Block 3 - STDs, TB, UTI Flashcards
Patho of Tb?
Tubercle bacilli droplet is inhaled and smaller % enter bloodstream
Within 2-8wks, macrophages ingest them and they form a barrier shell (granuloma) aka latent Tb
If they cant keep it under control, bacilli multiplies
If latent Tb is present, what can it be detected by?
TST or IGRA
(T/F) Peeps with latent Tb are infectious
False, they dont spread to others
What are the classic CSF findings for Tb meningitis?
Hypoglycorrhachia (<45 glucose or ≤0.5 serum glucose of CSF)
What are the risks of developing Tb in someone with normal and weak immune systems?
Normal = about 10% will develop Tb in some point in their life
Weak = Untreated HIV individuals will have 7-10%/yr + children <5 have increased risk
Additional RF = diabetes and excessive alcohol use
M. tuberculosis is a (fast/slow) - growing organism that replicates in ____ hours and is visible in the culture at weeks ____
Slow growing organism - replicates in 20 hours and visible culture growth at 3-8 weeks
Immune response to Tb?
T lymphs are required
CD4 secrete interferon (IFN)-y to activate macrophages
Reactivation of Tb occurs when?
~10%; usually in the first 2 years (5%)
Duration of Tb Tx, regardless of AFB or CXR smear
How long is it?
2 months
Duration of Tb Tx, if both CXR and AFB smear are negative
How long is it?
Additional 4 months (6 months total)
or in some populations an additional 7 months (9 months total)
Duration of Tb Tx, if both CXR and AFB smear are positive
How long is it?
If the 2 month culture is negative, addition of 4 months (6 months total)
If 2 months = positive, check cavitation, if negative it’s also an additional 4 months (6 months total)
If that cavitation was present, then additional 7 months (9 months total)
On the Mantoux Tb test, what should you look for?
Raised, hard area or swelling
Redness alone isnt part of the rxn
What is the booster effect on the Tb skin test?
Pt shows up negative initially but has positive rxn if retested
Immunize them with BCG vaccine
They may have had tuberculosis in the past
≥5mm for TB skin test is positive in what groups?
HIV+
Recent contacts of infectious TB
w/ fibrotic changes consistent with prior TB
w/ organ transplant or other immunosuppressed pts
≥10mm for TB skin test is positive in what groups?
Recent arrivals in high-prevalence countries
IVDU
High-risk congregate settings (work, etc)
Mycobacteriology personnel
Increased risk for progressing to TB
Children <4yo
≥15mm for TB skin test is positive in what groups?
No risk factors for TB
What can cause false-positives in Tb skin tests?
NON tuberculous mycobacteria
BCG vaccine
Problems with TST admin
QuantiFERON-TB GOLD (QTF) is used to diagnose what?
Latent TB ONLY!
What does a positive TB skin test tell you?
That they are infected with TB bacteria. Not if its latent or active
Rifampin MOA?
Bactericidal, concentration dependent
Inhibits DNA-dependent RNA polymerase
How should rifampin be taken?
Empty stomach
Rifampin AE?
Liver damage, rash, orange-red urine
Rifampin DI?
Potent INDUCER of CYP450
If given with non nucleoside reverse transcriptase inhibitors (nevirapine or efavirenz) they need their doses increased
Bunch of other drug doses would need to be adjusted as well
Isoniazid MOA?
Bactericidal for dividing organisms and bacteriostatic for resting bacteria
Disrupts cell wall synthesis by inhibiting mycolic acid synthesis
How should isoniazid be taken?
Empty stomach!!
Isoniazid AE
Liver damage
Peripheral neuropathy (take w/ pyridoxine)
Neurotoxicity
Hematologic toxicity
Isoniazid DI?
Inhibits certain CYPs
Also interacts with tyramine
Pyrazinamide MOA?
Unknown, but bactericidal at acidic pH
Pyrazinamide AE?
