commonly caused by?
A
Haemophilus influenzae
24
Q
What pathogens are the most common cause of NOSOCOMIAL BACTERIAL MENINGITIS especially seen in patients s/p NEUROSURGICAL PROCEDURES/HEAD TRAUMA (placement of ventricular drains)?
A
Staphylococcus aureus, Pseudomonas aeruginosa and Propionibacterium acnes
25
Whom is the PNEUMOCOCCAL (Streptococcus pneumoniae) VACCINE recommended for in order to prevent MENINGITIS?
Those 11-18 years old and RE-VACCINATION for those at PROLONGED INCREASED RISK
26
How is BACTERIAL MENINGITIS diagnosed?
CSF EXAMINATION (glucose, protein, WBC's) with Gram STAIN and CULTURE (if negative, can do PCR)
27
When a patient is suspected to have BACTERIAL MENINGITIS, what must be DONE IMMEDIATELY?
BLOOD Cultures and LUMBAR puncture for CSF analysis
28
Should a patient suspicious for MENINGITIS but also for a CNS MASS lesionundergo LUMBAR PUNCTURE EMERGENTLY?
NO!! (herniation and death) - do HEAD CT FIRST!!
29
What should be done FIRST when a patient with a suspected CNS MASS lesion OR IMMUNOCOMPROMISED with h/o CNS disease present with NEW-ONSET SEIZURES or AMS, FOCAL NEUROLOGIC DEFICITS or PAPILLEDEMA?
HEAD CT BEFORE Lumbar Puncture!!
30
A GLASGOW COMA SCALE score ≤11/15, AMS, POSTURING, IRREGULAR RESPIRATIONS and SEIZURE are all possible signs of what condition for which you MUST NOT EMERGNTLY perform a LUMBAR PUNCTURE?
IMPENDING BRAIN HERNIATION (do a HEAD CT first)
31
What is the NEXT step in treatment of a patient AFTER CSF and BLOOD cultures have been obtained in which BACTERIAL MENINGITIS is suspected?
EMPIRIC antibiotics + DEXAMETHASONE (does not work for ICH - use mannitol)
32
What is the NEXT step in treatment of a patient if CSF sampling is DELAYED or unattainable in which BACTERIAL MENINGITIS is suspected?
Obtain BLOOD cultures and START EMPIRIC antibiotics + DEXAMETHASONE (does not work for ICH - use mannitol)
33
What ADDITIONAL agent to EMPIRIC ANTIBIOTIC TREATMENT, when started in patients with suspected BACTERIAL MENINGITIS, has been shown to DECREASE MORTALITY and NEGATIVE NEUROLOGIC SEQUELAE?
DEXAMETHASONE (corticosteroids)
34
BECAUSE DEXAMETHASONE can interfere with adequate CSF levels of VANCOMYCIN when treating BACTERIAL MENINGITIS, what should be done?
INCREASE DOSE of VANCOMYCIN (check serum troughs for at least 15-20 µg/mL), do NOT stop dexamethasone
35
What is the RECOMMENDED ANTIBIOTIC REGIMEN for the treatment of BACTERIAL MENINGITIS with Streptococcus pneumoniae (the most COMMON cause for bacterial meningitis currently in the US)?
VANCOMYCIN + (cefoTAXIME/cefTRIAXONE) ("Vanco + 3 taxi")
36
What should be done if a patient does NOT improve as expected after having started the APPROPRIATE antibiotic treatment for BACTERIAL MENINGITIS?
REPEAT LUMBAR PUNCTURE in 36-48 HOURS to check for CSF sterility
37
What patients CAN be treated as OUTPATIENTS with IV antibiotics for BACTERIAL MENINGITIS?
1. Treated as INPATIENTS for >6 DAYS
2. NO FEVER for 24 HOURS
3. NO significant neurologic dysfunction (seizures, focal)
4. Clinically STABLE
5. Can tolerate PO FLUIDS
6. Has access to HOME NURSING to administer drugs
7. Compliance, SAFE environment, Physician availability
38
70% of patients who present with Streptococcus pneumonia MENINGITIS have what?
IMMUNOCOMPROMISED or have an underlying disorder (OTITIS MEDIA, SINUSITIS, PNA)
39
How should a patient be treated who is STRONGLY suspected to have BACTERIAL MENINGITIS however their CSF Gram STAIN is NEGATIVE?
EMPIRIC antibiotics + DEXAMETHASONE (does not work for ICH - use mannitol) - no targeted therapy as CSF Gram stain was negative
40
Should you STILL do a LUMBAR puncture in a patient suspected to have BACTERIAL MENINGITIS that initially presented with PAPILLEDEMA, AMS, IMMUNOCOMPROMISE w/CNS DISEASE, NEW-ONSET SEIZURES, was APPROPRIATELY started on EMPIRIC ANTIBIOTICS + DEXAMETHASONE AFTER BLOOD CULTURES were taken but had a NEGATIVE HEAD CT?
YES!! after the NEGATIVE HEAD CT
41
HOW do you treat a patient with COMMUNITY-ACQUIRED BACTERIAL MENINGITIS 1. AGED 2-50 2. >50 3. IMMUNOCOMPROMISED?
1. VANCOMYCIN + (cefoTAXIME/cefTRIAXONE)
2. 1 + AMPICILLIN
3. VANCOMYCIN + AMPICILLIN + cefEPIME/MEROPENEM
42
HOW do you treat NOSOCOMIAL BRAIN ABSCESS or BACTERIAL MENINGITIS in a patient with a basilar SKULL FRACTURE?
Same as for community-acquired bacterial meningitis - VANCOMYCIN + (cefoTAXIME/cefTRIAXONE)
43
HOW do you treat NOSOCOMIAL BACTERIAL MENINGITIS in a patient with s/p NEUROSURGERY/VENTRICULAR CATHETER?
VANCOMYCIN + cefTAZIDIME/cefePIME/MEROPENEM
44
What medication is NOT added to the treatment regimen for NOSOCOMIAL bacterial meningitis?
AMPICILLIN
45
Once CULTURES are POSITIVE, what is the TARGETED antibiotic therapy for treating Streptococcus pneumoniae MENINGITIS?
VANCOMYCIN + (cefoTAXIME/cefTRIAXONE)
46
Once CULTURES are POSITIVE, what is the TARGETED antibiotic therapy for treating EITHER Neisseria meningitidis or Haemophilus influenzae MENINGITIS?
cefoTAXIME/cefTRIAXONE (3rd gen cephalosporins)
47
Once CULTURES are POSITIVE, what is the TARGETED antibiotic therapy for treating Listeria monocytogenes MENINGITIS?
AMPICILLIN/PENICILLIN-G
48
A cephalosporin such as cefTAZIDIME (3rd gen)/cefePIME (4th gen) or AZTREONAM/MEROPENEM/CIPRO are used to TARGET treat what pathogen that can cause nosocomial meningitis?
Pseudomonas aeruginosa
49
MRSA or Staphylococcus epidermidis (nosocomial) - caused meningitis can be treated with what TARGETED antibiotic?
VANCOMYCIN
50
A patient with an infection of the MIDDLE EAR, MASTOID CELLS or PARANASAL SINUSES is at risk for what CNS condition that presents most commonly with HEADACHE?
BRAIN ABSCESS - MRI - (can also be from hematogenous spread from any chronic disease - lung, skin, osteomyelitis, cholecystitis, abdominal and endocarditis)
51
A patient who presents with the TRIAD of HA+FEVER+FOCAL NEUROLOGIC DEFICIT likely has?
BRAIN ABSCESS (do MRI)
52
What is the BEST diagnostic imaging modality for BRAIN abscess which can DIFFERENTIATE between abscess and solid mass?
BRAIN MRI
53
What should be done for ALL BRAIN ABSCESSES >2.5 cm?
Excised/Aspirated + EMPIRIC IV ANTIBIOTICS
54
What should be done in a patient with multiple BRAIN ABSCESSES or with ABSCESES
Aspirated, Cultured, START EMPIRIC IV ANTIBIOTICS (6-8 weeks)
55
What should be done in a patient with BRAIN ABSCESS with CEREBRAL EDEMA/MASS EFFECT?
Besides empiric IV antibiotics AFTER aspiration of abscess, ADD DEXAMETHASONE
56
How often and for how long should NEUROIMAGING be done after a patient has completed ANTIBIOTIC therapy for a BRAIN ABSCESS?
BIWEEKLY x 3 MONTHS
57
What disease can cause a CRANIAL SUBDURAL EMPYEMA that presents with rapidly progressive HA/MASS EFFECT and s best diagnosed by MRI?
PARANASAL SINUSITIS
58
What ANTIBIOTICS are used to treat a BRAIN ABSCESS caused by OTITIS MEDIA, MASTOIDITIS or SINUSITIS (most common causes)?
METRONIDAZOLE + cefoTAXIME/cefTRIAXONE (3rd gen)
59
How do you treat a BRAIN ABSCESS in the setting of ENDOCARDITIS?
VANCOMYCIN + GENTAMICIN
60
How do you treat BRAIN ABSCESS in the setting of DENTAL or PULMONARY INFECTION?
METRONIDAZOLE + PENICILLIN (add sulfonamide for pulm)
61
How is a CRANIAL SUBDURAL EMPYEMA that presents with rapidly progressive HA/MASS EFFECT and is best DIAGNOSED by MRI treated?
MEDICAL/SURGICAL EMERGENCY (craniotomy)!! EMPIRIC ANTIBIOTICS - VANCOMYCIN + METRONIDAZOLE + either 3-taxi/cefTAZIDIME
62
What is the most COMMON pathogen causing a SPINAL EPIDURAL ABSCESS, best DIAGNOSED by MRI (w/GADOLINIUM), that presents with FEVER, BACKACHE, FOCAL VERTEBRAL PAIN, NERVE ROOT PAIN (radiculopathy, paresthesias), SPINAL CORD DYSFUNCTION, PARAPLEGIA?
Staphylococcus aureus
63
How is a SPINAL CORD ABSCESS best DIAGNOSED by MRI (w/GADOLINIUM), that presents with FEVER, BACKACHE, FOCAL VERTEBRAL PAIN, NERVE ROOT PAIN (radiculopathy, paresthesias), SPINAL CORD DYSFUNCTION, PARAPLEGIA treated?
SURGICAL EMERGENCY!! (SURGICAL DECOMPRESSION/DRAINAGE within 24-26 HOURS + EMPIRIC ANTIBIOTICS - VANCOMYCIN + cefTAZIDIME/MEROPENEM
64
What is the RECOMMENDATION post SPINAL EPIDURAL ABSCESS treatment?
FREQUENT FOLLOW-UP to ensure complete resolution
65
When is SURGICAL DECOMPRESSION/DRAINAGE not required in the treatment of a SPINAL EPIDURAL ABSCESS?
In patients who have LOCALIZED PAIN/RADICULAR signs but NO SPINAL CORD DYSFUNCTION or PARAPLEGIA
66
What are the TWO (2) most COMMON pathogens involved in ENCEPHALITIS (AMS ≥24 HOURS) in the US?
HSV-2 and WEST-NILE VIRUS
67
A patient presenting with AMS ≥24 HOURS (decreased consciousness from mild confusion to coma), SEIZURES, FEVER, best DIAGNOSED by MRI and LUMBAR PUNCTURE with LYMPHOCYTIC CSF (viral picture) SHOULD ALWAYS BE TESTED for?
HSV (PCR) and WEST-NILE ENCEPHALITIS (IgM Ab's)
68
ALTHOUGH BOTH HSV-1 & 2 can cause these, WHICH HSV COMMONLY causes MENINGITIS and WHICH COMMONLY causes ENCEPHALITIS?
MENINGITIS - HSV-2
| ENCEPHALITIS - HSV-1
69
ENCEPHALITIS in the VERY YOUNG/OLD that involves the TEMPORAL LOBES is caused by what pathogen?
HSV (usually 1) - reactivation - diagnose with PCR and treat with IV ACYCLOVIR
70
TEMPORAL LOBE HEMORRHAGIC NECROSIS occurs if this condition is not recognized and treated right away?
HSV (1) ENCEPHALITIS - diagnose with PCR and treat with IV ACYCLOVIR
71
MRI demonstrating TEMPORAL LOBE INFLAMMATION and EEG demonstrating "periodic lateralizing epileptiform discharges localizing to the TEMPORAL LOBES" in a patient with AMS ≥24 HOURS with FEVER is most likely?
HSV (1) ENCEPHALITIS - diagnose with PCR and treat with IV ACYCLOVIR
72
How is HSV ENCEPHALITIS treated?
IV ACYCLOVIR (14-21 DAYS)
73
What if you STRONGLY suspect HSV ENCEPHALITIS in a patient whose PCR is negative, what do you do?
REPEAT HSV PCR on a second CSF sample 3-7 days after the FIRST LUMBAR PUNCTURE or TREAT with FULL COURSE of ACYCLOVIR (14-21 DAYS)
74
How is West-Nile Encephalitis SPREAD?
Culex MOSQUITO (late summer, early fall)
75
A patient >50 years old presents with c/o a self-limited febrile illness associated with fatigue, RASH, HA, ANOREXIA, BACK PAIN and myalgia and develops symptoms of MENINGITIS, ENCEPHALITIS and MYELITIS with FOCAL WEAKNESS that can progress to ACUTE FLACCID PARALYSIS and RESPIRATORY FAILURE with NORMAL MRI of brain and CSF shows predominantly a LYMPHOCYTOSIS however also NEUTROPHILS!?
West-Nile Encephalitis
76
How is West-Nile Encephalitis DIAGNOSED?
IgM Ab (PCR is NOT EFFECTIVE)
77
How is West-Nile Encephalitis treated?
SUPPORTIVELY ONLY
78
Progressive neurological impairment caused by "transmissible proteins" in the ABSENCE of CSF findings and the presence of SPONGIFORM changes on neuropathologic examination indicate what?
PRION DISEASE (CJD and variant CJD)
79
A patient is bit by an animal and experiences PARESTHESIAS at the site of the bite, is AGITATED and has INVOLUNTARY NECK CONTRACTIONS when DRINKING or THINKING about WATER (HYDROPHOBIA), BRAIN SWELLING and AUTONOMIC INSTABILITY, diagnosed by SEROLOGY or SALIVA PCR?
RABIES (treatment is SUPPORTIVE ONLY)
80
SIADH is seen in this particular type of VIRAL ENCEPHALITIS?
St. Louis Encephalitis
81
Patients on IMMUNOSUPPRESSIVE therapy that develop Progressive Multifocal Leukoencephalopathy (PML) due to JC-Virus should have what done?
Decrease or stop immunosuppression (treat with ART if AIDS)
82
An older patient 50-70 presents with PSYCHIATRIC MANIFESTATIONS, RAPID COGNITIVE DECLINE or MOTOR DYSFUNCTION (MYOCLONUS) with median survival after diagnosis of 5 MONTHS?
Creutzfeldt-Jakob Disease (CJD)
83
What if ANYTHING is seen in the CSF of CJD patients?
Elevated TOTAL PROTEIN level (14-3-3 protein)
84
A 65 yo patient presents with MYOCLONUS and RAPIDLY PROGRESSIVE DEMENTIA, mildly elevated CSF protein levels (14-3-3 protein) and EEG shows a 1-2 Hz PERIODIC SHARP-WAVE PATTERN, MRI shows areas of FOCAL CORTICAL HYPERINTENSITY, what is the likely diagnosis?
Creutzfeldt-Jakob Disease
85
A form of CJD that develops in YOUNG patients (UK) mean age of 29, with DELAYED onset of DEMENTIA and SLOW disease PROGRESSION and HEAVY CONCENTRATIONS of AMYLOID PLAQUE in CEREBRUM/CEREBELLUM and MRI characteristic for PULVINAR nuclei hyperintensity?
VARIANT CJD
86
Group A β-hemolytic streptococci and Staphylococcus aureus are the MOST COMMON organisms to cause these infections?
SKIN and soft-tissue
87
When there is a SKIN finding of LYMPHANGITIS (inflammation/infection of lymphatic channels) and a "peau d'orange" appearance, this indicates a SKIN or SOFT-TISSUE infection with what pathogen?
Group A β-hemolytic streptococci
88
When there is an ABSCESS or DRAINAGE is seen from a wound or PENETRATING TRAUMA, the most likely infective pathogen is what?
Staphylococcus aureus
89
ERYSIPELAS (superficial infection of the UPPER DERMIS with TENDER, WARM, ERYTHEMATOUS plaques with WELL-DEMARCATED/INDURATED BORDERS and ASSOCIATED EDEMA - UE, LE and FACE and FEVER) is caused by?
Group A β-hemolytic streptococci
90
What infection of the SKIN involves the DEEP DERMIS and SUBCUTANEOUS FAT that is NOT WELL DEMARCATED because it SPREADS?
CELLULITIS
91
What infection of the SKIN involves the SUPERFICIAL UPPER DERMIS which is WELL DEMARCATED?
ERYSIPELAS (Group A β-hemolytic streptococci)
92
What pathogen is the causative agent in CELLULITIS when FURUNCLES, CARBUNCLES or ABSCESSES are present?
Staphylococcus aureus
93
Due to POOR UTILITY, in what patients should BLOOD cultures be taken when presenting with SKIN infections?
Those who appear TOXIC or IMMUNOCOMPROMISED
94
If a case of CELLULITIS is DIFFUSE and non-traumatic caused with non-diagnostic cultures, what is the most likely causative pathogen and how is it treated?
Group A β-hemolytic streptococci
| TREAT - β-lactam antibiotics (meropenem, aztreonam)
95
If the CELLULITIS is PURULENT, what is the likely causative pathogen and how is it treated?
