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Kirsty FTY > Infections & treatment > Flashcards

Infections & treatment Flashcards

1
Q

What is Pneumonia?

A

Pneumonia is an acute infection of the lung parenchyma - affects alveoli.

It is a respiratory infection.

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2
Q

What culture and sensitvity testing can be done to narrow down Abx use in patients with pneumonia?

A

Sputum culture

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3
Q

What is the most likely causative organism for CAP?

What are other possible bacteria?

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae, Staphylococcus aureus, group A streptococci, Moraxella catarrhalis, and atypical bacteria such as Mycoplasma pneumoniae, Chlamydia, and Legionella species
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4
Q

How quick should abx be administered after diagnosis of Pneumonia?

A

Antibacterial treatment should be started as soon as possible and within 4 hours of establishing a diagnosis (within 1 hour if the patient has suspected sepsis)

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5
Q

What scoring system is used to help support a diagnosis’ of pneumonia and determine severity?

A

CRB65:

confusion, respiratory rate 30/minute or more, blood pressure (systolic less than 90 mmHg or diastolic 60 mmHg or less), age 65 or more

CURB65:

confusion, urea more than 7 mmol/litre, respiratory rate 30/minute or more, blood pressure (systolic less than 90 mmHg or diastolic 60 mmHg or less), age 65 or more

CRB65 - community

CURB65 - hospital

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6
Q

When is pneumonia classified as HAP?

A

It is classified as hospital-acquired when it develops 48 hours or more after hospital admission.

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7
Q

(based on clinical judgement and guided by a CRB65 score 0 or a CURB65 score 0 or 1 when these scores can be calculated)
What is first-line treatment for CAP if low severity?

A

Amoxicillin 500mg TDS for 5 days (higher doses of amox can be used - see bnf)

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8
Q

(based on clinical judgement and guided by a CRB65 score 0 or a CURB65 score 0 or 1 when these scores can be calculated)
What is first-line oral treatment for CAP when low severity if there is a penicillin allergy or amoxicillin is unsuitable)?

A

A
Doxycycline:

200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)
Clarithromycin:

500 mg twice a day for 5 days
Erythromycin (in pregnancy):

500 mg four times a day for 5 days

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9
Q

( CRB65 score 1 or 2, or a CURB65 score 2 when these scores can be calculated; guided by microbiological results when available)
What is First-choice oral antibiotics if moderate severity CAP?

A

A
Amoxicillin:

500 mg three times a day (higher doses can be used; see the BNF) for 5 days With (if atypical pathogens suspected)
Clarithromycin:

500 mg twice a day for 5 days
Erythromycin (in pregnancy):

500 mg four times a day for 5 days

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10
Q

(CRB65 score 1 or 2, or a CURB65 score 2 when these scores can be calculated; guided by microbiological results when available)
What are alternative oral antibiotics if moderate severity, for penicillin allergy?

A

Doxycycline:

200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)
Clarithromycin:

500 mg twice a day for 5 days

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11
Q

(CRB65 score 3 or 4, or a CURB65 score 3 to 5 when these scores can be calculated)
What are first-choice antibiotics if high severity CAP?

A

Co-amoxiclav:

500/125 mg three times a day orally or 1.2 g three times a day intravenously for 5 days
With

Clarithromycin:

500 mg twice a day orally or intravenously for 5 days
Or

Erythromycin (in pregnancy):

500 mg four times a day orally for 5 days

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12
Q

(CRB65 score 3 or 4, or a CURB65 score 3 to 5 when these scores can be calculated)
What are first-choice antibiotics if high severity CAP and penicillin allergy?

A

Levofloxacin (consider safety issues):

500 mg twice a day orally or intravenously for 5 days

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13
Q

When should IV antibiotics be reviewed to consider switch to oral?

A

Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.

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14
Q

Describe treatment of HAP i.e. when empirical and when microbiological therapy should be used

A

For patients with non-severe signs or symptoms and not at higher risk of resistance, treatment should be guided by microbiological results when available. For patients with severe signs or symptoms or at higher risk of resistance, treatment should be based on specialist microbiological advice and local resistance data.

Higher risk of resistance includes signs or symptoms starting more than 5 days after hospital admission, relevant comorbidity, recent use of broad-spectrum antibacterials, colonisation with multidrug-resistant bacteria, and recent contact with a health or social care setting before the current admission.

In patients with signs or symptoms of pneumonia starting within 3 to 5 days of hospital admission who are not at higher risk of resistance, consider following the recommendations for community-acquired pneumonia for choice of antibacterial treatment.

