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Clinical Practice > Acute medicine and infectious diseases > Flashcards

Acute medicine and infectious diseases Flashcards

1
Q

what is the first line treatment of post-herpetic neuralgia?

A

amitriptyline
gabapentin
duloxetine
pregabalin

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2
Q

what are the causes of bilateral swellings?

A 
systemic
cardiac
renal
low serum albumin
dependency oedema
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3
Q

what are the causes of unilateral swellings?

A 
arterial
venous
lymphatic
cellulitis
baker's cyst
haematoma
joint pathology
lymphoedema
superficial thrombophlebitis
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4
Q

what questions would you ask a patient regarding limb swelling?

A 
uni/bilateral
acute/chronic
history of pain
history of trauma
skin changes
adverse impact on mobility
systemic symptoms; fever, dyspnoea, night sweats, weight loss, loss of appetite
medical history; DVT, malignancy, lymphoedema
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5
Q

what are the mode of action of OCP?

A

inhibit ovulation by suppressing the release of gonadotrophins from hypothalamus

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6
Q

what are the common side effects of OCP?

A 
nausea
breast tenderness
mood changes
break-through bleeding
increased risk of thromboembolism, ischaemic disease, breast cancer
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7
Q

what are the clinical features of compartment syndrome?

A

loss of muscle function
pain on active or passive contraction
muscle eventually shortens
patient develops ischaemic contracture

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8
Q

what are the causes of compartment syndrome?

A

venous occlusion
trauma
reperfusion injury
misplaced arterial or venous cannula

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9
Q

how is a patient with a Well’s score >/= 2 managed?

A

USS of leg
DVT; anticoagulant
negative; check D-dimer, if positive, do another USS in 6-8 days

or

check D-dimer
positive; anticoagulant
USS within 24hrs
positive; continue anticoagulant
negative; stop anticoagulant and repeat USS in 6-8 days
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10
Q

what are the causes of fever?

A 
infection
malignancy
drug fever
autoimmune
inherited fever syndromes; familial Mediterranean fever
acute inflammatory processes; PE
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11
Q

describe serology

A

used to detect antibodies against a certain pathogen or detect antigens associated with a certain pathogen
e.g.; HIV, EBV, ASOT, leptospirosis, malaria, leishmania

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12
Q

what are the advantages and disadvantages of serology?

A

can identify organisms that are difficult to culture
point of care tests
retrospective diagnosis
can be used to monitor treatment response

false positives/negatives
relies on correct interpretation

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13
Q

what is associated with neutrophil increase?

A

acute inflammation/bacterial

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14
Q

what is associated with lymphocyte increase?

A

viral

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15
Q

what is associated with eosinophil increase?

A

allergy

psoriatic infection

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16
Q

what biochemical and clinical values are required in sepsis?

A 
oxygen levels; requiring mechanical ventilation
platelets
bilirubin
GCS
MAP
vasopressor requirements
creatinine
urine output
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17
Q

what are the signs and symptoms associated with UTIs?

A 
dysuria
new nocturia
increased frequency
urgency
strong smelling urine
cloudy urine
blood stained urine
persistent lower abdominal pain
upper UTIs; loin pain, fever
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18
Q

describe lower UTIs

A

cystitis; bladder

urethritis; urethra

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19
Q

describe upper UTIs

A

pyelitis; proximal part of the ureters
pyelonephritis; kidneys
can cause renal scarring, abscess, failure and sepsis

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20
Q

what are the risk factors for developing UTIs?

A 
sexual activity
use of spermicidal agents
female
UTI Hx
increasing age
urologic abnormalities
debilitating comorbid conditions
urinary catheter
recent urinary tract instrumentation
wiping back to front
not urinating/drinking water within 15 minutes of sex
washing genitals with soap after urinating
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21
Q

what is the management of asymptomatic bacteruria?

A

nothing in non-pregnant women

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22
Q

what is the initial management of suspected pyelonephritis or suspected sepsis?

A

urine culture
antibiotics/management for upper UTI/sepsis
refer if symptoms or signs of serious illness or condition appear

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23
Q

describe urinalysis results in UTIs

A

nitrite; positive helpful to rule in a UTI, negative does not exclude a UTI
leucocyte esterase; produced in response to inflammation

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24
Q

how is a UTI diagnosed?

A

in the presence of 2 or more urinary symptoms (dysuria, frequency, urgency, visible haematuria, nocturia) and a positive dipstick test result for nitrite

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25
Q

describe asymptomatic bacteruria and UTIs in pregnancy

A

asymptomatic bacteruria; risk factor for pyelonephritis and premature labour
UTIs; associated with developmental delay, cerebral palsy, foetal death

treat after confirming with 2nd sample to exclude contamination

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26
Q

what is the treatment of a lower UTI?

