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ID Flashcards

1
Q

Treatment SPICE-HAM (Amp C) and ESBL (Kleb/Ecoli)

A

Carbapenems, Septra, Fluoroquinolones, Aminoglycoside

*Serratia, Providencia, Indole+ proteus, citrobacter, enterobacter, Hafnia, Acinetobacter, Morganella

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2
Q

IE “Early” Surgical Indications

A

Class I

  • Valve dysfunction with CHF refractory to medical tx
  • LS native valve IE w Staph, fungi or other resistant orgs
  • Persistent fever/bacteremia > 5 days of abx
  • Heart block, destructive penetrating lesion or annular/ root abscess
  • IE with ICD/PPM/CRT leads in situ (require removal)

Class II

  • Native valve with veggie >10mm
  • Recurrent embolic events with persistent vegetation despite abx
  • Minor embolic stroke/TIA without ICH with indication for surgery (delay if major ischemic/hemorrhagic stroke)
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3
Q

IE “Delayed” Surgical Indication

A

Relapsing infection of prosthetic valve (new fever/bacteremia after abx course and interval sterile BCx w/o another source)

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4
Q

Duke Criteria for Diagnosis IE

A

Definite Dx: + Veggie Cx or 2 Major or 1 Major + 3 Minor or 5 min
Possible: 1M +1m OR 3m

Major:

  1. Microbiologic evidence of typical IE causing organism (S aureus, Viridans, S gallolyticus/Bovis, Enteroccocus, HACEK)
  2. 2 cultures >12h apart OR >3 blood Cx >1h apart OR 1 cx showing coxiella burnetti OR Coxiella antiphase 1 IgG >1:800
  3. Echo evidence of endocardial involvement (new valve regurg, oscillating mass, abscess, prosth valve dehiscence)

Minor:

  1. Fever >38C
  2. Blood cultures positive but not meeting major crit
  3. Predisposing Dz (IVDU, prosthetic valve, heart defect)
  4. Immune: +RF, GN, Osler nodes, Roth
  5. Vascular: Stroke/TIA, septic infarcts (pulm, renal, hepatic, splenic), mycotic aneurysm, ICH, conjunctival hemorrhage, Janeway lesions
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5
Q

Treatment for Prosthetic Valve/Lead associated IE

A

Add Rifampin and Gentamicin to regimen x6 weeks

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6
Q

IE Prophylaxis: Indications

A
  1. Appropriate underlying condition:
    - Past IE
    - Any prosthetic heart valve (incl TAVI, LVAD, rings/clips; NOT PPM/ICD/stents)
    - Unrepaired congenital heart disease or repaired within 6 mo or with residual defect (NOT for septal defects w/ complete closure)
    - Cardiac transplant patients who develop valvulopathy

PLUS

  1. Appropriate procedure:
    - Dental procedure with gingival manipulation
    - Respiratory tract procedure (or bronch if bx planned)
    NOT FOR GI/GU procedures
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7
Q

IE PPX: What to use?

A

Amox 2g PO x1 , Or single dose Amp/ Keflex/ Doxy/ Azithro/ Ancef / CTX

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8
Q

Empiric Treatment of Cystitis

A

1st line: Nitrofurantoin x5 days (avoid if concern for pyelo), Septra x3 days (avoid in preg), or Fosfomycin x1 (useful for ESBL, avoid if pyelo)
2nd line: B-lactam or FQ

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9
Q

Empiric Treatment of Pyelonephritis

A

IV Beta-lactam (preferred in preg) x7-14d or FQ x5-7d

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10
Q

Indications to treat asymptomatic bacteruria

and duration

A

1) Pregnant - treat x4-7 days

2) Invasive urologic procedure - tx 1-2 days

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11
Q

Treatment Gonorrhea

A

Ceftriaxone 500 mg IV x1 + Doxy 100mg BID x7d (Chlam Co-Tx) **no doxy in T2/T3 of preg
*Pen all: Azithro + Gent/Cipro or Gent+Doxy
Test of cure for all GC infxn

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12
Q

Treatment DGI

A

CTX 1g IV/IM Q24 hrs x 7 days min

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13
Q

Two clinical syndromes of disseminated gonococcal infection

A

1) Tenosynovitis, Dermatitis (pustules), Arthralgias

2) Septic arthritis (typ monoarthritis)

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14
Q

Treatment Chlamydia

A

Doxy 100mg PO BID x7d (or azithro 1 g PO x1)

Test of cure only needed if ongoing sx, suboptimal compliance, alternative regimen, or pregnant

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15
Q

Clinical Features of Lymphogranuloma venereum (LGV) from Chlamydial Infection

A

Bloody bowel movements
Painful and purulent lymphadenopathy
Proctitis with crypt abscesses, granulomas and giant cells on biopsy

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16
Q

Treatment of LGV

A

Doxycycline x 21 days and treat partners with Azithro

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17
Q

Stages of Syphillis

A

Primary (w/in 3 wks): Painless chancre, regional LN

Secondary (w/in 6 months): Fever, rash, alopecia, meningitis, uveitis, hepatitis, LN, arthralgias, condylomata lata

Latent Early (<1 yr) or Late (>1yr): + Serology, no Sx.

