Infectious Disease

Question 1

Antibiotic guidelines

Answer 1

Exacerbations of chronic bronchitis

Amoxicillin or tetracycline or clarithromycin

Uncomplicated community-acquired pneumonia

Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)

Pneumonia possibly caused by atypical pathogens

Clarithromycin

Hospital-acquired pneumonia

Within 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Skin

Impetigo

Topical fusidic acid, oral flucloxacillin or erythromycin if widespread

Cellulitis

Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)

Cellulitis (near the eyes or nose)

Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)

Erysipelas

Flucloxacillin* (clarithromycin, erythromycin or doxycycline if penicillin-allergic)

Animal or human bite

Co-amoxiclav (doxycycline + metronidazole if penicillin-allergic)

Mastitis during breast-feeding

Flucloxacillin

Ear, nose & throat

Condition

Recommended treatment

Throat infections

Phenoxymethylpenicillin (erythromycin alone if penicillin-allergic)

Sinusitis

Amoxicillin or doxycycline or erythromycin

Otitis media

Amoxicillin (erythromycin if penicillin-allergic)

Otitis externa**

Flucloxacillin (erythromycin if penicillin-allergic)

Periapical or periodontal abscess

Amoxicillin

Gingivitis: acute necrotising ulcerative

Metronidazole

Genital system

Condition

Recommended treatment

Gonorrhoea

Intramuscular ceftriaxone + oral azithromycin

Chlamydia

Doxycycline or azithromycin

Pelvic inflammatory disease

Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole

Syphilis

Benzathine benzylpenicillin or doxycycline or erythromycin

Bacterial vaginosis

Oral or topical metronidazole or topical clindamycin

Gastrointestinal

Condition

Recommended treatment

Clostridium difficile

First episode: metronidazole
Second or subsequent episode of infection: vancomycin

Campylobacter enteritis

Clarithromycin

Salmonella (non-typhoid)

Ciprofloxacin

Shigellosis

Ciprofloxacin

Question 2

Bacterial vaginosis

Answer 2

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.

Features

vaginal discharge: ‘fishy’, offensive

asymptomatic in 50%

Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present

thin, white homogenous discharge

clue cells on microscopy: stippled vaginal epithelial cells

vaginal pH > 4.5

positive whiff test (addition of potassium hydroxide results in fishy odour)

Management

oral metronidazole for 5-7 days

70-80% initial cure rate

relapse rate > 50% within 3 months

the BNF suggests topical metronidazole or topical clindamycin as alternatives

Question 3

Tetanus: vaccination

Answer 3

The tetanus vaccine is a cell-free purified toxin that is normally given as part of a combined vaccine.

Tetanus vaccine is currently given in the UK as part of the routine immunisation schedule at:

2 months

3 months

4 months

3-5 years

13-18 years

This therefore provides 5 doses of tetanus-containing vaccine. Five doses is now considered to provide adequate long-term protection against tetanus.

Intramuscular human tetanus immunoglobulin should be given to patients with high-risk wounds (e.g. Compound fractures, delayed surgical intervention, significant degree of devitalised tissue) irrespective of whether 5 doses of tetanus vaccine have previously been given

If vaccination history is incomplete or unknown then a dose of tetanus vaccine should be given combined with intramuscular human tetanus immunoglobulin for high-risk wounds

Question 4

BCG vaccine

Answer 4

The Bacille Calmette-Guérin (BCG) vaccine offers limited protection against tuberculosis (TB). In the UK it is given to high-risk infants. Until 2005 it was also routinely given to children at the age of 13 years.

The Greenbook currently advises that the vaccine is administered to the following groups (below is summary, please see the link for more details):

all infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater

all infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. The same applies to older children but if they are 6 years old or older they require a tuberculin skin test first

previously unvaccinated tuberculin-negative contacts of cases of respiratory TB

previously unvaccinated, tuberculin-negative new entrants under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater

healthcare workers

prison staff

staff of care home for the elderly

those who work with homeless people

The vaccine contains live attenuated Mycobacterium bovis. It also offers limited protection against leprosy.

Administration

any person being considered for the BCG vaccine must first be given a tuberculin skin test. The only exceptions are children < 6 years old who have had no contact with tuberculosis

given intradermally, normally to the lateral aspect of the left upper arm

BCG can be given at the same time as other live vaccines, but if not administered simultaneously there should be a 4 week interval

Contraindications

previous BCG vaccination

a past history of tuberculosis

HIV

pregnancy

positive tuberculin test (Heaf or Mantoux)

The BCG vaccine is not given to anyone over the age of 35, as there is no evidence that it works for people of this age group.

Question 5

Campylobacter

Answer 5

Campylobacter is the commonest bacterial cause of infectious intestinal disease in the UK. The majority of cases are caused by the Gram-negative bacillus Campylobacter jejuni. It is spread by the faecal-oral route and has an incubation period of 1-6 days.

Features

prodrome: headache malaise
diarrhoea: often bloody

abdominal pain: may mimic appendicitis

Management

usually self-limiting

the BNF advises treatment if severe or the patient is immunocompromised. Clinical Knowledge summaries also recommend antibiotics if severe symptoms (high fever, bloody diarrhoea, or more than eight stools per day) or symptoms have last more than one week

the first-line antibiotic is clarithromycin

ciprofloxacin is an alternative although the BNF states that ‘Strains with decreased sensitivity to ciprofloxacin isolated frequently’

Complications

Guillain-Barre syndrome may follow Campylobacter jejuni infections

Reiter’s syndrome

septicaemia, endocarditis, arthritis

Question 6

Chancroid

Answer 6

Chancroid causes painful genital ulcers

Important for meLess important

The painful genital ulcer with a ragged border associated with tender inguinal lymphadenopathy points to chancroid. Chancroid is caused by Haemophilus ducreyi.

