ID Flashcards
Treatment SPICE-HAM (Amp C) and ESBL (Kleb/Ecoli)
Carbapenems, Septra, Fluoroquinolones, Aminoglycoside
*Serratia, Providencia, Indole+ proteus, citrobacter, enterobacter, Hafnia, Acinetobacter, Morganella
IE “Early” Surgical Indications
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)
IE “Delayed” Surgical Indication
Relapsing infection of prosthetic valve (new fever/bacteremia after abx course and interval sterile BCx w/o another source)
Duke Criteria for Diagnosis IE
Definite Dx: + Veggie Cx or 2 Major or 1 Major + 3 Minor or 5 min
Possible: 1M +1m OR 3m
Major:
- Microbiologic evidence of typical IE causing organism (S aureus, Viridans, S gallolyticus/Bovis, Enteroccocus, HACEK)
- 2 cultures >12h apart OR >3 blood Cx >1h apart OR 1 cx showing coxiella burnetti OR Coxiella antiphase 1 IgG >1:800
- Echo evidence of endocardial involvement (new valve regurg, oscillating mass, abscess, prosth valve dehiscence)
Minor:
- Fever >38C
- Blood cultures positive but not meeting major crit
- Predisposing Dz (IVDU, prosthetic valve, heart defect)
- Immune: +RF, GN, Osler nodes, Roth
- Vascular: Stroke/TIA, septic infarcts (pulm, renal, hepatic, splenic), mycotic aneurysm, ICH, conjunctival hemorrhage, Janeway lesions
Treatment for Prosthetic Valve/Lead associated IE
Add Rifampin and Gentamicin to regimen x6 weeks
IE Prophylaxis: Indications
- 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
- Appropriate procedure:
- Dental procedure with gingival manipulation
- Respiratory tract procedure (or bronch if bx planned)
NOT FOR GI/GU procedures
IE PPX: What to use?
Amox 2g PO x1 , Or single dose Amp/ Keflex/ Doxy/ Azithro/ Ancef / CTX
Empiric Treatment of Cystitis
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
Empiric Treatment of Pyelonephritis
IV Beta-lactam (preferred in preg) x7-14d or FQ x5-7d
Indications to treat asymptomatic bacteruria
and duration
1) Pregnant - treat x4-7 days
2) Invasive urologic procedure - tx 1-2 days
Treatment Gonorrhea
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
Treatment DGI
CTX 1g IV/IM Q24 hrs x 7 days min
Two clinical syndromes of disseminated gonococcal infection
1) Tenosynovitis, Dermatitis (pustules), Arthralgias
2) Septic arthritis (typ monoarthritis)
Treatment Chlamydia
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
Clinical Features of Lymphogranuloma venereum (LGV) from Chlamydial Infection
Bloody bowel movements
Painful and purulent lymphadenopathy
Proctitis with crypt abscesses, granulomas and giant cells on biopsy
Treatment of LGV
Doxycycline x 21 days and treat partners with Azithro
Stages of Syphillis
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)
Screening/Diagnostic Tests for Syphillis
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)
Treatment of Syphillis
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
SSTI Association: Salt Water
And Tx
Vibrio (Doxy + ceftaz)
SSTI Association: Fresh Water
Aeromonas (doxy + ceftaz)
SSTI Association: DM
Polymicrobial, pseudomonas
SSTI Association: Colon CA
Clostridium (PCN + clinda)
SSTI Association: Bites - bugs and tx
*when to do tetanus
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
Treatment Purulent skin and soft tissue infection eg folliculitis (hair follicle), furuncle (follicle into dermis/SC), carbuncle (several follicles), abscess (pus in dermis/SC)
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
Treatment non-purulent skin and soft tissue infections eg Impetigo (S aureus), Erysipelas (GAS; epidermis and dermis), Cellulitis (GAS; epidermis, dermis, SC), Nec Fasc
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
Treatment necrotizing fasciitis (erythema, systemic tox, gangrene, induration, hemorrhagic bullae, pain out of proportion)
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
Categories necrotizing fasciitis
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
Indications for ABX Prophylaxis for skin and soft tissue infection
> =3 episodes cellulitis/year despite managing rf (revascularization, wound care, footwear, compression, tinea)
Diagnosis: Streptococcal Toxic Shock Syndrome
- Hypotension (sBP<90) +
- Isolation of GAS from sterile site +
- 2 of: AKI (Cr>177), Coagulopathy (plt <100, DIC), AST/ALT/bili >2x ULN, ARDS, generalized rash
