INFECTIOUS DISEASE Flashcards
1
Q
Name Gram +ve cocci
A
SSE
S Staphylococcus
S Streptococcus
E Enterococcus
2
Q
Name Gram +ve bacilli/rods
A
Corny Mike’s List of Basic Cars
Corneybacteria
Mycobacteria
Listeria
Bacillus
Nocardia
3
Q
Name Gram +ve anaerobes
A
CLAP
Clostridium
Lactobacillus
Actinomyces
Propionibacterium
4
Q
Name Gram -ve cocci
A
NNM
Neisseria Meningitis
Neisseria gonorrhoea
Moraxella catarrhalis
5
Q
Name Gram -ve bacilli/rods
A
Escherichia coli
Klebsiella pnuemoniae
Pseudomonas aeruginosa
6
Q
Name Gram -ve coccobacilli
A
Haemophillus influenza
7
Q
Antibiotics that inhibit bacterial cell wall synthesis?
A
Penicillin
Carbapenems
Cephalosporin
Vancomycin
Teicoplanin
8
Q
Antibiotics that inhibit bacterial folic acid synthesis?
A
Trimethoprim
Sulfamethoxazole
9
Q
Abx that stops bacterial nucleic acid synthesis ?
A
Metronidazole (v good for anaerobes)
10
Q
Abx that inhibit bacterial protein synthesis ?
A
Macrolides
Clindamycin
Tetracyclines e.g. Doxyclycline
Gentamicin
11
Q
Define sepsis
A
Life threatening organ dysfunction caused by a dysregulated host response to an infection
12
Q
Define septic shock
A
Subset of sepsis with profound circulatory, cellular and metabolic abnormalities. Associated with greater risk of mortality than sepsis alone
Z2F: this is when arterial BP drops resulting in organ hypo-perfusion
13
Q
How can septic shock be measured?
A
Systolic BP less than 90 despite fluid resuscitation
HYPERlactaemia - where lactate is >4 mmol/l
14
Q
Pathophysiology of sepsis?
A
3 main parts: Cytokine - Coag - Lactate
Cytokines:
1) Pathogens recognised by macrophages, lymphocytes and mast cells
2) Cells release cytokines - cytokines activates other parts of immune system.
3) activation causes vasodilation
4) cytokines make endothelial lining of BV more permeable = so fluid leaks out —> get oedema and reduced intravascular vol.
5) oedema around BV means less O2 can reach tissues
COag:
6) Coag system is activated too!
7) fibrin deposits throughout circulation = also reducing tissue perfusion.
8) Platelets and clotting factors are used up to make clots —> causes thrombocytopenia, haemorrhages (so can’t make any other clots or stop bleeding). = DIC.
Lactate:
9) Get anaerobic resp as no O2 reaching tissues = so blood lactate rises. (as lactate is waste prod of anaerobic resp).
15
Q
SEPSIS mnemonic
A
Slurred speech or confusion
Extreme shivering or muscle pain
Passing no urine (in 24hrs)
Severe breathlessness
I feel like I’m going to die
Skin mottled or discoloured
16
Q
RF for developing sepsis?
A
V young or old - under 1, over 75
Chronic conditions e.g. COPD, DM
Immunosuppressed - chemo, immunosuppressants, steroids
Surgery, trauma, burns
Pregnancy, permpartum (just before or after birth)
Indwelling medical devices - catheter, cannula
17
Q
Presentation of sepsis?
A
Scoring on NEWS.
What is involved?:
Temp, HR, RR, O2 sats, BP, consciousness level (AVPU)
18
Q
Signs of sepsis on examination?
A
- Sources of infection - cellulitis, wound discharge, cough, dysuria
- Non blanching rash
- Mottled skin
- Cyanosis
- Arrythmia - new onset AF
19
Q
Investigations for sepsis?
A
FBC - Wcc, neutrophils
U&Es - renal function, AKI
LFTs - liver function, liver is potential source of infection
CRP - assess inflammation
Coag screen/clotting - DIC
Blood cultures - bacteraemia
Blood gas - lactate, pH, glucose
Also could do:
- Urine dip and culture
- CXR
- CT scan abdo - suspect infection or abscess
- Lumbar puncture - suspect meningism
20
Q
Management for sepsis
A
1) Assessed and treated within 1 hour of presentation
2) Perform sepsis 6:
Take blood lactate, take urine output, take blood cultures.
Give oxygen, broad spec abx, IV fluids
3) escalate - senior, HDU, ICU
21
Q
Define neutropenic sepsis
A
Sepsis in pt with low neutrophil count of less than 1 x10(9) L
22
Q
Causes of neutropenia in pts?
A
Anti- cancer chemo
Immunosupressants for RA - Hydroxychloroquine, Methotrexate, Sulfasalazine
Other immunosuppressants - Infliximab, Rituximab
Malaria treatment - Quinine
HyperThyroid treatment - Carbimazole
23
Q
Why is neutropenic sepsis so urgent to manage?
A
Pts do not have immune system to fight infection - so are at high risk of death. Need emergency admission and management
24
Q
Specific treatment for neutropenic sepsis
A
Immediate broad spec abx:
Piperacillin with tazobactam (tazocin)
25
What is osteomyelitis?
Inflammation of bone and bone marrow, usually caused by bacterial infections
26
Most common bacteria causing osteomyelitis?
Staphylococcus aureus
27
Risk factors for developing osteomyelitis?
Open fractures
Orthopaedic operations - esp w prosthetic joints
DM - esp w diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression
28
Presentation of osteomyelitis?
