Infectious Disease Flashcards
MCC bacterial endocarditis
staph aureus
Native valve endocarditis
Staph aureus, strep bovix, strep gp D (enterococci) -> Vanco/gentamycin empiric
Prosthetic valve
staph epi, streptococci, G neg fungi -> vanco, rifampin (clears sticky bugs - staph epi), gentamycin
IVDU
staph aur, enteroccus, g neg strep viridans -> vanco + gentamycin
Indications for endocarditis surgery
Severe CHF - bacteremia x 6 days (if repeat bcx 48 hrs +, cont abx, repeat ctx, recurrent emboli, valve abscess, large fungal vegetation
Rt sided endocarditis with septic emboli - abx?
Daptomycin
Pt with sympt endocarditis - bctx done, vanco/gent started - 72hrs later bctx + strept sens to PCN - abx changed to PCN - gnet d/c’d - reepat bctx still + 24hrs later wtd?
continue abx, repeat bctx in 48hrs
IVDA rec with fever, cough hempotysis, pleuritis CP - II/VI SEM - 2-3 nodules on CXR - dx?
Rt sided endocarditis -> vanc/gent
Pt fever, +BCtx for clostr sept/ Strep bovis - wtd
Colonoscopy r/o malignancy
IVDA suspected for endocarditis vanc/gent started - ctx +PCN enterocci - vanc stopped - pcn started but then with prurtis swelling lip swelling - wtd?
D/C PCN start vanc
Vanc develops itching/redness
redman’s - slow IV infusion +- benadryl
Pt s/p TURP 2 wks later with fever growing enterococci
older men, AV>MV, more CHF less embolic events, more conduction defects - don’t use ceftriaxone (doesn’t kill)
Valve replacement
NOT in pt febrile on abx - mild AR EF 60% - BUN cr 25/2 -> immune complex phenomenon - see splinter hemorrhage, janeway lesion, roth spots
Pt treated for endocardtisi defervesces and WBC dec bu twith 1st deg AVB - concerned?
yes - r/o valvular abscess - TEE
Pt on imipenum/cilastatin for nosocomial infxn h/o seizure d/o - has dz - related to imipenum?
Yes - inc’d incidence of seizures at higher doses
Endocarditis ppx only for high risk procedures in high risk conditions…
High risk condition - ALL prosthetic valve, prev h/o endocarditis, congential heart dz, unrepaired CHD, repaired CHD within 6 months, post tx heart WITH valvular dz, repaired CHD with prostesis or patch (forever)
High Risk procedure - likely to cause bleeding->endocarditis - dental extraction, periodontal procedures, root canal, implants
NOT HIGH RISK - GI/GU (only if risk of mucosal damage
Low risk conidtions - ASD secundum, 6 months after repair of ASD/VSD/PDA, prev CABG/HOCM, PPM, MVP with murmur MS/AS, fxn murmur
Low risk procedures - cavity filling, endotrach intub, bronch all GI/GU, vaginal hyterectomy, D/C C section, IUD, cath, circumcision
Endocarditis ppx
Amox 2g po 1 hr prior, if no PO then amp IV, PCN all - azithro, post procedure - > NOTHING
Pt witih PDA going for cystoscopy
NO ppx
Pt with bacteremia s aur due to IV line - vanc started wtc
TTE - neg tx x 2 weeks, + tx 4-6 weeks
Pt with susp diverticulitis pw f/c/abd pain - 3 days later temp 101, catheter site clean wbc 17K - wtd
vanc/imipenum
obesity with vanc
1.5g IV q12h
Surgical site infxn ppx
IV abx 1 hr prior to surgery/24 hrs after
35yo IVDA fever/chills wit hmurmur, vegetation on TV bctx MRSA - tx?
