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1
Q

Name 3 gram negative cocci

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

Name 2 spore forming gram positive rods

A
  1. Bacillus sp.
  2. Clostridium sp.
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3
Q

Name 2 non-spore forming gram positive rods

A
  1. Corynebacterium sp.
  2. Listeria sp.
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4
Q

Name 2 anaerobic gram positive bacilli

A
  • Cutibacterium
  • Actinomyces
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5
Q

Name 4 lactose fermenting gram negative bacilli

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

*“gut bugs”

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6
Q

Name 2 non-lactose fermenting gram negative bacilli

A
  1. Pseudomonas
  2. Stenophotomonas
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7
Q

Name 2 anaerobic gram negative bacilli

A
  1. Bacteroides
  2. Fusobacterium
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8
Q

Name 3 spirochetes

A
  1. Treponema sp.
  2. Leptospirosis
  3. Borrelia
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9
Q

Name 2 yeasts

A
  1. Candida
  2. Cryptococcus
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10
Q

Name a mould

A

Aspergillus

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11
Q

Name 3 dimorphic fungi

A
  1. Blastomycosis
  2. Histoplasmosis
  3. Coccidiomycosis
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12
Q

List the HECK-Yes (SPICE-HAM) Organisms

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

A
  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

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13
Q

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

A
  1. E. Coli
  2. Klebsiella
  3. Carbapenems
  4. TMP-SMX
  5. FQ
  6. AG
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14
Q

What antimicrobials can be considered in CPE producing organisms

A
  1. Colistin
  2. AG
  3. Tigecycline
  4. Possibly FQ or TMP-SMX if lucky
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15
Q

What antimicrobials can be considered to treat MRSA

A
  1. Vancomycin
  2. Doxycycline
  3. TMOP-SMX
  4. Clindamycin
  5. Linezolid
  6. Daptomycin
  7. Ceftobiprole
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16
Q

What antimicrobials can be considered to treat pseudomonas

A
  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
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17
Q

What antimicrobials can be considered to treat enterococcus

A
  1. Ampicillin (if S)
  2. Vanco (not VRE)
  3. Linezolid
  4. Daptomycin
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18
Q

Name symptoms associated with meningitis

A
  • Predminantly headache, neck stiffness and fever
  • altered LOC late in the course
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19
Q

Name symptoms associated with encephalitis

A
  • Predominantly altered LOC and fevers
  • Can get seizures and focal neurological signs
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20
Q

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

A
  1. Fever
  2. Neck stiffness
  3. Altered mental status
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21
Q

What physical exam sign has the highest sensitivity for meningitis

A

Jolt accentuation

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22
Q

What 2 physical exam signs are the most specific for meningitis

A

Kernig’s and Brudzinski’s

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23
Q

What are symptoms of basal skull meningitis

A
  1. Regular meningitis symptoms plus:
  2. CN palsies
  3. long tract signs
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24
Q

What organisms are known to cause basal skull meningitis?

A
  1. Tb
  2. Listeria
  3. Cryptococcus
  4. Syphilis
  5. Lyme
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25
Q

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

A
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26
Q

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

A

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

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27
Q

Describe an approach to investigating suspected meningitis

A
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28
Q

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?

A
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29
Q

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?

A
  • Glucose <1.9
  • Protein >2.2
  • WBC>2000
  • PMNs>1180
  • CSF:blood glucose <0.23
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30
Q

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

A
  • Biochemistry and cell count minimally affected
  • Culture yield decreased
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31
Q

For how long should bacterial meningitis be treated

A
  • 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
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32
Q

When should Dexamethasone be given for meningitis

A
  • 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

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33
Q

Who should get N. Meningitidis chemoprophylaxis

A
  • 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
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34
Q

Within how many days should you give N. Meningitidois chemoprophylaxis

A

10 days

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35
Q

What agents can be used for N. Meningitidis chemoprophylaxis?

A
  • Ciprofloxacin 500mg po x1 (increasing resistance!)
  • Ceftriaxone 250 mg IM x1
  • Rifampin 600mg PO BID x 2 days
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36
Q

Who should get N. Meningitidis immunoprophylaxis?

A
  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
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37
Q

What agents can be used for N. Meningitidis immunoprophylaxis

A
  • Depends on serotype of index case and age/underlying conditions of contact
    • Men-C-ACYW
    • 4CMenB
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38
Q

What is the diagnostic workup for suspected endocarditis?

A
  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
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39
Q

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

A
  • 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
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40
Q

List the Duke criteria for diagnosis of IE

A
  • 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
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41
Q

What is necessary for a diagnosis of IE

A
  • 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
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42
Q

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

A

Cloxacillin or cefazolin

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43
Q

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

A

Vancomycin

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

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44
Q

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

A

Pen G or ceftriaxone

*If higher MIC to PNC levels, consider adding an aminoglycoside

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45
Q

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

A

Ampicillin + gentamycin

OR

Ampicillin + ceftriaxone

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46
Q

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

A

Vancomycin + gentamycin

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47
Q

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

A

Ceftriaxone

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48
Q

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

A

Cloxacillin OR cefazolin

AND

Rifampin

AND

Gentamicin

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49
Q

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

A

Vancomycin

AND

Rifampin

AND

gentamicin

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

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50
Q

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

A

Pen G OR ceftriaxone

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51
Q

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

A

Ampicillin + Gentamicin

OR

Ampicillin + Ceftriaxone

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52
Q

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

A

Vancomycin + Gentamicin

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53
Q

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

A

Ceftriaxone

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54
Q

for how long should IE be treated?

