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Infectious Disases Flashcards

1
Q

Preventive measures for contact infectious

A

Contact precaution

Barrier precaution

Safe needle/sharp practices

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2
Q

Example of droplet borne infections

A

Influenza

Mumps

N.meningitidis

Bordetella pertussis

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3
Q

Prevention of droplet borne diseases

A

Contact/droplet precaution

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4
Q

Droplet borne range

A

Up to 2 meters

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5
Q

Airborne infections examples

A

TB
VZV
measles

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6
Q

Preventive measures for airborne diseases

A

Airborne precaution

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7
Q

Preventive measures for food/water borne infections

A

Vaccination where available

Clean food/water supply

Contact precautions

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8
Q

Preventive measures for zoonotic infections

A

Prophylactic meds

Vaccination

Protective clothing

Repellents

Mosquito nets

Tick inspection

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9
Q

Preventive measures for vertical infections

A

Prenatal screening

Prophylactic treatment

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10
Q

Definition of nosocomial infections

A

Acquired more than 48 h after admission

Or

Within 30 days from discharge

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11
Q

RFs for nosocomial infection

A

Prolonged hospital stay

AB use

Hemodialysis

Intensive care

Colonization with a resistant organism

Immunodeficiency

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12
Q

Common nosocomial infectious agents

A

MRSA

VRE

C.difficile

Extended spectrum B-lactamase producing E.Coli, K.Pneumoniae

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13
Q

Inv for nosocomial MRSA

A

Admission screening culture from nares and peri-anal region (to identify colonization)

Culture of infected sites

CXR

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14
Q

Mx of MRSA nosocomial infection

A

Contact precaution

Vancomycin
Linezolid
Daptomycin

Decolonization:
2% chlorhexidine wash
+doxy/TMP-SMX/refampin x7d
+mupirocin bid to nares x7d

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15
Q

Inv for vancomycin resistant enterococcus

A

Rectal/perirectal swab Or Stool culture For colonization

Culture of infected site

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16
Q

Management of nosocomial VRE

A

Contact precautions

Ampicillin

Linezolid

Tigecycline

Daptomycice

No effective decolonization method

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17
Q

C. Difficile inv

A

Stool PCR for toxin A and B genes

Stool immunoassay for toxins A and B (less sensitive than PCR)

AXR

Sigmoidoscopy (avoid if known colonic dilatation)

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18
Q

Mx of nosocomial C. Difficile

A

Contact precautions

Stop culprit AB

IV fluid

Mild-mod: metronidazole, PO, x 10-14 d

Severe: vancomycin, PO, x 10-14 d

Toxic megacolon: metronidazole IV + Vancomycin PO + general surgery consult

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19
Q

Most common culprit ABs for C.difficile

A

Q

Cephalosporins

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20
Q

ESBL producing E.Coli, K. Pneumoniae inv

A

Blood/sputum/urine/aspirated fluid culture

Imaging at infected site: CXR, CT, U/S

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21
Q

Mx of ESBL producing

A

Carbapenems

Non-betalactams

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22
Q

The most common organisms in community-acquired pneumonia

A 
Typical
S. Pneumoniae
M.catarrhalis
HI
S.aureus
GAS

Atypical:
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumophila

Viral:
Influenza virus
Adenovirus

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23
Q

The most common organisms in nosocomial pneumonia

A

Enteric GNB

Pseudomonas

S. Aureus

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24
Q

Aspiration

A

Oral anerobes

Enteric GNB

S. Aureus

Gastric contents

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25
Q

The most common organisms in pneumonia in ImmComp pts

A

P. Jiroveci

Fungi

Nocardia

CMV

HSV

TB

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26
Q

The most common organisms in pneumonia in alcoholic pt

A

Klebsiella

Enteric GNB

S. Aureus

Oral anaerobes

TB

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27
Q

As of klebsiella

A

Alcoholic

Aspiration

Abscess

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28
Q

Red currant jelly sputum

A

Klebsiella

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29
Q

Most common location for aspiration pneumonia

A

Right middle or lower lobes

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30
Q

Inv for pneumonia

A

Pulse oximetry, ABG

CBC, diff, Electrolytes

Urea, Cr, U/A

Troponin/CK,

LFT

Sputum Gram stain/C&S

Blood C&S

Serology/viral detection

Pleural fluid C&S

CXR, CT

Bronchoscopy, washing

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31
Q

Indication of pleural effusion assessment in pneumonia

A

If effusion > 5cm

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32
Q

Indication of bronchoscopy and washing in pneumonia

A

Severely ill pt refractory to Tx

ImmComp

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33
Q

Tx of pneumonia

A

ABC

O2

IV fluid

Salbutamol

Determining the need for hospitalization, and AB

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34
Q

CURB 65 score for pneumonia admission

A

Confusion: 1

Urea/BUN: > 7/20 : 1

RR > 30: 1

BP > 90/60 : 1

Age > 65 : 1

If 2: hospitalize
If 4: ICU

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35
Q

AB for CAP
outpatient
No comorbidity
No AB within last 3 mo

A

Macrolide
Or
Doxy

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36
Q 
AB for CAP
Outpatient
With comorbidity
Or
AB within last 3 mo
A

Respiratory Q (moxi, gemi, levo)

Or

B-lactam (cefotax, ceftria, ampi-bactam)+ Macrolide

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37
Q

AB for CAP
Inpatient
Ward

A

Respiratory Q

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38
Q

AB for CAP
Inpatient
ICU

A

B-lactam + macrolide
Or
B-lactam+ Q

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39
Q

Tx of HAP
No increased likelihood if MRSA
No hogh risk of mortality

A 
Piperacillin-tazobactam
Or
Cefepime
Or
Levo
Or
Imipenem
Or
Meropenem
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40
Q

Tx of HAP
With increased likelihood of MRSA
Not at high risk of mortality

A 
Piperacillin-tazobactam
Or
Cefepime
Or
Ceftazidime
Or
Levo
Or
Cipro
Or
Imipenem
Or
Meropenem
Or
Aztreonam

PLUS
Vancomycin
Or
Linezolid

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41
Q

If HAP
with high risk of mortality
Or
Recipient of IV AB within last 3 mo

A 
Two of (avoid 2 Beta)
Piperacillin-tazobactam
Or
Cefepime
Or
Ceftazidime
Or
Levo
Or
Cipro
Or
Imipenem
Or
Meropenem
Or
Aztreonam
Or amika/genta/tubra

PLUS
MRSA: vanco Or linezolid
Or MSSA: piperacillin-tazobactam, cefepime, levo, imipenem, meropenem

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42
Q

Tx of VAP

A

Double anti pseudomonas/gram negative coverage + MRSA coverage

Piperacillin-tazobactam
Or
Cefepime
Or
Ceftazidime
Or
Imipenem
Or 
Meropenem
Or
Aztreonam
PLUS
Cipro
Or
Levo
Or
Amika/genta/tubra
Or
Polymyxin (colistin or polymyxin B)

PLUS
Vanco
Or
Linezolid

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43
Q

High risk of mortality in pneumonia:

A

Need for ventilatory support

Septic shock

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44
Q

Indications for S. Aureus coverage in pneumonia

A

IV AB Tx within 3 mo

Prevalence of MRSA > 20% or unknown

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45
Q

Summary of HAP/VAP Tx

A

If HAP: 1 anti gram negative/pseudomonas

If HAP + Risk of MRSA:
1 anti-pseudomonas/gram neg + 1 anti-MRSA

If HAP + High risk for mortality:
2 anti pseudo/gram negative + 1 anti-MRSA/MSSA (depending on risk)

If VAP:
2 anti-pseudomonas/gram negative + 1 anti-MRSA

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46
Q

Pneumonia prevention

A

Influenza A and B vaccine:
Annually, for all ages 6 mo and higher

PPSV (pneumovax):
All > 65
2-65 yr: if high risk of invasive pneumococcal disease (asplenia, Immdef…)

PCV (prevnar):
All < 5 yr
5-17 yr: if high risk for invasive pneumococcal disease and who have not received prevnar before.
CDC: adults at high risk for invasive pneumococcal disease

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47
Q

Seasonal influenza is the result of:

A

= epidemic

New subtypes due to antigenic drift (point mutations)

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48
Q

Pandemic influenza is the result of

A 
Antigenic shift
(Mixing of two different viral strains from different hosts= new strain)

Only with type A

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49
Q

Transmission of influenza

A

Droplet

Possible airborne

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50
Q

Influenza incubation period

A

1-4 d

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51
Q

Influenza course

A

7-10 d

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52
Q

Dx if influenza

A

Clinical

Gold: RT-PCR of nasopharyngeal swab

Rapid Ag detection: DFA

Serology: rarely

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53
Q

Tx of influenza

A

Supportive

If severe/ high-risk of complication:
Zanamivir (Tx and Px against flu A and B)
Oseltamivir (Tx and Px against flu A and B)

If Tx within 48 h: decreased duration and severity

Tx beyond 48 h: in ImSup and critically ill pts

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54
Q

RF of cellulitis with G-, fungi

A

Water exposure

ImComp

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55
Q

RF for cellulitis

A 
Trauma
Surgery
PVD
Lymphedema
DM
Cracked skin
Tinea pedis
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56
Q

