Infectious Disease Flashcards
What does penicillin G, VK, benzathine treat?
Viridians strep Strep pyogenes Oral anaerobes Syphilis Leptospira
What are the beta lactam antibiotics?
Penicillin
Cephalosporin
Carbapenems
Aztreonam
What does ampillicin and amoxicillin cover?
Covers same as penicillin E. Coli Lyme Other gram - bacilli Amoxicillin - HELPS
What does HELPS stand for in coverage by amoxicillin?
H - h. Influenzae E - e.coli L - listeria P - proteus S - salmonella
Penicillins including amoxicillin and ampillicin are the best initial therapy for what?
OM
Dental infection & endocarditis prophylaxis
Lyme disease limited to joint, rash, CN 7
UTI in pregnant women
Listeria monocytes
Enterococcal infection
What do Penicillinase resistant penicillins treat aka semisynthetic?
Skin infections - cellulitis, impetigo, erysipelas
Endocarditis, meningitis, bacteremia from staphy
Osteomyelitis, septic arthritis when organism is proven sensitive
* not active MRSA and enterococcus
- When Staphylococcus is sensitive to the semisynthetic penicillins and if concurrent Gram-negative infection is not suspected, these are the ideal agents. They are more efficacious than vancomycin is when the organism is sensitive.
Penicillinase - resistant penicillins -name them?
Oxacillin Cloxacillin Dicloxacillin Nafcillin Methicillin belongs to this group of antibiotics as well and was one of the original drugs developed in the class. Methicillin is not used clinically, however, because it may cause interstitial nephritis.
What are the penicillins that cover pseudomonas?
Piperacillin
Ticarcillin
Azlocillin
Mezlocillin
What can you use to treat MRSA?
Vancomycin Linezolid Daptomycin Ceftaroline - Vanco derivative 5th generation tigecycline
What are the anti pseudomonals best initial therapy for?
Cholescystitis & ascending cholangitis Pyelonephritis Bacteremia Hospital acquired and ventilator associated pneumonia Neutropenia and fever
What are the gram - rods ( bacilli )?
C- citrobacter M - morganella S - serratia P - pseudomonas E - e.coli E - enterbacter
If patient has rash to penicillin - what do you give?
Cephalosporin
If patient has anaphylaxis to penicillin - what do you give?
Non beta lactam antibiotic
What is the 2nd generation cephalosporin?
Cefotetan Cefoxitin Cefaclor Cefprozil Cefuroxime Loracarbef
What are the 1st generation cephalosporin?
Cefazolin
Cephalexin
Cephradrine
Cefadroxyl
What does cefuroxime, loracarbef, cefaclor?
Respiratory infections like bronchiolitis, OM, sinusitis
Cefotetan & cefoxitin are best initial therapy?
PID with doxycycline
Cefotetan and cefoxitin increasing risk of bleeding and give disulfiram like reaction w alcohol
What are the 3rd generation of cephalosporins?
Ceftiaxone
Cefotaxime
Ceftazdime
What age group do you avoid ceftriaxone?
Neonates b/c impaired biliary metabolism
What does ceftriaxone treat?
First line for pneumococcus Meningitis Cap pneumonia w macrolides Gonorrhea Lyme involving heart or brain
What does cefotaxime treat?
Give to Neonates
SBP - spontaneous bacterial peritonitis
What are the 4th generation cephalosporin? What do they treat?
Cefepine
Treats neutropenia and fever
Ventilation associated pneumonia
What the Carbapenems? What do they cover?
Imipenem Meropenem Ertapenem Doripenem - covers gram - bacilli, neutropenia and fever
What is the 5th generation cephalosporin treats MRSA?
Ceftaroline
What is the only Carbapenems that doesn’t cover pseudomonas?
Ertapenems
What are the fluroquinolones?
Ciprofloxacin
Gemifloxacin
Levofloxacin
Moxifloxacin
What does azetronam cover?
Only gram - bacilli
No cross reaction w penicillin
What do fluoroquinolones used to treat?
Best therapy for cap pneumonia including penicillin- resistant pneumococcus
Ciprofloxacin treats cystitis and pyelonephritis
Diverticulitis and GI infections - all will be combined w metro to treated anaerobes
What are the side effects of fluoroquinolones?
Bone growth abnormalities in children and pregnant women
Tendonitis and Achilles tendon rupture
Which fluoroquinolones treats diverticulitis w/o combo metro?
Moxifloxacin
Name the aminoglycosides?
Gentamicin, Tobramycin, Amikacin
What are the side effects of aminoglycosides?
Nephrotoxic and ototoxic
What do aminoglycosides treat?
