Infectious Diseases Flashcards
Most common CAP vs Nosocomial pneumonia
CAP=Strep. Pneumo
Nosocomial=E. coli, Pseudo, and S. Aureus
Atypical pneumonia common bugs and signs
Mycoplasma pneumonia, Chlamydia pneumonia, Coxiela, legionella, influenza
Dry cough, headache, sore throat
Normal pulse with high fever
Legionella common demographics
Organ transplant recipeients, renal failure, patients with chronic lung disease, and smokers
Nursing home residents common infection
Psuedomonas predilection for upper lobes
CD4 count less than 500 infections
Tb, recurrent pneumonias, vaginal candidiasis, and herpes zoster
CD4 count less than 200 infections and prophylaxis
pneumocystis jirovecii, cryptococcis (treat with IV amphotericin B plus flucytosine and chronic suppression with fluconazole, frequent lumbar punctures), histoplasmosis, or cryptospordiosis
Prophylaxis with TMP-SMX for pneumocystis one double strength tablet daily
P02 less than 70 and A-a gradient more than 35 have poor prognosis and should be given prednisone before TMP-SMX
CD4 count less than 50 infections
Mycobacterium aviium intracellulare complex, disseminated histoplasmosis, CMV retinitis, colitis, adrenalitis, and esophagitis (IV ganciclovir, foooscarnet or cidofovir), CNS lymphoma (diagnose with stereotactic brain biopsy or with CSF for epstein barr virus)
MAC with CD4 count less than 50 treatment
Clarithromycin, ethambutol, and rifabutin for weeks
MAC prophylaxis-clarithromycin 500 mg twice daily
Azithromycin 1200 mg weekly
Don’t need concomitant HAART therapy with prophylaxis once CD4 counts recover
CD4 count less than 100
Prophylaxis with daily dosing of TMP-SMX
toxoplasmosis (sulfadiazine and pyrimethamine)
CURB 65 guidelines
Confusion Uremia >20 BUN RR >30 BP less than 90/60 >65 More than 2= inpatient More than 4=ICU
Outpatient younger than 60 with pneumonia bugs and treatment
S. pneumo, Mycoplasma, Chlamydia or legionella
Treatment: Macrolides (azithromycin or clarythromycin)
or doxycycline
For 5 days
Older than 60 or with comorbidiites outpatient pneumonia treatment
Fluroquinolone (levofloxacin, moxifloxacin)
Second or third cephalosporin
For 5 days
Co morbidities to consider for pneumonia
Heart disease, sickle cell, pulmonary disease, diabetes, alcoholic cirrhosis
Inpatient CAP treatment
Macrolides + cephalosporin
Or fluorquinolone
ICU CAP treatment
Cephalosprin + macrolide (IV)
Cephalsoprin + flluoroquinolone
Hospital acquired pneumonia (in hospital for >72 hours)
ceftazidime or cefepime
Imipenem
piperccillin/tazobactam
Ventilator associated pneumonia diagnosis and treatment
Diagnosis: new inflitrate on CXR, purlent secretion from endotracheal tube
Bronchoalveolar lavage
Treatment: 3 drugs
- ceftazdimine/cefipime OR pipercillin/tazobactam OR carbapenem (Pseudo)
- Aminoglycoside or fluoroquinolone (Pseudo)
- Vanco or linezolid (gram +)
Lung abscess treatment
Postural drainage
Antibiotics:
Gram positive: ampicillin or amoxicillin/clavulanic acid, ampicillin/sulbactam, or Vanco
Anaerobes: clinda or metro
Gram negative: fluoroquinolone or ceftazidime
Continue until cavity is gone or until CXR have improved considerably
Results of PPD test results and treatment
Used for latent TB not active TB (active TB order a sputum culture)
Positive if >15 mm in patients with no risk factors
High risk (high prevelance areas, immigrants, health care workers, nursing home residents, close contact with TB, alcoholics, diabetics)=10 mm positive
HIV, steroid users, organ transplant, close contact with active TB, radiographic evidence of primary TB=5 mm is positive
Never have had a PPD test before do another test in 1-2 weeks
If positive use chest X ray to rule out active disease-if excluded use 9 months of isoniazid (even if have had BCG vaccine)
Treatment of TB
2 months of RIPE (or streptomycin) and then 4 months of INH and rifampin
Ages and treatment of suspected meningitis
less than 4 weeks: aminoglycoside
Infants (less than 3 mos): cefotzxime +ampicillin +vanco
3 mos to 50 years: ceftriaxone or cefotaxime + vanco
greater than 50: ceftriaxone or cefotaxime+vanco+ampicilin
Impaired cellular immunity: ceftazidime +ampicilin +vanco
Aseptic is supportive
