ID

Question 1

Name 3 gram negative cocci

Answer 1

1. Neisseria meningitidis
2. Neisseria gonorrheae
3. Moraxella spp,

Question 2

Name 2 spore forming gram positive rods

Answer 2

1. Bacillus sp.
2. Clostridium sp.

Question 3

Name 2 non-spore forming gram positive rods

Answer 3

1. Corynebacterium sp.
2. Listeria sp.

Question 4

Name 2 anaerobic gram positive bacilli

Answer 4

• Cutibacterium
• Actinomyces

Question 5

Name 4 lactose fermenting gram negative bacilli

Answer 5

1. E. Coli
2. Klebsiella sp.
3. Enterobacter sp.
4. Proteus sp.

*“gut bugs”

Question 6

Name 2 non-lactose fermenting gram negative bacilli

Answer 6

1. Pseudomonas
2. Stenophotomonas

Question 7

Name 2 anaerobic gram negative bacilli

Answer 7

1. Bacteroides
2. Fusobacterium

Question 8

Name 3 spirochetes

Answer 8

1. Treponema sp.
2. Leptospirosis
3. Borrelia

Question 9

Name 2 yeasts

Answer 9

1. Candida
2. Cryptococcus

Question 10

Name a mould

Answer 10

Aspergillus

Question 11

Name 3 dimorphic fungi

Answer 11

1. Blastomycosis
2. Histoplasmosis
3. Coccidiomycosis

Question 12

List the HECK-Yes (SPICE-HAM) Organisms

What is special with these organisms and what antibiotics should be used in infections involving them

Answer 12

1. Hafnia
2. Enterobacter
3. Citrobacter
4. Klebsiella aerogenes
5. Yersinia enterocolitica
6. Seratia
7. Providencia
8. Indole postitive proteus
9. Acinetobacter
10. Morganella

Inducible amp-c resistance, must be treated with a carbapenem, TMP-SMX, FQ, AG

Question 13

List 2 ESBL producing organisms. What antibiotics can be used to target them

Answer 13

1. E. Coli
2. Klebsiella
3. Carbapenems
4. TMP-SMX
5. FQ
6. AG

Question 14

What antimicrobials can be considered in CPE producing organisms

Answer 14

1. Colistin
2. AG
3. Tigecycline
4. Possibly FQ or TMP-SMX if lucky

Question 15

What antimicrobials can be considered to treat MRSA

Answer 15

1. Vancomycin
2. Doxycycline
3. TMOP-SMX
4. Clindamycin
5. Linezolid
6. Daptomycin
7. Ceftobiprole

Question 16

What antimicrobials can be considered to treat pseudomonas

Answer 16

1. Pip-tazo
2. Ceftazidime
3. Cefepime
4. Carbapenems (not ertapenem)
5. Ciprofloxacin
6. AG
7. Azetronam
8. Colistin
9. Tigecycline
10. Ceftazidime-avibactam
11. ceftolozame-tazobactam

Question 17

What antimicrobials can be considered to treat enterococcus

Answer 17

1. Ampicillin (if S)
2. Vanco (not VRE)
3. Linezolid
4. Daptomycin

Question 18

Name symptoms associated with meningitis

Answer 18

• Predminantly headache, neck stiffness and fever
• altered LOC late in the course

Question 19

Name symptoms associated with encephalitis

Answer 19

• Predominantly altered LOC and fevers
• Can get seizures and focal neurological signs

Question 20

Name 3 signs that, if all absent, rule out meningitis (99%)

Answer 20

1. Fever
2. Neck stiffness
3. Altered mental status

Question 21

What physical exam sign has the highest sensitivity for meningitis

Answer 21

Jolt accentuation

Question 22

What 2 physical exam signs are the most specific for meningitis

Answer 22

Kernig’s and Brudzinski’s

Question 23

What are symptoms of basal skull meningitis

Answer 23

1. Regular meningitis symptoms plus:
2. CN palsies
3. long tract signs

Question 24

What organisms are known to cause basal skull meningitis?

Answer 24

1. Tb
2. Listeria
3. Cryptococcus
4. Syphilis
5. Lyme

Question 25

What are the most common pathogens in meningitis and what antibiotics should be used empirically

Answer 25

Question 26

What should be the empiric coverage for meningitis in the case of a penicillin allergy?

Answer 26

Vancomycin + Moxifloxacin +/- TMP-SMX(if need to cover listeria)

Question 27

Describe an approach to investigating suspected meningitis

Answer 27

Question 28

Other than a positive culture, what would you expect to find on an LP in the case of bacterial meningitis, viral meningitis, TB meningitis and fungal meningitis?

Answer 28

Question 29

When looking at glucose, protein, WBC, PMN on an LP ad well as the ratio of CSF:blood glucose, which thresholds are 99% specific for _bacterial_ meningitis?

Answer 29

* Glucose \<1.9 * Protein \>2.2 * WBC\>2000 * PMNs\>1180 * CSF:blood glucose \<0.23

Question 30

If an LP is performed 2 days after the start of antibiotics, what values can you still rely on and what values may have already corrected on your LP results

Answer 30

* Biochemistry and cell count minimally affected * Culture yield decreased

Question 31

For how long should bacterial meningitis be treated

Answer 31

* Depends on the bacteria * S. Pneumoniae: 10-14 days * N. Meningitidis: 7 days * L. Monocytogenes: 21 days * No pathogen found: * Depends on clinical context * Consult ID

Question 32

When should Dexamethasone be given for meningitis

Answer 32

* Before or with first dose of antibiotics * Usually give 10mg IV q6h x 4 days * Stop if CSF non-turbid, low cell count, non-pneumococcal by culture \* DO NOT START IF ANTIBIOTICS HAVE ALREADY BEEN GIVEN

Question 33

Who should get N. Meningitidis chemoprophylaxis

Answer 33

* Close contacts of N. Meningitidis meningitis cases as defined: 1. **Household contacts** 2. Persons **Sharing sleeping arangements** 3. Persons who have direct nose/mouth contamination with oral/nasal secretions 4. **Healthcare workers who have had intense unprotected (no mask) contact** 1. **​****Intubating** 2. **resuscitating** 3. **closely examining nasopharynx** 5. Airline passengers sitting immediately on either side of the case when total time on aircraft \>8hours

Question 34

Within how many days should you give N. Meningitidois chemoprophylaxis

Answer 34

10 days

Question 35

What agents can be used for N. Meningitidis chemoprophylaxis?

Answer 35

* Ciprofloxacin 500mg po x1 (increasing resistance!) * Ceftriaxone 250 mg IM x1 * Rifampin 600mg PO BID x 2 days

Question 36

Who should get N. Meningitidis immunoprophylaxis?

Answer 36

1. **Household contacts** of a case of invasive menigococcal disease (IMD) 2. Persons **sharing sleeping arrangements** with a case of IMD 3. Persons who have direct nose/mouth contamination with oral/nasal secretions of a case with IMD 4. Children and staff in contact with a case of IMD in childcare or nursery school facilities

Question 37

What agents can be used for N. Meningitidis immunoprophylaxis

Answer 37

* Depends on serotype of index case and age/underlying conditions of contact * Men-C-ACYW * 4CMenB

Question 38

What is the diagnostic workup for suspected endocarditis?

Answer 38

1. 2 sets of blood cultures prior to antibiotics 2. Initial TTE for everyone 1. TEE if indicated (class 1): 1. non-diagnostic TTE 2. suspected IE complications 3. intracardiac leads

Question 39

Who can be considered for a stepdown to oral antibiotics after initial IV antibiotics in IE?

Answer 39

* Patients with left-sided endocarditis caused by streptococcus, E. Faecalis, S. Aureus or CNST: * Deemed stable by multidisciplinary team * TEE MUST be done prior to switch and show no paravalvular infection * Frequent and appropriate follow-up can be assured by the care team * A follow-up TEE can be preformed 1-3 days before the completion of the antibiotic course

Question 40

List the Duke criteria for diagnosis of IE

Answer 40

* **Major** * Microbiological evidence * Typical organisms: S. Aureus, Viridans group strep, S. gallolyticus (prev. bovis), Enterococcus, HACEK group * 2 cultures \>12hrs apart or 3 cultures \> 1hr appart * OR 1 blood culture demonstrating Coxiella brunetii OR Coxiella anti-phase 1 IgG \> 1:800 * Endocardial involvement * Oscillating valvular/prosthetic mass * Valvular abscess * Dehiscence of prosthetic valve * New valvular regurgitation * **Minor** * **​**Predisposition * Heart defect * Prosthetic valve * IVDU * Fever * Temp \>38 * Vascular phenomenon * Arterial emboli * septic pulmonary infarcts * Mycotic aneurysms * IC hemorrhage * Conjunctival hemorrhage * Janeway lesions * Immunological phenomenon * GN * Osler nodes * Roth spots * Positive RF * Microbiological evidence * + blood culture not meeting major criterion

Question 41

What is necessary for a diagnosis of IE

Answer 41

* **Definite IE** * **​**Positive vegetations on culture or histiopathology * 2 major criteria * 1 major + 3 minor criteria * 5 minor criterria * **Possible IE** * **​**1 major + 1 minor criteria * 3 minor criteria

Question 42

What antibiotics should be used to treat native valve IE caused by MSSA

Answer 42

Cloxacillin or cefazolin

Question 43

What antibiotics should be used to treat native valve IE caused by MRSA or CNST

Answer 43

Vancomycin \*Most CNST are beta lactam resistant. If susceptible can treat like MSSA

Question 44

What antibiotics should be used to treat native valve IE caused by Viridans group strep or S. Gallolyticus

Answer 44

Pen G or ceftriaxone \*If higher MIC to PNC levels, consider adding an aminoglycoside

Question 45

What antibiotics should be used to treat native valve IE caused by E. Faecalis

Answer 45

Ampicillin + gentamycin OR Ampicillin + ceftriaxone

Question 46

What antibiotics should be used to treat native valve IE caused by E. Faecium

Answer 46

Vancomycin + gentamycin

Question 47

What antibiotics should be used to treat native valve IE caused by HACEK group bacteria

Answer 47

Ceftriaxone

Question 48

What antibiotics should be used to treat _prosthetic_ valve IE caused by MSSA

Answer 48

Cloxacillin OR cefazolin AND Rifampin AND Gentamicin

Question 49

What antibiotics should be used to treat _prosthetic_ valve IE caused by MRSA or CNST

Answer 49

Vancomycin AND Rifampin AND gentamicin \*Most CNST are beta lactam resistant. If susceptible can treat like MSSA

Question 50

What antibiotics should be used to treat _prosthetic_ valve IE caused by viridans group streop or S. Gallolyticus?