Inv for cellulitis

A

CBC, diff

Blood C&S if febrile

Skin swab if open wound with pus

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57
Q

Tx of cellulitis

A

Cephalexin

G- coverage if RFs present

IV cefazolin if:
Extensive erythema
Systemic symptoms

Consider MRSA coverage

Limb rest and elevation

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58
Q

Necrotizing fasciitis types

A

Type I:
Polymicrobial

Type II:
Monomicrobial with GAS&raquo_space;S. Aureus

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59
Q

Inv for necrotizing fasciitis

A

DO NOT WAIT FOR RESULTS BEDORE STARTING Tx

Clinical/surgical Dx

Blood/tissue C&S

Serum CK

Plain Xray

Surgical exploration

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60
Q

Tx of necrotizing fasciitis

A

IV Fluids

Emergency debridement

IV AB:
Meropenem OR piperacillin/tazobactam
+ clindamycin IV
+ vancomycin (if MRSA considered)

If Type I: piperacillin/tazobactam + clinda IV

If Type II: cefazolin (or cloxacillin) + clinda
If Confirmed GAS: penicillin G + clinda
AND: evaluate for streptococcal TSS (IVIg)

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61
Q

Diarrhea definition

A

3 or more loose/liquid stool/d
Or
> 200 g/d for >2/d

Acute: >2 d but < 14 d

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62
Q

Purpose of evaluation of acute diarrhea

A

Identifying characteristics of the illness or patient that warrants further investigation

Assessing volume status for appropriate method of rehydration

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63
Q

Tx of diarrhea

A

Mainstay:
Hydration: oral, IV if oral insufficient

Antidiarrheal agents (loperamide, bismuth):
Contraindications: 
Fever
Bloody stool
C. Difficile

AB: rarely indicated

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64
Q

Risks of AB in diarrhea

A

No effect for viral (most common cause)

Eradication of normal flora, predisposing to C. Difficile

Prolongs shedding of Salmonella and other bacteria

HUS if EHEC

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65
Q

Indications for investigations in acute diarrhea

A

Fever

Blood in stool

Severe abdominal pain +/- peritoneal signs

Profuse diarrhea with signs of hypovolemia

Hospitalized or recent use of antibiotics

Age 65 or higher with comorbidities

Immunocompromised

Diarrhea more than 7 days duration

Exposure to suspicious foods or untreated water

Sexual contacts: MSM

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66
Q

Investigations for acute diarrheazg

A

Stool for leukocyte

Stool C&S for: Salmonella, Shigella, Campylobacter

Special tests:

If blood in stool:
Stool C&S for EHEC
Stool for shiga toxin

If recent AB/hospitalization/>65+comorbidities/ImSup:
Stool for C. Difficile toxins A and B

If diarrhea >7d, exposure to untreated water, HIV, MSM:
Stool O&P for giardia/cryptospordium/E.histolytica

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67
Q

If there are no indications for further investigation in acute diarrhea what’s next step

A

Rehydration

Anti-diarrheal agents

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68
Q

Indications for antimicrobial therapy for acute diarrhea

A 
Absolute indications:
S. Typhi
Shigella
C. Difficile
Cryptospordium
E. Histolytica
ImmComp pts

Relative indications:
V.cholerae
Non-typhoid salmonella
Campylobacter
Yersinia
Giardia
ETEC
(Based on severity of illness)
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69
Q

B. Cereus types

A 
Type A: 
Emetic, no fever, no pain, no blood
Rice dishes. Preformed exotoxin
Inc: 1-6 h
Dur: <12 h

Type B:
Diarrhea, no other Sx
Meat, veg, dried beans, cereal. 2° endotoxin
Inc: 8-16 h
Dur: <24
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70
Q

Campylobacter jejuni

A

Most common bacterial cause of diarrhea in Canada

Uncooked meat
Especially poultry

Inc: 2-10d

Fever, diarrhea, bloody stool, abdominal pain, N/V

Dur: < 1wk

AB:
Macrolide
Quinolone
If: >1wk, bloody, ImComp

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71
Q

C. Difficile

A

Can be present in colon in small numbers

+/-Fever, pain, bloody diarrhea

Tx:
Stop culprit

AB

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72
Q

C. Perfringens

A

Meat, poultry

Inc: 8-12 h

Diarrhea, fever, abdominal pain

Dur < 24 h

Heat resistant spores
2° enterotoxin
Enteroinvasive

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73
Q

EIEC

A

Food/water

Inc: 1-3 d

Fever, bloody stool, diarrhea, abd pain

Dur: 7-10d

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74
Q

ETEC

A

Food/water, travel

Inc: 1-3 d

Diarrhea, abd pain

Dur: 3 d

If mod-severe:
Q
Azithro

Heat liable and heat stable toxins

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75
Q

EHEC

A

Hamburger
Raw milk
Drinking/recreational water

Inc: 3-8 d

Diarrhea, blood, pain, N/V

Dur: 5-10

NO AB, NO ANTIDIARRHEA (increase HUS)

Shiga toxin
Monitor renal function

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76
Q

Salmonella Typhi/paratyphi

A

Fecal-oral

Food, water, travel

Inc: 10-14 d

Diarrhea, fever, blood, pain, N/V

Dur: <5-7 d

Tx:
Ceftriaxone, cipro, azithro

Rose spot, fever, abd pain precede diarrhea in S. Typhi

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77
Q

Non-typhoid salmonella

A

Egg, poultry, meat, milk

Inc: 12-72 h

Diarrhea, fever, blood, pain, N/V

Dur: 3-7 d

Tx: Q:
If severe, extremes of age, joint prostheses, valvular heart disease, severe atherosclerosis, cancer, uremia

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78
Q

Shigella

A

Fecal-oral

Food/water

Inc: 1-4 d

Diarrhea, fever, blood, pain, N/V

Dur:< 1wk

Tx:
Q

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79
Q

S. Aureus

A

Unrefrigerated meat/dairy products (custard, pudding, potato salad, mayo)

Inc: 2-4 h

Diarrheal, pain, N/V

Dur: 1-2 d

Heat-stable preformed exotoxin

Tx: none

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80
Q

Vibrio cholerae

A

Food/water, shellfish

Diarrhea

Inc: 1-3 d

Dur: 3-7 d

Tx:
Q, tetra

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81
Q

Yersinia

A

Food, milk

Incu: 5 d

Diarrhea, fever, pain, N/V, blood

Dur: up to 3 wk

If severe: Q

Mainly children

Mesenteric adenitis, terminal ileitis mimicking appendicitis

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82
Q

Cryptospordium

A

Fecal-oral

Inc: 7 d

Diarrhea, fever, N/V

Dur: 1-20 d

Tx: Paromomycin + nitazoxanide

Immune reconstitution if ImSup

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83
Q

Entamoeba histolytica

A

Fecal-oral

Inc: 2-4 wk

Diarrhea, fever, blood, N/V

Tx:
Metro + iodoquinol/paromomycin

If asymptomatic cyst passage:
Iodoquinol/paromomycin

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84
Q

Giardia

A

Food/water, fecal-oral

Inc: 1-4 w

Diarrhea, pain, N/V

Tx:
Metro, nitazoxanide
Asymptomatic carrier: none

Daycare children
Untreated water
MSM
ImDef 
May need duodenal Bx
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85
Q

Diarrhea causing Guillain-Barré

A

Campylo

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86
Q

Dysentery agent mimicking appendicitis

A

Yesinia

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87
Q

Diarrheal agent causing liver abscess

A

E. Histolytica

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88
Q

E. Histolytica sigmoidoscopy

A

Flat ulcers with yellow exudates

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89
Q

Beaver fever

A

Giardia

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90
Q

Diarrhea in pts with decreased IgA

A

Giardia

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91
Q

Norovirus (norwalk)

A

Fecal-oral

Inc: 24h

Diarrhea, pain, N/V

Dur: 24 h

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92
Q

Rotavirus

A

Fecal-oral

Inc: 2-4 d

Diarrhea, fever, N/V

Dur: 3-8 d

All children infected by 3 yr of age

Oral vaccine: at 2-4 mo

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93
Q

Most common traveller diarrhea agent in southeast Asia

A

Campylo

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94
Q

Tx of traveller diarrhea

A

Rehydration:
Sealed beverages
Oral rehydration solution if severe (1 package in 1 litre boiled/treated water)

Loperamide, bismuth

AB if mod-sev: cipro, azithro, rifaximin

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95
Q

Prevention from traveller diarrhea

A 
Proper hygiene practices:
Avoid unhygienic food/beverage
Avoid raw fruits, vegetables without peel
Avoid raw/undercooked meat/seafood
Avoid untreated water

Bismuth

Vaccine

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96
Q

Antidiarrheal agent, causing stool be mistaken for melena

A

Bismuth

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97
Q

Dukorel

A

Oral vaccine against:
V. Cholerae
ETEC

Indications:
Short-term travellers, >2yr, who are high-risk (chronic illness): CRF, CHF, DM1, IBD

ImSup

Hx of repeat traveller diarrhea

Increased risk of acquiring traveller diarrhea:
Hypochlorhydria, young children > 2yr

Cholera endemic area

Vaccine against S. Typhi available

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98
Q

Septic arthritis RFs

A

N. Gonorrhea:
Previously 75% of cases in young sexually active adults

S. Aureus:
All ages. Most non-gono cases

GAS, GBS

G- :
Neonates, elderly, IV drug, ImComp

S. Pneumoniae:
Children

Kingella kingae:
Children <4 yr

HIB:
Unvaccinated children

Salmonella:
SCA

Coagulase - staph:
Prosthetic joints

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99
Q

RFs for gonococcal septic arthritis

A

<40

Multiple partners

Unprotected intercourse

MSM

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100
Q

Rf for non-gono arthritis

A

Most affected children: No R

Bacteremia

Prosthetic joint

Recent joint surgery

Underlying joint disease

ImmComp

Loss of skin integrity

Age > 80

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101
Q

Gonococcal arthritis forms

A

Bacteremic form:

Fever, malaise, chills

Migratory polyarthralgias, tenosynovitis next to inflammed joint, pustular dermatitis

Septic arthritis form:

Local symptoms in involved joint.