Diagnosis and treatment of encephalitis
CSF PCR
MRI of brain-T2 signal in frontotemporal region=HSV encephalitis
EEG=tempral lobe discharges
Treatment: HSV=acycylovir for 2-3 weeks
CMV=ganciclovir or foscarnet
Importance of HBeAg, HBsAg, anti-HBs, anti-HbC
HbeAg: indicates infectivity
HbsAg: earliest to arrive
anti-HBs-natural or vaccine induced immunity
Anti-HbC: present during window period
diagnosis of Hep C
PCR detects viral load
Diagnosis Treatment of botulism
Diagnosis: ID toxin in serum, stool or gastric contents (bioassay)
gastric lavage if within several hours
High suspicion=antitoxin
Wounds=penicillin and wound cleansing
Complicated UTI
extends beyond blader: pyelo, prostatits, urosepsis)
Risks: men, diabetes, pregnancy, RF, history of pyelo, obstruction, catheter, resistant organism, immunocompromised
Treatment of UTI
uncomplicated: TMP/SMX (bactrim): 3 days nitrofurantoin: 5-7 days Fosfomycin: single dose Ciprofloxacin: 3 days
Pregnant: ampicllin, amoxicciln or oral cephalosporins: 7-10 days
Men: same as uncomplicated but for 7 days
Recurrent: 2 more weeks of treatment and culture
2+ UTIs per year: TMP/SMx after sex or at first symptoms
or low dose TMP/SMX for 6 months
Phenzopyridine: urinary analgesic
Treatment of Pyelonephritis
Uncomplicated
TMP/SMX or fluroquinolone for 10-14 days
Amoxcillin
Single dose of ceftriaxone or gentamicn
Ill, elderly, pregnant, unable to tolerate orals, urosepsis
Hospitalize and give IV fluids
Ampicillin plus gentamicn or cipro-parenterally
Treat until patient is afebrile for 24 hrs then 14-21 day course
Urosepsis: IV antibiotics for 2-3 weeks
Recurrent:
same organism: 6 week treatment
dif. organism: 2 week treatment
Treatment of acute and chronic prostatits
Acute: IV TMP/SMX if extremely ill
Mild: TMP/SMX or fluoroquinolone or doxycycline for 4-6 weeks
Chronic: fluroquinolone
HPV treatment
ticholracetic acid, podophyllin, inqiquimoid, surgery
Diagnosis and treatment of HSV
Diagnosis:
Tzanc smear is quickest test shows multinucleated giant cells
Culture of HSV is gold standard-swab base of ulcer
Elisa- minutes to hours
encephaltiis: PCR of CSF is gold standard, EEG prominent intermittent high amp with slower waves
oral or topical acyclovir for 7-10 days
Foscarnet for resistant or immunocompromised
Disseminated: hospitalize and parenteral acyclovir
When is syphilis not contagious?
late latent phase if serology has been positive for >1 year
Diagnosis and treatment of syphilis
Diagnosis: start with VDRL or RPR if positive then do a FTA-ABS
Test for HIV
Treatment: Benzathine penicillin (one dose IM)
if allergic doxycycline for 2 weeks
Latent or tertiary: penicclin 3 doses IM once per week
Chancroid diagnosis and treatment
haemphoilus ducreyi
Diagnosis: painful genital ulcer, unilateral tender inguinal lymphadenopathy
Rule out syphilis and HSV
Treatment: azithormycin or ceftriaxone (IM) (one dose)
Lymphogranuloma venereum
C. Trachomatis
Painless ulcer, tender inguinal lymphadenopathy, constitutinal symptoms
Can lead to perianal fissures, andretal stricture or elephantiasis of genitals
Diagnosis: serology-complement fixation, immunofluorescnce
Treatment: doxy for 21 days
Pediculosis Pubis
Pubic lice
diagnosis: examination of hair under the microscope
Treatment: permethrin 1% shampoo (Elmite)
Cellulitis:treatment Local trauma- wounds. abscesses Immersion in water Acute sinusitis
trauma-Strep. pyogenes
wounds-S. aureus
immersion-pseudo, aeromonas hydrophila, Vibrio vulnificus
Sinusitis-H. influenza
Treatment: Oxacililn/nafcillin or cephalosporin-IV until infection improves
then 2 weeks of oral antibiotics
Erysipelas
Cellulits confined to dermis and lymphatics
Caused by Strep. pyogenes
Fiery red, well demarcated, painful lesion
High fever and chills
Predisposing factors: lymphatic obstruction, local trauma, fungal infections, diabetes, alcoholism
Complications: sepsis, local spread to subQ tissues, necrotizing fasciitis
Treatment: IM or oral penicillin or erythromycin
Tetanus treatment
Admit to ICU and provide respiratory support
Diazepam for tetany
Neutralize unbound toxin with passive immunization-give single dose of tetanus immune globulin (if large wound and unknown tetanus status, >10 yrs since boster or less than 3 Td)