Answer 50

Pen G OR ceftriaxone

Question 51

What antibiotics should be used to treat _prosthetic_ valve IE caused by E. Faecalis

Answer 51

Ampicillin + Gentamicin OR Ampicillin + Ceftriaxone

Question 52

What antibiotics should be used to treat _prosthetic_ valve IE caused by E. Faecium

Answer 52

Vancomycin + Gentamicin

Question 53

What antibiotics should be used to treat prosthetic valve IE caused by HACEK bacteria

Answer 53

Ceftriaxone

Question 54

for how long should IE be treated?

Answer 54

4-6 weeks Longer for increasing beta-lactam resistance, S. Aureus, prosthetic valve

Question 55

List the HACEK organisms

Answer 55

* Haemophilus * Aggregatibacter * Cardiobacterium * Eikenella * Kingella

Question 56

List the class 1 indications for early surgery in IE

Answer 56

Early surgery: during initial hospitalisation before full treatment course of antibiotics 1. **Decisions about surgery should be made by a "multidisciplinary heart valve team" of cardiologists, CV surgeons, and ID specialists** 2. Valve dysfunction with signs or symptoms of heart failure 3. Left sided IE caused by S. Aureus, fungi or highly resistant organisms 4. Heart block, annular/aortic root abscess, destructive penetrating lesions 5. Persistant bacteremia or fever \> 5d after starting appropriate ABx 6. Complete removal of implantable electronic cardiac device systems in patients with definite IE

Question 57

List the class 1 indications for delayed surgery in IE?

Answer 57

1. prosthetic valves: relapsing infection 1. Defined as new fever/bacteremia after a complete course of appropriate antibiotics and interval sterile blood cultures. No other source or portal of infection \*In patients with recurrent endocarditis in the setting of continued IVDU, consultation with addiction medicine before repeat surgical intervention is considered

Question 58

List the class II surgical indications in endocarditis

Answer 58

* **Early surgery** is reasonable in those with recurrent emboli and persistent vegetation despite appropriate antimicrobial therapy * **Early surgery** may be considered in patients with native left-sided endocarditis with mobile vegetation \>10mm _with or without_ embolic phenomenon. Especially if it's on the anterior MV leaflet * Early (as opposed to late) surgery in patients who have had a minor (no extensive neuro deficits) embolic stroke without ICH, in patients with an indication for IE surgery * Consider delay surgery \>4 weeks in HD stable patients after a major ischemic or hemorrhagic stroke

Question 59

When should IE prophylaxis be considered?

Answer 59

Question 60

What ABx regimen should be given for endocarditis prophylaxis when such intervention is indicated?

Answer 60

* Amoxicillin 2g PO x1 * If NPO give 2g IV or IM or cefazolin/ceftriaxone 1g IV/IM * If PNC allergy: Cephalexin 2g PO OR azithromycin 500mg PO OR doxycycline 100mg PO * NPO + PNC allergy: Cefazolin/Ceftriaxone 1g IM/IV

Question 61

How is pneumonia diagnosed?

Answer 61

Clinical (Fever, productive cough, SOB, consolidation) + Radiographic findings (CXR infiltrate)

Question 62

What criterias can be used to decide who should be hospitalised in pneumonia?

Answer 62

* PSI/PORT (prefered by IDSA/ATS 2019) * CRB-65

Question 63

List the CRB 65 criteria

Answer 63

1. Confusion 2. RR\>30 3. SBP\<90 or DBP\<60 4. Age ≥ 65 if 0-1 treat as outpatient if ≥2 admit to hospital

Question 64

Give the IDSA/ATS criteria to define severe CAP

Answer 64

1. Minor criteria 1. RR\>30 2. PaO2/FiO2 ≤250 3. Multilobar infiltrates 4. Confusion/disorientation 5. Uremia (BUN\>20) 6. Leukopenia (WBC\<4) 7. Thrombocytopenia (plt\<100) 8. Hypothermia (T\<36) 9. Hypotension requiring aggressive fluid resuscitation 2. Major criteria 1. Septic shock with need for vasopressors 2. Respiratory failure requiring mechanical ventilation

Question 65

What are common pathogens in CAP

Answer 65

1. **S. Pneumoniae** 2. H. Influenzae 3. M. Pneumoniae 4. C. Pneumoniae 5. Respiratory viruses 1. Influeza 2. Parainfluenza 3. RSV 4. rhinovirus 5. adenovirus 6. coronaviruses 6. Legionella pneumophila (severe disease)

Question 66

What pathogens should also be considered in patients with pneumonia who have multiple comorbidities, antibiotic exposure or hospital exposures?

Answer 66

1. Gram negatives 1. Klebsiella pneumoniae 2. Pseudomonas 3. S. Aureus inc. MRSA

Question 67

In which patients should sputum cultures be obtained in the context of CAP?

Answer 67

1. inpatients with severe CAP 2. intubated patients 3. Patients being treated empirically for MRSA or pseudomonas

Question 68

What other investigations (other than CXR, basic blood work, sputum cultures, and blood cultures) should be considered in patients with CAP and in what setting should they be considered?

Answer 68

1. Pneumococcal + Legionella Ag +/- lower tract legionella NAAT 1. In severe CAP or when indicated by epidemiological factors such as an outbreak 2. Rapid influenza NAAT + COVID test when these viruses are circulating \*Do not send procalcitonin

Question 69

What are the outpatient treatment options for CAP?

Answer 69

* Healthy outpatients * **Amoxicillin 1g TID (preferred)** * Doxycycline 100mg BID * Azithromycin 500mg PO x1 then 250mg PO BID only in areas with low pneumococcal resistance * Not in most of Canada * Patients with comorbidities (chronic heart, lung, liver, renal, DM, alcoholism, malignancy, asplenia) * Amox-clav _or_ cephalosporin (cefpodoxime, cefuroxime) _plus_ macrolide _or_ doxycycline * Respiratory fluoroquinolone (moxi, levo) * adds additional coverage for H. Flu and moraxella catarrhalis as well as coverage for S. aureus and gram negatives

Question 70

What are the inpatient treatment options for CAP?

Answer 70

* Non-ICU with no risk factors for MRSA or pseudomonas * Beta lactam (CTx, amp-sulbactam, cefotaxime, ceftaroline) _plus_ macrolide * Doxy is a _third line_ option if unable to give other options * Respiratory fluoroquinolones (levo, moxi) * \* Insufficient evidence for omadacycline * ICU without risk factors for MRSA or pseudomonas * Beta-lactam _plus_ macrolide * Beta lactam _plu__s_ respiratory fluoroquinolone * Some evidence for decreased death with beta-lactam + macrolide * Aspiration pneumonia * Don't add empiric anaerobe coverage unless empyema or abscess present

Question 71

When should MRSA be covered in CAP and what agents can be used

Answer 71

* Based on local risk factors * Use Vancomycin or Linezolid * Daptomycin can't be used in respiratory infections as it is _inactivated by surfactans_

Question 72

When should pseudomonas be covered in CAP and with what agents?

Answer 72

* Based on locally validated risk factors * Use: * Piptazo * Cefepime * ceftazidime * azetronam * meropenem

Question 73

In admitted patients with CAP, when can a transition to PO antibiotics be considered

Answer 73

When the patient is hemodynamically stable, improving, tolerating PO intake and absorbing from GI tract

Question 74

For how long should CAP be treated

Answer 74

* 5 days in well selected patients * Afebrile x48hrs * ≤1 sign of CAP clinical instability (HR\>100, RR\>24, SBP\<90, PaO2\<90%, can tolerate PO, normal mental status) * Otherwise 10 days

Question 75

When should steroids be considered in CAP

Answer 75

Only in refractory shock

Question 76

How should influenza pneumonia be treated

Answer 76

* Oseltamivir if Sx \<48hrs and hospitalized * COnsider treating bacterial superinfection

Question 77

What are the pathogens involved in HAP/VAP

Answer 77

* S. Pneumoniae * **MSSA** * H. Influenzae * **GNB including pseudomonas**

Question 78

How is HAP/VAP diagnosed

Answer 78

Based on clinical gestalt + sputum/ETT/blood cultures \*CPIS score NOT recommended by IDSA

Question 79

List the risk factors for MDR VAP and HAP

Answer 79

* RF for MDR VAP 1. Prior IV ABx use within 90 days 2. septic shock at time of VAP 3. ARDS preceding VAP 4. ≥ 5 days hospitalization prior to VAP 5. Acute renal replacement therapy prior to VAP onset * RF for MDR HAP 1. Priorr IV ABx use within 90 days * RF for MRSA HAP/VAP 1. Prior IV ABx use within 90 days * RF for MDR Pseudomonas VAP/HAP 1. Prior IV ABx use within 90 days

Question 80

How should HAP/VAP be treated empirically?

Answer 80

Question 81

In which patients should stool cultures be sent for Salmonella, Shigella, Campylobacter, yersinia and STEC

Answer 81

* Diarrhea and: * Fever * Bloody or mucoid stools * Severe abdo pain * Sepsis

Question 82

In which patients presenting with diarrhea should you send C. Difficile testing

Answer 82

* Recent antibiotics * Persons who work in healthcare, LTC, prison * Compatible syndrome * **IBD flare**

Question 83

In what patients with diarrhea should blood cultures be sent?

Answer 83

* Immunocompromise * Sepsis * Suspicion of enteric fever

Question 84

In what patients with diarrhea should stool samples be sent for Ova and parasites?

Answer 84

* Diarrhea ≥ 14 days * Immunocompromise * Travel

Question 85

How can you increase the yield of stool Ovo and parasite testing?

Answer 85

Order daily x 3 days

Question 86

Which patients with bloody diarrhea should get empiric antibiotic treatment?

Answer 86

1. Sick immunocompetent patients with bacillary dysentery (frequent scant bloody stools, abdo pain, tenesmus, fevers), suggestive of shigella 2. Recent travel with high fevers (\>38.5) and/or sepsis 3. Sick immunocompromised patients

Question 87

What empiric antibiotic should be used when treating patients with bloody diarrhea? (empiric)

Answer 87

Question 88

What is the first choice and alternative choice antibiotic to treat campylobacter diarrhea

Answer 88

First choice: Azithromycin Alternative choice: Ciprofloxacin

Question 89

What is the first choice and alternative choice antibiotic to treat S. enterica typhi and paratyphi diarrhea?

