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Dunedin RACP Study Course > ID - Guideline Updates > Flashcards

ID - Guideline Updates Flashcards

1
Q

Who should you suspect Listeria Meningitis in?

A

age >50 years, and in those with compromised cell-mediated immunity e.g. diabetes

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2
Q

Diagnosis of listeria meningitis

A
  • LP essential to diagnosis and should be performed promptly
  • CT head prior to LP is not necessary in all patients. Consider only if immunocompromised or features of raised ICP
  • Blood and CSF culture prior to antimicrobials is helpful, but do not delay treatment if not able to be obtained expeditiously
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3
Q

Meningitis Risk Factors

A
  • Abnormal communication between nasopharynx and subarachnoid space due to trauma or anatomic abnormality
  • Anatomic or functional asplenia or immunoglobulin deficiency are risk factors for infection from encapsulated organisms (Pneumococci, Meningococci)
  • Complement deficiency
  • Terminal complement inhibitory - Eculizumab (2000 fold risk)
  • HIV (not as much these days)
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4
Q

Kernig’s sign

A

Inability for fully flex knee when hip flexed to knee degrees

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5
Q

Brudzinski sign

A

spontaneous hip flexion during passive neck flexion

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6
Q

Indications for CT prior to LP: IDSA

A
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7
Q

Characteristic LP finding for HSV meningitis

A

CSF often contains many red cells – “bloody tap”

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8
Q

WCC predominance in Viral and TB meningitis

A

polymorphs may predominate early in the illness and later switch to lymphocytic predominant

Overall more lymphocyte predominant

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9
Q

pathogen most common for Mollaret’s meningitis?

A

HSV-2

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10
Q

LP findings for TB vs cryptococcal?

A

More WCC with TB, more protein

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11
Q

Empiric treatment for meningitis in adults

A
  1. Dexamethasone 10mg IV q6h (maximum 4 days)
  2. Ceftriaxone 2g IV BD

+/- Vancomycin 1.5g q12h (if pneumococcal risk)

+/- Benzylpenicillin 2.4g q4h (if listeria suspected)
(Ceftriaxone does NOT cover Listeria)

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12
Q

Typical TB meningitis presentation

A

Subacute presentation with fever, headache, drowsiness, meningism, and confusion over 2-3 weeks

  • 50% have abnormal chest x-ray - an important clue!
  • Predominant lymphocytic CSF >50%, with low CSF:blood glucose ratio (<0.5) and a high protein conc. >1.0 g/L
  • Low numbers of bacilli in CSF - yield of ZN staining & culture adequate only if large volume of CSF is examined (>5 ml)
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13
Q

Typical Cryptococcus meningitis presentation

A
  • Subacute presentation: headache, fever, altered mental state
  • May not have classic meningism
  • Advanced HIV (CD4 count <100) is main risk factor
  • May be associated with cerebral mass lesion e.g. cryptococcoma
  • Typically significantly elevated ICP – may need drainage or shunting to prevent vision/hearing loss
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14
Q

Cryptococcus species -> cryptococcus meningitis?

A

Cryptococcus neoformans (immunocompromised)

Cryptococcus gattii* (immuno-competent, on gum leaves etc)

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15
Q

Most common predisposing lesion for IE?

A

Mitral prolapse + regurg
(previous RHD MS)

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16
Q

Which Staph Aureus patients should you push for a TOE in?

A

Four high risk criteria requiring TOE identified:

  1. Community-acquired bacteremia
  2. IV drug use
  3. High risk cardiac condition
  4. Indeterminate or positive TTE

Or in a seperate study:

Main risk factors identified were:

  1. Patients with community-acquired SAB
  2. Prolonged bacteraemia >72 hours
  3. Cardiac prosthesis (i.e. ICD, PPM, or valve)
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17
Q

Streptococcus species most likely to cause IE?

A

Mutans

Gordonii

Sanguinis

S. Gallolyticus

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18
Q

Strep Gallolyticus

A

Previously known as Strep Bovis

Virulence factors:
- transmigration
- adherence to collagen-rich surfaces of cardiac valves
- biofilm formation

Endocarditis strongly associated with colon pathology
– 60% have concomitant adenoma / carcinoma on colonscopy

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19
Q

Significant of HACEK organisms

A

Oral Flora

If bacteraemic with highly suggestive of IE

20
Q

What are HACEK organisms?