Tertiary: Cardiac (Aortitis), MSK (Gummatous arthritis), Late neurosyphillis (tabes dorsalis, paresis, argyle pupil)

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18
Q

Screening/Diagnostic Tests for Syphillis

A

Screening: VDRL or RPR (ie. non-treponemal tests)

If + –> Diagnostic test (= treponemal tests)

  • enzyme immunoassay (EIA)
  • darkfield microscopy
  • Fluorescent treponemal Ab absorption (FTA-ABS)
  • Treponema pallidum particle agglutination assay (TPPA)

Either +RPR or +TPPA w/ +screen = recent/prior infxn
+RPR and -TPPA = inconclusive (FP vs early vs old treated or untreated)

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19
Q

Treatment of Syphillis

A

Primary, Secondary, Early Latent: PenG 2.4 MU IM x1

Late Latent (>1y since acquisition)/Tertiary: PenG 2.4 mU IM qweekly x3*

Neurosyphillis: Aq Penicillin 4mU Q4hrs IV x14 days –> Pen G 2.4MU IM x1 if possible late latent *

*for PCN allergy: desensitize if late latent/tertiary, neurosyphilis, or preg

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20
Q

SSTI Association: Salt Water

And Tx

A

Vibrio (Doxy + ceftaz)

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21
Q

SSTI Association: Fresh Water

A

Aeromonas (doxy + ceftaz)

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22
Q

SSTI Association: DM

A

Polymicrobial, pseudomonas

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23
Q

SSTI Association: Colon CA

A

Clostridium (PCN + clinda)

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24
Q

SSTI Association: Bites - bugs and tx

*when to do tetanus

A

Human: Eikenella, strep/s aureus, anaerobes
Animal: Pasturella, capnocytophaga canimorsus, staph/strep, anaerobes

All treated w/ amox-clav OR 2nd/3rd gen ceph + flagyll, or moxi, or doxy + clinda
Minor wound: Tetanus if >10y since booster and completed series or unknown/incomplete series (immigrant),
All other wounds: >5y since booster and completed series. Unknown gets vaccine + TIg

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25
Q 
Treatment Purulent skin and soft tissue infection
eg folliculitis (hair follicle), furuncle (follicle into dermis/SC), carbuncle (several follicles), abscess (pus in dermis/SC)
A

1) I&D - all
2) +/- empiric ABX
- Mild: None
- Moderate (systemic signs of infxn): Keflex (if low MRSA prev), Septra, Doxy
- Severe (immunocomp, systemic signs infxn, failed prior abx/I&D): Vanco for MRSA, Ancef for MSSA

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26
Q 
Treatment non-purulent skin and soft tissue infections
eg Impetigo (S aureus), Erysipelas (GAS; epidermis and dermis), Cellulitis (GAS; epidermis, dermis, SC), Nec Fasc
A

Treat predisposing trauma, tinea pedis, xerosis, lymphedema

Mild (no purulence or signs systemic infxn): Keflex x 5 days
Moderate (fever but VSS): Ancef –>Keflex x5-7d
Severe (abn VS, unstable) - see nec fasc

*Cover MRSA if penetrating trauma, IVDU, hx MRSA

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27
Q

Treatment necrotizing fasciitis (erythema, systemic tox, gangrene, induration, hemorrhagic bullae, pain out of proportion)

A

1) Urgent surgical consult - immediate OR
2) Empiric ABX: Pip-tazo + Clinda + Vanco +/- IVIG if shock or pre-op
4) Post-op once recovering, narrow based on cultures

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28
Q

Categories necrotizing fasciitis

A

Type 1 = GAS (pyogenes) –> hemorrhagic bullae, elevated CK, younger, minor trauma –> definitive tx. = Pen + Clinda
Type 2 = Polymicrobial –> DM, gas/crepitus, older, pelvic wounds –> Tazo + Vanco or carbapenem

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29
Q

Indications for ABX Prophylaxis for skin and soft tissue infection

A

> =3 episodes cellulitis/year despite managing rf (revascularization, wound care, footwear, compression, tinea)

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30
Q

Diagnosis: Streptococcal Toxic Shock Syndrome

A
  1. Hypotension (sBP<90) +
  2. Isolation of GAS from sterile site +
  3. 2 of: AKI (Cr>177), Coagulopathy (plt <100, DIC), AST/ALT/bili >2x ULN, ARDS, generalized rash
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31
Q

Treatment: Toxic Shock Syndrome

and chemoppx

A

Droplet/Contact precautions
Surgical debridement +/- IVIG if severe infxn
Beta Lactam + Clindamycin, IVF
Chemoprophylaxis: Keflex x10d (clinda if allergy)

*Hyperbaric O2 efficacy UNKNOWN

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32
Q

Black eschar in nose of a diabetic or along palatal mucsa

A

Mucormycosis (Rhizopus sp)

Tx with ampho B

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33
Q

Otitis externa in diabetic

A

Pseudomonas

Treat with ciprodex

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34
Q

Empiric treatment of osteomyelitis and PJI

*MC bugs

A

Hold ABX until bone bx or aspirate obtained
Then CTX 2g IV Q24h + Vancomycin pending Cx
Duration = 4-6 weeks or high dose oral
Surgery for PJI

MC: S Aureus; DM (strep, GNB, anaerobes), IC (candida, myco, aspergillus)