Daptomycin
Empiric tx meningitis
Head trauma/NSx - staph aur MRSA, S pneumo, G neg bacilli - vanc + ceftazidme
60yo Listeria, S pneumo, neisseria -> Ampicicillin (listeria), CFTtx (S pneumo), Vanco (MRSA)
15yo - S.pneuo, neisseria, h flu -> Ceftriaxone
2 month - strep agalactiae, E. Coli, Listeria - Ceftx + ampilcillin (listeria)
Normal CSF
<5cells, lymph, Gluc 40-80, Protein 15-45
Bacteria CSF
10-100K cells, PMNs, dec gluc, inc protein, inc opening pressure
West nile CSF
10-1K cells, Lymph, dec gluc, inc protein, muscle wk, rash, dec DTR
TB CSF
10-1K, lymph, dec gluc, very inc protein,
Aseptic CSF
10-2K, lympoh normal gluc, inc to normal protein, enterovirus, OKT3, NSAIDS, bactrim
Early bacterial CSF
10-1K, lymphs > PMN, dec gluc, inc protein, CSDF to ser glu <0.4
Encephalitis CSDF
1-2K, lymph, normal gluc, normal to inc protein
HSV enceph CSF
1-2K, lymph, N gluc, n to inc protein, +RBC 1:1 ratio
70yo Pt with DM p.w mental status change spinal tap with many WBCs mainly PMN G stain neg ctx pending wtc
ceeftx + vanc cover resistant strep pneumo + ampicillin cover listeria
55yo post renal tx on steroids pw fever, neck stiffness with g po rods diphteroids in csf; PMN 65% and lymphs 35% - dx?
Listeria - tx ampicillin + gentamycin (bactrim if PCN all)
24yo M neck pain, h/a, neck sign + spinal tap WBC 105, lymphs no RBC gluc 50 - cause?
entero/echo virus meningitis
Causes of aseptic meningitis
OKT3 ab, NSAID, bactrim, echo/enterovirus
70yo COPD PNA twice in 1 year p/w cough, fever, chills, MS change - WBC 17 PMN, LLL consolidation, CTH no bleed - spinal tap WBC >20K, PMN, dec gluc, inc protein, gram stain cocci in pairs - wtd?
empiric thx - ceftriaxone + vancomycin + dexamethasone
37yo woman solid organ tx couple weeks later with diarrhea/low grade fever then photophobia, h/a confusion - temp 102, CSDF 250WBC 55% PMN, gluc 35 - g stain neg - empiric tx?
ceftriaxone + ampicillin (listeria)
Pt with meningitis - LP WBC 75, gluc 28, elev protein - elev OP - crypt ag neg, g stain neg - tx for?
bacterial meningitis empirically
16yo MS change, fever BP 80/60 - exam midline scar abdomen - lab leukocytosis - h/o MVA 2ya splenectomy
organism - s pneumo (capsule)
Meningitis by h&P - wtd
IV abx - do not wait!
Pt with h/a x 2 days - now dizzy, lethargic - meningieal + sign - 7th episode in 6 years dx - CSDF granular cells?
beningn recurrent lymphocytic meningitis - HSV-2 - supportive care only (antivirals no benefit) - Mollarett’s meningitis
Fever, h/a, vom/seizure - smelling fishy odor/burning rubber, auditory hallucination - MR brian hyper intensity temporal lobe -> EEG sharp and slow waves temporal lobe - LP WBC 200 lymphs, gluc 45, protein 75 RBC 65! dx?
Herpes encelphalitis - IV acyclovir
70yo h/a, fever x 5 days, confused, ocular pain, diplopia - hiking partner similar sx which resolved - mild neck signs + or focal wk one side body DTR absent - LP WBC 55, 100% lymph, protein 90 gluc 50 wtd
WNV IgM ab check - prognostic factor is age - >75 is bad
Reservoir - birds, transmitting agent=mosquitos
Pt fever h/a x 2 days - neck stiffness WBC 8800 68% PMNs - 8% bands - spinal tap WBC 85 54% PMN 33 lymph RBC 0 - gluc 26, protein 68
early bacterial meningitis
20yo F college with tonic clonic sz - h/a and strange behavior x 1 week with anxiety/paranoid behavior, no psych/drug abuse hx - orthostatic hypotension, choreform movements difficulty choosing words - CSF 40WBC 96% lymph, 3 RBC, gluc 62, protein 30 CTH normal - tx’d for HSV enceph no improvement HSV PCR neg - dx?