A

4-6 weeks

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

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55
Q

List the HACEK organisms

A
  • Haemophilus
  • Aggregatibacter
  • Cardiobacterium
  • Eikenella
  • Kingella
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56
Q

List the class 1 indications for early surgery in IE

A

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
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57
Q

List the class 1 indications for delayed surgery in IE?

A
  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

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58
Q

List the class II surgical indications in endocarditis

A
  • 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
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59
Q

When should IE prophylaxis be considered?

A
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60
Q

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

A
  • 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
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61
Q

How is pneumonia diagnosed?

A

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

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62
Q

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

A
  • PSI/PORT (prefered by IDSA/ATS 2019)
  • CRB-65
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63
Q

List the CRB 65 criteria

A
  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

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64
Q

Give the IDSA/ATS criteria to define severe CAP

A
  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
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65
Q

What are common pathogens in CAP

A
  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)
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66
Q

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

A
  1. Gram negatives
    1. Klebsiella pneumoniae
    2. Pseudomonas
    3. S. Aureus inc. MRSA
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67
Q

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

A
  1. inpatients with severe CAP
  2. intubated patients
  3. Patients being treated empirically for MRSA or pseudomonas
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68
Q

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?

A
  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

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69
Q

What are the outpatient treatment options for CAP?

A
  • 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
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70
Q

What are the inpatient treatment options for CAP?

A
  • 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
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71
Q

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

A
  • Based on local risk factors
  • Use Vancomycin or Linezolid
    • Daptomycin can’t be used in respiratory infections as it is inactivated by surfactans
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72
Q

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

A
  • Based on locally validated risk factors
  • Use:
    • Piptazo
    • Cefepime
    • ceftazidime
    • azetronam
    • meropenem
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73
Q

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

A

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

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74
Q

For how long should CAP be treated

A
  • 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
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75
Q

When should steroids be considered in CAP

A

Only in refractory shock

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76
Q

How should influenza pneumonia be treated

A
  • Oseltamivir if Sx <48hrs and hospitalized
  • COnsider treating bacterial superinfection
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77
Q

What are the pathogens involved in HAP/VAP

A
  • S. Pneumoniae
  • MSSA
  • H. Influenzae
  • GNB including pseudomonas
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78
Q

How is HAP/VAP diagnosed

A

Based on clinical gestalt + sputum/ETT/blood cultures

*CPIS score NOT recommended by IDSA

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79
Q

List the risk factors for MDR VAP and HAP

A
  • 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
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80
Q

How should HAP/VAP be treated empirically?

A
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81
Q

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

A
  • Diarrhea and:
    • Fever
    • Bloody or mucoid stools
    • Severe abdo pain
    • Sepsis
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82
Q

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

A
  • Recent antibiotics
  • Persons who work in healthcare, LTC, prison
  • Compatible syndrome
  • IBD flare
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83
Q

In what patients with diarrhea should blood cultures be sent?

A
  • Immunocompromise
  • Sepsis
  • Suspicion of enteric fever
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84
Q

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

A
  • Diarrhea ≥ 14 days
  • Immunocompromise
  • Travel
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85
Q

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

A

Order daily x 3 days

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86
Q

Which patients with bloody diarrhea should get empiric antibiotic treatment?

A
  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
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87
Q

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

A
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88
Q

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

A

First choice: Azithromycin

Alternative choice: Ciprofloxacin

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89
Q

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

A

First line: ceftriaxone OR ciprofloxacin

Alternatives: Ampicillin OR TMP-SMX OR azithromycin

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90
Q

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

A

First line: Azithromycin OR ciprofloxacin OR ceftriaxone

Alternative: TMP-SMX OR ampicillin

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91
Q

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

A

First line: Doxycycline

Alternative: Ciprofloxacin, Azithromycin, ceftriaxone

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92
Q

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

A

First line: TMP-SMX

Alternative: cefotaxime, ciprofloxacin

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93
Q

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

A

No ABx, risk of HUS

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94
Q

How is testing performed for C. Diff

A
  • Stool toxin testing:
    • EIA for GDH, toxin
    • NAAT PCR for toxin
  • Pseudomembranes on colonoscopy
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95
Q

Describe the clinical findings of CDiff

A

Unexplained new-onset ≥3 unformed stools in 24 hours

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96
Q

List the criteria for severe C. Diff

A
  1. WBC ≥ 15 OR Serum creatinine 1.5 x pre-morbid levels
  2. Age > 65, immunosuppression, T>38, albumin <30
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97
Q

List the findings in fulminant C. diff

A
  • Sepsis
  • Shock
  • Illeus
  • perforation
  • toxic megacolon (colon dilation > 6cm)
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98
Q

How is the first episode of C. Diff treated

A
  • STOP unnessessary antibiotics
  • Stop PPI if not needed
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99
Q

Why is fidaxomicin superior to Vancomycin?

A

Less recurrence!

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

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100
Q

What are the risk factors for C. Diff recurrence?

A
  1. Recurrent CDI in the last 6 months
  2. Age >65
  3. immunocompromised
  4. Severe CDI on presentation
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101
Q

How is recurrent C. Diff treated?

A
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102
Q

How are intra-abdominal infections managed?

A
  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
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103
Q

How long should antibiotics be continued for intraabdominal infections?

A

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

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104
Q

What are the criteria for a complicated UTI?

A
  • Hemodynamically unstable
  • Male
  • Pregnancy
  • Indwelling Foley catheter, instrumentation
  • Functional or anatomic anomalies
  • Urinary tract obstruction
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105
Q

How is a UTI diagnosed?

