Infectious Diseases Flashcards
1
Q
UTI Facts
A
- Cystitis: Infection of bladder (lower urinary tract)
- Pyelonephritis: Infection of the kidney (Upper UT)
- UTI is 2nd most common UT problem in children, behind enuresis
- 2nd only to URI as most common infection in adults
2
Q
UTI S/S
A
- Dysuria
- Frequency
- Urgency
- Suprapubic pain
- Hematuria
- Fever
- ** May be asymptomatic
3
Q
Pyelonephritis S/S
A
- May or may not have s/s or UTI
- Fever and chills
- Flank pain
- CVAT
- N/V
- Presentation may mimic PID
4
Q
Honeymoon Cystitis
A
- UTI during or shortly after a honeymoon or vacation
- Sexual activity can push bacteria back into urethra
5
Q
UTI Diagnosis
A
- 75-95% of cystitis and pyelo- is E. coli
- UA for pyuria - present in almost all women with acute cystitis or pyelo-
- WBC casts are pathognomic for pyelonephritis
- Hematuria is NOT a predictor of complication
6
Q
Enterobacteriaceae
A
- Group of gram-negative rods
- Salmonella, E. coli, Y. pestis, Klebsiella, and shigella
7
Q
Pyuria
A
- presence of pus (leukocytes and WBC)
- Alone is asymptomatic
8
Q
Urine volume
A
- Normal=600-1500mL
- Polyuria= >2L
- Oliguria= <200mL
9
Q
Polyuria causes
A
- DM
- DI
- Polycystic kidney
- CRF
- Diuretics
- IV NaCl or glucose
10
Q
Oliguria causes
A
- Dehydration
- Renal ischemia
- Acute tubular necrosis
- Obstruction
- ARF
11
Q
Urine color: Yellow
A
- Normal: Pale-light amber
- Milky: UTI
- Orange urine
- Meds: rifampin, sulfasalazine, phenazopyridine, some laxatives, some chemo
- Hx: Blockage, infection or Dz of the liver or bile duct –> Esp. w/ light colored stools, dehydration, fever
12
Q
Urine color: Blue or Green
A
- Blue or green:
- Dyes: food dyes, kidney/bladder tests
- Meds: amitriptyline, indomethacin, propofol
- Hx: Hypercalcemia, “blue diaper syndrome” (rare); UTI caused by pseudomonas
13
Q
Urine color: Orange
A
- Orange urine
- Meds: rifampin, sulfasalazine, phenazopyridine, some laxatives, some chemo
- Hx: Blockage, infection or Dz of the liver or bile duct –> Esp. w/ light colored stools, dehydration, fever
14
Q
Urine color: Dark amber or Tea-colored
A
- Liver dysfunction
- Increased muscle damage –> adverse Rx to statin, hepatitis, rhadomyolysis
- Food: Large amounts of fava beans, rhubarb, or aloe
- Meds: antimalarial drugs, metronidazole, nitrofurantoin, laxatives containing cascara or senna, and methocarbamol
15
Q
Urine color: red or pink
A
- blood
- secondary to UTI, BPH, neoplasms, cystic kidneys, long-distance running, renal calculi
- Food: beets, blackberries, and rhubarb
- Meds: rifampin, laxatives containing senna
Toxins: chronic lead or mercury poisoning
16
Q
Urine pH
A
- Normal: 4.6-8
- Acidic pH: Ketosis*, starvation, fever, acidosis, UTI E. coli
- Alkaline: strict vegetarian, systemic alkalosis, UTI proteus
17
Q
Urine Odor
A
- Normal: little to no odor
- Highly concentrated: ammonia
- Food/meds: asparagus, vitamins (esp. B6)
- Pathologic:
- acute liver failure, UTI, dehydration, DKA, metabolic disorders
- Maple sugar urine disease (Branched-Chain Ketoaciduria): body has trouble breaking down amino acids
- rectovaginal fistula
18
Q
Urine specific gravity
A
- Normal: 1.002-1.030
- High SG: Adrenal insufficiency; hepatorenal syndrome, CHF, dehydration; glycosuria; renal artery stenosis; shock; SIADH
- Low: DI, Renal failure; pyelonephritis, acute tubular necrosis, psychogenic polydipsia; hypoaldosteronism
19
Q
Prerenal ARF
A