Treatment: Toxic Shock Syndrome
and chemoppx
Droplet/Contact precautions
Surgical debridement +/- IVIG if severe infxn
Beta Lactam + Clindamycin, IVF
Chemoprophylaxis: Keflex x10d (clinda if allergy)
*Hyperbaric O2 efficacy UNKNOWN
Black eschar in nose of a diabetic or along palatal mucsa
Mucormycosis (Rhizopus sp)
Tx with ampho B
Otitis externa in diabetic
Pseudomonas
Treat with ciprodex
Empiric treatment of osteomyelitis and PJI
*MC bugs
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)
Septic Arthritis Empiric Treatment
CTX 2g IV Q24hrs + Vancomycin (if MRSA RFs)
COVID-19: Risk factors for severe infection
Male
Non-white (black, hispanic)
Older age
Pre-existing: DM, CVD, HTN, lung dz, obesity, Ca, IC
COVID-19: Markers of prognostic significance
High D-dimer, LDH, CRP, Ferritin, troponin/CK, LFTs
Low lymphocyte count
COVID-19: Treatment
- 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
COVID-19: Isolation
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
Manifestations Lyme Disease
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)
Treatment Lyme Disease
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
When to obtain CT Head prior to LP for meningitis?
Immunocompromised
Signs of elevated ICP: papilledema, new sezures, altered mental status, FND
CSF parameters in bacterial meningitis
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
CSF parameters in viral meningitis
WBC <1000, lymphocytic
Glucose normal
Protein normal/high
CSF parameters in TB/Fungal meningitis
WBC variable, lymphocytic
Glucose low
Protein high
Bacterial Meningitis: Empiric Treatment
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
Bacterial meningitis: Duration of treatment
Strep pneumo (GP diplococci): 10-14 days
Neisseria (GN diplococci): 7 days
Listeria (GPB): 21 days
Indications for chemoprophylaxis for contacts of person with acute bacterial meningitis from Neisseria
-and what drug
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
What to give for meningitis chemoprophylaxis
Ceftriaxone 250 g IM x1 or Cipro 500 mg PO x1 or Rifampin 600 mg PO BID x 2d
WITHIN 10 days
Indications for IMMUNOppx (vaccine) for contacts of person with acute bacterial meningitis from Neisseria
-and what tx
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
Empiric Pneumonia Treatment: Healthy Outpatients
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
Empiric Pneumonia Treatment: Outpatients with comorbidities (chronic heart, lung, liver, renal, diabetes, EtOH, Ca, asplenia)
Amox-Clav 875/125 BID + Azithro 500->250 x5-7 days
Resp FQ (Moxi, Levo)
Empiric pneumonia treatment: Inpatients
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
MC HAP/VAP bugs and Empiric Treatment
*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
Indications to treat bloody diarrhea empirically
- Suspicion for C.diff
- Immunocompromised + sick +/- dysentry (freq bloody BM, abdo pain, tenesmus, fever)
- Recent travel with T>=38.5 or S&S sepsis
Antimicrobials for travelers diarrhea
C- Cipro for Central/South america
A- Azithro for Asia
Indications to send stool O&P
> =14 day duration
Travel
Immunocompromised
*increased yield if ordered dailyx3d
Definition severe C.diff
WBC >=15 or Cr >1.5x baseline
RF for severe illness: Age >65, T>38, IC, Alb <30
Definition Complicated/Fulminant C.diff
Sepsis or Shock or Ileus or Perforation or Toxic Megacolon (dilation >6cm)
Treatment 1st episode C.diff
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
Treatment of C.diff relapse
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
Empiric Treatment intra-abdominal infection
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
Nocardia Gram Stain
GP Bacillus
Branching
Weakly positive AFB
Fungi Classification
Yeast: Candida, Cryptococcus
Moulds: Aspergillus (hyphae)
Dimorphic Fungi: Blasto-, Histo-, Coccidio-mycosis
DDX Fever in Returning Traveller
<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
Criteria for complicated malaria infection
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
Treatment Malaria
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
HIV-related CNS Infections
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