Gram-negative bacilli (bowel, urine, bacteremia)
Synergistic w beta-lactam antibiotics for enterococci & staphylococci
no effect on anaerobe
What does doxycycline treat?
Chlamydia
Lyme disease limited to rash, joint, or seventh cranial nerve palsy
Rickettsia
MRSA of skin and soft tissue -cellulitis
Primary and secondary syphilis in those allergic to penicillin
Borrelia, Ehrlichia, and Mycoplasma
What is the side effects of tetracyclines?
tooth discoloration (children), Fanconi syndrome (Type II RTA proximal), photosensitivity, esophagitis/ulcer
TRP-SMX used to treat?
Cystitis
Pneumocystis pneumonia & prophylaxis
MRSA - skin & soft tissue - cellulitis
What are the beta lactam/beta-lactamase combo drugs?
amox/clavulanate
ticarcillin/clavulante
ampicillin/sulbactam
piperacillin/tazobactam
What are side effects of TRP-SMX?
rash, hemolysis in G6PD def
bone marrow suppression due to folate antagonist
What these combo drugs cover?
First choice for anaerobes for the mouth & GI abscess
What is the best initial therapy for gram +
oxacillin, cloxacillin, dicloxicillin, nafcillin
1st - gen cephalo - cefazolin, cephalexin
fluoroquinolones
macrolides (last choice b/c less effective)
What treats minor MRSA skin infection?
all oral TRP-SMX Clindamycin Doxycycline Linezolid
Most common causes of meningitis? Bugs…
Streptococcus pneumonia (60%), group B streptococci (14%), Haemophilus injluenzae (7%), Neisseria meningitidis (15%), and Listeria
What will cover gram - bacilli?
Quinolone aminoglycosides carbapenems piperacillin, ticarcillin azetronam cephalosporin
What are S/S of meningitis? How do you know when to do CT?
fever, headache, neck stiffness (nuchal rigidity), & photophobia
Do CT if presence of papilledema, seizures, focal neurological abnormalities, confusion
Meningitis
Name Epidemiology, RFs, Criteria
Epi = MC in neonates> adults, Streptococcus pneumoniae is the most common cause of meningitis for all patients beyond the neonatal period.
- Haemophilus influenzae was the most common cause in children (decreased due to vaccine)
- Neisseria meningitidis is spread by respiratory droplets and is the most common cause of meningitis in adolescents.
- Listeria monocytogenes is more common in those with immune system defects, particularly of the cellular (T-cell) immune system and sometimes neutrophil defects.
RFs = nonimmunized, asplenia, VP shunts
Criteria - isolation of n. meningitis from CSF,
blood, joint, scrapings of purpuric lesions
What is the CSF profile for bacterial, viral, TB?
Bacterial - Cell ct = 1000, neutrophils, protein level incr, glucose decr, do culture & stain
Viral = 10-100s lymphocytes, normal pressure, normal glucose
TB = 10-100 lymphocytes, highly elevated, normal to low glucose, neg stain & culture
What is the best initial test & most accurate test?
LP for both
When do you add treatment for listeria? what drug? alt?
Add ampicillin….alt = TRP-SMX Elderly, neonates, steroids, AIDs & HIV, immunocomp including ETOH, pregnant
What is the treatment of meningitis? alt if allergic?
Bacterial initially treated w/ ceftriaxone or ceftaxime and vancomyocin + steriods
alt to cephalo = carbapenem, meropenem, chloramphetical, aminoglycosides
What are the long term complications of meninigtis? Prevent?
CN8 deafness, cogn/behavorial impairment
Prevention w/ meningococcal vaccine, Hib vaccine
Encephalitis - what is it? Epi? RFs? Dx initial and accurate? Bug that causes? Complications? prevention?
Epi = 50 likely due to infectious, HSV RF’s = organ transplant, immunodef Dx = clinical Dx, most accurate = PCR Tx = acyclovir Complication - dealth, neuro sequelae Prevention - MMR vaccine, BCG for TB
If HSV is resistant to acyclovir, what can you give instead?
Foscarnet
What is the SE of foscarnet?
renal toxicity, acyclovir is less renal toxic
OM - define? epi? etiology? RF’s? Hx & PE?
Epi - MC in kids
Etio - caused by viruses mainly or bacteria
s. pneumoniae > h. influenza > morxella cata
RFs - daycare, lack of breast feeding, Native
American & Alaskan
Hx & PE = pain, redness, immobility (most important factor), bulging, decrease light reflex of TM
OM - what Dx studies? Criteria? Tx?
