INFECTIONS Flashcards
UTI pathogens
E coli 80-85% Staph saprophyticus Proteus mirabilis Klebsiella pneumoniae Enterococcus
UTI treatment?
TMP-SMX
Nitrofurantoin
Fluoroquinolone
3-7 days
Ulcerative lesion causes?
Herpes
Syphilius
Chancroid
Lymphogranuloma venerum
Crohn’s disease, Behcet’s disease
Syphilis lesions
1) Chancre- painless, round, firm ulcer with raised edges. Develops ~3 wks after inoculation. Regional adenopathy.
Material inside has motile spirochetes on dark-field microscopy
2) 1-3 months later has systemic flu-like symptoms with fever and myalgias. Maculopapular rash on palms and soles.
LATENT PHASE
3) GRANULOMAS (gummas) of skin and bones.
Cardiovascular/aortitis.
Neurosyph.
Syphilis treatment
Benzathine penicillin
IV penicillin for neurosyphilis
Could have the Jarisch-Herxheimer rxn (usu within 8-24 hours after starting treatment).
This is NOT A DRUG RXN. It’s endotoxin release that causes systemic release of cytokines.
Basically everyone gets penicillin. If this is truly a big problem then give:
Doxy tetra ceftriaxone azithromycin combo.
Syphilis tests? Do the antibodies disappear after treatment? False positive antibodies?
VDRL and RPR
Antibodies POSITIVE for 6-12 months after treatment with progressively dec titers.
False positives with autoimmune, other infections, malignancy, pregnancy, IVDU. Therefore, positive result must be confirmed with specific treponemal antibody studies like FTA-ABS and TPPA (particle agglutination assay).
What if they’re asymptomatic with a positive antibody titer?
Early latent or late latent stage.
Genital herpes pathogen?
HSV-2 but up to 80% of NEW cases are from HSV-1.
Recurrence more frequent with HSV-2
Genital herpes incubation period, symptoms.
2-10 days. Flu-like symptoms.
Vulvar burning and pruritis precede the multiple vesicles that appear, happens for 24-36 hours then evolves into painful genital ulcers. These ulcers req 10-22 days to heal.
Recurrence less severe than initial outbreak.
SUBCLINICAL ASYMPTOMATIC SHEDDING CAN OCCUR. IS MORE FREQUENT DURING THE FIRST 6 MONTHS AND IMMEDIATELY BEFORE OR AFTER RECURRENT OUTBREAKS.
Herpes diagnosis
Viral culture
Tzanck smear isn’t sensitive or specific
Herpes treatment
Acyclovir
Chancroid characteristics
Difficult to culture so we underestimate rates
Males»_space; females
Is a COFACTOR for HIV transmission
Painful, nonindurated ulcer anywhere in the anogenital region, usually just one ulcer. Painful suppurative inguinal LAD.
Chancroid treatment
Ceftriaxone or azithromycin
Lymphogranuloma venereum pathogen
Chlamydia trachomatis L serotypes
LG stages
3-12 day incubation
Primary: Local lesion that’s a papule or shallow ulcer. Painless, transient, can go unnoticed.
Secondary: Inguinal syndrome. 2-6 wks later with PAINFUL inflammation and enlargement of inguinal nodes (usu unilateral).
Tertiary (Rectal exposure only): Anogenital syndrome with proctolitis, rectal structure, rectovaginal stricture, elephantiasis.
LG diagnosis
Clinical.
Genital/lymph node specimen culture, direct immunofluorecence, nucleic acid detection also possible.
LG treatment
Doxycycline
Erythromicin ok
Nonulcerative lesion causes?
- Condyloma acuminata
- Molluscum contagiosum
- Phthirus pubis (crab louse)
- Sarcoptes scabiei (itch mite)
Etiology of condyloma acuminatum
HPV 6 and 11
Warts diagnosis
Biopsy
Warts treatment? Recurrence rate?
Local excision- best for a large/bleeding lesion
Cryotherapy
Topical trichloroacetic acid
Topical 25% podophyllin- not recommended for extensive disease bc of toxicity (peripheral neuropathy)
5-FU cream- for intractable condyloma
The medicines require weeks or months to be effective!
Imiquimod and podoilox
Recurrence rate 20%
HPV vaccines and coverage
Cervarix 16, 18
Gardasil 6, 11, 16,18
Molluscum contagiosum
Pox virus
1-5mm domed papule with an umbilicated center
Wright or giemsa stain
Anywhere on skin except palms and soles.
Local excision, cryotherapy, or trichloroacetic acid.
Pediculosis
Confined to pubic hair (crabs)
Permethrin 1% cream, wash after 10min
Piperonyl butoxide, wash after 10min
Scabies
Permethrin cream to all areas of body, wash in 8-14 hrs
Ivermectin oral.
BV risk factors
New or multiple sex partners Lack of vaginal lactobacilli Female sexual partners Douching Smoking
BV cause
Shift in predominant bacterial species in vagina.
POLYMICROBIAL
Most common organism is Gardnerella.
BV diagnosis
KOH whiff test
pH greater than 4.5
Clue cells on microscope
Profuse nonirritating white milky discharge with malodorous fishy amine odor.
GRAM STAIN IS GOLD STANDARD.
BV treatment
Metronidazole (avoid alcohol) 7 days
Clindamycin ok
Recurrence up to 30%
Candidasis diagnosis
KOH prep
Gram stain and culture (for IDing non-albicans species that may be less responsive to azole therapy)
Candidiasis treatment
Azoles for 1-3 days topical or suppository
Oral: fluconazole (especially for recurrent cases)
Non-albicans: boric acid capsules, intravaginally
Trichomonas diagonsis
- Frothy green-gray profuse malodorous discharge.