A

CLinically, supported by UA and culture

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106
Q

What are the first line empiric treatment options for cystitis?

A
  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

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107
Q

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

A
  • Fluoroquinolones (Levo or cipro)
  • Beta lactams
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108
Q

What are the first line empiric treatment options for pyelonaphritis?

A
  1. IV beta lactam (prefered in pregnancy) x7-14 days
  2. Fluoroquinolones (if resistance rates are low) x 5-7 days
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109
Q

What organisms usually cause prostatitis

A
  • E. Coli
  • Pseudomonas
  • Enterococcus
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110
Q

When should proatatitis be treated

A
  • If symptomatic
  • Do not treat if asymptomatic unless
    • elevated PSA
    • planning for Bx
    • infertility
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111
Q

What are the symptoms of acute prostatitis?

A
  • Fever
  • intense local pain
  • sepsis
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112
Q

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

A

UA+culture

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113
Q

What is the empiric antimicrobial treatment for acute prostatitis?

A
  • If well
    • Fluoroquinolone
  • If unwell
    • Fluoroquinolone
    • 3rd gen cephalosporin
    • Pip-tazo
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114
Q

How long should acute prostatitis be treated for?

A

2-4 weeks

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115
Q

What are the symptoms of chronic prostatitis

A
  • May or may not be symptomatic
  • If they are symptomatic, the symptoms are the same as acute prostatitis
    • Fever
    • Local pain
    • Sepsis
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116
Q

What antibiotics should be used to treat chronic prostatitis?

A

Fluoroquinolones or pathogen directed therapy

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117
Q

For how long should chronic prostatitis be treated?

A
  • If using a fluoroquinolone: 4-6 weeks
  • If using any other ABx: 8-12 weeks
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118
Q

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

A
  • Group B strep
  • enterococci
  • S. Aureus
  • anaerobic GPC
  • E. Coli
  • Gardnerella
  • Bacteroides

(polymicrobial)

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119
Q

What are the symptoms of post-partum endometritis?

A
  • Fever
  • Uterine tenderness
  • Bleeding
  • Foul-smelling lochia
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120
Q

Why do we worry about post-partum endometritis

A

It can progress to sepsis

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121
Q

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

A
  • Retained products of conception
  • abscesses
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122
Q

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

A
  • Clindamycin + Aminoglycoside(Add ampicillin or vancomycin if suspected enterococcus)
    • Stepdown to oral once deferveses
    • No good evidence on duration
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123
Q

What are the indications to treat asymptomatic bacteriuria?

For how many days should you treat for each indication

A
  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)
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124
Q

What is the incubation period for gonorrhea?

A

2-7 days

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125
Q

What symptoms can be associated with gonorrhea?

A
  • Can be asymptomatic
    • Rectal and pharyngial infections more likely to ba asymptomatic
  • Purulent discharge
  • pelvic pain
  • proctitis
  • pyuria
  • dysuria
  • epididymitis
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126
Q

What symptoms can be associated with Chlamydia?

A
  • Can be asymptomatic
    • Rectal and pharyngial infections more likely to ba asymptomatic
  • Purulent discharge
  • pelvic pain
  • proctitis
  • pyuria
  • dysuria
  • epididymitis
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127
Q

How is gonorrhea diagnosed?

A
  • NAAT /culture as indicated
    • Urine
    • Cervical
    • rectal
    • Pharyngeal
  • Add blood, joint pustule swab for disseminated

*cultures are generally preferred for sensitivity testing

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128
Q

How is gonorrhea treated

A
  • 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
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129
Q

Name possible complications of gonorrhea and chlamydia

A
  • 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
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130
Q

What is the incubation period of chlamydia?

A

2-6 weeks

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131
Q

What percentage of chlamydia and gonorrhea infected patients are asymptomatic

A

50% Gono

70% chlam

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132
Q

How is chlamydia diagnosed?

A

Urine, cervical, vaginal, rectal, pharyngeal NAAT

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133
Q

How is chlamydia treated?

A

Doxycycline 100mg PO x 7 days

Azithro 1g PO x1 is an alternative

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134
Q

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

A

Abstinence x7days and until partner is treated

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135
Q

How is chlamydia treated differently in pregnancy?

A

Doxy is contraindicated 2nd and 3rd trimester of pregnancy

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136
Q

What criterias define treatment failure in chlamydia or gonorrhea?

A
  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

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137
Q

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

A
  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
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138
Q

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

A

All individuals

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139
Q

What are the clinical manifestations of primary syphilis

A

Painless chancre and regional LN

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140
Q

How long after initial syphilis infection can primary syphilis last?

A

1st 3 weeks after infection

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141
Q

What are the manifestations of secondary syphilis?

A
  1. Fever
  2. Malaise
  3. Rash
  4. Alopecia
  5. uveitis
  6. meningitis
  7. LN
  8. herpatitis
  9. arthralgias
  10. condyloma lata
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142
Q

How long after initial syphilis infection can secondary syphilis last?

A

6 months

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143
Q

What timeframe differentiates early latent syphilis from late latent syphilis?

A

Early (<1 year since infection)

Late (>1 year or unknown duration)

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144
Q

What are the manifestations of latent syphilis

A

None

simply have positive serology

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145
Q

What are the manifestations of tertiary syphilis?

A
  • Cardiovascular
    • Aortitis
  • Gummatous
  • Late neurosyphilis
    • Tabes dorsalis
    • General paresis
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146
Q

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

A

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

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147
Q

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

A

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

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148
Q

What is the treatment for neurosyphils?