- most common type of ARF
- can be a complication of almost any disease, condition, or medication that causes a decrease in the normal amoutn of blood volume
- Blood loss, hypotension, sepsis, ACE’s, NSAID’s, severe dehydration or burns, pancreatitis and liver Dz
- Tx: Correct the cause
- Often reverses itself in 2-3d
- If left untreated, can lead to intrinsic acute renal failure
20
Q
Renal Failure (AKA renal insufficiency or chronic renal insufficiency)
A
- 2 types:
1) Acute: 2/t acute kidney injury
2) Chronic: 2/t chronic kidney Dz
Detected by: - Elevated serum creatinine and decrease in GFR
- S/S: abnormal fluids levels; deranged acid-base balance; abnormal K, Ca, and Phos; hematuria; anemia
21
Q
Postrenal failure
A
- occurs when there is an obstruction, causing waste to build up
- Causes: Calculi; BPH; neurologic insult to the spinal nerve or neurologic disorders (Parkinson’s, CVA, MS); blood clots; neoplasm
22
Q
Proteinuria causes
A
- Prerenal: heavy exercises, fever, HTN, multiple myeloma, eclampsia
- Renal: acute/chronic glomerulonephritis, renal tubular dysfunction, polycystic kidney, nephrotic syndrome
- Post renal: acute/chronic cystitis, tuberculosis cystitis
23
Q
Microalbuminuria
A
- ** Cannot be detected by dipstick
- Detected by 24hr specimen
- Most common risks: DM & HTN
- Other risks: meds, trauma, toxins, infections, immune disorders, obesity, age >65, family Hx, preeclampsia, race & ethnicity
- Increased production of proteins can cause it: multiple myeloma, amyloidosis
- ** Orthostatic proteinuria: more proteinuria standing than lying
24
Q
Bence-Jones proteins
A
- A type of proteinuria usually associated with multiple myeloma
- detected in 24hr specimen
- can also occur with: amyloidosis; CLL; lymphoma
25
Q
Creatinine
A
- Waste product of muscle metabolism
- Produced from creatine, which is important in energy production
26
Q
BUN
A
- Measures the amount of nitrogen in blood that comes from the waste product urea
- a by-product of protein metabolism, made in the liver, and excreted through kidneys
- High: HF, dehydration, high protein diet
- Low: Liver Dz or damage, 2nd or 3rd trimester of pregnancy
27
Q
Microscopic exam of urine
A
- RBC’s
- Inflammation, injury, or Dz in kidney or UT
- Can be a contaminant from hemorrhoids or menstruation
- WBC
- infection or inflammation
- Epithelial cells
- from bladder or external urethra
- Microorganisms
- bacteria, yeast, trichomonads
- Casts
- Identified by substances in them: RBC, WBC, hyaline casts
- Crystals
- formed in excessively alkaline or acidic urine, temperature also promotes formation
28
Q
UA Dipstick analysis
A
- Glucose
- Ketones
- Hgb
- Leukocyte esterase: suggests WBCs in urine
- Nitrites: evidence of bacteria
- Bilirubin/urobilinogen: liver Dz or RBC breakdown
29
Q
UTI Treatment
A
- TMP-SMX DS 160/800mg PO q12hr
- Bactrim, septra
- Avoid if prevalence of resistance is >20%
- Avoid if patient has taken TMP-SMX for cystitis in 3mo
- Nitrofurantoin: 100mg PO q12hr x 5d
- Macrobid, Macrodantin
- Fosfoycin trometamol: 3g PO x1 dose
- Monurol
- Not as effective as others
30
Q
UTI Alternative treatment
A
If TMP-SMX, nitrofurantoin, and fosfomycin can not be used, move to fluoroquinolones
31
Q
How to ease dysuria
A
- Phenazopyridine (Pyridium)
- Treats symptoms
- NO effect of infection
- Turns urine BRIGHT orange
- Take with lots of water
- Limits doses, may mask worsening infection
