Infectious Diseases Flashcards
Mechanisms of resistance (3)
- Antibiotic - beta-lactamases, pneumococcus & macrolides, enzymatic modification of ahminoglycosides
- Alteration of target - pneumococcus & penicillin, staph. aureus and methicillin-like abx
- Decreased uptake - pseudomonas using porins for carbapenems, efflux pneumococcus & macrolides; pseudomonas & multiple agents
MIC definitions for MRSA, VISA and VRSA + mechanism
Vancomycin MIC
MRSA <2
VISA 4-8 = thicker cell wall - many more targets for vancomycin to bind prior to inactivating glycosyltransferase
VRSA >16
VRE - which, how, risk, treatment
Enterococcus faecium more common than faecalis
Van A, B, and C genes - changes D-ala-D-ala to alter binding, eliminates it, dipeptidase to cleave it
Van A will be also resistant to teicoplanin
Risk increased with anti-anaerobic abx
Treat with ticoplanin, linezolid, daptomycin, tigecycline
Penicillin resistance definition in normal vs meningitis
Sensitive <2
Intermediate 4
Resistant >8
Meningitis
Sensitive <0.06
Resistant >0.12
26M brought into ED with severe dyspnoea, hypoxia and fevers. Rapidly requires intubation and transfer to ICU for mechanical ventilation and vasopressors. See CXR. Needle marks in left cubital fossa. Soft ESM. Appropriate antibiotic therapy?
A. Benzylpenicillin and doxycycline
B. Ceftriaxone and azithromycin
C. Benzylpenicillin, flucloxacillin and gentamicin
D. Vancomycin, ceftriaxone and azithromcyin
E. Linezolid and meropenem
D. Vancomycin, ceftriaxone and azithromcyin
IVDU - more likely to have MRSA
Beta-lactamase enzymes - Ambler classes
A - Penicillinases (TEM, SHV, CTX-M)
B - Metalloenzymes (NDM, VIM, IMP)
C - Cephalosporinases (AmpC)
D - Oxacillinases (OXA)
Organism with Class C - inducible beta-lactamase
ESCAPPM - AmpC-type - chromosome mediated
Enterobacter (E. cloacae & K. aerogenes)
Serratia marcescens
Citrobacter freundii
Acinetobacter
Providencia spp.
Proteus (Indole-positive i.e., P. vulgaris)
Morganella morganii
Class A - EXTENDED-SPECTRUM BETA-LACTAMASES (ESBL)
- how they arise
- spread
- which bugs
- treatment
Arise by:
* Mutations in old β-lactamase genes (e.g., TEM, SHV)
* Plasmid-mediated transfer
Spread by:
* Person to person
* Antibiotic pressure
Klebsiella, E. coli, Salmonella, Proteus, Enterobacter, Citrobacter, Serratia, Pseudomonas
* In vitro inhibition by beta-lactamase inhibitors
* Can be hard to detect in the lab
Treat with:
* Carbapenems, colistin, amikacin, cipro (fosfomycin or nitrofurantoin for cystitis)
CLASS B – METALLO-BETA-LACTAMASES
- Zn-dependent
- Pseudomonas & Acinetobacter
- Plasmid mediated usually
- Hydrolyse all beta lactams (except aztreonam)
- Includes carbapenems
- Susceptible to ion chelators like EDTA
- New Delhi version = NDM
72F admitted with sepsis from presumed urinary source. BC positive with Klebs. pneumoniae and is found to be ESBL; susceptible to mero & colistin. MIC for piperacillin/tazobactam is 2 mg/l
Which of the following is true?