NMDA rct encephalitis
H/A confusion, petechial maculopapular rash - CT neg, LP WBC >2K - PMN and low gluc - G stain G neg diplococci - meningiococcal meningitis - tx with ceftx 3 days later hypotensive shock
b/l adrenal hemorrhage -> IV hydrocortisone
Who to PPX for meningitis
prophylax day care/nursery school contacts, household contacts
How to PPX meningitis
rifampin 600po BID x 2 days If no rifampin cipro x 1 dose If on OCP - change contraception while on rifampin If preg ceftx 250mg IM x 1 Droplet precautions
Pt tx’d for meningiococcal meningitis since yesterday - how long continue isolation
D/C isolation now
52yo M p/w h/a - fever/neck signs - spinal tap elev open press, WBC 45 lymphs, protein 52, gluc 65, abx coverage for strep pneumo and hsv - 2 days later ctx neg, HSV pcr neg
d/c all meds and d/c home
HSV-2 causes…
aseptic meningitis - and can be accomopanied by gential ulcers and HSV-1 encephalitis
UTI
cystitis -> mostly ecoli - young women, staph saprophyticus, epi
Pyelonephritis
Catheter relted
Prostatis
Uncomplicated cystitis
3 days nitrofurantoin/bactrim/cipro - if sx persist >3 days c/s tx x 7 days
Cystitis in pregnancy
nitrofunatoin or amoxicillin x 7 days
Asx bacteruria in pregnancy
TREAT
Asx bacteriuria in DM
DO NOT TX
Asx bacteriuria post transplant
TREAT
Asx funguria with foley
DO NOT TREAT
asx bacteriria in foley
DO NOT TREAT
Recurrent cystitis
c/s and tx then suppressive regimen (bactrim/cipro)
Pyelonephritis
chills, fever, flank pain, tenderness, inc WBC urine
24yo F fever, chills, flank pain dysuria inc freq urin - +flank tenderness, +u/a 40WBC
tx cipro 7-10 days (quinolong)
if preg - admit and start ceftriaxone or amp + gent
If still temp in 3 days - renal US r/o structural abn
PCN allergy - aztreonam
32yo flnak pain, UA WBC >20 with many bacteria temp 102, HR 110 - started on amp-sulbactam - 3 days later pt eating/ambulating temp 99 HR 86 - grows ESBL E.coli and BCtx g neg rod -
still ok to d/c change to amox-clavulanate (augmentin)
Elderly male dysuria inc freq, tender prostate
Acute prostatitis - E.Coli
Tx: bactrim or quinalone (cipro) 4-6 wks
NH pt with foley and recurrent UTI - ppx?
nothing effective
Pt with foley - urosepsis -
change foley, start abx
NH pt with stroke, chronic foley with urosepsis several times/year - minimize risk of UTI?
close drainage catheter system
When is foley justified in elderly pt to promote healing
Stage IV sacral ulcer
STD - Gonnococcus, Chlamydia
no ulcer, no adenopathy, +discharge
Gonococcus
tx ceftriaxone
Chlamydia
Tx doxycycline or azithro
GC & Chlamydia
ceftriaxone + azithro 1gm or Azithro 2g one dose
Presentation GC/Chylamydia
urethritis, epidiymitis, mucopurulent cervicitis, dysuria, pyuria without bacteriuira, PID, diss gonococcal infxn (DIG)
24yo F college student sexually active with fever, chills.n,v x 3 days no vaginal d/c, tmep 102, HR 106, MM dry, left flank tenderness, mild suprapubic tenderness - no cervical motion tenderness - preg test neg
Admit - bctx, tx with IV cipro or bactrim
Vaginitis - Trichomonas
yellow d/c, strawberry cervix, pH>5
tx - metroniidazole 2g x 1 dose -> TX PARTNER
Bacterial vaginosis (gardnerella)
think d/c, clue cells, fishy odor pH>5
Tx Metronidazole x 7 days (whole garden - tx many days) - or metronid gel x 5 days, or clinda cream x 7 days - DO NOT TX PARTNER
Candidiasis
not smelling, thick white d/c
Tx - fluconazole 150 x1, topical clomazole x 3-7 days
tx partner only if balantitis present
pt with scanty foul smelling dc OTC vag azole and oral fluconazole don’t work - wtd?
NOT Candidasis - treat for gardenerella/trichomonas with flagyl or clinda po or cream - check vaginal pH - if scraping bleeding - chlamydia
Pt with dysuria - d/c on exam - UA WBC and clue cells - tx?