Provide active immunization with tetanus/diptheria toxoid
Thoroughly clean and debride wounds with tissue necrosis
Give metroniadzole or penicillin G
If have greater than 3 doses of Td do not have to provide passive or active immunity
Osteomyelitis diagnosis and treatment
Diagnosis:
ESR and CRP useful in monitoring response to therapy
Needle aspiration or bone biopsy: most direct and accurate means of diagnosis
MRI: most effective imaging study
Treatment: IV antibiotics for 4-6 weeks only after etiology is based on cultures
Empircally:
Penicillinase resistatn penicillin-oxacillin or 1st gen cephalosporin-cefazolin
Aminoglycoside and B-lactam Ab if possilbility of gram-
Surgical debridement
Organisms and acute infectious arthritis
S. Aureus-most common overall
Young sexually active-gonorrhea
sickle cell, immunodefiency, IV drug abuse-salmonella, pseudo
Diagnosis and treatment of acute infectious arthritis
Diagnosis
Joint aspiration->50,000 WBC with 80% PMNs
PCR of fluid if gonorrhea suspected
Elevated ESR
Elevated CPR-mointoring clinical improvement
CT or MRI-sacroiliac or facet joints involved
Treatment:
Daily aspiration or surgical drainage
Healthy adult: (S. aureus)-Parenteral, oxacillin and cephazolin for 4 weeks
Immunocompromised or other gram-indications: parenteral ceftriaxone or aminoglycoside for 3-4 weeks
tazobactam+pipercillin if pseudo
Gonnorrhea: parenteral ceftriaxone until improvement then cipro for 3-10 days orally also doxy
Diagnosis and treatment of Lyme disease
Diagnosis: Clinical-treat empirically
IgM Abs peak 3-6 weeks after onset of symptoms
Serologic studies: ELISA (serum IgG and IgM) during first month of illness
Western blot
Treatment: Localized disease 10 days of antibiotics Early Lyme disease: Oral doxcycline-21 days Amoxicclin and cefuroxime if pregnant or less than 12
facial nerve palsy, arthritis, or cardiac disease (30-60 days) of antibiotic therapy
CNS: treat antibioticcs for 4 weeks
Treatment of Rocky Mountain spotted fever
Doxycycline for 7 days orally or IV if vomiting
CNS manifestations or pregnant: chloramphenicol
Treatment of malaria
Chloroquine phosphate unless resistance is suspected (pretty much everywhere)
Qunine sulfate and tetracycline or atovaquone-proguanil and mefloquine
P. faliciparum (no remission of fever) may require IV quinidine and doxycycline
P. Vivax and ovale may requrie primaquine phosphate for hypnozoites in liver
Prophylaxis: mefloquine or chloroquine if not going to resistant areas
Diagnosis and treatment of rabies
Diagnosis: virus or viral Ag in infected tissue
Serum Ab titers
Negri bodies histologically
PCR detection of virus RNA
Treatment
Clean the wound thoroughly
Wild animal bites: find animal capture and destroy them and send to lab for immunofluorescen of brain tissue
Healthy dog or cat: capture animal and observe for 10 days
Known exposure
Passive immunization: Administer human rabies immunoglobulin into the wound and gluteal region
Active immunization: administer antirabies vaccine in three IM doses into deltoid or thigh over a 28 day period
HIV prophylaxis s/p needle stick
Tenofovir-emtricitabin, raltegravir for 4weeks
Serology: immediately, 6wk, 3m, 6m
Candidiasis Treatment
oropharyngeal candidiasis: clotrimazole troches five times per day
Nystatin mouthwas: three to five times per day
Oral ketoconazole or fluconazole
Vaginal: miconazole or clotrimazole
Cutaneous: oral nystatin powder
Systemic: amphotericin B or fluconazole or vorinconazole or caspfungin
Treatment for leptospirosis
oral: tetracycline or doxycycline if severe IV penicillin G
Diagnosis and treatment of cryptococcosis
Diagnosis: LP is essential if meningitis suspected
Latex agglutiation detects cryptococcal Ag in CSF
Tissue biopsy is characterized by lack of inflammatory response
Treatment: amphotericin B with flucytosine for approx. 2 weeks followed by oral fluconazole
Catheter related sepsis organisms
S. aureus and S. epidermidis
Precautions for neutropenic patients
Reverse isolation precuations: positive pressure room, masks, and strict handwashing
amount of time to wait after mono to play sports
3-4 weeks after symptoms onset