Answer 89

First line: ceftriaxone OR ciprofloxacin Alternatives: Ampicillin OR TMP-SMX OR azithromycin

Question 90

What is the first choice and alternative choice antibiotic to treat Shigella diarrhea

Answer 90

First line: Azithromycin OR ciprofloxacin OR ceftriaxone Alternative: TMP-SMX OR ampicillin

Question 91

What is the first choice and alternative choice antibiotic to treat Vibrio cholerae diarrhea

Answer 91

First line: Doxycycline Alternative: Ciprofloxacin, Azithromycin, ceftriaxone

Question 92

What is the first choice and alternative choice antibiotic to treat Yersinia enterocolitica diarrhea

Answer 92

First line: TMP-SMX Alternative: cefotaxime, ciprofloxacin

Question 93

What is the first choice and alternative choice antibiotic to treat STEC diarrhea

Answer 93

No ABx, risk of HUS

Question 94

How is testing performed for C. Diff

Answer 94

* Stool toxin testing: * EIA for GDH, toxin * NAAT PCR for toxin * Pseudomembranes on colonoscopy

Question 95

Describe the clinical findings of CDiff

Answer 95

Unexplained new-onset ≥3 unformed stools in 24 hours

Question 96

List the criteria for severe C. Diff

Answer 96

1. WBC ≥ 15 **OR** Serum creatinine 1.5 x pre-morbid levels 2. Age \> 65, immunosuppression, T\>38, albumin \<30

Question 97

List the findings in fulminant C. diff

Answer 97

* Sepsis * Shock * Illeus * perforation * toxic megacolon (colon dilation \> 6cm)

Question 98

How is the first episode of C. Diff treated

Answer 98

* STOP unnessessary antibiotics * Stop PPI if not needed

Question 99

Why is fidaxomicin superior to Vancomycin?

Answer 99

Less recurrence! They have similar efficacy at treating the initial C.Diff infection

Question 100

What are the risk factors for C. Diff recurrence?

Answer 100

1. Recurrent CDI in the last 6 months 2. Age \>65 3. immunocompromised 4. Severe CDI on presentation

Question 101

How is recurrent C. Diff treated?

Answer 101

Question 102

How are intra-abdominal infections managed?

Answer 102

1. Source control! 1. Percutaneous\>laparoscopic 2. If \<3cm, can forgo source control initially 2. Empiric antibiotics 1. CA-no previous hospitalisations 1. Ceftriaxone + Flagyl OR Cipro + flagyl 2. Healthcare associated or critically ill 1. Pseudomonas coverage: Pip-tazo, meropenem, ceftazidime or cipro AND metronidazole 2. Add enterococcal coverage (vanco) if immunocompromised. post-op or recurrent or if valvular heart disease/intravascular prosthesis 3. Consider targetted antifungal coverage in severe or nosocolilal IAI if candida isolated from intraabdomional or blood cultures 1. In other cases no mortality benefit

Question 103

How long should antibiotics be continued for intraabdominal infections?

Answer 103

If source control is achieved: 3-5 days (STOP-it trial)

Question 104

What are the criteria for a complicated UTI?

Answer 104

* Hemodynamically unstable * Male * Pregnancy * Indwelling Foley catheter, instrumentation * Functional or anatomic anomalies * Urinary tract obstruction

Question 105

How is a UTI diagnosed?

Answer 105

CLinically, supported by UA and culture

Question 106

What are the first line empiric treatment options for cystitis?

Answer 106

1. Nitrofurantoin 100 BID x5 days 1. Avoid if concerns for pyelo 2. Septra DS 1 tab BID x 3 days 1. Avoid if recently used or in pregnancy 3. Fosfomycin 3g x1 1. Avoid if concerns for pyelo 2. Covers ESBLs JAMA 2018: Nitrofurantoin superior to fosfomycin

Question 107

What are the second-line empiric treatment options for cystitis?

Answer 107

* Fluoroquinolones (Levo or cipro) * Beta lactams

Question 108

What are the first line empiric treatment options for pyelonaphritis?

Answer 108

1. IV beta lactam (prefered in pregnancy) x7-14 days 2. Fluoroquinolones (if resistance rates are low) x 5-7 days

Question 109

What organisms usually cause prostatitis

Answer 109

* E. Coli * Pseudomonas * Enterococcus

Question 110

When should proatatitis be treated

Answer 110

* If symptomatic * Do not treat if asymptomatic unless * elevated PSA * planning for Bx * infertility

Question 111

What are the symptoms of acute prostatitis?

Answer 111

* Fever * intense local pain * sepsis

Question 112

What should be obtained before giving empiric antibiotics if there is suspicion for _acute_ proatatits?

Answer 112

UA+culture

Question 113

What is the empiric antimicrobial treatment for acute prostatitis?

Answer 113

* If well * Fluoroquinolone * If unwell * Fluoroquinolone * 3rd gen cephalosporin * Pip-tazo

Question 114

How long should acute prostatitis be treated for?

Answer 114

2-4 weeks

Question 115

What are the symptoms of chronic prostatitis

Answer 115

* May or may not be symptomatic * If they are symptomatic, the symptoms are the same as acute prostatitis * Fever * Local pain * Sepsis

Question 116

What antibiotics should be used to treat _chronic_ prostatitis?

Answer 116

Fluoroquinolones or pathogen directed therapy

Question 117

For how long should chronic prostatitis be treated?

Answer 117

* If using a fluoroquinolone: 4-6 weeks * If using any other ABx: 8-12 weeks

Question 118

What are the bacteria that tend to cause post-partum endometritis?

Answer 118

* Group B strep * enterococci * S. Aureus * anaerobic GPC * E. Coli * Gardnerella * Bacteroides (polymicrobial)

Question 119

What are the symptoms of post-partum endometritis?

Answer 119

* Fever * Uterine tenderness * Bleeding * Foul-smelling lochia

Question 120

Why do we worry about post-partum endometritis

Answer 120

It can progress to sepsis

Question 121

What should you assess for once you diagnose post-partum endometritis?

Answer 121

* Retained products of conception * abscesses

Question 122

What empiric antibiotics can be used to treat post-partum endometritits?

Answer 122

* Clindamycin + Aminoglycoside(Add ampicillin or vancomycin if suspected enterococcus) * Stepdown to oral once deferveses * No good evidence on duration

Question 123

What are the indications to treat asymptomatic bacteriuria? For how many days should you treat for each indication

Answer 123

1. Pregnancy 1. Treat for 4-7 days 2. Invasive urological procedures 1. Treat for 1-2 days 3. Areas of limited evidence 1. First month after renal transplant 2. High risk neutropenia (ANC\<0.1 for ≥ 7 days)

Question 124

What is the incubation period for gonorrhea?

Answer 124

2-7 days

Question 125

What symptoms can be associated with gonorrhea?

Answer 125

* Can be asymptomatic * Rectal and pharyngial infections more likely to ba asymptomatic * Purulent discharge * pelvic pain * proctitis * pyuria * dysuria * epididymitis

Question 126

What symptoms can be associated with Chlamydia?

Answer 126

* Can be asymptomatic * Rectal and pharyngial infections more likely to ba asymptomatic * Purulent discharge * pelvic pain * proctitis * pyuria * dysuria * epididymitis

Question 127

How is gonorrhea diagnosed?

Answer 127

* NAAT /culture as indicated * Urine * Cervical * rectal * Pharyngeal * Add blood, joint pustule swab for disseminated \*cultures are generally preferred for sensitivity testing

Question 128

How is gonorrhea treated

Answer 128

* Ceftriaxone 500mg IM x1 * Alternatives: * Gentamycin 240mg IM x1 AND Azithromycin 2g PO x1 OR cefixime 800mg PO x1 * Doxy x 7 days if chlamydia not excluded

Question 129

Name possible complications of gonorrhea and chlamydia

Answer 129

* In males * Urethral strictures with fistula * epididymitis (chlamydia\>gonorrhea) * Infertility (rare) * In females * PID * infertility * ectopic pregnancy * Fitz-Hugh-Curtis syndrome * In both * Re-infection * reactive arthritis * DGI: arthritis * dermatitis * endocarditis * meningitis (more common in pregnant women, or MSM) * Increased risk of HIV

Question 130

What is the incubation period of chlamydia?

Answer 130

2-6 weeks

Question 131

What percentage of chlamydia and gonorrhea infected patients are asymptomatic

Answer 131

50% Gono 70% chlam

Question 132

How is chlamydia diagnosed?

Answer 132

Urine, cervical, vaginal, rectal, pharyngeal NAAT

Question 133

How is chlamydia treated?

Answer 133

Doxycycline 100mg PO x 7 days Azithro 1g PO x1 is an alternative

Question 134

How should patients be counciled regarding sexual activity after a diagnosis of chlamydia or gonorrhea?

Answer 134

Abstinence x7days and until partner is treated

Question 135

How is chlamydia treated differently in pregnancy?

Answer 135

Doxy is contraindicated 2nd and 3rd trimester of pregnancy

Question 136

What criterias define treatment failure in chlamydia or gonorrhea?

Answer 136

1. Positive gram stain \>72hrs after treatment 2. Positive culture \>72hrs after treatment 3. Posiitve NAAT 2-3 weeks after treatment \*\*\*Reinfection is more common that Tx failure

Question 137

Which are the indications to perform a test of cure after treatment of chlamydia or gonorrhea?

Answer 137

1. All gonococcal infections, especially if suspected Tx failure/drug resistance, alternative Rx, pregnancy, pre-puberty or pharyngeal infection 2. Chlamydia in pregnancy (4 weeks post Tx) 3. Chlamydia Tx with ongoing symptoms, alternative regimen, suboptimal adherence

Question 138

What are the indications for repeat testing (3 months later) after chlamydia or gonorrhea infection?

Answer 138

All individuals

Question 139

What are the clinical manifestations of primary syphilis

Answer 139

Painless chancre and regional LN

Question 140

How long after initial syphilis infection can primary syphilis last?

Answer 140

1^st 3 weeks after infection

Question 141

What are the manifestations of secondary syphilis?

Answer 141

1. Fever 2. Malaise 3. Rash 4. Alopecia 5. uveitis 6. meningitis 7. LN 8. herpatitis 9. arthralgias 10. condyloma lata

Question 142

How long after initial syphilis infection can secondary syphilis last?

Answer 142

6 months

Question 143

What timeframe differentiates early latent syphilis from late latent syphilis?

Answer 143

Early (\<1 year since infection) Late (\>1 year or unknown duration)

Question 144

What are the manifestations of latent syphilis

Answer 144

None simply have positive serology

Question 145

What are the manifestations of tertiary syphilis?