Herpes simplex virus also causes painful genital ulcers, but they are generally smaller and multiple and primary attacks are often associated with fever.

The other organisms are causes of painless genital ulcers: C. trachomatis causes lymphogranuloma venereum; T. pallidum causes syphilis; K. granulomatis causes granuloma inguinale

Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.

Question 7

Chlamydia

Answer 7

Chlamydia is the most prevalent sexually transmitted infection in the UK and is caused by Chlamydia trachomatis, an obligate intracellular pathogen. Approximately 1 in 10 young women in the UK have Chlamydia. The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic

Features

asymptomatic in around 70% of women and 50% of men

women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria

Potential complications

epididymitis

pelvic inflammatory disease

endometritis

increased incidence of ectopic pregnancies

infertility

reactive arthritis

perihepatitis (Fitz-Hugh-Curtis syndrome)

Investigation

traditional cell culture is no longer widely used

nuclear acid amplification tests (NAATs) are now the investigation of choice

urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique

for women: the vulvovaginal swab is first-line

for men: the urine test is first-line

Chlamydiatesting should be carried out two weeks after a possible exposure

Screening

in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years

the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years

relies heavily on opportunistic testing

Pap smear demonstrating infected endocervical cells. Red inclusion bodies are typical

Management

doxycycline (7 day course) or azithromycin (single dose). The 2009 SIGN guidelines suggest azithromycin should be used first-line due to potentially poor compliance with a 7 day course of doxycycline

if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice ‘following discussion of the balance of benefits and risks with the patient’

patients diagnosed with Chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM

for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms

for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted

contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

Question 8

Hepatitis C

Answer 8

Hepatitis C is likely to become a significant public health problem in the UK in the next decade. It is thought around 200,000 people are chronically infected with the virus. At risk groups include intravenous drug users and patients who received a blood transfusion prior to 1991 (e.g. haemophiliacs).

Pathophysiology

hepatitis C is a RNA flavivirus

incubation period: 6-9 weeks

Transmission

the risk of transmission during a needle stick injury is about 2%

the vertical transmission rate from mother to child is about 6%. The risk is higher if there is coexistent HIV

breastfeeding is not contraindicated in mothers with hepatitis C

the risk of transmitting the virus during sexual intercourse is probably less than 5%

there is no vaccine for hepatitis C

After exposure to the hepatitis C virus only around 30% of patients will develop features such as:

a transient rise in serum aminotransferases / jaundice

fatigue

arthralgia

Investigations

HCV RNA is the investigation of choice to diagnose acute infection

whilst patients will eventually develop anti-HCV antibodies it should be remembered that patients who spontaneously clear the virus will continue to have anti-HCV antibodies

Outcomearound 15-45% of patients will clear the virus after an acute infection (depending on their age and underlying health) and hence the majority (55-85%) will develop chronic hepatitis C

Question 9

Chronic hepatitis C

Answer 9

Chronic hepatitis C may be defined as the persistence of HCV RNA in the blood for 6 months.

Potential complications of chronic hepatitis C

rheumatological problems: arthralgia, arthritis

eye problems: Sjogren’s syndrome

cirrhosis (5-20% of those with chronic disease)

hepatocellular cancer

cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal)

porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse

membranoproliferative glomerulonephritis

Management of chronic infection

treatment depends on the viral genotype - this should be tested prior to treatment

the management of hepatitis C has advanced rapidly in recent years resulting in clearance rates of around 95%. Interferon based treatments are no longer recommended

the aim of treatment is sustained virological response (SVR), defined as undetectable serum HCV RNA six months after the end of therapy

currently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used

Complications of treatment

ribavirin - side-effects: haemolytic anaemia, cough. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic

interferon alpha - side-effects: flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia

Question 10

Clostridia

Answer 10

Clostridia are gram-positive, obligate anaerobic bacilli.

C. perfringens

produces α-toxin, a lecithinase, which causes gas gangrene (myonecrosis) and haemolysis

features include tender, oedematous skin with haemorrhagic blebs and bullae. Crepitus may present on palpation

C. botulinum

typically seen in canned foods and honey

prevents acetylcholine (ACh) release leading to flaccid paralysis

C. difficile

causes pseudomembranous colitis, typically seen after the use of broad-spectrum antibiotics

produces both an exotoxin and a cytotoxin

C. tetani

produces an exotoxin (tetanospasmin) that prevents the release of glycine from Renshaw cells in the spinal cord causing a spastic paralysis

Question 11

Enteric fever (typhoid/paratyphoid)

Answer 11

The Salmonella group contains many members, most of which cause diarrhoeal diseases. They are aerobic, Gram-negative rods which are not normally present as commensals in the gut.

Typhoid and paratyphoid are caused by Salmonella typhi and Salmonella paratyphi (types A, B & C) respectively. They are often termed enteric fevers, producing systemic symptoms such as headache, fever, arthralgia.

Pathophysiology

typhoid is transmitted via the faecal-oral route (also in contaminated food and water)

Features

initially systemic upset as above

relative bradycardia

abdominal pain, distension

constipation: although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid

rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid

Possible complications include

osteomyelitis (especially in sickle cell disease where Salmonella is one of the most common pathogens)

GI bleed/perforation

meningitis

cholecystitis

chronic carriage (1%, more likely if adult females)

Question 12

Gastroenteritis causes

Answer 12

Gastroenteritis may either occur whilst at home or whilst travelling abroad (travellers’ diarrhoea)

Travellers’ diarrhoea may be defined as at least 3 loose to watery stools in 24 hours with or without one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool. The most common cause is Escherichia coli.

Another pattern of illness is ‘acute food poisoning’. This describes the sudden onset of nausea, vomiting and diarrhoea after the ingestion of a toxin. Acute food poisoning is typically caused by Staphylococcus aureus, Bacillus cereus or Clostridium perfringens.