A
  • Aqueous penicliiin 4mU q4h IV x 14 days

No alternatives, desensitize if allergy to PNC

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149
Q

What are the treponemal tests

A
  • Immunoassay
  • TPPA
  • FTA-ABS
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150
Q

What are the non-treponemal tests?

A
  • VDRL
  • RPR
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151
Q

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

A
  • Treponemal
    • Specific antibody against Treponema Pallidum
    • Persists for life
  • Non-treponemal
    • non-specific antibody released during infection
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152
Q

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

A
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153
Q

What are the indications for PNC desensitization in syphilis patients

A
  1. Neurosyphilis
  2. Pregnancy
  3. Late latent or latent of unknown duration syphilis
  4. Tertiary syphilis
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154
Q

What are the indications to get an LP in syphilis?

A
  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)
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155
Q

What should be considered in persistant PID, urethritis or cervicitis

Especially if initial gono-chlam comes back negative after empiric Tx

A
  • 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
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156
Q

What is the organism responsible for chancroid?

A

H. Ducreyi

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157
Q

What are the symptoms and signs of chancroid

A
  • Painfull ulcer with granulomatous base that bleeds
  • Painfull inguinal LN
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158
Q

What is the treatment for chancroid?

A

Azithromycin 1g PO x1

CTx 250 mg IM x1

Cipro 500 mg PO BID x3days

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159
Q

What is the organism causing LGV

A

Chlamydia. Serovars L1-L3 more invasive

160
Q

What are the symptoms of LGV

A
  • Painfull LN
  • Hemorrhagic proctitis
161
Q

How is LGV treated

A

Doxycycline 100 mg PO BID x21 days and treat partners

162
Q

What are the symptoms of genital HSV?

A

Painfull vesicles/ulcers with prodrome

163
Q

What can be used to treat genital HSV

A
  1. Acyclovir
  2. Valacyclovir
  3. Famcyclovir
164
Q

What can be used to treat anogenital warts

A
  • HPV vaccine for prevention
  • For treatment
    • Spontaneous resolution
    • consider imiquimod or cryotherapy
165
Q

What are the symptoms of trichomonas vaginalis

A
  • Vaginal pH >4.5
  • Neg Whiff
  • yellow frothy discharge
  • strawberry cervix
166
Q

How is trichomonas vaginalis treated?

A
  • Metronidazole
    • 2g PO x1
    • OR 500 mg po x 7 days
  • Treat partners
167
Q

What are the symptoms and diagnostic tests for vulvovaginal candidiasis?

A
  • Vagina pH < 4.5
  • Neg whiff
  • wet mount with 10% KOH budding yeast
168
Q

How is vulvovaginal candidiasis treated?

A
  • clotrimazole or miconazole cream
  • fluconazole 150mg PO x1
169
Q

What are the symptoms and diagnostic tests for bacterial vaginosis?

A
  • Vaginal pH >4.5
  • pos whiff
  • clue cells on gram stain
  • fishy odor
170
Q

How is bacterial vaginosis treated?

A
  • Metrronidazole 500mg PO BID x 7 days or 5g application PV x 5 days
171
Q

Name 4 purulent skin and soft tissue infections

A
  • 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
172
Q

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

A
  • Impetigo
    • S. Aureus
  • Erysipela
    • GAS
  • Cellulitis
    • GAS
  • Necrotizing fasciitis
    • Depends on type
173
Q

How should purulent SSTIs be managed

A

I&D and C&S should be performed

174
Q

How should non-purulent SSTIs be managed?

A

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

175
Q

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

A
  • Consider if ≥3 episodes of cellulitis a year despite controlling other risk factors
  • Use penicillin or an equivalent beta lactam (amoxicillin, cephalexin)
176
Q

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

A

COmpression

177
Q

What symptoms suggest nec. fasc.

A
  • Erythema with
    • systemic toxicity
    • gangrene/anesthesia
    • hard induration
    • hemorrhagic bullae
    • pain out of proportion
    • Pain extending beyond erythema
178
Q

How is necrotizing fasciitis treated emipically?

A
  • Emergent surgical inspection/debridement
    • Consult surgery urgently
  • Empiric antibiotics
    • Piptazo + Vanco + Clindamycin
  • Consider IVIG if shock or pre-operative
179
Q

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

180
Q

Who gets type 1 nec. fasc.

A
  • Usually younger patients
  • following minor trauma
  • they can have DM/PAD/IVDU
181
Q

Who gets type 2 nec. fasc.?

A
  • Older patients
  • DM
  • pelvic wounds
182
Q

What is associated with clostridium induced nec. fasc.

A
  • Trauma
  • colon Ca
183
Q

What is associated with vibrio vulnificus nec. fasc.

A
  • Saltwater exposure
  • Underlying liver disease
  • seafood ingestion
184
Q

What is associated with Aeromonas hydrophila induced Nec. Fasc.

A

Freshwater exposure, injury

185
Q

What bacteria cause toxic shock syndrome?

A
  • GAS
  • S. aureus
186
Q

What are the diagnostic criteria for toxic shock syndrome?

A
  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
187
Q

How is toxic shock syndrome managed?

A
  • 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)
188
Q

What microbiology is classically associated with diabetes

A
  • Polymicrobial infections
    • Often pseudomonas and anaerobes
189
Q

What SSTI microbiology is classically associated with water exposure?