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15
Q

Non severe signs & not at high risk of resistance
What is first-line empirical treatment for hospital acquired pneumonia?

What if the first-line is unsuitable?

A
  1. Co-amoxiclav 500/125 TDS for 5 days (then review)
  2. Penicillin allergy:

Doxycycline 200mg stat then 100mg OD for total 5 days
Co-trimoxazole 960mg BD for 5 days (off-label)
Cefalexin 500mg 2-3x a day (can be increased to 1-1.5g 3-4x a day)
Levofloxacin 500mg 1-2x a day for 5 days (only when switching from IV with specialist advice, off label)

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16
Q

Severe signs or higher risk of resistance
What is first-line empirical treatment for hospital acquired pneumonia?

What if MRSA suspected?

What route is used?

A

1.First-line:

Meropenem OR
Levofloxacin OR
Piper/tazo OR
Ceftazidine OR
Ceftriaxone OR
cefuroxime OR
ceftazidime with avpactam

  1. Add:

Vancomycin OR
Teicoplanin OR
Linezolid

  1. IV route
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17
Q

What are UTIs most commonly caused by?

What are the common causative agents?

A

A
Bacteria from the GIT entering the urinary tract.

The most common bacteria that cause UTI are as follows:

  • E.coli (gram negative)
  • Staphylococcus. Saprophyticus (gram positive)
  • Klebsiella. Pneumoniae (gram negative) Staphylococcus.

Aureus is common for pregnant and catharised patients.

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18
Q

What are the different types of UTIs?

A

Cystitis - lower UTIs (infections of bladder)
Pyelonephritis - upper UTIs (infection of kidneys or ureters.
Prostasis - infection of prostate

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19
Q

What factors mean a UTI is complicated?

A

Pregnancy
Catheterisation
Neurological or structural abnormalties
Co-morbidities such as immunosupression
atypical or resistant organisms

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20
Q

What are symptoms of lower UTIs (cystitis)?

A

urinary frequency (polyuria)
Polydypsia
Urgency
Nocturia
cloudy urine
smelly urine
subprapubic pain
blood in urine

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21
Q

What are symptoms of upper UTIs?

A

Those of lower UTIs plus systemic features such as:

fever
loin / flank pain
nausea
vomitting

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22
Q

Q
What are symptoms of prostatsis?

A

sudden onset fever
acute urinary retention
irrative voiding

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23
Q

What are non-antibiotic treatments for UTIs?

A

Fluid intake
Wipe front to back
Don’t delay peeing
avoid occlusive underwear
use para / ibuprofen for pain

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24
Q

When should patients seek help after starting abx for UTI

A

After 48h if no improvement in symptoms

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25
Q

When should asymptomatic bacteria in UTIs be treated?

A

Only in pregnancy!! Risk of developmental delay, cerebral palsy, fetal death

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26
Q

What is first-line treatment for Lower UTIs?

A

First-line:

Nitrofurantoin 100mg MR BD for 3 days
Trimethoprim 200mg BD for 3 days

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27
Q

What is second-line treatment for lower UTIs?

A

Second-line if no improvement after 48h:

Nitrofurantoin 100mg MR BD for 3 days
Pivmecillinam 400mg stat then 200mg TDS for 3 days
Fosfomycin 400mg stat
Amoxicillin 500mg TDS 3 days

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28
Q

What is first-line treatment for UTIs in men?

A

First-line:

Nitro 100mg MR BD for 7 days
Trimethoprim 200mg BD for 7 days

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29
Q

What is second-line treatment for UTIs in men?

A

Second-line:

MICRO

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30
Q

What is first-line treatment for UTIs in pregnant women?

A

First-line:

Nitrofurantoin 100mg MR BD for 7 days

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31
Q

What is second-line treatment for UTI in pregnant women?

A

Second-line:

Cefalexin 500mg BD for 7 days OR
Amox 500mg TDS for 7 days (if sensitive)

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32
Q

What is first-line treatment for non-pregnancy women and men with pyelonephritis?

What if sensitivities are known?

A

First-line:

Cefalexin 500mg 2-3x a day for 7-10 days

Sensitivities:

co-amox 500/125 TDS for 7-10 days
trimethoprim 200mg BD for 14 days
Ciprofloxacin 500mg D for 7 days

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33
Q

Q
What is first-line treatment for pyelonephritis in pregnant women?

A

Cefalexin 500mg 2-3x a day for 7-10 days

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34
Q

What is first-line treatment for prostatsis?

