High Yield Flashcards
Treatment for Trichinella
Albendazole/Mebendazole
What are notable misses of Amphotericin?
candida lusitanae
candida auris
aspergillus terreus
scedosporium (vori)
Fusarium (+/-)
What does vori miss?
Mucor
When does CAP turn into HAP?
48 hours
vanco IgA bullous dermatosis
Traveller returns from Thailand with fever, myalgias and headache. He returned 3 weeks ago before onset of symptoms.
What is in play?
Malaria (up to 40 day incubation)
Typhoid (5-21 day incubation)
Shorter incubations:
Dengue up to 14
Zika up to 14
Chikungunya up to 14
Rickettsial/Salmonella/JEV/Yellow fever all shorter
Difference between FMF and TRAPS?
Rash in TRAPS - rare in FMF
When do you start ART?
In general, start immediately or next clinic visit. Reasonable to delay if concern for active comorbid condition/OI.
Even with most OI’s star w/in 2 weeks. Zolopa et al 2009. early ART arm resulted in lower AIDS progression and mortality with no increase in AE’s compared to alter arm.
Patient is Dx with AIDS AND ACTIVE PULMONARY TB. How do you approach?
Start anti TB therapy (RIPE)
- if CD4 < 50, start ART w/in 2 weeks (severe IRIS is a risk, however benefits of AIDS progression/mortality with early ART outweigh that risk)
- if CD4 > 50, start ART within 8 weeks
Patient is Dx with AIDS AND CNS TB. How to approach?
Delay ART x 4-8 weeks of TB therapy. IRIS can manifest as paradoxical worsening and cause increase cerebral edema. Also give steroids.
Torok et al 2011 https://www.nejm.org/doi/10.1056/NEJMoa040573
Patient is Dx with AIDS AND CRYPTO MENINGITIS. How to approach?
- Ampho + Flucytosine (fluconazole)
- Initiate ART 2-10 weeks after antifungal therapy is initiated (IDSA Guideline).
- Benefits of immune recovery vs risk of IRIS. Trials show improved survival in delayed ART in crypto meningitis patients. Studies are in resource-limited countries – unclear if same applies to resource-rich. 20415574 24963568 23362285
- NO STEROIDS (it’s like sugar for fungus)
What do you do if an patient is Dx with AIDS and:
- Cocci (not meningitis)
- PCP
- Toxo
- CMV retinitis and neurologic disease
- Cocci: initiate within 2 weeks (except in meningitis)
- PCP: Initiate within 2 weeks of dx (preferably when stable on PCP regimen; Zolopa et al 2009 19440326)
- Toxo: Initiate within 2 weeks of dx (preferably when stable on toxo regimen; Zolopa et al 2009, IDSA guideline)
- CMV: Evidence Unclear – but recommended to start ART within 2 weeks after initiating therapy for CMV (IDSA guideline)
How to approach HIV and pregnancy?
Initiate ART ASAP (if not suppressed by 28 weeks, much higer rates of transmission)
Bictegravir and TAF not currently preferred in pregnancy (limited clinical data)
Preferred NRTI backbones in pregnancy?
TDF-FTC
abacavir-lamivudine
Preferred integrase and protease inhibitors in pregnancy?
dolutegravir (prev assoc w/NT defects, but subsequent data does not suggest) and raltegravir
Darunavir/Riton or Atazanavir/Riton
treatment for RMSF in pregnancy?
chloramphenicol
(aplastic anemia)
How do you approach TB in pregnancy:
Latent
Active
- Latent: avoid until 3 months post partum (not worth it unless AIDS or exposure to known active pulmonary TB- Rif regimens preferred)
- Active: treat with INH + rif + ethambutol x 2 months, then INH/Rif x 7 months (plus pyridoxine)
- *pyrazinamide is recommended by WHO but not CDC due to lack of safety data
- *avoid aminoglycosides, quinolones
A patient from TX presents with 6 plaques over his body on which he has no feeling. What is this and what is the treatment?
Does he need to be isolated?
Multibacillary or Lepromatous Leprosy
Dapson, rifampicin and clofazimine x 2 years
No - all guidelines suggest against isolation (although appears to be transmitted through respiratory droplets)
Patient starts treatment for lepromatous leprosy and develops multiple erosions and ulcers with serrated edges. What is this?
How would you treat?