Fever
Gangrene
Pain and tenderness
Erythema
Swelling
Non-specific - w fever, lethargy, nausea and muscle aches
29
Investigations to do for suspected osteomyelitis?
MRI - best for establishing dx
XR - not good in early disease. Signs on XR = periosteal reaction, localised osteopenia, destruction of bone
FBC - raised WCC,
CRP, ESR
Blood cultures - causative organism and find abx sensitivity.
30
Management for osteomyelitis?
Surgical debridement of infected bone and tissues
ABx therapy- 4-6 weeks or 3-6 months in chronic osteomyselitis
If in prosthetic joint = prosthetic replacement surgery.
31
BNF recommendation for abx therapy of acute osteomyelitis?
6 weeks flucloxacillin +/- Rifampicin or fusidic acid for first 2 weeks
Alternative of flucloxacillin = Clindamycin. If MRSA related = vancomycin or teicoplanin
32
Name atypical bacteria that cause atypical pneumonia
Legions of Psittaci MCQs
Legionella pneumophila
Chlamydia psittacosis
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Q fever - coxiella burneti
33
Abx options for MRSA?
Doxycycline
Clindamycin
Vancomycin
Teicoplanin
Linezolid
34
Cause of malaria?
Blood protozoan (single celled organism) parasite - Plasmodium species. Spread via bites from female Anopheles mosquito carrying the disease.
35
Types of Plasmodium species causing malaria?
Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
36
Presentation of malaria - symptoms?
NON SPECIFIC
Abrupt onset rigors
High fever
Sweats
Severe headache
Myalgia
Malaise
Nausea
Vomiting
37
Common bacteria that cause chest infections/pneumonia ( spell them too!)
Streptococcus pneumoniae
Haemophilus influenzae
38
Less common/opportunistic bacteria that cause chest infections/pneumonia and when?
Moraxella catarrhalis- in immunocompromised patients and those with chronic pulmonary disease
Pseudomonas aeruginosa- patients with CF or bronchiectasis
Staphylococcus aureus- In patients with CF
39
Main investigation for malaria?
Malaria blood film - need 3 to diagnose malaria
40
What do blood results for malaria show?
Anaemia
Thrombocytopenia
Leukopenia
Abnormal Liver enzymes
41
Chest infection presentation?
Cough
Sputum production
Fever
Lethargy
Crackles on the chest
42
Common bacteria that cause chest infections ( spell them too!)
Streptococcus pneumoniae
Haemophilus influenzae
43
Management for complicated or severe malaria?
(Dr Tom said this is more likely to come up in exam)
Has to be IV:
1. Artesunate (most effective, but not licensed)
2. Quinine dihydrochloride
* a parasite counts of more than 2% will usually need parenteral treatment irrespective of clinical state
* intravenous artesunate is now recommended by WHO in preference to intravenous quinine
* if parasite count > 10% then exchange transfusion should be considered
* shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse
44
Antibiotic for chest infection in community?
Amoxicillin or erythromycin or doxycycline
45
Complications from malaria by Plasmodium falciparum?
Cerebral malaria
Seizures
Reduced consciousness
AKI —\> renal failure
Pulm oedema
DIC - disseminated intravascular coagulopathy
Severe haemolytic anaemia
Death
46
Blood film for malaria has been done. What other investigations to order?
Rapid antigen test
FBC - haemolysis, low HB, low platelets, thrombocytopenia
U&Es - AKI. high creatinine.
LFTs - ALT, jaundice (pre hepatic)
Glucose - reduced
Coagulation screen
Head CT if CNS symptoms - confusion - can see bleeding or signs of cerebral malaria
CXR - see ARDS
47
Management for uncomplicated malaria?
Admit P falciparum pts for treatment
Discuss with local ID unit
Oral options as follows:
1 Artemether with lumefantrine (called Riamet)
2 Proguanil and atovaquone (Malarone)
3 Quinine sulphate
4 Doxycycline
48
Management for complicated or severe malaria?
(Dr Tom said this is more likely to come up in exam)
Has to be IV:
1. Artesunate (most effective, but not licensed)
2. Quinine dihydrochloride
49
Main management for malaria with Plasmodium falciparum?
Admit
IV artesunate treatment
Monitor for complications.
50
Blood film for malaria has been done. What other investigations to order?
Rapid antigen test
FBC - haemolysis, low HB, low platelets, thrombocytopenia
U&Es - AKI. high creatinine.
LFTs - ALT, jaundice (pre hepatic)
Glucose - reduced
Coagulation screen
Head CT if CNS symptoms - confusion - can see bleeding or signs of cerebral malaria
CXR - see ARDS
51
Malaria prophylaxis advice to give pts?
Know where is high risk
Mosquito spray
Mosquito nets and barriers when sleeping
Antimalarial medication.
52
Exam patient with Chlamydophila pneumoniae?
School aged child with mild- moderate chronic pneumoniae and wheeze
53
Q fever exam patient?
Farmer with flu like symptoms
Q-fever linked to animal exposure and their bodily fluids
54
Chlamydia psittaci exam pt?
Parrot owner- contracted from infected birds
55
Define meningitis
Inflammation of the meninges
56
Gram stain of Neisseria meningitidis?
Gram negative diplococci
57
Symptoms of meningitis?
Signs of meningitis?
Symptoms: fever, headaches, photophobia, nausea and vomiting, seizures, drowsiness,
Signs: purpuric rash (non-blanching), neck stiffness
58
Common bacterial causes of meningitis in 6 years - 60 years?
Neisseria meningitidis
Streptococcus pneumoniae
59
Causes of meningitis? (i.e which pathogen groups?)