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35
Q

Septic Arthritis Empiric Treatment

A

CTX 2g IV Q24hrs + Vancomycin (if MRSA RFs)

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36
Q

COVID-19: Risk factors for severe infection

A

Male
Non-white (black, hispanic)
Older age
Pre-existing: DM, CVD, HTN, lung dz, obesity, Ca, IC

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37
Q

COVID-19: Markers of prognostic significance

A

High D-dimer, LDH, CRP, Ferritin, troponin/CK, LFTs

Low lymphocyte count

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38
Q

COVID-19: Treatment

A
  • No O2 requirements: Supportive Care
  • Needing O2/MV/admitted: Dex 6 IV/PO x 10 days
  • Needing O2 NOT intubated: Remdesivir 200mg IV x1 then 100mg IV x4d
  • Needing O2/MV + systemic inflammation (CRP>75) and worsening despite 24-48h steroids: Tocilizumab (mort benefit)
  • VTE prevention
  • Baricitinib (JAKi) for mod COVID (req O2 by NP) and criticially ill (O2 by HFNC, NIV, MV, ECMO) decreases mort and progression to MV
  • Do not start abx empirically
  • Colchicine, IFN, vit D, plaquenil, ivermectin, lopinavir or ritonavir NOT recommended
  • In mild outpatient unvaccinated: sotrovimab, remdesevir, molnupiravir
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39
Q

COVID-19: Isolation

A

Droplet Contact minimum 10 days from symptom onset + symptom improvement demonstrated
Avoid nebulized meds (increased airborne spread)

10 days isolation at home
14d isolation in hospital unless IC or severe illness then 21d bc prolonged shedding

All household contacts - isolation x14 days

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40
Q

Manifestations Lyme Disease

A

Early: Erythema Migrans = clinical dx, no need for serology
Early/Late:
- CNS: Meningoencephalitis, CN palsies, encephalopathy (late), peripheral neuropathy (late)
- Cardiac: Heart block, myopericarditis
Late: Arthritis (oligoarthritis most common)

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41
Q

Treatment Lyme Disease

A

Doxycycline 100 BID for most

  • x 10 days for erythema migrans
  • x14-21 days for all other manifestations, 28d for arthritis

CTX 1g IV Q24hrs x14-21d for CNS or cardiac lyme or treatment failure for lyme arthritis with objective severe synovitis
*DMARD/biologic if post-abx lyme arthritis

  • no additional abx without objective evidence of reinfection
  • consider coinfection (babesia/anaplasma) if fevers on abx
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42
Q

When to obtain CT Head prior to LP for meningitis?

A

Immunocompromised

Signs of elevated ICP: papilledema, new sezures, altered mental status, FND

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43
Q

CSF parameters in bacterial meningitis

A

WBC >1000, neutrophilic (not always in early presenters)
Low glucose (<1.9 = 99% Sn)
High protein (>2.2 = 99% Sn)
*Biochem/Cell count minimally affected by ABX w/i 48hr

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44
Q

CSF parameters in viral meningitis

A

WBC <1000, lymphocytic
Glucose normal
Protein normal/high

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45
Q

CSF parameters in TB/Fungal meningitis

A

WBC variable, lymphocytic
Glucose low
Protein high

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46
Q

Bacterial Meningitis: Empiric Treatment

A

1) Dexamethasone 10mg IV Q6hrs x4d before/with 1st ABX (stop if CSF nonturbid, low cell count, OR non-pneumococcal by Cx)
2) ABX: CTX 2g IV Q12hrs, Vanco 1g IV Q8 hrs, +/- Ampicillin 2g IV Q4hrs (if age >=50 or immunocomp for listeria)
* Pen allergic: Vanco + Moxi + Septra OR Mero + Vanco

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47
Q

Bacterial meningitis: Duration of treatment

A

Strep pneumo (GP diplococci): 10-14 days
Neisseria (GN diplococci): 7 days
Listeria (GPB): 21 days

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48
Q

Indications for chemoprophylaxis for contacts of person with acute bacterial meningitis from Neisseria
-and what drug

A

Household contacts, sharing sleeping quarters, exposed to oral/nasal
HCW with close unprotected contact
Daycare contacts
Airline passenger beside patient (not aisle) if >8 hr flight

Ceftriaxone 250 g IM x1 or Cipro 500 mg PO x1 or Rifampin 600 mg PO BID x 2d
WITHIN 10 days

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49
Q

What to give for meningitis chemoprophylaxis

A

Ceftriaxone 250 g IM x1 or Cipro 500 mg PO x1 or Rifampin 600 mg PO BID x 2d
WITHIN 10 days

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50
Q

Indications for IMMUNOppx (vaccine) for contacts of person with acute bacterial meningitis from Neisseria
-and what tx

A

Contacts with patient with invasive meningococcal disease (IMD):
Household contacts with shared sleeping quarters or nasal/oral contam
Daycare contacts

Tx: Men-C-ACYW or 4CMenB can be considered

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51
Q

Empiric Pneumonia Treatment: Healthy Outpatients

A

Amoxicillin 1g PO TID x5-7 days or
Doxy 100 mg PO BID x5-7 days or
Azithro 500 mg x1 –> 250 OD x 5days