Liver issues, arthralgia, gout exacerbation and photosensitivity
Ethambutol MOA?
Bacteriostatic
Interferes with mycolic acid incorporation into mycobacterium cell wall
Ethambutol AE?
Optic neuritis
Decreased visual acuity or red-green discrimination
Ethambutol DI?
Dont give w/ antacids
Which Rx are risk factors for UTI?
SGLT2 inhibitors (-gliflozin)
Ascending + Descending routes of UTI, what causes them?
Ascending (most common) = urethra colonized by fecal flora
Descending = hematogenous from distant infections
Which patient population is considered “complicated” UTI?
Pregnant
Males
Children
Diabetics
Any structural abnormalities
Clinical presentation in UTI?
Lower = local symptoms, systemic is rare
Upper = local symptoms often not present, but there is systemic effects
In the urinalysis (macroscopic), what should you focus on?
Leukocyte esterase (detects presence of WBC)
Nitrite test (only enterobacteriaceae + forms by bacteria that reduces nitrate to nitrite)
In the urinalysis (microscopic), what should you focus on?
≥10^5 CFU indicates UTI
≥10^2 is diagnostic in presence of Sx
In uncomplicated UTI, what are the causative organisms?
E. coli
+
S. saprophyticus (usually found in young sexually active females)
In complicated UTI, what are the causative organisms?
E. coli + Enterococcus spp
What bug causes pH of urine to increase?
Proteas (produces urease)
What are the common ESBL organisms for UTI?
E. coli + K. pneumoniae
Which bug doesnt reduce nitrate to nitrite?
Pseudomonas
What are the medications used for asymptomatic bacteriura?
≥10^5
Nitrofurantoin, Cephalexin, Augmentin
Bactrim (avoid in 1st and 3rd trimester)
What are the Rx for acute uncomplicated cystitis?
Nitrofurantoin x 5 days
Bactrim x 3 days (avoid if local resistance >20%)
Fosfomycin x once
How do you treat mild/moderate pyelonephritis?
FQ are first line (cipro, levo), if resistance >10% use 1g Rocephin or amino
Cipro x 7 days
Levo x 5 days
Could use Bactrim x 14 days
How do you treat severe pyelonephritis?
IV Abx for 10-14days
3rd/4th Cephs Extend-spec B-lac FQs Aminos Carbapenems
Explain the cipro surrogate marker
Levo’s susceptibility can be assumed based off of cipro’s for Enterobacteriaceae only
Peeps with recurrent UTI have what minimum of infections /year?
3+; start long-term prophylaxis and urine cultures every 1-2 months
What is the prophylaxis Tx for recurrent UTI?
Bactrim 0.5-1 tablet daily
Nitrofurantoin 50-100mg PO daily
**post-coital therapy = Bactrim 1 tablet after activity
What are the parenteral Tx options for complicated UTI?
3rd/4th Cephs Extend-spec B-lac FQs Aminos Carbapenems Aztreonam
What are the oral Tx options for complicated UTI?
Nitrofurantoin Bactrim FQs Augmentin Cefdinir or cefpodoxime Fosfomycin
Oral Abx for complicated UTI + AE?
Bactrim - rash, hyperkalemia, and increased SCr
Nitro - brown urine
FQ - QTc prolongation, hypo/hyperglycemia, BBW of tendonitis, other CNS stuff
How long do you Tx complicated UTI?
10-14 days
What is catheter-associated UTI?
S/Sx of UTI AND ≥10^3cfu in a single urine specimen (previous 48hrs0
How do you treat catheter-associated UTI?
Asymptomatic - remove catheter and no Abx needed
Symptomatic - remove catheter and treat as complicated infection
Other considerations: bacteriuria ≥48hrs, Abx may be needed
How long do you treat catheter-associated UTI?