Staphylococcus aureus
| TREAT to include MRSA (outpatient) - TMP-SMX or DOXYCYCLINE (can also use clindamycin and linezolid)
96
This pathogen causes CELLULITIS with minor skin trauma when exposed to LAKES, STREAMS, RIVERS and LEECHES?
Aeromonas hyrophila
97
This pathogen causes CELLULITIS with HEMMORRHAGIC BULLAE when exposed to SALT WATER or RAW SEAFOOD?
Vibrio
98
This pathogen causes CELLULITIS of the HAND OR ARM when handling SALTWATER/MARINE LIFE, FISH, SHELLFISH, POULTY or other MEAT
Erysipelothrix
99
This pathogen causes CELLULITIS after a CAT scratch/bite?
Pasteurella multocida
100
This pathogen causes CELLULITIS and SEPSIS in patients with ASPLENIA when exposed to DOGS?
Capnocynthophaga CANImorsus
101
This pathogen causes an EDEMATOUS, PRURITIC LESION with CENTRAL ESCHAR when exposed to this BIOTERRORISM substance?
Bacillus anthracis
102
This pathogen causes an ULCERATIVE LESION with CENTRAL ESCHAR AND LOCALIZED TENDER LYMPHADENOPATHY after CONTACT/BITE by CATS, TICKS, RABBITS "Hunter's Disease"?
Francisella tularensis
103
This pathogen causes a TRAUMA-ASSOCIATED lesion (scraping of hand) when cleaning FRESH/SALTWATER AQUARIUMS/SWIMMING POOLS and involves HAND/ARM with PAPULAR LESIONS that ULCERATE with ASCENDING LYMPHATIC SPREAD?
Mycobacterium marinum
104
This COMMUNITY-ACQUIRED pathogen infects YOUNG, HEALTHY people (athletes, inmates, homosexuals, children in daycare, IVDA, homeless and military) causing leukocyte destruction, tissue necrosis with PURULENT and SOFT-TISSUE infections?
Community-Acquired Methicillin Resistant Staphylococcus Aureus (CA-MRSA)
105
How are CUTANEOUS ABSCESSES treated?
Incision and Drainage ± ANTIBIOTICS
106
What are the indications for treatment of a CUTANEOUS ABSCESS that has been INCISED & DRAINED with ANTIBIOTICS?
1. VERY young/old
2. Multiple abscesses, Systemic illness, co-mornidities, Immunosuppression
3. Quickly progressing infection associated w/CELLULITIS
4. Located on FACE, GENITALS or HANDS
107
When an OUTPATIENT presents with PURULENT CELLULITIS, what do you treat for and how?
1. Treat for CA-MRSA
| 2. Empiric ORAL Antibiotics (TMP-SMX, Clindamycin, Doxycycline, Linezolid)
108
What IV antibiotic is most commonly used for MRSA?
VANCOMYCIN
109
What ORAL antibiotics are most commonly used for CA-MRSA/MRSA?
TMP-SMX, Clindamycin, Doxycycline, Linezolid
110
What are the ONLY two ORAL ANTIBIOTICS that provide GOOD coverage for Group A β-hemolytic streptococci?
Clindamycin and Linezolid
111
How should a patient presenting with COMPLICATED DEEP INFECTIONS, INFECTED BURNS/ULCERS and SURGICAL WOUND INFECTIONS be treated?
SURGICAL DERIDEMENT + BROAD SPECTRUM ANTIBIOTICS (that cover MRSA - VANCOMYCIN, LINEZOLID, DAPTOMYCIN, TELAVANCIN, CEFTAROLINE)
112
A Skin and Soft Tissue Infection (SSTI) that spreads BEYOND the epidermis, dermis and subcutaneous fat involving the underlying FASCIA and MUSCLE is called?
NECROTIZING FASCIITIS (LIFE-THREATENING)
TYPE-I (polymicrobial)
TYPE-II (Streptococcus pyogenes "flesh-eating")
113
Patients who are IMMUNOCOMPROMISED or have IRON OVERLOAD (cirrhosis) are at increased risk of NECROTIZING FASCIITIS with this SALTWATER (Gulf of Mexico) pathogen if in contact with TRAUMATIZED SKIN or eat RAW or UNDERCOOKED SHELLFISH?
Vibrio
114
A NECROTIZING FASCIITIS that presents with GAS GANGRENE involving MUSCLE and is associated with IVDA, TRAUMA, or recent SURGERY is caused by?
Clostridium perfringens
115
What patients and parts of the BODY are PREDISPOSED to NECROTIZING FASCIITIS?
Those with PRE-EXISTING SKIN INFECTIONS or TRAUMA (stasis/pressure ulcers, diabetic foot ulcers, surgical wounds) involving the LOWER then UPPER EXTREMITIES
116
When a patient has NECROTIZING FASCIITIS that is ASSOCIATED with TOXIC SHOCK SYNDROME, what pathogen is likely INVOLVED?
Streptococcus
117
What imaging modality can determine the depth of affected tissues in NECROTIZING FASCIITIS?
MRI
118
How would you treat NECROTIZING FASCIITIS?
SURGICAL DEBRIDEMENT with CULTURE of TISSUES and surgical re-evaluation in 24-36 hours + EMPIRIC ANTIBIOTICS that COVER MRSA (VANCOMYCIN/ DAPTOMYCIN/LINEZOLID + Piperacillin-Tazobactam/cefePIME+metronidazole or a CARBAPENEM (meropenem/imipenem)
119
How should NECROTIZING FASCIITIS be treated when it is due to TYPE-II (Streptococcus pyogenes) or Clostridium perfringens (with GAS GANGRENE)?
Treat with Clindamycin + Penicillin
120
What does a patient with EARLY NECROTIZING FASCIITIS present with?
SEVERE PAIN and EDEMA (later, with fever, crepitus, hypotension, AMS, tachycardia, leukocytosis, multi-organ dysfunction and elevated ESR, CRP, CK)
121
TOXIN-PRODUCING Staphylococci and Streptococci (Group A β-hemolytic - S.pyogenes) can cause this syndrome that manifests with FEVER, HYPOTENSION, RASH, MULTI-ORGAN INVOLVEMENT and is seen with PROLONGED use of TAMPONS, NASAL PACKING, SURGICAL WOUND INFECTIONS, OSTEOMYELITIS, IVDA, SKIN ULCERS/BURNS and NSAID USE?
Toxic Shock Syndrome (TSS)
122
Fever >39ºC (102ºF) + SBP 100,000 or Disorientation)?
Toxic Shock Syndrome (TSS)
123
What medication has been associated with development of TOXIC SHOCK SYNDROME?
NSAID's
124
How is TOXIC SHOCK SYNDROME treated?
REMOVAL of causative device, debridement and EMPIRIC ANTIBIOTIC THERAPY (VANCOMYCIN/DAPTOMYCIN/LINEZOLID + Piperacillin/Tazobactam or cefePIME+Metronidazole or Carbapenem + Cindamycin (inhibits toxin)
125
Besides appropriate surgical and antibiotic measures for NECROTIZING FASCIITIS and TOXIC SHOCK SYNDROME patients, if the causative pathogen is suspected to be Group A β-hemolytic streptococcus, what else should be done for at LEAST 24 HOURS?
CONTACT ISOLATION
126
What TWO (2) factors are IMPORTANT to find out about ALL animal bites?
LOCATION of bite and ANIMAL involved
127
Which animal bite/scratch is MORE likely to become infected, DOG or CAT?
CAT (Pasteurella multocida)
128
Can BOTH DOG and CAT bites/scratches be due to BOTH Pasteurella multocida and Capnocytophaga canimorsus?
YES
129
Although DOG bites are LESS likely to become infected than CAT bites, what is the danger of a DOG bite/scratch in an ASPLENIC or IMMUNOCOMPROMISED patient?
OVERWHELMING SEPSIS
130
When BONE involvement or Crepitus is present with an animal bite, what should also be done?
Imaging
131
What is the ANTIBIOTIC PROPHYLAXIS recommended for ANIMAL bites that are more than just superficial skin tears AFTER IRRIGATION and DEBRIDEMENT have been done?
Amoxicillin-Clavulanate (3-5 days), if PCN-allergic, can take Fluoroquinolone or Doxycycline or TMP-SMX+Clindamycin
132
When is HOSPITALIZATION needed after an ANIMAL bite/scratch, how do you treat?
INFECTED HAND, crush injuries, nerves or tendons, severe/deep infections, TREAT with IV ceFOXITIN/MEROPENEM or Fluoroquinolone+Clindamycin
133
HOW is CAT-SCRATCH DISEASE different than infection due to a CAT scratch/bite?
Cat-Scratch DISEASE - Bartonella henselae (self-limited papule/pustule with tender lymphadenopathy)
Infection due to Cat scratch/bite - Pasturella multocida (cellulitis)
134
A PAPULE/PUSTULE forms at the site of the scratch/bite of a CAT DAYS to WEEKS after the event with TENDER LYMPHADENOPATHY that DRAINS and is SELF-LIMITED but is not CELLULITIS and does NOT require antibiotics?
Cat-Scratch DISEASE (Bartonella Henselae) - can be treated with azithromycin if needed
135
As HUMAN bites (punches to mouth, nail biting) are polymicrobial, what specific microbe is found in MOST HUMAN BITES?
Eikenella corrodens (must also check for HIV, HCV, HSV, Syphilis)
136
When MUST special attention, follow-up, imaging and consultation with surgeon be done with HUMAN BITES?
When they involve the HAND (deeper, involving joints, tendons, bone, loss of function)
137
When should patients with HUMAN BITES be given OUTPATIENT PROPHYLACTIC antibiotics?
When NO evidence of INFECTION exists and NO CLENCHED-FIST injury (Amoxicillin-Clavulanate) 3-5 days
138
Which ANTIBIOTICS are GOOD BROAD-SPECTRUM agents for ANAEROBIC COVERAGE?
β-lactam(penicillins, cefoTAXIME - 3rd gen)/β-lactamase inhibitors (clavulanate, tazobactam, sulbactam), ceFOXITIN (2nd gen), CARBAPENEMS (meropenem, imipenem)
139
What antibiotics are used to treat CA-MRSA ORAL/IV?
ORAL - TMP-SMX, Clindamycin, Doxycycline, Linezolid, Minocycline
IV - Vancomycin, Daptomycin, Linezolid, Telavancin
140
A patient presents with a CLENCHED-FIST injury after punching another in the mouth, what should be done for TREATMENT?
ADMIT to HOSPITAL, X-RAYS, HAND-SURGEON consult, ANTIBIOTICS (Amoxicillin-Clavulanate - covers anaerobes + Vancomycin - covers MRSA)
141
What kind of a DIABETIC FOOT infection is purulent, inflamed, with pain, erythema, warmth and induration and superficial cellulitis no more than 2 cm around ulcer WITHOUT systemic findings (fever, tachycardia, hypotension, leukocytosis)?
MILDLY-infected diabetic foot ulcer
142
What kind of DIABETIC FOOT infection has cellulitis >2 cm around ulcer, has gangrene, lymphangitic spread, deep-tissue abscess involving bone, joint, tendon WITHOUT systemic findings (fever, tachycardia, hypotension, leukocytosis)?
MODERATELY-infected diabetic foot ulcer
143
When is a DIABETIC FOOT infection considered SEVERE?
When there are SYSTEMIC FINDINGS (fever, tachycardia, hypotension, leukcytosis) - LIMB-THREATENING infection
144
Should a DIABETIC FOOT ULCER be treated with ANTIBIOTICS in the absence of PURULENCE or INFLAMMATION (signs of infection)?
NO!!
145
How are MILD and MODERATE DIABETIC FOOT INFECTIONS treated?
ORAL, BROAD-SPECTRUM ANTIBIOTICS
146
How are SEVERE DIABETIC FOOT INFECTIONS treated?
SURGICAL EVALUATION and BROAD-SPECTRUM ANTIBIOTICS (arterial insufficiency and osteomyelitis) with OFF-LOADING of FOOT PRESSURE
147
Pneumonia acquired in a person who has NOT been recently hospitalized NOR living in a CARE-FACILITY s called what?
Community-Acquired Pneumonia (CAP)
148
What COMMUNITY-ACQUIRED PNEUMONIA is NOT associated with UNDERLYING LUNG DISEASE (COPD, Heat Disease, Chronic Bronchitis, DM) or SMOKING?
Legionella (inhalation of contaminated aerosolized WATER)
149
How is COMMUNITY-ACQUIRED PNEUMONIA (CAP) caused?
MICRO-aspiration of organisms that colonize the OROPHARYNX, usually during SLEEP, commonly in the ELDERLY (>65)
150
What is the MOST COMMON cause of DEATH from an INFECTIOUS DISEASE in the US?
Pneumonia
151
What are the THREE (3) most COMMON pathogens that cause COMMUNITY-ACQUIRED PNEUMONIA (CAP) in order of PREVALENCE?
1. STREPTOCOCCUS PNEUMONIAE (urine-Ag test)
2. Haemophilus influenzae
3. Moraxella catarrhalis
152
What is the most COMMON pathogen to cause COMMUNITY-ACQUIRED PNEUMONIA (CAP) in an ALCOHOLIC (due to aspiration)?
Klebsiella pneumoniae
153
What is the most COMMON pathogen to cause COMMUNITY-ACQUIRED PNEUMONIA (CAP) in a patient with UNDERLYING LUNG DISEASE (bronchiectasis, cystic fibrosis)?
Pseudomonas aeruginosa
154
What is the most COMMON pathogen to cause COMMUNITY-ACQUIRED PNEUMONIA (CAP) in a patient s/p RECENT INFLUENZA (flu) who is an IVDA, has lung CAVITATIONS, no risk factors for aspiration and in patients with recent h/o skin/soft-tissue infection?
Staphylococcus aureus (higher mortality, prolonged hospitalization)
155
What is the most COMMON pathogen to cause COMMUNITY-ACQUIRED PNEUMONIA (CAP) in a patient with a recent TRAVEL history especially in the SUMMER?
Legionella (legionella urine-Ag test)
156
Acute onset of PRODUCTIVE COUGH (purulent sputum), FEVER/CHILLS, PLEURITIC chest pain and DYSPNEA are characteristic of this disease?
PNEUMONIA
157
What is the most SENSITIVE (RULE OUT) SYMPTOM in the elderly (>65) for PNEUMONIA, as they may not present with the typical fever/chills, pleuritic chest pain or dyspnea symptoms due to underlying heart/lung disease, etc.?
TACHYPNEA (rapid breathing)
158
What is NECESSARY for diagnosis of PNEUMONIA as clinical findings ALONE are NOT sufficient?
CXR after positive FOCAL AUSCULTATORY findings with REPEAT CXR in 24-48 HOURS if initial is NEGATIVE
159
Which patients with COMMUNITY-ACQUIRED PNEUMONIA (CAP) SHOULD have BLOOD CULTURES (BEFORE ABX are started), SPUTUM Gm-STAIN & CULTURES (or endotrachial aspirate) as well as pneumococcal and legionella urine-Ag testing?
ALL hospitalized ICU-REQUIRING patients
160
When should a hospitalized patient with PNEUMONIA with PLEURAL EFFUSION undergo THORACENTESIS for drainage?
WHEN >50% of lung is opacified on UPRIGHT film or when >1 cm effusion on DECUBITUS film
161
COMMUNITY-ACQUIRED PNEUMONIA (CAP) with CAVITARY infiltrates suggest what pathogens?
CA-MRSA, TB
162
COMMUNITY-ACQUIRED PNEUMONIA (CAP) with cough >2 WEEKS with "WHOOP" or POST-COUGH VOMITING suggest what pathogen?
Bordetella pertussis
163
COMMUNITY-ACQUIRED PNEUMONIA (CAP) in a COPD or SMOKER can be caused by which pathogens?
ANY and ALL (H.influenza, S.pneumoniae, P.aeruginosa, Legionella, Moraxella, Chlamydophila)
164
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to BAT/BIRD droppings can be caused by what pathogen?
Histoplasma capsulatum
165
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to EXPOSURE to BIRDS can be caused by what pathogen?
Chlamydophilla psittaci (psitacossis) - "bird handler"
166
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to EXPOSURE to RABBITS be caused by what pathogen?
Francisella tularensis ("hunter's pneumonia")
167
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to FARM ANIMALS or PREGNANT CATS can be caused by what pathogen?
Coxiella burnetii ("cat got cox")
168
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to RAT/RODENT droppings can be caused by what pathogen?
Hantavirus
169
COMMUNITY-ACQUIRED PNEUMONIA (CAP) in a patient with LATE HIV INFECTION can be caused by what pathogens?
PNEUMOCYSTIS JIROVECII, CRYPTOCOCCUS, Histoplasma, Aspergillus, Mycobacteria, Pseudomonas aeruginosa
170
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to HOTELS/CRUISE SHIPS, can be caused by what pathogen?
Legionella
171
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to TRAVEL or LIVING in SOUTHWESTERN USA (Colorado, Nevada, California, Utah, Arizona, New Mexico) can be caused by what pathogen?
Coccidioides, Hantavirus
172
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to TRAVEL or LIVING in SOUTHEASTERN USA and EAST ASIA (Kentucky, Virginia, Tennessee, North & South Carolina, Mississippi, Alabama, Florida) can be caused by what pathogen?
Burholderia pseudomallei ("hold my drink, I may have mallaise")
173
COMMUNITY-ACQUIRED PNEUMONIA (CAP) in IVDA can be caused by what pathogen?
Staphylococcus aureus
174
COMMUNITY-ACQUIRED PNEUMONIA (CAP) in patients with BRONCHIECTASIS or CYSTIC FIBROSIS can be caused by what pathogen?