Stereotypical histories

Infection

Typical presentation

Escherichia coli

Common amongst travellers
Watery stools
Abdominal cramps and nausea

Giardiasis

Prolonged, non-bloody diarrhoea

Cholera

Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travellers

Shigella

Bloody diarrhoea
Vomiting and abdominal pain

Staphylococcus aureus

Severe vomiting
Short incubation period

Campylobacter

A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
May mimic appendicitis
Complications include Guillain-Barre syndrome

Bacillus cereus

Two types of illness are seen

vomiting within 6 hours, stereotypically due to rice

diarrhoeal illness occurring after 6 hours

Amoebiasis

Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

Incubation period

1-6 hrs: Staphylococcus aureus, Bacillus cereus*

12-48 hrs: Salmonella, Escherichia coli

48-72 hrs: Shigella, Campylobacter

> 7 days: Giardiasis, Amoebiasis

*vomiting subtype, the diarrhoeal illness has an incubation period of 6-14 hours

Question 13

Genital warts

Answer 13

Genital warts (also known as condylomata accuminata) are a common cause of attendance at genitourinary clinics. They are caused by the many varieties of the human papilloma virus HPV, especially types 6 & 11. It is now well established that HPV (primarily types 16,18 & 33) predisposes to cervical cancer.

Features

small (2 - 5 mm) fleshy protuberances which are slightly pigmented

may bleed or itch

Management

topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy

imiquimod is a topical cream which is generally used second line

genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years

Question 14

Giardiasis

Answer 14

Giardiasis is caused by the flagellate protozoan Giardia lamblia. It is spread by the faeco-oral route

Features

often asymptomatic

lethargy, bloating, abdominal pain

flatulence

non-bloody diarrhoea

chronic diarrhoea, malabsorption and lactose intolerance can occur

stool microscopy for trophozoite and cysts are classically negative, therefore duodenal fluid aspirates or ‘string tests’ (fluid absorbed onto swallowed string) are sometimes needed

Treatment is with metronidazole.

Question 15

Gonorrhoea

Answer 15

Gonorrhoea is caused by the Gram-negative diplococcus Neisseria gonorrhoeae. Acute infection can occur on any mucous membrane surface, typically genitourinary but also rectum and pharynx. The incubation period of gonorrhoea is 2-5 days

Features

males: urethral discharge, dysuria
females: cervicitis e.g. leading to vaginal discharge

rectal and pharyngeal infection is usually asymptomatic

Microbiology

immunisation is not possible and reinfection is common due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)

Local complications that may develop include urethral strictures, epididymitis and salpingitis (hence may lead to infertility). Disseminated infection may occur - see below

Management

ciprofloxacin used to be the treatment of choice. However, there is increased resistance to ciprofloxacin (around 36% in the UK) and therefore cephalosporins are now more widely used

there was a change in the 2019 British Society for Sexual Health and HIV (BASHH) guidelines. Previously the first-line treatment was IM ceftriaxone + oral azithromycin. The new first-line treatment is a single dose of IM ceftriaxone 1g (i.e. no longer add azithromycin). If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given

if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used

Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of DGI is not fully understood but is thought to be due to haematogenous spread from mucosal infection (e.g. Asymptomatic genital infection). Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis. Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)

Key features of disseminated gonococcal infection

tenosynovitis

migratory polyarthritis

dermatitis (lesions can be maculopapular or vesicular)

Question 16

Trichomonas vaginalis

Answer 16

Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).

Features

vaginal discharge: offensive, yellow/green, frothy

vulvovaginitis

strawberry cervix

pH > 4.5

in men is usually asymptomatic but may cause urethritis

Investigation

microscopy of a wet mount shows motile trophozoites

Management

oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Infertility secondary to pelvic inflammatory disease (PID) is the most common complication of gonorrhoea. It is the second most common cause of PID after Chlamydia. Arthropathy may occur but it is far less common.

Lymphogranuloma venereum is caused by Chlamydia trachomatis.

Question 17

Herpes simplex virus

Answer 17

There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap

Features

primary infection: may present with a severe gingivostomatitis

cold sores

painful genital ulceration

Management

gingivostomatitis: oral aciclovir, chlorhexidine mouthwash

cold sores: topical aciclovir although the evidence base for this is modest

genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir

Pregnancy

elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation

women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low

Question 18

HIV anti-retrovirals

Answer 18

Highly active anti-retroviral therapy (HAART) involves a combination of at least three drugs, typically two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). This combination both decreases viral replication but also reduces the risk of viral resistance emerging

Following the 2015 BHIVA guidelines it is now recommended that patients start HAART as soon as they have been diagnosed with HIV, rather than waiting until a particular CD4 count, as was previously advocated.

Entry inhibitors

maraviroc (binds to CCR5, preventing an interaction with gp41), enfuvirtide (binds to gp41, also known as a ‘fusion inhibitor’)

prevent HIV-1 from entering and infecting immune cells

Nucleoside analogue reverse transcriptase inhibitors (NRTI)

examples: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir

general NRTI side-effects: peripheral neuropathy

tenofovir: used in BHIVAs two recommended regime NRTI. Adverse effects include renal impairment and ostesoporosis
zidovudine: anaemia, myopathy, black nails
didanosine: pancreatitis

Non-nucleoside reverse transcriptase inhibitors (NNRTI)

examples: nevirapine, efavirenz

side-effects: P450 enzyme interaction (nevirapine induces), rashes

Protease inhibitors (PI)

examples: indinavir, nelfinavir, ritonavir, saquinavir

side-effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition

indinavir: renal stones, asymptomatic hyperbilirubinaemia
ritonavir: a potent inhibitor of the P450 system

Integrase inhibitors

examples: raltegravir, elvitegravir, dolutegravir

Question 19

HIV Kaposi’s sarcoma

Answer 19

Kaposi’s sarcoma

caused by HHV-8 (human herpes virus 8)

presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract)

skin lesions may later ulcerate

respiratory involvement may cause massive haemoptysis and pleural effusion

radiotherapy + resection

Question 20

Animal and human bites

Answer 20

Animal bites

The majority of bites seen in everyday practice involve dogs and cats. These are generally polymicrobial but the most common isolated organism is Pasteurella multocida.