Women <65 w/o upper UTI sx after catheter removal = 3 days
Quick resolution of sx = 7 days unless its levo, then 5 days
Persistent sx = 10-14 days
How does acute vs chronic prostatitis present?
Acute = systemic effects
Chronic = lower back pain, suprapubic discomfort
How long do you treat prostatitis?
Acute = 4-6wks
Chronic = 6-12wks
Prostatitis Tx?
Bactrim, FQs
Zosyn, 3rd Gen cephs, doxy/mino
Treating latent TB with Isoniazid, what is the direction?
300mg daily for 9 months, give w/ HAART
Treating culture positive pulmonary TB, what is the regimen?
RIPE for 7 days/week for 8 weeks (initial phase)
R+I only for 7 days/week for 18 weeks
Monitoring parameters of specimen for TB?
Acid-fast bacilli smear, sample q1-2wks until 3 consecutive smears are negative
Do monthly sputum cultures until 2 consecutive cultures are negative
Who receives DOT (direct observation therapy) for Tb?
Tx failure, HIV, Drug-R isolate, Positive smear, substance abuse, psychiatric issues, non-adherence
What causes gonorrhea and chlamydia?
Gonorrhea = N. gonorrhoeae
Chlamydia = Chlamydia trachomatis
What bug causes syphilis?
T. pallidum
What bug causes chancroid?
H. ducreyi
For frequent co-infections of urethritis or cervicitis, what bugs should the drug regimen cover?
Gonorrhea and chlamydia
Presentation of gonorrhea?
Often asymptomatic (esp in females
Dysuria
Green/white discharge
RF for STDs?
of partners (#1 greatest RF)
Male on Male
Prostitution
Illicit Rx use
Colonizers and bugs in vagina/prostate?
Colonizer for vagina only: LAG (lactobacillus, anaerobes, G. vaginalis)
Pathogens for vagina: TEC (T. vaginalis, enteric pathogens, C. albicans)
Pathogens for prostate: PES (UT pathogens + P.aeruginosa, enterococcus spp., S. aureus)
How is gonorrhea treated?
Ceftriaxone 250mg IM AND azithromycin 1g PO x1
How does disseminated gonococcal infection presented?
Skin lesions (red/purple spots), asymmetric arthralgia or septic arthritis
How is disseminated gonococcal infection treated?
Ceftriaxone 1g IM/IV for at least 7 days AND azithromycin 1g PO x1
How is chlamydia presented?
Often asymptomatic
How is chlamydia treated?
Azithromycin 1g PO x 1
or
Doxy 100mg PO BID x 7days
How is bacterial vaginosis diagnosed?
3 of the 4 are required:
Thin, white discharge
Vaginal skin cell + bacteria stuck to edges
pH>4.5
Whiff test positive (fishy odor before or after 10% KOH is added)
How is bacterial vaginosis treated?
Flagyl 500mg PO BID x7days
Flagyl 5g gel intravaginallydaily x5days
Clinda 5g cream intravaginally at bedtime x7days
How is syphilis diagnosed?
SCREENED via nontreponemal test (detects anti-cardiolipin ABs or RPR test)
CONFIRMED via treponemal test (detects anti-treponemal or fluorescent AB)
Primary syphilis info?
10-90 days after infection
Single painless ulcer found where the bacteria entered body
Secondary syphilis info?
2-8wks after initial infection
Painless skin rash, mucocutaneous lesions, systemic sx
Latent syphilis info?
Sx of primary or secondary syphilis
Seroconversion in nontreponemal titers for >2weeks
If it occurs within a year = early latent
If >1yr or unknown = late latent
Tertiary syphilis info?
10-30 yrs after initial infection
Muscle issues or paralysis
Gradual blindness
Dementia
Gumma (soft inflammatory masses)
Neurosyphilis info?
Occur at any stage
Neurological issues
Syphilis Tx?