Second-line?

A

First-line:

Ciprofloxacin or ofloxacin

Second-line:

Levofloxacin or co-trimoxaole

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35
Q

What is first-line treatment for CAUTI in non-pregnant women and men? - NO symptoms

Second-line?

A

Nitro 7 days
Trimeth 7 days
Amox 7 days

Second-line:

Pivmicillinam 400mg inital then 200mg TDS for 7 days

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36
Q

What is first-line treatment for CAUTI in non-pregnant women and men? - Symptoms

A

Cefalexin
co-amox
trimethoprim
Ciprofloxacin

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37
Q

What is first-line treatment for CAUTI in pregnancy

A

Cefalexin

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38
Q

What is epiglotitis?

A

Inflammation often caused by infection of the epiglotis (flap which closes over trachea when eating)

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39
Q

What microorganisms commonly cause epiglottitis?

A

haemophilus influenza most common

Also step.pneumoniae

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40
Q
  1. What is the treatment for epiglottitis?
  2. what if allergy to first-line?
A
  1. cefotaxime (or ceftriaxone)
  2. Chloramphenicol
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41
Q

What is bronchiectasis?

A

A persistent or progressive condition cause by chronic inflammatory damage to the airways and is characterised by thick-walled, dilated bronchi

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42
Q

What treatment is involved in bronchiectasis?

A

7- 14 days treatment of…

First-line (oral):
- Amox or
- Clarith or
- Doxy

If high risk of treatment failure:
- co-amoxiclav or
- levofloxacin

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43
Q

What is the first-line treatment for COPD

What if there is high risk of failure?

A

First-line:

  • amox
  • doxy
  • clarith

High risk:

  • Co-amox or
  • levoflo
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44
Q

What is the second-line treatment for COPD if there has been no improvement after 2-3 days?

A
  • co-amox or
  • levoflo or
  • co-trim (only if good reason)
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45
Q

What is first-line treatment of COPD (IV)?

Second-line (IV)?

A

First-line:

Co-amox, co-trim, piper/taz, clarithy

Second-line:

micro

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46
Q

How long do coughs typically take to resolve and what advice can be given to patients?

A
  • 3-4 weeks
  • Normally viral UTRI
  • use honey and ocugh exp / supressants
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47
Q
  1. If abx is needed for cough what should be given first-line?
  2. What if this is unsuitable?
  3. Pregnancy?
A

5 days!

  1. First-line:
  • Doxy
  1. Alt:

amox
ethyro
clarithro

  1. Preg:

amox
ethro

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48
Q

What is sepsis?

A

Sepsis is a syndrome defined as life-threatening organ dysfunction due to dysregulated host response to infection.

The most common sites of infection leading to sepsis are the respiratory tract, GI, Renal and genitourinary tracts.

49
Q

What are risk factors for sepsis?

A

Extremes of age
Frailty
Immunocompromised/immunosuppressed
recent trauma or surgery
Breach in skin integrity
Pregnant / recent termination / miscarriage
Catheterised

50
Q

What are complications of sepsis?

A

Organ failure
Death
Reccurent or secondary infections

51
Q

What are common bacteria involved within sepsis?

A

E.coli
Staph. Aureus
Pseudomonal species

in children: Neisseria meningitides and haemophilus influenza

52
Q

What does treatment of sepsis involved and what time-frame should treatment be started?

(i.e. think sepsis six).

A

Treatment should be started within 1 hour!!

  1. Give IV fluids
  2. Give IV Abx
  3. Give O2 (>94%)
  4. Take lactate
  5. Take/check urine output
  6. Take Bloods & micro sample
53
Q

What is antibiotic treatment for septicemia? (both hospital and community acquired?

A

Broad Spectrum B-lactam Abx : e.g. tazocin (pipericillin and tazobactam). If allergic: meropenem.

(or broad spectrum cephalosporin in CA e.g. cefuroxime)

If MRSA suspected: add Vancomycin

if Anaerobic: add Metronidazole

If Pen/ceph allergy: Chloramphenicol

54
Q

What is the abx treatment for meningococcal septicaemia?

A

First-line:
- Benzylpenicillin
- Cefotaxime (or ceftriaxone)

Penicillin allergy:
- Chloramphenicol

55
Q

What is meningitis?

A

Bacterial meningitis is a life-threatening condition that can affect all ages, but is most common in babies and children.

Meningitis is an infection of the protective membranes that surround the brain and spinal cord (meninges)

56
Q

How is meningitis spread?