A

nitrofurantoin 100mg 6hrly PO with food
or
pivmecillinam 400mg PO loading dose, then 200mg PO 8hrly
female 3 days, male 7 days

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27
Q

what is the treatment of an upper UTI?

A

gentamicin 5mg/kg 24hrly IV
or
piperacillin-tazobactam 4.5mg 8hrly IV
7-10 days

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28
Q

what is the treatment of urosepsis?

A

piperacillin-tazobactam 4.5mg 8hrly IV
+
gentamicin 5mg/kg 24hrly IV

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29
Q

what is the lifestyle management of UTIs?

A

increasing fluid intake
NSAIDs
insufficient evidence for cranberry juice, herbal products, lactobacillus

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30
Q

describe the pathogenesis of meningitis

A

haematogenous spread, direct contiguous spread, iatrogenic
immune system activation
cytokine production
increased BBB permeability, altered cerebral blood flow, leukocyte adherence to capillary endothelium, increased reactive oxygen species
changes in CSF flow and composition
neuronal damage, increased ICP and cerebral oedema

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31
Q

what is the differential diagnosis of acute bacterial meningitis?

A 
fungal meningitis
TB meningitis
amoebic meningitis
syphilis
atypical infections in the immunocompromised
vial meningitis/encephalitis
inflammatory meningitis
carcinomatous/lymphomatous meningitis
SAH
intracranial venous thrombosis
tonsilitis
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32
Q

what are the clinical signs of meningitis?

A

rash; neiserria meningiditis in adults, meningococcal meningitis in children
children; kernig’s sign, brudzinski’s sign

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33
Q

what investigations are required to diagnose meningitis?

A 
bloods; FBC, U&E, creatinine, LFTs, coag
procalcitonin
meningococcal and pneumococcal PCR
serology sample
glucose
throat swab; bacterial culture
CSF; protein, glucose, lactate, meningococcal and pneumococcal PCR, microscopy, culture, sensitivity
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34
Q

what features of infection should delay a LP?

A 
signs of severe sepsis
rapidly evolving rash
respiratory/cardiac compromise
anticoagulant therapy
known thrombocytopenia
infection at LP site
focal neurological signs
papilloedema
continuous/uncontrolled seizures
GCS <12
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35
Q

describe viral meningitis

A 
accounts for 50-80% of total meningitis
WCC and CRP often normal
CSF used for PCR
no treatment of proven benefit
IV aciclovir; suspected HSV encephalitis, changes in personality, behaviour, cognition or altered conscious level
36
Q

describe infection control in viral meningitis

A

isolation until meningococcal disease excluded or 24hrs IV ceftriaxone
antibiotic chemoprophylaxis for those exposed to respiratory secretions or droplets of meningococcal disease; during CPR or intubation

37
Q

what are the risk factors of staphylococcus aureus bacteraemia?

A 
recent hospitalisation
surgery
vascular device
IV drug use
haemodialysis
previous SAB
38
Q

what are the sources of staphylococcus aureus bacteraemia?

A 
vascular device
skin/soft tissue/wound
septic arthritis
osteomyelitis
discitis
endocarditis
prosthesis
infected DVT/septic thrombophlebitis
pneumonia
39
Q

what is the treatment of staphylococcus aureus bacteraemia?

A

minimum 2 weeks IV flucloxacillin

40
Q

what is the clinical management of staphylococcus aureus bacteraemia?

A

examine and investigate to find source
source control; joint washout, remove IV device
transthoracic echo (in all patients)
repeat blood cultures 48-96hrs after starting IV antibiotics

41
Q

what are the symptoms and signs of infective endocarditis?

A 
fever
chills
poor appetite
weight loss
heart murmurs
emboli to lung, spleen and brain
42
Q

what are the risk factors for developing infective endocarditis?

A 
prosthetic valve
native valve disease
cardiac device
male
IV drug use
recent dental procedure
43
Q

what are the causative organisms of infective endocarditis?

A 
streptococcus
staph aureus
coagulase negative staphylococci
enterococcus
HACEK
44
Q

what is the treatment of infective endocarditis?

A

ampicillin 12g IV with flucloxacillin 12g IV with gentamicin 3mg/kg/day IV
or
vancomycin 30-60mg/kg/day IV with gentamicin 3mg/kg/day IV

45
Q

in what cases should antibiotic prophylaxis be considered for infective endocarditis?

A

any prosthetic valve
previous episode of IE
current CAD
certain dental procedures (not all)

46
Q

what is the immediate management and investigations of VHF?

A 
isolate in a side room
urgent malaria investigation
FBC, U&E, LFT, coagulation, CRP, glucose, blood cultures
inform laboratory of possible VHF case
blood cultures
VHF screen
47
Q

what are the symptoms and signs of malaria infection?