- Strawberry mucosa (puncate epithelial papillae) in only 10%
WET PREP shows protozoan with flagella
Trichomonas treatment
Metronidazole 2g SINGLE ORAL DOSE Tinidazole
Treat partner.
Gonorrhea diagnosis
Thayer Martin chocolate agar of endocervical cultures
Nucleic amplification tests now more popular than cultures
Gonorrhea treatment
IM ceftriaxone 125 mg 1x
Oral cefexime 400mg 1 dose
Cotreat for chlaymida with Doxycycline or azithromycin
Gonorrhea and chlamydia rates of infections
Gonorrhea stable
Chlamydia increased
Chlamydia symptoms
Up to 70% asymptomatic
Chlamydia treatment
Azithromycin 1g oral single dose
Doxycycline 100mg oral 2x/day for 7 days
Endometritis and Endomyometritis risk factors
POLYMICROBIAL.
STIs, retained products of conception, intrauterine foreign bodies or growths, instrumentation of the cavity
MC after C/S but possible after vaginal deliveries and surgical pregnancy terminations
Endometritis is UNCOMMON in what? Therefore antibiotic prophylaxis not recommended
EMB, endometrial ablation, hysteroscopy, IUD placement
When is antibiotic prophylaxis advised for prevention of endometritis?
C/S
Surgical terminations of pregnancy
HSG or sonohysterography in women with hx of PID or dilated tubes
Chronic endometritis diagnosis
Clinically with uterine tenderness, fever, elevated WBC
EMB with plasma cells
Rx of endometritis unrelated to pregnancy
Same as for PID (cephalosporin like cefoxitin or cefotetan)
Rx of postpartum endometritis
Clindamycin gentamicin
Single agent: cephalosporins
Rx of chronic endometritis
Doxycycline 10-14 days
What is PID
Infection of the upper female genital tract including any combo of endometritis, salpingitis, tubo-ovarian access, pelvic peritonitis.
Infertility risk with PID? Successive episodes?
Risk inc with # of episodes
40% with 3 or more
Risk factors for PID
Nonwhite nonasian Multiple partners Douching Smoking Prior hx of PID
Minimum criteria for empiric treatment of PID?
Pelvic or lower abdominal pain in sexually active @ risk of STIs and ONE OR MORE OF:
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
Additional
- Fever >38.3
- Abnormal cervical or vaginal mucopurulent discharge
- WBC inc
- Elevated ESR and CRP
- Gonorrhea or chlamydia on cultures
Last resort for diagnosing PID
Laparoscopic only when appendicitis can’t be ruled out by clinical exam or if there’s a poor response to antibiotics.
Fitzhugh-Curtis
Occasional complication fo PID with RUQ pain and LFT elevations from perihepatitis
PID treatment
Often hospitalized
Broad-spectrum cephalosporin.
IV for 24 hrs until clinical improvement, then doxy 100mg orally for 2 weeks.
Allergic to cephalosporins: IV clinda and genta
Outpatient basis: Ceftriaxone IM
Pregnant: Clinda and genta
Silver lining of a TOA?
It’s not walled off like a true abscess so it’s more responsive to antimicrobial therapy.
TOA diagnosis
CLINICAL:
- Pelvic pain
- Fever/leukocytosis
- Adnexal or posterior cul-de-sac mass or fullness
ULTRASOUND
Get endocervical swab and blood cultures to r/o sepsis
TOA treatment
Trial of medical management with broad-spectrum antibiotics as inpatient
PARENTERAL Cefotetan or cefoxitin + Doxy
Clinda and genta
If responsive, patient can switch to oral
IF MORE SERIOUS NEED SURGERY
Toxic shock syndrome. Nonmenstrual causes?
Vaginal infections, vaginal delivery, c/s, postpartum endometritis, miscarriage, laser treatment of condyloma
TSS cause
Staph that produces TSST-1
Blood cultures often negative
TSS physical and lab findings
High fever, hypotension, desquamation of palms and soles, GI disturbances, inc BUN and creatinine, platelet count less than 100,000
TSS treatment
HOSPITALIZATION.
HYPOTENSION FIRST- IV fluids and pressors
Antibiotics not for toxin, but to dec recurrence chance.
Clinda + vanc (or linezolid), 10-14 days
HIV diagnosis
Screening test: ELISA
If positive, confirm with WESTERN BLOT.
Viral loads and CD4 counts to monitor progression
HIV pre-exposure prophylaxis?
New thing.
Tenofovir disoproxil fumarate _ emtricitabine (TDF/FTC).
HIV treatment
Nucleoside analogs- inhibit reverse transcription and interfere with viral replication (zidovudine, lamivudine, abcavir, etc.)
Protease inhibitors- interfere with the synth of viral particles and inc CD4 counts while dec viral load.
HAART
HIV vertical transmission %’s and modalities?
Intrapartum 50-80%
Intrauterine 20-50%
Postpartum 15%
GIVE IV ZIDOVUDINE DURING PREGNANCY AND LABOR.
ART in pregnancy started in 2nd trimester.
Should you do a c/s for HIV pregnancy?
Only if viral loads are HIGH and she hasn’t been getting treated.
NO BENEFIT if viral load is < 1000 copies/mL
Another thing to look out for in HIV
Cervical cancer!
Do routine pap smears at initial eval and 6 months later.