Answer 145

* Cardiovascular * Aortitis * Gummatous * Late neurosyphilis * Tabes dorsalis * General paresis

Question 146

What is the treatment for primary, secondary and early latent syphilis?

Answer 146

**Pen G 2.4 mU IM x1** Alternatives (really use penG if you can!): Doxycycline 100 mg PO x 14 days Tetracycline 500mg po QID x 14 days Ceftriaxone 1g IV /IM x 10 days

Question 147

What is the treatment for late latent, unknown duration or tertiary syphilis?

Answer 147

**Pen G 2.4 mU IM Weekly x 3** Alternative (Use pen G when possible) Doxycycline 100 mg PO BID x 14 days Tetracycline 500 mg QID PO x 14 days

Question 148

What is the treatment for neurosyphils?

Answer 148

* Aqueous penicliiin 4mU q4h IV x 14 days No alternatives, desensitize if allergy to PNC

Question 149

What are the treponemal tests

Answer 149

* Immunoassay * TPPA * FTA-ABS

Question 150

What are the non-treponemal tests?

Answer 150

* VDRL * RPR

Question 151

What is the difference between treponemal and non-treponemal tests?

Answer 151

* Treponemal * Specific antibody against Treponema Pallidum * Persists for life * Non-treponemal * non-specific antibody released during infection

Question 152

Interpret the various combinations of negative and positive Screening CIMA, confirmatory RPR and confirmatory TPPA tests

Answer 152

Question 153

What are the indications for PNC desensitization in syphilis patients

Answer 153

1. Neurosyphilis 2. Pregnancy 3. Late latent or latent of unknown duration syphilis 4. Tertiary syphilis

Question 154

What are the indications to get an LP in syphilis?

Answer 154

1. Neuro, occular or auditory symptoms or signs 2. HIV and neuro symptoms or signs 1. HIV and RPR ≥ 1:32 2. HIV and CD4 \< 350 3. Previously treated syphilis and failed to achieve adequate serological response to treatment (i.e. four fold drop in RPR)

Question 155

What should be considered in persistant PID, urethritis or cervicitis Especially if initial gono-chlam comes back negative after empiric Tx

Answer 155

* Retreat once for usual pathogens * Remember, risk of reinfection\>risk of Tx failure) * Consider mycoplasma genitalium or T. Vaginalis * Test available for mycoplasma henitalium at national microbiology lab in Winnipeg * Treat with moxifloxacin x7-14 days depending on extent of infection

Question 156

What is the organism responsible for chancroid?

Answer 156

H. Ducreyi

Question 157

What are the symptoms and signs of chancroid

Answer 157

* Painfull ulcer with granulomatous base that bleeds * Painfull inguinal LN

Question 158

What is the treatment for chancroid?

Answer 158

Azithromycin 1g PO x1 CTx 250 mg IM x1 Cipro 500 mg PO BID x3days

Question 159

What is the organism causing LGV

Answer 159

Chlamydia. Serovars L1-L3 more invasive

Question 160

What are the symptoms of LGV

Answer 160

* Painfull LN * Hemorrhagic proctitis

Question 161

How is LGV treated

Answer 161

Doxycycline 100 mg PO BID x21 days and treat partners

Question 162

What are the symptoms of genital HSV?

Answer 162

Painfull vesicles/ulcers with prodrome

Question 163

What can be used to treat genital HSV

Answer 163

1. Acyclovir 2. Valacyclovir 3. Famcyclovir

Question 164

What can be used to treat anogenital warts

Answer 164

* HPV vaccine for prevention * For treatment * Spontaneous resolution * consider imiquimod or cryotherapy

Question 165

What are the symptoms of trichomonas vaginalis

Answer 165

* Vaginal pH \>4.5 * Neg Whiff * yellow frothy discharge * strawberry cervix

Question 166

How is trichomonas vaginalis treated?

Answer 166

* Metronidazole * 2g PO x1 * OR 500 mg po x 7 days * Treat partners

Question 167

What are the symptoms and diagnostic tests for vulvovaginal candidiasis?

Answer 167

* Vagina pH \< 4.5 * Neg whiff * wet mount with 10% KOH budding yeast

Question 168

How is vulvovaginal candidiasis treated?

Answer 168

* clotrimazole or miconazole cream * fluconazole 150mg PO x1

Question 169

What are the symptoms and diagnostic tests for bacterial vaginosis?

Answer 169

* Vaginal pH \>4.5 * pos whiff * clue cells on gram stain * fishy odor

Question 170

How is bacterial vaginosis treated?

Answer 170

* Metrronidazole 500mg PO BID x 7 days or 5g application PV x 5 days

Question 171

Name 4 purulent skin and soft tissue infections

Answer 171

* Folliculitis * Infection of hair follicle * Furuncle * Infection of hair follicle extending into the dermis and sc tissue * Carbuncle * coalescence of several infected follicles * Abscess * collection of pus within the dermis + sc tissue

Question 172

Name 4 non-purulent skin and soft tissue infections and their most common infectious etiologies

Answer 172

* Impetigo * S. Aureus * Erysipela * GAS * Cellulitis * GAS * Necrotizing fasciitis * Depends on type

Question 173

How should purulent SSTIs be managed

Answer 173

I&D and C&S should be performed

Question 174

How should non-purulent SSTIs be managed?

Answer 174

Treat predisposing trauma, tinea pedis, xerosis, lymphedema, etc... Consider MRSA coverage if cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonisation with MRSA or IVDU If severely immunosuppressed, consider pip-taz vanco or mero-vanco

Question 175

When should prophylactic antibiotics be considered to _prevent_ recurrent cellulitis and which agent should be used?

Answer 175

* Consider if ≥3 episodes of cellulitis a year _despite controlling other risk factors_ * Use penicillin or an equivalent beta lactam (amoxicillin, cephalexin)

Question 176

What should be done in patients with lymphedema and recurrent cellulitis?

Answer 176

COmpression

Question 177

What symptoms suggest nec. fasc.

Answer 177

* Erythema with * systemic toxicity * gangrene/anesthesia * hard induration * hemorrhagic bullae * pain out of proportion * Pain extending beyond erythema

Question 178

How is necrotizing fasciitis treated emipically?

Answer 178

* Emergent surgical inspection/debridement * Consult surgery urgently * Empiric antibiotics * Piptazo + Vanco + Clindamycin * Consider IVIG if shock or pre-operative

Question 179

What are the organisms associated with each type of nec. fasc and how are they treated

Answer 179

Question 180

Who gets type 1 nec. fasc.

Answer 180

* Usually younger patients * following minor trauma * they can have DM/PAD/IVDU

Question 181

Who gets type 2 nec. fasc.?

Answer 181

* Older patients * DM * pelvic wounds

Question 182

What is associated with clostridium induced nec. fasc.

Answer 182

* Trauma * **colon Ca**

Question 183

What is associated with vibrio vulnificus nec. fasc.

Answer 183

* **Saltwater exposure** * Underlying liver disease * seafood ingestion

Question 184

What is associated with Aeromonas hydrophila induced Nec. Fasc.

Answer 184

Freshwater exposure, injury

Question 185

What bacteria cause toxic shock syndrome?

Answer 185

* GAS * S. aureus

Question 186

What are the diagnostic criteria for toxic shock syndrome?

Answer 186

1. Hypotension (SBP\<90) AND 2. Isolation of GAS for normally sterile site AND 3. At least 2 of: 1. Renal impairment (Cr \>177) 2. Coagulopathy (plt\<100 or DIC) 3. Liver function abnormalities (ALT/AST/bili 2x ULN) 4. ARDS 5. Generalized erythematous macular rash that can desquamate

Question 187

How is toxic shock syndrome managed?

Answer 187

* Contact + droplet precautions * Volume resuscitation * Surgery (esp. if necrotizing SSTI suspected) * ABx * Beta lactams + clindamycin * IVIG -- Limited evidence, can be considered if severe infection * Hyperbaric O2 -- efficacy unknown * Chemoprophylaxis -- cephalexin x 10 days (clinda if allergy)

Question 188

What microbiology is classically associated with diabetes

Answer 188

* Polymicrobial infections * Often pseudomonas and anaerobes

Question 189

What SSTI microbiology is classically associated with water exposure?

Answer 189

* Vibrio vulnificus (salt water) * Aeromonas spp (fresh water) * M. Marinum (fish tank exposures) * M. Fortuitum (hot tub exposure)

Question 190

What SSTI microbiology is classically associated with rose gardens?

Answer 190

sporothrix schenckii

Question 191

What SSTI microbiology is classically associated with meat, butchers and veterinarians?

Answer 191

Erysipelothrix rhusiopathiae

Question 192

What SSTI microbiology is classically associated with ecthyma gangrenous, malignant/invasive otitis external, hot tub folliculitis, and green nail syndrome?

Answer 192

Pseudomonas

Question 193

What SSTI microbiology is classically associated with herpetic whitlow and eczema herpeticum?

Answer 193

HSV-1 and HSV-2

Question 194

What SSTI microbiology is classically associated with umbilicated lesions, HIV, subacute meningitis and increased LP opening pressure?

Answer 194

Cryptococcus neoformans

Question 195

What SSTI microbiology is classically associated with burrows, pruritus and visible tracts in web spaces?

Answer 195

Scabies

Question 196

What SSTI microbiology is classically associated with HIV+ patients with white plaques on lateral aspects of the tongue that don't scrape off?

Answer 196

Oral hairy leukoplakia (EBV)

Question 197

What SSTI microbiology is classically associated with black eschar in nasal mucosa or palate of diabetic patients?

Answer 197

Mucormycosis (Rhizopus spp.)

Question 198

How does osteomyelitis develop (pathophysiology). Which pathophysiological mechanism is more likely to cause monomicrobial infections and which is most likely to cause polymicrobial infections?

Answer 198

* Hematogenous spread * More common in children * In adults, commonly causes vertebral OM * Monomicrobial * Contiguous spread * From SSTI, trauma, surgery * Polymicrobial

Question 199

Differentiate neuropathic, arterial and venous foot ulcers

Answer 199

* Neuropathic * Pressure points * punched-out appearance * deep ulcer * minimal pain * warm dry foot * Arterial * Lateral malleolous * Dry and punctate * Decreased pulses * Cold-dry foot * Venous * Medial malleolous * Irregular margins * Shallow depth * mildly painfull * venous stasis dermatitis/lipodermatosclerosis

Question 200

What are signs that a foot ulcer is infected

Answer 200

* Pain in a chronic wound (LR 11-20) * Foul odor (LR 1-3) * Purulence, exudate, erythema, warmth edema (LR\<1)

Question 201

What is the most likely microbiological etiology of osteomyelitis in patients with the following risk factors: * All patients * Foreign body, prosthetic infections * Nosocomia * DM * immunocompromise

Answer 201

Question 202

What clinical findings have the highest +LR and -LR for OM of the lower extremities in patients with diabetes?