Management

cleanse wound. Puncture wounds should not be sutured closed unless cosmesis is at risk

current BNF recommendation is co-amoxiclav

if penicillin-allergic then doxycycline + metronidazole is recommended

Human bites

Human bites commonly cause multimicrobial infection, including both aerobic and anaerobic bacteria.

Common organisms include:

Streptococci spp.

Staphylococcus aureus

Eikenella

Fusobacterium

Prevotella

Co-amoxiclav is recommended, as for animal bites.

The risk of viral infections such as HIV and hepatitis C should also be considered.

Question 21

Human papilloma virus vaccinatio

Answer 21

It has been known for a longtime that the human papilloma virus (HPV) which infects the keratinocytes of the skin and mucous membranes is carcinogenic.

There are dozens of strains of HPV. The most important to remember are:

6 & 11: causes genital warts

16 & 18: linked to a variety of cancers, most notably cervical cancer

HPV infection is linked to:

over 99.7% of cervical cancers

around 85% of anal cancers

around 50% of vulval and vaginal cancers

around 20-30% of mouth and throat cancers

It should of course be remembered that there are other risk factors important in developing cervical cancer such as smoking, combined oral contraceptive pill use and high parity.

Testing for HPV has now been integrated into the cervical cancer screening programme. If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV

if HPV negative the patient goes back to routine recall

if HPV positive the patient is referred for colposcopy

Immunisation

A vaccination for HPV was introduced in the UK back in 2008. As you may remember the Department of Health initially chose Cervarix. This vaccine protected against HPV 16 & 18 but not 6 & 11. There was widespread criticism of this decision given the significant disease burden caused by genital warts. Eventually in 2012 Gardasil replaced Cervarix as the vaccine used. Gardasil protects against HPV 6, 11, 16 & 18. This was initially just given to girls but from September 2019 boys were given the vaccine as well.

From September 2019, all 12- and 13-year-olds (girls AND boys) in school Year 8 will be offered the human papillomavirus (HPV) vaccine.

the vaccine is normally given in school

information given to parents and available on the NHS website make it clear that the daughter may receive the vaccine against parental wishes

given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy

HPV vaccination should also be offered to men who have sex with men under the age of 45 to protect against anal, throat and penile cancers.

Injection site reactions are particularly common with HPV vaccines.

Question 22

Infectious mononucleosis

Answer 22

Infectious mononucleosis (glandular fever) (EBV, also known as human herpesvirus 4, HHV-4) in 90% of cases. Less frequent causes include cytomegalovirus and HHV-6. It is most common in adolescents and young adults.

The classic triad of sore throat, pyrexia and lymphadenopathy is seen in around 98% of patients:

sore throat

lymphadenopathy: may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged

pyrexia

Other features include:

malaise, anorexia, headache

palatal petechiae

splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture

hepatitis, transient rise in ALT

lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes

haemolytic anaemia secondary to cold agglutins (IgM)

a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

Symptoms typically resolve after 2-4 weeks.

Diagnosis

heterophil antibody test (Monospot test) - NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.

Management is supportive and includes:

rest during the early stages, drink plenty of fluid, avoid alcohol

simple analgesia for any aches or pains

consensus guidance in the UK is to avoid playing contact sports for 8 weeks after having glandular fever to reduce the risk of splenic rupture

There is an interesting correlation between EBV and socioeconomic groups. Lower socioeconomic groups have high rates of EBV seropositivity, having frequently acquired EBV in early childhood when the primary infection is often subclinical. However, higher socioeconomic groups show a higher incidence of infectious mononucleosis, as acquiring EBV in adolescence or early adulthood results in symptomatic disease.

Question 23

Influenza vaccination

Answer 23

Seasonal influenza still accounts for a significant morbidity and mortality in the UK each winter, with the influenza season typically starting in the middle of November. This may vary year from year so it is recommended that vaccination occurs between September and early November. There are three types of influenza virus; A, B and C. Types A and B account for the majority of clinical disease.

Prior to 2013 flu vaccination was only offered to the elderly and at risk groups.

Remember that the type of vaccine given routinely to children and the one given to the elderly and at risk groups is different (live vs. inactivated) - this explains the different contraindications

Children
A new NHS influenza vaccination programme for children was announced in 2013. There are three key things to remember about the children’s vaccine:

it is given intranasally

the first dose is given at 2-3 years, then annually after that

it is a live vaccine (cf. injectable vaccine below)

Some other points

children who were traditionally offered the flu vaccine (e.g. asthmatics) will now be given intranasal vaccine unless this is inappropriate, for example if they are immunosuppressed. In this situation the inactivated, injectable vaccine should be given

only children aged 2-9 years who have not received an influenza vaccine before need 2 doses

it is more effective than the injectable vaccine

Contraindications

immunocompromised

aged < 2 years

current febrile illness or blocked nose/rhinorrhoea

current wheeze (e.g. ongoing viral-induced wheeze/asthma) or history of severe asthma (BTS step 4)

egg allergy

pregnancy/breastfeeding

if the child is taking aspirin (e.g. for Kawasaki disease) due to a risk of Reye’s syndrome

