Infectious Disease Flashcards by Kea Khaerloe Acha

You are called by the laboratory which reports gram-positive cocci in clusters growing from the blood culture bottles. What is the best next step in management?

a. Start Oxacillin
b. Start Erythromycin
c. Start Vancomycin
d. Start Doxycycline
e. Consult infectious diseases
f. Wait for speciation and sensitivity of the organism.
g. It is contamination; no treatment is needed

C. The best empiric therapy for gram-positive cocci growing from blood cultures is vancomycin

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Which is not an adverse effect of Linezolid?

a. Thrombocytopenia
b. interaction with MAO inhibitors
c. causes CPK elevation

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Should we use Tigecycline for MRSA in blood?

No.

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Which is not an adverse effect of Daptomycin?

a. causes CPK elevation
b. thrombocytopenia
c. not effective in the lung

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Give 4 medical management for minor MRSA infections.

TMP/SMX
Doxycycline
Clindamycin
Linezolid

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Which of the following is the most accurate test for an infectious disease?

a. Protein level of fluid
b. Culture
c. IgM levels
d. IgG levels
e. Gram stain
f. Response to specific

B. Culture

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Enumerate the bacteria covered by amoxicillin

(HELPS)

H. influenzae
E. coli
Listeria
Proteus
Salmonella

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Enumerate 6 diseases in which Amoxicillin is the best initial therapy

Otitis Media
Dental infection and endocarditis prophylaxis
Lyme disease limited to rash, joint, or seventh cranial nerve involvement
UTI in pregnant women
Listeria monocytogenes
Enterococcal infections

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Which of the following antibiotics will cover methicillin-resistant Staphylococcus aureus (MRSA)?

a. Nafcillin
b. Cefazolin
c. Piperacillin-Tazobactam
d. Ceftaroline
e. Azithromycin

D. The only cephalosporin that will cover MRSA is Ceftaroline.

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MRSA drugs

Vancomycin
Daptomycin
Linezolid
Tedizolid
Oritavancin
Dalbavancin
Telavancin
Ceftaroline

‘mycin’ ‘zolid’ ‘vancin’ ‘roline’

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If the case describes a RASH to penicillin, what would you give?

Cephalosporins

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If the case describes ANAPHYLAXIS from Penicillin, what would you use?

Non-beta-lactam antibiotic

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Give 2 medications from the family of the Cepalosporins that cover Anaerobes

Cefotetan and Cefoxitin

Inc. risk in bleeding and has a disulfiramlike reaction with alcohol

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What is the best initial therapy for Pelvic Inflammatory Disease (PID)?

Cefotetan or Cefoxitin combined with Doxycycline

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Which of the following is most likely to be effective for Morganella or Citrobacter?

a. Tedizolid
b. Dalbavancin
c. Ertapenem
d. Oritavancin
e. Erythromycin

C. Ertapenem

Ertapenem is a carbapenem antibiotic. All carbapenems are highly active against gram-negative bacilli. Morganella and Citrobacter are gram-neg bacilli in the same family as E.Coli. Ertapenem covers most gram-negative rods and bacilli except Pseudomonas

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A patient has a perforation of an abdominal portion of the bowel and leakage into the peritoneum. There is fever and hypotension. The report on the anaerobic bottle of blood cultures states that it is growing an organism. Which of the following is most appropriate to start while waiting for the speciation and sensitivity testing?

a. Aztreonam
b. Piperacillin/Tazobactam
c. Oxacillin
d. Cefepime
e. Doxycyline
f. Vancomycin

B. Piperacillin/Tazobactam is the only medication of those listed that covers anaerobes

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A man is admitted with E. coli bacteremia.

Which of the following is the most appropriate therapy?

a. Vancomycin
b. Linezolid
c. Quinolones, aminoglycosides, carbapenem, piperacillin, ticarcillin, or aztreonam
d. Doxycycline
e. Clindamycin
f. Oxacillin

C. All of the agents listed under “gram-negative bacilli” could be the right answer.

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You see a patient with fever, headache, neck stiffness, and photophobia. The patient is also confused, so a CT scan of the head is ordered. Ceftriaxone and vancomycin are administered. There is a delay of 12 hours in obtaining the lumbar puncture after a normal head CT. In the event that the antibiotics produce a false negative in culture, which of the following is most useful to identify a specific organism?

a. Gram stain
b. Glucose level
c. Latex agglutination antigen
d. Protein level

C. Latex agglutination antigens

They have the same specificity as a culture but less sensitivity. The advantage of the antigen test is that it wwill not become negative with a few doses of antibiotics. The other tests listed are neither as sensitive nor as specific.