A. Colistin should be the first-choice therapy
B. Standard q8 hourly dosing of pip/taz is acceptable
C. Use a higher dose of q6 hourly pip/taz
D. Even with the lowish MIC, pip/taz is inferior to mero
E. Mero is too much of a hassle because you’ll need to get an approval number from the AMS team
D. Even with the lowish MIC, pip/taz is inferior to mero
In vitro activity often looks better
MERINO Trial demonstrated mortality benefit of meropenem
New drugs against gram positives
- Linezolid
- inhibits protein synthesis, no advantage over vanc
- GI, cytopenia, neuropathy
- avoid SSRI, tramadol, pethidine - Daptomycin
- binds cell membrane inhibiting DNA, RNA, protein synthesis
- not for pneumonia - surfactant inhibits it
- effective against VRE - Tigecycline
- protein synthesis inhibitor
- low MIC for MRSA, MSSA, VISA, VRE - Ceftaroline (& ceftobiprole)
- new cephalosporin that is active for MRSA, NOT VRE
- works for MRS, VISA, NOT VRE
Drugs for gram negatives
- Colistin
- binds LPS & phospholipids > leakage + death
- renal + neurotoxicity
- against: Pseudomonas, Acinetobacter, E. coli, some Enterobacter spp., Klebsiella, Salmonella, Stenotrophomonas - Fosfomycin
- inhibits MurA required for cell wall synthesis
- for resistant UTIs - New combinations = ceftazidime+avibactam or ceftolozane+tazobactam
- for MDR Gram negatives including pseudomonas & ESBL - Cefiderocol
- binds iron
- for multi-resistant GNBs
- expensive
- SE: GI, LFTs, rash, injection site
Vancomycin + Pip/Taz = what issue
- Increased rates of AKI, especially >48hrs
- no association with vanc levels > due to pip/taz
- extrapolate to other penicillins
Antibiotic prophylaxis (4 categories)
- Cesarean, head&neck, thoracic, ortho - cefazolin
- Major ENT, GI, infrarenal vascular - Cefazolin + metronidazole
- Amputation - benzpen
- ERCP - gent
35F in ICU postMVA with multiple fractures and splenic laceration=> splenectomy. Remains intubated on D8, on cefazolin. Deteriorates with low BP, high HR, increasing respiratory requirements and high WCC. Started on empiric pip/taz and vanc for sepsis ?VAP. BC –ve and tracheal aspirate has mixed bugs incl. GNBs. 3 days later, still unwell, noted to have rise in creatinine from 110 to 236 μmol/L.
Which is true regarding the patient?
A.This is likely to represent augmented renal clearance in a young, previously
healthy patient
B. If no MRSA cultured, vanc could be safely ceased
C. They should be urgently vaccinated for the encapsulated organisms (pneumococcus, HiB, meningococcus)
D. Continue the vanc/pip/taz as it is more important to control the sepsis than worry about the kidneys
E.It is not appropriate to swap the pip/taz to cefepime as there is too much resistance to cefepime in ICU patients
B - true
A/D - incorrect, as this is AKI induced by vanco/pip/taz combo
C - when well or prior to splenectomy
TB - path, risk, therapy
Path - infects macrophages, elicits granuloma formation, resistance to ROS, inhibits lysosome fusion, and phagosome acidification
Resistance via point mutation
Risk - HIV, >15mg pred for >1 month, other immunosuppression
Therapy - 2HREZ + 4HR
- longer if big cavity or smear positive at 2 months, CNS, resistant, skeletal, or disseminated
- similar in pregnancy
TB paradoxical reaction
- Clinical or radiological deterioration of pre-existing lesions or else the appearance of new lesions whilst on therapy
- Median 2-3 months
- Presents with fever, nodes, resp. failure, neuro
deterioration, sinus formation - Treatment - continue current, corticosteroids +/- pus aspiration or excision, last line is anti TNF
MAC lung infections - 2 subtypes
Nodular bronchiectasis (NB)
* Little old white ladies, mainly in RML, lingular segment
* Multiple genotypes, often smear –ve & only grow in broth
Fibronodular Cavitatory (FNC)
* Middle-aged, male smokers/drinkers
* Single genotype, heavy growth
Treatment =
- Azithromycin + rifampicin + ethambul
- 3x weekly for NB or daily for FNC for 2 months
When trying to work out whether a patient with 6 weeks of cough with LOW and haemoptysis has TB, the Quantiferon Gold Assay can help in which of the following ways?
A. The degree of positivity can help differentiate latent from active TB
B. A negative result means that TB is so unlikely that other diagnoses are much more important to pursue
C. With successful therapy, the test will go from positive to negative some months later
D. A positive test can be caused by prior BCG vaccination
E. Neither a positive nor a negative result will help with ruling in or out the diagnosis of active TB so there is no point doing the test
E
Quantiferon Gold is a screening assay. It can be negative in acute infection and once it’s positive it just indicates exposure, cannot tell if it is active or latent.