Side-effects

blocked-nose/rhinorrhoea

headache

anorexia

The Department of Health recommends annual influenza vaccination for all people older than 65 years, and those older than 6 months if they have:

chronic respiratory disease (including asthmatics who use inhaled steroids)

chronic heart disease (heart failure, ischaemic heart disease, including hypertension if associated with cardiac complications)

chronic kidney disease

chronic liver disease: cirrhosis, biliary atresia, chronic hepatitis

chronic neurological disease: (e.g. Stroke/TIAs)

diabetes mellitus (including diet controlled)

immunosuppression due to disease or treatment (e.g. HIV)

asplenia or splenic dysfunction

pregnant women

adults with a body mass index >= 40 kg/m²

Other at risk individuals include:

health and social care staff directly involved in patient care (e.g. NHS staff)

those living in long-stay residential care homes

carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill (at the GP’s discretion)

The influenza vaccine

it is an inactivated vaccine, so cannot cause influenza. A minority of patients however develop fever and malaise which may last 1-2 days

should be stored between +2 and +8ºC and shielded from light

contraindications include hypersensitivity to egg protein.

in adults the vaccination is around 75% effective, although this figure decreases in the elderly

it takes around 10-14 days after immunisation before antibody levels are at protective levels

Question 24

Legionella

Answer 24

Legionnaire’s disease is caused by the intracellular bacterium Legionella pneumophilia. It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen

Features

flu-like symptoms including fever (present in > 95% of patients)

dry cough

relative bradycardia

confusion

lymphopaenia

hyponatraemia

deranged liver function tests

pleural effusion: seen in around 30% of patients

Diagnosis

urinary antigen

Management

treat with erythromycin/clarithromycin

Stereotypical features of Legionella include flu-like symptoms and a dry cough, relative bradycardia and confusion. Blood tests may show hyponatraemia

Important for meLess important

There are a number of features here which strongly suggest Legionella:

recent foreign travel

flu-like symptoms

hyponatraemia

pleural effusion

Question 25

Leptospirosis

Answer 25

Also known as Weil’s disease*, leptospirosis is commonly seen in questions referring to sewage workers, farmers, vets or people who work in an abattoir. It is caused by the spirochaete Leptospira interrogans (serogroup L icterohaemorrhagiae), classically being spread by contact with infected rat urine. Weil’s disease should always be considered in high-risk patients with hepatorenal failure

Features

fever

flu-like symptoms

renal failure (seen in 50% of patients)

jaundice

subconjunctival haemorrhage

headache, may herald the onset of meningitis

Management

high-dose benzylpenicillin or doxycycline

*the term Weil’s disease is sometimes reserved for the most severe 10% of cases that are associated with jaundice

Question 26

Lyme disease

Answer 26

Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks.

Features

early: erythema chronicum migrans (‘bulls-eye’) rash is seen in around 80%. Systemic features include fever, arthralgia
cardiovascular: heart block, myocarditis
neurological: facial nerve palsy, meningitis

Investigation

NICE recommend that Lyme disease can be diagnosed clinically if erythema migrans is present

erythema migrans is therefore an indication to start antibiotics

enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test

if negative and Lyme disease is still suspected in people tested within 4 weeks from symptom onset, repeat the ELISA 4-6 weeks after the first ELISA test. If still suspected in people who have had symptoms for 12 weeks or more then an immunoblot test should be done

if positive or equivocal then an immunoblot test for Lyme disease should be done

Management of asymptomatic tick bites

tick bites can be a relatively common presentation to GP practices, and can cause significant anxiety

NICE guidance does not recommend routine antibiotic treatment to patients who’ve suffered a tick bite

Management of suspected/confirmed Lyme disease

doxycycline if early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)

people with erythema migrans should be commenced on antibiotic treatment whilst awaiting results of ELISA

ceftriaxone if disseminated disease

Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

rythema chronicum migrans (‘bulls-eye’) rash occurs in around 80% of patients with Lyme disease

Important for meLess important

Other skin rashes associated with Lyme disease include acrodermatitis chronica atrophicans and Borrelia lymphocytosis. Erythema marginatum is seen in rheumatic fever whilst erythema ab igne refers to skin that is reddened secondary to long-term exposure to infrared radiation

Question 27

Malaria prophylaxis

Answer 27

There are around 1,500-2,000 cases each year of malaria in patients returning from endemic countries. The majority of these cases (around 75%) are caused by the potentially fatal Plasmodium falciparum protozoa. The majority of patients who develop malaria did not take prophylaxis. It should also be remembered that UK citizens who originate from malaria endemic areas quickly lose their innate immunity.

Up-to-date charts with recommended regimes for malarial zones should be consulted prior to prescribing

Drug

Side-effects + notes

Time to begin before travel

Time to end after travel

Atovaquone + proguanil (Malarone)

GI upset

1 - 2 days

7 days

Chloroquine

Headache

Contraindicated in epilepsy
Taken weekly

1 week

4 weeks

Doxycycline

Photosensitivity
Oesophagitis

1 - 2 days

4 weeks

Mefloquine (Lariam)

Dizziness
Neuropsychiatric disturbance

Contraindicated in epilepsy
Taken weekly

2 - 3 weeks

4 weeks

Proguanil (Paludrine)

1 week

4 weeks

Proguanil + chloroquine

See above

1 week

4 weeks

Pregnant women should be advised to avoid travelling to regions where malaria is endemic. Diagnosis can also be difficult as parasites may not be detectable in the blood film due to placental sequestration. However, if travel cannot be avoided:

chloroquine can be taken

proguanil: folate supplementation (5mg od) should be given

Malarone (atovaquone + proguanil): the BNF advises to avoid these drugs unless essential. If taken then folate supplementation should be given

mefloquine: caution advised

doxycycline is contraindicated

It is again advisable to avoid travel to malaria endemic regions with children if avoidable. However, if travel is essential then children should take malarial prophylaxis as they are more at risk of serious complications.

diethyltoluamide (DEET) 20-50% has been shown to repel up to 100% of mosquitoes if used correctly. It can be used in children over 2 months of age*

doxycycline is only licensed in the UK for children over the age of 12 years

Question 28

MRSA

Answer 28

Methicillin-resistant Staphylococcus aureus (MRSA) was one of the first organisms which highlighted the dangers of hospital-acquired infections.