Answer 202

Presence or absence of ulceration does not modify probability of disease

Question 203

What is the gold standard for diagnosis of lower extremity OM in diabetic patients?

Answer 203

* **Bone biopsy and culture** * Superficial swab cultures do not reliably predict bone microorganisms or diagnose infection

Question 204

What are the most commonly involved organisms in native vertebral OM?

Answer 204

* **S. Aureus (most common)** * Beta hemolytic strep * GNB * Less common * Tb * Brucella * Fungi

Question 205

List risk factors for native vertebral OM

Answer 205

* Elderly * immunocompromised * IVDU * Patients with PICCs/Ports

Question 206

What are the signs and symptoms of native vertebral OM?

Answer 206

* New/worstening back pain in the context of suggestive blood work * Fever in 45% of patients

Question 207

How can a diagnosis of native vertebral OM be posed? What is the workup

Answer 207

* **Biopsy** * Blood cultures (50% pos. if S. Aureus) * ESR, CRP (sens 94-100%) * MRI (sens. 97%, spec. 93%)

Question 208

When might a biopsy not be required when diagnosing native vertebral OM

Answer 208

* If S.Aureus bacteremia in last 3 months

Question 209

How is native vertebral OM treated?

Answer 209

* If no sepsis/neuro compromise, hold ABX until Bx results * If empiric ABx must be used : Ceftriaxone + vanco * Treat for 6 weeks * Surgery if * Neuro deficits * spinal cord compression * progression/recurrence despite appropriate ABx

Question 210

How should native vertebral OM be followed after ABx started?

Answer 210

* Monitor clinically and repeat inflamatory markers * repeat MRI _only if_ poor clinical response after ABx

Question 211

How should a possible prosthetic joint infection be worked up in patients with suggestive symptoms

Answer 211

1. Make a microbiological diagnosis 1. Withhold ABx if stable clinically 2. perform arthrocentesis

Question 212

What is the surgical management of prosthetic joint infections (i.e when do you change the prosthesis and when do you debride)?

Answer 212

Question 213

What are the empiric antibiotics of choice in prosthetic joint infections and for how long should a patient be treated

Answer 213

IV or high dose oral ABx for 4-6 weeks Empirically: Vanco + CTx

Question 214

Name 7 steps in the management of a new diagnosis of HIV

Answer 214

1. Stage the HIV infection * Confirm the positive test * CD4 count * Viral load * Genotype (assess for resistance) * Tropism testing (CCRS) 2. Assess for opportunistic infections * Treat if present * Prophylaxis based on CD4 count 3. Assess for co infections * TB: TST/IGRA, CXR * Serologies * CMV * toxoplasma * Hepatitis B/C * STIs and sexual health * Syphilis * Gono/chlam * pap-test (cervical +/- anal) 4. Immunizations * Hepatitis A if at risk * Hepatitis B * Annual influenza * COVID * HPV * PCV-13 then PPV-23 eight weeks later * Hib, meningiococcus * caution with live vaccines if CD4\<200 5. Assess general health * CBC, lytes, Cr, PO4 * Non-fasting lipids, glucs * UA, beta-HCG 6. Initiate ARV * Drug safety screening * HLA-B5701 (ABC hypersensitivity) * G6PD * Start ASAP and council on side effects 7. Follow-up and councilling * Prognosis * Safe sex * HIV in pregnancy * Duty to disclose

Question 215

What are the symptoms and signs of early HIV infection. Which ones have the highest +LR and -LR

Answer 215

* Fever * Nausea * emesis * weight loss * arthralgias/myalgias * pharyngitis * oral ulcers * rash * LADP

Question 216

Which patients with HIV should be getting ARV?

Answer 216

1. All individuals with HIV who are ready for treatment. No waiting period

Question 217

What are the recommended initial treatments for HIV

Answer 217

* 2 NRTIs PLUS INSTI OR NNRTI OR PI * bictegravir/tenofovir alafenamide/emtricitabine * Dolutegravir plus: * Tenofovir alafenamide/emtricitabine * Tenofovir disoproxil fumarate/emtricitabine * Tenofovir disoproxil fumarate/lamivutide * Dolutegravir/lamivudine with cavieats \*Tenofovir alafenamide has fewer bone and renal side effects wheras tenofovir disoprooxil fumarate is associated with lower lipid levels and lower costs

Question 218

Against what agents should prophylaxis be provided in HIV and at what CD4 count thresholds?

Answer 218

* CD4 \<200 * PJP prophylaxis * CD4 \<100 * Toxoplasmosis * CD4 \<50 * MAC (no longer recomended unless patients are noot on ART or not on fully suppressive ART

Question 219

What is the preferred agent for PJP prophylaxis? What are the alternatives?

Answer 219

* Prefered * TMP-SMX 1 DS tab daily * Alternatives * TMP-SMX 1 ss tab daily or 1 DS tab M/W/F * Dapsone * Atovaquone * aerosolized pentamidine monthly

Question 220

What is the preferred agent for Toxoplasmosis prophylaxis? What are the alternatives?

Answer 220

* Preferred * TMP/SMX 1 DS tab daily * Alternatives * TMP/SMX 1 SS tab daily or 1 DS tab M/W/F * Dapsone + pyrimethamine * Atovaquone

Question 221

What is the preferred agent for MAC prophylaxis? What are the alternatives?

Answer 221

* Prefered * Azithromycin 1200mg weekly * Clarythromycin 500mg BID * Alternative * Rifabutin

Question 222

What is the preferred and alternative _treatment_ for PJP in HIV patients

Answer 222

* Preferred * IV TMP SMX * If PaO2 \<70 or A-a gradient \>35 (severe PJP) * Prednisone 40mg PO BID x 5 days then * Prednisone 20 mg PO BID x 5 days then * Prednisone 20 mg PO daily x 11 days * Alternative * Moderate to severe * Primaquine + clindamycin IV * Pentamidine IV * Mild-moderatge * Dapsone + TMP * Primaquine + clindamycin PO * Atovaquone 750mg PO BID

Question 223

What is the preferred and alternative treatment for toxoplasmosis in HIV patients

Answer 223

* Preferred * Sulfadiazine + primethamine(AI) x 6 weeks +/- chronic maintenance if ongoing clinical or radiographic disease * Not available in Canada * Alternative * Primethamine + Clindamycin (AI) * TMP-SMX (b1) * Atovaquone +sulfadiazine * atovaquone + pirymethamine * Atovaquone

Question 224

What is the preferred and alternative treatment for MAC in HIV patients

Answer 224

* Preferred * Clarithromycin + ethambutol OR Azithromycin + ethambutol x 12 months * Alternative * COnsider ADDING rifabutin, amikacin, FQ if advanced HIV or severe disease

Question 225

What antimicrobials should not be used in G6PD deficiency

Answer 225

* Dapone * Primaquine

Question 226

What should be added to pyrimethamine to prevent toxicity

Answer 226

Leucovorin

Question 227

What HIV complications can arise with CD4 counts above 500

Answer 227

* Fever * Night sweats * LADP * headache * Malaise * Weight loss

Question 228

What additional complications can arise in HIV when the CD4 count drops to between 200-500

Answer 228

* Non-invasive candidiasis * Recurrent mucocutaneous HSV-1, HSV-2, VZV * Oral hairy leukoplakia (EBV) * Cutaneous KS (HHV-8) * Sinusitis, bacterial pneumonia (esp. invasive pneumococcus) * TB * Cervical dysplasia, cervical carcinoma in situ * CVD, stroke, CKD * Psoriasis, seborrheic dermatitis, bacillary angiomatosis, molluscum contagiosum * ITP

Question 229

What additional complications can arise in HIV when the CD4 count drops \<200

Answer 229

* HIV associated myelopathy * Visceral KS * Endemic fungi * Coccidiosis * Histoplasmosis * Blastomycosis * Non-endemic fungi * Aspergillosis * cryptococcus * PJP (subacute presentation over 2 weeks) * NHL\>HL, MM, leukemia, anal cancer, liver cancer, cervical cancer, vulvar/vaginal cancer

Question 230

What additional complications can arise in HIV when the CD4 count drops to between \<100

Answer 230

* Toxoplasmosis * PML (JC virus)

Question 231

What additional complications can arise in HIV when the CD4 count drops \<50

Answer 231

* CMV retinitis, colitis * **MAC** * CNS lymphoma, HAND

Question 232

When is it safe to get pregnant if you have HIV?

Answer 232

* When on ARV and undetectable viral load\

Question 233

How should HIV be managed through pregnancy?

Answer 233

* Always continue ARV * If VL \>1000 copies (or unknown) near delivery, give IV Zidovudine and recommend schedules C/S * If VL is suppressed, no increased risk with vaginal delivery

Question 234

How should HIV patients be managed in the post partum period?

Answer 234

* If maternal viral load not suppressed at birth, give zidovudine to baby x 6 weeks and nevirapine x 3 doses * **Breastfeeding NOT recommended**

Question 235

Describe the natural history of Tb

Answer 235

Question 236

How is latent Tb diagnosed

Answer 236

TST or IGRA

Question 237

What are the particularities of the TST and IGRA?

Answer 237

Question 238

Who should be tested for latent Tb?

Answer 238

* As a general rule: Patients with a high probability of infection or significant risk factors for reactivation and low risk of treatment toxicity and high probability of treatment completion: * Contacts of an active case of pulmonary Tb * Immigrants from countries with a high Tb incidence * Travelers to countries with high Tb incidence * Indigenous communities * People who inject drugs * Homeless * Health care workers * Residents of LTC facilities or correctional facilities

Question 239

How is a TST interpreted

Answer 239

* 0-4mm * Negative * 5-10 mm * Positive if: * **HIV** * **Contact with positive case within past 2 years** * **Presence of fibronodular disease on CXR** * **Organ transplant** * TNF alpha inhibitor user * Patients on immunosuppressive drugs * **ESRD** * \>10 mm * Positive in all situations

Question 240

How is latent Tb managed?