A

Transmission occurs through close contact, droplets, or direct contact with respiratory secretions.

57
Q

What are non-specific and specific symptoms of meningitis?

A

Non-specific symptoms: fever, nausea and vomiting, lethargy, irritable or unsettled mood, refusal of food and drink, headache, muscle ache or joint pain, and respiratory symptoms such as a cough.

More specific symptoms and signs: stiff neck, altered mental state (confusion, delirium and drowsiness, impaired consciousness), non-blanching rash, back rigidity, bulging fontanelle (in children younger than 2 years of age), photophobia, Kernig’s sign, Brudzinski’s sign, coma, paresis, focal neurological deficit, and seizures.

58
Q

How is bacterial meningitis empirically treated?

A

1) BENZYPENICILLIN- can be given before transfer to hospital (emergency situation in community)
2) If penicillin allergy- CEFOTAXIME (a cephalosporin)

If hypersensitivity to penicillin & cephalosporins: CHLORAMPHENICOL

4) Can consider addition of Dexamethasone
5) Consider Vancomycin if multiple use of antibiotics in previous 3 months

59
Q

What is the treatment for meningococcal meningitis?

A

Benzylpenicillin or cefotaxime (or ceftriazone) for 7 days

2nd line e.g. if allergy: Chloramphenicol For 7 days

60
Q

What is the treatment for pneumococcal meningitis?

A
  • Cefotaxime (OR ceftriaxone)

but If penicillin sensitive then change cefotaxime for benzylpenicillin.

  • If resistant consider adding: vancomycin (and if necessary) rifampicin
  • Consider adding dexamethasone

For 14 days

(?if allergy chloramphenicol)

61
Q

What is the treatment for meningitis caused by haemophilus influenza?

A

Cefotaxime (OR ceftriaxone) for 10 days
Consider adding dexamethasone

Allergy: chloramphenicol

62
Q

What is endocarditis?

A

Endocarditis is caused by bacteria in the bloodstream multiplying and spreading across the inner lining of your heart (endocardium)

63
Q

What is treatment for endocarditis?

A

1) amoxicillin

If resistant MRSA or pen allergy: vancomycin + low dose gent

2) staph: flucloxacillin, strep: benzylpenicillin

^ All +/- low-dose gentamicin hence the lower target level range for gentamicin in endocarditis (trough<1, peak 3-5)

64
Q

What antibiotic is indicated for gastro-enteritis?

A

This is usually self-limiting and an antibiotic not indicated

65
Q

What antibiotic is used for campylobacter enteritis

A

Frequently self-limiting. If severe or immunocompromised:

  • clarithromycin (or azithromycin or erythromycin)
  • alternative: ciprofloxacin
66
Q

What antibiotic is used for salmonella (non-typhoid)

A

Only treat if severe, immunocompromised or less than 6 months of age.

  • ciprofloxacin or cefotaxime.
67
Q

What antibiotic is used for typhoid fever?

A
  • cefotaxime or ceftriaxone
  • resistant: azithromycin or cipro
68
Q

What is the first-line antibiotic treatment for C.difficle infections:

A
69
Q

What type of bacteria is C.difficle?

A

Gram positive bacillus,
Obligate anaerobes (do not require O2 to grow)

70
Q

Does C.difficle produce toxins and if so what toxins?

A

Yes - it produces 2 toxins (A & B). A is more potent than B

Toxins are responsible for the manifestation of CDI

71
Q

What route is C.difficle spread

A

Oral - faecal route

72
Q

Describe the process by which C.difficle is spread

A

A patient may contract CDI under the right conditions. There should be an alteration of GUT flora (e.g. by antibiotic use - see later) and then the patient should be exposed to CDI (e.g. via contaminated environment//hands) from a contaminated HCW.

Once infected patients may be asymptomatic or have C.difficle associated diarrhoea (CDAD).

Antibiotics kill the infective bacteria and good bacteria required for normal digestion. This allows the chance for CDI to grow and germinate in the GUT. Specific antimicrobials are needed for CDI.

73
Q

True or False - CDI spores are killed by alcohol wipes?

A

NO! Water and soap is needed!!

74
Q

Signs and Symptoms of CDI

A

diarrhoea
Abdominal cramping/ pain
Nausea
High temperature
Increased WWC
Loss of appetite
Feeling Sick
Stomach ache

75
Q

How long do symptoms of CDI tend to last?

How long are patients infective for and what should they do?