Pseudomonas aeruginosa
175
COMMUNITY-ACQUIRED PNEUMONIA (CAP) due to BIOTERRORISM can be caused by what pathogen?
Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis ("it's raining bunnies!!" -ah What's Up Doc!?)
176
How do you decide whether a patient with COMMUNITY-ACQUIRED PNEUMONIA (CAP) requires HOSPITALIZATION or can be treated as OUTPATIENT (with monitored pulse oximetry) (CURB-65 score)?
If they score ≥2/5 (age >65; AMS; BUN >20; RR >30; SBP
177
DELAYED ICU-ADMISSION for PNEUMONIA results in what?
50% RISK of MORTALITY
178
If THREE (3) or MORE of these (AMS, Hypothermia, RR >30, Hypotension, Multilobar Pulmonary Infiltrates, PO2/FiO2 ≤250, WBC 20) are found, what should be done with a patient with COMMUNITY-ACQUIRED PNEUMONIA (CAP)?
ADMIT to ICU!!
179
What ANTIBIOTIC do you use for OUTPATIENT treatment of a previously-HEALTHY patient with COMMUNITY-ACQUIRED PNEUMONIA (CAP)?
MACROLIDE (azithromycin/clarithromycin/eryhtromycin) OR doxycycline - a tetracycline
180
What ANTIBIOTIC do you use for OUTPATIENT treatment of a patient with RISKS (co-morbidities, elderly, alcoholic, daycare worker, h/o past drug resistance) with COMMUNITY-ACQUIRED PNEUMONIA (CAP)?
FLUOROQUINOLONE (moxifloxacin/levofloxacin) OR (amoxicillin/amoxicillin-clavulanate/ceFUROXIME + MACROLIDE) OR doxycycline
181
To decrease MORTALITY rates for HOSPITALIZED patients with COMMUNITY-ACQUIRED PNEUMONIA (CAP), HOW EARLY should appropriate antibiotics be started?
WITHIN 6 HOURS of presentation and giving the FIRST DOSE while patient is still in the ER
182
What are the β-lactam antibiotics?
Amoxicillin/Amoxicillin-Clavulanate, cefPODOXIME (3r gen), ceFUROXIME (2nd gen)
183
What is the BEST INPATIENT (ICU or FLOOR) ANTIBIOTIC strategy for managing COMMUNITY-ACQUIRED PNEUMONIA (CAP)?
1. β-lactam + MACROLIDE/FLUOROQUINOLONE (Amoxicillin-Clavulanate + Azithromycin/Moxifloxacin)
2. If RISK for CA-MRSA, add Vancomycin/Linezolid
3. If RISK for Pseudomonas, make sure β-lactam covers (cefePIME/IMIPENEM/MEROPENEM/piperacillin-tazobactam)
184
What are the β-lactams that cover PSEUDOMONAS?
cefePIME, IMIPENEM/MEROPENEM, piperacillin-tazobactam
185
When can a HOSPITALIZED patient with COMMUNITY-ACQUIRED PNEUMONIA (CAP) be discharged?
When STABLE AND has been changed to ORAL antibiotic therapy
186
What vaccinations should HOSPITALIZED patients receive DURING their hospitalization for COMMUNITY-ACQUIRED PNEUMONIA (CAP)?
Pneumococcal and Influenza Vaccines
187
If a HOSPITALIZED pt treated for COMMUNITY-ACQUIRED PNEUMONIA (CAP) initially improves but then RELAPSES or has PERSISTENT FEVER, what should be suspected?
Pleural EFFUSION/EMPYEMA (check with CXR) or alternate diagnosis
188
What should be done as part of a FOLLOW-UP of patients >40 years old OR are SMOKERS, who were treated for COMMUNITY-ACQUIRED PNEUMONIA (CAP)?
CXR 6-8 WEEKS after treatment (NOT for others)
189
Ixodes scapularis TICK, Borrelia burgdorferi (spirochete)?
LYME disease
190
When does ERYTHEMA MIGRANS occur following an Ixodes scapularis tick bite?
1-2 WEEKS (in 70-80% of patients)
191
A patient mentions a tick bite 8-12 weeks ago and now has a FEBRILE illness with Myalgia, HA, Fatigue and Lymphadenopathy, and MULTIPLE (not one) Erythema Migrans lesions, what do they likely have?
LYME disease (late) - Heart Block, Bell Palsy (unilateral or B/L), Aseptic Meningitis and Radiculopathy
192
How is LYME disease diagnosed?
ELISA w/Western Blot for confirmation
193
What is the ANTIBIOTIC treatment of LYME disease?
DOXYCYCLINE (or Amoxicillin/ceFUROXIME/cefTRIAXONE)
194
How long do you treat LYME disease if it does NOT cause MENINGITIS/ENCHEPHALOPATHY, HEART INVOLVEMENT or ARTHRITIS? If it does?
1. 14-21 DAYS
| 2. Up to 28 DAYS
195
How is POST-LYME Disease Syndrome (HA, Arthralgia, Fatigue) treated?
SUPPORTIVELY, NO Antibiotics
196
What TICK/ANIMAL vector causes Rocky Mountain Spotted Fever?
DOG Tick (Rickettsia rickettsii)
197
What joint is COMMONLY affected by LYME ARTHRITIS (late LYME disease) and can recur MONTHS to YEARS after SPONTANEOUS improvement in the SAME or OTHER joint?
KNEE
198
For what STAGES of LYME disease is LABORATORY CONFIRMATION REQUIRED (ELISA with Western Blot)?
LATE stages (all stages but the early stage)
199
What is seen in the CSF of NEUROLOGICALLY-AFFECTED (meningitis, encephalitis, encehalomyelitis) LYME Disease patients?
INCREASED WBC's, POSITIVE Ab's and PCR
200
How long will Borrelia burgdorferi Ab's stay positive?
INDEFINITELY (so serial serologic testing does nothing)
201
When should you TREAT a patient who has been BITTEN by an Ixodes scapularis tick?
ONLY after they developed Erythema Migrans RASH or other SYMPTOMS
202
Tick-borne illness also transmitted by the Ixodes tick (as in LYME disease) and when symptomatic, can range from a self-limited FEBRILE ILLNESS to FULMINANT MULTI-ORGAN FAILURE and DEATH?
Babesiosis (Babesia microti)
203
Tick-borne illness that causes HEMOLYSIS, ACUTE KIDNEY INJURY, DIC, HF, HEPATO/SPLENOmegaly and JAUNDICE (much more severe in asplenic or older patients, immunocompromised, HIV)?
Babesiosis
204
Why does HEMOLYSIS present with MACROCYTIC anemia?
Because of the INCREASED number of RETICULOCYTES who are LARGE
205
How is BABESIOSIS diagnosed?
PCR
206
How is BABESIOSIS treated in SYMPTOMATIC patients with CONFIRMED disease AND ASYMPTOMATIC patients with PERSISTENT PARASITES >3 MONTHS?
ATOVAQUONE + AZITHROMYCIN or QUININE + CLINDAMYCIN
| If >10% parasitemia, EXCHANGE TRANSFUSION as well
207
What can BABESIA be MISTAKEN for under MICROSCOPIC examination of RBC's?
Falciparum malaria
208
What disease MIMICS LYME disease (Erythema Migrans and other symptoms) HOWEVER has NO LATE STAGES, is NEGATIVE for Borrelia burgdorferi and is treated the SAME way (Doxycycline/Amoxicillin/Cefuroxime)?
Southern Tick-Associated Rash Illness
209
Ehrlichiosis and Anaplasmosis are SIMILAR tick-borne DISEASES, what are the differences?
Ehrlichiosis - rash is RARE (maculopapular/petechial), Meningoencephalitis
Anaplasmosis - rash is COMMON (maculopapular/petechial)
210
TWO (2) TICK-borne diseases that have LOW WBC's (lymphocytes), LOW PLATELETS, ELEVATED LFT's and CSF findings show ELEVATED LYMPHOCYTES and PROTEIN?
Ehrlichiosis and Anaplasmosis
211
The presence of BACTERIAL CLUSTERS inside of LEUKOCYTES (WBC's) on BUFFY COAT STAIN is suggestive of what TWO (2) tick-borne illnesses?
Ehrlichiosis and Anaplasmosis
212
How and when should Ehrlichiosis and Anaplasmosis be treated?
RIGHT AWAY!! with DOXYCYCINE
213
TICK-borne illness with SYMPTOMS occurring 2-14 DAYS after BITE, characteristic for FEVER, CONFUSION, GI symptoms and a PETECHIAL rash that starts on the WRISTS and ANKLES and progresses to TRUNK, EXTREMITIES, PALMS and SOLES SPARING THE FACE?
Rocky Mountain Spotted Fever
214
1. In what TICK-borne illneses do you have LOW WBC's, LOW PLATELETS and ELEVATED LFT's?
2. In what TICK-borne illness do you have NORMAL WBC's but LOW PLATELETS and ELEVATED LFT's
1. Ehrlichiosis/Anaplasmosis (all THREE are affected)
| 2. Rocky Mountain Spotted Fever (affects Platelets & LFT's)
215
How can you diagnose Rocky Mountain Spotted Fever?
Skin BIOPSY (quicker), Serologic testing (2-4 weeks after)
216
How is Rocky Mountain Spotted Fever Treated?
DOXYCYCLINE
217
Which is the ONLY TICK-borne illness in which DOXYCYCLINE is NOT USED for treatment?
BABESIOSIS (ATOVAQUONE + AZITHROMYCIN or QUININE + CLINDAMYCIN)
If >10% parasitemia, EXCHANGE TRANSFUSION as well
218
If Rocky Mountain Spotted Fever is SUSPECTED and DOXYCYCLINE is started but the SEROLOGICAL tests are NEGATIVE what do you do?
CONTINUE DOXYCYCLINE!!
219
What pathogens are associated with RECURRENT UTI's and those associated with URINARY TRACT ABNORMALITIES?
Gm neg (Proteus, Pseudomonas, Klebsiella, Enterobacter)
220
What pathogens are associated with UTI's in patients with DM or INDWELLING CATHETERS?
CANDIDA
221
What are UTI's considered when they occur in MEN or PREGNANT WOMEN?
COMPLICATED
222
What do the symptoms of URINARY INCONTINENCE and AMS signify in the ELDERLY?
UTI
223
≥10 WBC's/µL of clean-catch is diagnostic for?
UTI
224
A URINE DIP-STICK positive for Leukocyte Esterase (pyuria) and NITRITE (produced by bacteria) is suggestive of?
UTI
225
What patients NEED a URINE culture for their UTI's?
ALL PREGNANT WOMEN with asymptomatic BACTERURIA, COMPLICATED UTI's, PYELONEPHRITIS or RECURRENT UTI (not associated with sex) and for ALL patients BEFORE UROLOGIC MANIPULATION (cystoscopy)
226
When is a URINE CULTURE POSITIVE for UTI?
When there are ≥100,000 Colony Forming Units
227
When is a URINE CULTURE POSITIVE for UTI in SYMPTOMATIC patients (DYSURIA, PYURIA)?
When there are ≥100 Colony Forming Units
228
What is the result of a URINE CULTURE when there is MIXED BACTERIA from a SINGLE urine culture sample?
CONTAMINATION
229
When are US/CT needed in patients with UTI's?
For PYELONEPHRITIS (flank pain/fever ≥72 hours of ABX)
230
What are the two antibiotics that are FIRST-LINE agents for the treatment of UNCOMPLICATED UTI's in WOMEN?
DS TMP-SMX BID x 3 days OR Nitrofurantoin BID x 5 days (can use Fosfomycin as well)
231
What are the recommended antibiotics for treating UTI's in PREGNANT WOMEN?
Amoxicillin or Nitrofurantoin (no TMP-SMX)
232
After an INITIAL UTI, if ANOTHER UTI occurs with the SAME PATHOGEN and WITHIN 2 WEEKS of competing the initial THERAPY, the second UTI is considered what?
RECURRENT (needs cultures)
233
The use of what should be avoided in sexually active women who develop UTI's?
Spermicides
234
When should a woman be considered for CONTINUOUS or POST-COITAL UTI PROPHYLAXIS (antibiotics)?
If ≥2 SYMPTOMATIC UTI's within 6 MONTHS or ≥3 in 12 MONTHS
235
What should a POST-MENOPAUSAL woman with recurrent UTI's be treated with PROPHYLACTICALLY?
Intravaginal ESTROGEN cream
236
What should be SUSPECTED and CHECKED for if RECURRENT UTI's due to PROTEUS occur?
NEPHROLITHIASIS
237
After a UTI, a patient p/w symptoms of FLANK PAIN radiating to the GOIN, with FEVER/CHILLS, N/V and UTI symptoms, what is the most likely diagnosis?
PYELONEPHRITIS
238
How would you treat PYELONEPHRITIS as an OUTPATIENT?
CULTURE urine, then start CIPROFLOXACIN or cefTRIAXONE 1 g IV x1 followed by PO Fluoroquinolones
239
What FLUOROQUINOLONE should NOT be used for the treatment of UTI's (complicated or uncomplicated)?
Moxifloxacin (good for PNA)
240
Which are the ONLY patients that REQUIRE screening for ASYMPTOMATIC BACTERURIA?
PREGNANT WOMEN and MEN/WOMEN undergoing INVASIVE UROLOGICAL PROCEDURES
241
A man develops a SUDDEN FEBRILE ILLNESS with chills and LOW BACK PAIN or PERINEAL PAIN with SYMPTOMS of a UTI with TENDERNESS on digital rectal exam?
ACUTE PROSTATITIS
242
TENDER digital rectal exam in a MAN with PYURIA and BACTERURIA most likely suggests what? How do you treat?
4-6 WEEKS with either
1. ACUTE PROSTATITIS
2. TMP-SMX or CIPRO/LEVOFLOXACIN
243
What are the TWO (2) most commonly-used tests for TB?
PPD (Mantoux) and INTERFERON-γ release assay
244
Localized scarring of the pulmonary parenchyma at the APICES of the lungs or SUPERIOR segment of the lower lobes and lymph nodes (Ghon complex) are suggestive of what disease?
LATENT TB (not contagious)
245
When do patients develop ACTIVE TB?
10% of those INFECTED either from the PRIMARY infection (unlikely with normal immune system) or REACTIVATION of LATENT TB ESPECIALLY IMMUNOCOMPROMISED (HIV, DM, CKD, Malnutrition, Cancer or MEDS - STEROIDS, anti-TNF-α Inhibitors)
246
FEVER, NIGHT-SWEATS, PRODUCTIVE COUGH with BLOOD/PURULENT, CHEST PAIN, WEIGHT LOSS, ANOREXIA?
Active TB infection
247
Why do we test with for TB with PPD or INTERFERON-γ release assays?
Because PEOPLE exposed to TB will MOSTLY be ASYMPTOMATIC but will have LATENT TB of witch 10% will develop ACTIVE TB
248
Can PPD (Mantoux) or INTERFERON-γ release assay distinguish between LATENT or ACTIVE TB?
NO
249
What should be done for a patient presenting with SUSPECTED ACTIVE TB?
SKIN test with either PPD (Mantoux) or INTERFERON-γ release assay, CXR, Acid-Fast STAINS and CULTURES
250
What is measured 48-72 HOURS after a PPD (Mantoux) skin test?
The diameter (if any) of the INDURATION (not erythema)
251
What should be done for IMMUNOCOMPROMISED patients and those with HIV if they are CLOSE CONTACTS of persons with ACTIVE TB?
TREAT for LATENT TB (once active TB is excluded) REGARDLESS of the PPD/INTERFERON-γ release assay results
252
How should you interpret the RESULT of a PPD test for a patient who received a BCG vaccine?
NO DIFFERENT THAN A patient who NEVER DID unless the BCG vaccine was very recent
253
What does it mean when a patient received a PPD test and 48-72 hours later its NEGATIVE but SEVERAL WEEKS later it becomes POSITIVE?
"BOOSTER EFFECT" a TRUE POSITIVE RESULT (represents a VERY remote exposure to TB - therefore Latent TB) - happens in patients with BCG vaccines
254
When should INTERFERON-γ release assay be used instead of the PPD (Mantoux)?
1. Pt received BCG vaccine or for cancer treatment
| 2. For NON-COMPLIANT patients (IVDA, Homeless)
255
Which test for TB exposure requires a follow-up for determining the result?
PPD (Mantoux)
256
How LARGE must the PPD induration diameter be for a patient with HIV, Recent Contact of a person with ACTIVE TB, CXR suggestive of OLD TB, ORGAN TRANSPLANTS, IMMUNOCOMPROMISED and those receiving >15 mg/day of PREDNISONE >4 weeks to be considered POSITIVE for latent TB and require TREATMENT?
≥5 mm
257
How LARGE must the PPD induration diameter be for a patient who arrived from a PREVALENT COUNTRY
≥10 mm
258
How LARGE must the PPD induration diameter be for a patient with NO RISK FACTORS for TB be to be considered POSITIVE for latent TB and require TREATMENT?
≥15 mm
259
Do the presence of positive acid-fast stains or caseating granulomas sufficient for diagnosis of ACTIVE TB?
NO
260
What is REQUIRED for the diagnosis of ACTIVE TB, even when acid-fast stains are NEGATIVE?
Positive SPUTUM CULTURES (take 3-5 weeks) or positive Nucleic Acid Amplification (NAA) of acid-fast positive stains
261
What does the CSF show in a patient with TB Meningitis?
LYPMHOCYTOSIS with LOW GLUCOSE and ELEVATED PROTEIN
262
What can EXUDATIVE pleural effusions in a patient with SUSPECTED ACTIVE TB be tested for in order to get diagnosis?
ADENOSINE DEAMINASE
263
What should be done in a patient with SUSPECTED ACTIVE TB but SPUTUM CULTURES are NEGATIVE?