Dx = clinical, most accurate tympanocentesis
Criteria - mild bulging of TM + recent onset
of ear pain, intense erythema of TM OR
mod/severe bulging of TM
Tx - only give antibiotics if no improvement in
2-3days, amoxicillin 10d
OM - how to prevent? what are the complications?
Prevention - BR feed, no smoking
Complications - OM w/ effusion - should
resolve in 3m otherwise drained
Brain abscess - define? Etio? S/S? Dx?
Brain abscess - collection of infected material with the brain parenchyma
Etio = due to Strep > Bacteriodes > Enterobacteriaceae, often polymicrobial
S/S = headache, focal neurologic deficit
Dx = initially CT scan, MRI more accurate - gram stain & culture fluid if bacterial
How do you treat brain abscess?
aspiration + surgical excision, antibiotics need to specific
Penicillin - covers strep
metro - covers anaerobes
ceftazidime - covers gram - bacilli
What is Otitis Externa? RFs? Epi? Hx & PE?
inflammation of external ear (mostly inflammation of ear canal) caused by Pseudo/s. aureus (polymicrobial) RF’s - cerum impaction, swimmers ear, diabetics Epi - usually in kids 7-12 yo Hx & PE = ear pain, tragus tenderness, ear canal swelling + erythema
How do Dx OE? Tx?
Dx = clinical Tx = clear ear canal —> pain control —> antibiotic ear drops for bacteria (1st line) - neomycin/polymycin B - if gram +/- then give ciprofloxacin + steroids (decrease inflammation)
Sinusitis - define? Epi? RFs? Hx & PE? Criteria?
Sinusitis - infection of sinuses (MC - maxillary then ethmoid, frontal, sphenoid) Epi - females, adults & kids RFs - URT infection, allergic rhinitis Hx & PE - facial pain/headache/ post nasal drainage/ purulent nasal discharge Criteria = s/s 10 d then possibly bacterial, give antibiotics
How would Dx Sinusitis? Tx?
Dx - clinical
Tx - mild/uncomp - decongestant
pseudoephedrine (3-5day otherwise rebound)
and oxymetazoline
severe - give antibiotics - amox/clavulate
Pharyngitis - Etio? RFs? Hx & PE?
Most commonly due to viruses, Group A strep (s.pyogenes)
RFs - nasal colonization, Group A strep, viral infection early spring - winter months
Hx & PE = pain on swallowing, enlarged lymph nodes in neck, exudate on pharynx, fever, NO COUGH & HOARNESS
What is the Dx of pharyngitis? Tx? Complication? Prevention?
Best initial test = rapid strep test
most accurate = culture
Tx = penicillin or amoxicillin 10 days; if allergic w rash then tx w cephalexin; if anaphylaxsis use macrolide & clindamycin
Complication - rheumatic fever & GN
Prevention if prophylaxis if Hx of rheumatic
fever
Influenza - Etio? RFs? Hx & PE?
Influenza - acute resp infection caused by viral - influenza A & B, transmitted by inhalation of infected resp secretion RFs - > 65 yo, chronic disease, health care workers Hx & PE = arthralagia/myalgias, nonprod cough, fever, headache & sore throat N/V/D in children
Influenza Dx? Tx? Prevention? Complication?
Dx - clinical, rapid Ag detection via naso swab if w/in 48 hrs Tx - symptomatic - give acetominophen and anti-tussives Criteria = if s/s within 48h then give oseltamir, zanamivir, if >48h then tx symptoms Prevention - vaccine to DM, elderly, preg women, health care workers Complication - OM/pneumonia
Pneumonia Community Acquired- Etio? Epi? RFs? Hx & PE?
CAP - MC is s. pneumoniae, however viruses are MC in kids 65 yo, recent resp infection, HIV, smoking
Hx & PE - cough, fever, sputum production, puritic chest pain (assoc w lobar pneumonia seen in pneumococcus) tachycardia, crackles/rales on ausculatation
Pneumonia CAP- Dx? Tx? Prevention? Complication
Dx - sputum culture - most specific test, CXR
Tx - empiric tx = azithromycin and clarithromycin; alt is new quinolones - moxi, levo, gemifloxacin
if hospitalized then pt gets new quinolone or 3rd gen cephalo + macrolide (or doxy)
Prevention - pneumococcal vaccine in >65 yo; 19-64 with chronic disease, functional asplenia, give influenza vaccine to elderly, health care workers
Complications - empyema, pleural effusion,
Pneumonia - HAP - Etio? RFs? Hx & PE? Dx? Criteria?