Viral
Bacterial
Fungal
Parasitic (v rare)
Bacterial meningitis is most clinically significant form because of its high mortality and morbidity
60
Most common bacterial cause of meningitis in neonates (0-3m)?
Group B Streptococcus (usually contracted during birth Group B strep that live harmlessly in the vagina).
61
Name of special tests to look for meningeal irritation?
Kernigs test
Brudzinki's test
62
Describe Kernig's test
Lying pt on back
Flex one hip and knee to 90deg
Slowly straighten knee while keeping hip flexed at 90deg
This creates stretch in meninges. If meningitis is present = spinal pain, or resistance to movement
63
Describe Brudzinki's test
Pt lays flat on back
Examiner lifts pt's head and neck off the bed and flex pt's chin to chest
If meningitis is present = cause involuntary flex of hips and knees.
64
Most common cause of meningitis in older people ?
Listeria monocytogenes
65
Viral causes of meningitis?
Herpes simplex virus
Enterovirus
Varicella zoster virus
66
Causes of non-infective meningitis?
Malignancy (leukaemia, lymphoma and other tumours)
Chemical meningitis
Drugs (NSAIDs, trimethoprim)
Sarcoidosis
Systemic Lupus Erythematosus
Behcet's disease
67
Investigations for meningitis?
Nice guidelines:
FBC
CRP
Coag screen
Blood culture
Whole-blood PCR
Blood glucose
ABG/VBG
Lumbar puncture - CSF analysis (if no signs of raised ICP)
68
Initial management of bacterial meningitis?
2g of IV ceftriaxone (or cefotaxime) twice daily.
Add IV amoxicillin if neonate or older person
Also require dexamethasone with 1st dose
69
Management of meningococcal meningitis?
Management of pneumococcal meningitis?
MM: Intravenous benzylpenicillin or ceftriaxone (or cefotaxime)
PM: IV ceftriaxone
If penicillin allergic = chloramphenicol IV
70
Management of meningitis with non-blanching rash in community setting before hospital transfer?
IM benzylpenicillin
71
Complications of meningitis?
Septic shock
DIC
Coma
Subdural effusions
SIADH
Seizures
Delayed complications : Sensorineural Hearing loss (most common), cranial nerve dysfunction, hydrocephalus, intellectual deficits, ataxia, blindness
Death
72
Patient with TB has insidious onset of personality change and headache. Also has N&V. What is top differential?
TB meningitis
73
Why does pt with miliary TB need lumbar puncture?
Exclude TB meningitis
74
Characteristics of CSF with bacterial meningitis:
Appearance?
Protein level?
Glucose level?
WCC?
Culture?
Appearance - cloudy
Protein level - high \>1g
Glucose level - low; less than half of plasma.
WCC - neutrophils, 1000+
Culture - bacteria - diplococci, Gram -ve
75
Characteristics of CSF with viral meningitis:
Appearance?
Protein level?
Glucose level?
WCC?
Culture?
Appearance - clear (sometimes cloudy)
Protein level - normal/slightly raised
Glucose level - 60-80% of plasma
WCC - lymphocytes, 1000+
Culture - no bacteria culture
76
Characteristics of CSF with TB meningitis:
Appearance?
Protein level?
Glucose level?
WCC?
Appearance - clear, slightly cloudy. Fibrin web may develop.
Protein level - high \>1g
Glucose level - low
WCC - lymphocytes, 1000+
77
Encephalitis features?
Fever, headache, psychiatric symptoms, seizures, vomiting
Focal features e.g. aphasia
78
Causes of encephalitis?
HSV-1 responsible for 95% of cases in adults
79
Where does encephalitis typically affect?
Temporal and inferior frontal lobes
80
Investigations + results for encephalitis?
CSF: lymphocytosis, elevated protein
PCR for HSV
Imaging: MRI is best- medial temporal and inferior frontal changes
Imaging normal in 1/3 of pts
ECG pattern: lateralised periodic discharges at 2Hz
81
Managment of encephalitis?
IV aciclovir should be started in all cases of suspected encephalitis
82
Prognosis of encephalitis?
Prompt treatment: 10-20% mortality
Untreated: 80% mortality
83
Aciclovir side effects?
Generalised fatigue/malaise (common)
Gastrointestinal disturbance (common)
Photosensitivity and urticarial rash (common)
Acute renal failure
Haematological abnormalities
Hepatitis
Neurological reactions
84
When should you suspect encephalitis?
Sudden onset behaviour changes, new seizures and unexplained acute headache with meningism
85
TB drug most likely to hepatotoxicity
Pyrazinamide
86
When is staph aureus likely to cause pneumonia?
After influenza
87
What causes diabetic foot disease?
secondary to neuropathy and peripheral artery disease
88
Why is diabetes a RF for peripheal arterial disease?
diabetes is RF for both microvascular and macrovascular ischaemia
89
Presentation of diabetic foot infection?
Neuropathy: loss of sensation
Ischaemia: lack of foot pulses, reduced ABPI, intermittent claudication
Complications: calluses, ulceration, cellulits, gangrene, osteomyelitis
90
What is low risk for diabetic foot disease?
No deformity, just calluses alone
91
What is moderate risk for diabetic foot disease?
deformity or
• neuropathy or
• non-critical limb ischaemia
92
What is high risk for diabetic foot disease?
Previous ulceration, previous amputation, on RRT, neuropathy + non-critical limb ischaemia, neuropathy + callus AND/OR defomity, non-critical limb ischaemia + callus AND/OR deformity
93
What is ankle brachial pressure index?
ratio of systolic BP in the lower legs to arms
94
What are the interpretations of ABPI?