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102
Q

Most common involved joins in non-gonococcal arthritis

A

Most often large, Wt-bearing joints

Wrists

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103
Q

RFs for polyarticular septic arthritis

A

RA

GBS

Endocarditis

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104
Q

Inv for septic arthritis

A

Gono:
Blood C&S
Endocervical/urethral/rectal/oropharyngeal testing

Non-gono:
Blood C&S

For all:
Arthrocentesis: CBC, diff, Gram, Crystals
Xray

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105
Q

Joint fluid in infectious arthritis

A

Opaque

WBC > 15000

PMN > 90%

Positive culture

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106
Q

Positive culture in gono septic arthritis

A

<50%

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107
Q

Empiric treatment for septic arthritis in adults

A

Ceftriaxone + vancomycin

Daily joint aspirations until sterile culture

Physiotherapy

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108
Q

Empiric treatment for septic arthritis in children

A

Cefazolin or cloxacillin IV, unless MRSA considered

Daily joint aspirations until sterile culture

Physiotherapy

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109
Q

If culture result is gono in septic arthritis, AB modification?

A

Change to Ceftriaxone + azithro

Responds well after 24-48 h

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110
Q

Duration of AB therapy in septic arthritis

A

Staph: 4 wk

Strep: 2-3 wk

GNB: 4 wk

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111
Q

Indications for surgical joint drainage in septic arthritis

A

Persistent positive culture on repeat arthrocentesis

Hip joint involvement

Prosthetic joint involvement

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112
Q

Diabetic foot ulcer infection organisms

A

Mild cases:
S. Aureus
Strep

Mod-sev cases:
Polymicrobial (aerobe, GNB, anaerobe)

Mild: no bone/joint involvement
Mod: bone/joint
Sev: systemic toxicity

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113
Q

When to consider infection in a diabetic ulcer?

A

Positive probe to bone

Ulcer > 30 d

Recurrent ulcers

Trauma

PVD

Prior amputation

Loss of protective sensation

Renal disease

Hx of walking barefoot

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114
Q

Dx of infected ulcer in diabetic foot

A

2 or more of cardinal signs of infection

Or

Presence of pus

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115
Q

Inv for diabetic ulcer

A

Curettage specimen from ulcer base

Aspirate from an abscess

Bone Bx

Blood C&S if fever

Xray or MRI to assess osteomyelitis

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116
Q

Negative initial Xray in diabetic foot ulcer. Next step?

A

Repeat 2-4 wk later

If high suspicion: MRI

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117
Q

Tx of diabetic foot ulcer

A

Early surgical debridement

Revascularization

Amputation

Eliminate/reduce pressure

Local wound care

AB:
Mild: cephalexin, clinda PO

Moderate:
Clinda + cipro/moxi/cftriaxone/ertapenem IV
+/- MRSA

Severe:
Piperacillin/tazobactam or meropenem
+/- vanco for MRSA

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118
Q

Clinical/paraclinical finding in favor of associated osteomyelitis in diabetic foot ulcer

A

Visualization of bone

Ulcer area > 2cm (and erythema > 2cm)

Probe-to-bone

Clinical judgment

ESR > 70

Plain radiographs findings

MRI findings

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119
Q

high-risk RFs for endocarditis

A

Prosthetic cardiac valve

Previous IE

Congenital heart disease (unrepaired, repaired within six months, repaired with defects)

Cardiac transplant with valve disease

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120
Q

Moderate-risk RFs for infective endocarsitis

A

Other congenital cardiac defects

Acquired valvular dysfunction

Hypertrophic CMP

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121
Q

Low/no-risk RFs for Infective endocarditis

A

Secundum ASD or Surgically repaired ASD < VSD, PDA, MV prolapse, IHD, Previous CABG

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122
Q

Non-cardiac RFs for infective endocarditis

A

IVDU

indwelling venous cath

Hemodialysis

Poor dentition

DM

HIV

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123
Q

Frequency of valve involvement in IE

A

MV»AV>TV>PV

In IVDU:
TV in 50%

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124
Q

IE etiology in native valve

A

Strep viridans>
S. Aureus
Entrococcus

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125
Q

IE etiology in IVDU

A

S. Aureus»>
Strep
Enterococcus

If using tap water to dilute drug: pseudomonas
Saliva: oral flora
Toilet water: GI flora

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126
Q

IE etiology in prosthetic valve

A

<2 mo surgery:
S.aureus>
S. epid

> 2mo:
Strep
S. Aureus
S. Epi
Enterococ
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127
Q

IE etiology in association with underlying cirrhosis

A

S. Bovis (gallolyticus)

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128
Q

IE etiology in association with underlying GI malignancy

A

S. Bovis

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129
Q

Culture negative IE etiologies

A

HACEK

Hemophilus parainfluenza

Aggregatibacter

Cardiobacterium

Eikenella

Kingella

Coxiella

Bartonella

Tropheryma whipplei

Fungi

Mycobacteria

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130
Q

Clubbing in IE

A

In subacute type

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131
Q

Immune complex lesions of IE

A

Osler
Roth
GN
Arthritis

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132
Q

Embolic/vascular lesions of IE

A 
Petechia over legs
Splinter hemorrhage
Janeway
FND
H/A
Splenomegaly (subacute)
Microscopic hematuria
Flank pain
Active sediment
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133
Q

Major Duke criteria for IE

A 
1. Positive Blood culture
Typical MO+
2 separate B/Cs
Or persistently positive B/C (>12h apart)
Or all 3 B/Cs positive
Or majority of > 3 B/Cs positive
Or single Coxiella positive
Or antiphase IgG titer > 1/800
  1. Evidence of endocardial involvement
    Echo: mass, abscess, new partial dehiscence
    Or new valvular regurgitation
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134
Q

Minor Duke criteria for IE

A

Predisposing condition

Fever 38

Vascular phenomena

Immunologic phenomena

Positive B/C not meeting criteria

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135
Q

Inv for IE

A

B/C:
3 sets, each containing one aerobic, one anaerobic sample
Collected from different sites
>1 h apart

Repeat B/C:
After 48-72 h of appropriate AB
At least x 2

CBC, diff
ESR
RF
BUN/Cr
U/A, urine C&amp;S
ECG
Echo: TEE if TTE not adequate/prosthetic valve/complicated IE
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136
Q

Dx of IE using Duke criteria

A 
Definite Dx:
2 major
Or
1 major + 3 minor
Or 
5 minor

Possible:
1 major + 1 minor
Or
3 minor

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137
Q

Tx of infective endocarditis

A

Wait for confirmation,

Treat empirically if pt is unstable (AFTER OBTAINING CULTURES)

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138
Q

1st line empiric AB for native valve IE

A

Vanco
+
Genta/ceftriaxone

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139
Q

1st line empiric AB for prosthetic valve IE

A 
Vanco
\+
Genta
\+
Cefepime
\+
Rifampin
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140
Q

IE prophylaxis indications

A 
High risk individuals:
Prosthetic valve
Previous IE
Cardiac transplantation valvuloparhy
Congenital heart disease...

Procedures:
Dental (bleeding)
Invasive respiratory tract procedures (incision, Bx)
Procedures on infected skin
Procedures on infected musculoskeletal tissue

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141
Q

AB for IE Px

A

Dental/respiratory:
Amoxi, single dose, 30-60 min prior

Skin/soft tissue:
Cephalexin, single dose, 30-60 min prior

Clinda if penicillin-allergic in both

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142
Q

Indications for surgical treatment of IE

A

Refractory CHF (MOST COMMON)

Abscess

Fungal

Valve perforation

Unstable prosthesis

2 or more major emboli

AB failure

Mycotic aneurysm

Staph on prosthesis valve

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143
Q

Adverse prognostic factors for IE

A

CHF

Prosthetic valve infection

Abscess

Embolization

Persistent bacteremia

Altered mental status

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144
Q

Highest mortality rates in IE

A

Prosthetic valve>

Non-IVDU S.aureus>

IVDU S. Aureus or Strep

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145
Q

Common organisms in meningitis

0-4 wk

A

GBS
E. Coli
Listeria
Klebsiella

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146
Q

Common organisms in meningitis

1-3 mo

A 
GBS
E. Coli
S. Pneumoniae
N. Meningitidis
HI
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147
Q

Common organisms in meningitis

> 3 mo

A

S. Pneumoniae
N. Meningitidis
Listeria if > 50 and comorbidities

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148
Q

Petechial rash location in meningococcal meningitis

A

Trunk

Lower extremities

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149
Q

Inv for meningitis

A

CBC, diff, Lytes

Blood C&S

CSF:
Opening pressure
Cell count, diff
Protein
Glucose
Gram, C&amp;S

Imaging:
CT, MRI, EEG, if FND

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150
Q

Further investigations for meningitis

A 
If viral etiology suspected:
WNV serology (summer, early fall)

PCR for: HSV, VZV, enteroviruses, if infant < 6m, parechoviruses

AFB, fungal C&S, cryptococcal Ag, if:
ImmComp, subacute, travel Hx, TB exposure

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151
Q

CSF WBC count in bacterial meningitis

A

500-10,000

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152
Q

CSF WBC in viral meningitis

A

10-500

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153
Q

Tx of bacterial meningitis

A

DO NOT DELAY AB FOR CT OR LP

<28 d:
Cefotaxime + ampicillin

1-3 mo:
Cefotaxime + vancomycin

> 3 mo:
Ceftriaxone + vancomycin + IV ampicillin if RFs for listeria

Dexa IV within 20 min prior to or with 1st dose of AB

Continue dexa if proven pneumococcal meningitis

Dexa not recommended for neonates

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154
Q

RFs for listeria

A

> 50 yr
ImComp
Alcoholism

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155
Q

Prevention of meningitis with vaccination

A

Immunization:
Children:
Vaccination: HIB, S. Pneumoniae (conjugate: Prevnar or Synflorix), N. Meningitisdis