Etio - pneumonia acquired after 48 hours of admission to the hospital; caused by gram - bacilli Pseudomonas,E.coli, Klebsiella, and Acinetobacter species
RFs - poor infection control, intubation
Hx & PE - same as pneumonia but with recent hospital admission
Dx - sputum, CXR
Criteria - HAP requires positive imaging plus 2 of 3 clinical features: fever >100.4°F (38°C), leukocytosis or leukopenia, or purulent secretions
Pneumonia - HAP - Tx? Prevention? Complication?
Monotherapy with ampicillin/sulbactam, ceftriaxone, ciprofloxacin, ertapenem, levofloxacin, or moxifloxacin
Prevention - wash hands
Complication - empyema, abscess
Bronchitis (acute & chronic) - Define? Etio? Epi? RFs?
Define - lower resp tract,
Epi - highest incidence in fall and winter
Etio - MCC of acute bronchitis is viral (coronavirus, rhinovirus, RSV); nonviral cases think Mycoplasma, c. pneumoniae; chronic - MCC s.pneu > h. infl > moraxella
RFs - viral and atypical bacterial exposure
Bronchitis - Hx & PE? Dx? Criteria? Tx? Prevention?
Hx & PE - cough w sputum (discolored sputum)
Dx - clinical dx
Criteria - An acute illness of <21 days, Cough as the predominant symptom, At least 1 other lower respiratory tract symptom such as sputum production, wheezing, chest pain
Tx - symptomatic treatment if viral - bronchodilators & cough suppressant
acute exacerbation - amox or doxy or TMP-SMP; complication - pneumonia/chronic cough
Prevention - no smoking
Lung Abscess - Define? Etio? RFs?
Define - most are anaerobes (oral)
Etio - assoc w peridonal disease or aspiration
RFs - chronic illness, poor dental hygiene, aspiration of gastric contents
Hx & PE = foul smelling sputum, fever, cough
Lung Abscess - Dx? Tx? Complication? Prevention?
Dx - CT/CXR, LL most common in upright position, post segment of RUL is MC in supine
Tx - best initial tx clindamycin
Complication - empyema, hemoptysis
Prevention - good oral hygiene
TB- define? Etio? RFs?
caused by mycobacterium tuberculosis
Etio - half the cases due to recent immigrants
RFs - alcoholics, health care workers, prisoners, homeless, weak immune systems
Hx & PE = wieght loss, night sweats, cough,fever, extrapulm manifestations
Dx - best initial - CXR; most specific test - culture
Tx - RIPE for 2 months, until sensitivity known then INH + rifampin for 6 more months; Tx meningitis (w steriods) for longer (12), pregnancy (9) and osteomyelitis
What is the SE of Ethambutol? PZA?
ethambutol causes optic neuritis
PZA - benign hyperuricemia (don’t treat unless gout assoc)
What is the PPD test guidelines for positive test?
> 5mm = close contacts w active TB, HIV +, abnormal CXR w healed TB, steriod/organ transplant
10mm = health care workers, prisoners, nursing homes, recent immigrants
15mm = low risk pts
+ PPD –> CXR —> abnormal –>3 sputum AFB done to see if active disease –>if + then treat w RIPE; if +PPD –> normal CXR or neg AFB smear then give 9m of INH + B6
What is the MCC of food poisoning?
Campylobacter
What bug causes food poisoning with
- poultry & eggs
- travelers diarrhea
- undercook hamburger meat
- fried rice
- fresh water on camping trip
- HIV patient
- samonella
- e. coli
- e. coli 0157:H7
- bacillus cereus
- giardia
- cryptosporidiosis
What organisms give bloody diarrhea?
Samonella Shigella Yersenia invasive e.coli Campylobacter
What organism associated w HUS?
E. coli 0157:H7
What protozoan is assoc w bloody diarrhea?
Entamoeba histolytica
What do NOT give bloody diarrhea (protozoan)?
Giardia
Cryptosporiodium
Cyclospora
What is the best initial Dx test for infectious diarrhea?
Stool for WBCs via methylene blue test
Culture - most specific for organism
What Dx do you do for Giardia & cryptosporidia?
AFB stain for Cryptosporidia
Stool ELISA for Giardia
Tx for infectious diarrhea?
oral fluids & electrolytes if severe (high fever, abd pain, tachy & hypotension) then give IV fluids & oral antibiotics
UTI - define? etio? epi? RFs?
infection of kidney/bladder/urethra, divided into complicated (structual impairment that decreases in efficacy) and uncomplicated (healthy nonpreg, w/o UT abnormalities)
Epi - MC in females, >18 yo
Etio - majority are uncomplicated caused by e. coli others are Proteus, Enterobacteriae, Klebsiella; complicated caused by citrobacter, enterobacter, pseudo, s. aureus
RFs - sex/foreign body, Hx of recurrent UTI, postmen women
UTI - Hx & PE? Dx? Tx? complication?