Oseltamivir - moa and effect
Neuraminidase inhibitor - stops release of virions
Reduces symptoms and spread
Remember in H&N in Flu with haemagglutinin responsible for entry
Pertussis - phases and treatment
Phases (generally no fever)
- sometimes catarrhal (“cold”)
- Paroxysmal
- Convalescent
PCR
Azithromycin
89F from HLC NH sent to ED after starting to cough while eating soup for dinner. SOB, moist sounding cough, CXR shows RML infiltrate.
Which of the following is true?
A. Oral anaerobes are only susceptible to metronidazole & not penicillins or cephalosporins
B. Culture the soup ASAP
C. Should use pip/taz to cover all Gram negs and anaerobes
D. Aspiration pneumonia requires specific anti-anaerobic therapy
E. Aspiration pneumonitis just requires respiratory support until it resolves without antibiotics
E - if systemically unwell or not improving by day 2/3 then treat as CAP
When to consider PO switch in bone & joint infections?
1 week per OVIVA Study
Old 3-6 week rule if critical such as axial skeleton, or clinical decision
Klebsiella pneumonia K1
Emerging in Asia (Taiwan)
Associated with: liver abscesses, endopthalmitis
Diabetics
Generally susceptible to ceftriaxone
Absolute (5) and relative (3) indications for surgery in IE
Absolute
* Severe aortic or mitral regurgitation
* Cardiac failure (related to valve dysfunction)
* Fungal or highly resistant organisms (VRE, MRSA)
* Perivalvular abscess or fistula
* Prosthetic valve endocarditis
Relative
* Multiple or severe embolism (on therapy)
* Uncontrolled infection (e.g., MSSA, Pseudomonas, Q fever)
* Size of vegetation (>1cm)
Strept (4) with high risk ratio for IE
Mutans 14.2
Bovis 5.9
Smitior 3.3
Sanguis 3
Culture negative endocarditis
Q fever
Bartonella
Streps
Legionella
Whipples
Mycoplasma hominis
Chlamydia
Fungi
Brucella
70M attends in winter with this lesion on their leg. Spent the summer on the Mornington Peninsula. No pain. Getting bigger over a few weeks. No response to cefalexin.
Which of the following is most true?
A. Standard bacterial swab will identify relevant bacteria, mycobacteria, and fungi
B. Buruli ulcer will require wide local excision to treat
C. PCR for Mycobacterium ulcerans has good sensitivity and PPV even on a dry lesion like this
D. M. ulcerans less likely as no pain
E. Perform a mycolactone toxin assay for diagnosis
C
Mycobacterium ulcerans
* Bairnsdale, Phillip Island, Point Lonsdale, Daintree
* Rifampicin + clarithromycin (or moxifloxacin) x 8/52 +/- Surgery
* Possible worsening with pain or new lesions on therapy - mycolactone initially dampens immune response making it painless to begin
Whipple’s Disease
Middle aged men
* Migratory large joint arthralgias
* Weight loss, Diarrhoea, Abdominal pain
* Other: dementia, eye signs, fever, skin changes, culture- negative endocarditis, pleural effusion
Small bowel biopsy or PCR
Ceftriaxone then long-term Bactrim
Bartonella
Cat Scratch Disease: B. henselae & B. quintana
* Cat bite or scratch or flea bite from cat
* Cutaneous lesion at bite site after 3 - 10 days
* Regional LAD after ~2 weeks
* Resolves in 1 - 4 months, sometimes much longer and systemic
Treatment = azithromycin
Inhalation anthrax presentation
- Flu-like for two days
- Sudden deterioration => severe SOB & hypoxia * Haemorrhagic mediastinitis
- => widened mediastinum on CXR
Treat with doxycycline - can use others
Treatment of rickettsial disease
doxycycline
Plague
- yersinia pestis
- rodent reservoir with transmission via fleas
- bubonic (lymph gland swelling) or pneumonic or others
- streptomycin
Tularaemia “rabbit fever”
- Francisella tularensis
- fever, chills, headache, malaise,
- glandular swellings
- streptomycin
QT prolonging abx
Voriconazole, macrolides, moxifloxacin, pentamidine,
mefloquine, bedaquiline
Important side effects
- Pro-convulsant effects - Very high doses of beta-lactams incl. imipenem
- Photosensitivity - Doxy, Cipro, Vori
- Hepatitis - INH & Pyrazinamide > Rif; flu/diclox, clavulanate, fusidic acid,
nitrofuantoin, minocycline, voriconazole, sulfonamides, dapsone - Nephrotoxic - Aminoglycosides, AmB, sulfonamides, pentamidine, cidofovir, foscarnet, tenofovir, vanc, (beta-lactams – interstitial nephritis)
- Peripheral neuropathy - Linezolid, metronidazole, isoniazid, DDI, DDC
Regarding oseltamivir, which is the most correct?