A

Gram negative bacilli that are slow to grow on culture media

Previously thought to cause lots of IE

21
Q

HACEK organisms

A
  • Haemophilus species
  • Aggregatibacter actinomycetemcomitans
  • Cardiobacterium
  • Eikenella corrodens
  • Kingella
22
Q

Bacteria -> Culture negative IE?

A
  • Bartonella
  • Coxiella burnetii (Q fever)
  • Brucella
  • Legionella
  • Tropheryma whipplei

Easier to grow these days.

23
Q

Investigations in culture negative IE

A

Ideally three sets of blood cultures taken before antibiotics

Serological investigation helpful (but not available for Tropheryma whipplei)

If valve resected then request “16s ribosomal RNA sequencing” of valve tissue

24
Q

Organisms in native vs prosthetic valve IE

A

native valve
* S. aureus
* Streptococci
* Enterococci
* HACEK

Prosthetic Valve
Early: <6 months post surgery
- Coag-neg Staphs
- S. aureus
- Enterococci

Late: >6 months post surgery Same as native valve (haematogenous spread)

25
Q

Empiric ABx for native vs prosthetic valve IE?

A

Native valve:
* Benzylpenicillin 1.8g IV q4h (for strep)
* Flucloxacillin 2g IV q4h
* Gentamicin IV daily

Prosthetic Valve
* Flucloxacillin 2g IV q4h
* Vancomycin IV
* Gentamicin IV daily

For both options vans + gent seems to be a legit option also.

26
Q

IE indications for surgery

A
27
Q

IE Prophylaxis Guidelines 2008

A

High risk cardiac condition

PLUS

High risk procedure

28
Q

High risk procedures for IE?

A
29
Q

IE prophylaxis drug of choice?

A

Amoxicillin

30
Q

CURB-65 components and score significance

A
31
Q

SMART-COP Criteria

A
32
Q

Treatment for CAP

A
33
Q

Who to use steroids for pneumonia in

A
34
Q

When should you use metronidazole for pneumonia?

A

aspiration pneumonia IF lung abscess or empyema is suspected

Not routine in aspiration pneumonia

(ATS/IDSA Pneumonia Guidelines 2019)

35
Q

What percent exposed people become infected with TB, and what % of those -> active TB?

A

about 10% for each

36
Q

What is the new terminology for TB?

A

latent TB -> TB infection

Active TB -> TB disease

37
Q

What time frame do people with TB develop active TB/ TB disease?

A

50% with in 2 years, 50% many years later

38
Q

CXR in TB/ HIV patient

A

Less typical - may be lower zone, diffuse infiltrate

cavitation uncoommon
less mediastinal adenopathy

39
Q

TB drugs and HIV

A

rifampicin will lower levels of protease inhibitors (so use efavirenz instead)

40
Q

TB testing in HIV patients?

A

should do a quant gold in all HIV +ve patients

May be falsely negative (esp if CD4 count < 100)

41
Q

How long is TB therapy

A
  • Initiation Phase: 2 months
  • Continuation Phase: 4+ months
  • Total course typically 6 months, but extended to 9 months if cavitary disease, pulmonary TB still positive at 2 months, bone or joint, TB meningitis (9 – 12 months)
42
Q

When do you give steroids in TB?

A

TB meningitis of TB pericarditis

43
Q

Drugs to use in MDR TB

A

Bedaquiline
Pretomanid
Linezolid
+/- Moxifloxacin

44
Q

Indications for Latent TB treatment?

A

Therapeutic Guidelines (eTG) recommend treatment if:

  • HIV infection
  • Recent acquisition of disease / skin test converter
  • Close contacts of patient with smear-positive pulmonary TB
  • Immunosuppresssed e.g. TNF-alpha inhibitors, steroids
  • Patients age <35 years even if no known TB contact*
  • Healthcare workers
45
Q

Risk for progression from latent to active disease

A
  • Age < 5 years at time of exposure
  • Body weight <90% of ideal weight
  • Diabetes mellitus (30% lifetime risk)
  • Gastrectomy or jejunoileal bypass
  • History of untreated or inadequately treated active TB
  • Immunosuppression
  • Lung parenchyma abnormalities in smokers, silicosis* or cancer of head neck or lung
  • Fibrotic changes on CXR consistent with past healed TB
  • Recent contact with a person who has active TB
  • Drug and alcohol use
  • Social-economic disadvantaged peoples
  • Very high risk especially when combined with HIV = S. African miners
46
Q

DM and TB

A

3x risk of active TB
Increased severity/ mortality
Decreased treatment response

47
Q

Treatment for latent TB?

A

Isoniazid
- 300g PO OD 6-9 months

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