\> 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
1. 0 - 1.2: normal
0. 9 - 1.0: acceptable
\< 0.9: likely PAD. Values \< 0.5 indicate severe disease which should be referred urgently
95
What is charcots arthropathy?
Bones in the foot become weak--\> dislocations and fractures--\> changes shape of foot/ ankle
Presents with 6Ds- destruction, deformity, degeneration, dislocation, dense bones and debris)
96
Define Cellulitis
Infection of subcutaeneous tissues and dermis
97
If cellulitis extends over a joint worry there might be\_\_\_1\_\_\_\_
\_\_\_2\_\_\_\_( ortho infection) may present as cellulitis
If cellulitis extends over a joint worry there might be\_\_\_septic arthritis\_\_\_\_
\_\_Osteomyelitis\_\_\_(ortho infection) may present as cellulitis
98
Key in cellulitis is a \_\_1\_\_\_ in the skins barrier for pathogens to enter.
1 Breakdown
bacteria need a point of entry
99
Give examples of how skin barrier may be broken to allow bacteria to enter and cause cellulitis
IV drug ucer infection around venepuncture
skin trauma
eczematous skin
fungal nail infections / athletes foot (cracks between toes)
ulcers
100
Who is susceptible to get cellulitis?
* DM - hyperglyacemia
* DM with Peripheral neuropathy - cant feel trauma
* Obesity - pressure sores/immobility
* IV drug users - infection / abscess around point of injection
* PAD - poor blood flow for healing and tendancy to ulcerate
101
What systemic features might point to bacteraemia rather than local infection in cellulitis?
fevers
sweats
rigors
102
How does cellulitis present ? (to look at)
Erythema (red discolouration)
Warm or hot to touch
Tense
Thickened
Oedematous
Bullae (fluid-filled blisters)
A golden-yellow crust can be present and indicate a staphylococcus aureus infection
103
Who is susceptible to MRSA cellulitis infection?
Recent hopsital admission and length of their stay
Ask: has MRSA screening been done? results please
104
What are the bacteria causes of cellulitis ?
Staphylococcus aureus
Group A Streptococcus (mainly streptococcus pyogenes)
Group C Streptococcus (mainly Streptococcus dysgalactiae)
MRSA
105
Compare the gram stain morphology of Staphylococcus and Streptococcus
Staph - clusters of gram +ve cocci
Strep - chains of gram +ve cocci
106
Cellulitis - if there is a hx of trauma with skin penetratio what immunisation status must be checked?
Tetanus
consider immunisation
107
If cellulitis errythema extends over a joint what do you need to assess?
* Range of movement of joint
* Septic Arthritis -pain restricts
* Osteomyelitis LL - weight bearing reduced
* Time course
* start on joint or spread to joint?
* Prosthics
* metalwork / recent arthroscopy
108
1. What is a lifethreatening complication of cellulitis?
2. What would you seen on plain Xray for the above?
1. Necrotising fascitis
2. Xray - may see gas bubbles within tissues
109
1. What are two differencials for an errythematous, swollen LL?
2. Can they co-exist?
1. Cellulitis / DVT
2. Yes - think elderly immobile woman with infected venous ulcers
110
What bedside investigation would you do for pt with suspected cellulitis and why?
Diabetic: BM - hyperglycaemia
Non Diabetics: fasting glucose
ASK : Is sliding scale of insulin needed for better glycaemic control?
111
Cellulitis - how should you examine the skin?
Note distribution and extent of errythema
Draw around at admission - judge extent
Broken skin? check between toes
Temperature difference
palpate local lymphadenopathy
112
If cellulitis includes joint - how examine?
Palpate for bony tenderness
Feel for effusioon
Assess passive and active range of movement
113
Cellulitis - if ulcers present how to examine?
Is any bone visible ?
Describe ulcer (slough, exudate, necrotic tissue, margins, depth)
Metal probe to see if can reach bone - indication of bony involvement
114
What lab investigations for suspected cellulitis and why?
Blood
* FBC - raised WCC (neutrophilia in bacterial)
* CRP
* Blood cultures - organism and sensitivities
Other
* Abscess I&D aspiration - bacterial cause
* Joint fluid aspiration - microscopy and culture - organism
* Deep bone biopsy - debridement see if osteomyelitis
115
What imaging for suspected cellulitis?
Plain Xray / MRI - look for joint destruction in septic arthritis and changes associated with osteomyelitis
116
Treatment for cellulitis?
1st line - IV / oral flucloxacillin
Allergy: IV clarithromycin or erythromycin if pregnant
117
What is the classification for severity of cellulitis?
Eron Classification
118
Outline Eron classification for cellulitis
Class 1 – no systemic toxicity or comorbidity
Class 2 – systemic toxicity or comorbidity
Class 3 – significant systemic toxicity or significant comorbidity
Class 4 – sepsis or life-threatening
119
What are some differencials for cellulitis ( BMJ best practice)
**Necrotising fascitis** - pain ++ / necrotic bulous changes/ crepitus
**Thrombophlebitis** (superficial) - tender palpable cord along vein (recent catheter)
**DVT**- previous DVT/ hypercoag/immobile
**Gout** - urate, knee, 1st metatarsopharangeal
**Lyme disease** - ticks
**Dermamtitis -** demarcated/pruritis/ Hx
**Fixed drug eruption -** Hx rxn, well demarcated, itching burning, lips/genitals involved
120
At which stages of Eron classification would you admit for IV AB?