Adults:
Vaccine: N. Meningitidis (if outbreak, epidemics, travel). S. Pneumoniae (Pneumovax, polysaccharide) if high risk

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156
Q

Post-exposure meningitis Px for HIB

A

For close contacts if:

They live with an inadequately immunized (<4y)
Or
They live with an ImComp child (<18yr)

“Rifampin”

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157
Q

Post-exposure meningitis Px for N. Meningitidis

A

Close or household contacts

Cipro
Rifampin
Ceftriaxone

Also meningococcal vaccine for post-exposure Px and outbreak control

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158
Q

Highest mortality rate among meningitis etiologies

A

Pneumococcal

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159
Q

Poor prognostic factors for meningitis

A

Extremes of age

Delay in Dx/Tx

Stupor/coma

Seizures

FND

Septic shock at presentation

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160
Q

Indication for pneumococcal polysaccharide vaccine (pneumovax)

A

> 65 yr

Can also give conjugate vaccine (polysaccharide 8 wk later than conjugate)

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161
Q

Indications for giving both polysaccharide and conjugate pneumococcal vaccines

A

Chronic cardiovascular/respiratory/hepatic/renal disorder. Asplenia. SCA. ImmSup

Polysaccharide 8 wks later than conjugate

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162
Q

Imdications for meningococcal vaccine

A

Healthy young adults

Asplenia

Travelers to high risk areas

Military

Lab personnel

Complement/ factor D, properdin deficiency

Eculizumab

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163
Q

Auto-Ab mediated encephalitis in adults is associated with

A

Malignancy

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164
Q

HSV encephalitis site

A

Medial temporal, inferior frontal lobes

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165
Q

HSV encephalitis pathologic process

A 
Acute
Necrotizing
Hemorrhagic
Lymphocytes
Plasma cells

HSV1&raquo_space;HSV 2

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166
Q

Encephalitis associated with influenza and respiratory viruses

A

Acute

Necrotizing

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167
Q

HSV encephalitis symptoms

A

Acute onset

FND: hemoparesis, ataxia, aphasia, seizures

Temporal lobe involvement: behavioral disturbances

Rapidly progressive

Sequela: memory and behavioral disturbances

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168
Q

Inv for encephalitis

A

CSF (including PCR for HSV, VZV, EBV, enterovirus, parechovirus, M.pneumonia…)

Serology: EBV, WNV, rabies, bartonella

Imaging: CT, MRI, EEG

Brain Bx

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169
Q

EEG in HSV encephalitis

A

Early focal slowing

Periodic discharge

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170
Q

Tx of encephalitis

A

Supportive

Monitor vital signs

Empirical IV acyclovir until HSV R/O

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171
Q

Pathophysiology of tetanus

A

Toxin travels back axons to CNS

In CNS it irreversibly binds presynaptic neurons

Inhibits release of inhibitory NTs (GABA)

Effect: disinhibition of spinal motor reflexes

Tetanus, autonomic hyperactivity

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172
Q

Tetanus Sx

A

Initial: trismus

Sustained contraction of skeletal muscle

Periodic painful spasm (triggered by sensory stimuli)

Paralysis descends to neck, abd (large muscle groups)

Apnea, respiratory failure, pharyngeal tonic contraction

Autonomic hyperactivity:
Diaphoresis, tachycardia, HTN, fever

173
Q

Inv for tetanus

A

Clinical Dx

( Hx of wound/ non-immunization is not always present)

CK

Culture wound

174
Q

Tx of tetanus

A

Stop toxin production:
Wound debridement
IV metro/penicillin G

Neutralize toxin:
TIg

Supportive therapy:
Intubation
Spasmolytic medications (benzodiazepines)
Quite environment
Cooling blanket

Autonomic dysfunction:
a-, B-blocker
MgSO4

175
Q

Prevention of tetanus

A

Vaccinate pt on diagnosis

INFECTION DOES NOT PRODUCE IMMUNITY

Tetanus toxoid vaccination

176
Q

Rabies transmission

A

Breaching of skin by teeth

Direct contact of skin/mucous membranes with saliva/neural tissue

177
Q

Pathogenesis of rabies

A

Bite

VIRUS travels via axon to CNS

Virus multiplies rapidly in brain

Then spreads to other organs

178
Q

Rabies Sx

A

Development of symptoms is concurrent with virus excretion in saliva

Animal can transmit rabies as soon as it shows signs of disease

Inc: 1-3 mo

Prodrome: < 1wk
Influenza-like
Pain, paresthesia, pruritus at wound sign

Acute neurologic syndrome:
Encephalitic:
Hyperactivity, fluctuating LOC, hydrophobia, aerophobia, hypersalvation, fever, seizures.
Painful laryngeal spasm on gust of air or drinking water

Paralytic:
Quadriplegia, loss of anal sphincter tone, fever

Coma:
Complete flaccid paralysis, respiratory and cardiovascular failure

Death

179
Q

Inv for rabies

A

Purpose:
Limit contact of pt with others
Identify others exposed to the infectious source

Anti-mortem:
DIF/PCR on saliva/skin Bx/serum/CSF

Post-mortem:
DIF on nerve tossue (Negri bodies)

180
Q

Tx of rabies

A

Post-exposure prophylaxis:

Wound care: promptly with soap and running water

HRIG: into wound site. Any remaining volume administered IM in site distant from vaccination

Vaccine: 4 shots (inactivated virus)

If Sx manifested, only supportive Tx

181
Q

Prevention of rabies

A

Vaccination for:

Lab staff working with rabies

Veterinarians

Animal/wildlife control workers

Long-term travelers to endemic areas

182
Q

Post exposure rabies prophylaxis in fully vaccinated pt

A

No need for HRIG

2 shots of HDCV instead of 4

183
Q

SIRS definition

A

2 of:

T<36 or >38

PR>90

RR>20
Or
PCO2<32

WBC <4000 or > 12000 or > 10% band

184
Q

Sepsis definition

A

SIRS + proven/provable infection

185
Q

Severe sepsis

A

Sepsis +

Signs of EOD or hypoperfusion

186
Q

Septic shock

A

Severe sepsis
+
Hypotension despite adequate fluid (<90 sBP)

187
Q

Inv for SIRS/sepsis

A 
CBC, diff
Lytes
BUN, Cr
Liver enzymes
ABG, lactate
INR, PTT, FDP
Blood C&amp;S x 2
U/A, C&amp;S
Culture of any wounds/lines
CXR
188
Q

Tx of sepsis

A 
ABC
Intubation
O2
Fluids +/- NE, 
ICU
IV AB
IV hydrocortisone (if shock unresponsive to fluid and vasopressors)
189
Q

Leprosy transmission

A

Nasal secretion

Skin lesions

190
Q

Leprosy Sx

A

1.Intact cell-mediated immunity:
Paucibacillary.
5 lesions or less skin lesions:
Well defined, dry, hypoesthetic, hypopigmented

Early nerve involvement:
Enlarged nerve, neuropathic pain

2.Weak cell-mediated immunity:
Multibacillary.
6 or more lesions. Symmetrical, leonine facies,

Late and insidious nerve involvement:
Sensory loss at the face and extremities

3.Borderline form

191
Q

Inv for leprosy

A

Skin Bx

Slit skin smear for AFB staining

PCR

Granuloma, lepra cells

192
Q

Tx of leprosy

A

Single skin lesion:
ROM (rifampin, ofloxacin, minocycline)

Paucibasillary:
Dapson daily
Rifampin monthly x 6 mo

Multibacillary:
Dapsone daily
Rifampin monthly x 12 mo
Clofazimine monthly x 12 mo
Clofazimine low dose daily
193
Q

Leprosy treatment reactions

A

ENL
Reversal reaction

Tx:
Mild: NSAID
Sev: pred
ENL: thalidomide

194
Q

Drug med causing hyperpigmentation

A

Clofazimine

195
Q

Primary reservoir for lyme disease

A

Rodents (mice)

196
Q

Hosts for lyme transmitting ticks

A

White-tailed deer

197
Q

Time and area of lyme infection

A

May-august

Low brush near wooded areas

Requires > 36 h tick attachment

198
Q

Lyme Sx

A

Stage 1:
7-14 d post-bite
Malaise, fatigue, H/A, myalgias, erythema migrans

Stage 2: (early disseminated)
Weeks
CNS: aseptic meningitis, CN palsies (VII)peripheral neuritis
Cardiac: transient block, myocarditis

Stage 3: (late persistent)
Months to years
May not have early stages
MSK: chronic monoarticular or oligoarticular arthritis.
Acrodermatitis chronicum atrophicans.
Neurologic: encephalopathy, meningitis, neuropathy

199
Q

Inv for lyme

200
Q

Prevention of lyme

A

Protective clothing,

Insect repellent

Inspection for ticks

Doxy: within 72 h of removal of an engorged tick, in hyperendemic (tick infection rate > 20%) areas, pts >8 yr who are not pregnant or lactating

201
Q

Tx of lyme

A

Stage 1: doxy/amoxicillin/cefuroxime

Stage 2-3: ceftruaxone

202
Q

Superantigens in TSS

A

Staphylococcal:
TSST-1

Streptococcal:
SPEA, SPEB, SPEC

203
Q

RFs for staphylococcal TSS

A

Tampon

Nasal packing

Wound infection

204
Q

RFs for streptococcal TSS

A

Minor trauma

Surgical procedure

Preceding viral illness (chickenpox)