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52
Q

Empiric Pneumonia Treatment: Outpatients with comorbidities (chronic heart, lung, liver, renal, diabetes, EtOH, Ca, asplenia)

A

Amox-Clav 875/125 BID + Azithro 500->250 x5-7 days

Resp FQ (Moxi, Levo)

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53
Q

Empiric pneumonia treatment: Inpatients

A

Non-ICU: (Beta-lactam + Macrolide) OR Resp FQ
ICU: (beta-lactam + macrolide) OR (beta-lactam +resp FQ)
Aspiration: NO empiric anaerobic coverage unless empyema/abscess
–> PO if afebrile x48 and <=1 of: HR>100, RR>24, SBP<90, paO2<90%, AMS, can take PO)

*Add vanco or linezolid if MRSA RFs
*Use ceftaz/cefepime/tazo as beta-lactam if psedo RFs
eg beta lactam: CTX, cefotaxime, ceftaroline, amp-sulbactam

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54
Q

MC HAP/VAP bugs and Empiric Treatment

A

*S Pneumo, H Influenza, MSSA, Pseudomonas
7days of:
1. Piptazo or cefepime or imi/meropenem or levoflox +/-
2. vanco or linezolid (if MRSA risks) +/-
3. Addnl anti-pseudomonal agent (ceftaz or AG or colistin or addnl agent from #1) if RFs for resistant pseudomonas

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55
Q

Indications to treat bloody diarrhea empirically

A
  1. Suspicion for C.diff
  2. Immunocompromised + sick +/- dysentry (freq bloody BM, abdo pain, tenesmus, fever)
  3. Recent travel with T>=38.5 or S&S sepsis
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56
Q

Antimicrobials for travelers diarrhea

A

C- Cipro for Central/South america

A- Azithro for Asia

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57
Q

Indications to send stool O&P

A

> =14 day duration
Travel
Immunocompromised

*increased yield if ordered dailyx3d

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58
Q

Definition severe C.diff

A

WBC >=15 or Cr >1.5x baseline

RF for severe illness: Age >65, T>38, IC, Alb <30

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59
Q

Definition Complicated/Fulminant C.diff

A 
Sepsis or
Shock or
Ileus or
Perforation or
Toxic Megacolon (dilation >6cm)
60
Q

Treatment 1st episode C.diff

A

Nonfulminant: Fidax 200 BIDx10d (alt = Vanco 125 mg PO QID x10 days or Flagyll 500 TID x10-14d

Fulminant: Vanco 500 PO/NG QID +/- IV Flagyll 500mg q8h +/- PR vanco for ileus +/- total colectomy

61
Q

Treatment of C.diff relapse

A

1st relapse: Fidax 200 BIDx10d or BIDx5d then 200mg every other day x20d (alt = Vanco tapered/pulsed or 125 mg PO QID x10 days)
*Adjunct: bezlotoxumab 10mg/kg IV once during therapy if RF for recurrence (prev recurrence in 6mo, age>65, severe CDI, immunocompromised)

2nd relapse: as above but consider rifaximin 400mg PO TID x20d after vanco x10d;
Adjunct: bezlotoxumab +/- fecal microbiota transplant (after 3 failed abx course), may need chronic suppression vanco

62
Q

Empiric Treatment intra-abdominal infection

A

1- Source control (Percut > open), can try abx alone if <3cm
2- ABX - continue for 3-5 d post source control
- If community acquired: (CTX or Cipro) + Flagyl
- if hospital acquired: (Ceftaz or Tazo or Mero or Cipro) + Flagyl +/- Vanco for enterococcal if IC, post-op, recurrent, or valvular heart dz / intravascular prosthesis

63
Q

Nocardia Gram Stain

A

GP Bacillus
Branching
Weakly positive AFB

64
Q

Fungi Classification

A

Yeast: Candida, Cryptococcus
Moulds: Aspergillus (hyphae)
Dimorphic Fungi: Blasto-, Histo-, Coccidio-mycosis

65
Q

DDX Fever in Returning Traveller

A

<14 days from travel:

  • Dengue, Chikingunya, Zika
  • Malaria
  • Travelers Diarrhea

> 14 days:

  • Malaria
  • Salmonella Typhoid/ Paratyphoid (esp diarrhea, rash, fever)
  • Viral hepatitis
  • TB
  • HIV
  • Leptospirosis
66
Q

Criteria for complicated malaria infection

A

Any end organ dysfcn:
Neuro: weakness, confusion, sz
Resp: ARDS, pulm edema
Heme: DIC (anemia, thrombocytopenia, high LDH), jaundice, hemoglobinuria (black water fever)
Hb <50, Glucose <2.2, pH <7.25, Bicarb <15
Lactic acidosis
Cr>=265
Parisitemia >=5% (if non-immune), >10% if semi immune

67
Q

Treatment Malaria

A

Uncomplicated: Chloroquine or Atovaquone/proguanil (+Primaquine if P. vivax or ovale)

Complicated: IV Artesunate x48hrs –> Atovaquone/proguanil or Doxy or clinda

*repeat smears q6-12 hrs to monitor parasitemia

68
Q

HIV-related CNS Infections

A

Space Occupying lesions:

  • Abscess: Bacterial, listeria, nocardia, TB, crypto
  • Cerebral toxoplasmosis
  • Primary CNS lymphoma
  • Gummatous syphillis