A

Diarrhoea due to C. difficile infection should resolve in 1–2 weeks. The person will remain infectious whilst they still have symptoms and they should stay away from work or school until they have been free from diarrhoea for 48 hours.

76
Q

What are risk factors for CDI?

A
  1. Increased age (>65)
  2. Frailty
  3. Previous history of C.difficle infection
  4. Exposure to other cases
  5. Concomitant use of PPI or other acid supressing drug
  6. Underlying co-morbidity (e.g. abdominal surgery, chronic renal disease, IBD, immunosupression)
  7. Antibiotic use (allows C.difficle to flourish by supressing normal bowel microbiota. Almost all drugs with antibacterial activity have been implicated with antibiotic-associated diarrhoea
  8. Prolonged hospitalisation or residence in nursing home

Infection risk increases with longer duration of antibacterial treatment, concurrent use of multiple antibacterials, or multiple antibacterial courses

77
Q

What medicines are associated with CDI infection?

A

Co-amox, Cephlasporins, ciprofloxacin (quinolones) and Clindamycin.

PPIs are also associated

78
Q

What are possible complications of CDI?

A

Pseudomembranous colitis, toxic megacolon, perforation of the colon, sepsis, death

79
Q

How do you test for CDI infections?

What other tests should be done?

A

Stool Sample

Also check:- FBC and Cr to determine severity of infection

80
Q

What abx should be used in C.difficle infections?

A

for CDI

A
https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2060/documents/2_algorithm1.pdf

https://www.nice.org.uk/guidance/ng199/resources/clostridioides-difficile-infection-antimicrobial-prescribing-pdf-66142090546117

Severity of Clostridium difficile infection can be defined as [Public Health England, 2013]:

Mild: not associated with an increased white cell count (WCC). It is typically associated with less than three episodes of loose stools (defined as loose enough to take the shape of the container used to sample it) per day.

Moderate: associated with an increased WCC (but less than 15 x 109/L) and typically associated with 3–5 loose stools per day.

Severe: associated with a WCC greater than 15 x 109/L, or an acutely increased serum creatinine concentration (that is, greater than 50% increase above baseline), or a temperature higher than 38.5°C, or evidence of severe colitis (abdominal or radiological signs). The number of stools may be a less reliable indicator of severity.

Life-threatening: signs and symptoms include hypotension, partial or complete ileus, toxic megacolon, or computerised tomography (CT) evidence of severe disease.

81
Q

What is bacterial vaginosis? What are common causative agents?

A

A bacterial infection of the vagina. Usually caused by overgrowth of naturally occurring bacteria such as gardnerella vaginalis or anaerobic bacteria such as mobiuncuis or prevotella

82
Q

What are symptoms of bacterial vaginosis?

A
  • thin fishy smelly discharge which is grey/white (esp after sex)
  • burning when peeing but not during sec
  • no itching/ soreness or redness
83
Q

What is the treatment for bacterial vaginosis?

A

either:

Oral metronidazole:
- 400-500mg BD for 5-7 days OR
- 2g for one dose

Vaginal gel metronidazole:
- 1 applicator full for 5 days (at night)

84
Q

Symptoms of chlamydia infection

A
  • Dysuria
  • Discharge from vagina, penis or rectum
  • Swelling testicles in men possible
  • Pain in tummy
  • Bleeding after sex and between periods
85
Q

Treatment for chlamydia infection

A

Contact tracing recommended.

Azithromycin:
- 1g as single dose followed by 500mg OD for 2 days (total duration 3 days)

OR

Doxycycline:
- 100mg BD for 7 days

Alternatively, erythromycin:
- 500mg BD for 14 days

86
Q

Gonorrhoea symptoms

A
  • Can be asymptomatic
  • Thin green/yellow discharge
  • In men foreskin can be inflamed
  • Dysuria
  • Sore throat
  • Sharp pain/tenderness in lower abdomen
  • Fever
87
Q

Gonorrhoea treatment

A

Contact tracing and test of cure following treatment are recommended. Consider chlamydia co-infection. Treatment is only recommended for those presenting within 14 days of exposure, or those presenting 14 days after exposure with a positive test. Sexual intercourse should be avoided until 7 days after patients and their partner(s) have completed treatment. Choice of alternative antibacterial regimen depends on locality where infection is acquired.

First line:
- If antimicrobial susceptibility unknown: intramuscular ceftriaxone.
- If micro-organism is sensitive to ciprofloxacin: oral ciprofloxacin.