Use of NSAID

205
Q

Tx of TSS

A

Fluid
Remove source

Staph:
MSSA: Clinda + cloxa x 10-14 d
MRSA: clinda + vanco x 10-14 d

Strep:
Penicillin IV + clinda + IVIg

206
Q

Cat scratch disease transmission

A

Cat bite
Cat scratch

B. Hensella

207
Q

Cat scratch Sx

A

Skin lesions 3-10 d post-inoculation

Fever

Regional tender LAP

In some pts, organisms disseminate:
FUO
HSM
retinitis
Encephalopathy

Usually self-limited

208
Q

Inv for cat scratch disease

A

Serology
PCR
LN Bx

209
Q

Tx of cat scratch disease

A

Mild-mod disease in immunocompetent pt:
Azithromycin 5 d

Disseminated disease:
Rifampin + Doxy/azithro

Aspiration of painful suppurative lymph nodes

210
Q

Organism of RMSF

A

Rickettsia rickettsii

Obligate intracellular

GN

Reservoir: rodents, dogs

211
Q

Pathophysiology of RMSF

A

Inflammation of endothelial lining of small blood vessels

Small hemorrhages, and thrombi

Widespread vasculitis

212
Q

Sx of RMSF

A

Summer

Following tick bite

Flu-like prodrome

Macular rash on day 2-4 of fever:
Begins on wrists and ankles
Spreads centrally (arms, legs, trunk, palms, soles)
10% spotless

H/A, CNS changes, death if delayed Tx

213
Q

Inv for RMSF

A

Skin Bx

Serology

214
Q

Tx of RMSF

A

Doxy 5-7 d (3 days after defervescence)

215
Q

West nile virus epidemiology

A

All US

Much of southern Canada

216
Q

WNV transmission

A

Mosquitoes (feeding on birds)

Transplacental

Blood products

Organ transplantation

217
Q

WNV Sx

A

Mostly asymptomatic

Symptomatic:
Mostly mild: H/A, backache, myalgia, anorexia, maculopapular non-pruritic rash on back, chest, arms

Severe complications: encephalitis, meningoencephalitis, acute flaccid paralysis (esp in those > 60)

218
Q

Inv for WNV

A

IgM in serum/CSF

IgM lasts for > 6mo (so may not indicate current infection)

CSF/tissue/blood/fluids PCR

CSF: elevated lymphocytes and proteins

219
Q

False positive WNV serology

A

Yellow fever vaccine

Japanese encephalitis vaccine

Dengue fever infection

St. Louis virus infection

222
Q

Tx and prevention of WNV

A

Treatment: supportive

Prevention: repellent (DEET), drain stagnant water, community mosquito control programs

223
Q

Syphilis Sx

A
  1. Primary
  2. Secondary
  3. Latent
  4. Tertiary
224
Q

Primary syphilis

A

3-90 d post infection

Chancre

Regional LAP

Lasts 3-6 wk

25% progress to 2°

225
Q

Secondary syphilis

A

2-8 wk following chancre

Maculopapular, non priritic rash

Generalized LAP

Low grade fever

Malaise

H/A

Aseptic meningitis

Ocular/otic syphilis

Chondyloma lata

226
Q

Latent syphilis

A

Asymptomatic

Following untreated primary or secondary syphilis

<1y : early latent

> 1y : late latent

Unknown duration : late latent

227
Q

Tertiary syphilis

A

1-30 y post infection

Gummatous syphilis

Aortic aneurysm, AI

Neurosyphilis: dementia, personality changes, argyll-robertson, tabes dorsalis

228
Q

Congenital syphilis

A

Abortion

Stillbirth

Malformations

Developmental delay

Deafness

Most newborns asymptomatic

Early infancy: rhinitis, LAP, HSM, psudoparalysis, rash

Late-onset (>2y): saddle nose, saber shin, glutton joints, Hutchinson’s teeth, mulberry molars, rhagades, CN VIII deafness, interstitial keratitis, juvenile paresis.

229
Q

Tx of syphilis

A

1°, 2°, early latent:
Benzathine penicillin G 2.4 mU IM x 1

Late latent, 3°:
Benzathine penicillin G 2.4 mU IM x 3

Allergic:
Doxy, 100 bid, 14 d

Neurosyphilis:
Aqueous penicillin G 18-24 mU/d x 14 d

Congenital:
Penicillin G IV x 10 d

230
Q

False positive VDRL/RPR

A 
Mononucleosis
Hepatitis
Drugs/substance abuse
Rheumatoid fever
Lupus
Leprosy
231
Q

Jarisch-Herxheimer reaction

A

In 2° and 3° syphilis treated with penicillin

Lysis of organism

Release of pyrogens: fever, chills, myalgia, flu-like

Lasting up to 24 h

232
Q

TB RFs

A

Travel/ birth in a country with high TB prevalence

Aboriginal

Crowded living condition

Low SES

Homeless

IVDU

Personal/occupational contact

ImmCom/ImmSup (HIV, extremes of age)

Silicosis

CRF + dialysis

Malig + chemo

Substance abuse (smoking, alcohol, drug)

233
Q

What’s the most common thing that happens to TB when it enters the body?

A 
Latent TB (95%):
Asymptomatic infection contained by host immune defenses
234
Q

Primary TB Sx

A

Usually asymptomatic

Can be progressive in children/ImComp

235
Q

Secondary TB infection/reactivation Sx

A

Constitutional symptoms

Site dependent symptoms:
1- pulmonary TB:
Chronic productive cough +/- hemoptysis 
CXR: consolidation, cavitation, LAP
Non-resolving pneumonia

2- miliary TB
Widely disseminated: lung, abd organs, marrow, CNS
CXR: 2-4 mm millet seed-like lesions

3-extrapulmonary
Lymphadenitis, pleurisy, pericarditis, hepatitis, peritonitis, meningitis, osteomyelitis (pott’s vertebral disease), adrenal, renal, ovarian

236
Q

Inv for TB

A

Screen:

PPD

IGRA (fewer false positive, since detecting Ag not present in BCG or other mycobacteria):
Preferable in Hx of BCG vaccination or pt who may not return for reading the test

If pulmonary:
Three sputum specimens: 1h apart. AFB smear and culture

BAL

CXR

237
Q

> 5mm PPD is positive if:

A

ImmComp

Close contact with active TB

238
Q

> 10 mm PPD is considered positive in:

239
Q

If positive PPD, what’s next step?

240
Q

False negative PPD

A

Poor technique

Anergy

ImmSup

Infection < 10 wk or remotely

241
Q

False positive PPD

A

BCG after 12 mo in a low-risk individual

Non-TB-MB

242
Q

Booster effect in PPD

A

Initially false negative test

Boost to true positive by testing procedure itself (happens in remote infection or BCG)

243
Q

TB CXR

A

Primary: middle/lower lobe
Secondary: apical

Nodular/alveolar infiltrate
Cavitation
Pleural effusion (unilateral, exudative)
LAP. Hilar, mediastinal (esp children)
Tuberculoma (semicalcified, well-defined, solitary nodule, 0.5-4 cm)
Miliary TB
Evidence of past disease( calcified hilar/mediastinal nodes, calcified pulmonary focus, pleural thickening and calcification, apical scarring)

244
Q

Inv for syphilis

A

Screening:
VDRL, RPR (non-treponemal)
CMIA, CLIA, EIA (treponemal)

Confirmatory tests:
TPPA
FTA-ABS
MHA-TP
TPI
Dark field with silver stain

LP

Long bone Xray (congenital)

245
Q

Indications for LP in syphilis

A 
Seropositive and 
Sx of neurosyphilis
Or
Treatment failure
Or
Other tertiary Sx
Or
HIV and late latent
Or
Congenital
246
Q

Prevention of TB

A

Primary prevention:
Airborne isolation

BCG vaccine:
Infants in high-incidence communities if no evidence of HIV/ImDef

Secondary prevention:
INH-sensitive: INH + B6 x 9 mo
INH-resistant: rifampin x 4mo

247
Q

Secondary prevention from TB in pregnancy

A

Defer, unless mother is high-risk

248
Q

Tx of active TB

A 
Pulmonary:
Initiation phase:
INH + rifampin + pyrazinamide + ethambutol + B6 x 2 mo
Continuation phase:
INH + rifampin + B6 x 4 mo

Extrapulmonary:
Same regimen
12 mo Tx if bone/joint/CNS/miliary-disseminated
+ CS if meningitis/pericarditis

249
Q

BCG can prevent?