BRONCHOSCOPY with LAVAGE and BIOPSY
264
What is the treatment for a patient with LATENT TB infection (positive PPD/INTERFERON-γ release assay) but NO ACTIVE TB?
9 MONTHS of INH (with Pyridoxine (vitamin B6) - to avoid peripheral neuropathy)
OR RIFAMPIN x 4 MONTHS
OR RIFAMPIN + INH (with Pyridoxine (vitamin B6) - to avoid peripheral neuropathy) once WEEKLY x 3 MONTHS
265
What is the treatment for a patient with ACTIVE TB?
2-PAHSE treatment:
1. 2 MONTHS of R.E.P.I. (Rifampin + Ethambutol + Pyrazinamide + INH)
2. 7 MONTHS of R.I. (Rifampin + INH) IF had CAVITARY lung disease at diagnosis and STILL positive sputum cultures, if NOT, then only 4 MONTHS
266
What MUST be done if a patient on ACTIVE TB treatment during the 1st PHASE (2 MONTHS of R.E.P.I.) has an interruption of ≥2 WEEKS without the meds?
RESTART REGIMEN FROM BEGINNING
267
How are TB MENINGITIS and TB PERICARDITIS treated?
INITIAL COURSE of STEROIDS, then 9-12 MONTHS of meds
268
What can the drug RIFAMPIN (RIF) do to OTHER drugs taken with it like WARFARIN?
POTENT INDUCERS of the CYT P-450 hepatic enzyme system therefore SIGNIFICANTLY REDUCING OTHER drug concentrations such as WARFARIN
269
Once ACTIVE TB diagnosis has been ESTABLISHED what TESTS must be done BEFORE starting TREATMENT?
LFT's, BUN/Cr, HEP B & C, Platelets, Color Vision and Visual Acuity testing
270
How are HIV patients with TB treated?
The same way/length of time, however TB treatment should start AT the same time or BEFORE HIV treatment is started if diagnosed at the same time
271
What DRUGS is Multi-Drug Resistant (MDR) TB resistant to?
Rifampin and INH (R.I.)
272
What DRUGS is Extensively-Drug Resistant (XDR) TB resistant to?
Rifampin and INH (R.I.) as well as Fluoroquinolones and others (-"mycins")
273
Why should the BCG vaccine NOT be given to IMMUNOCOMPROMISED patients?
BECAUSE it is a LIVE vaccine
274
What does the BCG vaccine protective against?
DISSEMINATED TB and TB MENINGITIS in CHILDREN
275
LUPUS-like syndrome and Peripheral Neuropathy are adverse effects seen with this TB drug?
INH (so add Pyridoxine - vitamin B6)
276
What adverse effects are common to all FIRST-LINE TB DRUGS (R.E.P.I.)?
Hepatitis and RASH
277
What can be used instead of the FIRST-LINE drug RIFAMPIN for treating TB which are SIMILAR in function?
RIFabutin, RIFapentine
278
What TB drug causes the adverse effect of OPTIC NEURITIS?
Ethambutol (requires baseline and periodic visual acuity tests and color vision)
279
What TB drugs require DOSE adjustments or are CONTRAINDICATED when taken with HIV drugs?
RIFampin, RIFabutin, RIFapentine (CONTRAINDICATED)
280
What TB medication colors body fluids ORANGE?
RIFAMPIN
281
What adverse effects do the -"mycin" (aminoglycosides) cause?
Auditory/Kidney TOXICITY
282
Second-LINE TB drug CYCLOSERINE causes what Adverse Effects?
Psychosis, Convulsions, Depression, HA (give pyridoxine)
283
YOUNG/OLD patients with UNDERLYING LUNG DISEASES, ESOPHAGEAL MOTILITY DISORDERS, SLENDER BODY HABITUS, PECTUS EXCAVATUM, SCOLIOSIS, MVP are SUSCEPTIBLE to these NON-TB MYCOBACTERIAL DISEASES?
Mycobacterium avium complex (MAC) and Mycobacterium kansasii
284
Inhaling the AEROSOLIZED microorganisms from SOIL/WATER (hot tubs) causes this non-TB mycobacterial disease that presents LIKE TB with LYMPHADENITIS of the HEAD and NECK and is seen VERY COMMONLY in HIV patients with CD4
Mycobacterium avium complex (MAC)
285
How do you treat Mycobacterium avium complex (MAC)?
R.E. + Macrolide (Azithromycin/Clarithromycin)
286
This RARE mycobacterial infection and is found in URBAN MUNICIPAL WATER SUPPLIES, with symptoms similar to TB?
Mycobacterium kansasii
287
How is Mycobacterium kansasii treated?
18 MONTHS of R.E.I. (with NEGATIVE sputum CULTURES for at LEAST 12 MONTHS)
288
A set of Rapidly Growing Mycobacteria (RGM) - fortuitum, chelonae and abscessus - are RARE but can cause infcetion usually from TAP WATER in health-care associated environments and require WHAT BEFORE STARTING THERAPY?
In-VITRO susceptibility testing
289
Can CANDIDA be a contaminant when obtained from a BLOOD culture?
NO!! (likely catheter-related disseminated infection)
290
Patients exposed to Broad-Spectrum ABX, Chemotherapy, Immunosuppressive drugs, Catheters and Prolonged Hospitalization/ICU are all at risk for INFECTION with this pathogen?
Systemic Candida
291
What are the CHARACTERISTIC manifestations of a SYSTEMIC CANDIDAL infection?
EYE (white retinal exudates) and SKIN (white on erythematous base) - can also affect kidneys, liver, spleen, brain
292
How do you diagnose SYSTEMIC CANDIDIASIS?
BLOOD CULTURE or ORGAN BIOPSY (if affects organs like kidney, liver, spleen, brain)
293
For NON-NEUTROPENIC patients, what is the recommended treatment for SYSTEMIC CANDIDA?
FLUCONAZOLE - if less critically ill (or caspofungin for critically ill) as well as removing catheters
294
Candida parapsilosis is associated with what candidal infection?
Catheter-related
295
For NEUTROPENIC patients, what is the recommended treatment for SYSTEMIC CANDIDA?
Caspofungin, VORICONAZOLE (not fluconazole) or Amphotericin B (catheters do not require removal in these patients)
296
VORICONAZOLE (especially in transplant patients) is associated with what malignancy?
Cutaneous Squamous Cell Carcinoma
297
How are SYMPTOMATIC CYSTITIS (UTI) or PYELONEPHRITIS with Candida treated?
Fluconazole
298
1. Septate-Hypahe at ACUTE angels on SILVER STAIN?
2. Broad, irregular, RIBBON-LIKE Hyphae without septations that exhibit broad RIGHT-ANGLE branching?
3. Spaghetti and Meatballs?
4. BROAD-BASED budding organisms in KOH prep?
1. Aspergillus - VORICONAZOLE
2. Mucormycosis - AMPHOTERICIN B
3. Tinea Versicolor (Malassezia furfur)
4. Blastomycosis - ITRACONAZOLE/AMPHOTERICIN B
299
What type of Aspergillus infection are CHRONIC ASTHMA and CYSTIC FIBROSIS sufferers are risk for?
Allergic Bronchopulmonary Aspergillosis
300
Eosinophilia, elevated serum IgE levels, central brinchiectasis, "Fleeting Pulmonary Infiltrates" on CXR in the setting of ASTHMA or CYSTIC Fibrosis?
Allergic Bronchopulmonary Aspergillosis
301
How is Allergic Bronchopulmonary Aspergillosis treated?
Oral corticosteroids and ITRACONAZOLE
302
A patient presents with cough, life-threatening HEMOPTYSIS, dyspnea, WEIGHT LOSS, fatigue, fever and chest pain with imaging showing a ROUNDED MASS in a pre-existing pulmonary cavity or cyst or in area of devitalized lung? How do you treat?
Aspergilloma - treat with SURGERY
303
What patients can develop invasive sinopulmonary aspergillosis and disseminated disease?
IMMUNOCOMPROMISED
304
HIV patient presents with fever, cough, chest pain, hemoptysis and WEDGE-SHAPED INFARCTS are seen on LUNG X-RAYS and CT shows a TARGET LESION (necrotic center surrounded by a ring of hemorrhage "halo"), can also go to the brain and cause ABSCESS?
Invasive SinoPulmonary Aspergillosis
305
How is Invasive Aspergillosis DIAGNOSED and how is it treated?
DIAGNOSED - by biopsy only (blood cultures are negative)
| TREATED - VORICONAZOLE, amphotericin B, caspofungin
306
What fungus appears as "Spaghetti and Meatballs" when examined histologically under the microscope?
Tinea Versicolor (Malassezia furfur or Pytosporum orbiculare)
307
Patients with HEMATOLOGIC MALIGNANCIES, IMMUNOSUPPRESSION, DM, BURNS, TRAUMA (with prolonged NEUTROPENIA) are at risk for infection with this fungal organism infecting the NASAL, SINUS PASSAGES and BRAIN?
MUCORMYCOSIS
308
A patient with DM or on CORTICOSTEROIDS or DEFEROXAMINE presents with HA, EPISTAXIS, PROPTOSIS, PERIORBITAL EDEMA, DECREASED VISION and examination of NOSE/PALATE shows BLACK, NECROTIC TISSUE?
MUCORMYCOSIS
309
How is MUCORMYCOSIS diagnosed and treated?
Diagnosed - Biopsy and Culture
| Treated - Surgical debridement AND AMPHOTERICIN B
310
IMMUNOCOMPROMISED patient presents with h/o cough and fever which progressed to MENINGITIS with symptoms of HA, AMS with MASS LESIONS seen on brain imaging. CSF and blood antigens are positive for this pathogen that appears CAPSULATED on INDIA INK?
CRYPTOCOCCOSIS
311
How is cutaneous CRYPTOCOCCOSIS treated? Disseminated disease? Organ Transplant recipients and those with CNS involvement?
1. Cutaneous - FLUCONAZOLE
2. Disseminated - AMPHOTERICIN B + FLUCYTOSINE followed by FLUCONAZOLE
3. Transplant recipients - LIFELONG THERAPY
4. CNS involvement - same as disseminated therapy + frequent Lumbar Punctures or VP-SHUNT
312
LUNG and SKIN infections with this organism that is endemic to the OHIO and MISSISSIPPI river valley, CANADA and Great Lakes and St. Lawrence River generally affect the IMMUNOCOMPROMISED, those with UNDERLYING LUNG DISEASE and show up as BROAD-BASED budding organisms on KOH prep?
BLASTOMYCOSIS
313
How is BLASTOMYCOSIS treated?
ITRACONAZOLE/AMPHOTERICIN B depending on severity
314
BROAD-BASED budding organisms on KOH prep?
BLASTOMYCOSIS
315
CAPSULATED organisms on INDIA INK?
CRYPTOCOCCOSIS
316
Infection with this FUNGUS can occur in the NORMAL patient as well as IMMUNOCOMPROMISED and like blastomycosis is also endemic to the OHIO and MISSISSIPPI river valleys causing GRANULOMATOUS, FIBROSING MEDIASTINITIS, BRONCOLITHIASIS and PULMONARY NODULES and is diagnosed by culture on SILVER STAIN (like Aspergillus)?
HISTOPLASMOSIS
317
What is the treatment for histoplasmosis?
FLUCONAZOLE/ketoconazole/itraconazole/AMPHOTERICIN B
318
A FUNGUS endemic to the DESERTS and infection present with PNA, FEVER and ERYTHEMA NODOSUM, diagnosed by culture with SPHERULES seen on SILVER STAIN and SEROLOGIC tests are used for the MENINGITIS form>
COCCIDIOIDOMYCOSIS
319
How long should therapy with FLUCONAZOLE be continued for in a patient with MENINGITIS caused by COCCIDIOIDOMYCOSIS?
LIFE-LONG (due to relapses)
320
While GARDENING, a PAPULE appeared on a patient's skin that later got ULCERATED with spread to the LYMPHATIC channels?
Sporotrichosis
321
How is SPOROTRICHOSIS diagnosed and treated?
Diagnosed - culture (macrophages with cigar-shaped yeast)
| Treated - ITRACONAZOLE
322
What happens if a woman with Chlamydia trachomatis infection does not get treated>
Can develop Pelvic Inflammatory Disease (PID), Ectopic Pregnancy and Infertility
323
Who should be ANNUALLY tested for Chlamydia trachomatis?
ALL sexually active women ≤25 and OLDER women with risk factors
324
When a WOMAN is found to be POSITIVE with Chlamydia trachomatis OR Neisseria gonorrhoeae, whom ALSO needs evaluation & treatment?
ALL SEXUAL PARTNERS in the last 60 DAYS
325
What is the MOST SENSITIVE (rules OUT disease) test for Chlamydia trachomatis AND Neisseria gonorrhoeae in WOMEN?
Nucleic Acid Amplification test "NAA" (endocervical/urethral swab or urine sample)
326
Intracellular Gram NEG DIPLOCOCCI on CERVICAL/URETHRAL smear?
Neisseria gonorrhoeae
327
This COMMON sexually-transmitted infection can also cause PHARYNGITIS with a FEBRILE ARTHRITIS-DERMATITIS syndrome and MIGRATORY POLYARTHRALGIA with RASH (necrotic vesicles on erythematous base?
Neisseria gonorrhoeae
328
Monoarticular SEPTIC arthritis in a sexually active patient?
Neisseria gonorrhoeae
329
How do you treat Chlamydia trachomatis AND Neisseria gonorrhoeae?
COMBO of cefTRIAXONE (250 mg IM x1 dose) + Azithromycin (1 g PO x1 dose) - "3-zits"
330
An ASCENDING infection of the URINARY tract is called?
| An ASCENDING infection of the GENITAL tract is called?
URINARY - Pyelonephritis
| GENITAL - Pelvic Inflammatory Disease (PID)
331
Untreated PID leads to what complications?
Fallopian tube scarring and infertility, ectopic pregnancy, tubo-ovarian abscess
332
Lower abdominal/Plevic pain and Cervical Motion Tenderness, Uterine tenderness and Adnexal tenderness in a sexually-active young woman with a mucopurulent cervical discharge suggests?
Pelvic Inflammatory Disease (PID) from Chlamydia or Gonorrhea
333
What women with PID require HOSPITAL admission?
PREGNANT, Poor outpatient treatment response, Suspected TUBO-OVARIAN Abscess or any other Surgical diagnosis, Systemic Toxicity and Inability to tolerate PO meds
334
Epididymitis is caused by Chlamydia and Gonorrhea in YOUNG, sexually active men, what is it caused by in older men?
UTI organisms (E.coli) in the setting of BPH and in GIVERS of anal sex
335
A man presents with UNILATERAL pain in the testicle with an enlarged, tender SPERMATIC cord and urine sample positive for UTI?
EPIDIDYMITIS (cefTRIAXONE + DOXYCYCLINE)Ho
336
SUDDEN-Onset of SEVERE testicular pain WITHOUT pyuria?
Testicular torsion - do US to assess flow and SURGERY!
337
cefTRIAXONE 250 mg IM x1 dose (or cefixime)?
GONORRHEA
338
AZITRHOMYCIN 1 g PO x1 dose (or doxycycline)?
CHLAMYDIA
339
How should DISSEMINATED Neisseria gonorrhoeae be treated (skin involvement, fever, etc.)?
1 g IM/IV cefTRIAXONE DAILY
340
How do you treat Pelvic Inflammatory Disease (PID)?
IV - cefoTETAN or ceFOXITIN + DOXYCYCLINE
| PO/IM - cefTRIAXONE + DOXYCYCLINE (like epididymitis)
341
Recurrent genital/perineal ulcers (MULTIPLE LESIONS AT VARIOUS STAGES ON AN ERYTHEMATOUS BASE) with CERVICITIS/URETHRITIS and TENDER INGUINAL LYMPHADENOPATHY seen in SYMPTOMATIC PRIMARY INFECTION with a PRODROME of BURNING/PRURITUS before appearance of ulcers are caused by what virus?
HSV-2 (diagnose by PCR)
342
This VIRUS most COMMONLY causes ORAL HERPES LESIONS and this one GENITAL HERPES LESIONS?
ORAL - HSV-1
| GENITAL - HSV-2
343
What DAILY HSV therapy has been shown to REDUCE HSV transmission between HETEROSEXUAL partners?
VALCYCLOVIR
344
How is HSV treated generally (PRIMARY, RECURRENT or SUPPRESSIVE)?
ACYCLOVIR (400 mg TID) - or famcyclovir/valcyclovir
345
ONE FIRM, PAINLESS ULCER with a RAISED, regular border AT the site of INFECTION (mouth, external genitals, perianal area, anal canal) and NON-TENDER INGUINAL LYMPHADENOPATHY?
PRIMARY Syphilis (SEROLOGIC TESTING - RPR)
346
A NON-PRURITIC, GENERALIZED RASH involving the PALMS and SOLES (silver-gray erosions with erythematous border) with SYSTEMIC symptoms?
SECONDARY Syphilis
347
A patient with a POSITIVE serologic tests for Syphilis but NO CLINICAL MANIFESTATIONS?
LATENT infection
348
Syphilis patients with NEUROLOGIC, OCULAR, CARDIOVASCULAR (aortitis) and GUMMAS (granuloma - soft, non-cancerous growth) should be checked HOW?
TERTIARY Syphilis, CHECK CSF if neurologic manifestations
349
How is Syphilis treated?
Benzathine PENICILLIN-G (ALL STAGES) - or DOXYCYCLINE if allergic
350
ALL patients diagnosed with SYPHILIS MUST ALSO be checked for what?
HIV (as well as ALL sexual partners)
351
When should PARTNERS of patients with ANY STAGE of Syphilis (except LATE-LATENT) also be treated even if serologic tests are NEGATIVE?