Alternatives due to allergy, needle phobia or contra-indications:
- Intramuscular gentamicin plus oral azithromycin.
- If parenteral administration is not possible: oral cefixime [unlicensed] plus oral azithromycin.
- In non-pharyngeal infections: intramuscular spectinomycin [unlicensed] plus oral azithromycin.
If unable to take standard therapy: oral azithromycin.

88
Q

Tichomniasis symptoms

A

Tichomniasis:
* Yellow/green frothy discharge
* Soreness, inflammation and itch
* Inner thigh can be itchy
* Pain during sex and when peeing
In men – more whitish discharge and increased frequency of urination and pain during urination and ejaculation

89
Q

Tichomniasis treatment

A

Metronidazole oral:
200 mg 3 times a day for 7 days
400–500 mg twice daily for 5–7 days
alternatively 2 g for 1 dose.

90
Q

What is syphillus?

A

An STD
Symptoms of syphilis include small sores around your genitals or bottom, a rash (usually on your hands or feet) and white patches in your mouth.
Syphilis is treated with an antibiotic injection or antibiotic tablets.

91
Q

Treatment of syphilis?

A

Typically:

first-line: benathine benzylpenicillin

Alternative: doxycyline (or erythromycin in preg)

92
Q

musculoskeletal and skin infections treatment generally

A

Generally first-line: flucloxacillin. (if near eyes co-amox)

Unsuitable: clarithromycin, erythromycin (preg) or doxycycline

Severe: co-amox

93
Q

What is Lyme disease

A

Lyme disease, also known as Lyme borreliosis, is an infection caused by bacteria called Borrelia burgdorferi. It is transmitted to humans by the bite of an infected tick. Ticks are mainly found in grassy and wooded areas including urban gardens and parks. Most tick bites do not cause Lyme disease, and the prompt and correct removal of the tick reduces the risk of infection.

94
Q

What are symptoms of lyme disease and when do they typically show?

A

Lyme disease usually presents with a characteristic erythema migrans rash. This usually becomes visible 1–4 weeks after a tick bite, but can appear from 3 days to 3 months, and last for several weeks. It may be accompanied by non-focal (non-organ related) symptoms, such as fever, swollen glands, malaise, fatigue, neck pain or stiffness, joint or muscle pain, headache, cognitive impairment, or paraesthesia.

Other signs and symptoms of Lyme disease may also appear months or years after the initial infection and are typically characterised by focal symptoms (relating to at least 1 organ system). These include neurological (affecting cranial nerves, peripheral and central nervous systems), joint (Lyme arthritis), cardiac (Lyme carditis), or skin (acrodermatitis chronica atrophicans) manifestations.

95
Q

First-line treatment for lyme disease?

What if this is unsuitable?

A

In patients presenting with erythema migrans rash with or without non-focal symptoms:

  1. oral doxycycline [unlicensed indication] is recommended as first-line treatment. (200mg in 1-2 divided doses for 21 days)
  2. If doxycycline cannot be given, oral amoxicillin should be used as an alternative. (1g TDS for 21 days)
  3. Oral azithromycin [unlicensed indication] should be given if both doxycycline and amoxicillin are unsuitable. (500mg OD for 17 days)

In patients presenting with symptoms of central nervous system involvement:

  1. intravenous ceftriaxone is recommended as first-line treatment.
  2. Oral doxycycline [unlicensed indication] should be used as an alternative if ceftriaxone cannot be given, or when switching to oral antibacterial treatment.
96
Q

What else should be considered/ given to patients after a human or animal bite?

A

Patients with a human or an animal bite should be assessed for their risk of tetanus, rabies, or a blood-borne viral infection (such as HIV, and hepatitis B and C), and should be managed accordingly. For guidance on the management of tetanus- and rabies-prone wounds, see Tetanus vaccine or Rabies vaccine.

97
Q

What antibiotics are used for human / animal bites?

A

For bites from a human, cat, dog, or other traditional pet, offer oral antibacterials to patients who are able to take medication orally and the severity of their condition does not require intravenous antibacterials.

Oral first line:
Co-amoxiclav.

Alternative in penicillin allergy or co-amoxiclav unsuitable: doxycycline with metronidazole; seek specialist advice in pregnancy.

Intravenous first line:
Co-amoxiclav.

Alternative in penicillin allergy or co-amoxiclav unsuitable: cefuroxime or ceftriaxone, with metronidazole; seek specialist advice if a cephalosporin is not appropriate.

98
Q

What is TB?