Meningoencephalitis

  • Crypto (high opening pressure)
  • Listeria
  • Nocardia
  • TB
  • Fungal
  • Syphillis

Diffuse Non-enhancing lesions:

  • PML
  • HIV leukoencephalopathy
  • CMV
69
Q

HIV Treatment options

A

2 NRTIs + (INSTI or NNRTI or PI)

  1. Bictarvy (bictegravir, tenofovir alafenamide, emtricitabine)
  2. Dolutegravir plus:
    - Tenofovir alafenamide (TAF)/emtricitabine or
    - Tenofovir disoproxil fumarate (TDF)/emtricitabine or
    - Tenofovir disoproxil fumarate/lamivudine

TAF less bone/renal tox
TDF lower lipid lvls and cost
*if preg or trying to conceive: Dolutegravir

70
Q

HIV Opportunistic Infections by CD4 count

A

Any CD4: Candida, HSV, VZV, TB, Bacterial infections
CD4 200-500: noninvasive Candidiasis, oral hairy leukoplakia (EBV; white tongue plaque that does not scrape off), recurrent mucocutaneous HSV1/2/VZV, invasive pneumococcus PNA/sinusitis
CD4 <200: PJP, Fungi (cocci, histo, blasto, aspergillus, crypto)
CD4<100: Toxoplasmosis, PML from JC virus
CD4<50: MAC, CMV

71
Q

Non-infectious HIV Complications by CD4 count

A

Any: Cutaneous Kaposi’s, ITP, CKD, CVD/stroke
CD4 200-500 CVD, stroke, CKD, cervical dysplasia/ carcinoma, psoriasis, seborrheic dermatitis, molloscum contagiosum, ITP

CD4<200: Visceral Kaposi’s, Heme Ca (NHL>HL, MM, leukemia), Anal/cervical/vulvovag CA, HCC, HIV associated myelopathy (paraplegia)

CD4<100: Progressive multifocal leukoencephalopathy (PML) from JC virus

CD4 <50: CNS lymphoma, HIV associated neurocog d/o

72
Q

PJP Prophylaxis (CD4<200 or pred >20mg/d for >4-8wks)

A

Treat until CD4>200 for 3+mo:
Septra DS OD (or SS daily or DS MWF) even if preg (give folic acid for NT defects in T1)
*Alts: Dapsone PO OD, Atovaquone PO OD, or aerosolized pentamidine monthly

*Dapsone ok for sulfa allergy unless SJS/TEN (must give atovaquone instead)

73
Q

PJP Treatment

A

Septra IV x21 days (+pred 40 BID x5d then 20BID x5d then 20 OD x11d for severe: PaO2<70 or AAgrad>35)

  • Alts:
  • Primaquine + Clinda (PO if mild or IV if sev)
  • Pentamidine IV (severe)
  • Dapsone + TMP PO (mild)
  • Atovaquone PO (mild)

Check G6PD before primaquine or dapsone

74
Q

Toxoplasmosis prophylaxis (CD4<100)

A

Septra DS OD

*Alts: Dapsone + Pyrimethamine (+leukovorin), Atovaquone PO

75
Q

Toxoplasmosis Treatment

A

Sulfadiazine + Pyrimethamine (+leukovorin) x6 wks

no tx in Canada

76
Q

MAC PPX (<50 if no intention to start ART ASAP)

A

Azithro weekly or clarithro BID (only if no ART started)

77
Q

MAC Treatment

A

[Clarithro or Azithro] + Ethambutol

+/- rifabutin, Amikacin, FQ (if advanced HIV or severe dz)

78
Q

TBST Cut offs

A

Most: >10mm (DM, malnutrition, silicosis, heme Ca, HNSCC, smoking/EtOH >3/d), TST conversion (within 2 years)

> 5 mm if: HIV+, immunosuppressed (TNFi, transplant), contact with infectious TB in past 2 years, fibronodular disease on CXR, ESRD

79
Q

When to order IGRA

A

To confirm + TBST if all of the following apply:

  • BCG after age 1
  • No exposure to active TB
  • Canadian born non-aboriginal or immigrant from non-endemic region
80
Q

Treatment Latent TB

A

INH 300 OD (+Vit B6) x 9 months or
Rifampin x4 months
Alt: INH + Rifampin x 3 months
*definitely tx if HIV+ (add pred if high risk IRIS)
*in preg: only tx after delivery unless exposure to active TB

81
Q

Treatment Active TB

-what to add for meningitis or pericardial dz

A

4-2-2-4 RIPE (even in preg)
First 2 months: Rifampin, INH (+ B6 to prev neuropathy), Pyrazinamide, Ethambutol
Next 4 months: Rifampin, INH (+ B6)

    • steroids for TB menignitis or pericardial dz
  • longer duration if cavity, CNS, bone or +Cx at 2mo
82
Q

HIV in pregnancy (C/S indication) and post-partum care

-and breastfeeding

A

IF VL>1000 or unknown near delivery - give IV zidovudine and deliver via C/S
If VL not supressed at birth: infants get zidovudine x6wks + nevirapine x3doses
**NO breastfeeding if HIV+

83
Q

Treatment Candidemia & duration

A

If stable, no recent azole exposure –> Fluconazole emp
If unstable, neutropenic, recent azole –> Caspo or Micafungin
Pregnancy –> Ampho B
CNS infections –> Ampho B + Flucytosine
*Always consult optho and remove lines. TTE if persistent candidemia.