A 
return from an exposed country
fever
headache
myalgia
abdominal pain
tachycardia
fever
48
Q

what is the treatment of malaria?

A

IV artesunate
IV meropenem; covered for fever
stop if blood cultures return negative and patient improves
improvement; switch to artemisinin-based combination therapy (ACT)

49
Q

describe the host defences to infection

A

physical barriers; skin, mucous, GI and urinary tract flushing, normal microbiota
innate immunity; phagocytes, complement system, NK cells
adaptive immunity; B and T lymphocytes

50
Q

what is the treatment of COVID-19 pneumonitis?

A

tocilizumab and dexamethasone

51
Q

what are the signs of infection that are inhibited by COVID-19 pneumonitis treatment?

A

tocilizumab; suppresses pyrexic response and CRP

dexamethasone; causes neutrophilia

52
Q

what are the symptoms and treatment of pneumocystis jirovecii infection?

A 
weight loss
exertional dyspnoea
fever
dry cough
pleuritic chest pain
immunosuppression

high dose co-trimoxazole 14 days

53
Q

describe pneumocystis jirovecii infection of a HIV positive patient

A 
gradual onset
time to respiratory failure 2 weeks to 2 months
more PCP and less neutrophils
less severe oxygen impairment
diagnosis with clinical picture and PCR
adjunctive corticosteroids in hypoxia
high dose co-trimoxazole 21 days
prophylaxis for CD4 <200
54
Q

describe pneumocystis jirovecii infection of an immunosuppressed patient (not HIV)

A

time to respiratory failure 1 week
less PCP and higher inflammatory markers in BAL
suggests severe or dysregulated inflammatory response
diagnosis more difficult; fewer organisms, upper respiratory samples frequently negative

consider use of beta D glucan
high dose co-trimoxazole 134 days

55
Q

describe HIV immunosuppression

A

HIV infects CD4+ T cells
normal CD4 count; evidence of immune dysregulation
heavily immunocompromised once CD4 <200

56
Q

describe immune reconstitution inflammatory syndrome

A

IRIS
occurs in patients with AIDS; CD4 <100mm3
preexisting infectious process that worsens paradoxically after initiation of highly active antiretroviral therapy

57
Q

define severe sepsis

A 
already in sepsis;
altered conscious level
or
hypoxia; <94%
or
shock; SBP <90
58
Q

how is neutropenic sepsis identified and treated?

A

assume in all haematology/oncology patients within 6/52 SACT
observations; temp, HR, BP, O2, AVPU
commence NEWS
IV access and blood; cultures, FBC, U&E, CRP, LFTs, venous lactate
treatment; 1st line antibiotics immediately, consider need for IVF and supplemental O2
commence neutropenic sepsis care pathway

59
Q

what is the antibiotic treatment in neutropenic sepsis?

A

piperacillin 4g and tazobactam 500mg IV QDS
or
ciprofloxacin 600mg slow IV BD, gentamicin 5mg/kg IV BD after line flush and teicoplanin 10mk/kg IV (BC x 3 then OD)

60
Q

describe the prophylaxis management of infection recurrence in stem cell transplants

A

HSV; acyclovir 400mg PO BD
CMV; letemovir 280mg PO OD 100 days post-transplant
PCP; co-trimozaxole once neutrophils and platelets recovered
fungal; posaconazole, itraconazole, fluconazole

61
Q

what infections should we watch for when beginning a TNF alpha inhibitor?

A 
TB; CXR, IGRA (latent TB)
hep B & C; HBsAg
HIV
VZV; VZV antibody test if they have no history of chickenpox
leishmaniasis
endemic mycoses
62
Q

what is the treatment of latent TB?

A

for those with HIV, <65 with evidence of latent TB and have been in contact with suspected/confirmed TB

3 months isoniazid and rifampicin
or
6 months isoniazid

63
Q

what is the management of patients with infection on immunosuppressive drugs?

A

lower threshold for starting broad spectrum antibiotics only
speak with team about potential for stopping/holding/decreasing dose of relevant drugs
do not stop their anti-rejection transplant drugs
hold any DMARDs for inflammatory conditions until infection resolved/resolving

64
Q

describe bacteriostatic antibiotics

A

inhibits bacterial growth

assumed to require phagocytic cells to definitely clear bacteria

65
Q

describe bactericidal antibiotics

A

kills bacteria
preferred in serious infection and immunocompromsied
e.g.; beta lactase, polymyxins, vancomycin, quinolone, rifampicin, chloramphenicol, aminoglycosides

66
Q

what is the treatment of cellulitis caused by MSSA?