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Give 3 initial treatment for bacterial meningitis.

Ceftriaxone, Vancomycin, Steroids

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A man comes to the emergency department with fever, severe headache, neck stiffness, and photophobia. On physical examination he is found to have weakness of his left arm and leg. What is the most appropriate next step in the management of this patient?

a. Ceftriaxone, vancomycin, and steroids
b. Head CT
c. Ceftriaxone
d. Neurology consultation
e. Steroids

When there is a contraindication to an immediate LP, the most important step is to initiate treatment.

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What is the most accurate test oh herpes encephalitis?

a. Brain biopsy
b. PCR of CSF
c. MRI
d. Viral culture of CSF
e. Tzanck prep
f. Serology for herpes (IgG, IgG)

PCR is more accurate than a brain biopsy

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A woman is admitted for herpes encephalitis confirmed by PCR. After 4 days of acyclovir her creatinine level begins to rise.

What is the most appropriate next step in management?

a. Stop acyclovir
b. Reduce the dose of acyclovir and hydrate
c. Switch to oral famciclovir or valacyclovir.
d. Switch to foscarnet

B. Oral medications such as famciclovir and valacyclovir are insufficient for herpes encephalitis. Although acyclovir may occasionally be renal toxic because the medication precipitates in the renal tubules, foscarnet has far more renal toxicity.

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Why do we need to avoid Ceftriaxone in neonates?

They have impaired biliary metabolism

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_______ is the first cephalosporin to cover MRSA.

Ceftaroline

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Which of the following is the most accurate in determining the etiology of infectious diarrhea? a. Recent history of eating chicken b. Frequency of bowel movement c. Blood in stool d. Odor of stool e. Recent interstate travel

C. Presence of blood in the stool

Listeria, MRSA, and Enterococcus are resistant to all forms of ________.

Cephalosporins

What can you prescribe for some negative gram-negative bacilli such as E. Coli, but NOT Pseudomonas as well as Osteomyelitis, Septic Arthritis, Endocarditis, Cellulitis

First Generation Cephalosporin Cefazolin, Cephalexin, Cephadrine, Cefadroxyl

What can you give for respiratory infections such as bronchitis, otitis media, and sinusitus?

2nd Gen Cephalosporin Cefuroxime, Loracarbef, Cefprozil, Cefaclor

What 3rd gen Cephalosporin is first line for pneumococcus, including partially insensitive organisms responsible for Meningitis, CAP, Gonorrhea, Lyme disease involving the heart or brain?

Ceftriaxone

What 3rd gen Cephalosporin is superior to Ceftriaxone in neonates and is also used for spontaneous bacterial peritonitis?

Cefotaxime

What 3rd gen Cephalosporin has pseudomonal coverage?

Ceftazidime

This is a 4th gen Cephalosporin that is used to treat neutropenia and Ventilator-associated pneumonia.

Cefepime

This is a 5th gen Cephalosporin that can treat gram-negative bacilli and MRSA but not Pseudomonas.

Ceftaroline

This is a group of drugs that cover gram-negative bacilli, including many that are resistant anaerobes, streptococci, and staphylococci. They are used to treat neutropenia and fever.

Carbapenems

_____ differs from the other carbapenems. It does not cover Pseudomonas.

Ertapenem

This is the only drug in the class of monobactams that is used exclusively for gram-negative bacilli including Pseudomonas. This has no cross-reaction to Penicillin

Aztreonam

This group of drugs is the best therapy for Community-acquired Pneumonia, including penicillin-resistant Pneumococcus. What is the exception for this group of drugs?

Fluroquinolones except Ciprofloxacin

What drug can you use for cystitis, pyelonephritis, and ventilator-associated pneumonia

Ciprofloxacin

_______ is a Fluroquinolone that can be used as a single agent for diverticulitis and does not need Metronidazole.

Moxifloxacin

What drug must be combined with Ciprofloxacin, Gemifloxacin, and Levofloxacin for Diverticulitits and GI infections for anaerobic coverage.

Metronidazole

What are adverse effects known from Fluroquinolones?