Duration: 2 weeks from 1st neg Cx if no metastatic focus

84
Q

Treatment Allergic bronchopulmonary aspergillosis (ABPA)

A

Steroids +/- Anti-IgE +/- itraconazole

85
Q

Treatment aspergilloma

A

Surgical resection if solitary lesion +/- antifungal

Anti-fungal x 6 months if multiple lesions

86
Q

Dx and Tx Invasive aspergillosis

A

Dx: serum/sputum galactomannan, CT chest
Tx: Voriconazole x >=6 weeks

*chronic cavitary pulm aspergillosis = 6mo antifungal

87
Q

Treatment Dimorphic fungi (Blasto, Histo, Coccidioides)

A

Itraconazole (mild-mod), Ampho B (severe)
Duration 6-12 months for blasto, 12 weeks histo
*Only treat coccidio with itraconazole if symptomatic

88
Q

Precautions for meningococcus

A

Droplet until 24 hrs post effective treatment

89
Q

Precautions for disseminated VZV

A

Airborne + Contact until all lesions crusted/dried

90
Q

Adult immunization schedule

A 
Td q10 years (one dose Tdap as adult)
Flu q1 yr
Pneumovax (Pneu-23): Once after 65
Shingrix: Once after 60 (or in some 50)
Pertussis - one dose as adult and during each preg
91
Q

Side effects INH

A

Peripheral neuropathy
Hepatotoxicity
Rash

92
Q

Side effects rifampin

A

Rash
Hepatitis
Drug interaction

93
Q

Side effects pyrazinamide

A

Hepatitis
Rash
Arthralgias

94
Q

Side effects ethambutol

A

Eye toxicity

Rash

95
Q

Pre-Biologic tests

A

TBST (all) + CXR in high risk (to r/o active disease)
Hep B (all)
Hep C (if for rheum indication)
Strongy (if from endemic area)

96
Q

Timing of initiation of HAART for HIV

A

In most: Initiate ASAP, including preg (regardless CD4)

Special circumstances to delay:

1) Concurrent Dx TB
- If TB meningitis - start @ 2-8 weeks
- If no meningitis, depends on CD4 count
- -> if <50: Start within 2 weeks
- -> If >50: Delay and start within 8 weeks

2) Concurrent Dx crypto meningitis
- Delay initiation to after 5 wks of anti-fungal tx

3) Concurrent Dx PJP- start within 2 weeks

97
Q

Definition of “extensive” TB

A

1) Smear + TB
2) Cavitary lesion
3) Severe extra-pulmonary disease

98
Q

Risk factors for pseudomonas

A 
Recent hospitalization/ICU admission
Recent/current intubation
Recent or frequent ABX use
IC: TNFi, HIV, post-bone marrow transplant, neutropenia
CF/Bronchiectasis
99
Q

Tx for MRSA and Pseudomonas

A

MRSA: Vanco, doxy, Septra, Clinda, Linezolid, Daptomycin, Ceftobiprole

Pseudomonas: Tazocin, Ceftazidime, Cefepime, Carbapenems (NOT erta), Cipro, aminoglycoside, colistin, azteonam, tigecycline, ceftolozane-tazobactam, cetazidime-avibactam

100
Q

Carbapenemase-producing Enterobacteriaceae (CPE)

A

Colistin, aminoglycoside, tigecycline, call ID

101
Q

Enterococcus Rx

A

Ampicillin (if sensitive) or Vanco (not VRE), linezolid, Daptomycin

102
Q

Basal skull meningitis features/bugs

A
  • CN palsies, long-tract signs (eg hyperreflexia, +Hoffman, +Babinski, +/- clonus)
  • TB, listeria, crytococcus, syphilis, lyme
103
Q

Meningitis JAMA

A

Highest sens: Jolt accentuation

Highest spec: Kernig’s and Brudzinski

104
Q

Indications for TEE in IE

A

TTE nondiagnostic
IE complications suspected
Intracardiac leads
Before early change to PO abx and 1-3d after abx course

105
Q

IE Tx and duration

A

4-6 weeks (longer if resistance, S aureus, prosthetic valve) of:
MSSA: Clox/Ancef
MRSA/CNST: Vanco
Viridans, S gallolyticus/bovis: CTX, PenG
E fecalis: Ampicllin + Gent/CTX
E faecium: Vanco + Gent
HACEK: CTX

*Add rifampin and gentamicin for prosthetic valve

106
Q

IV to PO abx for IE if:

A
  • TEE before switch shows NO paravalvular infection AND
  • Frequent/appropriate f/u can be assured AND
  • TEE can be done 1-3d after abx course
107
Q

When to hospitalize CAP

A 
CRB-65
Confusion
RR>30
sBP<90 or dBP <60
Age>65

2+ = admit

108
Q

Diarrhea Tx

A

Campylobacter: azithro (or cipro)
Salmonella: CTX or cipro (alt: amp, septra, or azithro)
Shigella: CTX or cipro or azithro (alt: amp, septra)
Vibrio: Doxy, (alt: CTX, cipro, azithro)
Yersinia: Septra (alt: cefotaxime, cipro)

