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Medicine > Infection - History Taking and Exam > Flashcards

Infection - History Taking and Exam Flashcards

1
Q

History for Queried Infection

A

Does this pt have an infection?
Where is it? (anatomically?) localised or systemic
Have they been exposed to a likely infection? (what is it? range of pathogens, antibiotic resistance)
Are they predisposed to any infection?

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2
Q

Fever - needs to be characterised
How ….? A vs C
How ….?
P…?
C… and rigors?

A

Acute - viral, bacterial infection, malaria etc
Chronic - TB, brucella, non-infective
How high?
Pattern? Sustained v swinging
Chills and rigors - rigors - bacteraemia, toxaemia, parasitaemia

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3
Q

Non-infective Fever causes (8)

A

Thyroid storm, Malignancy/tumour lysis, Surgery, Infarction, Thrombosis, Subarachnoid haemorrhage, Drugs/Transfusion, Pancreatitis

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4
Q

Non-infective Fever causes (8)

A

Thyroid storm, Malignancy/tumour lysis, Surgery, Infarction, Thrombosis, Subarachnoid haemorrhage, Drugs/Transfusion, Pancreatitis

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5
Q

Anatomical Focus - Infection

A 
Many infections (esp in GIM) are localised e.g. Urinary tract, skin, resp tract, GI tract, CNS 
Symptoms often generalised - fever, aches, pains 
Systemic enquiry very important - e.g. neurological symptoms in cerebral abscess, back pain in endocarditis
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6
Q 
Many infections (esp in GIM) are .... e.g. Urinary tract, skin, resp tract, GI tract, CNS 
Symptoms often .... - fever, aches, pains 
.... enquiry very important - e.g. ... symptoms in cerebral abscess, back pain in ....
A 
Many infections (esp in GIM) are localised e.g. Urinary tract, skin, resp tract, GI tract, CNS 
Symptoms often generalised - fever, aches, pains 
Systemic enquiry very important - e.g. neurological symptoms in cerebral abscess, back pain in endocarditis
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7
Q

Exposure to infection

  • From - People (Direct, Respiratory, Sexual/Blood, Faeco-Oral animals, Pets/Farming environment)
  • Encountered through - occupation, at home, travel and recreation
A
  • From - People (Direct, Respiratory, Sexual/Blood, Faeco-Oral animals, Pets/Farming environment
  • Encountered through - occupation, at home, travel and recreation
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8
Q

Case 1:

  • Wife increasingly worried as he became more confused and his level of consciousness dropped, called ambulance and taken to hospital
  • Admitted to ITU - never regained conscioussness and died
  • What is the missing info?
A
  • Travel HX missed - he had returned from west africa 10 days previously
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9
Q

Travel - the five Ws of the Wanderer

A
  • Where - exactly
  • When - exactly
  • Doing what?
  • With whom (and what has happened to them?)
  • Waccination (prophylaxis)
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10
Q

Exposure - dont forget to ask about…

A

Sexual hx, IV drug use, food/water exposure for enteric diseases

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11
Q

Causes of Immunocompromise:

… - Chemo, Steroids, Immunosuppression (T cell - mycophenolate, B cell - rituximab)

… - Sickle cell, trauma

… - X-linked agammaglobulinemia, Digeorge syndrome, Chronic granulomatous disease

… disease - HIV, Alcohol, Diabetes, Old age/Infancy, Pregnancy, Malnutrition

… - Lupus, Rheumatoid

… - Eczema, central lines, ventilation

A

Iatrogenic - Chemo, Steroids, Immunosuppression (T cell - mycophenolate, B cell - rituximab)

Hyposplenism - Sickle cell, trauma

Congenital - X-linked agammaglobulinemia, Digeorge syndrome, Chronic granulomatous disease

Underlying disease - HIV, Alcohol, Diabetes, Old age/Infancy, Pregnancy, Malnutrition

Autoimmune - Lupus, Rheumatoid

Physical - Eczema, central lines, ventilation

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12
Q

Causes of Immunocompromise:

Iatrogenic - …., Steroids, Immunosuppression (T cell - mycophenolate, B cell - rituximab)

Hyposplenism - …. cell, trauma

Congenital - X-linked agammaglobulinemia, …. syndrome, Chronic granulomatous disease

Underlying disease - HIV, …., …, Old age/Infancy, …., Malnutrition

Autoimmune - …., Rheumatoid

Physical - …., …. lines, ventilation

A

Iatrogenic - Chemo, Steroids, Immunosuppression (T cell - mycophenolate, B cell - rituximab)

Hyposplenism - Sickle cell, trauma

Congenital - X-linked agammaglobulinemia, Digeorge syndrome, Chronic granulomatous disease

Underlying disease - HIV, Alcohol, Diabetes, Old age/Infancy, Pregnancy, Malnutrition

Autoimmune - Lupus, Rheumatoid

Physical - Eczema, central lines, ventilation

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13
Q

In summary - for ID - remember INCEST acronym

A
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14
Q

Exam - where is the infection?