Who should be screened for MRSA?

all patients awaiting elective admissions (exceptions include day patients having terminations of pregnancy and ophthalmic surgery. Patients admitted to mental health trusts are also excluded)

from 2011 all emergency admissions will be screened

How should a patient be screened for MRSA?

nasal swab and skin lesions or wounds

the swab should be wiped around the inside rim of a patient’s nose for 5 seconds

the microbiology form must be labelled ‘MRSA screen’

Suppression of MRSA from a carrier once identified

nose: mupirocin 2% in white soft paraffin, tds for 5 days
skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to the axilla, groin and perineum

The following antibiotics are commonly used in the treatment of MRSA infections:

vancomycin

teicoplanin

linezolid

Some strains may be sensitive to the antibiotics listed below but they should not generally be used alone because resistance may develop:

rifampicin

macrolides

tetracyclines

aminoglycosides

clindamycin

Relatively new antibiotics such as linezolid, quinupristin/dalfopristin combinations and tigecycline have activity against MRSA but should be reserved for resistant cases

Question 29

Notifiable diseases

Answer 29

Below is a list of notifiable diseases in the UK. The ‘Proper Officer’ at the Local Health Protection Team needs to be notified. They in turn will notify the Health Protection Agency on a weekly basis.

Notable exceptions include:

HIV

In April 2010 the following diseases were removed from the list:

Dysentery

Ophthalmia neonatorum

Leptospirosis

Relapsing fever

Therefore, the current notifiable diseases are:

Acute encephalitis

Acute infectious hepatitis

Acute meningitis

Acute poliomyelitis

Anthrax

Botulism

Brucellosis

Cholera

Diphtheria

Enteric fever (typhoid or paratyphoid fever)

Food poisoning

Haemolytic uraemic syndrome (HUS)

Infectious bloody diarrhoea

Invasive group A streptococcal disease

Legionnaires Disease

Leprosy

Malaria

Measles

Meningococcal septicaemia

Mumps

Plague

Rabies

Rubella

SARS

Scarlet fever

Smallpox

Tetanus

Tuberculosis

Typhus

Viral haemorrhagic fever (VHF)

Whooping cough

Yellow fever

Question 30

HIV: Pneumocystis jiroveci pneumonia

Answer 30

Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci, the term Pneumocystis carinii pneumonia (PCP) is still in common use

Pneumocystis jiroveci is an unicellular eukaryote, generally classified as a fungus but some authorities consider it a protozoa

PCP is the most common opportunistic infection in AIDS

all patients with a CD4 count < 200/mm³ should receive PCP prophylaxis

Features

dyspnoea

dry cough

fever

very few chest signs

Pneumothorax is a common complication of PCP.

Extrapulmonary manifestations are rare (1-2% of cases), may cause

hepatosplenomegaly

lymphadenopathy

choroid lesions

Investigation

CXR: typically shows bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation. May be normal

exercise-induced desaturation

sputum often fails to show PCP, bronchoalveolar lavage (BAL) often needed to demonstrate PCP (silver stain shows characteristic cysts)

Management

co-trimoxazole

IV pentamidine in severe cases

aerosolized pentamidine is an alternative treatment for Pneumocystis jiroveci pneumonia but is less effective with a risk of pneumothorax

steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

Question 31

Post-exposure prophylaxis

Answer 31

Hepatitis A

Human Normal Immunoglobulin (HNIG) or hepatitis A vaccine may be used depending on the clinical situation

Hepatitis B

HBsAg positive source: if the person exposed is a known responder to HBV vaccine then a booster dose should be given. If they are in the process of being vaccinated or are a non-responder they need to have hepatitis B immune globulin (HBIG) and the vaccine

unknown source: for known responders the green book advises considering a booster dose of HBV vaccine. For known non-responders HBIG + vaccine should be given whilst those in the process of being vaccinated should have an accelerated course of HBV vaccine

Hepatitis C

monthly PCR - if seroconversion then interferon +/- ribavirin

HIV

the risk of HIV transmission depends heavily on the incident (e.g. needle stick, type of sexual intercourse, human bite etc) and the current viral load of the patient

please see the BHIVA link for charts which outline the risk depending on the incident. Generally, low-risk incidents such as human bites don’t require post-exposure prophylaxis

a combination of oral antiretrovirals (e.g. Tenofovir, emtricitabine, lopinavir and ritonavir) as soon as possible (i.e. Within 1-2 hours, but may be started up to 72 hours following exposure) for 4 weeks

serological testing at 12 weeks following completion of post-exposure prophylaxis

reduces risk of transmission by 80%

Varicella zoster

VZIG for IgG negative pregnant women/immunosuppressed

Question 32

Pseudomonas aeruginosa

Answer 32

Pseudomonas aeruginosa is an aerobic Gram-negative rod. It causes a number of clinically important infections in humans:

chest infections (especially in cystic fibrosis)

skin: burns, wound infections, ‘hot tub’ folliculitis

otitis externa (especially in diabetics who may develop malignant otitis externa)

urinary tract infections

Lab features

Gram-negative rod

non-lactose fermenting

oxidase positive

Pathophysiology

produces both an endotoxin (causes fever and shock) and exotoxin A (inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2)

Question 33

Rabies

Answer 33

Rabies is a viral disease that causes an acute encephalitis. The rabies virus is classed as a RNA rhabdovirus (specifically a lyssavirus) and has a bullet-shaped capsid. The vast majority of cases are caused by dog bites but it may also be transmitted by bat, raccoon and skunk bites. Following a bite the virus travels up the nerve axons towards the central nervous system in a retrograde fashion.

Rabies is estimated to still kill around 25,000-50,000 people across the world each year. The vast majority of the disease burden falls on people in poor rural areas of Africa and Asia. Children are particularly at risk.