Answer 240

* Rule out active disease * Balance the risks of reactivation and the risk of treatment adverse events * If treating, then * Prefered * Isoniazid daily x 9 months * Alternative * Isoniazid daily x 6 months * isoniazid + rifampin daily x 3 months * \* new evidence for rifampin x 4 months, not in guidelines

Question 241

What is the treatment for active Tb

Answer 241

* Caveats * EMB can be stopped early if fully susceptible isolate * Supplement INH with vitamin B6 to prevent peripheral neuropathy * Steroids in Tb Meningitis or *pericardial disease (not in newer guidelines)* * Consider prolonged treatment if persistent cavity, culture positive at 2 months CNS or bone disease

Question 242

What are the side effects of isoniazid?

Answer 242

* Common * Rash * hepatitis * neuropathy * Unusual but important * CNS toxicity * Anemia

Question 243

What are the side effects of rifampin?

Answer 243

* Common * Drug interactions * rash * hepatitis * Uncommon but impoortant * Hepatitis * Flu-like illness * Neutropenia * thrombocytopenia

Question 244

What are the side effects of pyrazinamide?

Answer 244

* Common * Hepatitis * Rash * arthralgias * Rare but important * Gout

Question 245

What are the side effects of ethambutol?

Answer 245

* Common * Eye toxicity * Rare but important * rash

Question 246

Rash and hepatitis are side effects of most anti Tb drugs. List Tb drugs in RIPE in the order of most to least likely to cause both of these side effects

Answer 246

Question 247

How should active Tb be managed in pregnancy?

Answer 247

* In pregnancy risk to the foetus from active Tb\>risk from Rx * In pregnancy INH, RIF, EMB are safe * WHO recommends the use of PZA in pregnancy * Some uncertanties about safety but no reports of teratogenic effects * Give in women with extensive disease or in patients who cannot tolerate other first line drugs

Question 248

When should Latent TB be treated in pregnancy?

Answer 248

* Close contact of TB case * Otherwise, wait until after delivery

Question 249

Who should get an HIV test after a diagnosis of Tb

Answer 249

Everyone

Question 250

Which HIV patients with latent Tb should be treated for latent Tb

Answer 250

Everyone, high risk of reactivation!

Question 251

When should ART be started in patients with HIV and Tb

Answer 251

* CD4\<50: within 2 weeks * CD4 \>50: Within 8 weeks * Pregnancy: ASAP regardless of CD4 * In the presence of Tb meningitis: defer 8 weeks given increased risk of IRIS, especially if low CD4 count

Question 252

What should be given to patients at high risk of Tb-IRIS

Answer 252

Preemptive predisone

Question 253

What is the new prefered treatment for latent Tb in HIV+ patients?

Answer 253

* Isoniazid + Pyridoxine x 6-9 months

Question 254

What are the diagnostic criteria non-tuberculous mycobacteria lung disease

Answer 254

* Clinical AND * pulmonary or systemic symptoms * Radiological PLUS * Nodular or cavitary lesion on CXR * Bronchiectasis on CT * one of: * 2 or more sputum positive for same species NTM * 1 BAL/bronch culture positive for NTM * Biopsy with mycobacterial histology (AFB/Granuloma) and positive culture

Question 255

How are NTM pulmonary infections treated

Answer 255

* Discussion around clinical factors, infecting species and patient priorities * Ideally treat based on succeptibilities * Minimum 3 drug regimen * Macrolide * ethambutol * +/-rifampicin * +/-aminoglycoside No empiric treatment

Question 256

Name 4 species of NTM

Answer 256

1. Mycobacterium avium ocmplex 2. mycobacterium Kansaii 3. Mycobacterim Xenopi 4. Mycobacterium abscessus

Question 257

what questions should you ask a patient with fever after travel

Answer 257

* pre travel * PMHx, meds * pre-travel consultation? * Vaccines? * malaria prophylaxis? * travel * purpose (greatest risk = VFR) * travel itinerary * Type of accommodation (urban or rural) * Insect precautions * Individual exposures * raw meat, seafood, street food, unclean water, unpasteurized dairy products * Freshwater exposure * Visits on farms, slaughterhouses, funerals, hospitals * Animal bites or scratches, insect or arthropod bites, hiking/caving * Body fluid exposure (tattoo, sexual activity) * Medical care overseas * Post-travel * Timing of fevers/clinical symptoms * Short incubation period: * Malaria, dengue, chikungunya, travelers diarrhea, viral URTI, influenza * Long incubation period * Malaria, TB, hepatitis, HIV, enteric fever, due to salmonella spp. * Pattern of fever * Daily: malaria, traveller's diarrhea, viral RTI, enteric fever * Biphasic: Malaria, Dengue * Relapsing: Malaria, enteric fever

Question 258

What is the main DDx for fever in returned travelers?

Answer 258

* Infectious -- Travel-related * **MALARIA** * Typhoid/enteric fever * Dengue, Chikungunya, Zika * Viral hepatitis * Rickettsiae, Brucellosis, Leptospirosis, Q-Fever, Ebola * STIs, acute HIV * Infectious -- Non travel related * UTI * CAP * mono * Meningitis * C. Diff. * influenza * COVID-19 * Non-infectious * VTE * Drug fevers * illicit drugs

Question 259

What are the initial investigations that should and can be sent in patients with fevers returning from travel?

Answer 259

* CBC+diff, peripheral smear * Electrolytes, Cr, urea, glucose * ALT, ALP, AST, bili, INR/PTT * Blood cultures x2, urine culture * CXR * Malaria x3 (over 24hrs) * RDT Consider * Stool C&S, stool O&P, C. difficile * Dengue, chikungunya, zika, PCR or serology * hepatitis serology * HIV, STI screen * NP swab for viral PCR

Question 260

How is malaria diagnosed?

Answer 260

* Thick and thin blood smear x3 over 24hrs separated by at least 6hrs * Thick smear: Looks for parasites * Thin smear: Identifies parasitemia (%) and speciation * Rapid detection test * Seperate tests for P. falciparum and others * Highest sensitivity for falciparum

Question 261

Name the 6 species of malaria

Answer 261

* P. Falciparum * P. Ovale * P. vivax * P. Malariae * P. Knowlesi * P. Simiun

Question 262

What is unique to P. Vivax and Ovale

Answer 262

Can present years later due to hypnozoites in the liver

Question 263

Name the severity criteria for malaria

Answer 263

* Essentially any end-organ damage: * Neurological: Confusion, prostration (severe weakness), seizures * Respiratory: ARDS, pulmonary edema * Hematological: DIC, Jaundice, hemoglobinuria. Black water fever * Severe anemia (Hb\<50) * Hypoglycemia (glucose\<2.2) * Acidosis (pH\<7.25, HCO3 \<15) * Renal impairment (Cr \>265) * Lactic acidosis * Hyperparasitemia * ≥ 5% for non-immune adults * ≥ 10% for semi-immune adults

Question 264

How is falciparum malaria managed

Answer 264

* Uncomplicated * From chloroquine sensitive area: Chloroquine * From chloroquine resistant area: * Atovaquone-proguanil * Quinine+doxycycline * Quinine + clindamycin * Complicated * IV artesunate x 48hrs then: * PO atovaquone proguanil * Doxycycline * Clindamycin

Question 265

How is non-falciparum malaria managed?

Answer 265

* Uncomplicated * Chloroquine sensitive area (most): Chloroquine * Chloroquine resistant area * Atovaquone-proguanil * Quinine + doxycycline * Complicated (unusual for non-falciparum) * IV artesunate x 48hrs then: * PO atovaquone proguanil * Doxycycline * Clindamycin

Question 266

Describe the areas of the world with chloroquine sensitive/resistant malaria

Answer 266

Sensitive=grey areas on map

Question 267

What agents can be used for malaria chemoprophylaxis?

Answer 267

1. Chloroquine in sensitive areas 2. Atovaquone proguanil 3. Doxycycline 4. Mefoquine 5. primaquine

Question 268

Which forms of malaria chemoprophylaxis are safe in pregnancy?

Answer 268

* Chloroquine * Mefloquine * Atovaquone proguanil has insuficient data regarding use in pregnancy

Question 269

What clinical findings have the highest +LR and -LR for malaria

Answer 269

Question 270

What is the incubation period of dengue?

Answer 270

\<2 weeks

Question 271

What are the clinical features of Dengue

Answer 271

* Fever * Maculopapular rash * retro-orbital pain * myalgias ("break bone fevers") * Cytopenias

Question 272

What is the treatment for Dengue?

Answer 272

* Supportive care * avoid NSAIDS

Question 273

What is the incubation period of Zika?

Answer 273

* \<2 weeks

Question 274

What are the clinical features of Zika virus?

Answer 274

* 75% are asymptomatic * Fever * Rash * arthralgias * myalgias * conjunctivitis * HA * retro-orbital pain * Association with GBS * If caught in the first trimester, association with congenital Zika: * Microcephaly * intracranial calcifications * renal and hearing abnormalities * Arthrigryposis

Question 275

How is Zika virus treated?

Answer 275

Supportive care

Question 276

What is the incubation period for chikungunya

Answer 276

\< 2 weeks

Question 277

What are the clinical findings in chikungunya?

Answer 277

* Fever * Polyarthralgias (usually arthritis) * Lymphopenia * Maculopapular rash

Question 278

What is the treatment for chikungunya

Answer 278

Supportive care

Question 279

What is the etiological agent for typhoid?

Answer 279

Salmonella Typhi/paratyphi

Question 280

What is the incubation period for typhoid?

Answer 280

5-21 days

Question 281

What are the clinical features in Typhoid?

Answer 281

* Fever * Flu-like illness * salmon colored spots * constipation * abdo pain * relative bradycardia

Question 282

How is typhoid treated?

Answer 282

* IV ceftriaxone * IV cipro * Azithromycin \* increasing FQ resistance in SE asia

Question 283

From what type of exposure can a person get Leptospirosis?

Answer 283

* Animal waste * Soil, water exposure

Question 284

What is the incubation period for Leptospirosis

Answer 284

2-26 days (average 10 days)`

Question 285

What are the clincal features of Leptospirosis?

Answer 285

* Fever * Myalgias * HA * Conjunctivitis * Hypokalemia * Cytopenias * sterile pyuria * Rarely in severe disease * Jaundice + Renal failure (weil's disease) * ARDS * Pulmonary hemorrhage

Question 286

How is leptospirosis treated?

Answer 286

* Mild disease * Doxycycline * Azithromycin * Severe disease * CTx * Penicillin * doxycycline

Question 287

What finding on a CBC increases suspicion for nematodes in returned travelers?

Answer 287

* Eosinophilia

Question 288

How is the diagnosis of nematode diseases posed?