1. If Eron stage 3 or 4 (toxic, co-morbidities ++, septic)
2. frail, very young or immunocompromised patients.
121
Causative organism(s) in Type 1 necrotising fasciitis?
Mixed organisms - aerobes and anaerobes.
122
Pts with _______ what condition? _____ most commonly get type 1 necrotising fasciitis post surgery?
Pts with diabetes most commonly get type 1 necrotising fasciitis post surgery
123
Difference between Cellulitis and Erysepilas in terms of where it affects the body?
Erysipelas - more superfical - epidermis and dermis
Cellulitis - dermis and subcut tissue
124
Necrotising fasciitis can be classified according to the causative organism:
Type 1 is caused by ____________ (often occurs post-surgery in diabetics). This is the most common type
Type 2 is caused by \_\_\_\_\_\_\_\_\_\_
Type 1 is caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type
Type 2 is caused by Streptococcus pyogenes
125
Which organism most commonly causes erysipelas ? compare to celluitis
**Erysipelas** - Streptoccous pyogenes (group A beta -haemolytic)
**Cellulitis** - Staphloccoccus aureus is most common
126
What is Waterhouse-Friderichsen syndrome?
Complication of meningoccoal meningitis- it is adrenal insufficiency secondary to adrenal haemorrhage
127
Risk factors for necrotising fasciitis?
IV drug use
Immunosupression
Diabetes mellitus - especially if being treated with SGLT-2 inhbitors
Skin factors: recent trauma, burns or soft tissue infections
128
Where does Erysipelas commonly occur and who does it usually affect ?
**Where?** Most commonly on face - cheeks and periorbitally
**Who?** often children / elderly / immunocompromised
129
When do you withhold dexamethasone in meningitis?
Septic shock
Meningococcal septicaemia
Immunocompromised
Meningitis following surgery
130
Presentation of necrotizing fasciitis?
Acute onset
Pain at affected site on skin - pain out of proportion to physical features
Swelling at affected site
Erythema at afected site
Rapidly worsening cellulitis
Tenderness over infected tissue - even with light touch
Skin necrosis, gas gangreen, dusky - late signs
Fever and tachycardia - late signs or absent
131
Management of necrotising fasciitis?
Urgent surgial referral debridement
IV abx (broad spec e.g meropenem).
132
What is discitis?
133
Define necrotising fasciitis
Necrotizing fasciitis — a destructive and rapidly progressive soft tissue infection that involves the deep subcutaneous tissues and fascia (and occasionally muscles), which is characterized by extensive necrosis and gangrene of the skin and underlying structures (from NICE)
134
Features of discitis?
Back pain
Pyrexia
Rigors
Sepsis
Neurological features: e.g. changing lower limb neurology
135
Causes of discitis?
Bacterial- staphyloccocus aureus
Viral
TB
Aseptic
136
Diagnosis of discitis?
MRI- highest sensitivity
CT guided biopsy may be required for
137
Treatment of discitis?
6-8 weeks of IV antibiotics (flucloxacillin for staph aureus )
Choose antibiotic based on cultures
138
Complications of discitis?
139
What else do you need to be aware of for discitis?
Usually due to haematogenous spread implying bacteriaemia and seeding has occured.
Consider doing an transthoracic echo as pt may have endocarditis
140
Presentation of infective endocarditis?
Main symptom and sign = fever and murmer (aortic valve regurgitation)
Symptoms: Headache, myalgia, weight loss, abdominal pain, night sweats, pleuritic chest pain, cough
Signs: Janeway lesions, osler nodes, non-blanching petechiae. murmer.
141
Investigations for suspected infective endocarditis?
ECG
FBC, U+Es, LFTs, CRP
3 blood culture samples (from different sites) - check have not missed infection
1st line imaging = transthoracic echo
Most sensitve imaging modality = transoesophageal echo
CXR
142
RF for infective endocarditis?
Valvular damage
* prosthetic valve
* age related valvular damage
* previous rheumatic heart disease
IV drug use
Male
Age 60 +
Poor dentition
Previous endocarditis
143
Initial management of endocarditis (called Blind therapy)?
Benzylpenicillin and gentamicin
144
Management of native valve (i.e. not prosthetic valve) infective endocarditis caused by Staphylococcus aureus?
* Flucloxacillin 4 weeks
* Penicillin allergy = Vancomycin + rifampicin 4 weeks
145
Management of prosthetic valve infective endocarditis caused by Staphylococcus aureus?
Flucloxacillin + gentamicin + rifampicin for 4-6 weeks
146
Management of infective endocarditis caused by Steptococci sp?
Benzylpenicillin 4-6 weeks
147
Complications of infective endocarditis?
Heart failure - from acute valvular insufficiency
Stroke, haemorrhages
Renal failure
Osteomyelitis
Septic arthritis
148
Common valve affected in IV drug users with infective endocarditis?
Tricuspid valve on R side of the heart
149
Entry mechanism of Strep viridans causing infective endocarditis?
Poor dental hygiene
150
Entry mechanism for Staph epidermidis which causes infective endocarditis?
Indwelling devices - cannulas.
151
**Major** clinical criteria of Modified Dukes criteria for infective endocarditis?
1. Blood culture positive
2. Echo positive or PET CT +ve or CardioCT +ve
152
**Minor** clinical criteria of Modified Dukes criteria for infective endocarditis?
1. Predisposition present - IVDU, Heart condition
2. Fever of 38C\<
3. Vascular phenomena present - arterial emboli, infarcts, conjunctival haemorrages
4. Immunological phenomena present - glomerulonephritis, osler nodes, Rheumatoid factor
5. Serology evidence of infective endocarditis
153
How is definitive infective endocarditis calculated using Dukes Modified criteria?