Bone growth abnormalities in children and pregnant women, Tendonitis and Achilles tendon rupture

This group of drugs can be used for gram-negative bacilli (bowel, urine, bacteremia) and is synergistic with beta-lactam antibiotics for enterococci and staphylocci. It has no effect against anaerobes, since they need oxygen to work.

Aminoglycosides (Gentamicin, Tobramycin, Amikacin)

What are 2 common adverse effects of Aminoglycosides

Nephrotoxic and Ototoxic

This drug is used for treatment of Chlamydia, Lyme disease that is limeted to rash, joint, or seventh cranial nerve palsy, Rickettssia, MRSA of skin and soft tissue (cellulitis), Primary and secondary syphilis in those allergic to penicillin, Borrelia, Ehrlichia, and Mycoplasma.

Doxycycline

What are the common adverse effects of Doxycycline?

``` Tooth discoloration (children) Fanconi syndrome (Type II RTA proximal) ```

This drug can be used in cystitis, pneumocystis pneumonia treatment and prophylaxis, MRSA of skin and soft tissue (cellulitis)

Trimethoprim/Sulfamethoxazole

Give adverse effects of Trimethoprim/Sulfamethoxazole.

Rash Hemolysis with G6PD deficiency Bone Marrow Suppression because it is a folate antagonist

What can you give for Oral (above the diaphragm) anaerobe infection?

Penicillin (G, VK, Ampicillin, Amoxicillin) | Clindamycin

What can you give for Abdominal anaerobic infection?

Metronidazole Beta-lactam/lactamase combinations Carbapenems

What is the MOST LIKELY DIAGNOSIS for a patient presenting with fever, headache, nausea, and vomiting that has an accompanied stiff neck, photophobia, and meningismus?

Meningitis

What is the MOST LIKELY DIAGNOSIS for a patient presenting with fever, headache, nausea, and vomiting that has an accompanied confusion?

Encephalitis

What is the MOST LIKELY DIAGNOSIS for a patient presenting with fever, headache, nausea, and vomiting that has an accompanied focal neurologic findings?

Abscess

What organism is most likely present in a patient with AIDS <100 CD4 cells/ul?

Cryptococcus

What organism is most likely present in a camper/hiker patient with target shaped rash, joint pain, facial palsy, and sometimes presence of tick?

Lyme disease

What organism is most likely present in a camper/hiker patient with rash that moves from arms/legs to trunk?

Rocky Mountain Spotted Fever (Ricketssia)

What organism is most likely present in an adolescent patient with petechial rash with symptoms of fever, headache, nausea and vomiting?

Neisseria

What is the best initial and most accurate test for Meningitis?

Lumbar Puncture

Lab results for a patient you suspect with Meningitis came back. Cell count 1000s, neutrophils, Elevated Protein Level, Decreased Glucose Level, 50-70% positive in stain and 90% in culture What is the most likely etiology?

Bacterial Meningitis

Lab results for a patient you suspect with Meningitis came back. Cell count 10-100s, lymphocytes, Possibly elevated Protein Level, Possibly decreased Glucose Level, Negative in stain and culture What is the most likely etiology?

Cryptococcus, Lyme, Ricketssia

Lab results for a patient you suspect with Meningitis came back. Cell count 10-100s, lymphocytes, Markedly elevated Protein Level, Possibly decreased Glucose Level, Negative in stain and culture What is the most likely etiology?

Tuberculosis

Lab results for a patient you suspect with Meningitis came back. Cell count 10-100s, lymphocytes, usually normal Protein Level, usually normal Glucose Level, Negative in stain and culture What is the most likely etiology?

Viral

When is a Head CT the best initial test for Meningitis?

If you suspect a space-occupying lesion that may cause herniation as evidence by symptoms like Papilledema, Seizures, Focal neurologic abnormalities, Confusion interfering with the neurologic exam

If there is a contraindication to immediate LP in a patient with meningitis, what is the best initial step in management?

Give Antibiotics

When is a bacterial antigen test indicated?

When the patient has received antibiotics prior to LP and the culture may be falsely negative

What is/are the most accurate diagnostic test for Meningeal Tuberculosis?

Acid fast stain and culture on 3 high-volume lumbar punctures. TB has the highest CSF protein level

What is/are the most accurate diagnostic test for Lyme and Rickettsia?

Specific serologic testing ELISA Western blot PCR

What is/are the most accurate diagnostic test for Cryptococcus?

India ink is 60-70% sensitive Cryptococcal antigen is more than 95% senistive and specific Culture of fungus is 100% specific

Listeria is resistant to all _______ but sensitive to ______.

Cephalosporins; Penicillins

If the patient with Listeria has the following risk factors: Elderly, Neonates, Steroid use, AIDS or HIV, Immunocompromised including alcoholism, Pregnant, what medical management should you initiate?