A – only active against influenza A
B – It has been shown to reduce the average duration of symptoms of influenza illness by 3 – 4 days
C – Used prophylactically, it has been shown to reduce the number of cases amongst close contacts of people with influenza
D – During recent influenza outbreaks, oseltamivir was the most important factor in reducing severity
E – It cannot be used safely in pregnancy or during breast feeding
C – Used prophylactically, it has been shown to reduce the number of cases amongst close contacts of people with influenza
Flu A>B, reduces symptoms 1-2 days, can be used in pregnancy.
Vaccine reduces severity - factors increasing severity: viral factors, obesity, respiratory disease, immunosuppression, liver, renal, diabetes, pregnancy
Which of the following is correct regarding the New Delhi Metallo-beta-lactamase (NDM-1) enzyme?
A. This encodes for resistance to all extended spectrum penicillins and cephalosporins but is susceptible to carbapenems and aztreonam
B. This is mostly seen in Salmonella and Shigella species
C. This enzyme can only be transferred between bacteria of
the same genus and species
D. Bacteria carrying this enzyme have only been found in India, Pakistan and Sri Lanka
E. Treatment options are limited but include colistin or cefiderocol
E. Treatment options are limited but include colistin or cefiderocol
Hydrolyse all beta lactase
Mostly pseudomonas and acinetobacter
Plasmid mediated to any bacteria
28yo presents with red, cellulitic leg with very severe pain in the thigh. Temp=39.5, HR=130, BP=95/55. WCC, CRP, creatinine and CK all elevated. Best management?
A – Surgical exploration and debridement of devitalised tissue
B – IV benzylpenicillin & clindamycin
C – IV meropenem
D – IVIG
E – All of the above
E – All of the above
Usually group A strep but may be polymicrobial
Penicillin, clindamycin, pip/taz +/- gentamicin +/- IVIg
Surgery
A strain of Clostridium difficile with increased virulence is being reported overseas and now in Australia. This is called ribotype 027. Which of the following is correct regarding this new strain?
A. The most likely risk factor is recent use of clindamycin
B. This strain remains susceptible to fluoroquinolone antibiotics
C. This strain produces substantially larger quantities of toxins A and B in vitro than other C. difficile strains
D. It has deletion of the usual binary toxin gene
E. Diarrhoea is usually self-limiting in younger, healthier patients
C. This strain produces substantially larger quantities of toxins A and B in vitro than other C. difficile strains
Pathogenicity = ability to produce disease
Virulence = degree or level of disease
Transmissibility = spread
53 yo M has 2 days of red, hot & swollen knee. LMO gave cefalexin yesterday. Temp 37.4O and WCC 11.3. Aspirate has 130,000 cells/mm3 with 95% neutrophils. Gram stain is negative and no crystals.
Most appropriate initial management?
A – IA steroids
B – IV fluclox
C – Oral cephalosporin
D – Oral colchicine
E – Surgical washout of the knee
E – Surgical washout of the knee
23yo post MVA in ICU has been ventilated for 6 days. Diagnosis of VAP in the context of being on pip/taz. Broncho-alveolar lavage (BAL) done for sample, and his antibiotics are changed to meropenem and vancomycin. Subsequently, his BAL specimen is reported as culturing a heavy growth of Candida albicans. All other cultures of blood and urine are negative.