2 major criteria + 3 minor criteria
OR
All 5 minor criteria present
154
What should a travel Hx include about a persons acivity when they return unwell from abroad?
* Countries - stop overs / time
* Activities - lakes (water contact ) / rural backpacking
* water supply - bruhsing teeth / drinking
* Types of Food
* Insect bites - repellent / nets at night
* Accomodation
* Vaccination status / Prophylaxis for malaria taken
* Any symptoms? then or anyone travelling with
* Sexual Hx - condom use/ sex worker/ MSM
* Medical conditons - predispose to infection e.g. diabetes / immunosuppressive therapy
155
What DDx could a patient traveller coming form aboard have if they describe insect bites?
* Malaria
* Dengue fever
* Leishmaniasis
156
What DDx could a patient traveller coming form aboard have if they describe Diarrhoea?
* Giardia
* Ameobiasis
* typhoid / para typhoid
* schistomiasis
* tapeworm
157
What DDx could a patient traveller coming form aboard have if they describe abdominal pain?
* Typhoid / para typhoid
* schistomiasis
* giardia
* amoedbiais
* tapeworm / hookworm / roundworm
158
What DDx could a patient traveller coming form aboard have if they describe haematemesis?
* Dengue fever
* viral haemorrhagic fever
159
What DDx could a patient traveller coming form aboard have if they describe urinary symptoms?
* Schistomiasis - urinary freq / dysuria / haematuria
160
What DDx could a patient traveller coming form aboard have if they describe rigors / high fevers?
* classic for malaria
161
What DDx could a patient traveller coming form aboard have if they describe night sweats?
* malaria
* TB
* Brucellosis
* Visceral leishmaniasis
162
What DDx could a patient traveller coming form aboard have if they describe cough?
* Typhoid / paratyphoid
* schistomiasis
* visceral leishmaniasis
163
What DDx could a patient traveller coming form aboard have if they describe chest pain?
* Typhoid / paratyphoid
164
Unwell traveller from abroad - what are some differencials if 0-10 days?
* Dengue
* Rickettsia
* Viral (including mononucleosis)
* GI ( bacterial / amoeba)
165
Unwell traveller from abroad - what are some differencials if 10-21 days?
* Malaria
* Typhoid
* Primary HIV infection
166
Examinatioin of pt returned from abroad what should you examine the eyes for?
Conjunctival pallor - Anameia:
* Malaria - haemolysis
* Typhoid / paratyphoid
* typhus
Conjunctival Suffusion
* Leptospirosis
167
Examinatioin of pt returned from abroad and see: jaunice .....what DDx you thinking?
* Malaria
* Hep A - viral hepatitis from food poisoning breakout
168
Examinatioin of pt returned from abroad and see: ROSE SPOTS (pink macules 2 -3 mm on chest / abdomen) .....what Diagnosis you thinking?
* Typhoid / paratyphoid
169
Examinatioin of pt returned from abroad and see: crusted ulcer healing by scarring .....what Diagnosis you thinking?
Hallmark of cutaeneous Leishmaniasis
170
Investigations for pt returned from abroad: what abnormalities are you looking for in a FBC and why might this be?
Haemolytic anaemia :
* Malaria
* Typhoid / paratyphoid
* typhus
Eoisinophilia:
* worm infections
171
Investigations for pt returned from abroad: what abnormalities are you looking for in a Renal Function U&E and why might this be?
Impaired in:
* Malaria
* Typhus
172
Investigations for pt returned from abroad: what abnormalities are you looking for in a LFTs and why might this be?
Derranged in:
* Typhoid / paratyphoid
* ameobic abscesses
* schistomiasis
173
Investigations for pt returned from abroad: what abnormalities are you looking for in a thick and thin blood film ?
3 sets required separate in time
* detect malaria parasite and species
* ring form in Plasmodium falciparum
* Crenulated edge
174
Investigations for pt returned from abroad: why would you do blood cultures and blood glucose?
* cultures - look for organism
* Glucose - critical in treatment of falciparium as treatment with quinine can cause hypoglycaemia
175
Investigations for pt returned from abroad: bedside tests might you do?
* urine dip - haemoglobinuria in falciparum malaria
* commericial malaria antigen test kit
176
What lab required tests might you send off for when investigation a patient returned from abroad ?
* Stool culutes - inclide test for Ova, Cysts and Parasites
* urine specimens for M&S
* Skin lesion biopsy
* Liver biopsy - inflamm response schistomiasis
* lymph node biopsy - leishmaniasis
* Bone marrow cultues -typhoid / paratyphoid / leishmania
177
Unwell traveller from abroad :
\>21 days what are your differencials
* Malaria
* Chronic bacterial (brucella. coxiella, endocarditis, bone and hoint infections)
* TB
* Parasitic infection (helminths / protozoa
178
Examination of a unwell returned traveller from abroad - black necrotic ulcer with erythematous margins what are you thinking?
Rickettsia (tick exposure)
179
Examination of unwell returned traveller - what could a maculopapular rash indicate?
Dengue fever
Leptospiroiss
Rickettsia
Infection mononucleosis (EBV, CMV)
childhood : rubella, parovirus B19
primary HIV infection
180
Examination of unwell returned traveller - what could splenomegaly indicate?
Mononucleosis
Malaria
visceral leishmaniasis
typhoid fecer
brucellosis
181
What neurological symptoms can you get in a returned traveller who is unwell? How serious is this?