A
  • Vibrio vulnificus (salt water)
  • Aeromonas spp (fresh water)
  • M. Marinum (fish tank exposures)
  • M. Fortuitum (hot tub exposure)
190
Q

What SSTI microbiology is classically associated with rose gardens?

A

sporothrix schenckii

191
Q

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

A

Erysipelothrix rhusiopathiae

192
Q

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

A

Pseudomonas

193
Q

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

A

HSV-1 and HSV-2

194
Q

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

A

Cryptococcus neoformans

195
Q

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

196
Q

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

A

Oral hairy leukoplakia (EBV)

197
Q

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

A

Mucormycosis (Rhizopus spp.)

198
Q

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

A
  • Hematogenous spread
    • More common in children
    • In adults, commonly causes vertebral OM
    • Monomicrobial
  • Contiguous spread
    • From SSTI, trauma, surgery
    • Polymicrobial
199
Q

Differentiate neuropathic, arterial and venous foot ulcers

A
  • 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
200
Q

What are signs that a foot ulcer is infected

A
  • Pain in a chronic wound (LR 11-20)
  • Foul odor (LR 1-3)
  • Purulence, exudate, erythema, warmth edema (LR<1)
201
Q

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
202
Q

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

A

Presence or absence of ulceration does not modify probability of disease

203
Q

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

A
  • Bone biopsy and culture
    • Superficial swab cultures do not reliably predict bone microorganisms or diagnose infection
204
Q

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

A
  • S. Aureus (most common)
  • Beta hemolytic strep
  • GNB
  • Less common
    • Tb
    • Brucella
    • Fungi
205
Q

List risk factors for native vertebral OM

A
  • Elderly
  • immunocompromised
  • IVDU
  • Patients with PICCs/Ports
206
Q

What are the signs and symptoms of native vertebral OM?

A
  • New/worstening back pain in the context of suggestive blood work
  • Fever in 45% of patients
207
Q

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

A
  • Biopsy
  • Blood cultures (50% pos. if S. Aureus)
  • ESR, CRP (sens 94-100%)
  • MRI (sens. 97%, spec. 93%)
208
Q

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

A
  • If S.Aureus bacteremia in last 3 months
209
Q

How is native vertebral OM treated?

A
  • 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
210
Q

How should native vertebral OM be followed after ABx started?

A
  • Monitor clinically and repeat inflamatory markers
  • repeat MRI only if poor clinical response after ABx
211
Q

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

A
  1. Make a microbiological diagnosis
    1. Withhold ABx if stable clinically
    2. perform arthrocentesis
212
Q

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

213
Q

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

A

IV or high dose oral ABx for 4-6 weeks

Empirically: Vanco + CTx

214
Q

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

A
  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
215
Q

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

A
  • Fever
  • Nausea
  • emesis
  • weight loss
  • arthralgias/myalgias
  • pharyngitis
  • oral ulcers
  • rash
  • LADP
216
Q

Which patients with HIV should be getting ARV?

A
  1. All individuals with HIV who are ready for treatment. No waiting period
217
Q

What are the recommended initial treatments for HIV

A
  • 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

218
Q

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

A
  • 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
219
Q

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

A
  • 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
220
Q

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

A
  • Preferred
    • TMP/SMX 1 DS tab daily
  • Alternatives
    • TMP/SMX 1 SS tab daily or 1 DS tab M/W/F
    • Dapsone + pyrimethamine
    • Atovaquone
221
Q

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

A
  • Prefered
    • Azithromycin 1200mg weekly
    • Clarythromycin 500mg BID
  • Alternative
    • Rifabutin
222
Q

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

A
  • 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
223
Q

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

A
  • 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
224
Q

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

A
  • Preferred
    • Clarithromycin + ethambutol OR Azithromycin + ethambutol x 12 months
  • Alternative
    • COnsider ADDING rifabutin, amikacin, FQ if advanced HIV or severe disease
225
Q

What antimicrobials should not be used in G6PD deficiency

A
  • Dapone
  • Primaquine
226
Q

What should be added to pyrimethamine to prevent toxicity

A

Leucovorin

227
Q

What HIV complications can arise with CD4 counts above 500

A
  • Fever
  • Night sweats
  • LADP
  • headache
  • Malaise
  • Weight loss
228
Q

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

A
  • 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
229
Q

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

A
  • 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
230
Q

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

A
  • Toxoplasmosis
  • PML (JC virus)
231
Q

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

A
  • CMV retinitis, colitis
  • MAC
  • CNS lymphoma, HAND
232
Q

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

A
  • When on ARV and undetectable viral load\
233
Q

How should HIV be managed through pregnancy?

A
  • 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
234
Q

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

A
  • If maternal viral load not suppressed at birth, give zidovudine to baby x 6 weeks and nevirapine x 3 doses
  • Breastfeeding NOT recommended
235
Q

Describe the natural history of Tb

236
Q

How is latent Tb diagnosed

A

TST or IGRA

237
Q

What are the particularities of the TST and IGRA?

238
Q

Who should be tested for latent Tb?

A
  • 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
239
Q

How is a TST interpreted

A
  • 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
240
Q

How is latent Tb managed?

A
  • 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
241
Q

What is the treatment for active Tb

A
  • 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
242
Q

What are the side effects of isoniazid?

A
  • Common
    • Rash
    • hepatitis
    • neuropathy
  • Unusual but important
    • CNS toxicity
    • Anemia
243
Q

What are the side effects of rifampin?

A
  • Common
    • Drug interactions
    • rash
    • hepatitis
  • Uncommon but impoortant
    • Hepatitis
    • Flu-like illness
    • Neutropenia
    • thrombocytopenia
244
Q

What are the side effects of pyrazinamide?