Add Ampicillin to Ceftriaxone and Vancomycin

What should you give the relatives or those who come in close contact with a patient with Neisseria meningitidis?

Rifampicin, Ciprofloxacin, or Cefttiaxone

What is the most common neurologic deficit of untreated bacterial meningitis?

Eight cranial nerve deficit or deafness

What is the best initial treatment for Herpes Encaphalitis?

Acyclovir

What is used for Acyclovir-resistant Herpes?

Foscarnet

What would you perform for a patient presenting with symptoms of Influenza with the onset not longer than 48 hours?

Nasopharyngeal swab or wash

How would you treat Influenza with less than 48 hours of symptoms?

Oseltamivir, Zanamivir (these drugs treat both Influenza A and B) Peramivir is the intravenous version

How would you treat Influenza with more than 48 hours symptoms?

Symptomatic treatment Analgesics, rest, antipyretics, hydration

Patient came in with complaint of blood in stool. Upon history, there is ingestion of some kind of poultry. Lab shows WBC in stool. What is the most likely etiology?

Salmonella

This is the most common cause of blood in stool and is associated with GBS.

Campylobacter

What is the organism responsible for Hemolytic Uremic Syndrome (HUS)?

E. coli 0157:H7

What organism is the second most common association with HUS?

Shigella

Patient came in with complaint of blood in stool. Upon history, there is ingestion of shellfish and boarding a cruise ship. Lab shows WBC in stool. What is the most likely etiology?

Vibrio parahaemolyticus

Patient came in with complaint of blood in stool. Upon history and PE, there is ingestion of shellfish, history of liver disease and presence skin lesions. Lab shows WBC in stool. What is the most likely etiology?

Vibrio vulnificus

This organism has high affinity for iron, seen in hemochromatosis, and blood transfusions

Yersinia

Patient came in with complaint of blood in stool. Lab shows red and white cells.

Clostridium difficile

What is the best initial test for a patient with blood in stool?

Blood and/or fecal leukocytes Lactoferrin is a BETTER answer than fecal leukocytes if it in one of the choices

What is the most accurate test for a patient with blood in stool?

Stool Cultrue

Patient came in with complaints of loose bowel movements. There are no blood in stool. There is a history of camping/hiking and drinking unfiltered fresh water. What is the most likely organism?

Giardia

Medical management for Giardia

Metronidazole, Tinidazole

Medical management for Cryptosporidiosis

Treat underlying AIDS, Nitazoxanide

Patient came in with complaints of loose bowel movements. There are no blood in stool. Patient has AIDS with less then 100 CD4 cells. What is the most likely diagnosis and how can you detect it?

Cryptosporidiosis; Modified Acid Fast Stain

These are types of Hepatitis that can be transmitted via food and water

Hepatitis A and E

These are types of Hepatitis that can be transmitted via sex, blood, and perinatally.

Hepatitis B, C, and D

This type of hepatitis rarely presents with an acute infection and is found as a "silent" infection on blood tests, and unfortunately when patients present with cirrhosis

Hepatitis C

This type of hepatitis exists exclusively in those who have active viral replication of Hepatitis B.

Hepatitis D

This type of hepatitis is typically worst in pregnancy, especially among patients from East Asia.

Hepatitis E

What will you expect in the lab results of a patient diagnosed with Hepatitis?

Increased direct bilirubin Increased ALT to AST ratio Increased Alkaline Phospatase

Which of the following correlates the best with an increased likelihood of mortality in a patient with Hepatitis? a. Bilirubin b. Prothrombin time c. ALT d. AST e. Alkaline phospatase

B. Prothrombin time If PT is elevated, there is a markedly increase risk of fulminant hepatitis failure and death

What is the best initial diagnostic test for Hepatitis A, C, D, E

IgM antibody for acute infection IgG antibody to detect resolution of infection

What test detects disease activity of hepatitis C, which assesses RNA level that tells the amount of active viral replication

PCR

Which of the following will become abnormal first after acquiring hepatitis B infection? a. Bilirubin b. e-antigen c. Surface antigen d. Core IgM antibody e. ALT f. Anti-hepatitis B e-antibody

C. Others are the measure of the body's response to the infection.

Which of the following is the most direct correlate with the amount, or quantity, of active viral replication (Hepatitis)? a. Bilirubin b. e-antigen c. Surface antigen d. Core IgM antibody e. ALT f. Anti-hepatitis B e-antibody

B. e-antigen Hepatitis B e-antigen is directly correlated with the degree of DNA polymerase. It is present only when there is a high level of DNA polymerase activity.