metronidazole (bacterial vaginosis)
PID
lower abd pain, CMT, adnexal tenderness, mucopurulent d/c, uterine tenderness
Etiolgoy - Neiseria gonorrhea, chlamydia, vaginal anaeroboes
Complications of PID
infertility, ectopic preg, perihepatitis, tuboovarian abscess
Tx of PID
Outpt - Ceftx 250 IM, dox 100 bid x 2 weeks (PCN ofloxacin +clinda/flagyl)
Inpt - vomiting/sev pain - cefoxitin/cefotetan + doxy 100mg bid x 2 weeks (PCN allergy - clinda/flagyl + genta + doxy)
25yo F p/w progressie lower abd pain for past 4 days with nausea, vomiting, fever - denies dysuria or flank pain - temp 101, HR 100 lower abd tenderness - cervical d/c and CMT on exam - WBC 17, 70% pmn - ctx P
Admit and tx with IV cefoxitin iv doxy for PID (not tolerating PO)
24 yo sexually active man with uretheral d/c - given ceftx 250 x 1 and d/c 10 days later with uretheral d/c - wtc?
chlymida (gonnorrhea treated) - doxy 100 bid x 7 days or aithro 1g x 1 - always tx for both gonorrhea and chylamydia
Gonorreha (2-6 day incubation)
Chlymydia (1-4 wk incubation)
Young woman on OCP, sexually active with yellow mucoid dc - exam non-tender but bleeding and cervix erythematous swollen - smear with wbc bacteria no hypahe - organism?
Chlamydia
20 yo F dysuria x 1 week - no fever or flank pain - pelvic exam no CMT no bacteriuria, wbc 20/hpf pyuria
dx chlamydia - check urine nucleic acid
tx doxycycline or azithro
Repeat chylmydia test
false + (test neg after 3 weeks)
>3 weeks - true positive retreat pt and partner
Student on spring break - p.w tenderness in posterior testes 1 week later - striping of urethra with d/c
chlamydia epidiymitis - tx azithro
24yo F sexually active pain on movement of wrist joint - single pustular lesion on dorsum of hang, swollen right knee - greatest yield of culture from…
cervical culture or history
do not need parents permission to tx STD
Gay pt c/o constipation, pain on defication and generlized wk - ulcer in perieal area - ulcer in anal canal on anoscopy - dx?
HSV
Pt with acute testicular pain - h/o several sexual encounters - no truam - US normal - dx of epidiymitis - organism?
35yo E.Coli, entero
Uncircumcised pt wit pearly penile papules wtd?
do nothing
Genital ulcers
HSV, syphilis, H ducreyi, Lymphogranuloma venerium, granuloma inguinale
Pt with painful ulcers - started as grouped vesicles - lymph nodes +- -> fever, h/a, myalgias
HSV (DNA virus) Tx - 1st episoe - acyclovir x 10 days 2nd -> acyclovir x 5 days recurrent >6/year - acyclovir ppx severe dz - iv acyclovir - reduces duration of sx and asympt viral shedding
Pt w/ painful genital ulcers, irreg borders initially started as tenderpapules painful adenopathy fluctulant -> rupture - schools of fish/boxcar - GRAM NEG Bacillus
H. ducrey -
tx - ceftrx 250 IM x1 or azithro 1gm x1 or erythro 500 x 7 days
Pt with PAINLESS gential ulcer - disappears in 1 week - 2-6 weeks later LAD - buboes, fistulae rectal scaring
Lymphogranulum venerum (LGV) - Chylymia tracho tx - Doxy 100mg bid x 21 days
Pt with terrible looking PAINLESS ulcers on penis + LAD looks like penile CA
Granuluoma Infuinale - klebsiella granulomatis
Micro: Donovan bodies - bipolar safety pin intracytoplasmic inclusions
Tx - Doxy x 21 days or bactrim/erythro
Young woman 4 montsh ago with PAINLESS genital ulcer - dark field +, RPR neg at time - tx’d with PCN now p/w sever small ulcer - tender RPR 1:8 -
has herpes infxn - acyclovir
Asx pt RPR screening 1:8 postive FTA +
If pt RPR neg last year->early latent syphilis-> benz PCN 2.4 mu x1
If Pt RPR neg >1 yr ago -> late latent syphilis - 2.4 mill units wk x 3
Pt with painless genital ulcer raised with indurated margin and clean base wtd?
Dark field microscopy
tx - benz PCN 2.4 units x1 or doxy x 14 days
Pt with fever h/a generalized adenopathy, maculopap rash palms/soles, ele ast/alt alk phos, hereophile Ag neg, elisa neg, HIV RNA <50 wtd
VDRL/RPR to r/o 2ndary syphilus - FTA+ for life
tx - Benz PCN 2.4 mu x 1
if repeat VDRL titer dec 4 fold tx sucess
If repeat VDRL inc/stay same -> LP to r/o neural sypilis
40yo for regular checkup - pupils 4mm when figer to nose, eyes converge and pupils 3mm, flashing light left pupil doesn’t constrict - Arygl robertson pupil
Spinal tap VDRL r/o neuro syphilus
Spinal tap WBC 410 lymph VDRL +, high protein, gluc 60 - wtd?