Hx & PE = dysuria, fever, frequency, urgency, burning
Dx = initial UA best initial test, most accurate is urine culture
Tx = uncomp = nitrofuratoin x5day, TRP-SMX x3day
comp = 7d w/ quinolone (cipro)
Complications = pyelonephritis/perirenal abscess
What if the patient is resistant to TRP-SMX for UTI - what do you give?
quinolone for 3 days as 1st line
What do you give to preg women w UTI?
Nitrofuratoin
Amox/clavulate
cephalexin
Urethritis - Etio?Epi? RFs? Hx & PE?
STD presenting w urethral d/c, dysuria and or puritis @ end of urethra
Epi - c. tracho is MC, 2nd = n.gono
Etio - divided into gonococcal and nongonoccal (caused by c. tracho/ureaplasma/mycoplasma)
RFs - 15-24 yo females/multi sex parters/prior hx of STD, no condom use
Hx & PE - urethral d/c dysuria, urethra itching
Urethritis - Dx? Criteria? Tx? complication?
Dx - best initial = urethral swab for gram stain (UA) most accurate = urine culture
Criteria = urethral d/c + >5 PMNs on UA
Tx = for gono = IM single dose ceftriaxone or oral cefixime; c. tracho = azithromycin or doxy
complications = GU abscess/ disseminated gonococcal, urethral stricture/fistula
Cervicitis - Etio?RFs? Hx & PE? Criteria? Dx? Tx?
due to inflammation of cervix, prurulent endocervical exudate or easily induced endocervical bleeding
Etio = divided into infectious (n. gono & c. tracho) and noninfectious
RFs = 15-25 female, multiple sex partners, BV, hx of STD
Hx & PE - purulent cervical d/c, intermenstrual bleeding, dysuria, urinary freq,
Criteria - easily induced cervical bleeding +mucopurulent d/c
Dx - urethral swab then urine culture
Tx - same as urethritis
PID - etio? epi? RF’s? Hx & PE?
inflammation of female upper genital tract (endometritis/salpingitis/tubo ovarian abscess/pelvic peritonitis)
Epi - young/single/sexually active F w hx of STD
Etio - polymicrobial infection esp c. tracho & n. gono
RFs - prior infection w c. tracho/n.gono, young age of onset of sex, prior hx of PID, IUD use
Hx & PE? - lower abd tenderness/lower abd pain/fever/ cervical motion tenderness/ leukocytosis
PID - Criteria? Dx? Tx?
Criteria - young sexually active F w lower abd pain + >1 of (adnexal tenderness, uterine tenderness, cervical motion tenderness)
Dx - cervical swab/DNA probe/ PCR confirms etiology; most accurate - laproscopy
Tx - rest & analgesics –> antibiotics - outpt gets ceftriaxone + azithromycin 100mg BID 14d and if no response then hospitalize and give IV (cefotetan or cefoxitin) +doxycycline
What if they have anaphylaxsis to penicillin if they have PID?
Give outpt = levofloxacin + metro
inpatient = clinda + gentamycin
Syphilis - define? Etio? RFs?
STD infection caused by spirochete, treponema palladium
Etio - acquired through sex or congenital
RFs - sex w infected pt, men sex w men, multiple sex partners, illicit drug use
Primary syphilis? Secondary syphilis? Tertiary?
Primary - chancre - painless genital ulcer w heaped indurated edges, painless lymphadenopathy
Secondary - 4-8wk after primary = rash (palms & soles) alopecia acreta, mucous patches, condylomata lata
Tertiary - if untreated then neurosyphilis - tabes dorsalis, general paresis, argyll robertson pupil, aortitis, gumma
How do you Dx? Tx? syphilis
Dx - VDRL/RPR - initial, confirmed w FTA-ABS
Tx - primary & secondary w/o neurosyphilis tx w IM benzathine Pen G, if allergic to Pen then give doxy but if tertiary or neurosyphilis give pen & desensitize if allergic
What does congenital syphilis cause?
Hutchinson teeth, saber shins (bony abnormalities), scars of intestinal keratitis
Chancroid - define? Etio? Hx & PE? Dx? Tx?
painful genital ulcers w fluctuant lymphadenitis (bubo) caused by H. ducreyi (gram - bacillus)
Hx & PE = painful papules become shallow ulcers, inguinal nodes are tender and painful
Dx = clinically, gram stain initially then confirm w culture
Tx = azithromycin single dose OR IM ceftriaxone
Lymphogranuloma Venereum -define?Etio? Hx & PE? Dx? Tx?