Primary, secondary, early latent syphilis = BENZATHINE Peng G 2.4mil x1
Tertiary, late latent syphilis, or unknown = BENZATHINE Peng G 2.4mil weekly x 3 doses
Neuro or ocular syphilis = Aq crystalline Pen for 10-14 days
What is a Jarisch-Herxheimer Rxn?
May occur in first few hrs after Pen. is given for syphilis. Treat w/ antipyretics, but dont stop Pen. regimen
Pen. allergy + syphilis Tx?
Primary/Sec syphilis = Doxy, tetra, ceftriaxone x ~14 days
Latent = Doxy, tetra x28 days
Tertiary = ID specialist
If pregnant or neurosyphilis, do penicillin desensitization
Chancroid presentation?
Multiple painful genital ulcers w/ or w/o regional lymphadenopathy
How is Chancroid treated?
Azithromycin 1g PO x1
or
Ceftriaxone 250mg IM x1
or
Cipro 500mg PO BID x3days
Follow up in 3-7days
How are HPV genital warts presented?
Often asymptomatic
Soft growth on genitals
Types 6 + 11 are the ones that cause genital warts
How are genital warts treated?
Specific antivirals are not recommended
You can prevent them with HPV vaccine. Recommended at 11-12 yrs old, CDC says 9-26 is okay, now FDA says 27-45 is good too
Genital wart vaccine info?
Cervarix (bivalent) covers only 16 + 18 (cervical cancer only)
Gardasil (covers 6,11,16,18)
Gardasil-9
All given with 3 dose series over 6 months
Genital herpes info?
Type 1: usually oral, but can be genital
Type 2: genital
Chronic lifelong infection with painful lesions
Genital herpes treatment?
First episode: acyclovir 400mg PO TID x7-10days
or
Valacyclovir 1g PO BID x7-10days
Then use suppressive therapy
Pretty much the same above but daily + famciclovir 250 mg PO BID
Trichomoniasis presentation?
Occurs in males and females
Most prevalent non-viral STD in US
Trichomoniasis treatment?
Flagyl 2g PO x1
or
Tinidazole 2g PO x 1
Follow up in 3months in women
VVC presentation?
Painful intercourse, abnormal discharge,
Not usually sexually transmitted, but has STD-like sx
Classification of VVC?
Recurrent OR severe OR Non-albicans candida OR has DM, immunocompromised or debilition = Complicated
Uncomplicated would be milder versions above and would include “AND” for each item
How is uncomplicated VVC treated?
OTC = Tioconazole, Miconazole, Clotrimazole
Rx = Fluconazole 150mg x1, butoconazole, terconazole
How is complicated VVC treated?
Topical therapy for 7-14 days or fluconazole 150 PO every 72hrs (2 doses)
What is the expedited partner therapy program?
Treat all partners of chlamydia or gonorrhea for the past 60 days (heterosexual)
Which PID pt can be treated in outpatient?
Temp <38, WBC<11k, minimal evidence of peritonitis, active bowel sounds, and is able to tolerate oral nourishments
Outpatient PID tx?
- Ceftriaxone 250mg IM x1 + doxy 100mg PO BID 14 days
- Cefoxitin 2g IM x1 + Probenecid 1g PO x1 + Doxy 100mg PO BID x 14 days
- Flagyl 500mg PO BID x14 days can be added for more anaerobic coverage
Inpatient Beta lactam regimen for PID?
Cefotetan 2g q12h + doxy 100mg q12h
Cefoxitin 2g q6h + doxy 100mg q12h
Unasyn 3g q6 + doxy 100mg q12
**doesnt cover M. genitalium
Inpatient Beta lactam free regimen for PID?
Clinda 900mg q8h + gent 2mg/kg LD then 1.5mg/kg q8h
**doesnt cover M. genitalium
When can pt be switched from IV to PO for PID?
After they are stable for 24-48 hrs
If tx failure exists for PID, whats next?
Check for M. genitalium, then start Moxi 400mg PO daily for 14 days