PCN G 2m units Q4h x 2 weeks
If PCN allergic - desensitize in ICU
repeat spinal tap q6m till WBC normal
Pt dx with syphilis started on PCN couple hours later with HA/fever, myalgias - BP 90/70, HR 104
Jarisch Herxheimer rxn - wtd?
Bed rest, ASA, continue PCN (NOT ANAPHYLAXIS)
45yo M h/a, difficulty walking, imbalance, fever double vision - HIV CD4 395, VL<24 dx?
neurospyphilis - spinal tap VDRL
Tick borne
RMSF, Lyme, Erlichia (anaplasma), babesia, Tularemia, STARI (southern tick associated rash illness)
ONLY ONE WITHOUT RASH COMMON IS ERLICHIA**
22yo N carolina camp c/o h/a, fever, myalgia 3 days later macular rash extremities - next day petechial
NMSF - doxycycline/tetracycline
57yo M cramping p/w complaint of h/a, fever, myalgias can’t recall tick bite - exam low grade temp, mild confusion no rash - WBC 2.5, Hg 13, plt 60 AST/ALT eleve 150/120 - cause?
Erlichia - anaplasma - only one without common rash!
Pt vacationing nantucket/long island p.w fever, shaking chills, drenching sweats NO RASH - blood smear ring forms, maltese cross, tetrads - Hg dec inc retic (hemolysis) dx?
Babesia
Tx - mild form - Azithro + atoquone
Severe - Quinine + clindamycin
Pt at MD office in NJ with skin lesionon thigh, erythematous lesion w/ central clearing - lesion smaller few days ago dx?
erythema migrans - secondary lyme (serology not reliable - clinical dx)
Tx - doxy, if preg then amox (fever, h/a LAD, arthralgia)
Pt fishing onnantucket - rash on leg which disappeared few days later - 2 wks later pt with dizziness - ii/iii heart block
Lyme secondary - cardiac
Tx: PCN/Ceftx (NO DOXY)
Cardiac I/II/III heart block
Neuro: aseptic meningitis, bell’s palsy, foot drop
Pt with disseminated or late stage lyme usually has…
western blot IgG banding+ > 5 bands
22yo wk left foot, no trauma - hiking several weeks ago with as rash cleared in few days doesn’t recall tick bite - dec power L foot, dec reflexes L foot dx?
Foot drop 2/2 lyme dz stage II
Stage II months to years later - presents as monoarticular arthritis or chronic neuro sx
Pt hiking in NE on friday, found tick monday - no rash no sx
> 24hr with tick - doxycycline even if asx
if < 24 hrs with tick can observe if asx
Pt hiking NE for bird watching - p/w facial palsy - cluster of vesicular eruption over auditory canal - dx?
Herpes zoster - DNA virus
tx - acyclovir
40yo F refereed with rash, central clearing - tx’d with doxy x 3 weeks - rath better but then malaise - to urgent care center repeat doxy x 2 week - f/u at MD office - 7/10 IgG bands _ and all bands + IgM
Post lyme syndrome - takes 6 months for sx to resolve
Tx - reassure do not retreat
Pt p.w tick attached - wtd?
place forceps at base of tick and lift gently
22yo Pt hiking in wisconsin - to ED with new onset weakness, DTR absent, denies tick bite - wtd?
search scalp for tick - tick paralysis better in hours once tick removed
Elderly pt with fiery red, well demarcated cellulits on face
Erysipelas - strep - cocci in chains
Tx - PCN
Complication - endocarditis
Female from singapore, honey crusted lesions mouth and chin - dx?
Staph infxn - impetigo
Strep throat complication
Acute glomerular nephritis
Pt with cellulits of leg, started on cephalosporin 1st gen - 72hr later cellulitis worse no brawny edema or bullous lesions, no DM wtd?
D/C cephaloporin and start bactrim, vanc or clinda
32yo cellulits on left leg wtd?
bactrim and cephalexin (cover MRSA and strep)
Invasive MRSA commonlypresents as ?
Bacteremia