STD having transitory primary lesion followed lymphangitis
Etio - c. tracho
Hx & PE = transient lesion that ulcerates and heals quickly w unilateral enlargement of inguinal lymph nodes
Dx - clinically, c. tracho serology, confirm w PCR
Tx - doxy (erythromycin alt)
Granuloma Inguinale - define? Etio? Hx & PE? Dx? Tx?
chronic granulomatous condition
Etio = donovania granulomatis; c. granulomatis
Hx & PE = painless, red nodule w elevated granulomatous mass
Dx - clinically, do Giemsa or Wright stain (Donovan bodies)
Tx = doxy or ceftriaxone or TMP-SMZ
Genital Herpes - etio? Hx & PE? Dx? Tx?
Etio - due to HSV
Hx & PE - vesicles on skin, painful circular ulcers
Dx - Tzanck and culture
Tx - acyclovir, famiciclovir, valacyclovir
Prevention - but treat the partner
Genital warts - Etio? Epi? RFs? Hx & PE?
Etio - common STD, caused by HPV esp 6 & 11,
Epi - peak 16-25 yo
Hx & PE - found in moist areas in genital areas, veruccus papules
Dx - clinically, no initial test
Tx - patient applied = podophyllin/imiquimod
clinician applied = cryotherapy/destruction (currettage/sclerotherapy/TCA)
Cystitis - define? Etio? Epi? RFs? Hx & PE?
infection of the urinary bladder in young/sexual active
Epi - F > M; 18-24 yo
Etio = e.coli
RFs - freq sex/ Hx of UTI/urinary catheter/pregnancy/ diabetes
Hx & PE = dysuria (urgency/freq), suprapubic pain, barely fever
Cystitis - Dx? Tx? Complication? Prevention?
Dx - UA - look for WBCs; Nitrate + = gram - bac
confirm w culture
Tx = uncomplicated TRP-SMX 3d/ nitrofuratoin 3day if there’s resistance then use cipro
Complication - pyelonephritis/ urinary retention
Prevention - wipe front to back
Pyelonephritis - define? Epi? Etio? RFs? Hx & PE?
inflammation of renal parenchyma/calcies/ pelvis
Epi - gram - bac; MC e. coli > proteus > klebsiella
Etio - divided into uncomplicated (younger women) & complicated (older men, preg women, diabetics)
RFs - freq sex/ UTI/ DM/ stress incontinence, obstruction in kidneys/ anatomical urinary abnormality/preg
Hx & PE - CVA tenderness/flank, fever
Pyelonephritis - Dx? Tx?
Dx - UA, culture (MC)
Tx - indication for hospitalization (hypotension/vomiting/dehydration), fever >102, increase WBCs, severely ill w comorbidity
use ampicillin + gentamycin until cultures come back (w genta - pts w renal dysfunction decrease dosage)
Perinephric Abscess - Etio? Hx & PE? Dx? Tx?
collection of infected material surrounding kidney
Etio - predisposing to pyelonephritis - like stones;
Hx & PE - persistant pyelonephritis not responding to treatment
Dx - UA/culture - best initial; confirm w imaging either CT/MRI; aspiration needed for bac etio
Tx - antibiotics that cover gram - rods (3rd gen cephalo or antipseudo penicillin or ticarillin/clavulanate + amino
Drainage is needed
Endocarditis - etiology? Hx & PE?
Endocarditis is an infection of the valve of the heart leading to a fever and a murmur. Etio = Regurgitant and stenotic lesions confer increased risk. Prosthetic valves are associated with the highest risk, IV drug users Hx & PE = fever, new murmur - Splinter hemorrhages - Janeway lesions (flat and painless) - Osler nodes (raised and painful) - Roth spots in the eyes - Brain (mycotic aneurysm) - Kidney (hematuria, glomerulonephritis) - Conjunctival petechiae - Splenomegaly - Septic emboli to the lungs
Endocarditis Dx & Tx?
Best initial test = blood culture
Most accurate = TEE
CRITERIA =
1. Oscillating vegetation on echocardiography
2. Three minor criteria:
- Fever >100.3°F (38°C)
- Risk such as injection drug use or prosthetic valve - Signs of embolic phenomena
Tx = best empiric therapy is vancomycin and gentamicin
Endocarditis assoc w organism and treatment?
