Infectious Disease Flashcards
Risk Factors for Fungiema
Prolonged ICU stay >8 days
Abdominal surgery
Central line placement
RRT
TPN
Previous colonization
exposure to antibiotics
Preferred treatment for candiasis
Echinocandins
MOA: inhibit synthesis of 1-3 Beta Glucan which in turn prevents formation of the cell wall.
- Poor bio-availabilibilty
- Not good eye penetration therefore need eye exam
Resistance seen in C. Galbrata due to FKS1 OR FKS2 mutations (control enzyme targeted by Echinocandins
Treatment of candemia with and without eye involvement
With : 4-6weeks
Without: 2 weeks AFTER negative cultures
Risk factors for Mycobacterium Infection
Previous lung disease
- COPD, Bronchiectasis, CF
Immunodeficiencies:
- With medications
- Alpha anti-trypsin
- Hypogammaglobinemia (specifically IgG)
Patient profile:
- Age >65yo, female, low BMI, tall
- Chest wall abnormalities
- Mitral valve prolapse
- Vitamin D deficiency
Diagnose Mycobacterium
- TWO positive Sputum cultures of SAME MYCOBACTERIUM SPECIES
or: - BAL (one culture)
or: - Culture from sterile site (pleural fluid)
Resistance Patterns in Mycobacterial disease
M. Avium
- 23SrRNA - macrolide
- 16srRNA- amikacin
M. abscessus-
- 23srRNA - macrolide (seen at 3 days of incubation
- ERM41 gene - inducible macrolide resistance (seen at 14 days of incubation)
M. Kanasii
- rpo B gene - Rifamycin
Macrolide okay to use if MIC <8
Amikacin okay to use if MIC <16
Indication for surgery in Mycobacterial disease
- Medication unresponsiveness
- hemoptysis
- De-bulking of disease (if you have 2+ cavities)
- Uncontrolled symptoms
- Rapid growing mycobacterial disease
Improve outcomes by 30%.
Treatment for M.Abscessus
if ERM gene positive
—– Then amikacin plus 2 more (linezolid, tigecylcin, clofazamine, imipenem etc)
If erm NEGATIVE:
—- Macrolide, amikacin plus one from above
*** if responding to treatment- can treat for 2 months and then switch to oral agent. Need IV for 2 months!
Treat for 12 months after negative sputum.
Airway clearance is main stay of treatment.
Focal Bronchiectasis Causes
Aspiration, Stenosis
Post obstructive (cancer)
Radiation
NTM disease
Diffuse Bronchiectasis causes
Upper lobe- CF, Sarcoid, CTDs
middle lobe- immotile cilia, post transplant, HIV,
Central - ABPA
Lower lobes- aspiration
When to treat Active Primary TB for 9months (inh and rifampin)
- Extensive cavitary disease
- If they cannot tolerate PZA
- If no sputum conversion at 2m
- Prolongation to decrease risk of relapse (nutritional status)
TB treatment
- INH, RIFAMPIN + ETHAMBUTOL AND PZA
- once Sensitivities return and pan sensitive can drop the ethambutol.