Necrotic Vasculitis or “Lucio’s Phenomenon”
Hemorrhagic/Necrotic vasculitis resulting from treatment of lepromatous leprosy
treat with steroids and supportive care. Consider plasmapharesis and severe cases.
Also consider:
Type 1: Reversal Reaction (worsening of nodules/plaques treated with steroids)
Type 2: Erythema Nodosum Leprosum (similar except develop fevers/fatigue - treated with steroids and thalidomide)
*both can also develop neuritis
What is the post exposure ppx rabies shot series in a patient previously unvaccinated?
0 , 3, 7, and 14
https://www.cdc.gov/rabies/medical_care/vaccine.html
what is the infectious differential for eosinophilic meningitis (5)?
What are the associations and treatment?
Angiostrongylus - Asia, Hawaii, rats, snails/slugs - supportive care
Baylisascaris - US, racoons - albendazole
Gnathostoma - wide-spread, fish, pigs, snakes - no proven rx (albendazole)
Cryptococcus - HIV - Ampho+fluc
Coccidioides - West- fluc
which steroid is not metabolized by CYP?
beclometasone
When do you start ART in a patient diagnosed with MAC and AIDS?
ART should be started as soon as possible after the diagnosis of MAC disease
What are the indications for Valve Surgery in IE?
STRONG INDICATIONS
- HF
- Pulm HTN
- Fungi/highly resistant orgs
- INVASION (abscess, sinus, heartblock, etc)
Less Strong Indications
- emboli
- vege > 10mm
Patient with neisseria meningitis started on treatment - when to DC airborne precautions?
24 hours on treatment
Who gets Post Exposure Ppx for neisseria meningitis?
When should it be initiated?
What regimen?
- “Close Contacts” in general 8 hours of exposure within 3 feet
- Healthcare workers (unless direct exposure to respiratory secretions) usually do not need to be treated
- Ideally within 1 hour - but up to 14 days (Beyond 14 days not recommended)
- Rifampin, Cipro or ceftriaxone (2 days or single dose ceftriaxone)
Patient with ICD and + BCx for Staph aureus. When can device be re-implanted?
Negative blood cultures x 72 hours
When might you consider NOT removing an ICD with a positive blood culture?
GNR (e coli) with negative TEE and no suspicion of pocket infection
what bacteria have intrinsic resistance to polymyxins?
MAPPS
Morganella “and”
providencia
proteus
Serratia
Chroni
N155H, Y143C, T66I
Integrase mutations
Preferred treatment for NDM infection?
Avy-Caz + Aztreonam
or, cefiderocol
Aztreonam is resistant to NDM, but susceptible to other BL’s - therefore give Avy-Caz so the avibactam protects the aztreonam.
commercially available beta lactamase inhibitor for NDM?
Doesn’t exist…
what mutation causes dapto resistance in staph aureus?
mprF - changes charge of cell membrane disrupting dapto binding
treatment for cat scratch fever?
azithromycin
(also doxy for severe disease)
streptococcus iniae
fish-borne GPC causes cellulitis, bacteremia, endocarditis
Tilapia!
Patient on TB therapy
Rifabutin!
can cause uveitis w/eye pain, vision changes and hypopyon. Ethambutol causes optic neuritis - which presents as difficulties with color discrimination and painless visual blurring
50M with kidney transplant p/w swollen fingers/hands
voriconazole periostitis (patient was being treated for disseminated fungal infection)
elevated fluoride levels
alk phos
worsened by CNI’s (tacro)
must stop vori
management of chronic active hep B in pregnant patient?
Tenofovir with start of 3rd trimester, then Hep immune prophaylxis (HBIG and Vaccination) at birth
Dx and Rx of relapse Brucella?
Dx: rise in Ab titer 1:160 after rx of streptomycin/doxy x 6weeks
Rx: rifampin/doxy
PAS-positive granules in foamy macrophages of the lamina propria
whipples disease
Rx: doxy+hydroxychloroquine x 1 year
What cells serve as a reservoir for HHV8?
CMV?
HHV8 - B lymphocytes
CMV - lung, salivary glands and immune-privileged tissues
Treatment for Primary VZV in adult?
Give VZIG?