Viridans streptococci - Ceftriaxone for 4 weeks
Staphylococcus aureus (sensitive) - Oxacillin, nafcillin, or cefazolin
Fungal - Amphotericin and valve replacement
Staphylococcus epi or resistant Staph - vanco
Enterococci - Ampicillin and gentamicin
For endocarditis - what do you add for resistant organisms
aminoglycoside
When is surgery the answer for endocarditis?
- CHForrupturedvalveorchordaetendineae
- Prostheticvalves
- Fungal endocarditis
- Abscess
- AV block
- Recurrentemboliwhileonantibiotics
What are the organisms that are difficult to culture for endocarditis? tx?
• Haemophilus aphrophilus • Haemophilusparainfluenzae • Actinobacillus • Cardiobacterium • Eikenella • Kingella Tx = use ceftriaxone
When do you give prophylaxis for endocarditis?
1.Significant cardiac defect Prosthetic valve Previous endocarditis Cardiac transplant Unrepaired cyanotic heart disease 2. Risk of bacteremia - Dental work with blood - Respiratory tract surgery that produces bacteremia best initial management is amoxicillin prior to the procedure, if pen allergic =clindamycin or azithromycin or clarithromycin
Lyme disease? etio? PE?
Lyme disease is an arthropod-borne disease from the spirochete Borrelia burgdorferi transmitted via deer tick (Ixodes)
Etio = found in northeast states, CT, NY, NJ, Mass
PE = rash MC manifestation = ash is erythema migrans. It is a round red lesion with a pale area in the center; most common long term complication is joint pain (if no tx then 60% get joint pain); neuro = Seventh cranial nerve or Bell palsy is the most common neurological manifestation of Lyme disease and cardiac = AV block is the most common cardiac
Lyme disease - dx? tx?
Dx - clinical
Criteria - ELISA/IFA if neg then do Western blot,
prophylaxsis started w/in 72 hr of tick bite, tick bite>36 hr, doxy contraindicated for children <8 yo, pregnancy, lactation give amoxicillin instead
Tx - single doxy or amox or cefuroxime for CVS/CNS s/s give IV ceftriaxone
When do you give single dose of doxy within 72 hours?
- Ixodes scapularis clearly identified as the tick causing the bite
• Tick attached for longer than 24 to 48hours
• Engorged nymph-stage tick
• Endemic area
HIV - stages? stucture?
gp 41/120 - envelope proteins gp 24 - capsid protein RT - makes dsDNA from RNA, dsDNA integrates into host genome HIV - Criteria Stages 1. Acute HIV syndrome 2. asymptomatic stage - 10y post infectious stage 3. symptomatic stage 4. AIDS - HIV + and AIDs defining illness - HIV + and CD4 ct <200
What are the opportunistic infections according CD4 count in HIV?
Opportunistic infections according CD4
200-500 = oral thrush, Karposi, TB, Zoster,
lymphoma, Herpes, bacteria pneumonia,
100- 200 = PJP, dementia, PML, disseminated
histoplasmosis, coccidiomycosis
<50 = CMV, MAC, PML, CNS lymphoma
Best initial test for HIV? confirm?
best initial test for HIV is the ELISA test, confirmed with Western blot testing
infants are diagnosed with PCR or viral culture - which detects DNA of HIV
When do you use viral load testing?
- Measure response to therapy (decreasing levels are good)
- Detect treatment failure (rising levels are bad)
- Diagnose HIV in babies
Treatment for HIV?
choice of medications to select 3 drugs from 2 different classes to which the patient’s virus is susceptible, best initial drug regimen is a combination of emtricitabine, tenofovir, and efavirenz.
What are the NNRTIs? SE?
- Zidovudine = leukopenia • Didanosine = pancreatitis, peripheral neuro • Stavudine • Lamivudine • Emtricitabine • Abacavir = hypersen rxn • Tenofovir - zalcitabine - pancreatitis, perineuropathy, lactic acidosis
What are the NRTIs? SE?
- Efavirenz = neuro s/s
- Etravirine
- Nevirapine = rash
- Rilpivirine
What are the protease inhibitors? SE?