Fever and altered mental state - meningo-encephalitis (EMERGENCY)
e.g. cerebral malaria, Japanese encephalitis, West Nile virus
(also common causes N. meningitis, Strep. pmeumonia, Herpes Simplex virus)
182
What vaccinications should you ask about in returning traveller who is unwell?
Hep A / B
Typhoid
Tetanus
Childhood vaccines (MMR, yellow fever, rabies)
183
Baseline investigations for patients newly diagnosed with HIV
Confirmatory HIV test
CD4 count
HIV viral load
HIV resistance profile
HLA B5701 status
Serology for syphilis, hep B (sAg, cAb,sAb), hep c,hep A
Toxoplasma IgG, measles IgG, varicella IgG, rubella IgG
FBC, U&Es, LFTs, bone profile, lipid profile
Schistosoma serology (if spent \>1mnth in sub-Saharan Africa)
Wome should have annual cervical cytology
184
Where is support provided for patient with HIV?
HIV clinical nurse, community support groups, psych support if needed
185
What is post-exposure prophylaxis in HIV
Depends on the type of incidents- low risk may not need PEP
Combination of oral anti-reterovirals as soon as possible for 4 weeks
Serological testing at 12 weeks following completion of PEP
Reduces risk of transmission by 80%
186
What is the HIV seroconversion reaction?
Symptomatic in 60-80% of patients
3-12 weeks after infection
The HIV has entered the body is now rapidly multiplying
187
Features of seroconversion reaction?
Sore throat, lymphadenopathy, malaise, mylagia, arthralgia, diarrhoea, maculopapular rash, mouth ulcers
188
Diagnosis of HIV?
Combination tests of HIV antibodies and P24 antigen
If positive, repeat to confirm the diagnosis
Viral load may also be measured- HIV RNA level
Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, if negative, offer a repeat test at 12 weeks
189
What is anti-retroviral therapy?
Involves a combination of at least 3 drugs, usually 2 nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitors (NNRTI)
190
As well as their normal ART treatment what else should patients with HIV and a low CD4+ count be on?
CD4\< 200--\> co-trimoxazole 480mg PO OD as primary prophylaxis against PCP
CD4\<50 --\> Azithromycin 1250mg PO once weekly protect against MAI, also be assessed by opthalmology with dilated fundoscopy to look for intra-ocular infections
191
Nucleoside analogue reverse transcriptase inhibtors side effects?
Periperheral neuropathy
Tenofovir: renal impairment and osteroporosis
Zidovudine: anaemia, myopathy, black nails
Didanosine: pancreatitis
192
non- Nucleoside analogue reverse transcriptase inhibtors side effects
P450 enzyme interactions
rashes
193
Protease inhibtors side effects
Diabetes, hyperlipdaemia, buffalo hump, central obsesity, p450 enzyme inhibition
194
What is Septic Arthritis ?
Infection of the joint and synovial fluid
195
What organsims cause septic arthritis?
Staphloccus aureus (most common cellulitis)
Strep pyogenes
Haemophilus influenzae type B (\<5yrs / non working spleen)
Strep pneumoniae (no spleen / hyposplensim)
Mycobaterium tuberculosis (immunosuppressed TB in body)
196
Briefly outline the pathophsyiology of septic arthritis
Results from either direct bacterial invasion from overlying cellutlis or osteomyelitis. Can also result from haemotoligcal spread from bacteraemia. Cabn occur following surgery e..g total hip replacement
197
What are the clincial features of septic arthritis?
Hot
Swollen
Tender joint
Reduced rang of movement (active and passive) due to pain
Fever (more likely with haematological spread)
(NOTE: TB septic arthtirits can get COLD joint!)
198
What are some RF for septic arthritis (BMJ BP)
OA / RA
low socioeconomic status
Prosthetic Joint
\>80 yrs
Immunosuppressed (HIV/diabetes/ alcohol misuse)
concurrent infection
ulcers
recent joint surgery
interarticular injections
199
What investigations would you do for septic arthritis?
Joint aspiration microscopy, sensitivity and culutre
WCC count of aspirate
Blood cultures
CRP / ESR / WCC
U&Es
LFTs
200
How treat septic arthritis
THINK SEPSIS - start sepsis 6
Flucloxacillin
Penicillin allergic - Clindamycin
refer to Ortho for surgical washout if severe/ prosthetic joint removal
201
What are some complications of septic arthritis
Damange to synovium and cartilage - osteomyelitis and arthritis
sepsis
death
202
Xray features of Mycoplasma pneumoniae?
Bilateral consolidation
203
You suspect malaria in a pt. After thick and thin blood film the parasite count was 5%. In the last six hours, she had become progressively drowsy. What intravenous treatment is most appropriate?
IV artesunate
This is SEVERE malaria
Or IV quinine until artesunate is available. quinine ( cardiac monitoring + regular BMs - risks of arrhythmias + hypoglycemia)
204
Definition of cystitis?
UTI that affects the bladder
205
Cause of cystitis?
Eschericha coli - from colon --\> transurethral movement into the bladder.
206
Clinical features of cystitis?
Urinary frequency
Dysuria
Urgency
Foul smelling urine
Suprapubic pain
Suprapubic tenderness on palpation of region
207
Ddx to cystitis?
Pyelonephritis
208
Investigations for cystitis?
Urine dipstick - positive for leucocytes and nitrites
MSSU (especially in men, children and pregnant women) - to culture and treat accordingly
209
Management of cystitis?
Oral nitrofurantoin or trimethoprim
Conservative measures to reduce risk of further infections - regular fluid intake, post-coital voiding.