Which is correct?
A - This is very unlikely to represent a true pathogen and anti-fungal therapy is not required at this time.
B - Therapy with fluconazole should be commenced.
C - Therapy with caspofungin should be commenced.
D - Therapy with amphotericin should be started but could be changed to fluconazole later, provided that the isolate is susceptible.
E - Surgical resection of a fungal ball may be required.
A - This is very unlikely to represent a true pathogen and anti-fungal therapy is not required at this time.
Up to 20% of all intubated patients will grow candida on BAL - number increases with duration of ventilation.
One study positively identified 0.7% (5/824) of candida pneumonia for those with positive BAL - so it is a rare entity. Look for other cultures/ signs of infection.
Which of the following statements concerning the systemic antifungal agent caspofungin is true?
A. it inhibits ergosterol synthesis
B. it is not active against Candida krusei
C. it can be used to treat cryptococcal meningitis in patients intolerant of amphotericin
D. it has activity against Aspergillus fumigatus
E. dosage reduction is required in patients with renal failure
D. it has activity against Aspergillus fumigatus
MOA = cell wall synthesis
Ergosterol = triazoles
Membrane function = amphotericin
Krusei can get resistance
Cryptococcus = amphotericin + flucytosine
Aspergillosis = fluconazole
Regarding syphilis serology, which of the following is true?
A. By the time a chancre is present, the serology will be positive
B. Positive RPR in pregnancy usually requires treatment to prevent congenital syphilis
C. FTA-Abs will remain positive after curative therapy
D. CSF VDRL will always be positive in neurosyphilis
E. Following successful treatment for late latent syphilis, the RPR level will fall to undetectable with 6 months
C. FTA-Abs will remain positive after curative therapy
- start being positive at 2-4 weeks, increase and plateau - i.e. remain positive
Follow-up RPR/VDRL titres at 3, 6, 12 months
- 4 fold reduction = cure
- 4 fold increase = re-infection
Which of the following best explains the mechanism of resistance to vancomycin in enterococci?
A. The Gram-positive cell wall is thickened leading to an increased number of D-Ala-D-Ala molecules that trap the vancomycin
B. Porins excrete the vancomycin that diffuses into the enterococci
C. It is due to alterations in the glycopeptide binding proteins
D. There is intracellular methylation of vancomycin
E. The D-Ala-D-Ala in the cell wall is changed to D-Ala-D-Lac which binds vancomycin with lower affinity
E. The D-Ala-D-Ala in the cell wall is changed to D-Ala-D-Lac which binds vancomycin with lower affinity
Which of the following is most correct regarding extended-spectrum beta-lactamase producing bacteria?
A. Given their increasing prevalence, likely Gram-negative infections should always be treated initially with meropenem
B. Modern laboratory systems can identify them reliably and quickly
C. If the MIC for piperacillin-tazobactam is in the susceptible range (1-2mcg/mL), that agent can be safely used
D. There have been no reports of resistance to colistin so that is a potential salvage therapy option
E. As they can be spread within the hospital, appropriate contact precautions are indicated (gowns, gloves & ABH)
E. As they can be spread within the hospital, appropriate contact precautions are indicated (gowns, gloves & ABH)
34 year old male recently returned from a business trip to Bangkok. He has had several days of worsening asymmetric oligoarthritis. No fever. Most correct answer?
A. A high CRP or high joint aspirate cell count would differentiate septic arthritis from gout
B. Disseminated gonococcal infection is unlikely in the absence of a rash/fever
C. Send off an alpha-defensin test on joint fluid to sort out whether this is infection or not
D. If he’s been up to no good, empiric ciprofloxacin is indicated to treat for disseminated gonococcal infection
E. As per D but empiric ceftriaxone rather than ciprofloxacin
E. As per D but empiric ceftriaxone rather than ciprofloxacin
Moxifloxacin is appropriate for which of the following?
