Infectious Disease Flashcards
Antibiotic guidelines
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
Bacterial vaginosis
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
Tetanus: vaccination
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
BCG vaccine
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.
Campylobacter
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
Chancroid
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.
Chlamydia
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)
Hepatitis C
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
Chronic hepatitis C
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
Clostridia
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
Enteric fever (typhoid/paratyphoid)
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)
Gastroenteritis causes
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
Genital warts
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
Giardiasis
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.
Gonorrhoea
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)
Trichomonas vaginalis
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.
Herpes simplex virus
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
HIV anti-retrovirals
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
HIV Kaposi’s sarcoma
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
Animal and human bites
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.
Human papilloma virus vaccinatio
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.
Infectious mononucleosis
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.
Influenza vaccination
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
Legionella
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
Leptospirosis
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
Lyme disease
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
Malaria prophylaxis
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
MRSA
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
Notifiable diseases
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
HIV: Pneumocystis jiroveci pneumonia
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)
Post-exposure prophylaxis
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
Pseudomonas aeruginosa
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)
Rabies
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.
Mycoplasma pneumoniae
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:
Respiratory pathogens
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.
Sepsis
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:
- Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
- Take blood cultures
- Give broad spectrum antibiotics
- Give intravenous fluid challenges: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes
- Measure serum lactate
- Measure accurate hourly urine output
Sepsis Traffic Light
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
STI ulcers
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
Syphilis management
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
Trichomonas vaginalis
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
Trimethoprim
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.’
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
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
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
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
Vaccinations
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)