Answer 288

* Stool/urine/sputum(strogyloides) microscopy (Ova and parasites) * +/- serology (positive for life)

Question 289

Where can one get Strongyloides stercoralis?

Answer 289

Soils in Africa, South America, Asia

Question 290

How does strongyloides stercorales manifest in _immunocompromised patients_

Answer 290

* Disseminated disease * Polymicrobial GNB bacteremia * GNB meningitis

Question 291

How is strongyloides stercoralis treated?

Answer 291

Ivermectin

Question 292

How can one get schistosomia?

Answer 292

Contact with water (water/snail host) in troopical/sub-tropical areas

Question 293

What are the manifestations of Schistosoma

Answer 293

1. Chronic infection 2. Can predispose to liver and bladder Ca

Question 294

How is Schistosoma treated?

Answer 294

Praziquantel

Question 295

How is taenia solium treated?

Answer 295

Neurocysticercosis: albendazole +/- praziquantel +/- steroids

Question 296

How can one get Taenia Solium

Answer 296

By eating infected/uncooked meat (taeniasis) or eggs (neurocysticercosis)

Question 297

How might one get trichinella spiralis?

Answer 297

From eating undercooked wild animal meat (bear/pork)

Question 298

List symptoms of trichinella spiralis

Answer 298

* GI symptoms * Muscle pains (cysts)

Question 299

How is Trichinella spiralis treated?

Answer 299

Albendazole/mebendazole

Question 300

How is COVID 19 transmitted?

Answer 300

Droplets Aerosols in AGMP

Question 301

What is the incubation period of COVID 19?

Answer 301

2-14 days (average 5-6 days)

Question 302

What are the clinical features of COVID 19?

Answer 302

* Fever * Cough * SOB * fatigue * anosmia * GI Sx * anorexia

Question 303

How is COVID 19 diagnosed?

Answer 303

RT-PCR Highest sensitivity with LRT specimen Rapid antigen available

Question 304

Listt risk factors for severe COVID 19 infections

Answer 304

Question 305

What are the side effects of viral vector-based COVID vaccines?

Answer 305

* Common vaccine side effects * VTE (VITT) * capillary leak syndrome * GBS * anaphylaxis

Question 306

What are the side-effects of COVID 19 mRNA vaccines?

Answer 306

* Myocarditis/pericarditis * Bell's palsy * Anaphylaxis

Question 307

Who should get a booster shot of the COVID-19 vaccine?

Answer 307

* Should be offered at least 6 months after primary series * Adults \> 50 * Adults living in LTC or other settings that provide congregate care for seniors * Recipients of a viral vector vaccine only series * Adults from or in first nation communities * Frontline healthcare workers regardless of interval from initial series * Can be considered in other adults 18-49 * Adults with moderate to severe immunocompromise * Active cancer treatment * Transplant recipients * CAR-T or HSCT in last 2 years * Advanced untreated HIV * immunosuppressive meidications

Question 308

List therapies that can be used in COVID 19 and when they should be used

Answer 308

* Dexamethasone 6mg PO/IV x 10 days * If requiring O2, hospitalized, intubated * Remdesevir 200mg IV x1 then 100mg IV x4 days * If needing O2 but _not intubated_ * Tocilizumab * If requiring O2/intubation with systemic inflammation (CRP\>75) and worstening despite 24-48hrs of steroids * Casirivimab+imdevimab and sotrovimab * Consider in certain population * Mild-moderate COVID 19 in adults and adolescents at high risk for progression to hospitalisation and death * Within 10 days of positive test * VTE prophylaxis * More in heme deck * Antibiotics * Do not start empirically * Not recomended * Colchicine, IFN, Vit D * Recomended against * Hydroxychloroquine, Ivermectin, lopinavir/ritonavir

Question 309

Where is Zika virus endemic?

Answer 309

* **Most of carribean and south america** * Africa * South east asia

Question 310

How is Zika transmitted?

Answer 310

* Primarily through mosquito bites "day biters" * Reports of transmission via sexual intercourse or blood donations

Question 311

How is zika virus diagnosed

Answer 311

* Molecular testing * Within 2 weeks of symptom onset * Confirmatory plaque reduction neutralization test * Acute and convalescent serologies * Carefull: cross reactions, lack of specificity * Order \>10 days after symptom onset

Question 312

Who should get tested for Zika?

Answer 312

* Relevant exposure and: * Symptomatic patient within 3 days of arriving or 14 days of departing a high risk area * _Symptomatic_ pregnant women

Question 313

What is the incubation period of Ebola?

Answer 313

8-12 days usually (2-21 day range theoretically)

Question 314

What are the symptoms of Ebola?

Answer 314

* Fevers * Myalgias * GI Sx * Anorexia * Bleeding \<20%

Question 315

What should be the isolation protocol for patients with Ebola?

Answer 315

Droplet/contact and call IPAC vs impermeable neck to toe with N95 and face shield

Question 316

How is Ebola diagnosed?

Answer 316

* Viral cultures * NAAT * viral antigen testing * Serology from appropriate sites

Question 317

How is Ebola treated?

Answer 317

* Supportive care, essential procedures only * Don't forget to rule out malaria

Question 318

What is the case fatality rate of Ebola?

Answer 318

60%

Question 319

What is the incubation period of Measles

Answer 319

14 days

Question 320

What are the symptoms of measles

Answer 320

1. Fever 2. Cough 3. Coryza 4. conjunctivitis 5. Koplik spots 6. rash (centrifugal)

Question 321

How should patients with measles be isolated?

Answer 321

1. Airborne precautions

Question 322

Who should be contact traced after a diagnosis of measles?

Answer 322

1. Contacts 4 days before and after onset of rash

Question 323

How is measles diagnosed

Answer 323

PCR of pharynx, NP, urine Serology possible but can be false negative early

Question 324

List possible complications of measles

Answer 324

1. Pneumonia 2. Encephalitis 3. subacute sclerosing pancreatitis

Question 325

What should be used for post-exposure prooophylaxis in measles

Answer 325

* MMR vaccine * Immunoglobulins \*based on time from exposure

Question 326

Describe the testing for lyme disease

Answer 326

Question 327

In what condition can you diagnose Lyme disease without serology?

Answer 327

In the presence of erythema migrans = clinical diagnosis

Question 328

What are the manifestations of CNS lyme disease

Answer 328

1. meningitis 2. radiculoneuritis 3. mononeuritis multiplex 4. CN palsy 5. Spinal cord inflamation

Question 329

How is CNS lyme disease diagnosed

Answer 329

Serum antibody testing (not with PCR or culture of CSF!)

Question 330

What should be considered in Lyme patients with persistent fevers on antibiotics

Answer 330

COnsider co-onfections (Babesia, anaplasma)

Question 331

How should Lyme disease be treated?

Answer 331

Question 332

What is the definition of Fever of Unknown origin?

Answer 332

T^o \>38.3 over 3 weeks with 1 week investigations

Question 333

What is the DDx of FUO?

Answer 333

* Infection * Intra-abdominal abscess (30%) * IE * Sinusitis * TB * CMV * EBV * HIV * Inflammatory (25%) * GCA * Still's disease * IBD * Malignancy (15%) * Lymphoma * RCC * CRC * leukemia * Drugs/misc (10%) * VTE * Antimicrobials * NSAIDs * Allopurinol * Anti-epileptics * Idiopathic (25%)

Question 334

What are the first line investigations that should be sent in the context of FUO?

Answer 334

1. Hx & PE. Comprehensive fever diary 2. CBC + Differential + blood film 3. Lytes Cr, 4. LDH, TSH, CK, LFTs, SPEP 5. Blood cultures, urine C&S 6. HIV, CMV IgM, Hepatitis serologies 7. CXR, Abdo U/S 8. ANA, ANCA, RF 9. Consider EBV, monospot, q-fever serologies in right setting

Question 335

What second line investigations/steps should be undertaken if the first line investigations don't lead to any diagnosis?

Answer 335

* in this order 1. Discontinue non-essential medications, institute fever diary 2. CT abdomen 3. Nuclear imaging 4. TTE and duke criteria 5. Doppler U/S bilaterally -- lower extremities (R/O DVT) 6. Temporal artery biopsy (IF ESR\>50, patient\>50) 7. Liver biopsy \*Empiric trials of ABx or steroids rarely establish a diagnosis. Discouraged

Question 336

What workup should be sent before starting long-term corticosteroids?

Answer 336

* TST/IGRA: * If planning Prednisone\>15mg for \>4 weeks AND \> 1 other Tb risk factor * RF: close contact, recent immigration, high risk work/life exposure * Hepatitis B * If prednisone \>7.5 mg * PJP * Consider prophylaxis if pred \>20mg for \>4-8 weeks * Strongyloides * Screen with serology +/- stool O&P if any immunosuppression and lived (or extended travel) to endemic areas

Question 337

Which cancer patients on chemotherapy should get antimicrobial prophylaxis?

Answer 337

* Prophylaxis with **ciprofloxacin** in those at high risk for FN or prolonged profound neutropenia (ANC\<0.1 for \>7 days) * **Antifungal** (oral triazole or echinocandin) if prolonged and profound neutropenia such as in AML/MDS, HSCT. _Not in solid tumors_ * **TMP-SMX** in chemo with PJP risk \>3.5% (e.g. prednisone ≥20mg for \>1 month) * Patients who are _HSV +_ undergoing allo-HSCT or leukemia induction should get prophylactic **acyclovir** * **NRTI** if high risk of hep B reactivation * Yearly flu vaccine * Avoid environments with high concentrations of fungal spores

Question 338

How should Healthcare-associated ventriculitis and meningitis be managed?

Answer 338

1. Complete removal of infected CSF shunt/hardware and replacement with external drain 2. Empiric ABx: 1. Vanco + (ceftazidime OR Meropenem) 1. Add rifampin if staph isolate 2. Intraventricular ABx if no response to systemic ABx 3. Repeat CSF cultures to confirm negative growth 1. After the end of treatment: 1. 10-14 days post last + culture for gram positives 2. 21 days post last + culture for gram negatives 4. Reimplantation of new shunt once repeat CSF culture negative for 7-10 days

Question 339

When should a line infection be suspected?

Answer 339

* Fever + line: Dx should be considered * Get peripheral + line cultures

Question 340

How are line infections treated?

Answer 340

* Remove line if possible * ALWAYS for S. aureus and candida or with complicated infection (IE, OM, thrombophlebitis) * Directed therapy x 7 days * Minimum 14 days if S. Aureus or candida

Question 341

How are surgical infections managed

Answer 341

* Superficial * Treat as cellulitis * deep or organ space * Drainage +/- ABx

Question 342

How are catheter associated UTIs managed?