STEC incl 0157 - NO ABX

109
Q

C diff Syndrome

A

Unexplained new onset >3 unformed stools in 24hrs

positive test w/o syndrome = colonized

110
Q

Complicated UTI

A
  • Hemodynamically unstable,
  • Male
  • Pregnancy
  • Instrumentation
  • Indwelling foley
  • Functional/anatomic anomalies, or obstruction
111
Q

Prostatitis Tx - when to tx w/ what drugs

and MC bugs

A

Only treat if elevated PSA, planning for Bx or infertility

Acute: UA/Cx before empiric abx (tazo, 3rd gen ceph, FQ if unwell; if well = FQ) x2-4 weeks
Chronic: FQ x4-6wks or pathogen directed x8-12wks

MC Bugs: E coli, Enterococcus, Pseudomonas

112
Q

Endometritis (postpartum)

and MC bugs

A

Clinda + aminoglycoside (+/- amp or vanco if suspect enteroccocus) –> PO when defervesce. no evidence for duration
*assess for retained products of conception/abscess

MC Bugs: GBS, enterococci, S aureus, anaerobic GPC, E coli, Gardnerella, Polymicriobial

113
Q

Gonorrhea/Chlamydia Tx Failure IF:

A
  • Positive gram stain or culture >72hrs after tx

- Positive NAAT 2-3 weeks after tx

114
Q

When to LP Syphilis

A
  • Neuro, ocular, auditory s/s
  • HIV and neuro s/s if RPR>=1:32 or CD4<350cells/ul
  • Previously tx but failed to achieve serologic response (4-fold drop in RPR)
115
Q

Persistent Pelvic inflamm dz, urethritis/cervicitis

A
  • Retreat once for gonorrhea/chlamydia

- Consider Mycoplasma genitalium or T vaginalis and tx w/ Moxi 400 OD x7-14d

116
Q

Ulcer types and characteristics

A

Neuropathic: pressure points, punched out, minimal pain, warm/dry foot
Arterial: lateral malleolus, dry and punched out, decreased pulses, cold/dry foot
Venous: medial malleolus, irregular margins, shallow, mildly painful, stasis dermatitis

*Pain = highest LR for infection (erythema, pus, swelling does nto change probability)

117
Q

OM highest + and - LR

A

+LR: ESR>70, Bone exposure, ulcer area, + PTB

-LR: negative MRI, ESR<70, -PTB

118
Q

STI Ulcers

A

Painful:

  • Herpes - vesicles
  • Chancroid from H ducreyi

Painless:

  • Primary syphilis
  • LGV
119
Q

STI Discharge

A

Vaginal (bacterial vaginosis, trichomoniasis, vulvovaginal candidasis),
Anal (gonorrhea, HS, LGV),
Pharyngeal (gonorrhea, syphilis, EBV, HIV, HSV)

120
Q

STI Misc

Warts, flat papules, epididymitis

A 
Warts (HPV - dome topped), 
Flat papules (syphilis condylomata lata), 
Epididymitis/PID (CT and NG)
121
Q

Trichomonas vs Candidiasis vs Vaginosis

A

Trichomonas: strawberry cervix with yellow frothy discharge
Candidiasis: wet mount w/ KOH shows budding yeast
Vaginosis: POSITIVE WHIFF, clue cells on gram stain; fishy

122
Q

Who to test for latent TB

A
  • Contacts of active TB
  • Immigrants/Travelers from/to countries with hgih TB incidence
  • Indigenous communities
  • IVDU, homeless, prison
  • Health care workers or residents of LTC
123
Q

NTM (nonTB mycobacteria) Pulm Dz Dx criteria

A

Clinical (pulm or systemic sx) AND radiologic (nodular/cavitary CXR lesions or CT bronchiectasis)
PLUS 1 of:
-2+ sputum positive for same NTM species
-1 BAL/bronch culture positive for NTM
-Biopsy w/ mycobacterial histology (AFB/granuloma) and positive culture

124
Q

NTM Tx

A

Minimum 3-drug regimen (macrolide, ethambutol, +/- rifampicin +/- aminoglycoside)
Ideally susceptibility based (not empiric)

125
Q

LR for Malaria

A

+LR: Hyperbili, Thrombocytopenia, Splenomegaly, Fever, Jaundice
-LR: presence of cough/dyspnea, absence of fever

126
Q

Dengue features and tx

A

fever, rash, retroorbital pain, breakbone fever, cytopenias
AVOID NSAIDs
Supportive care

127
Q

Zika Epi, Pt, Dx, Tx

A

Epi: Carribean/SA, Africa, Asia via mosquito, sex, transfusion
Pt: Fevers, rash, retroorbital pain, assoc’d w/ microcephaly and GBS
Dx: molecular testing w/ confirmatory PRNT if exposure + recent travel to endemic OR symptomatic pregnant women (NOT for asymptomatic pregnant)
Tx: Supportive care, no NSAID until r/o dengue
*preg do not need to avoid Zika areas