A – Acute exacerbations of chronic bronchitis
B – Enterococcus faecium infection
C – Stenotrophomonas maltophilia infection
D – Moderate to severe pneumonia in a patient with severe penicillin allergy
E – Cough with haemoptysis in a patient from Somalia
D – Moderate to severe pneumonia in a patient with severe penicillin allergy
A - treat with doxy or amoxy
B - gram+ treatment, consider VRE
C - bactrim
E - sounds like TB
37yo cattle farmer presents with fevers, aches, drenching sweats, nausea, LOA and dry cough for 10 days. Did not respond to Augmentin. Has systolic murmur heard but otherwise normal exam. Keen to get back to farm as it is calving season. Which of the following is true?
A – He has man ‘flu and should get oseltamivir
B – Should receive another round of Augmentin
C – Should get a PET scan
D – Check serology for Q fever, leptospirosis, brucellosis
E – If this is Q fever, he should get vaccinated for it after this
D – Check serology for Q fever, leptospirosis, brucellosis
Q fever, Bartonella, Streps, Legionella, Whipples, Mycoplasma hominis, Chlamydia, fungi, Brucella (Not HACEK now)
Role of NAT incl. 16S PCR (or 18S PCR for fungi)
27F from Vanuatu presents with recurrent boils in axillae and groin as well as painful pustules in nose. Other family members have similar issues. Not getting better on cefalexin. Known to have positive Quantiferon assay when immigrating.
What is the best answer?
A. This sounds like hidradenitis suppurative and could be treated with
infliximab
B. Incision & drainage alone will be curative
C. Short course clindamycin indicated
D. Give ivermectin for scabies
E. Incision and drainage but larger lesions with surrounding cellulitis may also need antibiotics such as Bactrim or clindamycin
E
Inflammatory disease of apocrine glands
Treatment = nil effective
- Decolonize with bleach bath/ chlorhexidine +/- top clindamycin
- PO doxycycline 100mg (increase to BD if needed) if not working/ more severe then use clindamycin 300mg BD + rifampin 600mg daily
- Other systemic agents have been tried but are minimally effective: steroids, isotretinoin, antiandrogens/ or estrogens
- Excision via surgery may be needed - recurrance still common
- Adalimumab (TNF-a inhibitor)
A nurse in a neonatal unit develops a persistent cough, with paroxysms starting in the second week. PCR of nasopharyngeal aspirate confirms that she has whooping cough.
Which of the following is most correct?
A. She can continue to work if the mothers of the babies in the neonatal unit are immunised
B. As she is now in the second week of illness, she is no longer contagious
C. All staff and patients in the neonatal unit should be immediately
vaccinated
D. As this is spread via aerosolised droplets, she can pass this on to people even without direct contact and the morbidity and mortality in neonates is substantially higher
E. It is now too late to give her antibiotic therapy such as azithromycin as she is no longer contagious
D. As this is spread via aerosolised droplets, she can pass this on to people even without direct contact and the morbidity and mortality in neonates is substantially higher
35yo male in ICU post multi-trauma develops fever and high WCC. Blood cultures MRSA. Vancomycin given. Trough level 19 mg/L. Ongoing fever, & positive cultures at day 6. Vanc MIC = 2mg/L. Getting worse. Appropriate course of action?
A – Increase the vanc dose, aiming for a higher trough
B – Change to colistin
C – Add rifampicin and fusidic acid
D – Change to linezolid
E – Change to daptomycin
D – Change to linezolid
Mechanism is NOT the same as VRE
Rather it is through wall thickening (thus more targets of vanc) and through penicillin binding protein (PBP)
hVISA is 1-2 - thus some resistance
Vancomycine intermediate staph aureus (VISA) is MIC 4-8
VRSA is 16 or higher
Which of the following is most true regarding culture-negative endocarditis?