If exposed within the LAST 3 MONTHS (90 days)
352
Associated with CRACK-COCAINE, PROSTITUTES, this STI presents with SINGLE/MULTIPLE PAINFUL ERYTHEMATOUS PAPULES that become PUSTULAR and RUPTURE to for PAINFUL ULCERS with PAINFUL, ENLARGED UNILATERAL INGUINAL LYMPH NODES that suppurate and drain?
Chancroid (Haemophilus ducreyi) - "they do cry"
353
What must be excluded when testing for CHANCROID?
HSV (painful) and Syphilis (no pain)
354
How is CHANCROID (Haemophilus ducreyi) treated?
Azithromycin 1 g PO x1 dose, FOLLOW-UP visit in 1 WEEK
355
An STI mostly seen in HOMOSEXUAL MEN, caused by Chlamydia trachomatis (not cervicitis/urethritis) that presents with a PAINLESS PERINEAL ULCER that resolves spontaneously, with PAINFUL, UNILATERAL INGUINAL LYMPHADENOPATHY and PROCTITIS/PROCTOCOLITIS with FEVER/MALAISE diagnosed by Nucleic Acid Amplification (NAA)?
LYMPHOGRANULOMA VENERUM
356
How is LYMPHOGRANULOMA VENERUM treated?
DOXYCYCLINE (BID x 21 days)
357
HPV (6, 11)? (16, 18)?
6, 11 - Condylomata Acuminata (warts)
| 16, 18 - Cervical, Anal CANCER
358
Whom should receive the HPV Vaccine?
ALL MALES and FEMALES up to the age of 26
359
When should CONDYLOMATA ACUMINATA (HPV-genital warts) be treated?
If SYMPTOMATIC or COSMETIC
360
What are the MOST COMMON pathogens involved in OSTEOMYELITIS?
S.aureus (pseudomonas - IVDA, salmonella - sickle cell)
361
DULL PAIN, LOCAL erythema, warmth, edema and tenderness with possible SEPTIC ARTHRITIS or CHRONIC PAIN after PROSTHETIC JOINT and DRAINING SINUS TRACT?
OSTEOMYELITIS
362
What is the BEST imaging modality for OSTEOMYELITIS?
MRI or CT
363
Why are follow-up MRI's NOT done after treating OSTEOMYELITIS?
Because BONE MARROW EDEMA interferes with imaging
364
What MUST be done in ALL cases of OSTEOMYELITIS even though BEST results are only obtained when POSITIVE in ACUTE disease?
BLOOD CULTURES (if positive, can eliminate more extensive testing)
365
What is the GOLD standard for DIAGNOSIS of OSTEOMYELITIS?
BONE BIOPSY (microorganism inflammation and osteonecrosis)
366
Should CULTURES be obtained from wounds in OSTEOMYELITIS?
NO!! due to polymicrobial contamination
367
How should a patient with OSTEOMYELITIS be treated if NO CULTURE is available?
CHRONIC SUPPRESSIVE ANTIBIOTIC treatment
368
GAS in the soft tissues of a DIABETIC FOOT ULCER with crepitus, bullous formation, and skin color changes can suggest?
NECROTIZING FASCIITIS
369
HOW is OSTEOMYELITIS treated (AFTER BLOOD CULTURES/BIOPSY)?
CHRONIC (6-8 WEEKS after debridement) IV ANTIBIOTICS (Vancomycin + cefePIME/cefTRIAXONE)
(Piperacillin-Tazobactam/cefePIME+metronidazole or a CARBAPENEM (meropenem/imipenem can also be used)
370
When is PROLONGED (6 WEEKS) of antibiotics NOT necessary for the treatment of a diabetic foot ulcer with OSTEOMYELITIS?
If the affected BONE was surgically removed, completely
371
When OSTEOMYELITIS affects the LUMBAR SPINE (surgery, catheters, usually due to bacteremia), like other places, caused by S.aureus, how is it treated/diagnosed?
DIAGNOSED - needle biopsy
| TREATED - 6-8 WEEKS IV ANTIBIOTICS (Vancomycin + cefePIME/cefTRIAXONE) AFTER BLOOD CULTURES/BIOPSY
372
Does OSTEOMYELITIS of the SPINE require debridement?
Usually NOT
373
What serological studies are VERY HIGH in OSTEOMYELITIS?
ESR and CRP
374
1. Illness that lasts ≥3 WEEKS with a FEVER ≥38ºC (100.4ºF) WITHOUT a DIAGNOSIS after pt has spent at LEAST 3 DAYS in the HOSPITAL or had 2 OUTPATIENT VISITS?
2. FEVER ≥38ºC (100.4ºF) WITHOUT a DIAGNOSIS after pt has spent at LEAST 3 DAYS in the HOSPITAL with infection NOT present on ADMISSION?
1 & 2. Fever of UNKNOWN origin (FUO)
375
What does an FUO that initially responds to ANTIBIOTICS but then relapses suggest?
A possible occult ABSCESS (kidney, liver, spleen) or VERTEBRAL OSTEOMYELITIS
376
What is the HACEK group of pathogens?
Those that most COMMONLY cause infective ENDOCARDITIS (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
377
TB, Infective ENDOCARDITIS, INTA-ABDOMINAL/PELVIC ABSCESSES can cause what type of FEVER?
FUO
378
In patients with FUO that have INTERVALS ≥14 days WITHOUT FEVER, what should be considered?
HEREDITARY PERIODIC-FEVER SYNDROMES (hyper-IgD syndrome "HIDS", TNF receptor-1-associated periodic syndrome "TRAPS", Muckle-Wells syndrome and familial Mediterranean fever)
379
Should patients with FUO be treated with EMPIRIC ANTIBIOTICS ± STEROIDS?
NO!!
380
In how many patients with FUO is a diagnosis never found?
50%
381
When patients present with FREQUENT, MULTIPLE or PROLONGED infections with S.pneumoniae, Neisseria and H.influenzae, especially since childhood, what should be suspected?
PRIMARY IMMUNODEFICIENCY SYNDROMES
382
What is the most common PRIMARY IMMUNODEFICIENCY SYNDROME?
Selective IgA Deficiency (treated with antibiotic prophylaxis for chronic infections and by VACCINATIONS to prevent infections)
383
Recurrent URI, ATOPIC disorders, Autoimmune disorders, GI and UROGENITAL infections and may have SEVERE ANAPHYLACTIC reactions to IgG or BLOOD products?
Selective IgA Deficiency
384
What is found in up to 40% of patients with Selective IgA Deficiency?
Anti-IgA Ab's
385
A young patient
Common Variable Immune Deficiency (CVID)
386
Pt with IBD, Pernicious Anemia and Non-caseating granulomas of lymphoid and solid organs and NO response to vaccines?
Common Variable Immune Deficiency (CVID)
387
How is Common Variable Immune Deficiency (CVID) treated?
IVIgG (only use prophylactic antibiotics in those with chronic diseases - lung, etc.)
388
Deficiencies in COMPLEMENT (C1-inhibitor, C1, C2, C3, C4, factor H, factor I and properdin, C5, C6, C7, C8) predispose patients to infections with ENCAPSULATED organisms (S.pneumoniae, H.influenzae, Neisseria, Group B Strep, Kelbsiella, Salmonella). Which is the MOST COMMON AUTOIMMUNE DISEASE in patients with COMPLEMENT DEFICIENCY?
SLE
389
How do you DIAGNOSE a COMPLEMENT DEFICIENCY?
Test for CH50 (total hemolytic complement), and if VERY LOW, test for individual components
390
How do you treat COMPLEMENT DEFICIENCY?
VACCINATION (conjugate, not polysaccharide) to prevent infections
391
What is a BIOTERRORISM CLASS A AGENT?
Greatest potential for causing a MAJOR public health impact, associated with HIGH MORTALITY
392
Anthrax (bacillus anthracis), Smallpox virus (variola), Plague (yersinia pestis), Botulism (clostridium botulinum), Tularemia (francisella tularensis) and Viral Hemorrhagic Fever?
CLASS A BIOTERRORISM AGENTS
393
How is ANTHRAX treated?
CIPROFLOXACIN
394
How is SMALLPOX (variola virus) treated?
Supportive/Vaccine
395
How is Plague (yersinia pestis) treated?
Streptomycin/Gentamicin
396
How is BOTULISM treated?
ANTITOXIN
397
How is TULAREMIA (Francisella tularensis) treated?
Streptomycin/Gentamicin (can also use doxycyxline/cipro)
398
PRURITIC cutaneous papule that ulcerates with BLACK ESCHAR and BOX-CAR shaped Gm POS bacillus found in soil forms SPORES, the INHALED form is the most lethal?
ANTHRAX (cipro x 60 days)
399
This pathogen causes a flu-like illness with dyspnea and chest pain, CXR shows mediastinal widening and is followed by FULMINANT SEPTIC SHOCK and DEATH?
ANTHRAX (cipro x 60 days)
400
How is inhalational ANTHRAX treated?
IV CIPROFLOXACIN x 14 days followed by PO for 60 days total (doxycycline can also be used)
401
Is the cutaneous eschar affected by CIPRO therapy in cutaneous anthrax?
NO
402
What virus is a SELECTIVE, HUMAN-ONLY virus (inhaled)?
VARIOLA (smallpox virus) - eradicated
403
URI with HIGH-FEVER, BACKACHE, HA, VOMITING, rash appears on BUCCAL and PHARYNGEAL mucosa, then hands, face, arms, legs and feet with all lesions in the SAME STAGE of development, then become crusted. Blindness can occur and pt is infective until ALL scabs and crusts are shed?
Smallpox (variola virus)
404
How is the VARICELLA (chicken pox) rash different than the SMALLPOX (variola)?
VARICELLA (chicken pox) - rash starts on TRUNK, lesions are at DIFFERENT stages of maturation
VARIOLA (smallpox) - rash starts in MOUTH and lesions are all at the SAME stage of maturation
405
How is SMALLPOX treated?
Give VACCINE within 3 DAY as well as to close contacts, otherwise SUPPORTIVE (can try cidofovir)
406
Rodents carry this infected tick which transmits the disease that causes PURULENT LYMPHADENITIS then PULMONARY involvement (hemoptysis and bronchopneumonia - inhaled) and when disseminated, causes DIC and multi-organ dysfunction. It is easily CONTAGIOUS and looks like a SAFETY-PIN on microscopy?
Plague (yersinia pestis) - treat with Streptomycin + Gentamicin (or doxycycline + fluoroquinolone)
407
What is the MOST LETHAL BIOLOGIC SUBSTANCE KNOWN?
Botulinum TOXIN (antitoxin)
408
This TOXIN prevents ACETYLCHOLINE release thus causing flaccid paralysis?
Botulinum TOXIN (antitoxin)
409
Home-made canned foods, honey ingestion by infants or wound contamination?
Botulinum TOXIN (antitoxin)
410
Descending flaccid paralysis with BULBAR SIGNS (4 D's - Diplopia, Dysarthria, Dysphonia, Dysphagia), and looks like Guillain-Barré or Myasthenia Gravis with no fever and normal mental status?
Botulinum TOXIN (antitoxin)
411
How is BOTULISM treated?
ANTITOXIN (does NOT reverse existing paralysis)
412
Is TULAREMIA (Francisella tularensis) contagious?
NO
413
Abrupt-Onset FEVER/CHILLS, MYALGIA and ANOREXIA, SORE THROAT, ABDOMINAL PAIN, DIARRHEA and BRADYCARDIA, can develop SEVERE RESPIRATORY FAILURE, PULMONARY INFILTRATES and PLEURAL EFFUSIONS with HILAR LYMPHADENOPATHY and can progress to SEPTIC SHOCK, diagnosed by PCR or IMMUNOFLUORESCENCE? How do you treat?
Tularemia (Francisella tularensis) - inhaled (bioterrorism)
| Treated with Streptomycin + Gentamicin (can use doxycycline or cipro as well)
414
Fever followed by petechial hemorrhages followed by SHOCK and GENERALIZED BLEEDING from MUCUS MEMBRANES, SKIN, GI, LUGS and in a BIOTERRORISM attack, would be disseminated by aerosol for inhalation?
Viral Hemorrhagic Fever (Flaviviridae - yellow/dengue fevers, Filoviridae - ebola/marburg hemorrhagic fevers, Arenaviridae - Lassa fever, Bunyaviridae - Rift Valley/Crimean Congo fevers and Hantavirus
415
How are the Viral Hemorrhagic Fevers treated?
Intensive, Supportive care (ISOLATION)
416
What disease is transmitted by the ANOPHELES mosquito?
MALARIA
417
This disease can be prevented by using BED NETS, at least 30% DEET and Prophylactic antibiotics when traveling?
MALARIA
418
Fever that occurs in 48-72 HOUR cycles with intra-RBC parasites with a FLU-LIKE illness?
MLARIA
419
After a mosquito bite while traveling, infection with this pathogen causes AMS, SEIZURES, HEPATIC FAILURE, DIC, BRISK INTRAVASCULAR HEMOLYSIS, METABOLIC ACIDOSIS, KIDNEY INSUFFICIENCY and HYPOGLYCEMIA, can present with SPLENOMEGALY and ANEMIA if long-standing disease?
Plasmodium falciparum malaria
420
What two MALARIAL pathogens are potentially LETHAL however DO NOT RELAPSE as the other THREE DO?
Plasmodium falciparum and Plasmodium knowlesi
421
What MALARIAL pathogens are CHLOROQUINE RESISTANT?
Plasmodium vivax and Plasmodium falciparum
422
Recent travel to AFRICA, EARLY ONSET of infection upon returning from trip, peripheral smear shows thin ring-forms within erythrocytes?
MALARIA
423
Infection with this MALARIAL pathogen shows NO trophozoites or schizonts on peripheral blood smear however there are BANANA-SHAPED gametocytes?
Plasmodium falciparum
424
What should PREGNANT women be advised about MALARIA?
DO NOT TRAVEL TO ENDEMIC AREAS
425
What is the PROPHYLAXIS for MALARIA recommended for travelers?
CHLOROQUINE or MEFLOQUINE (if chloroquine resistant) to be STARTED 1-2 days BEFORE travel and continued from 7 days to 4 weeks
426
What should RELAPSE of MALARIA be treated with?
PRIMAQUINE
427
MALARIA RESISTANT to CHLOROQUINE can be treated PROPHYLACTICALLY with what?
MEFLOQUINE, DOXYCYCLINE, ATOVAQUONE/PROGUANIL
428
While traveling, if water or food is contaminated with HUMAN FECES and symptoms of DAILY enteric FEVER develop, with HEPATOSPLENOMEGALY with macular RASH on TRUNK with DIARRHEA then CONSTIPATION, with INTESTINAL HEMORRHAGE and PERFORATION and can INVADE GALLBLADDER especially with gallstones and create a long-term carrier state of this pathogen and disease?
Salmonella enterica - serotype typhi (THYPOID FEVER)
429
How is TYPHOID FEVER (salmonella enterica - serotype typhi) treated?
Typhoid vaccine (liver or killed) or CIPRO/cefTRIAXONE
430
E.coli, Salmonella, Shigella, Campylobacter, ROTA virus, Cryptosporidium, Giardia?
TRAVELER's DIARRHEA
431
Do this to avoid TRAVELER's DIARRHEA?
Avoid TAP water (drinks, ice, brushing teeth, fruits not peeled just before eating, fresh vegetables and undercooked meats or unpasteurized dairy
432
How can water be made safe from TRAVELER's DIARRHEA?
BOIL x 3 minutes; add SODIUM HYPOCHLORITE or tincture of IODIDE
433
What medicine can be used to treat or prevent the diarrhea?
Bismuth subsalycilate or RIFAXIMIN 200 mg
434
What anti-diarrheal agents should NOT be used when dysenteric disease or bloody diarrhea is present?
Diphenoxylate (Lomotil) or Loperamide (Imodium); use bismuth subsalycilate or rifaximin
435
This virus is transmitted by the Aedes aegypti mosquito and causes a SIGNIFICANT LUMBO-SACRAL PAIN, ACUTE FEVER with FRONTAL HA, RETRO-ORBITAL PAIN, PURPURA, MELENA, CONJUNCTIVAL INJECTION, RASH when fever goes away SPARING the palms and soles. Hemorrhagic SHOCK with LIVER FAILURE and ENCEPHALOPATHY can develop especially if infected BEFORE, with LEUKOPENIA and THROMBOCYTOPENIA?
DENGUE FEVER (flaviviridae)
436
How is DENGUE FEVER (flaviviridae) treated?
SUPPORTIVE ONLY
437
Vaccination for this VIRAL INFECTION is recommended 1 MONTH BEFORE travel and a SECOND dose 6-12 MONTHS after INITIAL VACCINATION. The VIRUS is transmitted through food and water?
Hep A
438
How do you treat patients who have not been vaccinated for Hep A and those who are immunocompromised once infected with Hep A?
IVIG or supportive
439
What is the PREFERRED treatment of ANY RICKETTSIAL infection (fever, HA, malaise followed by rash)?
DOXYCYCLINE
440
Exposure to contaminated, unpasteurized MILK, UNDERCOOKED MEAT or animal GIVING BIRTH (skin wounds, mucus membranes, inhalation) causes an illness with fever and NIGHT SWEATS, ENDOCARDITIS and NEUROPSYCHIATRIC SYMPTOMS (neuropathy, radiculopathy, stroke, depression, dementia)?
BRUCELLOSIS
441
How is BRUCELLOSIS treated?
DOXYCYCLINE + RIFAMPIN + STREPTOMYCIN/GENTAMICIN
442
Histoplasma, Coccidioides, Penicillium fungi can cause serious disease in what patients?
