Infectious Disease

Question 1

Patients who are undergoing cardiothoracic or orthopedic surgery should be screened for what?

Answer 1

Nasal carriage of S. aureus. If positive, decolonize

Question 2

First line therapy for coccidiomycosis?

Answer 2

Fluconazole, may need for life if diagnosing with meningitis

Consider amphotericin B if not responding to azoles

May present as acute/chronic pulmonary infection, cutaneous infection, meningitis or MSK infection

Question 3

Empiric therapy for severe CAP (requiring ICU admission)

Answer 3

1) Strep pneumo, h flu and gram-negative bacilli covera with a beta lactam (ampicillin-sulbactam, cefotaxime, ceftriaxone, ceftaroline) PLUS
2) Legionella coverage (macrolide or quinolone)

Question 4

Studies for FUO (defined as fever for 3+ weeks, undiagnosed after two ambulatory visits)

Answer 4

CBC with diff, CMP, blood culture set x3, ESR, TB eval, HIV testing, consider imaging with CT of C/A/P

Question 5

How to diagnose suspected invasive aspergillus infection

Answer 5

Serum galactomannan, if negative consider BAL/Bronchosocopy

Consider invasive aspergillus in patients with:

1) prolonged neutropenia
2) SCT/Solid organ transplant
3) Fever, cough, chest pain and hemoptysis with pulmonary infiltrates/wedge-shaped densities on imaging

Question 6

Leptospiral meningitis diagnostic criteria

Answer 6

1) Biphasic illness (weeks after exposure)
2) Uveitis
3) rash
4) Conjunctival suffusion (key finding)
5) Sepsis
6) LAD
7) AKI
8) HSM

Question 7

Rapidly growing, nontuberculous mycobacterial findings

Answer 7

Chronic, nonhealing wounds anywhere the bacteria has been introduced that do not respond to typical therapy for skin/soft tissue infection

1) Mycobacterium fortuitum (pedicures, freshwater footbath)
2) Mycobacterium abscessus
3) Mycobacterium chelonae

Question 8

PID vs cervicitis therapy

Answer 8

PID: IM ceftriaxone and doxy
Cervicitis: IM ceftriaxone and azithromycin

Question 9

PEP regimen for HIV exposure

Answer 9

Tenofovir, emtricitabine, and dolutegravir (or raltegravir) for 4 weeks

Test for HIV at time of exposure, 4-6 weeks later, and 3 months after exposure

Question 10

Patients with selective IgA deficiency are susceptible to what infection?

Answer 10

Giardia lambila (suspect with chronic abdominal cramping, bloating and diarrhea (usually nonbloody))

Question 11

Most common cause of viral meningitis? Seasonality?

Answer 11

Enteroviruses - Mary to November

If winter time, consider HSV2, especially if recurrent benign lymphocytic meningitis (aka Mollaret meningitis).

No need for acyclovir with HSV-2 meningitis, outcomes are usually favorable. Contrast with HSV-1 encephalitis, which requires prompt treatment

Question 12

Most common cause of viral meningitis? Seasonality?

Answer 12

Enteroviruses - Mary to November

If winter time, consider HSV2, especially if recurrent benign lymphocytic meningitis (aka Mollaret meningitis).

No need for acyclovir with HSV-2 meningitis, outcomes are usually favorable

Question 13

Features of Brucellosis

Answer 13

Animal reservoir (sheep/goats)

• Mediterranean/Middle East
• Sx: Fever, HA, myalgias, arthralgias, depression
• Signs: HSM, LAD, Granulomas on reticuloendothelial tissues
• May present as relapsing/chronic
• Diagnosis: Serum agglutination (>1:160), Rose Bengal slide
• Treatment: Doxycycline, rifampin, streptomycin (or gentamicin) for several weeks. Substitute ceftriaxone for streptomycin in neurobrucellosis

Question 14

CSF findings in sporadic Creutzfeldt-Jakob disease (CJD)

Answer 14

Positive for total Tau or 14-3-3 protein

Consider with progressive cognitive decline and vision loss

Question 15

CSF findings in sproadic Creutzfeldt-Jakob disease (CJD)

Answer 15

Positive for total Tau or 14-3-3 protein

Consider with progressive cognitive decline and vision loss

Question 16

Babesiosis

Answer 16

• Intraerythrocytic protozoan infection
• Black-legged deer tick, seen in areas of Lyme
• Sx: fever, fatigue, myalgia, jaundice, HSM
• Findings: Hemolytic anemia (Not seen in HME/anaplasmosis), thrombocytopenia, AKI, ARDS, elevated liver enzymes
• Maltese cross, get peripheral smear
• Severe illness more likely in asplenia

Treatment: atovaquone and azithromycin
- if severe: Clinda + quinine +/- exchange transfusion (parasitemia >10%)

Question 17

Treatment for cyclospora parasitic infection

Answer 17

TMP-SMX DS x7-10d

Endemic in Peru, Guatemala, Haiti and Nepal
Modified acid-fast staining will demonstrate oocysts

Question 18

Treatment for cyclospora parasitic infection

Answer 18

TMP-SMX

Question 19

What screening test should be performed while taking Ethambutol?