A

May be obvious

  • All systems - be thorough
  • ENT
  • CNS
  • Gynae/Pelvis
  • Skin
  • Line sites
  • Lymphadenopathy - regional infection or systemic process
  • Hepatosplenomegaly
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15
Q

Exam - how sick?

A
  • Generalised inflammatory response to infection- tachycardia, tachypnoea, changes in vascular tone = cap refill time <2 secs
  • Later - dehydration
  • Failure of homeostasis/organ dysfunction - hypotension, change in cognitive function, diarrhoea
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16
Q

What tests do we do ? (infection)

A

FBC, U&E, LFTs, CRP, VBG, Lactate - marker of organ hypoperfusion (>4mmol is predictive of impending shock)

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17
Q

What is a marker of organ hypoperfusion?

A

Lactate - marker of organ hypoperfusion (>4mmol is predictive of impending shock)

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18
Q

Specific Investigations (INFECTION)

  • Direct demonstration of pathogen (MC+S, Blood, urine, CSF, sputum, swabs)
  • Serology - for infections you can’t culture - send a save serum
  • Molecular - TB PCR, HIV, Hep B and C, resp viruses
  • Imaging - CXR, U/S, Echo, CT
A
  • Direct demonstration of pathogen (MC+S, Blood, urine, CSF, sputum, swabs)
  • Serology - for infections you can’t culture - send a save serum
  • Molecular - TB PCR, HIV, Hep B and C, resp viruses
  • Imaging - CXR, U/S, Echo, CT
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19
Q

Specific Investigations (INFECTION)

  • Direct demonstration of pathogen (MC+S, Blood, urine, CSF, sputum, swabs)
  • Serology - for infections you can’t culture - send a save serum
  • Molecular - TB PCR, HIV, Hep B and C, resp viruses
  • Imaging - CXR, U/S, Echo, CT
A
  • Direct demonstration of pathogen (MC+S, Blood, urine, CSF, sputum, swabs)
  • Serology - for infections you can’t culture - send a save serum
  • Molecular - TB PCR, HIV, Hep B and C, resp viruses
  • Imaging - CXR, U/S, Echo, CT
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20
Q

Many infections are …. limiting or …

A

self limiting or untreatable

  • e.g. viral sore throat, toxin mediated food poisoning, bacterial enteritis
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21
Q

Choosing empiral antimicrobial therapy - three helpful questions:

A

where is the focus?

whats the microbial epidemiology of this infection?

how sick is the patient? sicker patients - need to be more sure youre covering the cause

22
Q

Treatment of infection - not just antibiotics - what else\?

A

Source control - drain abscess, remove line etc

Supportive - fluids, ICU

Step-down antibiotics when micro results known

23
Q

Specific investigations in CAP

A

CXR

Blood cultures

sputum

Upper resp tract viral swab for molecular tests

serology for atypicals

urine for legionella antigen

24
Q

Serology

  • For diagnosis of organisms you can’t ….
  • Takes …-… weeks for abs to develop
  • ….-fold rise in titre
  • Mycoplasma, legionella, chlamydia - … serology
  • need ‘… samples’ admission and f/up
A
  • For diagnosis of organisms you can’t culture
  • Takes 4-6 weeks for abs to develop
  • four-fold rise in titre
  • Mycoplasma, legionella, chlamydia - atypical serology
  • need ‘paired samples’ admission and f/up
25
Q

Treatment - focus, chest - microbiological differential of CAP

A

Amoxicillin alone, amoxicillin plus doxicycline - other, allergies important!

26
Q

Cellulitis

  • Common causes - haemolytic streptococci (mostly …. … - group A strep), s aureus too
  • Weird and wonderful causes - aeromonas (cellulitis associated with …. contact), erysipelothrix rhusiopathiae (cellulitis associated with p….gs) Salmonella (….), mixed anaerobes (….)
A
  • Common causes - haemolytic streptococci (mostly S pyogenes - group A strep), s aureus too
  • Weird and wonderful causes - aeromonas (cellulitis associated with water contact), erysipelothrix rhusiopathiae (cellulitis associated with pigs) Salmonella (Reptiles), mixed anaerobes (bites)
27
Q

Why may cellulitis get worse on amoxicillin?

A

Dose too small - probably

Resistant organism/strain (unlikely)

Wrong diagnosis - DVT? NF?