HIV Treatment options
2 NRTIs + (INSTI or NNRTI or PI)
- Bictarvy (bictegravir, tenofovir alafenamide, emtricitabine)
- 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
HIV Opportunistic Infections by CD4 count
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
Non-infectious HIV Complications by CD4 count
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
PJP Prophylaxis (CD4<200 or pred >20mg/d for >4-8wks)
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)
PJP Treatment
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
Toxoplasmosis prophylaxis (CD4<100)
Septra DS OD
*Alts: Dapsone + Pyrimethamine (+leukovorin), Atovaquone PO
Toxoplasmosis Treatment
Sulfadiazine + Pyrimethamine (+leukovorin) x6 wks
no tx in Canada
MAC PPX (<50 if no intention to start ART ASAP)
Azithro weekly or clarithro BID (only if no ART started)
MAC Treatment
[Clarithro or Azithro] + Ethambutol
+/- rifabutin, Amikacin, FQ (if advanced HIV or severe dz)
TBST Cut offs
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
When to order IGRA
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
Treatment Latent TB
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
Treatment Active TB
-what to add for meningitis or pericardial dz
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
HIV in pregnancy (C/S indication) and post-partum care
-and breastfeeding
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+
Treatment Candidemia & duration
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
Treatment Allergic bronchopulmonary aspergillosis (ABPA)
Steroids +/- Anti-IgE +/- itraconazole
Treatment aspergilloma
Surgical resection if solitary lesion +/- antifungal
Anti-fungal x 6 months if multiple lesions
Dx and Tx Invasive aspergillosis
Dx: serum/sputum galactomannan, CT chest
Tx: Voriconazole x >=6 weeks
*chronic cavitary pulm aspergillosis = 6mo antifungal
Treatment Dimorphic fungi (Blasto, Histo, Coccidioides)
Itraconazole (mild-mod), Ampho B (severe)
Duration 6-12 months for blasto, 12 weeks histo
*Only treat coccidio with itraconazole if symptomatic
Precautions for meningococcus
Droplet until 24 hrs post effective treatment
Precautions for disseminated VZV
Airborne + Contact until all lesions crusted/dried
Adult immunization schedule
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
Side effects INH
Peripheral neuropathy
Hepatotoxicity
Rash
Side effects rifampin
Rash
Hepatitis
Drug interaction
Side effects pyrazinamide
Hepatitis
Rash
Arthralgias
Side effects ethambutol
Eye toxicity
Rash
Pre-Biologic tests
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)
Timing of initiation of HAART for HIV
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
Definition of “extensive” TB
1) Smear + TB
2) Cavitary lesion
3) Severe extra-pulmonary disease
Risk factors for pseudomonas
Recent hospitalization/ICU admission Recent/current intubation Recent or frequent ABX use IC: TNFi, HIV, post-bone marrow transplant, neutropenia CF/Bronchiectasis
Tx for MRSA and Pseudomonas
MRSA: Vanco, doxy, Septra, Clinda, Linezolid, Daptomycin, Ceftobiprole
Pseudomonas: Tazocin, Ceftazidime, Cefepime, Carbapenems (NOT erta), Cipro, aminoglycoside, colistin, azteonam, tigecycline, ceftolozane-tazobactam, cetazidime-avibactam
Carbapenemase-producing Enterobacteriaceae (CPE)
Colistin, aminoglycoside, tigecycline, call ID
Enterococcus Rx
Ampicillin (if sensitive) or Vanco (not VRE), linezolid, Daptomycin
Basal skull meningitis features/bugs
- CN palsies, long-tract signs (eg hyperreflexia, +Hoffman, +Babinski, +/- clonus)
- TB, listeria, crytococcus, syphilis, lyme
Meningitis JAMA
Highest sens: Jolt accentuation
Highest spec: Kernig’s and Brudzinski
Indications for TEE in IE
TTE nondiagnostic
IE complications suspected
Intracardiac leads
Before early change to PO abx and 1-3d after abx course
IE Tx and duration
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
IV to PO abx for IE if:
- 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
When to hospitalize CAP
CRB-65 Confusion RR>30 sBP<90 or dBP <60 Age>65
2+ = admit
Diarrhea Tx
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
C diff Syndrome
Unexplained new onset >3 unformed stools in 24hrs
positive test w/o syndrome = colonized