IMMUNOCOMPROMISED (usually asymptomatic in immunocompetent hosts)
443
Soil contaminated with BIRD or BAT droppings causes the aerosolization of this fungus in its MOLD form?
Histoplasmosis
444
Immunocompromised (and HIV) patients traveling to SOUTHEAST ASIA can become infected with this NEW fungus if they are EXPOSED TO DUST (without dust masks) for which if caught EARLY (high MORTALITY), will require LIFETIME treatment with antifungals?
Penicillium marneffei
445
What is considered "persistent" diarrhea in a HEALTHY person?
>7 DAYS (suggests a parasitic/non-infectious origin)
446
When diarrhea is associated with symptoms >72 HOURS, FEVER, TENESMUS, BLOODY or MUCUS stools, what should be done?
STOOL CULTURE
447
N/V WITHOUT DIARRHEA, WITHIN 6 HOURS of EATING can be caused by which pathogens?
S.aureus, B.cereus (due to PRE-FORMED TOXIN)
448
What is the most COMMON cause of INFECTIOUS DIARRHEA (diarrhea that occurs within 24-72 HOURS of inoculation) in the HEALTHCARE and PRESCHOOL setting due to fecal-oral infection?
Shigella (VERY FEW organisms are required for infection -
449
NON-FEBRILE INFECTIOUS DIARRHEA (diarrhea that occurs within 24-72 HOURS of inoculation) that is GROSSLY BLOODY is associated with what pathogen?
E.coli O157:H7/O104:H4
450
What are FECAL WBC's (leukocytes) suggestive of?
Infectious pathogen
451
BESIDES E.coli (O157:H7/O104:H4), which other COMMON pathogens are associated with BLOOD-containing DIARRHEA?
Shigella, Salmonella and Campylobacter
452
Patients with DIARRHEA and symptoms of FEVER, ABD PAIN or BLOODY STOOLS should NOT use what medications?
LOPERAMIDE (Imodium) or diphenoxylate (Lomotil)
453
Eating RAW/UNDERCOOKED EGGS (also chicken, fruits, vegetables), exposure to TURTLES, SNAKES, LIZARDS and developing a self-limited BLOODY DIARRHEA (gross or heme-positive) with possible AORTITIS in susceptible patients, most likely is caused by this pathogen?
SALMONELLA enterica (serotype typhi) - NEVER treat with ANTIBIOTICS as this WORSENS disease UNLESS >50 AND REQUIRE HOSPITALIZATION (LEVOFLOXACIN/CIPRO)
454
Exposure to UNDERCOOKED POULTRY, PUPPYS/KITTENS with diarrhea and developing FEVER, ABD PAIN and BLOODY STOOLS (gross or heme-positive) most likely is caused by this pathogen?
CAMPYLOBACTER
455
Eating PORK INTESTINE ("chitterlings") and developing DIARRHEA (watery or bloody) and SEVERE ABDOMINAL PAIN that MIMICS APPENDICITIS with PEYER PATCH (ileum) involvement and MESENTERIC LYMPHADENOPATHY is most likely due to exposure to this pathogen?
YERSINIA enterocolitica
456
Eating RAW/UNDERCOOKED SEAFOOD or exposure to SEAWATER and developing ABDOMINAL PAIN and DIARRHEA is most likely due to exposure to this pathogen?
VIBRIO vulnificus
457
DIARRHEA while on/after a CRUISESHIP exposure is most likely due to exposure to this pathogen?
NOROVIRUS
458
Drinking WATER from UNTREATED, NATURAL bodies of WATER (lakes, rivers) and developing DIARRHEA is most likely due to exposure to this pathogen (parasite)?
GIARDIA lamblia (rarely Aeromonas/Plesiomonas - shellfish)
459
Exposure to Shigella, Giardia, Norovirus and Rotavirus with resultant DIARRHEA are COMMON to these types of businesses?
Day Care Centers
460
Exposure to this pathogen that causes BLOODY DIARRHEA can cause REACTIVE ARTHRITIS and GUILLAIN-BARRÉ Syndrome?
Campylobacter jejuni
461
What patients should be TREATED for certain INFECTIOUS DIARRHEA as MOST of these are SELF-LIMITED and resolve?
SEVERE SYMPTOMS (DEHYDRATING DIARRHEA, FEVER, BLOODY STOOLS), SYMPTOMS >7 DAYS, patients at EXTREMES of AGE, with CO-MORBIDITIES or IMMUNOCOMPROMISED
462
What ANTIBIOTIC can be used to TREAT infectious diarrhea caused by Campylobacter jejuni?
AZITHROMYCIN/ERYTHROMYCIN (macrolides)
463
Exposure to this pathogen that causes "DYSENTERY" (intestinal inflammation with BLOODY DIARRHEA) with BLOOD/MUCUS, ABD CRAMPS, TENESMUS, HGH-FEVER and can RARELY (more rarely than Campylobacter) can cause REACTIVE ARTHRITIS after resolution REQUIRES TREATMENT for ALL infected in order to DECREASE duration of BACTERIAL SHEDDING and reduce spread of infection?
SHIGELLA (treat with LEVOFLOXACIN/CIPRO)
464
ALL patients fund to be exposed to this INFECTIOUS DIARRHEA pathogen REQUIRE TREATMENT in order to DECREASE duration of BACTERIAL SHEDDING and reduce spread of infection?
SHIGELLA (treat with LEVOFLOXACIN/CIPRO)
465
Exposure to this pathogen causes a BLOODY DIARRHEA that can cause OSTEOMYELITIS and AORTITIS (diagnosed by CT-scan), especially in older patients ≥65 with ATHEROSCLEROTIC vascular disease, IMMUNOCOMPROMISED, SICKLE-CELL DISEASE, those treated with ANTACIDS (PPI's), CORTICOSTEROIDS or are TRANSPLANT recipients presenting with persistent bacteremia despite ANTIBIOTIC therapy?
SALMONELLA - NEVER treat with ANTIBIOTICS as this WORSENS disease UNLESS >50 AND REQUIRE HOSPITALIZATION (LEVOFLOXACIN/CIPRO)
466
INFECTIOUS DIARRHEA pathogen that can cause AORTITIS and OSTEOMYELITIS in susceptible patients?
SALMONELLA - NEVER treat with ANTIBIOTICS as this WORSENS disease UNLESS >50 AND REQUIRE HOSPITALIZATION (LEVOFLOXACIN/CIPRO)
467
How do you treat SHIGELLA/SALMONELLA/YERSINIA/VIBRIO?
LEVOFLOXACIN or CIPRO
468
Infection with SHIGA-TOXIN producing E.Coli (STEC) - O157:H7/O104:H4 (fecal-oral) can cause WHAT DISEASE that presents with HEMOLYTIC ANEMIA, ACUTE KIDNEY FAILURE and THROMBOCYTOPENIA?
Hemolytic Uremic Syndrome (HUS) - supportive with DIALYSIS as needed
469
What MUST be REQUESTED if suspecting infection with E.coli O157:H7/O104:H4?
SPECIFIC LAB testing (sorbitol-MacConkey agar)
470
What should be done with ANY ANTIBIOTICS a patient might be taking if found to be infected with E.coli O157:H7/O104:H4?
STOP ANTIBIOTICS IMMEDIATELY!! (can trigger HUS and worsen disease)
471
What should with ANTIBIOTICS patients may be taking if they present with BLOODY DIARRHEA, especially E.coli O157:H7/O104:H4?
STOP ANTIBIOTICS IMMEDIATELY!! (can trigger HUS and worsen disease)
472
How is E.coli O157:H7/O104:H4 treated?
SUPPORTIVE
473
What POST-INFECTIOUS complications can be seen with YERSINIA enterocolitica?
Reactive Arthritis and Erythema Nodosum
474
Exposure to this pathogen can cause LIFE-THREATENING, DEHYDRATING DIARRHEA due to INADEQUATE SANITATION and can contaminate SALT WATER and RAW SHELLFISH and in patients with LIVER DISEASE, this can cause secondary SEPSIS!!?
VIBRIO (cholerae and parahaemolyticus)
475
Is Clostridium difficile killed by alcohol-based hand sanitizers?
NO!!
476
Significant LEUKOCYTOSIS (>30,000/µL WBC's), TOXIC MEGACOLON (≥7 cm), FEVER, PSEUDOMEMBRANOUS COLITIS, watery diarrhea with abdominal pain/cramps and associated with a 20% RELAPSE rate, antibiotic use and hospitalization?
CLOSTRIDIUM DIFFICILE - associated diarrheal colitis
477
When should a patient TREATED for C.difficile DIARRHEAL INFECTION be re-tested?
ONLY if SYMPTOMATIC after resolution
478
How do you TEST for C.diff?
Toxins A & B, Glutamate Dehydrogenase (GDH) or PCR
479
How is C.diff COLITIS and associated DIARRHEAL illness treated?
PO METRONIDAZOLE (can use IV if ileus) or PO VANCOMYCIN (IV form is useless for treating this disease)
480
What TWO (2) VIRUSES are most COMMONLY associated with DIARRHEA and cause a SUDDEN-ONSET N/V/D (watery) ± FEVER, is SELF-LIMITED with symptoms resolving AFTER 72 HOURS but INFECTIVITY PERSISTS?
NORO VIRUS and ROTA VIRUS (cruise ships, schools, health-care institutions)
481
How are NORO VIRUS and ROTA VIRUS - associated DIARRHEA treated?
SUPPORTIVE (vaccine is for infants)
482
What COMMONLY causes DIARRHEA >7 DAYS?
PARASITES (Blastocystis, Giardia, Cryptosporidium, Amebiasis)
483
Hikers, Campers, Outdoor enthusiasts that drink WATER from Rivers, Lakes, Streams after infected ANIMALS shit in them contaminating them with this PARASITE that causes a FOUL-SMELLING, WATERY DIARRHEAL illness with BLOATING, FLATULENCE and BELCHING with WEIGHT LOSS and patients with SELECTIVE IgA DEFICIENCY have SEVERE/CHRONIC INFECTION?
GIARDIA lamblia
484
What PARASITIC infection with DIARRHEA can cause TEMPORARY LACTOSE INTOLERANCE?
GIARDIA lambila
485
How is GIARDIA lamblia SYMPTOMATIC DIARRHEAL illness treated?
With METRONIDAZOLE/mebendazole/albendazole
486
This PARASITE that invades MUNICIPAL WATER SUPPLIES and affects the IMMUNOCOMPROMISED with PROLONGED DIARRHEA with significant WEIGHT LOSS and WASTING as well as infection of the BILIARY TREE (low CD4) with ACALCULOUS CHOLECYSTITIS?
CRYPTOSPORIDIUM
487
How is CRYPTOSPORIDIUM parasitic DIARRHEA treated (immunocompromised), immunocompetent?
With treatment of UNDERLYING DISEASE, REHYDRATION and NUTRITION
IMMUNOCOMPETENT (severe sympt.) - NITAZOXANIDE
488
Infection with this PARASITE causes an INFLAMMATORY COLITIS with BLOODY STOOLS more commonly seen in the ELDERLY and IMMUNOCOMPROMISED and can cause LIVER ABSCESS?
ENTAMOEBA histolytica
489
Which patients should be treated for ENTAMOEBA histolytica and with what agents?
ALL (symptomatic and not) with METRONIDAZOLE + PAROMOMYCIN/IODOQUINOL
490
What anti-rejection drugs are used in a post-TRANSPLANT patient?
STEROID (prednisone) + CALCINEURIN INHIBITOR (cyclosporine/tacrolimus) + ANTIMETABOLITE (mycophenolate mofetil/azathioptine/methotrexate/cyclophosphamide)
491
LIMITING the use of this anti-rejection drug reduces incidence of infection with PNEUMOCYSTIS jirovecii and other FUNGAL infections?
PREDNISONE (corticosteroids in general)
492
The use of this anti-rejection medication reduces the incidence of OVERALL INFECTIONS?
CYCLOSPORINE
493
REDUCED levels of these WBC's or their INTENTIONAL DESTRUCTION in TRANSPLANT patients INCREASES the RISK for infection with CMV, EBV, polyoma BK virus, P.jirovecii and FUNGI?
T-lymphocytes
494
CYCLOSPORINE, TACROLIMUS and SIROLIMUS interact with these particular MEDS and can result in INCREASED LEVELS of ALL of these meds?
MACROLIDES and AZOLES (antifungals)
495
Which are the TWO (2) CALCINEURIN inhibitors used in anti-rejection regimens?
CYCLOSPORINE and TACROLIMUS
496
Which are the TWO (2) RAPAMYCIN inhibitors used in anti-rejection regimens?
SIROLIMUS and EVEROLIMUS
497
Which are the LYMPHOCYTE (B & T, CD3, IL-2) DEPLETING Ab's used in anti-rejection regimens?
ANTITHYMOCYTE GLOBULIN, -"mab"
498
Which are the CYTOTOXIC (antimetabolite) agents used in anti-rejection regimens?
MYCOPHENOLATE MOFETIL, AZATHIOPRINE, METHOTEXATE, CYCLOPHOSPHAMIDE
499
What are POST-TRANSPLANT patients at HIGHEST RISK for in the FIRST MONTH (early) post transplant?
SURGICAL SITE/WOUND INFECTION (bacterial) and NOSOCOMIAL infections (central line, PNA, C.diff, UTI)
500
What are POST-TRANSPLANT patients at HIGHEST RISK for >MONTH (middle) post transplant?
IMMUNOSUPPRESSION (HSV/CMV/EBV reactivation, polyoma BK virus, Hep B & C, Legionella and P.jirovecii)
501
What are POST-TRANSPLANT patients at HIGHEST RISK for a FEW MONTHS (late) post transplant?
IMMUNOSUPPRESSION (CMV/EBV/polyoma BK virus, Listeria, Nocardia, FUNGI)
502
Because of SEVERE NEUTROPENIA, what pathogens are post-HSCT patients at greatest risk for?
BACTERIAL and FUNGAL
503
What is the most IMPORTANT VIRAL infection post-TRANSPLANT (2 WEEKS - 4 MONTHS after)?
CMV (from seropositive donor) - fever, leukopenia/thrombocytopenia, PNEUMONITIS (high mortality), GI/Liver disease
504
POST-SOLID ORGAN TRANSPLANT infection with this pathogen causes B-LYMPHOCYTE PROLIFERATION causing POST-TRANSPLANT LYMPHOPROLIFERATIVE DISEASE (PTLD) with FEVER, EXTRA-NODAL MASS or LYMPHADENOPATHY?
EBV
505
POST-TRANSPLANT (especially KIDNEY transplant) infection with this pathogen causes NEPHROPATHY, URETERAL STRICTURES and HEMORRHAGIC CYSTITIS (with HSCT)?
polyoma BK virus
506
Infections in post-TRANSPLANT patients with 1. COLITIS and DIARRHEA, SEVERE, 2. RAPIDLY PROGRESSIVE multi-lobar PNA, 3. MENINGOENCEPHALITIS, 4. LUNG NODULES with BRAIN ABSCESS and 5. FUNGAL REACTIVATION with sweats and weigh-loss are due to these COMMON pathogens?
1. C.diff
2. LEGIONELLA
3. LISTERIA
4. NOCARDIA
5. TB
507
What is the most COMMON fungal infection after TRANSPLANT and after HSCT? How are these prevented?
ASPERGILLUS (involves LUNGS and BRAIN) as well as MUCOR and RHIZOPUS, CANDIDA
PREVENTED - with FLUCONAZOLE, TMP-SMX (P.jirovecii)
508
Multiple RING-ENHANCING lesions in the BRAIN and other CNS manifestations after TRANSPLANT or CARDIAC involvement suggests reactivation of what pathogen?
TOXOPLASMA gondii
509
This parasite can persist for MANY years in a subclinical state however in post-TRANSPLANT patients, because of immunosuppression, it can migrate in the LUNG and GI tract causing PNA with HIGH-MORTALITY?
Strongyloides stercoralis
510
Besides avoiding EXPOSURE and providing IMMUNIZATION, how are post-TRANSPLANT infections PREVENTED?
FLUCONAZOLE + FLUOROQUINOLONE + GANCYCLOVIR/VALGANCYCLOVIR + TMP-SMX
511
When are IMMUNIZATIONS given to TRANSPLANT PATIENTS (SOLID organs and HSCT)? What immunizations are NOT given (contraindicated) post-TRANSPLANT?
SOLID-ORGAN - immunize BEFORE transplant
HSCT - immunize AFTER (once immune system rebuilds)
CONTRAINDICATED - LIVE vaccines (MMR, Varicella, Influenza)
512
An infection that occurs AFTER 48 HOURS of HOSPITALIZATION without evidence of the infection being present PRIOR to hospitalization is called?
NOSOCOMIAL (hospital-acquired infection, infusion centers, long-term care facilities)
513
What is the MOST IMPORTANT measure in preventing HOSPITAL-ACQUIRED INFECTIONS?
HAND HYGIENE (soap & water 15-30 seconds BEFORE & AFTER patient contact)
514
What causes >97% of UTI's acquired in the HOSPITAL?
Urinary CATHETERS
515
Signs of UTI, ≥1000 COLONY FORMING UNITS of one or more bacterial species in a SINGLE catheter urine specimen in a patient with an INDWELLING urinary catheter or intermittent catheterization?
CATHETER-associated UTI
516
What does PYURIA suggest in a hospital-catheterized patient?
NOTHING, it is NOT a reliable indicator for UTI
517
What should be done BEFORE treatment is started in a HOSPITALIZED patient with a CATHETER-associated UTI?