This drug reactivates hepatitis B surface antigen carriers.

Rituximab

Which of the following indicates that a patient is no longer a risk for transmitting infection to another person (active infection has resolved)? a. Bilirubin normalizes b. No e-antigen found c. No surface antigen found d. No core IgM antibody found e. ALT normalizes f. Anti-hepatits B e-antibody

C. As long as there as surface antigen is present, there is still some viral replication potentially occurring

Which of the following is the best indication of the nees for treatment with anti-viral medications in chronic disease (Hepatitis)? a. Bilirubin b. e-antigen c. Surface antigen d. Core IgM antibody e. ALT f. Anti-hepatitis B e-antibody

B. The person most likely to benefit from antiviral medication is the with the greatest degree of active viral replication

This method detects the viral load level in both hep B and C. It measure the DNA of hep B and RNA of hep C. It is not the right test for initial diagnosis but is used to determine if a person is responding to treatment. It also answer the question of who is the most likely patient to transmit the disease.

PCR

Which of the following is the best indicator that a pregnant woman with hepatitis will transmit infection to her child? a. Bilirubin b. e-antigen c. Surface antigen d. Core IgM antibody e. ALT f. Anti-hepatitis B, e-antibody

What is the difference of e-antigen from DNA polymerase?

e-antigen is qualitative (tells you if it is positive or negative) DNA polymerase is quantitative (tells you an amount; more precise)

What is the most common method of transmission worldwide for Hepatitis?

Perinatal

Among the types of Hepatitis, which one gets medical therapy to prevent chronic infection?

Hepatitis C

Which one is the worst choice in the all the treatment of Chronic Hepatitis B? a. Entecavir b. Adefovir c. Lamivudine d. Telbivudine e. Interferon f. Tenofovir

E. Interferon (it has the most adverse effects)

Give the adverse effects of interferon.

Arthralgia/myalgia Leukopenia and thrombocytopenia Depression and flu-like symptoms

Give the 3 treatment options for Hepatitis C

Velpatasvir (best option: covers all genotypes) Ledipasvir Sofosbuvir

What is the role of liver biopsy in a patient with Hep B or C?

To detect fibrosis If there is active viral replication, fibrosis will progress to cirrhosis Begin treatment right away!

What is a known side effect of Ribavirin?

Anemia

What is the difference between Urethritis and Cystitis?

Both give dysuria with urinary frequency and burning, but cystitis does not give URETHRAL DISCHARGE

What is the best initial test for Urethritis?

Urethral swab for Gram stain

What are accurate test for Urethritis?

Urethral culture, DNA probe, Nucleic acid amplification test (NAAT) for N. gonorhoeae and Chlamydia trachomatis.

This presents with cervical discharge and an inflamed "strawberry" cervix on physical examination.

Cervicitis

How do you diagnose Cervicitis?

Self-administered swab for NAAT

How do you treat Cervicitis?

Ceftriaxone and Azithromycin as a single dose

A patient came in with lower abdominal tenderness, lower abdominal pain, fever, cervical motion tenderness, and leukocytosis. What would you do first? What is a probable diagnosis?

Pregnancy Test PID

What is the most accurate test for PID?

Laparoscopy

How would you diagnose PID?

Cervical swab for culture DNA probe NAAT

How would you treat patients with PID in an inpatient basis? If the patient is allergic to penicillin?

Cefoxitin or Cefotetan + Doxycycline Clindamycin, Gentamicin, Doxycycline

How would you treat patients with PID in an outpatient basis?

Ceftriaxone and Doxycycline (possibly with Metronidazole) Levofloxacin and Metronidazole

Patient came in with genital ulcer and inguinal adenopathy. Ulcer was described to be painless. What is the MOST LIKELY diagnosis?

Syphilis

Patient came in with genital ulcer and inguinal adenopathy. Ulcer was described to be painful. What is the MOST LIKELY diagnosis?

Chancroid (H. ducreyi) ' i cry' - painful

Patient came in with genital ulcer and inguinal adenopathy. Lymph nodes were tender and suppurating. What is the MOST LIKELY diagnosis?

Lymphogranuloma venereum

Patient came in with genital ulcer and inguinal adenopathy. Vesicles appeared before the ulcer and ulcer was described to be painful. What is the MOST LIKELY diagnosis?

Herpes simplex

What diagnostic tests you can order for Syphilis?

Dark-field microscopy (if + for spirochetes, no further testing necessary) VDRL or RPR FTA or MHA-TP (confirmatory)

What diagnostic tests you can order for Chancroid?

Stain and culture on specialized media

What diagnostic tests you can order for Lymphogranuloma venereum?

Complement fixation titers on blood | NAAT

What diagnostic tests you can order for Herpes Simplex?