- Do not prescribe for more than 2 days
32
Q
UTI Special populations
A
- DM more prone to UTI
- Pregnancy is a risk factor for UTI
- Due to the protective effect of estrogen, after menopause, women are more prone to UTI
33
Q
UTI Follow-Up
A
- Urine Culture
- Not needed unless patient has s/s after 48-72hrs of ABX or recurrent symptoms within a few weeks of treatment
34
Q
Tickborne Dz Facts
A
- Anaplasmosis –> Black-legged Dz: Northeast, upper midwest, & Pacific coast
- Babesiosis –> Black-legged tick: Eastern US
- Ehrlichiosis –> Lone Star tick: south-central and eastern US
- Lyme Dz –> Black-legged tick: Northeastern, upper midwest, and pacific coast
- Rickettsia –> Gulf Coast Tick
- Rocky Mountain Spotted Fever –> American dog tick, Rocky mountain wood tick, & brown dog tick in US
- Souther tick-associated rash illness (STARI) –> lone star tick: southeastern and eastern US
- Tickborne relapsing fever (TBRF) –> soft ticks
- Tularemia –> dog tick, wood tick, and lone star tick: throughout US
- 36D Rickettsiosis –> Pacific coast tick
35
Q
STARI
A
- STARI
- Rash: red, expanding bulls-eye lesion that develops around bite
- Appears within 7d of bite (shorter onset than lyme)
- c/o fever, fatigue, HA, and myalgia (less likely to have other s/s than lyme)
- Redness at bite does not necessarily indicate infection
- pts. more likely to recall bite
- Same Tx as lyme with faster recovery
36
Q
Lyme Dz
A
- Erythema migrans (“bulls-eye” rash)
- – Occurs in about 70-80%
- – begins at the site of tick bite in 3-30d (~7d)
- Rash expands over several days (more likely to have multiple lesions than with STARI)
- May measure up to 30cm (12in)
- Usually feels warm to touch
- Rarely itchy or painful
- May appear on any part of body
37
Q
STARI/ Lyme Tx
A
- Usually same regimen as lyme
1) Doxycycline 100mg PO BID x 12-21d
2) Amoxicillin 500mg PO TID x 14-21d
3) Ceftin (cefuroxime axetil) 500mg PO BID x 14-21d - For Lyme with Neuro s/s:
- Ceftriaxone IV
- PCN IV
38
Q
Lyme: Early Localized stage (3-30d after bite)
A
- EM Rash
- Fatigue, chills, fever, HA, muscle and joint aches, and lymphadenopathy (HIV, mono, both have similar s/s)
- REMEMBER, some people may not develop rash, and some people have tick bite with no lyme Dz
ns and dizziness
39
Q
Lyme: Early disseminated stage (days-to-weeks after bite)
A
- If untreated, may spread systemically and produce intermittent s/s
- Additional EM lesions
- Severe HA and nuchal rigidity (meningitis)
- Pain and swelling in large joints
- shooting pains that may interfere with sleep
- Heart palpitations
40
Q
Lyme: Late Disseminated stage (months-to-years after bite)
A
- ~60% have intermittent bouts of arthritis, with severe joint pain and swelling
- Large joints most often affected, particularly knees
- ~5% may develop chronic neurologic s/s
- – shooting pains, numbness/tingling in hands or feet, & problems with short-term memory
41
Q
Complications of Lyme: Post-treatment Lyme disease syndrome (PTLDS)
A
~10-20% have s/s that last for months-to-years after treatment
- S/S: muscle/joint aches; cognitive defects; sleep disturbance; fatigue
- May be caused by autoimmune disorder
42
Q
Other complications of Lyme
A
- Chronic joint inflammation (knees)
- Lymphocytic meningitis
- Neuritis
- Myocarditis
- Transient AV blocks
- Neurologic s/s (fascial palsy, neuropathy)
- Cognitive defects (impaired memory)
43
Q
Staphylococcus aureus facts
A