Immunocompetent Valtrex
Immunosuppressed IV Acyclovir
*VZIG is given only for PPX (susceptible persons with immunocompromise: HIV, malignanc,y pregnancy, steroids) < 96 hours
what cephalosporin does aztreonam cross react with?
ceftazadime
Post Exposure Prophylaxis for Meningitis in Prego’s and Children
Ceftriaxone
3 factors linked with decreased transmission of HIV from mother 2 baby
- Short interval between ROM and delivery
- VL < 1000
- cesarian section
In NVE, when do you add gent to PCN for Strep Viridans?
PCN MIC > 0.12
Difference between lesions from KS and Bacillary Angiomatosis?
Bacillary Angiomatosis lesions are painful and bleed easily
what is the treatment for
Corynebacterium diphtheriae
- Diphtheria antitoxin (obtain from CDC, +1 770-488-7100) + Erythromycin 40 mg/kg/d (maximum dose 500 mg four times a day) IV or po (as tolerated) in 3-4 divided doses x 14 days
- Document with 2 neg cx
- Close contacts should get vax booster and PCN G or erythromycin 7-10 days
first line pangenotypic treatment for Hep c NO cirrhosis
w/compensated cirrhosis?
glecapravir/pibrentasvir x 8
or
sofosbovir/velpatasvir x 12
same except genotype 3
bamboorat
Talaromyces marneffei
beavers
giardia
elephants
TB
Ppx for RF?
RF with NO carditis/residual disease: 5 years or 21yo (whichever longer)
RF with carditis but NO residual disease: 10 years or 21yo (whichever longer)
RF with carditis AND residual disease: 40/lifelong
abacavir NOT to be used when HIV RNA > 100 UNLESS?
combined with dolutegravir
Hep B non responder exposed - PPx?
Hep B unknown Status exposed - PPx?
HBIG x 2 1 month apart
HBIG and initiate accelerated vaccine
bullous lesions and sepsis in cirrhotic patient
Rx?
Vibrio Vulnificus!
ceftriaxion/ceftax + cipro/doxy
What are the recommendations for PPX against rheumatic fever?
monthly benzathine PCN, or daily PO Pen VK
no Carditis
-5 years since most recent episode or 21 y/o, whichever is longer
Carditis but no valvular damage
-10 years since most recent episode or into adult which, whichever is longer
Carditis with residual heart disease
-until age 40 or 10 years after last ARF, whichever is longer
Infliximab > adalimumab > etanercept increases risk of:
TB reactivation (TNF)
abatacept increases risk of:
severe infections in general (CD28 binding, inhibiting T cell stimulation)
alemtuzumab (campath) increases risk of:
PJP, herpes, CMV
natalizumab increases risk of:
PML/JC virus (blocks VCAM1 inhibiting leukocyte migration)
rituximab increases risk of:
hep B, PJP, JC virus
fulminant hepatitis in pregnant woman with no foodborne exposures
HSV
(hep E if exposure/travel)
how long is VZIG good for?
3 weeks - if a new exposure, check serology, administer VZIG if negative
*VZIG offers no additional benefit if Ab+
what is first line antibiotic for tetatnus infection?
metronidazole
first line therapy for mild cutaneous leish?
topical paramomycin (aminoglycoside)
visceral leish species?
L. donovani, L infantum chgasi
what are the sizes from small to big of AF intestinl parasites?
where does microsporidium fit in?
crypto (5), cyclo (10), cysto/iso (20-30)
microsporidium is ~1 but not acid fast
what survives in swimming pools even with chlorine?
cryptosporidium
What is a better test for recent strep infection? ASO or DNAse Abs?
DNAse Ab - while both are increased in pharyngitis, only dnase is elevated after SSTI
Gent trough and peak?
<1
4-10
What are the most and least hepatotoxic RIPE Drugs?
INH > PZA > RIF >>>EMB (which is not really hepatotoxic)
Feared complication of typhoid?
terminal ileum perforation
TB
What is Sens/Spec PPV/NPV?
Sensitivity=[a/(a+c)]×100
Specificity=[d/(b+d)]×100
Positive predictive value(PPV)=[a/(a+b)]×100
Negative predictive value(NPV)=[d/(c+d)]×100.
peripartum HIV management
mother VL > 1000 → c-section at 38 weeks
mother VL < 1000 ok for SVD
High Risk Birth: combination ART PPX (AZT,3TC,raltegravir) for baby
Low Risk Birth: Zidovudine PPX for baby