Then treat with INH, RIFAMPIN AND PZA for 2 months followed up
INH and Rifampin for 4 additional months
6 months total treatment
IPA
Sinopulmonary disease
Tracheobronchitis (HIV patients)
IPA:
Highest risk in neutropenic patients
- BMT
- Chronic granulomatous disease
- COPD
- Transplant
- HIV
Spreads hematongenously
Halo sign—- IPA
Dx:
—- Histopathology - septated branching at 45 degress
—- Culture 1-3 days however non-sensitive
—- Consider context
—- BAL - positive culture: very specific, not very sensitive
B-galactomannan (BAL) - most sensitive and specific in bone marrow patients
Tx: Voriconazole,
IPA prophy in AML, MDS, GVHD - posaconazole
Chronic Necrotizing Aspergillous
- CAP that wont go away
- cough malaise fevers chills
- Progressive infiltrates
Risk factors: immuno-compromise, underlying structural lung disease (previous TB, empyema, COPD, etc)
Dx: Clinical suspicion on imaging and IgG positive for aspergillus (active immune activity)
Tx with azoles
Aspergilloma Tx
If asymptomatic: watch
if hemoptysis: then surgical resection 1st line and/or bronchial artery resection
Treatment with itraconazole
Treatment of latent TB
- Normal
- Pregnancy
- HIV
Options:
- Rifampin x 4 months
- Rif/INH x 3 months
- Rifapentine and INH x weekly (12 doses)
pregnancy:
- Do they really need to be treated right away? if not wait until 3m after pregnancy. If so can treat with above regiments
OCPS:
- Tx with INH x 6m (rifampin interacts with CYP reduces level of OCP in body)
HIV:
- rifapentin/INH q weekly x12 doses
- INH for 6/9months
- Among HIV-positive persons living in areas with a high TB incidence, isoniazid is complementary to antiretroviral therapy in preventing TB disease.
Definition of severe PNA per IDSA
½
— Intubation
— septic shock
or
At least 3:
- Confusion (new onset)
- uremia >20
- respirations >30
- bp<90/60
- Low BP requiring aggressive resuscitation
- P/F <250
- Leukopenia <4000
- Thrombocytopenia <100k
- Hypothermia
- multilobar infiltrates
Risk factors for MDR VAP
Previous IV ABX use in the last 90 days ****
Septic shock at time
Preceding ARDS
RRT
5+ days of hospitalization prior to VAP
Blasto
Pulmonary disease
Osteomyelitis (lytic lesions)
Verrucus, ulcerative skin lesions
Anyone, worse in immunocompromised
Midwest and South
Dx:
- Broad based budding yeast
- Antigen/Antibody
- Histopath
Treatment:
- Ampho (severe)
- Itraconazole (6-12months)
- CNS - ampho
- Pregnancy - ampho
Histoplasmosis
Spectrum of disease from
– very asx (self limiting)
– Disseminated disease (HIV)
– Respiratory failure
Other manifestations:
- Broncholiths : eroding calcified nodules - antifungals don’t typically work
– Fibrosing mediastinitis: cement- calcifications - issues with airway patency
– Splenic and hepatic calcifications
Dx:
- Antigen
- Antibody (2-6wks to develop)
- Intracellular in macrophages on micro
Tx:
- ASX (MILD) - NONE
- moderate: itraconazole
- Severe: Ampho
PJP Treatment
FIRST LINE:
- Bactrim for 21 days
- IF A-a >35 or pAO2 <70 then add steroids
Alternatives
Clindamycin + primaquine + IV pentamidine (severe disease)
Bactrim + dapsone (mild)
Atovoquone (mild)
Cryptococcus
In solid organ transplant patients
Nodules/consolidations in immunocompromised patients that live on the west coast
Lungs: fluconazole
CNS: Ampho + flucytosine
** if pulmonary - do LP to determine if CNS is infected
Nocardia
Aerobic, gram +, weakly acid fast positive
– In immunocompetant and immunocompromised people
Pulmonary disease is most common:
– Immunocompromised:
—– Abscesses/cavity/large consolidation.
– Immunocompetant:
—- Bronchiectasis, nodules
Spreads hematogenously- fascial planes intact
Extrapulmonary manifestions:
- Pleural effusions
- mediastinitis/pericarditis
- Brain/bone/skin
Tx:
- 2 agents until sensitivities come back:
—- bactrim/amikacin
– minocycline
– linezolid
If CNS :
- imipenem
- amikacin
- bactrim
Actinomyces
Anerobic
Gram positive
immunocompetant and compromised
Colonizes mouth, vagina, colon — therefore need positive sulfur granules for it to be deemed a true infection
ETOH/poor dentition
Will spread by direct invasion - destroy wall
Infection may not be pulmonary- mouth/abdominal and spread
Treatment:
- Penicillins
- Erythromycin, clinda, tetracycline