Obtain URINE SPECIMEN for CULTURE (if catheter has been in for ≥2 WEEKS and needs to stay, get urine specimen after replacing with a NEW catheter)
518
Do screening for BACTERURIA (except in pregnant patients and those having invasive urological procedures), catheter IRRIGATION, ROUTINE CATHETER CHANGES or CLEANING the GENITAL area PRIOR/DURING CATHETER INSERTION or use of ANTISEPTIC-COATED CATHETERS prevent catheter-associated UTI's?
NO!! so DON'T DO THEM
519
PROLONGED duration of CATHETERIZATION, APPROPRIATE CATHETER CARE, CATHETER PLACEMENT AFTER DAY 6 of HOSPITALIZATION and CATHETER PLACEMENT OUTSIDE of the OR are all what factors affecting CATHETER-associated UTI's in HOSPITALIZED patients?
MODIFIABLE RISK FACTORS (whereas female sex, >50 yo, DM and Cr >2.0 are NOT modifiable)
520
1. What is the TIME LIMIT for an infection occurring in the SKIN/SOFT TISSUES directly related/involved in a SURGICAL PROCEDURE to be considered a SURGICAL-SITE INFECTION? 2. What is the most COMMON pathogen?
1. ≤30 DAYS and up to ONE YEAR for IMPLANTS
| 2. S.aureus (MRSA)
521
Avoiding CATHETERIZATION/EARLY REMOVAL, using CONDOM CATHETERS or INTERMITTENT CATHETERIZATION, using SMALLER CATHETERS (avoid urethral trauma), SECURING the CATHETER, using a CLOSED DRAINAGE SYSTEM are all measures for the prevention of what?
PREVENTING CATHETER-associated UTI's.
522
Surgical site with PURULENT drainage, TENDERNESS, REDNESS, WARMTH suggest?
SURGICAL SITE INFECTION
523
Where should CULTURES (ALWAYS) be obtained from a suspected SURGICAL SITE INFECTION?
The DEEPEST LAYER involved (OR or needle aspiration), NOT SWABS
524
What imaging modalities can help determine DEAPTH of a SURGICAL SITE INFECTION or OSTEOMYELITIS?
MRI or CT
525
How are SURGICAL SITE INFECTIONS treated?
OPENING INCISION and DEBRIDEMENT + ANTIBIOTICS
526
What is the ONLY SURGERY in which PRE-OP NASAL DE-COLONIZATION of S.aureus and CHLORHEXIDINE BATHING have been shown to be effective in preventing SURGICAL SITE INFECTIONS?
CARDIOTHORACIC SURGERY
527
What ANTIBIOTIC PROPHYLAXIS is given 30-60 MINUTES PRIOR to SURGICAL PROCEDURES and STOPPED ≤24 HOURS AFTER in order to PREVENT SURGICAL SITE INFECTIONS?
VANCOMYCIN + FLUOROQUINOLONES
528
What plasma GLUCOSE levels are PREFERRED for ≥48 HOURS POST-OP to avoid SURGICAL SITE INFECTIONS?
529
Do POSITIVE cultures of CENRAL VENOUS CATHETER TIPS performed as a ROUTINE SCREENING PROTOCOL in the ABSENCE of POSITIVE BLOOD CULTURES require treatment?
NO
530
What does it mean when there is a 3 times GREATER number of a bacterial colony count when obtaining BLOOD CULTURES from a CENTRAL LINE compared to a peripheral source?
STONG PREDICTOR of CENTRAL LINE INFECTION
531
Where should BLOOD CULTURES ALWAYS be drawn from when a patient has a CENTRAL LINE?
2 SETS, obtained from DIFFERENT anatomic SITES where AT LEAST one site is PERIPHERAL
532
What should be done when the catheter TIP is POSITIVE for INFECTION in a patient with POSITIVE BLOOD CULTURES for infection?
REMOVE CATHETER and treat with ANTIBIOTICS
533
HOW can an INFECTED CENTRAL LINE be saved if it HAS to be?
Using an "antibiotic LOCK" (the antibiotic-impregnated pad that us used to cover the external portion of the central line)
534
What VEIN should be avoided when placing a CENTRAL LINE? What is the PREFERRED SITE?
SITE to AVOID - FEMORAL VEIN
| PREFERED SITE - SUBCLAVIAN VEIN
535
What are the reasons CENTRAL LINE CATHETERS get infected?
Bacteria introduced during INSERTION, USE and CARE
536
What should the SKIN be STERILIZED with prior to CENTRAL LINE CATHETER placement?
CLORHEXADINE
537
What should be done for ALL patients with CENTRAL LINES in place in order to prevent CENTRAL LINE INFECTION?
DAILY CHLORHEXADINE BATHS
538
How OFTEN should IV administration sets be replaced (tubing, connectors, etc.)?
EVERY 96 HOURS (4 days)
539
When should an ANTIBIOTIC-COATED CENTRAL LINE CATHETER be used?
ONLY if INFECTION rate does NOT DECREASE in a center that FOLLOWS ALL INFECTIOUS DISEASE PRECAUTIONS and strategies to reduce CENTRAL LINE INFECTION rates
540
Should ANTIBIOTIC/ALCOHOL LOCKS be used PROPHYLACTICALLY on CENTRAL LINES to prevent infection and should ANTIBIOTIC PROPHYLAXIS be given to patients in whom CENTRAL LINES are used? Should CENTRAL LINES be routinely replaced?
NO
541
What should ALWAYS be done when the infection of a CENTRAL LINE CATHETER is found to be with S.aureus, Pseudomonas or Candida?
REMOVE LINE
542
Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP) are judged to be so if the PNEUMONIA occurred under which circumstances?
≥ AFTER HOSPITAL ADMISSION/VENT PLACEMENT and was not INCUBATING at the time of ADMISSION or VENT PLACEMENT
543
The GREATEST RISK for HOSPITAL-ACQUIRED PNA is what?
MECHANICAL VENTILATION
544
In order to diagnose a HOSPITAL-ACQUIRED PNEUMONIA, what testing MUST BE DONE?
BLOOD CULTURES and LOWER RESPIRATORY TRACT SAMPLES for CULTURE must be obtained BEFORE ANTIBIOTICS are started
545
In a patient ADMITTED to the HOSPITAL ≥48 HOURS ago in which FEVER, LEUKOCYTOSIS, PURULENT SPUTUM and a POSITIVE LOWER RESPIRATORY TRACT CULTURE are present but WITHOUT a NEW LUNG INFILTRATE, what would be the diagnosis since it CANNOT be HOSPITAL-ACQUIRED PNEUMONIA?
NOSOCOMIAL TRACHEOBRONCHITIS
546
TPN, a personal medical h/o PREMATURE BIRTH and a site other than the SUBCLAVIAN VEIN for the placement of a CENTRAL LINE CATHETER are all RISK factors for what?
CENTRAL LINE CATHETER INFECTION
547
H2 BLOCKERS, NASOGASTRIC TUBE PLACEMENT, ABDOMINAL/THORACIC SURGERY, PREVIOUS ANTIBIOTIC USE, TRAUMA, AMS and OLD AGE are all RISK FACTORS for WHAT HOSPITAL-ACQUIRED DISEASE?
HOSPITAL-ACQUIRED PNA
548
What BROAD-SPECTRUM ANTIBIOTICS should be started for a patient with HOSPITAL ACQUIRED PNA if there is a suspicion for multi-drug RESISTANT organisms (recent use of ABX, current hospitalization is ≥5 DAYS, immunosuppression)?
Those covering MRSA and P.aeruginosa (VANCOMYCIN + ceftaZIDIME with DE-ESCALATION once cultures have resulted
549
How LONG should patients with HOSPITAL-ACQUIRED PNA be treated for with ANTIBIOTICS if pathogens are NOT PSEUDOMONAS or ACINETOBACTER?
8 DAYS
550
Keeping HEAD of BED elevated >30º, DAILY assessments for readiness to WEAN use of CHLORHEXADINE MOUTH CARE and INTERMITTENT SUBGLOTTIC SUCTIONING are all preventative measures for what?
VENTILATOR-ASSOCIATED PNA
551
What are the FOUR (4) components of TREATING HOSPITAL-ACQUIRED PNA?
1. Treat EARLY
2. EMPIRIC, BROAD-SPECTRUM ANTIBIOTICS
3. DE-ESCALATE ABX once CULTURES have RESULTED
4. SHORT-DURATION (8-DAY) THERAPY
552
If in an MRSA-infected patient, MIC is ≥2 for vancomycin (resistance), what ALTERNATIVE antibiotics MUST be used for PNA and for BLOOD infections?
PNA - LINEZOLID/CLINDAMYCIN
| BLOOD Infections - DAPTOMYCIN
553
Treating Vancomycin Resistant Enterococci (VRE) usually requires LINEZOLID or CLINDAMYCIN however what ALTERNATIVE agent is PREFERRED if there is SUSCEPTIBILITY?
AMPICILLIN
554
When treating Extended Spectrum β-Lactamase producing pathogens, CARBAPENEMS (ertapenem) can be used as long as the infections are NOT caused by THESE TWO (2) pathogens (or USE FLUOROQUINOLONES)?
PSEUDOMONAS or ACINETOBACTER
555
What are the options for CARBAPENEM-RESISTANT pathogens?
Polymyxin, Tigecycline, Aminoglycosides (amikacin)
556
What should be used to treat MULTI-DRUG resistant pathogens like ACINETOBACTER and PSEUDOMONAS?
POLYMYXIN or MINOCYCLINE (preferred) or TIGECYCLINE
557
What assures the SUCCESS of preventative measures such as CONTACT PRECAUTIONS?
COMPLIANCE of health-care workers
558
PROSTHETIC materials, DAMAGE to heart valves and TURBULENT blood flow all contribute to this disease process?
NIDUS for THROMBUS formation consisting of PLATELETS, FIBRIN and MICROBES causing INFECTIVE ENDOCARDITIS
559
STREPTOCOCCI, STAPHYLOCOCCI and ENTEROCOCCI are the HIGHEST-RISK pathogens involved in this BLOOD-associated disease process?
INFECTIVE ENDOCARDITIS
560
Patients with a H/O INFECTIVE ENDOCARDITIS, PROSTHETIC VALVES, CONGENITAL HEART DISEASE repaired with prosthetic device for the first 6 MONTHS POST-OP or with residual defects and POST CARDIAC TRANSPLANT that DEVELOPS VALVE DISEASE should be treated with what REGARDLESS of PROCEDURE (DENTAL or INVASIVE RESPIRATORY TRACT PROCEDURES) that can cause TRANSIENT BACTEREMIA?
ANTIBIOTIC PROPHYLAXIS for INFECTIVE ENDOCARDITIS
561
WHEN should ANTIBIOTIC PROPHYLAXIS be given for INFECTIVE ENDOCARDITIS prior to DENTAL and INVASIVE RESPIRATORY TRACT PROCEDURES?
30-60 MINUTES BEFORE and UP TO 2 HOURS AFTER
562
Should ANTIBIOTIC PROPHYLAXIS be given for INFECTIVE ENDOCARDITIS prior to GI, GU or GYN procedures?
NO
563
What are the preferred 1. ORAL/ALL, 2. IV/ALL PROPHYLACTIC ANTIBIOTICS for INFECTIVE ENDOCARDITIS?
1. PO - AMOXICILLIN 2 g
PCN allergy - cefaLEXIN or CLINDAMYCIN or AZYHROMYCIN or CLARITHROMYCIN
2. IM/IV - AMPICILLIN 2 g (or cefaZOLIN or cefTRIAXONE)
PCN allergy - cefaZOLIN or cefTRIAXONE or CLINDAMYCIN
564
What is the drug Emtricitabine/Tenofovir Disoproxil Fumarate?
The ONLY PRE-EXPOSURE PROPHYLACTIC DRUG available for HIV
565
An ACUTE, SYMPTOMATIC ILLNESS (simple febrile to mononucleosis-like) 2-4 weeks after EXPOSURE that lasts 2-3 WEEKS then RESOLVE and are HIGHLY-INFECTIVE however NEGATIVE Ab's but POSITIVE PCR, followed by YEARS of ASYMPTOMATIC infection?
HIV
566
CHRONIC symptoms of HIV infection (FEVER, LYMPHADENOPATHY, PHARYNGITIS, RASH, MYALGIA, ARTHRALIGIA, DIARRHEA, HA, night sweats, fatigue, weight loss, skin/nail disorders, oral/gingival diseases, peripheral neuropathy, nephropathy, anemia/leukopenia/thrombocytopenia) and PROLONGED usual infections occur due to what?
PROGRESSIVE CD4 T-lymphocyte depletion
567
What is diagnostic of AIDS?
OPPOTUNISTIC diseases/malignancies or CD4
568
Who should be tested for HIV?
ALL people 13-75 years of age, at LEAST ONCE and those at risk ANNUALLY, ALL PREGNANT WOMEN
569
How is HIV tested for in the lab?
ELISA (if NEG, NO HIV unless in EARLY "window" period) if POSITIVE, REPEAT ELISA and if 2nd positive, confirm by WESTERN BLOT. If MUST KNOW during EARLY "window" period, do PCR
570
What are the TWO (2) most important lab tests for HIV to monitor EFFECTIVENESS of TREATMENT and DISEASE STAGE?
CD4 COUNT and RNA VIRAL LOAD
571
What STANDARD labs should be performed PRIOR to STARTING HIV THERAPY, when CHANGING THERAPY, 2-8 WEEKS AFTER CHANGING THERAPY and EVERY 3-6 MONTHS while on STABLE THERAPY?
CD4 COUNT, RNA VIRAL LOAD, CBC, LFT's and BUN/Cr
572
What VACCINATIONS SHOULD HIV patients SPECIFICALLY GET besides ALL the other VACCINATIONS everyone else gets, EXCEPT LIVE VACCINATIONS (MMR, Varicella-Zoster)?
PNEUMOCOCCAL vaccine every 5 YEARS, ANNUAL INFLUENZA vaccine and Hep B vaccine (3 shots)
573
If SUSPICION for EITHER MAC (blood culture) or TB (PPD, or INTERFERON-γ release assay) exist in an HIV patient, what MUST BE DONE PRIO to starting PROPHYLAXIS for these pathogens?
EXCLUDE ACTIVE INFECTION because agents used for prophylaxis DO NOT TREAT active infection and RESISTANCE COULD OCCUR
574
What is BASELINE VIRAL RESISTANCE TESTING for HIV and whom is it done for?
ALL NEWLY-DIAGNOSED patients with HIV to guide choice of treatment
575
When should PROPHYLAXIS for P.jirovecii be started in a patient with HIV and with what agent?
WHEN: CD4
576
When should PROPHYLAXIS for TOXOPLASMOSIS (after positive serology) be started in a patient with HIV and with what agent?
WHEN: CD4
577
When should PROPHYLAXIS for MAC be started in a patient with HIV and with what agent?
WHEN: CD4
578
When should PROPHYLAXIS for TB (after positive PPD >5 mm/INTERFERON-γ release assay) be started in a patient with HIV and with what agent?
WHEN: whenever DIAGNOSED
WHAT: INH + Pyridoxine (vitamin B6) x 9 MONTHS
579
What effect does HIV infection have on LIPIDS?
DECREASES TOTAL, LDL and HDL cholesterol levels and INCREASED TRIGLYCERIDES
580
What effect do HIV MEDICATIONS have on LIPIDS?
INCREASE TOTAL and LDL (HDL remains decreased and TRIGLYCERIDES remain INCREASED)
581
What ART medication for HIV requires starting STATINS (atorvastatin) at a decreased level?
RITONAVIR
582
What happens to BODY FAT DISTRIBUTION with ART therapy in HIV patients?
TRUNCAL and VISCERAL FAT accumulation and FACIAL and EXTREMITY FAT LOSS
583
What effect does ART therapy in HIV patients have on blood glucose?
INCREASES due to INSULIN RESISTANCE that DEVELOPS or WORSENS with therapy
584
Avoiding which TWO (2) ART therapy drugs used in HIV can prevent BODY FAT DISTRIBUTION changes?
STAVUDINE and ZIDOVUDINE
585
Aside from BODY FAT REDISTRIBUTION seen with STAVUDINE and ZIDOVUDINE, these two agents as well as DIDANOSINE have a serious effect on a cellular component that can result in FATAL LACTIC ACIDOSIS and must be recognized EARLY?
MITOCHONDRIAL TOXICITY (replace the agents with EMTRICITABINE, LAMIVUDINE and TENOFOVIR
586
How is HIV-associated NEPHROPATHY treated?
By treating the HIV (can require dialysis/transplant)
587
What happens to patients co-infected with HIV and Hep B or Hep C?
TREAT for BOTH HIV and Hep B or C, patients may progress faster to CIRRHOSIS
588
What should be done with patients infected with HIV who have cardiovascular disease?
TREAT for BOTH, otherwise cardiovascular disease worsens and MORTALITY increases
589
What is IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME (IRIS)?
As HIV patients start ART treatment, their newly-rejuvenated immune systems react to existing antigen burden and cause significant inflammatory response
590
What pathogens are most COMMONLY associated with IRIS and how is IRIS handled?
FUNGI (MAC, TB), CONTINUE TREATMENT and ADD CORTICOSTEROIDS as needed
591
At what CD4 count do OPPORTUNISTIC infections become an issue, the SAME CD4 count that is DIAGNOSTIC of AIDS?
CD4
592
What FUNGAL infection can occur with HIV patients with CD4 counts >200/µL that occurs in immunocompetent patients as well, however affects HIV patients more profoundly?