28
Q

Necrotising Fasciitis

  • Fulminant deep soft tissue infection caused by …
  • Mortality - ….% with treatment
  • Presents like cellulitis but - systemic, ….+++, diagnosis suggested by raised …., Treatment ABs and urgent … surgery
A
  • Fulminant deep soft tissue infection caused by S.pyogenes
  • Mortality - 50% with treatment
  • Presents like cellulitis but - systemic, pain+++, diagnosis suggested by raised CK, Treatment ABs and urgent radical surgery
29
Q

Antibiotic Terms

  • … - ‘best guess’ based on predicted pathogens
  • … … - active against a wide range of pathogens
  • ….-… - refining antibiotic treatment based on microbiological results to narrowest spectrum possible
A
  • Empirical - ‘best guess’ based on predicted pathogens
  • Broad spectrum - active against a wide range of pathogens
  • De-escalation - refining antibiotic treatment based on microbiological results to narrowest spectrum possible
30
Q

Infection Factors:

  • Likely pathogens - …. vs ….. therapy
  • Resistance - e.g. …., local resistance patterns, recent AB history, …., MIC of causative organism
  • …. of infection
  • Severity - local/…, …. s…, … production e.g. PVL Staphylococcus, iGAS
A
  • Likely pathogens - empirical vs targeted therapy
  • Resistance - e.g. MRSA, local resistance patterns, recent AB history, travel, MIC of causative organism
  • Site of infection
  • Severity - local/systemic, septic shock, toxin production e.g. PVL Staphylococcus, iGAS
31
Q

Patient Factors (Prescribing in infectious diseases)

A
  • Allergies
  • Pregnancy and breast-feeding
  • IV or Oral route
  • Medication history, drug interactions
  • Age
  • Renal/hepatic function
  • Obesity
  • PMH - drug-disease interactions
32
Q

Drug factors: (prescribing in infectious diseases)

  • activity against predicted/known pathogen - mechanism of action
  • pharmacokinetic profile (ADME) e.g. … to site of infection
  • D…
  • … vs … e.g. synergisitc effect of aminoglycosides with B-lactams in endocarditis
  • … spectrum - review and revise by …hrs , i.e. stop, switch (IV to oral), …, de-…
A
  • activity against predicted/known pathogen - mechanism of action
  • pharmacokinetic profile (ADME) e.g. penetration to site of infection
  • Dose
  • Monotherapy vs combination e.g. synergisitc effect of aminoglycosides with B-lactams in endocarditis
  • Broad spectrum - review and revise by 72hrs , i.e. stop, switch (IV to oral), escalate, de-escalate
33
Q

Cellulitis: What is it?

A
34
Q

Cellulitis is characterised by…

A
  • heat, erythema, induration, localised tenderness, orange skin appearance
  • blisters of bullae
  • not raised and without a well demarcated edge
  • may have systemic inflammatory response and regional lymphadenopathy
35
Q

Causes of cellulitis:

A
  • Infection occurs following minor breach of skin - insect bite, tinea pedis
  • Infection risk increased in - immunocompromised, following trauma/surgery, diabetes mellitus/lymphoedema, morbidly obese
36
Q

Bacteria - Cellulitis

A
  • Group A Streptococcus (streptococcus pyogenes)
  • Staphylococcal aureas (MSSA and MRSA)
  • Other beta haemolytic streptococci (B, C and G)
  • Dog/cat bite pasteurella multicida, capnocytophaga carnimorsus, human bite eikonella corridens
  • Salt water exposure vibrio vulnificus
37
Q

Points to consider - prescribing in infectious diseases

A

What patient factors will you consider before prescribing antibiotic therapy?

What empiric antibiotic therapy would you consider?

Which route of administration will you choose?

What patient factors would you monitor to determine infection improvement?

38
Q

Penicillins

A
39
Q

Penicillins

A
40
Q

Sudden, life-threatening, occurs up to 24 hours post exposure (usually within 1 hour) what type of allergy?

A
41
Q

IgE-mediated penicillin allergy (T1 reactions)

  • Timing?
  • Severe?
  • Reactions?
A
42
Q

Cross - sensitivity - cephalosporins

A
43
Q

Cross - sensitivity - other beta-lactam abs

A
44
Q

Penicillin allergy - what to do

A
45
Q

IV-oral switch

A
46
Q

Aminoglycosides are not absorbed where?

A

GI tract - give IV or IM

47
Q

Aminoglycosides excretion virtually entirely via ..

A

kidneys

48
Q

Aminoglycosides - synergistic with…

A
49
Q

Glycopeptides are not absorbed from the … and excretion via…

A
  • gut - is given IV (except CDiff)
  • Excretion via glomerular filtration into the urine
50
Q
A
51
Q

ONCE daily dosing for which ab? and what mg per kg?

A

Gentamicin (5-7mg/kg)

52
Q

Monitoring gentamicin levels

A

Medicine (14 decks)

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