A

Miliary TB and Meningeal TB in children

250
Q

MDR TB is resistant to

A

INH and rifampin

Suspect if:
Previous Tx for TB
Exposure to known MDR
Immigration from a high-risk area

251
Q

XDR TB is resistant to

A

INH + rifampin + Q + 1 or more of injectables, 2nd lines

252
Q

Most new cases of HIV in Canada is among

253
Q

HIV transmission probability based on receiver site

A 
Contaminated blood product >
Intrapartum/breast milk >
Placental >
Rectal (via semen) >
Sharp/Needlestick >
Female genital tract (via semen) >
Male genital tract
254
Q

Acute retroviral syndrome Sx

A

2 to 6 weeks post exposure
Lasting 10 to 15 days
Fever, pharyngitis, LAP, rash, arthralgias, H/A, myalgia, G.I. symptoms, oral ulcers, weight loss.
Aseptic meningitis

High level of plasma virion
High risk of transmission
HIV RNA/p24 in CSF

255
Q

Asymptomatic/latent phase

A

HIV replicates in CD4 in LNs

Normal CD4 counts (500-1100)

CD4 drops 60-100/y

256
Q

Definition of AIDS

A

HIV + and one of:

Opportunistic infections (PCP, esophageal candidiasis, CMV, MAC, TB, toxo)

Malignancy (kaposi, invasive cervical cancer)

Wasting syndrome

Or CD4 < 200 (or < 15%)

257
Q

Clinical manifestations of HIV Associated with CD4 count <500

A

Often asymptomatic

Constitutional Sx

Mucocutaneous lesions:
SD, HSV, VZV, OHL (EBV), Candidiasis (oral, esophageal, vaginal), KS

Recurrent bacterial infections

TB

Lymphoma

258
Q

Clinical manifestations of HIV Associated with CD4 count <200

A

PCP

KS

Oral thrush

Local/disseminated fungal infections:
Cryptococcus
Coccidioides
Histoplasma

259
Q

Clinical manifestations of HIV Associated with CD4 count <100

A

PML (JC virus)

CNS toxoplasmosis

260
Q

Clinical manifestations of HIV Associated with CD4 count <50

A

CMV: retinitis, colitis, cholangiopathy, CNS

MAC

Bacillary angiomatosis

Primary CNS lymphoma

261
Q

Inv for HIV

A

Anti-HIV-Ab:
Detectable in all after up to 3 mo (3 mo window period)

Screening test:
ELISA Anti-HIV
Or
Combination p24 Ag/HIV-Ab (p24 may be positive during window period)

Confirmatory test:
Western blot (Ab against at least 2 HIV protein bands: p24, gp41, gp120/160)
262
Q

Mx of HIV positive pts

A

F/U q 3-6 mo

Routine CD4 count

Routine HIV-RNA level (important indicator of ART effect)

Baseline HIV resistance testing

HLA-B*5701 genetic test (abacavir hypersensitivity)

CCR5 tropism testing (if Tx with CCR5 antagonist considered)

Baseline PPD

Baseline serologies (hepatitis A,B,C, syphilis, toxo, CMV, VZV)

Routine biochemistry and hematology, CXR, U/A

Annual FBS and lipid profile (ART side effect)

263
Q

Education for HIV pt

A

Regular F/U on CD4 count/viral load

Strict adherence to ART

Safe sex and needle practice

Barrier protection during sex (to prevent HIV superinfection)

Importance of disclosing HIV status to partners (risk of criminal prosecution of non disclosure)

Connect to relevant community groups and resources

264
Q

Dx of HIV in infants born to HIV + mothers

A

Detection of HIV RNA

Maternal Ab positive up to 18 mo

265
Q

Health care maintenance in HIV pt

A

Assessment of psychosocial concerns

Referral to psychiatry or social worker if needed

Vaccines:
Influenza/y
23-valent pneumococcal/ q 5 yr
HBV
HIV

Annual PAP smear and STI

Mx of comorbid conditions, provision of general primary care

266
Q

Indication of PCP Px in HIV

A

CD4 < 200

Hx of oral candiduasis

267
Q

Prophylactic regimen for PCP

A

TMP-SMX 1 SS or DS OD

268
Q

Indication of toxo Px in HIV

A

CD4 < 100 and IgG to toxo

269
Q

Prophylaxis regimen for toxo in HIV

A

TMP-SMX DS OD

270
Q

Indication of TB Px in HIV

A

PPD > 5mm
Or
Contact with case of active TB

271
Q

Indication of MAC Px in HIV

272
Q

Prophylaxis regimen for MAC

A

Azithromycin 1200 mg q 1 wk

273
Q

When to discontinue 1° and 2° Px against opportunistic infections?

A

If CD4 > threshold for > 6mo while on ART

274
Q

Anti-retroviral pre-exposure Px for HIV prevention in high risk individulals

A

Daily oral tenofovir +/- emtricitabine

275
Q

Targets for ART Tx

A

All HIV + pts

May defer treatment on the basis of clinical and psychosocial factors

276
Q

Goal of ART

A

Viral load < 40 copies/ml (undetectable)

Viral load should decrease 10 fold within 4-8 wk

Viral load should be undetectable within 6 mo

Restore immunological function

NO INTERMITTENT ART OR DRUG HOLIDAYS

277
Q

How much does ART reduce risk of HIV transmission to partner?

278
Q

ART recommendation for Tx of naïve pts

A

2 NRTI + 1 INSTI/PI

279
Q

Tx failure definition in HIV

A

Viral load persistently > 200/ml

280
Q

Symptoms of lactic acidosis

A

Abdominal pain
N/V
Fatigue
Muscle weakness

281
Q

Lipodystrophy by ART

A

Lypohypertrophy: PI

Lipoatrophy: NRTI (AZT, d4T)

282
Q

Prevention of HIV infection

A

Education, harm reduction:
Safer sex practice: condom, barrier fir oral sex
Avoid sharing needles if IVDU

Prevention of vertical infection:
ART should be initiated prior to pregnancy or as early as possible during pregnancy
Blood/body precautions for healthcare workers.
Post exposure Px

Pre-exposure Px (oral, topical)

ART (96% decrease in partner transmission)

Screening of blood/organ donation

283
Q

Post-exposure Px for HIV

A

2-3 drug regimen

Started immediately (within 72 h)

Continue for 4 wk

284
Q

Nominal/name-based HIV testing

A

Person ordering the test knows the identity of pt

Test ordered using the name of the pt

Person ordering the test, legally obliged to notify public health if positive test

Test result recorded in the health care record

285
Q

Non-nominal/Non-identifying HIV testing

A

Test ordered using a code or initials of pt

All others similar to nominal

286
Q

Anonymous HIV testing

A

Available at specialized clinics

Person ordering the HIV test does not know the identity of the person being tested

HIV test carried out using a unique non-identifying code that only the person being tested for HIV knows

Results not recorded on the healthcare record of person

Patient identification and notification of public health required to gain access to ART

287
Q

HIV pre-and post test counseling

A

Required since a diagnosis of HIV is overwhelming and associated with stigma and discrimination

Should be connected with local support services

Goals:
Assessing risk
Making informed decision to be tested
Education to protect themselves and others
Where to go for more information and support

288
Q

Subcutaneous fungus

A

Sporothrix schenckii

289
Q

Transmission of sporothrix schenckii

A

Rose thorn, splinter

290
Q

Sx of sporotricosis

A

Nodule/ulcer at inoculation site

Nodular lymphangitis

291
Q

Tx of sporotricosis

A

Itraconazole

IV amphitricin B if severe/disseminated

292
Q

Endemic mycoses transmission

A

Inhalation of spores, inoculation injury

Dimorphic:
Mould in cold
Yeast in warm

Three major ones:
Histoplasmosis
Blastomycosis
Coccidioidomycosis

293
Q

Transmission of histoplasmosis

A

Chicken coops

Bird roosts

Bat caves

Ontario, Quebec

294
Q

Sx of histoplasmosis

A

Mostly asymptomatic

Primary pulmonary:
Fever
Cough
Chest pain
H/A
Myalgia
Anorexia
CXR(acute): pulmonary infiltrate +/- hilar LAP
CXR(chronic): infiltrate, cavitation
Disseminated disease:
In ImComp
Bone marrow (pancytopenia)
GI tract (ulcer)
Lymphadenitis
Skin, liver, adrenal, CNS
295
Q

Inv for histoplasmosis

A

Fungal culture
Fungal stain
Ag detection (urine, serum)
Serology

296
Q

Blastomycosis Sx

A

Asymptomatic

Primary:
Acute/chronic pneumonia
Fever, cough, chest pain, chills, night sweats, Wt loss.
CXR (acute): lobar/segmental pneumonia
CXR (chronic): lobar, fibronodular interstitial disease

Disseminated:
Verrucous skin lesions, ulcers, SQ nodules,
Bones (osteomyelitis, osteolytic lesions)
GU (prostatitis, epididymitis)

297
Q

Inv for blastomycosis

A

Smear and culture (sputum)

Direct exam of clinical specimens:
Broad-based budding yeast

BBBB:
Broad based budding blastomycosis

298
Q

Coccidioides

A

Valley fever:
Subacute fever, chills, cough, chest pain, sore throat, fatigue,

Lasts weeks to months

Hypersensitivity with arthralgia, EN

Disseminated:
Skin ulcers
Synovitis
Lytic bone lesions
Meningitis

Opportunistic in HIV

299
Q

Inv for coccidioides

A

Sputum culture

Direct exam of clinical specimen

300
Q

Epidemiology of blastomycosis

A

Northern ontario

Along the great lakes

301
Q

Tx of endemic mycoses

A 
Mild-mod:
Oral azole (itra)

Sev:
IV ampho B if systemic

302
Q

Sx of PCP

A

Fever
Non-productive cough
Progressive dyspnea

303
Q

Inv for PCP

A

Sputum/BAL/endotracheal aspirate to demonstrate organism

CXR:
Bilateral
Diffuse opacities
Normal in 20-30 %

CT:
Cysts

NEVER PLEURAL EFFUSION

304
Q

Tx of PCP

A 
O2, keep O2 sat > 90%
AB:
TMP/SMX
Dapsone + TMP
Clinda + primaquine
Pentamidine
Atovaquone

CS if:
pO2 < 70
A-a gradient > 35

305
Q

PCP Px

A

HIV with CD4 < 200

Non HIV immunocompromised

306
Q

Cryptococcus transmission

A

Airborne:
From Soil contaminated with pigeon droppings (C. Neoformans)
Eucalptus, Douglas fir (C. Gatti)

Neoformans: ImmComp pts
Gatti: healthy hosts

307
Q

Sx of cryptococcus

A

Asymptomatic

Pulmonary:
Pneumonitis, asymptomatic, self-limited
Productive cough, chest tightness, fever