A
  • Common
    • Hepatitis
    • Rash
    • arthralgias
  • Rare but important
    • Gout
245
Q

What are the side effects of ethambutol?

A
  • Common
    • Eye toxicity
  • Rare but important
    • rash
246
Q

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

247
Q

How should active Tb be managed in pregnancy?

A
  • 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
248
Q

When should Latent TB be treated in pregnancy?

A
  • Close contact of TB case
  • Otherwise, wait until after delivery
249
Q

Who should get an HIV test after a diagnosis of Tb

250
Q

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

A

Everyone, high risk of reactivation!

251
Q

When should ART be started in patients with HIV and Tb

A
  • 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
252
Q

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

A

Preemptive predisone

253
Q

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

A
  • Isoniazid + Pyridoxine x 6-9 months
254
Q

What are the diagnostic criteria non-tuberculous mycobacteria lung disease

A
  • 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
255
Q

How are NTM pulmonary infections treated

A
  • 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

256
Q

Name 4 species of NTM

A
  1. Mycobacterium avium ocmplex
  2. mycobacterium Kansaii
  3. Mycobacterim Xenopi
  4. Mycobacterium abscessus
257
Q

what questions should you ask a patient with fever after travel

A
  • 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
258
Q

What is the main DDx for fever in returned travelers?

A
  • 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
259
Q

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

A
  • 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
260
Q

How is malaria diagnosed?

A
  • 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
261
Q

Name the 6 species of malaria

A
  • P. Falciparum
  • P. Ovale
  • P. vivax
  • P. Malariae
  • P. Knowlesi
  • P. Simiun
262
Q

What is unique to P. Vivax and Ovale

A

Can present years later due to hypnozoites in the liver

263
Q

Name the severity criteria for malaria

A
  • 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
264
Q

How is falciparum malaria managed

A
  • 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
265
Q

How is non-falciparum malaria managed?

A
  • 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
266
Q

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

A

Sensitive=grey areas on map

267
Q

What agents can be used for malaria chemoprophylaxis?

A
  1. Chloroquine in sensitive areas
  2. Atovaquone proguanil
  3. Doxycycline
  4. Mefoquine
  5. primaquine
268
Q

Which forms of malaria chemoprophylaxis are safe in pregnancy?

A
  • Chloroquine
  • Mefloquine
  • Atovaquone proguanil has insuficient data regarding use in pregnancy
269
Q

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

270
Q

What is the incubation period of dengue?

271
Q

What are the clinical features of Dengue

A
  • Fever
  • Maculopapular rash
  • retro-orbital pain
  • myalgias (“break bone fevers”)
  • Cytopenias
272
Q

What is the treatment for Dengue?

A
  • Supportive care
  • avoid NSAIDS
273
Q

What is the incubation period of Zika?

274
Q

What are the clinical features of Zika virus?

A
  • 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
275
Q

How is Zika virus treated?

A

Supportive care

276
Q

What is the incubation period for chikungunya

277
Q

What are the clinical findings in chikungunya?

A
  • Fever
  • Polyarthralgias (usually arthritis)
  • Lymphopenia
  • Maculopapular rash
278
Q

What is the treatment for chikungunya

A

Supportive care

279
Q

What is the etiological agent for typhoid?

A

Salmonella Typhi/paratyphi

280
Q

What is the incubation period for typhoid?

281
Q

What are the clinical features in Typhoid?

A
  • Fever
  • Flu-like illness
  • salmon colored spots
  • constipation
  • abdo pain
  • relative bradycardia
282
Q

How is typhoid treated?

A
  • IV ceftriaxone
  • IV cipro
  • Azithromycin

* increasing FQ resistance in SE asia

283
Q

From what type of exposure can a person get Leptospirosis?

A
  • Animal waste
  • Soil, water exposure
284
Q

What is the incubation period for Leptospirosis

A

2-26 days (average 10 days)`

285
Q

What are the clincal features of Leptospirosis?

A
  • Fever
  • Myalgias
  • HA
  • Conjunctivitis
  • Hypokalemia
  • Cytopenias
  • sterile pyuria
  • Rarely in severe disease
    • Jaundice + Renal failure (weil’s disease)
    • ARDS
    • Pulmonary hemorrhage
286
Q

How is leptospirosis treated?

A
  • Mild disease
    • Doxycycline
    • Azithromycin
  • Severe disease
    • CTx
    • Penicillin
    • doxycycline
287
Q

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

A
  • Eosinophilia
288
Q

How is the diagnosis of nematode diseases posed?

A
  • Stool/urine/sputum(strogyloides) microscopy (Ova and parasites)
  • +/- serology (positive for life)
289
Q

Where can one get Strongyloides stercoralis?

A

Soils in Africa, South America, Asia

290
Q

How does strongyloides stercorales manifest in immunocompromised patients

A
  • Disseminated disease
    • Polymicrobial GNB bacteremia
    • GNB meningitis
291
Q

How is strongyloides stercoralis treated?

A

Ivermectin

292
Q

How can one get schistosomia?

A

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

293
Q

What are the manifestations of Schistosoma

A
  1. Chronic infection
  2. Can predispose to liver and bladder Ca
294
Q

How is Schistosoma treated?

A

Praziquantel

295
Q

How is taenia solium treated?

A

Neurocysticercosis: albendazole +/- praziquantel +/- steroids

296
Q

How can one get Taenia Solium

A

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

297
Q

How might one get trichinella spiralis?