A

Tuberculosis is a curable infectious disease caused by bacteria of the Mycobacterium tuberculosis complex (M. tuberculosis, M. africanum, M. bovis or M. microti) and is spread by breathing in infected respiratory droplets from a person with infectious tuberculosis. The most common form of tuberculosis infection is in the lungs (pulmonary) but infection can also spread and develop in other parts of the body (extrapulmonary).

The initial infection with tuberculosis clears in the majority of individuals. However, in some cases the bacteria may become dormant and remain in the body with no symptoms (latent tuberculosis) or progress to being symptomatic (active tuberculosis) over the following weeks or months. In individuals with latent tuberculosis only a small proportion will develop active tuberculosis.

Many cases of tuberculosis can be prevented by public health measures and when clinical disease does occur most individuals can be cured if treated properly with the correct dose, combination and duration of treatment. Drug-resistant strains of tuberculosis are much harder to treat and significantly increase an individual’s risk of long-term complications or death.

99
Q

What infective agents can cause TB?

A

Mycobacterium tuberculosis complex (M. tuberculosis, M. africanum, M. bovis or M. microti)

100
Q

How many treatment phases is there for TB?
What are these phases referred to as?

A

The standard treatment of active tuberculosis is completed in two phases—an initial phase using four drugs and a continuation phase using two drugs, in fully sensitive cases.

101
Q

True or False you can get a supervised or unsupervised TB treatment regiemen?

A

Within the UK there are two regimens recommended for the treatment of tuberculosis: unsupervised or supervised. The choice of either regimen is dependent on a risk assessment to identify if an individual needs enhanced case management.

In all phases of treatment for tuberculosis, fixed-dose combination tablets should be used, and a daily dosing schedule should be offered in active pulmonary tuberculosis and considered as first choice in active extrapulmonary tuberculosis.

Unsupervised treatment:

The unsupervised treatment regimen is for individuals who are likely to take antituberculosis drugs reliably and willingly without supervision.

Supervised treatment:

For individuals requiring supervised treatment (directly observed therapy, DOT), this is offered as part of enhanced case management. Daily supervised treatment is the preferred option wherever feasible. A 3 times weekly dosing schedule can be considered in individuals with tuberculosis if they require enhanced case management and daily directly observed therapy is not available. Antituberculosis treatment dosing regimens of fewer than 3 times a week are not recommended.

Directly observed therapy should be offered to individuals who:

have a current risk or history of non-adherence;
have previously been treated for tuberculosis;
have a history of homelessness, drug or alcohol misuse;
are in prison or a young offender institution, or have been in the past 5 years;
have a major psychiatric, memory or cognitive disorder;
are in denial of the tuberculosis diagnosis;
have multi-drug resistant tuberculosis;
request directly observed therapy after discussion with the clinical team;
are too ill to self-administer treatment.

102
Q

What is the initial treatment phase for TB?

A

As standard treatment for individuals with active tuberculosis, offer rifampicin, ethambutol hydrochloride, pyrazinamide and isoniazid (with pyridoxine hydrochloride) in the initial phase of therapy; modified according to drug susceptibility testing; and continued for 2 months.

Treatment should be started without waiting for culture results if clinical signs and symptoms are consistent with a tuberculosis diagnosis; consider completing the standard treatment even if subsequent culture results are negative.

103
Q

What does the continuation treatment of TB involve?

A

After the initial phase, offer standard continuation treatment with rifampicin and isoniazid (with pyridoxine hydrochloride) for a further 4 months in individuals with active tuberculosis without central nervous system involvement. Longer treatment for 10 months should be offered in individuals with active tuberculosis of the central nervous system, with or without spinal involvement.

Treatment should be modified according to drug susceptibility testing.

104
Q

How long should TB treatment be if you are HIV positive?

A

For individuals who are HIV-positive with active TB, treatment with the standard regimen should not routinely exceed 6 months, unless the tuberculosis has central nervous system involvement, in which case treatment should not routinely extend beyond 12 months.

105
Q

What is the treatment for CNS TB?

A

Individuals with central nervous system tuberculosis should be offered standard treatment with initial phase drugs for 2 months (see Initial phase for specific drugs). After completion of the initial treatment phase, standard treatment with continuation phase drugs should then be offered (see Continuation phase for specific drugs); and continued for a further 10 months. Treatment for tuberculous meningitis should be offered if clinical signs and other laboratory findings are consistent with the diagnosis, even if a rapid diagnostic test is negative.

An initial high dose of dexamethasone or prednisolone should be offered at the same time as antituberculosis treatment, then slowly withdrawn over 4–8 weeks. For additional information on corticosteroid use, see NICE clinical guideline: Tuberculosis (see Useful resources).