``` Tzanck prep (best initial test) PCR (most accurate test) ```

What is the treatment of choice for Syphilis?

Single dose of intramuscular benzathine penicillin | Doxycycline if penicillin allergic

What is the treatment of choice for Chancroid?

Azithromycin (single dose)

What is the treatment of choice for Lymphogranuloma venereum?

Doxycycline

What is the treatment of choice for Herpes simplex?

Acyclovir, Valacyclovir, Famciclovir | Foscarnet for acyclovir-resistant herpes

A woman comes to clinic with multiple painful genital vesicles. What is the next step in management? a. Acyclovir orally b. Acyclovir topically c. Tzanck prep d. Viral culture e. Serology f. PCR

A. If the presentation is clear for herpes with multiple vesicles of the mouth, genitals, diagnostic testing is not necessary

What stage of Syphilis has painless genital ulcer with heaped-up indurated edges (it becomes painful if it becomes secondarily infected with bacteria) and has painless adenopathy? a. Primary b. Secondary c. Tertiary

What stage of Syphilis presents with rash on palms and soles, Alopecia areata, Mucous patches, and Condylomata lata? a. Primary b. Secondary c. Tertiary

What stage of Syphilis presents with neurosyphilis, aortitis, and gummas? a. Primary b. Secondary c. Tertiary

Patient came in with painless genital ulcers, aortitis, and gummas. There is loss of position and vibratory sense, incontinence, cranial nerve dysfunction). What is the diagnosis?

Tabes dorsalis

This is a complication of tertiary syphilis where the pupils react to accommodation but not light

Argyll Robertson pupil

What is the difference of VDRL or RPR to FTA-ABS in terms of diagnosing Syphilis?

FTA-ABS is more sensitive than VDRL or RPR in all stages of Syphilis

Which of the following is most sensitive test of CSF for neurosyphilis? a. VDRL b. RPR c. FTA d. Stain e. Dark field f. Culture

C. FTA is 100% sensitive in CSF A negative FTA RULES OUT neurosyphilis VDRL and PCR and SPECIFIC. (+) VDRL and PCR = (+) neurosyphilis

What is the treatment for Tertiary Syphilis?

Intravenous penicillin. DESENSITIZE if allergic

This is a reaction from penicillin treatment of that produces fever and worsens symptoms. How will you manage?

Jarisch-Herxheimer reaction Give aspirin and antipyretics, it will pass

How would you diagnose genital warts (Condylomata Acuminata)? a. Biopsy b. Serology c. Stain d. Inspection (Visual Appearance) e. Smear f. Culture

How do you remove Genital Warts?

Cryotherapy with liquid nitrogen Surgery for large ones Podophyllin or Trichloroacetic acid (melts the lesion) Imiquimod (apply locally and will lead to sloughing off of the lesion)

This are found on hair-bearing areas (scalp, axilla, pubis) that causes itching and visible on surface

Pediculosis (Crabs)

How do you treat Pediculosis?

Permethrin | Lindane (equal in efficacy but more toxic)

This are found in web spaces between fingers and toes or at elbows or genitalia, around nipples, burrows are visible

Scabies

How do you diagnose Scabies?

Scrape and Magnify

How do you treat Scabies?

Permethrin | Ivermectin for widespread disease

What is the most common cause of UTI?

E. Coli

What group of drugs is the best initial therapy for Pyelonephritis?

Quinolones

What is the best initial test for Cystitis?

Urinalysis with more than 10 WBCs

What is the most accurate test for Cystitis?