Complicated UTI
- Hemodynamically unstable,
- Male
- Pregnancy
- Instrumentation
- Indwelling foley
- Functional/anatomic anomalies, or obstruction
Prostatitis Tx - when to tx w/ what drugs
and MC bugs
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
Endometritis (postpartum)
and MC bugs
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
Gonorrhea/Chlamydia Tx Failure IF:
- Positive gram stain or culture >72hrs after tx
- Positive NAAT 2-3 weeks after tx
When to LP Syphilis
- 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)
Persistent Pelvic inflamm dz, urethritis/cervicitis
- Retreat once for gonorrhea/chlamydia
- Consider Mycoplasma genitalium or T vaginalis and tx w/ Moxi 400 OD x7-14d
Ulcer types and characteristics
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)
OM highest + and - LR
+LR: ESR>70, Bone exposure, ulcer area, + PTB
-LR: negative MRI, ESR<70, -PTB
STI Ulcers
Painful:
- Herpes - vesicles
- Chancroid from H ducreyi
Painless:
- Primary syphilis
- LGV
STI Discharge
Vaginal (bacterial vaginosis, trichomoniasis, vulvovaginal candidasis),
Anal (gonorrhea, HS, LGV),
Pharyngeal (gonorrhea, syphilis, EBV, HIV, HSV)
STI Misc
Warts, flat papules, epididymitis
Warts (HPV - dome topped), Flat papules (syphilis condylomata lata), Epididymitis/PID (CT and NG)
Trichomonas vs Candidiasis vs Vaginosis
Trichomonas: strawberry cervix with yellow frothy discharge
Candidiasis: wet mount w/ KOH shows budding yeast
Vaginosis: POSITIVE WHIFF, clue cells on gram stain; fishy
Who to test for latent TB
- 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
NTM (nonTB mycobacteria) Pulm Dz Dx criteria
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
NTM Tx
Minimum 3-drug regimen (macrolide, ethambutol, +/- rifampicin +/- aminoglycoside)
Ideally susceptibility based (not empiric)
LR for Malaria
+LR: Hyperbili, Thrombocytopenia, Splenomegaly, Fever, Jaundice
-LR: presence of cough/dyspnea, absence of fever
Dengue features and tx
fever, rash, retroorbital pain, breakbone fever, cytopenias
AVOID NSAIDs
Supportive care
Zika Epi, Pt, Dx, Tx
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
Chikungunya features and tx
fever, polyarthralgia, lymphopenia
Supportive care
Salmonella features
Salmon colored spots, fever, abd pain, constipation, relative brady
Leptospirosis Epi, Pt, Tx
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
Worms features and tx
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
S/E of COVID vaccines
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
Indication for COVID booster
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
Ebola: Epi, Pt, Dx, Tx
Epi: Congo
Pt: Fever, myalgia, GI, anorexia
Dx: NAAT, viral Cx/Ag/serology
Tx: Supportive care, essential procedure/bw only; droplet/contact
FUO defn and ddx
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
W/U if immunosuppressing
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
Mono LR
LR+ atypical lymphocytosis, palatine petechiae, splenomegaly, posterior cervical LN
LR- NO adenopathy
Antimicrobial ppx in Oncology
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
Line/Ventriculitis infections
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)
RF Candidemia
- Broad-spectrum abx
- ICU admission
- CVC
- TPN
- Neutropenia
- Immunsuppresed
- Necrotizing panceatitis
- Intraabdo surgery
Droplet + contact for:
Invasive GAS (TSS/NF/PNA/meningitis), Ebola
When to abx prophylax in bites
- Immunocompromised
- Asplenic
- Advanced liver dz
- Pre-existing or resultant edema
- Mod/severe injury to hand/face
- Penetrating injury to joint capsule or periosteum
Influenza tx
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
Infectious Mono bug, features, dx
Bug: EBV
Features: atypical lymphocytosis, hepatitis, cervical LAD and tenderness, airway obstruction, fever, malaise, splenomegaly, splenic rupture with sports,
Dx: anti-heterophile AB
Isolation for Herpes
Routine for encephalitis or mucocutaneous
Contact for disseminated/severe (until lesion crusted) or neonatal infxn (for duration of symptoms)
Droplet contact:
N. meningitis, H flu, M. Pneumonia, Pertussis, Mumps, rubella, Flu Parvovirus 19, Rhinovirus GAS
Airborne precautions:
Varicella, TB, Measles, smallpox