- Community-acquired MRSA (CA-MRSA, CMRSA)
- Hospital-acquired or health-care-acquired MRSA (HA-MRSA or HMRSA
- epidemic MRSA (EMRSA)
44
Q
MRSA colonization
A
- Individuals can serve as a reservoir
- The anterior nares are the most common site
- If the nares are colonized, transmission can be spread more readily with URI or sinus infection
45
Q
MRSA Treatment wound
A
- If a patient has a fluctuant or purulent SSTI:
- Should have I&D
- Send debrided material for culture
- I&D may be sufficient for abscess I&D + ABX
46
Q
MRSA Treatment PO
A
- Unknown what is best choice
- Clindamycin 300-450mg PO q6-8hr
- TMP-SMX x2 DS tabs PO q12hr
- AVOID tetracyclines
- Linezolid ONLY for patients who can’t take clinda or TMP-SMX
- – Costly; high toxicity
47
Q
Alternative MRSA Tx
A
- Rifampin
- Shows great activity vs. MRSA
- Used in combination with first line agents
- Use of rifampin alone is contraindicated (rapid development of resistance
- Fluoroquinolones
- ABSOLUTELY contraindicated
- Highly resistant to cipro
- MRSA fluoroquinolone resistance prevalent in many regions of US
48
Q
Community-Acquired Pneumonia (CAP)
A
- Prevention
- Pneumococcal vaccine
- Influenza vaccine
- Who should get vaccine?
- 65+ yo
- High risk patients age 2-64; chronic illnesses, Heart, lung Dz, HIV, Immunocompromised, smokers
49
Q
PNA Vaccine
A
- Pneumococcal polysaccharide (PPSV23)
- 1 or two doses between ages 19-64 with other risk factors
- 1 dose at 65
- Pneumococcal 13-valent conjugate (PCV13)
- 1 dose
50
Q
CAP Fact Dx
A
- ONLY definitive way to diagnose PNA is with CXR
51
Q
CAP Predicting mortality
A
- Pneumonia severity index (PSI) - more complex
- CURB-65 –> Assign one point for each variable
- Confusion
- Uremia: BUN >20
- Respiratory rate >30
- low Blood pressure: SBP 65
- **CRB-65 can be used in community
- ** Hospitalize for 2-3pts.
- SMART-COP –> CXR, tachypnea, O2 sats, RR, BP, Albumin, mental status, ABG
52
Q
Reasons to admit for CAP
A
- Complication of PNA: sepsis; cavitary PNA;
- Exacerbation of underlying Dz: COPD
- Inability to reliably take meds or follow-up
- Multiple risk factors: COPD, heart dz, smoking, etc.
53
Q
CAP most common organism
A
- Streptococcus pneumoniae
54
Q
When to culture sputum?
A
- Before ABX given
- Hx of travel
- Hx of MRSA
55
Q
CAP Epidemiology
A
- Hx of COPD or HIV=increased risk
- High fever >104, male sex, multilobar involvement, GI and neurologic abnormalities–> Associated with Legionella
- Presentation more subtle in older adults
- ** If AMS in older adult, always get UA and CXR
- REMEMBER influenza often overlaps
56
Q
CAP Treatment: Outpatient
A
- Patient previously healthy, no ABX in last 3mo, & no risk factors for drug resistant S. Pneumoniae
- Macrolide
- ** Azithromycin 250mg: 500mg day 1, 250mg x4d; Clarithromycin or erythromycin
- – Now commonly given 500mg Azithromycin PO qd x3d
- ** Doxycycline: BID
57
Q
CAP Treatment: Outpatient with comorbidities
A
- A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin)
- A beta-lactam: (1st: high-dose amoxicillin, augmentin, 2nd: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, erythromycin)
58
Q
CAP Outpatient follow-up
A
1) In office in 2-5d
2) Follow-up CXR in 6-8wk
59
Q
Risk factors for Penicillin-resistant PNA
A
- Age >65, beta-lactam or macrolide therapy in past 6mo, ETOH, medical comorbidities, immunosuppressive illness or therapy; exposure to child in day care center