Answer 342

* Only get culture if patient symptomatic * If Sx and + culture, treat for 7 days * Remove/change catheter if possible

Question 343

List prevention strategies for VAP

Answer 343

1. Avoid intubation if possible (lol) 1. Use NIPPV if possible 2. Keep head of bed at 30-45 degrees 3. Daily oral care with chlorhexidine 4. Daily sedation vacation and assessment of readiness to extubate 5. Facilitate early mobilisation

Question 344

List prevention strategies for central line associated infections

Answer 344

1. Subclavian ≥ Jugular \> femoral 2. Use maximal sterile barrier precautions and sterile full body drapes when inserting CVCs 3. Clean skin with chlorhexidine before inserting line 4. chlorhexidine bathing 5. Use sterile gauze or transparent, semi-permeable dressing to cover catheter site 6. Daily assessment of wether CVC is needed

Question 345

List prevention strategies for catheter-associated UTIs

Answer 345

1. Hand hygiene; insert catheter using aseptic technique and sterile equipment 2. Use smallest possible catheter 3. Maintain sterile, continuously closed drainage system 4. keep collection bag below the level of the bladder 5. Empty collection bag regularly 6. Daily discussion of indication for catheter 7. Avoid unnecessary re-insertion

Question 346

List the sensitivity profiles of the various species of Candia

Answer 346

Question 347

List risk factors for Candidemia

Answer 347

1. Use of broad spectrum antibiotics 2. ICU admission 3. CVC 4. TPN 5. Neutropenia 6. Immunosupressive agents 7. Intra-abdominal surgical procedures 8. Necrotizing pancreatitis 9. Candida colonization in 3 sites

Question 348

How is Candidemia treated?

Answer 348

* IF stable, no recent azole exposure: Fluconazole * IF unstable, neutropenic or recent azole exposure: Echinocandin * **Pregnancy: Amphotericin B** * **CNS infections: Amphotericin B +/- flucytosine** **\***Consult ophthalmology to R/O endophtalmitis \*remove CVC \*Treat for 2 weeks after 1st negative BC \*Consider TTE if persistent candidemia. R/O IE

Question 349

What are 4 syndromes associated with aspergillus infections?

Answer 349

* ABPA/Allergic rhinosinusitis * Aspergiloma * Chronic cavitary pulmonary aspergilosis * Invasive aspergilosis

Question 350

What is ABPA and what are its clinical/lab findings

Answer 350

* Hyper-sensitivity response to Aspergillus antigens/precipitants * Presents with Asthma-like Sx, brown sputum, eosinophilia, bronchiectasis, elevated IgE

Question 351

What is an aspergilloma

Answer 351

* Mycetoma that forms within a pre-existant cavity * "Fungus ball"

Question 352

What is Chronic cavitary pulmonary aspergillosis and what are its clinical/lab findings

Answer 352

* Progression of aspergilloma in pre-existing structural lung disease (most commonly COPD) * Weight loss, Worsening cough +/- hemoptysis

Question 353

What is invasive aspergillosis and how is it diagnosed

Answer 353

* Opportunistic infection seen in neutropenia/cellular immunocompromise * Diagnosis using: * CT chest * indirect tests (Serum/sputum galactomannan) * Direct tests (fungal culture or pathology)

Question 354

How is ABPA treated?

Answer 354

* Steroids/anti-IgE +/- itraconazole (anti-fungal controversial)

Question 355

How are aspergillomas treated

Answer 355

* Single lesion: surgical resection +/- antifungals * Multiple lesions: Antifungals x6 months

Question 356

How is chronic cavitary pulmonary aspergillosis treated?

Answer 356

Antifungals x 6 months

Question 357

How is invasive aspergillosis treated

Answer 357

Voriconazole ≥ 6 weeks or longer

Question 358

Where is blastomycosis endemic?

Answer 358

Border of the great lakes (incl. northern Ontario) Southeastern/central USA St. Lawrence river valley

Question 359

What are the symptoms of Blastomycosis?

Answer 359

Pneumonia Skin/joint infections

Question 360

How is blastomycosis diagnosed?

Answer 360

* Fungal cultures * PCR * Pathology * Serum/urine antigen

Question 361

How is blastomycosis treated?

Answer 361

* Mild to moderate: Itrraconazole * Severe: Amphotericin B * Treat for 6-12 months or 3 months after complete resolution

Question 362

Where is Histoplasma endemic?

Answer 362

St. Lawrence and Ohio rivers

Question 363

What are the clinical manifestations of Histoplasmosis?

Answer 363

* Self limited PNA * TB mimicker

Question 364

How is Histoplasmosis diagnosed?

Answer 364

* Fungal culture * PCR * Pathology * Urine antigen

Question 365

How is histoplasmosis treated?

Answer 365

* Mild: no Tx * Moderate: Itraconazole * Severe: Amphotericin B Treat for 12 weeks

Question 366

Where is Coccidioides endemic

Answer 366

* Valley fever * New mexico * Arizona * Mexico * Central America

Question 367

In which patients should we suspect Coccidiodomycosis?

Answer 367

* Returned travelers with PNA, meningitis

Question 368

How is coccidiodomycosis diagnosed?

Answer 368

* Fungal culture * Path * antigen test * LP if meningitis symptoms

Question 369

How is coccidiodomycosis treated?

Answer 369

Only treat if symptomatic Itraconazole

Question 370

List aerosol generating medical procedures

Answer 370

1. Intubation/extubation, manual ventilation 2. Open endotracheal/deep succison 3. CPR (\*not chest compressions but airway manipulations) 4. Bronchoscopy and BAL 5. Tracheostomy/laryngoscopy 6. Sputum induction 7. Nebulized therapy (not MDI) 8. HFNC 9. NIPPV 10. Some dental procedures 1. Drilling 2. U/S scaling

Question 371

What isolation precautions need to be taken in the following diseases, for how long: * Tb * Disseminated VZV * Primary or disseminated, extensive varicella * Measles * COVID-19 * Mumps * Meningococcus * VHF inc. ebola

Answer 371

Question 372

What isolation precautions need to be taken in the following diseases, for how long: * Invasive GAS (TSS/NF/PNA/meningitis) * C. Difficile * Disseminated/primary extensive HSV * Diphteria (pharyngeal) * Influenza * Norovirus * Scabies * Antibiotic resistant organisms

Answer 372

Question 373

Which patients should get prophylactic or pre-emptive antibiotics antibiotics after a bite?

Answer 373

* Immunocompromised * Asplenic * Advanced liver disease * Pre-existing or resultant edema of affected area * Moderate to severe injury (especially to hand or face) * Penetrating injuries to periosteum or joint capsule

Question 374

What is the microbioology of animal bites

Answer 374

* Pasteurella multocida * Capnocytophagia Canimorsus * Staph * strep * anaerobes

Question 375

What empiric antibiotic regimens can be considered following an animal bite?

Answer 375

* Clavulin * 2nd or 3rd generation cephalosporin + metronidazole * Moxifloxacin * Doxy + clinda

Question 376

What empiric antibiotic regimens can be considered following a human bite?

Answer 376

* Clavulin * 2nd or 3rd generation cephalosporin + metronidazole * Moxifloxacin * Doxy + clinda

Question 377

What is the microbiology of human bites?

Answer 377

* Eikenella corrodens * Strep * S. Aureus * Anaerobes

Question 378

Who should get a tetanos shot and/or immunoglobulins after wound management

Answer 378

Question 379

In which patients with bite wounds should you give rabies post-exposure prophylaxis?

Answer 379

* If exposure to rabies is considered likely * Ask about animal species, type of exposure, circumstance, behavior and vaccination status of the animal, domestic vs stray animal, provoked vs unprovoked attack, location and severity of the bite * Make sure to immediately clean and flush the bite for 15 min * Call public health for assistance in risk management

Question 380

What should be given for rabies post-exposure prophylaxis

Answer 380

RabIg + vaccination If prior vaccination, no need to give RabIg

Question 381

What tests should be sent following a bloodborne pathogen exposure?

Answer 381

Question 382

How much time does it take before an HIV, HCV and HBV test become positive after an exposure?

Answer 382

Question 383

What is the risk of transmission from percutaneous exposure to HIV, HCV and HBV

Answer 383

* HIV: 0.23-1.3% * HBV: 6-30% * HCV: 3-10%

Question 384

What post-exposure prophylaxis should be offered after HIV exposure?

Answer 384

Truvada + Dolutegavir (or raltegravir) x 28 days within 72 hrs of exposure

Question 385

What post-exposure prophylaxis should be offered after HBV exposure

Answer 385

* Immune Anti HBs\>10: No further management * Non-immune (non-vaccinated or Anti HBs\<10) or unknown: Vaccine series +/- HBIG

Question 386

What post-exposure prophylaxis should be offered to patients following hep-c exposure

Answer 386

None. Repeat testing in 4-6 months

Question 387

Which vaccines should be given to adults, and at what age

Answer 387

Question 388

Which adult patients should get a Hib vaccine

Answer 388

* Asplenia/hyposplenism * HIV * Malignant hematological disorders * PID * Solid organ transplant * Cochlear implants

Question 389

Which adult patients should get a meningococcal vaccine?

Answer 389

* Asplenia/hyposplenism * HIV * Complement deficiency * Travelers to "meningitis belt" (subsaharan africa) * Pilgrims to hajj * military personnel * lab workers * close contacts to a case

Question 390

Which adult patients should get the pneu-c-13 followed by pneu-P-23 8 weeks later (pneumococcal vaccine). with single re-immunisation with pneu-p-23 5 years after?

Answer 390

* Asplenia/hyposplenism * Sickle cell disease * hemoglobinopathies * HIV * nephrotic syndrome * solid organ transplant * leukemia * lymphoma * immunisupressed * complement deficiencies

Question 391

Which adult patients should get 1 dose of pneu-p-23 then a second one 5 years later?

Answer 391

* Age \> 65 * Chronic CSF leak * Chronic cardiac/pulmonary disease * DM * CKD * CLD * EtOH * smokers * homeless persons * LTC * IVDU

Question 392

How should patients be managed when there is a suspicion for influenza? (who should be tested and treated empirically)

Answer 392

Question 393

For how many days should Oseltamivir treatment be given

Answer 393

5 days, longer if immunocompromised, severe PNA, ARDS

Question 394

When should patients with influenza be treated for bacterial coinfection?

Answer 394

* Initial severe disease * Failure to improve * Biphasic response