A

From eating undercooked wild animal meat (bear/pork)

298
Q

List symptoms of trichinella spiralis

A
  • GI symptoms
  • Muscle pains (cysts)
299
Q

How is Trichinella spiralis treated?

A

Albendazole/mebendazole

300
Q

How is COVID 19 transmitted?

A

Droplets

Aerosols in AGMP

301
Q

What is the incubation period of COVID 19?

A

2-14 days (average 5-6 days)

302
Q

What are the clinical features of COVID 19?

A
  • Fever
  • Cough
  • SOB
  • fatigue
  • anosmia
  • GI Sx
  • anorexia
303
Q

How is COVID 19 diagnosed?

A

RT-PCR

Highest sensitivity with LRT specimen

Rapid antigen available

304
Q

Listt risk factors for severe COVID 19 infections

305
Q

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

A
  • Common vaccine side effects
  • VTE (VITT)
  • capillary leak syndrome
  • GBS
  • anaphylaxis
306
Q

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

A
  • Myocarditis/pericarditis
  • Bell’s palsy
  • Anaphylaxis
307
Q

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

A
  • 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
308
Q

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

A
  • 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
309
Q

Where is Zika virus endemic?

A
  • Most of carribean and south america
  • Africa
  • South east asia
310
Q

How is Zika transmitted?

A
  • Primarily through mosquito bites “day biters”
  • Reports of transmission via sexual intercourse or blood donations
311
Q

How is zika virus diagnosed

A
  • 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
312
Q

Who should get tested for Zika?

A
  • Relevant exposure and:
    • Symptomatic patient within 3 days of arriving or 14 days of departing a high risk area
    • Symptomatic pregnant women
313
Q

What is the incubation period of Ebola?

A

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

314
Q

What are the symptoms of Ebola?

A
  • Fevers
  • Myalgias
  • GI Sx
  • Anorexia
  • Bleeding <20%
315
Q

What should be the isolation protocol for patients with Ebola?

A

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

316
Q

How is Ebola diagnosed?

A
  • Viral cultures
  • NAAT
  • viral antigen testing
  • Serology from appropriate sites
317
Q

How is Ebola treated?

A
  • Supportive care, essential procedures only
  • Don’t forget to rule out malaria
318
Q

What is the case fatality rate of Ebola?

319
Q

What is the incubation period of Measles

320
Q

What are the symptoms of measles

A
  1. Fever
  2. Cough
  3. Coryza
  4. conjunctivitis
  5. Koplik spots
  6. rash (centrifugal)
321
Q

How should patients with measles be isolated?

A
  1. Airborne precautions
322
Q

Who should be contact traced after a diagnosis of measles?

A
  1. Contacts 4 days before and after onset of rash
323
Q

How is measles diagnosed

A

PCR of pharynx, NP, urine

Serology possible but can be false negative early

324
Q

List possible complications of measles

A
  1. Pneumonia
  2. Encephalitis
  3. subacute sclerosing pancreatitis
325
Q

What should be used for post-exposure prooophylaxis in measles

A
  • MMR vaccine
  • Immunoglobulins

*based on time from exposure

326
Q

Describe the testing for lyme disease

327
Q

In what condition can you diagnose Lyme disease without serology?

A

In the presence of erythema migrans = clinical diagnosis

328
Q

What are the manifestations of CNS lyme disease

A
  1. meningitis
  2. radiculoneuritis
  3. mononeuritis multiplex
  4. CN palsy
  5. Spinal cord inflamation
329
Q

How is CNS lyme disease diagnosed

A

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

330
Q

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

A

COnsider co-onfections (Babesia, anaplasma)

331
Q

How should Lyme disease be treated?

332
Q

What is the definition of Fever of Unknown origin?

A

To >38.3 over 3 weeks with 1 week investigations

333
Q

What is the DDx of FUO?

A
  • 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%)
334
Q

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

A
  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
335
Q

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

A
  • 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

336
Q

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

A
  • 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
337
Q

Which cancer patients on chemotherapy should get antimicrobial prophylaxis?

A
  • 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
338
Q

How should Healthcare-associated ventriculitis and meningitis be managed?

A
  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
339
Q

When should a line infection be suspected?

A
  • Fever + line: Dx should be considered
    • Get peripheral + line cultures
340
Q

How are line infections treated?

A
  • 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
341
Q

How are surgical infections managed

A
  • Superficial
    • Treat as cellulitis
  • deep or organ space
    • Drainage +/- ABx
342
Q

How are catheter associated UTIs managed?

A
  • Only get culture if patient symptomatic
  • If Sx and + culture, treat for 7 days
  • Remove/change catheter if possible
343
Q

List prevention strategies for VAP

A
  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
344
Q

List prevention strategies for central line associated infections

A
  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
345
Q

List prevention strategies for catheter-associated UTIs

A
  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
346
Q

List the sensitivity profiles of the various species of Candia

347
Q

List risk factors for Candidemia

A
  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
348
Q

How is Candidemia treated?

A
  • 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

349
Q

What are 4 syndromes associated with aspergillus infections?