A

flucloxacillin IV 2g QDS
penicillin allergic alternative; vancomycin or clindamycin
check weight, renal function and drug interactions before prescribing

67
Q

how is an anaphylaxis reaction diagnosed?

A

look for;
acute onset of illness
life-threatening breathing/airway/circulation problems
usually skin changes

68
Q

what is the management of an anaphylaxis reaction?

A

IM adrenaline; 500mcg IV (>12yrs)
IVF challenge; 500-1000ml
stop IV colloid; may be the cause of anaphylaxis

69
Q

describe a type 1 hypersensitivity reaction

A

allergy
IgE mediated
symptoms; urticaria, anaphylaxis

70
Q

describe a type 2 hypersensitivity reaction

A

IgG and FC receptor mediated

symptoms; blood cell dyscrasia

71
Q

describe a type 3 hypersensitivity reaction

A

IgG complement/FC receptor

symptoms; vasculitis

72
Q

describe a type 4 hypersensitivity reaction

A

T-cell mediated

symptoms; eczema, exanthema, DRESS, TEN

73
Q

what is the difference between a severe and non-severe penicillin allergy?

A

severe; anaphylaxis, angioedema, urticarial rash, pruritus, wheezing/stridor usually within 1hr
non-severe; maculopapular/morbilliform rash, serum sickness usually within 24hrs

74
Q

what is the standard treatment of a patient with pneumonia with a CURB65 of 2?

A

no cultures back
amoxicillin 1g 8hrly PO IV + clarithromycin 500mg 12hrly PO
or
doxycycline 100mg 12hrly PO

75
Q

what is the best antibiotic treatment for a patient with legionella pneumophilia pneumonia?

A

levofloxacin

alternative; in torsade de pointes, doxycycline

76
Q

what is the management of levofloxacin-induced tornadoes de pointes?

A

stop all drugs known to prolong the QT interval
correct electrolyte abnormalities, especially hyperkalaemia
magnesium sulphate 2g IV / 10mins
adverse features; arrange immediate synchronised cardioversion
pulseless; attempt defibrillation immediately
stop levofloxacin; treatment with alternative (doxycycline)

77
Q

which drugs prolong the QT interval?

A

antiarrhythmics
antihistamines
antipsychotics; haloperidol, chlorpromazine
atypical antipsychotics; citalopram, zimelidine
antibiotics; macrolides, fluoroquinolones, anti-malarials, pentamidine
anti-emetics; ondansetron, domperidone

78
Q

name the macrolide antibiotics

A

erythromycin
clarithromycin
azithromycin

79
Q

name the fluoroquinolone antibiotics

A

ciprofloxacin
levofloxacin
moxifloxacin
ofloxacin

80
Q

what are the dangerous side effects of fluoroquinolone antibiotics (stop taking immediately)?

A 
tendon pain or swelling
join pain
swelling of the arms, shoulders, legs
abnormal pain or sensations; pins and needles etc.
weakness; in legs, arms, difficulty walking
severe tiredness
depressed mood
anxiety
problems with memory
sleeping problems
changes in vision, smell, taste, hearing
81
Q

describe fulminant c. diff infection

A

presence of hypotension, shock, ileus, toxic megacolon, colonic perforation

82
Q

what is the management of fulminant c. diff infection?

A

discontinue concomitant antibiotics
stop any PPI treatment if unnecessary
surgical review indicated
vancomycin 500mg PO NG QDS + metronidazole 500mg IV TDS 10-14 days

presence of ileus/NBM; intra-colonic vancomycin 500mg in 100ml NaCl 0.9% QDS + IV metronidazole 500mg TDS 10-14 days

83
Q

what antibiotics have c. diff as a common side effect?

A 
clindamycin
cephalosporins
monobactams
carbapenems
fluoroquinolones
penicillins
tetracyclines
84
Q

what is the clinical presentation of IM?

A

abrupt onset of severe sore throat with cervical lymphadenopathy
or
gradual onset of low-grade fever, malaise, arthralgia, myalgia

acute, generalised maculopapular rash, non-itchy
more intense and extensive cutaneous eruption appears in up to 90% 2-10 days after starting antibiotics

85
Q

describe the immediate treatment of someone with a bacterial infection

A

thorough drug allergy history
antibiotic treatment within 1hr of diagnosis of severe sepsis or life-threatening infection
comply with local antibiotic prescribing guidance
document clinical indicate, dose and route
include review/stop date
obtain cultures prior to commencing therapy if possible but do not delay treatment

86
Q

describe the clinical review and decision at 48-72hrs of someone with a bacterial infection

A

check microbiology; stop, IV to oral switch, change antibiotic, continue, OPAT
document all decisions

Clinical Practice (14 decks)

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