Answer 19

Vision screening

Can cause optic neuritis affecting acuity and color vision

Question 20

Hepatitis A travel vaccination recommendations

Answer 20

Ideally 2-4 weeks before departure as a single dose

Can give a single dose any time before travel

A booster can be given between 6 and 18 months after the initial vaccination, provides up to 10 years of protection

Question 21

Hepatitis A travel vaccination recommendations

Answer 21

Ideally 2-4 weeks before departure as a single dose

Can give a single dose any time before travel

Question 22

ESBL MDR UTI - first line treatment

Answer 22

Carbapenem class

Sensitivities may indicate susceptibility to agents such as Pip-tazo, but the susceptibility breakpoint used does not often convey clinical success

Question 23

Monitoring parameters for daptomycin

Answer 23

Kidney function and CK level

Question 24

What should be added for treatment of osteomyelitis with residual hardware?

Answer 24

Rifampin

Question 25

Preventative therapies for OI after HSCT

Answer 25

1) TMP-SMX for toxo/PJP 2) Antifungal therapy with posaconazole or voriconazole for the first several months after HSCT 3) Test and treat for CMV or empiric valgancyclovir/ganciclovir, however monitoring preferred d/t side effects of antiviral therapy (neutropenia)

Question 26

Treatment for severe candidemia

Answer 26

Echinocandin Fluconazole is good for prevention, not treatment of severe candidemia ``` Blood cultures with yeast are never a contaminant! Risk factors: - neutropenia - malignancy and chemotherapy - organ transplant - intravascular catheters - broad spectrum Abx - HD ```

Question 27

Treatment for severe candidemia

Answer 27

Echinocandin Blood cultures with yeast are never a contaminant, Risk factors: - neutropenia - malignancy and chemotherapy - organ transplant - intravascular catheters - broad spectrum Abx - HD

Question 28

Treatment for histoplasmosis

Answer 28

1) Itraconazole (6-12 weeks) | 2) For severe/disseminated infection: Liposomal amphotericin B

Question 29

Treatment for various bioterrorism agents (Anthrax, Smallpox, Plague, Tularemia)

Answer 29

Anthrax: ciprofloxacin, levofloxacin, moxifloxacin PLUS two additional agents Smallpox: Supportive care +/- tecovirimat Plague: Streptomycin/gentamicin Botulism: Antitoxin, supportive care Tularemia: Streptomycin/gentamicin or doxy/cipro if severe disease

Question 30

Banana-shaped gametocytes are indicative of what?

Answer 30

Plasmodium falciparum spp High degree of parasitemia (along with Plasmodium knowlesi)

Question 31

CMV treatment in HSCT patients

Answer 31

Ganciclovir Consider if >1 month since HSCT with non-specific symptoms (pneumonitis, esophagitis, colitis, hepatitis)

Question 32

Treatment duration for VAP

Answer 32

7 days

Question 33

Treatment for aeromonas hydrophila

Answer 33

Eval for nec fasc, provide GN coverage --> ciprofloxacin and doxycycline

Question 34

Preferred treatment for candida esophagitis

Answer 34

Oral fluconazole Consider EGD if not responding to therapy

Question 35

Antibiotic duration for prevention of acute rheumatic fever if: 1) uncomplicated 2) with carditis, no valvular disease 3) with carditis and valvular disease

Answer 35

Treatment is penicillin G benzathine every 3-4 weeks 1) for 5 years or until age 21 2) for 10 years or until age 21 3) for 10 years or until age 40 *Note these treatments are for whatever duration is longer

Question 36

Treatment for candidal esophagitis and thrush with known HIV

Answer 36

Trial oral fluconazole x14-21 days If not responding in 72 hours, schedule EGD for further evaluation (HSV, CMV)

Question 37

First line treatment for onychomycosis

Answer 37

Oral terbinafine (minimum 6 weeks) Second line is itraconazole BID once weekly per month for two months (pulse therapy)

Question 38

Clinical presentations for 1) Blastomycosis 2) Histoplasmosis 3) Coccidiomycosis

Answer 38

1) Cutaneous plaques/ulcerations, bone lesions with sinus tracts, GU involvement, CNS (rare) 2) Hilar lymphadenopathy, HSM, Pancytopenia, Adrenal Insufficiency 3) Skin lesions, lymph node involvement, meningitis, osteoarticular involvement

Question 39

What causes a chronic, non-tender indurated facial mass in patient with diabetes/dental caries/malnutrition? Treatment?

Answer 39

Cervicofacial actinomycosis Mandible most commonly involved Treat with penicillin