Disseminated:
Esp in HIV +
CNS: meningitis
Skin: molluscum-like
Bone, LN, BM, soft tissue, eyes
308
Q

Leading cause of meningitis in HIV pts

A

Cryptococcus

309
Q

Inv for cryptococcus

A

Serum Ag

CSF: India-ink stain, Ag, culture

310
Q

Tx of cryptococcus

A

In HIV with severe pulmonary form or meningitis:

Amphotricin B (+ flucytosine) x 2 wk
\+ fluconazole x at least 8 wk
\+ fluconazole at lower dose for prolonged maintenance
311
Q

C. Gatti epidemio

312
Q

RFs of candidiasis

A

ImComp:
DM
CS

ICU pt:
CV-line
Broad-spectrum AB
TPN

Obesity

313
Q

Tx of candidiasis

A

Thrush:
Nystatin for mild
Fluconazole for severe

Vulvovaginal:
Topical imidazole, nystatin
Oral fluconazole if recurrent

Cutaneous infection:
Topical imidazole

Opportunistic infection in HIV, systemic infection:
Fluconazole
Echinocandin

Chronic mucocutaneous:
Azoles

314
Q

Aflatoxin is produced by

A

Aspergillus

315
Q

Aflatoxin found in

A

Nuts
Grains
Rice

316
Q

Allergic bronchopulmonary aspergillosis

A

IgE-mediated
Asthma-type reaction

Dyspnea, high fever, transient pulmonary infiltrates

More frequently in pts with asthma and allergies

317
Q

Aspergilloma

A

Ball of hyphae in pre-existing cavity

Asymptomatic

Massive hemoptysis

CXR: round opacity surrounded by thin lucent rim of air in upper lobes (air-crescent sign)

318
Q

Invasive aspergillosis

A

In prolonged persistent neutropenia
Or
Transplantation

Sx:
Pneumonia (most common):
Fever, cough, dyspnea, cavitation, 
CXR: 
Local/diffuse infiltrate
Pulmonary infarction
Nodule with surrounding ground glass (halo sign)

May disseminate to brain, skin…

319
Q

Sx of mycotoxicosis by aflatoxin

A

Liver hemorrhage, necrosis, hepatocellular carcinoma

320
Q

Tx of aspergillosis

A

Ampho B
Voriconazole

Aspergilloma: surgical resection

ABPA: CS +/- itra

321
Q

E. Histolytica transmission

A

Fecal-oral

322
Q

Sx of E.histolytica

A
  1. asymptomatic carrier
  2. Abd pain, cramping, colitis, dysentery, low grade fever
  3. Liver abscess (hematogenous):
    RUQ pain, Wt loss, fever, hepatomegaly
323
Q

Inv for E. Histolytica

A

Serology
Fecal/serum Ag
Stool exam
Colon Bx

324
Q

Tx of E. Histolytica

A

Metro + iodoquinol/paromomycin

Liver abscess:
AB 
Aspiration if: 
Risk of rupture
Poor response to Tx
Diagnostic uncertainty

Asymptomatic cyst shedding:
Iodoquinol/paromomycin

325
Q

Prevention od E. Histolytica

A

Good personal hygiene

Purification of water supply:
Boiling, filtration

CHLORINATION NOT EFFECTIVE

326
Q

Infective form of E. Histolytica

A

Cyst (not trophozoite)

327
Q

Giardia transmission

A

Fecal-oral

Cyst ingestion

328
Q

Sx of giardiasis

A

Asymptomatic

Mild watery diarrhea

Malabsorption syndrome

Nausea, malaise, abd cramps, bloating, flatulence, fatigue, wt loss, steatorrhea

NO HEMATOCHEZIA, NO MUCOUS IN STOOL

329
Q

Inv for giardia

A

Multiple stool samples (daily x 3d)

Stool Ag

Small bowel aspirate, Bx

330
Q

Tx of giardia

A

Metronidazole, nitazoxide

331
Q

Prevention of giardia

A

Good personal hygiene and sanitation

Water purification (iodine better than chloriniation)

Outbreak investigation

332
Q

Transmission of TV

333
Q

TV Sx

A

Often asymptomatic.

Occasionally urethritis/prostatitis in males

Vaginitis in female:
Discharge, pruritus, dysuria, dyspareunia

334
Q

Inv for TV

A

Wet mount

Ag detection

Culture

Males: urine PCR

335
Q

Tx of TV

A

Metro for pt and partners

336
Q

Cryptospordium transmission

A

Fecal-oral

Water contaminated by humans and cows

337
Q

Sx of cryptospordium

A

Asymptomatic

Self-limited watery diarrhea

Chronic, severe, non-bloody diarrhea

N/V, anorexia

Wt loss, death in ImComp

338
Q

Inv for cryptospordium

A

Modified acid-fast stain of stool or tissue

S/E

Stool Ag

339
Q

Tx of cryptospordiosis

A

Supportive

If HIV:
ART, increase CD4 to > 100

If failure:
Nitazoxanide

340
Q

cryptospordium Px

A

Water filtration

Personal hygiene

341
Q

Malaria transmission

A

Anopheles bite

Vertical(rare)

Blood transfusion

342
Q

Sx of malaria

A

Flu-like prodrome

Paroxysms of high spiking fever and shaking chills

Abd pain, myalgia, H/A, cough, diarrhea

Hepatomegaly, thrombocytopenia

343
Q

In which type of malaria are there relapsing attacks after several months?

A

Oval and vivax

Due to reactivation of dormant liver hypnozoites

344
Q

Most common malaria

A

Falciparum

345
Q

Most lethal malaria

A

Falciparum

346
Q

Complications of falciparum

A

CNS involvement (seizures, coma)

Severe anemia

Acute kidney injury

ARDS

Death

347
Q

Inv for malaria

A

Blood smear q 12-24 h (x3)
Thick smear
Thin smear

Rapid Ag

348
Q

Tx of malaria

A

Vivax, Oval:
Chloroquine
+ primaquine (to eradicate liver forms)

Chloroquine resistance vivax:
Atovaquone/proguanil + primaquine
Or
Quinine and doxy + primaquine

P. Malariae: chloroquine

P. Knowlesi: chloroquine

P. Falciparum:
Artesunate + doxy/clinda/atovaquone-proguanil
Or
Quinine + doxy/clinda
Or
Atovaquone/proguanil
349
Q

Malaria prevention

A

Covering exposed skin

Bed nets

Insect repellents

Meds:
Atovaquone-proguanil

Doxycycline

350
Q

Trypanosoma cruzi transmission

A

Reduviid: Kissing bug (stool rubbed into bite site by host)

Placental
Organ donation
Blood transfusion
Ingestion of contaminated food

351
Q

Trypanosoma cruzi Sx

A

Acute:
Asymptomatic
Local swelling (Roman’s sign)
Fever, LAP, HSM, cardiomegaly

Chronic indeterminate phase:
Asymptomatic
Increasing Ab level in blood

Chronic determinate phase (30-40% of individuals):
10-25 y after infection:
Dilated CMP
Esophagomegaly
Megacolon
352
Q

Inv for Chagas

A

Thick and thin blood smears:
Wet prep, Giemsa

Serology

PCR

353
Q

Tx of Chagas

A

Acute:
Nifurtimox
Benznidazole

Indeterminate phase:
Treat as above for age <50

Chronic determinate:
Symptomatic, surgery
Antiparasitic Tx

354
Q

Prevention of chagas

A

Insect control

Bed nets

355
Q

Toxo transmission

A

Exposure to cat feces

Ingestion of undercooked meat

Vertical

Organ transplantation

Gardening without gloves (cat feces)

Whole blood transfusion

356
Q

Sx of congenital toxo

A

Result of: acute primary infection of mother during pregnancy

Stillbirth
Chorioretinitis
Blindness
Seizures
Severe developmental delay
Microcephaly

Or asymptomatic in infancy with adolescence/adulthood:
Chorioretinitis

357
Q

Sx of acquired toxo

A

Asymptomatic

Mononucleosis-like syndrome

Remains latent for life, unless reactivation due to ImSup

358
Q

Toxo Sx in ImSup pts

A

Encephalitis

Focal CNS lesions:
Single/multiple ring-enhancing lesions

H/A, FND

LAP, HSM, pneumonitis

Chorioretinitis

359
Q

Inv for toxo

A

Serology

CSF:
Wright-Giemsa stain, Ag, PCR

Bx

CT if ImComp

Ophthalmologic examination

360
Q

Toxo serology in AIDS

A

might be false negative

361
Q

Toxo Tx

A

None

If pregnant:
Spiramycin
Or pyrimethamine + sulfadiazine (+ folinic acid)
Avoid undercooked meat
Refrain from emptying cat litter boxes

If HIV:
Pyrimethamine + sulfadiazine

If eye disease, meningitis:
CS

362
Q

Toxo Px

A

Hand hygiene

Cook meat thoroughly

363
Q

Pinworm transmission

A

Fecal oral : self-inoculation

Fomite: person to person

364
Q

Pinworm Dx

A

Sticky tape test x 5-7 times

365
Q

Pinworm Tx

A

Mebendazole
Albendazole

Pregnancy: pyrantel

Tx all family members

Prevention:
Change underwear
Bathe in the morning
Pajamas to bed
Wash hands
Trim fingernails
366
Q