128
Q

Chikungunya features and tx

A

fever, polyarthralgia, lymphopenia

Supportive care

129
Q

Salmonella features

A

Salmon colored spots, fever, abd pain, constipation, relative brady

130
Q

Leptospirosis Epi, Pt, Tx

A

Epi: animal waste –> soil, water exposure
Pt: Fever, myalgias, conjunctivitis, hypoK, cytopenias, sterile pyuria. (Rare: ARDS, pulm hemorrhage, jaundice)

Tx: Mild: Doxy or azithro
-Severe: IV CTX, pen, or doxy

131
Q

Worms features and tx

A

Consider if eosinophilia
Dx: microscopy (stool, urine, sputum), O&P +/- serology (lifetime positive)
Tx:
Strongy (african, SA, asian soil): GN bacteremia or meningitis –> Ivermectin
Schisto (tropical water/snail –> liver/bladder Ca) –> Praziquantel
Taenia (pork –> neurocysticercosis) –> albendazole +/- praziquantel +/- steroids
Trichinella (undercooked bear/pork –> GI sx, muscle pain) –> albendazole

132
Q

S/E of COVID vaccines

A

AZ/JJ: VTE, capillary leak syndrome, GBS, anaphylaxis

Moderna/Pfizer: myocarditis, pericarditis, Bell’s palsy, anaphylaxis

C/I if: anaphylaxis or severe allergic rxn after 1st dose

133
Q

Indication for COVID booster

A 
Give 6mo after primary series:
Adults >50
Adults in LTC, front line workersc
Recipients of viral vector vaccine only (AZ/JJ)
First nations, inuit, metis
134
Q

Ebola: Epi, Pt, Dx, Tx

A

Epi: Congo
Pt: Fever, myalgia, GI, anorexia
Dx: NAAT, viral Cx/Ag/serology
Tx: Supportive care, essential procedure/bw only; droplet/contact

135
Q

FUO defn and ddx

A

T>38.3C x3 weeks w/ 1 week investigations
Ddx:
-Infection: abscess, IE, sinusitis, TB, CMV/EBV/HIV
-Inflamm: GCA, Stills, IBD
-Malig: lymphoma, RCC, CRC, Leukemia
-Drugs: AED, NSAIDs, allopurinol, antimicrobial
-VTE

136
Q

W/U if immunosuppressing

A

LTBI: if pred >15mg/d >4 weeks and TB rf, tx LTBI if positive
Hep B: screen w/ HBsAg (+/- core) if Pred >7.5mg/d. Consider need for tx/ppx
PJP: Septra if pred >20mg/d for 4-8wks
Strongy: serology +/- O&P if IC or endemic –> Ivermectin day 1 and 14

137
Q

Mono LR

A

LR+ atypical lymphocytosis, palatine petechiae, splenomegaly, posterior cervical LN
LR- NO adenopathy

138
Q

Antimicrobial ppx in Oncology

A

Feb neut or prolonged neutropenia (>7d ANC<0.1): Cipro, Antifungal (if in AML/MDS, HSCT; NOT solid tumor)
HSV+ undergoing alloHSCT or leukemia induction: acyclovir for ppx
High risk Hep B eactivation: NRTI (tenofovir or entecavir)

Yearly flu vaccine

139
Q

Line/Ventriculitis infections

A

Ventriculitis: erythema/pain over shunt tubing –> remove + empiric Vanco + Ceftaz/Mero +/- Rifampin (if staph), +/- intraventricular abx if no response to systemic abx x10d (gram+) - 21d (gram-). Reimplant shunt ater CSF negative x7-10d

Line: Cx line and periph at same time. Remove line and culture tip if shock
Tx: ALWAYS remove for SAureus, GNB, Enterococcus Candida, or complicated infxn (IE, OM, thrombophlebitis) and directed abx x7-14d (14 or S Aureus/candida)

140
Q

RF Candidemia

A
  • Broad-spectrum abx
  • ICU admission
  • CVC
  • TPN
  • Neutropenia
  • Immunsuppresed
  • Necrotizing panceatitis
  • Intraabdo surgery
141
Q

Droplet + contact for:

A

Invasive GAS (TSS/NF/PNA/meningitis), Ebola

142
Q

When to abx prophylax in bites

A
  • Immunocompromised
  • Asplenic
  • Advanced liver dz
  • Pre-existing or resultant edema
  • Mod/severe injury to hand/face
  • Penetrating injury to joint capsule or periosteum
143
Q

Influenza tx

A

Oseltamivir x5d, longer if IC, severe PNA, ARDS
-Tx for bacterial coinfection if: init severe dz, fail to improve, biphasic response
Prophylaxis w/i 48h and continue until 7d post exposure if IC with exposure

144
Q

Infectious Mono bug, features, dx

A

Bug: EBV
Features: atypical lymphocytosis, hepatitis, cervical LAD and tenderness, airway obstruction, fever, malaise, splenomegaly, splenic rupture with sports,
Dx: anti-heterophile AB

145
Q

Isolation for Herpes

A

Routine for encephalitis or mucocutaneous

Contact for disseminated/severe (until lesion crusted) or neonatal infxn (for duration of symptoms)

146
Q

Droplet contact:

A 
N. meningitis, H flu, M. Pneumonia, 
Pertussis, Mumps, rubella, 
Flu
Parvovirus 19, Rhinovirus
GAS
147
Q

Airborne precautions:

A

Varicella, TB, Measles, smallpox

RCE (18 decks)

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