210
Definition of pyelonephritis?
UTI affecting kidneys / renal pelvis
211
Cause of pyelonephritis?
Escherichia coli - from colon transurethrally to kidney
212
Clincal features of pyelonephritis?
Fever/ rigors
Malaise
Loin/flank pain
Vomiting
Clinical exam = fever, loin and or flank tenderness
213
Differentials for pyelonephritis?
Cystitis - (but pts rarely have flank/loin tenderness or be pyrexial )
Lower UTI
Men - acute prostatis
Acute abdo condition - if have N&V
Women - PID, gynae conditions
214
Investigations for pyelonephritis?
Urine dip - positve for leucocytes and nitrites
FBC - raised WCC
U+Es - renal impairment
Blood cultures
Urine MSSU - for MC&S
Renal USS - for hydronephrosis of kidney with severe infection
215
Management for pyelonephritis?
Admit
IV abx - broad spec cephalosporin/quinolone/gentamicin
IV fluids if dehydrated
216
What AB drug is used for chemoprophylaxis for close contacts of a pt with bacterial meningitis?
Rifampicin
A commonly used alternative is Ciprofloxacin, although off license.
217
Symptoms of pneumonia
Cough Sputum Dyspnea Chest pain - may be pleuritic Fever
218
Signs of pneumonia
Fever Tachycardia Reduced oxygen sats On auscultation - reduced breath sounds and bronchial breathing
219
CXR findings for pneumonia ?
Consolidation
220
Investigations for pneumonia and corresponding findings ?
CXR - consolidation
FBC - neutrophillia I.e. high WCC
U+Es - dehydration - urea in CURB6
CRP - raised as response to infection
ABG - indicated if O2 sats are low
Sputum culture - find sensitivity for abx
221
Classic organism causing pneumonia in alcoholics?
Klebsiella pneumoniae
222
Baseline investigations for all new pts diagnosed with HIV?
* Confirmatory HIV test
* CD4 count
* HIV viral load
* HIV resistance profile
* HLA B\*5701 status - as allele can cause hypersensitivity to some drug treatments
* Serology for other conditions: syphillis, hep B, hep C, hep A
* Immunoglobulin status for Measles, Rubella, Toxoplasma, Varicella
* FBC, U+Es, LFTs, bone profile and lipid profile
* Women - annual cervical cytology
* If spent 1m\< in sub saharan Africa, need a schistosomiasis screen
223
Which vaccinations should pts with HIV get?
Hep B
Pneumococcus
Annual influenza vaccine
224
Treatment for typhoid?
IV ceftriaxone 2g OD (empirical - before sensitivity known)
Once sensitivities known - switch to PO Ciprofloxacin 500mg BD or Azithromycin 500mg OD
225
C.diff abc?
oral Metronidazole or vancomycin
226
what is minimum inhibitory conc?
Min conc of an abx required to inhibit bacterial growth
Abx specific
Organism specific
Isolate specific
227
Classical definition of Pt with PUO?
Temp 38\< (on many occasions)
Illness for 3+ weeks
No diagnosis despite having inpaient investigations for 1+ week
228
Common causes of Pyrexia with unknown origin?
Infective - TB, abscess, infective endocarditis, brucellosis
AutoImmune/connective tissue - temporal arteritis, Wegener's granulomatosis
Neoplastic - leukaemias, lymphomas, renal cell carcinoma
Other - drugs, VTE, hyperthyroidism, adrenal insufficiency
229
What to ask in Hx of Pt with pyrexia of unknown origin?
Chrolonolgy of Sx
Pets/animal exposure?
Travel - in last year?
Occupation?
Meds?
FHx?
Vaccination history?
Sexual contacts?
230
What to examine in a patient with Pyrexia of unknown origin?
LN? - swollen? where?
Stigmata of endocarditis?
Weight loss/cachexia?
Joint abnormalities?
231
What investiagtions to do in pt with pyrexia of unknown origin?
***Bloods:*** FBC, U+Es, LFTs, bone profile CRP, clotting, TFTs, MULTIPLE sets of blood cultures (2-3), LDH, B12, ferritin, folate. If you think is related to AI disease = immunoglobulins, RF, ANA, dsDNA etc
***Microbiology/virology:*** HIV, HEP B+C, syphillis, MSU, sputum cultures, malaria films (x3 from 3 diff sites at diff times, for pts w/ travel Hx). Viral swabs, CMV+EBV serology, Brucella serology, fungal serology
***Imaging:*** CXR, CT TAP, MR head, MR spine, PET scan (if relevant)
***Biopsies:*** MC+S, TB culture, histology done on all samples. Need biopsy from bone marrow, LN, abscess, liver
232
What needs to be monitered when pt is on TB treatment?
LFTs
Visual aquity tests
233
How to prescibe abx?
| Mnemonic GRASP
G- guidelines
R- renal function/ liver function
A- allergies
S-sentivities
P- previous abx
234
How to look at drug chart?
| PRESCRIBER mnemonic
P- patient details: name, DOB
Re- allergic reactions- check and ask, what happens
S- Signature (prescription not valid otherwise)
C- contraindication- use BNF
R- Route
I- indication + duration
B- blood clots- VTE risk assessment
E- anti-Emetics
R- pain Relief
| FYI generic name of drug and when to review/ stop- 48 hours if not sure
235
What is Rickettsial disease?
* occur worldwide and are associated with the patient having been bitten by an ectoparasite such as a louse, mite, flea, mosquito, or most commonly, a tick.
* usually divided into the spotted fever group, where patients present with fever and spots, and the typhus group.