Urine Culture (Do not do unless there are WBCs in urinalysis)

What are your treatment options for Cystitis?

Nitrofurantoin or fosfomycin TMP-SMX if local resistance is low Ciprofloxacin (reserved from routine use to avoid resistance) Cefixime

A 36-year-old generally healthy woman comes to the office with urinary frequency and burning. The urinalysis shows more than 50 WBC per high power field. What is the most appropriate next step in management? a. Nifurantoin for 3 days b. Nifurantoin for 7 days c. Urine culture d. Ultrasound of urinary system e. CT scan of urinary system

A. 3 days is sufficient for uncomplicated cystitis 7 days is used if there is an anatomic abnormality

Patient came in with dysuria, flank pain or costovertebral tenderness, and high fever. Urinalysis shows increased WBCs. What is the most likely diagnosis?

Pyelonephritis

What diagnostic test will you order if you suspect Pyelonephritis?

CT or Sonogram (to detect anatomic abnormality causing infection)

What is the first line treatment for Pyelonephritis?

Ceftriaxone (Any of the drugs for gram-neg bacilli would be effective) You can also give Ampicillin and gentamicin and Oral Ciprofloxacin for outpatient

Patient came in with recent complaints of dysuria with perineal pain and tender prostate upon examination. What is the most likely diagnosis?

Acute Prostatitis

What would you do to increase diagnostic yield of urine culture of a patient with Acute Prostatitis?

Prostate Massage

How would you treat Acute Prostatitis?

(same as pyelonephritis) Ceftriaxone Ampi-Genta Ciprofloxacin (outpatient)

How would you treat Chronic Prostatitis?

Ciprofloxacin or TMP/SMX for 6 to 8 weeks

What is the single biggest difference between the treatment of prostatitis and cystitis in a 60 year-old man? a. Causative organism b. Duration of therapy c. Use of urinalysis d. Efficacy of trimethroprim/sulfamethoxazole e. Efficacy of intravenous medications

Patient presents with symptoms of Pyelonephritis. Treatment was initiated and there is persistence of symptoms after 5 to 7 days. What is the diagnosis? What would you order for diagnostic test? What is the treatment?

Perinephric Abscess CT Scan or Sonogram Drainage of fluid then culture to guide therapy

_______ is an infection of the valve of the heart leading to a fever and a murmur. It is diagnosed with vegetations seen on echocardiogram and positive cultures.

Endocarditis

What is the organism associated with Endocarditis?

Staphylociccus aureus

What are the two findings you need to look for to establish the diagnosis of Endocarditis?

Fever and new murmur or change in murmur

Complications of Endocarditis

``` 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 ```

What is/are the best initial test for Endocarditis?

``` Blood culture (95-99% sensitive) Transthoracic echocardiogram (60% sensitive but 95-100% specific) Transesophageal echocardiogram (95% sensitive and specific) ```

A man comes into the emergency department with fever and a murmur. Blood culture grow Clostridium septicum. Transthoracic echocardiography shows a vegetation. What is the most appropriate next step in the management of this patient? a. Colonoscopy b. Transesophageal echocardiogram c. CT of the abdomen d. Repeat the blood cultures e. Surgical valve replacement

A. Clostridium septicum is associated with colonic pathology ranging from diverticuli to polyps to colonic cancer

How would you establish a culture negative endocarditis?

1. Oscillating vegetation on echocardiography 2. Three minor criteria: - Fever >100.3F (38C) - Risk such as injection drug or prosthetic valve - Signs of embolic phenomena

What is the best initial empiric therapy for Endocarditis?

Vancomycin and Gentamicin

Patient is diagnosed with Endocarditis. Culture returned with Viridans streptococci. How would you treat?

Ceftriaxone for 4 weeks

Patient is diagnosed with Endocarditis. Culture returned with Staphylococcus aureus (sensitive). How would you treat?

Oxacillin, nafcillin, or cefazolin

Patient is diagnosed with Endocarditis. Culture returned with Fungal infection. How would you treat?

Amphotericin and valve replacement

Patient is diagnosed with Endocarditis. Culture returned with Staphylococcus epidermidis or resistant staphylococcus. How would you treat?

Vancomycin

Patient is diagnosed with Endocarditis. Culture returned with Enterococci. How would you treat?