A
  • ABPA/Allergic rhinosinusitis
  • Aspergiloma
  • Chronic cavitary pulmonary aspergilosis
  • Invasive aspergilosis
350
Q

What is ABPA and what are its clinical/lab findings

A
  • Hyper-sensitivity response to Aspergillus antigens/precipitants
  • Presents with Asthma-like Sx, brown sputum, eosinophilia, bronchiectasis, elevated IgE
351
Q

What is an aspergilloma

A
  • Mycetoma that forms within a pre-existant cavity
  • “Fungus ball”
352
Q

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

A
  • Progression of aspergilloma in pre-existing structural lung disease (most commonly COPD)
  • Weight loss, Worsening cough +/- hemoptysis
353
Q

What is invasive aspergillosis and how is it diagnosed

A
  • Opportunistic infection seen in neutropenia/cellular immunocompromise
  • Diagnosis using:
    • CT chest
    • indirect tests (Serum/sputum galactomannan)
    • Direct tests (fungal culture or pathology)
354
Q

How is ABPA treated?

A
  • Steroids/anti-IgE +/- itraconazole (anti-fungal controversial)
355
Q

How are aspergillomas treated

A
  • Single lesion: surgical resection +/- antifungals
  • Multiple lesions: Antifungals x6 months
356
Q

How is chronic cavitary pulmonary aspergillosis treated?

A

Antifungals x 6 months

357
Q

How is invasive aspergillosis treated

A

Voriconazole ≥ 6 weeks or longer

358
Q

Where is blastomycosis endemic?

A

Border of the great lakes (incl. northern Ontario)

Southeastern/central USA

St. Lawrence river valley

359
Q

What are the symptoms of Blastomycosis?

A

Pneumonia

Skin/joint infections

360
Q

How is blastomycosis diagnosed?

A
  • Fungal cultures
  • PCR
  • Pathology
  • Serum/urine antigen
361
Q

How is blastomycosis treated?

A
  • Mild to moderate: Itrraconazole
  • Severe: Amphotericin B
  • Treat for 6-12 months or 3 months after complete resolution
362
Q

Where is Histoplasma endemic?

A

St. Lawrence and Ohio rivers

363
Q

What are the clinical manifestations of Histoplasmosis?

A
  • Self limited PNA
  • TB mimicker
364
Q

How is Histoplasmosis diagnosed?

A
  • Fungal culture
  • PCR
  • Pathology
  • Urine antigen
365
Q

How is histoplasmosis treated?

A
  • Mild: no Tx
  • Moderate: Itraconazole
  • Severe: Amphotericin B

Treat for 12 weeks

366
Q

Where is Coccidioides endemic

A
  • Valley fever
    • New mexico
    • Arizona
    • Mexico
    • Central America
367
Q

In which patients should we suspect Coccidiodomycosis?

A
  • Returned travelers with PNA, meningitis
368
Q

How is coccidiodomycosis diagnosed?

A
  • Fungal culture
  • Path
  • antigen test
  • LP if meningitis symptoms
369
Q

How is coccidiodomycosis treated?

A

Only treat if symptomatic

Itraconazole

370
Q

List aerosol generating medical procedures

A
  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
371
Q

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
372
Q

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
373
Q

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

A
  • 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
374
Q

What is the microbioology of animal bites

A
  • Pasteurella multocida
  • Capnocytophagia Canimorsus
  • Staph
  • strep
  • anaerobes
375
Q

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

A
  • Clavulin
  • 2nd or 3rd generation cephalosporin + metronidazole
  • Moxifloxacin
  • Doxy + clinda
376
Q

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

A
  • Clavulin
  • 2nd or 3rd generation cephalosporin + metronidazole
  • Moxifloxacin
  • Doxy + clinda
377
Q

What is the microbiology of human bites?

A
  • Eikenella corrodens
  • Strep
  • S. Aureus
  • Anaerobes
378
Q

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

379
Q

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

A
  • 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
380
Q

What should be given for rabies post-exposure prophylaxis

A

RabIg + vaccination

If prior vaccination, no need to give RabIg

381
Q

What tests should be sent following a bloodborne pathogen exposure?

382
Q

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

383
Q

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

A
  • HIV: 0.23-1.3%
  • HBV: 6-30%
  • HCV: 3-10%
384
Q

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

A

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

385
Q

What post-exposure prophylaxis should be offered after HBV exposure

A
  • Immune Anti HBs>10: No further management
  • Non-immune (non-vaccinated or Anti HBs<10) or unknown: Vaccine series +/- HBIG
386
Q

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

A

None. Repeat testing in 4-6 months

387
Q

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

388
Q

Which adult patients should get a Hib vaccine

A
  • Asplenia/hyposplenism
  • HIV
  • Malignant hematological disorders
  • PID
  • Solid organ transplant
  • Cochlear implants
389
Q

Which adult patients should get a meningococcal vaccine?

A
  • Asplenia/hyposplenism
  • HIV
  • Complement deficiency
  • Travelers to “meningitis belt” (subsaharan africa)
  • Pilgrims to hajj
  • military personnel
  • lab workers
  • close contacts to a case
390
Q

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?

A
  • Asplenia/hyposplenism
  • Sickle cell disease
  • hemoglobinopathies
  • HIV
  • nephrotic syndrome
  • solid organ transplant
  • leukemia
  • lymphoma
  • immunisupressed
  • complement deficiencies
391
Q

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

A
  • Age > 65
  • Chronic CSF leak
  • Chronic cardiac/pulmonary disease
  • DM
  • CKD
  • CLD
  • EtOH
  • smokers
  • homeless persons
  • LTC
  • IVDU
392
Q

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

393
Q

For how many days should Oseltamivir treatment be given

A

5 days, longer if immunocompromised, severe PNA, ARDS

394
Q

When should patients with influenza be treated for bacterial coinfection?

A
  • Initial severe disease
  • Failure to improve
  • Biphasic response

RCPSC (14 decks)

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