PI = SE include hyperlipidemia, hyperglycemia, lipodystrophy • Darunavir • Atazanavir • Ritonavir • Saquinavir • Nelfinavir • Amprenavir • Fosamprenavir • Lopinavir • lndinavir = renal stones, hyperbilirubinemia • Tipranavir
PJP - s/s? Dx? Tx? Prophylaxis?
causes pneumonia, dry cough, fever Dx - bronchoscopy w BAL for direct ID CXR - bilateral interstitial infiltrate Tx - TRP-SMX steriods used for severe pneumonia - PaO 35 mmHg PROPHYLAXSIS - TRP-SMX > dapsone > atovaquone
CMV - s/s? dX? Tx? prophylaxis?
causes retinitis - blurry vision, visual
disturbance in HIV + w low CD4; esoghagitis
endoscopy shows shallows ulcers in distal
esophagus Dx - via fundoscopy
Tx - valganciclovir; foscarnet for alt
CMV prophylaxis is valganciclovir for life until CD4 ct 200
Foscarnet SE is renal toxicity
MAC ? Dx? Tx? Prophylaxis
inhalation results in fever, NS, wasting,
bacteremia, anemia
Dx - blood culture, biopsy of BM, liver biopsy
Tx - clarithromycin + ethambutol +/- rifabutin
PROPHYLAXIS - azithromycin (oral)1x/wk
Toxoplasmosis - Dx? Tx? Prophylaxis?
brain mass lesions
DX - ring enhanced lesions on CT w contrast
surrounded by edema; trial of treatment for
2 weeks is given and then re-CT to see if
lesion shrank; if no shrinkage then biopsy
needed to r/o cancer
Tx - pyrimethamine & sulfadiazine (alt is
clindamycin) leucovorin prevents BM supression
PROPHYLAXSIS - TMP-SMZ or dapsone +
pyrimethamine
Cryptococcosis - Dx? Tx? Prophylaxis?
causes meningitis - fever,
headache and malaise
Dx - LP w India ink stain then confirm w
cryptococcal Ag
worse prognosis - high Ag titer, high opening
pressure, low CSF cell ct
Tx - amphotericin IV 10-14 days w flucytosine
followed by fluconazole for oral maintence
PROPHYLAXIS - fluconazole - not usually
given
What vaccines do you give HIV + pt?
Pneumococcus
Influenza
Hep B
If HIV drug resistance occurs what are the next choices?
either atazanavir, darunavir, or raltegravir combined with emtricitabine / tenofovir
When do you do C - section for HIV + ?
Cesarean delivery is performed to prevent transmission of virus if the CD4 is low (below 350) or the viral load is high
Remember: Pregnant HIV-positive persons should be treated with anti-retrovirals during the whole pregnancy. Do not wait for the second trimester, and always use at least 3 drugs.
Q fever? etio? PE? Tx?
Q fever - caused by Coxiella burnetti - transmission by aerosol
Hx & PE - febrile illness, atypical pneumonia, hepatits
Dx - serology
Tx - doxy
RMSF? PE? Dx? Tx?
caused by Rickettsi transmitted by wood tick around midwest area
Hx & PE - fever, rash, headache - rash starts in wrist & ankles
spread centripetally
Dx - serology, biopsy of skin lesion
Tx - doxy
Leptospirosis - Dx? Tx?
caused by exposure to animal urine, results
fever & abd pain
Dx - serology, blood Ag
Tx - ceftriaxone or penicillin
TSST - Etio? PE? Dx? Tx?
caused by s. aureus (TSST-1) acquired from wound
and tampons
Hx & PE = hypotension, fever, sepsis, desquamative rash on
hands and feet
Dx - clinically
Tx - beta - lactam penicillin (naficillin, oxacillin)
Aspergillosis - etio? RF? PE? Dx? Tx?
pulm infection in immunocomp
Etio - due to A. fumigatus
RF - neutropenia, steriod use, cytotoxic drugs (azathioprine, cyclophosphamide)
Hx & PE - allergic bronchopul like asthma - fever, cough, wheezing
Myectoma - fungal ball - resides in pre-existing cavity w/ hemoptysis as CC
Dx - CXR - halo sign, biopsy confirm
Tx - voriconazole superior to Amp B (give if systemic s/s)
Blastomycosis - etio? RF? PE? Dx? Tx?
multiple nodules in lungs, broad budding yeast,
Etio - southeast area
Epi - inhalation of decaying wood
Hx & PE - pulm w fever/cough/chest pain/weight loss, skin lesions,
osteolytic bone lesion
Dx - sputum, biopsy confirms
Tx - amp B 8-12 wks; itraconazole/ketoconazole for mild disease
Coccidomycosis - etio? RF? PE? Dx? Tx?
pulm disease, hilar adenopathy, pleural effusion
Etio - southwest area - california
Hx & PE - fever, bone lesion, maculopap lesion
Dx - sputum, biopsy confirms
Tx - Amp B (systemic) and azoles for mild disease
Histoplasmosis - PE? Dx? Tx?
PE = palate ulcers, HSM, bat droppings hx
Etio - wet areas - Midwest area
Dx - urine Ag detection
Tx - Itraconazole