Features

prodrome: headache, fever, agitation
hydrophobia: water-provoking muscle spasms

hypersalivation

Negri bodies: cytoplasmic inclusion bodies found in infected neurons

There is now considered to be ‘no risk’ of developing rabies following an animal bite in the UK and the majority of developed countries. Following an animal bite in at-risk countries:

the wound should be washed

if an individual is already immunised then 2 further doses of vaccine should be given

if not previously immunised then human rabies immunoglobulin (HRIG) should be given along with a full course of vaccination. If possible, the dose should be administered locally around the wound

If untreated the disease is nearly always fatal.

Question 34

Mycoplasma pneumoniae

Answer 34

Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger patients. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma pneumoniae classically occur every 4 years. It is important to recognise atypical pneumonia as it may not respond to penicillins or cephalosporins due to it lacking a peptidoglycan cell wall.

Features

the disease typically has a prolonged and gradual onset

flu-like symptoms classically precede a dry cough

bilateral consolidation on x-ray

complications may occur as below

Complications

cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia

erythema multiforme, erythema nodosum

meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases

bullous myringitis: painful vesicles on the tympanic membrane

pericarditis/myocarditis

gastrointestinal: hepatitis, pancreatitis
renal: acute glomerulonephritis

Investigations

diagnosis is generally by Mycoplasma serology

positive cold agglutination test

Management

doxycycline or a macrolide (e.g. erythromycin/clarithromycin)

For each of the following scenarios please select the most likely causative respiratory pathogen:

Question 35

Respiratory pathogens

Answer 35

The table below lists the more common respiratory pathogens:

Pathogen

Associated condition

Respiratory syncytial virus - Bronchiolitis

Parainfluenza virus- Croup

Rhinovirus - Common cold

Influenza virus - Flu

Streptococcus pneumoniae

The most common cause of community-acquired pneumonia

Haemophilus influenzae

Community-acquired pneumonia
Most common cause of bronchiectasis exacerbations

Acute epiglottitis

Staphylococcus aureus

Pneumonia, particularly following influenza

Mycoplasma pneumoniae

Atypical pneumonia

Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme

Legionella pneumophilia

Atypical pneumonia

Classically spread by air-conditioning systems, causes dry cough. Lymphopenia, deranged liver function tests and hyponatraemia may be seen

Pneumocystis jiroveci

Common cause of pneumonia in HIV patients. Typically patients have few chest signs and develop exertional dyspnoea

Mycobacterium tuberculosis

Causes tuberculosis. A wide range of presentations from asymptomatic to disseminated disease are possible. Cough, night sweats and weight loss may be seen

The dry cough, erythema multiforme (symmetrical target shaped rash with a central blister) and the radiological findings point to a diagnosis of Mycoplasma.

Although pneumococcal pneumonia is the most common pneumonia in the community, you would expect lobar consolidation on x-ray as well as a productive, rather than dry, cough.

Klebsiella occurs in alcoholics, and although the woman drinks more than her allowance (for women this is 14 units a week) it is not at the level where it would predispose her to Klebsiella. Furthermore, it typically causes a cavitating pneumonia of the upper lobes.

Question 36

Sepsis

Answer 36

Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection

septic shock: a more severe form sepsis, technically defined as ‘in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone’*

qSOFA) score meeting >= 2 of the following criteria: respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100mmHg or less

qSOFA score
Respiratory rate > 22/min
Altered mentation
Systolic blood pressure < 100 mm Hg

Clearly the underlying cause of the patients sepsis needs to be identified and treated and the patient supported regardless of the cause or severity. If however any of the red flags are present the ‘sepsis six’ should be started straight away:

1. Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
2. Take blood cultures
3. Give broad spectrum antibiotics
4. Give intravenous fluid challenges: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes
5. Measure serum lactate
6. Measure accurate hourly urine output

Question 37

Sepsis Traffic Light

Answer 37

NICE recommend using the following criteria:

Red flag criteria

Systolic B.P <= 90 mmHg (or drop >40 from normal)

Heart rate > 130 per minute

Respiratory rate >= 25 per minute

Needs oxygen to keep SpO2 >=92%

Non-blanching rash, mottled/ ashen/ cyanotic

Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr

Lactate >=2 mmol/l

Recent chemotherapy

Amber

Relatives concerned about mental status

Acute deterioration in functional ability

Immunosuppressed

Trauma/ surgery/ procedure in last 6 weeks

Respiratory rate 21-24

Systolic B.P 91-100 mmHg

Heart rate 91-130 OR new dysrhythmia

Not passed urine in last 12-18 hours

Temperature < 36ºC

Clinical signs of wound, device or skin infection

Question 38

STI ulcers

Answer 38

Genital herpes is most often caused by the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type 1). Primary attacks are often severe and associated with fever whilst subsequent attacks are generally less severe and localised to one site. There is typically multiple painful ulcers.

Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The incubation period= 9-90 days.

Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.

Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis. Typically infection comprises of three stages

stage 1: small painless pustule which later forms an ulcer

stage 2: painful inguinal lymphadenopathy

stage 3: proctocolitis

LGV is treated using doxycycline.

Other causes of genital ulcers

Behcet’s disease

carcinoma

granuloma inguinale: Klebsiella granulomatis*

*previously called Calymmatobacterium granulomatis

Question 39

Syphilis management

Answer 39

Management

intramuscular benzathine penicillin is the first-line management

alternatives: doxycycline

the Jarisch-Herxheimer reaction is sometimes seen following treatment

fever, rash, tachycardia after the first dose of antibiotic

in contrast to anaphylaxis, there is no wheeze or hypotension

it is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment

No treatment is needed other than antipyretics if required

Question 40

Trichomonas vaginalis

Answer 40

Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).