Ampicillin and gentamicin

When is surgery indicated for Endocarditis?

``` When the patient has prosthetic valves Fungal etiology develops CHF from ruptured valve Abscess AV block Recurrent emboli while on antibiotics ```

What should you add in the treatment for prosthetic valve endocarditis with Staphylococcus.

Rifampicin

What is the singe strongest indication for surgery in Endocarditis?

acute valve rupture and CHF.

What are the two most common causes of culture-negative endocarditis?

Coxiella and Bartonella

Give the organisms that are difficult to culture that causes Endocarditis.

'HACEK' ``` Haemophilus aphrophilus Haemophilus parainfluenzae Actinobacillus Cardiobacterium Eikenella Kingella ```

What antibiotic will you give for the HACEK group of organisms?

Ceftriaxone

What is the best initial management prior to surgery of a patient with Endocarditis?

Amoxicillin If allergic: Clindamycin, Azithromycin, or Clarithromycin

What organism produces Lyme disease? How is it being transmitted?

Borrelia burgdorferi Ixodes scapularis tick (deer tick)

What is the most commonly affected joint in Lyme disease?

Knee

What is the proper term for the rash of Lyme Disease?

Erythema Migrans

How would you describe the rash in Lyme Disease?

Round red lesion with a pale area in the center (target or bull's-eye lesion)

What is the most common long term manifestation of Lyme Disease?

Joint Pain

What is the most common neurological manifestation of Lyme disease?

Seventh cranial nerve defect or Bell Palsy

What is the most common cardiac manifestation of Lyme disease?

Transient AV block

Patient came in with target rash on the thigh. You suspect Lyme disease. How would you treat?

Doxycycline | Amoxicillin or Cefuroxime

Patient came in with joint pain and seventh cranial nerve palsy. You suspect Lyme disease. How would you treat?

Doxycycline | Amoxicillin or Cefuroxime

Patient came in and you suspect him to have Lyme disease. He has also cardiac and neurological symptoms other than seventh cranial nerve palsy. How would you treat?

Intravenous Ceftriaxone

What is the best initial test for HIV?

ELISA

What is a confirmatory test for HIV?

Western Blot

How do you diagnose infants with mothers positive with HIV?

PCR or Viral Culture

How do you assess that the patient with HIV is responding to therapy?

decreasing viral load in PCR

How do you assess that the patient with HIV is NOT responding to therapy?

increasing viral load in PCR

___________ should be performed prior to initiating antiretroviral medications in HIV

Viral Resistance Testing (Genotyping)

Which of the following patients will derive the greatest benefit in reducing mortality from the use of anti-retroviral therapy (ART)? a. Viral load greater than 100,000 copies b. CD4 less than 200 c. CD4 less than 350 d. CD4 less than 500 e. Those with viral resistance

B. Although ART is encouraged at any level of detectable viral load or CD4 count, the greatest mortality benefit is in those with a low CD4 count.

What is the initial treatment of HIV?

2 nucleoside reverse-transcriptase inhibitors (NRTIs) and an integrase inhibitor

Give 3 examples of integrase inhibitors

dolutegravir elvitegravir raltegravir

Give 2 NRTI combinations

Tenofovir alafenamide and emtricitabine | Abacavir and lamivudine

Before using Abacavir, you must test for?

HLA B5701 Those with HLA B5701 mutation are at risk for Steven-Johnson syndrome

______ in a small dose is used to "boost" darunavir or atazanavir levels

Ritonavir

___________ inhibits elvitegravir metabolism, boosting its levels.

Cobicistat

What is the adverse effect of Zidovudine?

Anemia

What is the adverse effect of Stavudine and Didanosine?

Peripheral Neuropathy and Pancreatitis

What is the adverse effect of Abacavir?

Hypersensitivity, Steven-Johnson reaction

What is the adverse effect of Protease Inhibitors?

Hyperlipidemia, Hyperglycemia

What is the adverse effect of Indinavir?

Nephrolithiasis

What is the adverse effect of Tenofovir, Disoproxil?

Renal insufficiency, bone demineralization

What HIV medication should you avoid in pregnancy?

Efavirenz

What should the baby of an HIV mother receive during delivery and for 6 weeks afterward?

Zidovudine

What is the viral load cut-off that indicates CS as a mode of delivery in an HIV mother?

above 1000/ul

What medication can you use for pre-exposure prophylaxis for HIV?

Emtricitabine-Tenofovir start and continue for a month after the last exposure