A. Fastidious organisms (e.g., C. burnetii, L. pneumophila or T. whipplei) will be identified if the blood cultures are kept for two weeks
B. Combination of vancomycin and ceftriaxone will treat most aetiologies
C. 16S PCR techniques on explanted valve tissue will identify nearly all microbial causes
D. Blind sub-cultures from the blood culture bottle will help to identify HACEK organisms
E. The most likely cause is non-infectious (e.g., Libman-Sacks endocarditis)
B. Combination of vancomycin and ceftriaxone will treat most aetiologies
A 60-year-old male returns from trip to China. Recent issues with BPH symptoms. Sees LMO re dysuria and frequency and is started on trimethoprim for UTI. 2 days later, fevers and rigors. E. coli growing in MSU ordered by LMO. Gets admitted, BC taken, ceftriaxone started. Call from lab: “It looks like an ESBL”. Patient no better. Appropriate management:
A – Change to fosfomycin
B – Change to ciprofloxacin
C – Add gentamicin
D – Change to tigecycline
E – Change to meropenem
E – Change to meropenem
MERINO trial
22 yo F on a student visa from Nepal presented three months ago with several months’ history of cervical lymphadenopathy, fevers and weight loss. Node biopsy showed necrotising granulomata and cultured fully susceptible M. tuberculosis. She was started on standard 4 drug therapy with HREZ and then after 2 months continued on HR. During that time, she felt better and nodes got smaller. She now presents with acutely painful, swollen & fluctuant nodes, plus fevers and anorexia. Best course of action?
A – Add in moxifloxacin for drug-resistant resistant TB
B – Stop all therapy and arrange for node biopsy
C – Continue the therapy and perform I+D
D – Give infliximab
E – Go back to HREZ and make it DOT
C – Continue the therapy and perform I+D
Paradoxical reaction
- clinical or radiological deterioration
- fevere, nodes, resp. failure, near deterioration, sinus formation
Treatment
- corticosteroids
- aspiration of pus or excision
- continue anti-TB therapy
- anti-TNF only if very severe
52 yo female with RA, originally from Laos. Rheumatologist keen to start infliximab. BCG scar is present. Screening Quantiferon is positive. Which of the following is true?
A – Infliximab is contraindicated
B – Infliximab can be given as she has had BCG
C – Infliximab can only be given after 9 months of isoniazid
D – Infliximab could be started after > one month of isoniazid
E – The QFN result is likely false +ve from the BCG
D – Infliximab could be started after > one month of isoniazid
37 yo female diagnosed with DLBCL. Starts treatment with R-CHOP. Recognised side effects of rituximab include all of the following except:
A. Progressive multifocal leucoencephalopathy
B. Infusion reactions with death within 24/24
C. Severe bacterial or fungal infections
D. Reactivation of hepatitis C
E. CMV disease
D. Reactivation of hepatitis C
Significant risks of reactivation of latent TB include all the following except:
A. HIV infection
B. Cancer chemotherapy
C. Alcohol abuse
D. Corticosteroid use
E. Anti-TNF therapy
F. Diabetes mellitus
G. End stage renal failure
H. Cigarette smoking
C. Alcohol abuse
76 yo M with mechanical MVR needs gastroscopy & biopsy. What endocarditis prophylaxis is appropriate?
A – Amoxicillin
B – Ceftriaxone
C – Gentamicin
D – Metronidazole
E – No prophylaxis
E – No prophylaxis
- Cesarean, head&neck, thoracic, ortho - cefazolin
- Major ENT, GI, infrarenal vascular - Cefazolin + metronidazole
- Amputation - benzpen
- ERCP - gent
56M morbidly obese with T2DM on metformin and empagliflozin. Presents with urinary retention, extremely painful groin and features of sepsis. Immediate treatment should consist of all of the following except:
A. Hyperbaric oxygen therapy
B. Surgical debridement
C. Broad spectrum ABx (e.g., Taz)
D. Vasopressors to maintain BP
E. Cessation of empagliflozin
A. Hyperbaric oxygen therapy
30M from Somalia with 2 months of cough then LOW, sweats, haemoptysis. Presumed TB based on CXR and 3+ smear-positive sputum. Admitted, put in isolation. Started on HREZ (& vit B6 & D3). Two weeks later, still coughing, sputum still 2+ AFBs on smear. Which of the following is correct?
A. After 14 days of appropriate therapy, he can return home to be with his wife and newborn baby
B. This is the expected course and he should start to feel better in the next month
C. This is slow so it would be appropriate to add moxifloxacin
D. Genomic testing can confirm the presence of drug resistance to all four of
these drugs
E. He should remain in isolation in hospital until further resistance results known or there is clear improvement
E. He should remain in isolation in hospital until further resistance results known or there is clear improvement