Features

vaginal discharge: offensive, yellow/green, frothy

vulvovaginitis

strawberry cervix

pH > 4.5

in men is usually asymptomatic but may cause urethritis

Investigation

microscopy of a wet mount shows motile trophozoites

Management

oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Question 41

Trimethoprim

Answer 41

Trimethoprim is an antibiotic, mainly used in the management of urinary tract infections.

Mechanism of action

interferes with DNA synthesis by inhibiting dihydrofolate reductase

may, therefore, interact with methotrexate, which also inhibits dihydrofolate reductase

Adverse effects

myelosuppression

transient rise in creatinine: trimethoprim competitively inhibits the tubular secretion of creatinine resulting in a temporary increase which reverses upon stopping the drug

trimethoprim blocks the ENaC channel in the distal nephron, causing a hyperkalaemic distal RTA (type 4). It also inhibits creatinine secretion, often leading to an increase in creatinine by around 40 points (but not necessarily causing AKI)

Use in pregnancy

the BNF advises that there is a: ‘Teratogenic risk in first trimester (folate antagonist). Manufacturers advise avoid during pregnancy.’

Question 42

Urinary tract infection in adults: management

Answer 42

Lower urinary tract infections

Non-pregnant women

local antibiotic guidelines should be followed if available

CKS/2012 SIGN guidelines recommend trimethoprim or nitrofurantoin for 3 days

send a urine culture if:

aged > 65 years

visible or non-visible haematuria

Pregnant women

if the pregnant woman is symptomatic:

a urine culture should be sent in all cases

should be treated with an antibiotic for 7 days

nitrofurantoin (should be avoided near term), amoxicillin or cefalexin

asymptomatic bacteriuria in pregnant women:

a urine culture should be performed routinely at the first antenatal visit

Clinical Knowledge Summaries recommend an immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course

the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis

a further urine culture should be sent following completion of treatment as a test of cure

Men

an immediate antibiotic prescription should be offered

Catherised patients

do not treat asymptomatic bacteria in catheterised patients

if the patient is symptomatic they should be treated with an antibiotic

a 7-day, rather than a 3-day course should be given

Acute pyelonephritis

For patients with sign of acute pyelonephritis hospital admission should be considered

local antibiotic guidelines should be followed if available

the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days

This pregnant lady has symptoms consistent with a urinary tract infection. The BNF recommend that trimethoprim is avoided in the first trimester as it is a folate antagonist. Ciprofloxacin is contraindicated throughout pregnancy. As this patient clearly has a UTI and is pyrexial should be treated straightaway, rather than waiting for the MSU,

Urinary tract infection in adults: management

Lower urinary tract infections

Non-pregnant women

local antibiotic guidelines should be followed if available

CKS/2012 SIGN guidelines recommend trimethoprim or nitrofurantoin for 3 days

send a urine culture if:

aged > 65 years

visible or non-visible haematuria

Pregnant women

if the pregnant woman is symptomatic:

a urine culture should be sent in all cases

should be treated with an antibiotic for 7 days

nitrofurantoin (should be avoided near term), amoxicillin or cefalexin

asymptomatic bacteriuria in pregnant women:

a urine culture should be performed routinely at the first antenatal visit

Clinical Knowledge Summaries recommend an immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course

the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis

a further urine culture should be sent following completion of treatment as a test of cure

Men

an immediate antibiotic prescription should be offered

Catherised patients

do not treat asymptomatic bacteria in catheterised patients

if the patient is symptomatic they should be treated with an antibiotic

a 7-day, rather than a 3-day course should be given

Question 43

Acute pyelonephritis

Answer 43

For patients with sign of acute pyelonephritis hospital admission should be considered

local antibiotic guidelines should be followed if available

the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days

TI in pregnancy may be asymptomatic, but still requires prompt treatment to prevent the development of pyelonephritis.

Nitrofurantoin and trimethoprim are frequently used to treat UTIs; nitrofurantoin may be used during pregnancy, but should be avoided at term, as it can cause neonatal haemolysis. Trimethoprim should be avoided in pregnancy, especially in the first trimester. Penicillins and cephalosporins are suitable for use during pregnancy, but sulfonamides (such as sulfasalazine) and quinolones (such as ciprofloxacin) should be avoided in pregnancy.

This patient has SLE and is taking immunosuppressive medication, therefore she requires treatment for 7 days.

The following groups of women should be prescribed a 5-10 day antibiotic course

Impaired renal function.

An abnormal urinary tract.

Immunosuppression

Question 44

Vaccinations

Answer 44

It is important to be aware of vaccines which are of the live-attenuated type as these may pose a risk to immunocompromised patients. The main types of vaccine are as follows:

Live attenuated

BCG

measles, mumps, rubella (MMR)

influenza (intranasal)

oral rotavirus

oral polio

yellow fever

oral typhoid

Inactivated preparations

rabies

hepatitis A

influenza (intramuscular)

Toxoid (inactivated toxin)

tetanus

diphtheria

pertussis

Subunit and conjugate vaccines are often grouped together. Subunit means that only part of the pathogen is used to generate an immunogenic response. A conjugate vaccine is a particular type that links the poorly immunogenic bacterial polysaccharide outer coats to proteins to make them more immunogenic

pneumococcus (conjugate)

haemophilus (conjugate)

meningococcus (conjugate)

hepatitis B

human papillomavirus

Notes

influenza: different types are available, including whole inactivated virus, split virion (virus particles disrupted by detergent treatment) and sub-unit (mainly haemagglutinin and neuraminidase)
cholera: contains inactivated Inaba and Ogawa strains of Vibrio cholerae together with recombinant B-subunit of the cholera toxin

hepatitis B: contains HBsAg adsorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology

Live attenuated vaccines such as BCG are contraindicated in all HIV positive patients.

Other live attenuated vaccines which should not be given in immunocompromised patients are:

Yellow fever

Oral polio

Intranasal influenza

Varicella

Measles, mumps and rubella (MMR)