Referral for surgery should only be considered in individuals who have raised intracranial pressure; or have spinal TB with spinal instability or evidence of spinal cord compression.

106
Q

What is the treatment for Pericardial tuberculosis?

A

An initial high dose of oral prednisolone should be offered to individuals with active pericardial tuberculosis, at the same time as antituberculosis treatment, then slowly withdrawn over 2–3 weeks. For additional information on corticosteroid use, see NICE clinical guideline: Tuberculosis (see Useful resources).

107
Q

What is the treatment for malaria cause by P. falciparum

A
108
Q

What is the treatment for malaria caused by P. falciparum
in pregnancy?

A

Uncomplicated falciparum malaria in the second and third trimesters of pregnancy should be treated with Riamet (artemether with lumefantrine). Quinine with (or followed by) clindamycin [unlicensed indication] can be used in all trimesters. Quinine can increase the risk of uterine contractions and hypoglycemia.

109
Q

What is the treatment for Hep B?

A

Entecavir, peginterferon alfa, tenofovir alafenamide, and tenofovir disoproxil are options for the treatment of chronic hepatitis B infection.

Entecavir and tenofovir disoproxil can be used in patients with decompensated liver disease.

Other drugs licensed for the treatment of chronic hepatitis B infection include adefovir dipivoxil and lamivudine.

If drug-resistance emerges during treatment, consider switching to, or adding another antiviral drug to which the virus is sensitive; ensure the antiviral drug does not share cross-resistance. Hepatitis B viruses with reduced susceptibility to lamivudine have emerged following extended therapy.

Duration of treatment is dependent on several factors including response (e.g. viral suppression, antigen loss, seroconversion), patient characteristics (e.g. liver disease), and treatment tolerability. Treatment is usually continued long-term in patients with decompensated liver disease.

Brainscape:-

Peginterferon alpha Interferon alpha
Treatment with the above should be stopped if no improvement after 4 months
Entecavir
Tenofovir
Treatment should be changed to other antivirals if no improvement after 6-9 months

110
Q

What does HIV stand for?

A

Human Immunodeficiency virus

111
Q

What type of virus is HIV

A

Retrovirus

112
Q

How does HIV cause immunodeficiency?

A

immunodeficiency by infecting and destroying cells of the immune system, particularly the CD4 cells.

113
Q

What are CD4 cells

A

A type of white blood cell - in particular a T helper Cell

114
Q

HIV leads to AIDS (Acquired immune deficiency syndrome) - at what level do CD4 cells need to drop below for AIDs to occur?

What is the result of this?

A

Acquired immune deficiency syndrome (AIDS) occurs when the number of CD4 cells fall to below 200 cells/microlitre; opportunistic infections and malignancies (AIDS-defining illnesses) can develop

115
Q

What are the aims of treatment for AIDs?

A

Treatment aims to achieve an undetectable viral load, to preserve immune function, to reduce the mortality and morbidity associated with chronic HIV infection, and to reduce onward transmission of HIV, whilst minimising drug toxicity. Treatment with a combination of ART aims to improve the physical and psychological well-being of infected people.

116
Q

What patients should be given treatment for HIV after positive diagnosis?

A

All patients diagnosed as being HIV positive should be offered immediate treatment, irrespective of CD4 cell counts

117
Q

What can low commitment to HIV treatment lead to?

A

Commitment to, and strict adherence to treatment over many years is required. Low adherence can be associated with drug resistance, progression to AIDS, and death.

118
Q

What is the treatment for treatment naive HIV patients>

A

Treatment of HIV infection in treatment-naive patients is initiated with a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) as a backbone regimen plus one of the following as a third drug: an integrase inhibitor (INI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a boosted protease inhibitor (PI).

The regimen of choice contains a backbone of emtricitabine and either tenofovir disoproxil or tenofovir alafenamide. An alternative backbone regimen is abacavir and lamivudine. The third drug of choice is either atazanavir or darunavir both boosted with ritonavir, or dolutegravir, or elvitegravir boosted with cobicistat, or raltegravir, or rilpivirine. Efavirenz may be used as an alternative third drug.

Patients who require treatment for both HIV and chronic hepatitis B should be treated with antivirals active against both diseases as part of fully suppressive combination ART. Regimens of choice are tenofovir disoproxil and emtricitabine, or tenofovir alafenamide and emtricitabine. For further information see British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy available at https://www.bhiva.org/guidelines.

Kirsty FTY (18 decks)

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