Onchocerca vulvulus

A

Blackfly bite

River blindness

Ivermectin + doxy

367
Q

Wuchereria bancrofti

A

Mosquito bite

LAP,
Lymphedema
Elephantiasis

Tx: diethylcarbamazine + doxy

368
Q

Trichuris trichiura

A

Ingestion of eggs in soil

Diarrhea (mucous, blood)
Rectal prolapse
Abd pain
Stunted growth

Tx: mebendazole, albendazole

369
Q

Strogyloides stercoralis

A

Fecal contamination of soil:
Walking barefoot, via unbroken skin

Autoinfection through GI mucosa or perianal skin

Adult worm in small intestine

370
Q

Pulmonary migration of larva

A

Loffler

SS
Ascaris

371
Q

Larva currens

A

Itchy rash due to SS

372
Q

Tx of SS

A

Ivermectin

Albendazole

373
Q

SS hyperinfection

A

Massive autoinfection in immunocompromised host

The most common RF:
Immunoablarive therapy including CS

374
Q

Taenia solium transmission

A

Cestode

Undercooked pork:
Taeniasis: mild abdominal symptoms

Human feces:
Cysticercosis: mass lesion in CNS, eye, skin, seizure

375
Q

Tx of taenia solium

A

Taeniasis:
Praziquantel

Cysticercosis:
CS + albendazole
Anti-epileptic if seizures

376
Q

Taenia saginata

A

Cestode

Undercooked beef

Mild GI symptoms

Tx praziquantel

377
Q

Diphyllobutrium latum

A

Cestode

North America

Europe

Asia

Raw fish

B12 deficiency

Tx: praziquantel

378
Q

Echinococcus granulosus

A

Cestode

Dog feces

Mass effect of cysts
Anaphylaxis during surgical release

Tx:
Albendazole +/- praziquantel

Surgery + peri-op albendazole

Percutaneous aspiration + peri-op albendazoke

379
Q

Clonorchis sinensis

A

Asia

Raw fish

Bile duct inflammation/cholangiocarcinoma

Tx: praziquantel

380
Q

Schistosoma transmission

A

Penetration of unbroken skin by the larvae in fresh water

Adult worms in terminal venules, passing eggs into urine/stool

381
Q

Schistosomiasis symptoms

A

Most asymptomatic

Swimmers’ itch (cercarial dermatitis)

Acute schistosomiasis:
Hypersensitivity to migrating parasite (4-8 wk later):
Fever, hives, H/A, Wt loss, cough, abd pain, chronic diarrhea, eosinophilia

Chronic:
S. Mansoni, S. Japonicum:
Worms in mesentric veins, eggs in portal tract of liver, and bowel.
Intestinal polyps, portal/pulmonary HTN, splenomegaly, hepatomegaly

S. Hematobium:
Worms in vesical plexus, eggs in distal ureter and bladder.
Granulomas and fibrosis
Hematuria
Obstructive uropathy
SCC if bladder
382
Q

Neurologic complications of schistosomiasis

A

Cerebral

Cerebellar

Transverse myelitis

Increased ICP

FND

Seizures

383
Q

Pulmonary complications of schistosomiasis

A

Pulmonary HTN

Corpulmonale

Granulomatous pulmonary endarteritis

384
Q

Inv for schistosomiasis

A

Serology

CBC

S/E (eggs in mansoni, japonicum)

Liver U/S: fibrosis

Rectal Bx

Bladder Bx

Hematobium: eggs in urine and occasionally feces

Kidney/bladder U/S

385
Q

schistosomiasis Tx

A

Praziquantel

If acute: add CS

If neurologic complications: add CS

386
Q

schistosomiasis Px

A

Proper disposal of human fecal waste

Molluscicide

Avoidance of infested fresh water

387
Q

Prevention of vector-borne diseases

A

Long sleeves

Long pants

Permethrin repellents to cloths, belongings, bed nets

DEET repellents for skin

388
Q

Prevention of food/water borne diseases

A

Avoid raw meat/seafood

Avoid uncooked vegetables

Avoid milk/dairy products

Drink only bottled beverages, Chlorinated water, Boiled water

389
Q

Prevention of recreation-related infections

A

Caution when swimming in schistosomiasis endemic regions, fresh water rafting/kayaking, beaches that may contain human/animal waste products, near storm drains, after heavy rainfalls

390
Q

Med prophylaxis for malaria

A

Chloroquine

Mefloquine

Atovaquone + proguanil

Doxy

391
Q

Med for traveler diarrhea Px

392
Q

Vaccinations for travelers

A

Std vaccines up to date:
Hep B, MMR, teranus/diphteria, varicella, pertussis, polio, influenza

Travel vaccines:
Hep A, B
Japanese encephalitis
Typhoid fever
Yellow fever
Rabies
ETEC
Cholera
393
Q

Prevention of STD, blood borne diseases

A

Safe sex practices

Avoidance of percutaneous injury (razor, tattoo, piercing)

394
Q

Fever in traveler,

Incubation < 21 d, consider:

A

Malaria

Thyphoid fever

Dengue fever

Chikunguny

Rickettsioses

R/O:
Hepatitis
TB

395
Q

Traveler fever

Incubation > 21 d

A

Malaria

TB

Typhoid

R/O:
Dengue
Chikungunya
Traveler diarrhea
Rickettsiosis
396
Q

Inv for fever in returned traveler

A 
CBC, diff
Liver enzymes
BUN, Cr
Lytes
Thick/thin blood smear x 3
Blood C/S
U/A, C/S if dysuria
Stool: C/S, O/P
CXR
IgM for dengue
397
Q

Dengue fever transmission

A

Mosquito

Urban

Day biting

SE Asia
Caribbean

398
Q

Dengue fever incubation

399
Q

Dengue fever Sx

A 
Sudden onset headache
H/A
Retro-orbital pain
Myalgia
Arthralgia
Leukopenia
Thrombocytopenia
Hemorrhagic manifestations
400
Q

Dx of dengue fever

A

Serology. IgM

401
Q

Tx of dengue fever

A

Acetaminophen

AVOID NSAIDS (BLEEDING)

402
Q

Typhoid geography

A

Mostly indian subcontinent

403
Q

Pathogens of enteric fever (typhoid)

A

Salmonella typhi/paratyphi

404
Q

Incubation period of Typhoid fever

405
Q

Typhoid fever Sx

A 
Sustained fever 39-40°
Abd pain
H/A
Loss of appetite
Cough
Constipation!
406
Q

Dx of enteric fever

A

Stool/blood/urine sample positive for salmonella typhi/paratyphi

407
Q

Tx of enteric fever

A

Quinolone
Ceftriaxone
Macrolide

408
Q

Tick typhus geography/agent

A

India, south Aftica, mediterranean

Rickettsia

Inc: 1-2 wk

409
Q

Tick typhus Sx

A 
Fever
H/A
Fatigue
Muscle aches
Eschar at site of tick bite
Thrombocytopenia
Elevated liver enzyme
410
Q

Dx of tick typhus

A

Serology

Eschar

411
Q

Tx of tick typhus

A

Doxycycline

412
Q

Mononucleosis pathogens and incubation period

A

EBV/CMV

Inc: 30-50 d

Tx: acetaminophen, NSAIDs, fluids

413
Q

Zika Sx

A

Flu-like

Inc: 3-12 d

Dx: RT-PCR, serology

414
Q

Zika Tx

A

Rest
Fluid
Analgesics/antipyretics (avoid NSAIDs until dengue R/O)

415
Q

Zika geography

A

Africa
SE Asia
S. America

416
Q

Plague vector

417
Q

Inv for FUO

A 
CBC, diff
Lytes
BUN, Cr
Ca profile
Liver enzymes
ESR, CRP
Muscle enzymes
RF, ANA
SPEP
Blood smear
Stool C/S, O/P

Cultures: blood x2, urine, sputum, stool, other fluids

Serology: HIV, monospot, CMV

Imaging: CXR, abd imaging

418
Q

If no Dx for FUO after all workups,

A

Consider empiric therapy vs watchful waiting

Good prognosis

419
Q

Infections associated with asplenia

A 
HIB
S. Pneumoniae
N. Meningitidis
Salmonella
Babesiosis
Malaria
Capnocytophaga canimorsus
420
Q

Neutrophil dysfunction makes vulnerable to

A 
Catalase-producing organisms:
Staph
Serratia
Nocardia
Aspergillus
421
Q

Febrile neutropenia definition

A 
Fever 38 or higher for more than 1 h
And:
ANC <0.5
Or
ANC <1 but trending down to 0.5
422
Q

Nutritional deficiencies causing neutropenia

A

B12, folate

423
Q

Most common etiology of infection in febrile neutropenia

424
Q

Inv for febrile neutropenia

A

PEx, including perianal region

DO NOT PERFORM DRE

Blood C/S x2
Urine C/S
Culture all indwelling caths
Sputum C/S
Nasopharyngeal swab

CBC, diff
BUN, Cr
Lytes
AST/ALT, total Bil

425
Q

Most common infections in febrile neutropenia

A

Mucositis

Line infection

426
Q

Indications for G-CSF or GM-CSF before chemo

A

Febrile neutropenia in previous chemo cycle

Or

Risk of febrile neutropenia > 20

Effect: decreased hospitalization (no effect on mortality)

427
Q

Prophylactic vaccination given before organ transplant

A

All:
DTaP, pneumococcal, influenza, hepatitis A and B

If low titer/poor documentation:
MMR, polio, varicella (booster 4-8 wk later)

428
Q

Immune reconstruction syndrome worse with

A

Lower pre-treatment CD4 count

Quick increase in CD4 count

429
Q

Settings in which immune reconstruction syndrome happens

A 
ART in HIV
Solid organ transplant recipients
Post-partum
Neutropenic pts
Anti-TNF therapy
430
Q

Tx of IRS

A

Mild-mod Sx:
Continue HAART in HIV

Life-threatening or potentially irriversible Sx:
D/C

Tx underlying infection (sometimes prior to HAART)

CS/NSAIDs

Med (25 decks)

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