OROPHARYNGEAL and ESOPHAGEAL CANDIDIASIS (treat with CLOTRIMAZOLE troches - oral or FLUCONAZOLE - esophageal)
593
This FUNGAL LUNG infection that DISSEMINATES to the SKIN and causes MENINGITIS typically occurs in HIV patients with CD4
CRYPTOCOCCAL infection
594
How is CRYPTOCOCCAL infection (pulmonary/skin/meningitis) treated in HIV patients (CD4
AMPHOTERICIN B + FLUCYTOSINE (for INDUCTION), then use FLUCONAZOLE
595
This FUNGAL PNA occurs in HIV patients with CD4
Pneumocystis jirovecii
596
How is Pneumocystis jirovecii pneumonia treated?
TMP-SMX (high-dose)
597
What happens EARLY on in the course of TREATMENT of Pneumocystis jirovecii in HIV patients with CD4
CLINICAL WORSENING with PO2
598
Eating UNDERCOOKED MEAT or contact with CAT FECES can cause ENCEPHALITIS in HIV patients with CD4
TOXOPLASMOSIS
599
How is TOXOPLASMOSIS treated in HIV patients (CD4
PYRIMETHAMINE + sulfadiazine/clindamycin OR TMP-SMX
600
What are the MOST COMMON OPPORTUNISTIC infections in HIV patients with CD4
Mycobacteria (MAC and TB)
601
What "RIF" drug CAN be used in treating TB in HIV patients (CD4
RIFABUTIN (NOT the standard rifampin)
602
How does TB tend to present in HIV patients (CD4
EXTRAPULMONARY (lymphadenopathy, HA, back pain, abd pain, abscess, pyuria) or with ATYPICAL lung findings (more commonly representing primary TB with ntra-thoracic LYMPHADENOPATHY and LOWER-LOBE disease than the expected "reactivation" TB)
603
Intra-thoracic LYMPHADENOPATHY and LOWER-LOBE disease is seen with what form of TB?
PRIMARY (REACTIVATION TB "secondary TB" usually involves the upper lung lobes and apices with infiltrates and cavitary lesions)
604
Infection with this FUNGAL OPPORTUNISTIC pathogen in HIV patients with CD4
Mycobacterium Avium Complex (MAC)
605
How is MAC treated in HIV patients (CD4
MULTI-DRUG regimen + CLARYTHROMYCIN or AZITHROMYCIN (MACROLIDES) "MAC - MACrolides"
606
Infection with this VIRUS in HIV patients with CD4
CMV (treat with GANCYCLOVIR or VALGANCYCLOVIR or FOSCARNET)
607
What MUST be done if you DIAGNOSE CMV RETINITIS in an HIV patient (CD4
IMMEDIATE OPHTHALMOLOGY evaluation with treatment using GANCYCLOVIR or VALGANCYCLOVIR or FOSCARNET
608
How is MOLLUSCUM CONTAGIOSUM (dome-shaped papules with central umbilication on FACE and NECK) - a POXVIRUS, treated in HIV patients?
By initiating ART, resolve on their own
609
What BARTONELLA-associated infection is confused with Kaposi Sarcoma in HIV patients?
Bacillary angiomatosis (cat scratch)
610
Bart and Pastur were both cats (Bartonella, Pasturella)
Mnemonic
611
MAC is treated with Multi-Drug regimen including MACrolides
Mnemonic
612
RED/PURPLE/BROWN macules, papules, plaques or nodules on SKIN and MUCUS MEMBRANES caused by Herpes Virus - 8 and occurs primarily in GAY MEN?
Kaposi Sarcoma
613
1. WHEN should you BEGIN TREATMENT of an HIV patient that is SYMPTOMATIC, CO-INFECTED with Hep B or C or one that has OR is at RISK for CARDIOVASCULAR DISEASE or with HIV-NEPHROPATHY, OPPORTUNISTIC DISEASES, MALIGNANCY or PREGNANT WOMAN? 2. WHEN should you BEGIN TREATMENT for ALL other HIV patients?
1. AS SOON AS DIAGNOSED with HIV REGARDLESS OF CD4 count
| 2. WHEN CD4
614
Treatment of HIV with at LEAST THREE (3) DRUGS from TWO (2) DIFFERENT CLASSES are required for what?
MAXIMAL SUPPRESSION of the HIV VIRUS
615
What is the PREFERRED HIV DRUG REGIMEN "Anti-Retroviral Therapy" in patients WITHOUT VIRAL DRUG RESISTANCE?
EMtricitabine + TENofovir + EFavirenz "Ten-Em-Ef" (ONCE DAILY, ONE PILL)
616
Which of the PREFERRED HIV DRUG REGIMEN drugs (Ten-Em-Ef) CANNOT be used in PREGNANT women?
"Ef" (EFavirenz, an RTI, due to Neural Tube Defects)
617
If you prescribe EFAVIRENZ to an HIV-infected PREGNANT woman you get an "EF"
Mnemonic
618
Which are the ALTERNATIVE drugs used instead of "Ef" (EFavirenz) that can be added to "Ten-Em" (EMtricitabine + TENofovir) when "Ef" (EFavirenz) is contraindicated such as in PREGNANT women?
RALTEGRAVIR or ATAZANAVIR or DARUNAVIR
619
What PURPOSE does RITONAVIR (protease inhibitor) serve when an HIV regimen must use other PROTEASE INHIBITORS (atazaNavir, daruNavir) such as when it is exchanged for "Ef" (EFavirenz) in PREGNANT women?
It INHIBITS the CYT P-450 enzyme thereby INCREASING the potency of the PROTEASE INHIBITORS (-"Navir")
620
What HIV drug is CONTRAINDICATED in combination with ANY PPI?
ATAZANAVIR - used as an alternate drug to "Ef" (EFavirenz) in PREGNANT women
621
What CLASS of HIV DRUGS are CONTRAINDICATED in combination with STATINS?
PROTEASE INHIBITORS -"Navir" (drugs that just end in "avir" without the "n" are NOT protease inhibitors)
622
For ALL NEWLY-DIAGNOSED HIV patients AND those with TREATMENT-FAILURE, this TESTING MUST be done?
RESISTANCE TESTING (for resistant viral strains) to guide therapy
623
WHEN should RESISTANCE TESTING for a possible HIV resistant viral strain BE DONE in a patient experiencing TREATMENT-FAILURE (rising viral loads that were once undetectable)?
WHILE STILL RECEIVING their standard drug regimen
624
Can HIV-infected women BREAST-FEED?
NO!!
625
What is the PREFERRED HIV DRUG THERAPY DURING PREGNANCY?
ZIDOVUDINE (AZT) + LAMIVUDINE (3TC) + lopiNavir/ritoNavir
626
ZIDOVUDINE (AZT) + LAMIVUDINE (3TC) + lopiNavir/ritoNavir is the PREFERRED HIV DRUG THERAPY for WHICH patients?
PREGNANT WOMEN
627
Influenza A & B VIRUSES involved with EPIDEMICS (affects a greater number of people than usual) and PANDEMICS (world-wide epidemic) are caused by what phenomenon?
Antigenic SHIFT ("shift" into high-gear") - only affects Influenza A virus
628
Influenza A & B VIRUSES involved with LOCALIZED outbreaks (small area) are caused by what phenomenon?
Antigenic DRIFT
629
Which INFLUENZA virus is MORE SEVERE and associated with Antigenic SHIFTS (responsible to epidemics and pandemics)?
Influenza A Virus
630
When are the INFLUENZA A & B viruses most active?
WINTER months (year-round in tropical regions)
631
In VERY YOUNG(65) and patients with chronic UNDERLYING disease, Influenza A/B viruses can cause what COMMON COMPLICATION?
PNA (primary viral, secondary bacterial - S.pneumoniae, S.aureus, H.influenzae)
632
If a RAPID INFLUENZA test is NEGATIVE?
DOES NOT EXCLUDE disease (low sensitivity - rules out)
633
If a RAPID INFLUENZA test is POSITIVE?
CONFIMERD DISEASE (high specificity - rules in)
634
WHOM can the LIVE, INTRA-NASAL INFLUENZA vaccine be used in?
HEALTHY, NON-pregnant and NON-immunocompromised persons AGED 2-49
635
What are OSELTAMIVIR and ZANAMIVIR?
Meds used BOTH for TREATMENT and PROPHYLAXIS against INFLUENZA A & B viruses (amantidine/rimantidine are no longer used due to resistance in U.S.)
636
Who should be treated or prophylaxed with OSELTAMIVIR or ZANAMIVIR for Influenza A & B viruses?
HOSPITALIZED patients, those with SEVERE, COMPLICATED or PROGRESSIVE illness and those at HIGH-RISK of influenza-associated COMPLICATIONS
637
WHEN should treatment with OSELTAMIVIR or ZANAMIVIR be started in APPROPRIATE patients for optimal effect?
WITHIN 2 DAYS of symptoms (can still be effective up to 4 days after symptoms especially for PREGNANT WOMEN and SEVERE illness)
638
WHOM SHOULD receive the ANNUAL INFLUENZA vaccine?
ALL persons >6 MONTHS (regardless of susceptibility)
639
What is the PRIMARY cause of CORNEAL BLINDNESS characterized by DENDRITIC ULCERS seen on FLUORESCEIN staining?
Recurrent HSV-1 KERATITIS
640
The most COMMON cause of sporadic ENCEPHALITIS that begins UNILATERALLY in the TEMPORAL LOBE causing HEMORRHAGIC NECROSIS presenting with AMS, personality/behavioral changes, fever, decreased consciousness and abnormal speech?
HSV
641
CSF findings in HSV ENCEPHALITIS (and all viruses)?
ELEVATED WBC's (pleocytosis - lymphocytes) and some RBC's with NORMAL GLUCOSE level and NORMAL/ELEVATED PROTEIN
642
What TOPICAL MEDICATION CANNOT be used in a patient with HSV-associated OCULAR infection?
TOPICAL CORTICOSTEROIDS
643
What medication is used to treat HSV ENCEPHALITIS?
IV ACYCLOVIR
644
What are VIDARABINE and CIDOFOVIR used to treat?
HSV-associated OCULAR INFECTION (keratitis)
645
What medication used INSTEAD of ACYCLOVIR to treat HSV ENCEPHALITIS (due to acyclovir resistance in severely immunocompromised patients) has been found to cause TTP after EXTENDED use in patients with AIDS?
VALCYCLOVIR (so use FOSCARNET or cidofovir)
646
A herpes virus, that when causing a PRIMARY infection p/w a HIGHLY-CONTAGIOUS generalized vesicular RASH that spreads from the FACE and EXTREMITIES to the TRUNK with lesions present in MULTIPLE STAGES (unlike in smallpox - variola virus)?
VARICELLA (chicken pox)
647
In HIGH-RISK patients such as IMMUNOCOMPROMISED, PREGNANT or NEWBORNS (born to mothers who have had peripartum varicella) who have a NEGATIVE or UNKNOWN h/o CHICKENPOX, have NOT BEEN VACCINATED against VARICELLA-ZOSTER and have been EXPOSED to the virus, what should be given as TREATMENT?
Varicella-Zoster Immune Globulin (IgG)
648
In patients (adults - not children, adolescents or high-risk for complications) who develop VARICELLA (chickenpox) or HERPES ZOSTER (shingles) infection, what is used for TREATMENT (within 24 HOURS of onset of lesions)?
ACYCLOVIR
649
Children 12-15 MONTHS old and AGAIN at 4-5 YEARS old should receive what VACCINATION?
VARICELLA vaccine (live)
650
A NEW IV antibiotic with coverage of AEROBIC Gm POS bacteria, especially MRSA and VRE and is ONLY indicated for the treatment of COMPLICATED SKIN and SOFT TISSUE INFECTIONS (SSI), BLOOD STREAM INFECTIONS and RIGHT-SIDED ENDOCARDITIS involving these organisms that ARE NOT RESPONSIVE to VANCOMYCIN (MIC ≥2) and is ABSOLUTELY NOT EFFECTIVE in the treatment of PNEUMONIA (inactivated by surfactant) but CAN cause a SERIOUS EOSINOPHILIC PNA as well as RHABDOMYOLYSIS requiring ALL patients on this drug to have ROUTINE CK-levels checked and drug STOPPED if >5x normal CK?
DAPTOMYCIN
651
A NEW IV antibiotic with coverage of AEROBIC Gm POS bacteria, especially MRSA, works BETTER than VANCOMYCIN (lower MIC and longer half-life), is used for the treatment of COMPLICATED SKIN and SOFT TISSUE INFECTIONS (SSI) ONLY but can cause NEPHROTOXICITY and therefore KIDNEY function MUST be monitored in ALL patients on this drug?
TELAVANCIN
652
A NEW IV & PO antibiotic with coverage of AEROBIC Gm POS bacteria, especially MRSA and VRE used for ORAL therapy and for PNEUMONIA (unlike DAPTOMYCIN) however can cause THROMBOCYTOPENIA (due to myelosuppression) requiring WEEKLY CBC's, MITOCHONDRIAL TOXICITY (fatal lactic acidosis) as well as PERIPHERAL & OPTIC NEUROPATHY?
LINEZOLID
653
A NEW IV antibiotic with coverage of AEROBIC Gm POS bacteria, especially MRSA, some Gm NEG bacteria including β-lactamase enterobacteria but has NO EFFECT on PSEUDOMONAS OR ACINETOBACTER and is used for the treatment of COMPLICATED SKIN and SOFT TISSUE INFECTIONS (SSI) including PNEUMONIA (unlike DAPTOMYCN) however NOT MRSA-PNEUMONIA?
CEFTAROLINE (5th gen cephalosporin)
654
A NEW IV CARBAPENEM antibiotic with HIGHER POTENCY against PSEUDOMONAS (than imipenem/meropenem) and is used to treat COMPLICATED ABDOMINAL and GU infections as well as HOSPITAl-ACQUIRED and VENTILATOR-ASSOCIATED PNEUMONIAS?
DORIPENEM
655
A NEW IV antibiotic with coverage of SOME ANAEROBES, AEROBIC Gm POS bacteria, especially MRSA and VRE, Gm NEG bacteria including CARBAPENEM-RESISTANT ENTEROBACTER (CRE) and ACINETOBACTER but NOT PSEUDOMONAS and used to treat COMPLICATED SKIN and SOFT TISSUE INFECTIONS (SSI), COMPLICATED ABDOMINAL infections and COMMUNITY-ACQUIRED PNEUMONIA (CAP) but CANNOT be used for treating BLOOD INFECTIONS (bacteremia) as it does NOT achieve high-serum concentrations nor adequate urine concentrations and thus cannot be used to treat GU infections - UTI's and has caused N/V and PANCREATITIS?
TIGECYCLINE
656
An antibiotic that is used for PROPHYLAXIS as well as TREATMENT of Pneumocystis jirovecii and has EXCELLENT MRSA coverage therefore used for treating COMPLICATED SKIN and SOFT TISSUE INFECTIONS (SSI) caused by CA-MRSA however can cause ALLERGY (Steves-Johnson Syndrome), HYPERKALEMIA and KIDNEY toxicity?
TMP-SMX
657
A NEW IV antibiotic(s) with coverage of Gm NEG bacteria including PSEUDOMONAS & ACINETOBACTER as well as ENTEROBACTER and are important in treating Gm NEG bacteria RESISTANT TO ALL other ANTIBIOTICS including CARBAPENEM-RESISTANT ENTEROBACTER (CRE) and is used in NEBULIZATION therapy for PNA in patients with CYSTIC FIBROSIS as well as for RESISTANT MENINGITIS however can cause NEUROTOXICITY and NEPHROTOXICITY?
COLISTIN (polymyxin E) and polymyxin B
658
A NEW PO antibiotic with coverage of Gm POS and Gm NEG bacteria including MRSA, VRE and MULTI-DRUG RESISTANT Gm NEG bacteria and is used in treating lower UTI's (CYSTITIS) especially in patients with DRUG-ALLERGIES as this medication does NOT cross-react with ANY other agent?
FOSFOMYCIN
659
These OLDER antibiotics have EXCELLENT activity against ACINETOBACTER, PSEUDOMONAS and CARBAPENEM-RESISTANT ENTEROBACTER (CRE) however they can cause NEPHROTOXICITY and OTOTOXICITY?
AMINOGLYCOSIDES (AMIKACIN, TOBRAMYCIN, GENTAMICIN, NEOMYCIN, STREPTOMYCIN)
660
This OLDER antibiotic has activity against MRSA and COAGULASE-NEG STAPHYLOCOCCI and is often used to treat infections associated with INDWELLING FOREIGN BODIES however CANNOT be used ALONE as monotherapy and is a STONG INDUCER of the hepatic CYT P-450 enzyme thus significantly lowering other drug levels used in the same patient?
RIFAMPIN
661
What TWO (2) medications are PREFERRED for OUTPATIENT ANTIMICROBIAL THERAPY (OPAT - IV/IM/SQ), AFTER the FIRST dose is administered under SUPERVISION, usually used for patients with SKIN and SOFT TISSUE INFECTIONS (SSI), OSTEOMYELITIS and BACTEREMIA because they are dosed INFREQUENTLY?
VANCOMYCIN and cefTRIAXONE
662
What FOUR (4) RECOGNIZED conditions is HYPERBARIC OXYGEN used to TREAT as an ADJUNCTIVE THERAPY and to decrease AMPUTATION RATES in persistent conditions despite APPROPRIATE MEDICAL and SURGICAL therapy?
Clostridial Gangrene, Necrotizing Fasciitis, Refractory Osteomyelitis and Chronic NON-HEALING Ulcers (diabetic, venous stasis, etc.)
663
Due to the ADVERSE EFFECTS of HYPERBARIC OXYGEN THERAPY such as BAROTRAUMA (middle ear, cranial sinuses and teeth), the TWO (2) ABSOLUTE CONTRAINDICATIONS to its use are what?
UNTREATED Pneumothorax and CHEMOTHERAPY with DOXORUBICIN or CISplatin ("Doc Says NO to OXYGEN")
