INFECTIOUS DISEASES Flashcards
Cystic Fibrosis
common bacterial pathogens in CF pneumonia
gram (-):
pseudomonas aeruginosa*, burkholderia cepacia, stenotophomonas mmatlophilia
gram (-) coccobacilli: nontypeable Haemophilus influenzae
gram + cocci in chains: strep pneumo
gram + cocci in clusters: staph aureus*
staph: vancomycin
antipseudo:
tobramycin (aminoglycosisde) + antipsuedomonal penicillin (ticarcillin-clavulanate, piperacillin-tazobactam)
OR
3/4 gen cephalosporin (cefepime, ceftazidime)
OR
carbapenam (meropenan, imipenen/cilastatin
- common combo: tobramycin, ticarcillin-clavulanate + vancomycin
- most common. pseudo > staph as get older
Chronic Bacterial Prostatitis
-treatment
first line treatment is 6 weeks of fluoroquinolone (ciporfloxacin) or trimethorpim-sulfamethoxazole
Cryptococcal Meningitis 1. treatment: 3 stages: a.induction b. consolidation c. maintenance
- role of serial lumbar punctures
- treatment:
3 stages:
a.induction: amphotericin B and flucytosine for 2 weeks or more until symptoms abate and sterile CSF
b. consolidation: high dose oral fluconazole for 8 weeks
c. maintenance: lower dose oral fluconazole for 8 weeks
2. role of serial lumbar punctures: relieve increased ICP
Dengue Fever
Classic vs hemorrhagic
mgmt
classic: flu-like with myalgias, retro-orbital pain, rash
hemorrhagic dengue: increased vascular permeability, thrombocytopenia, spontaneous bleeding (leading to shock), positive tourniquet test (petechiae after BP cuff)
mgmt: supportive
Dengue Fever
Classic vs hemorrhagic
mgmt
classic: flu-like with myalgias, retro-orbital pain, rash
hemorrhagic dengue: increased vascular permeability, thrombocytopenia, spontaneous bleeding (leading to shock), positive tourniquet test (petechiae after BP cuff)
“dengue shock syndrome” circulatory failure
mgmt: supportive
BCG vaccination & PPD skin testing
shouldn’t cause induration > 15mm on PPD skin testing. effect decreases after 15+ years of receiving vaccine
Neisseria Meningitidis prophylaxis-who and what meds
household members, roommates/intimate contacts, daycare workers, those directly exposed to patients oral/respiratory secretions (kissing, mouth-to-mouth resuscitation, endotrach intubation/mgmt), airline travelers seated adjacent to affected person for more than 8 hours
rifampin-4 doses orally
ceftriaxone-once IM, safe when pregnant
ciprofloxacin-once orally, not kids
Vaccines for adults
annual flu, Td booster every 10 years with Tdap as one time substitute, PCV13 at 65 years follow by PCV23 in 6-12months.
if patient chronic heart, lung, liver dx, dbts, alcoholic or smoker give PCV23 alone before 65 years.
very gigh risk: SCD, immunocomp, CKD, give PCV 12 and 23 before 65 years
Tb
1. alternative treatment for latent if isoniazid resistant
- rifampin
infective endocarditis
-mycotic aneurysm
-infected arterial aneurysm can happen in systemic or cerebral circulation due to septic embolization and localized vessel wall destruction as complication of IE. intracerebral mycotic aneurysms can present as an expanding mass with focal neuron findings or with aneurysm rupture and subarachnoid hemorrhage
Staph aureus-treatment
- MSSA
- MRSA
- MSSA
IV: oxacillin/nafcillin, or cezfazolin (1st gen cephalosporin)
oral: dixloxacillin or cephalexin (1st gen cephalosporin) - MRSA
severe: vancomycin, linezolid (AE: thrombocytopenia), daptomycin (myopathy), tedizolid
minor: TMP/SMX, clindamycin, doxycyline
Strep meds
penicillin, ampicillin, amoxicillin
gram negative rods
E. Coli, Enterobacter, Citrobacter, Morganella, Serratia, Pseudomonas
Exceptions:
a. ertapenem is the only cabapenem that doesn’t cover?
b. what do else do ticarcillin, piperacillin cover?
c. levo, gemi and moxi are excellent for?
d. aminoglycoside role in treatment staph& enterococcus
e. carbapenems excellent for?
f. what does tigecycline cover
g. use of polymyxin/colistin? toxicity?
ALL of these:
- Cephalosporins: cefepime, ceftazidime
- Penicillins: Ticarcillin, piperacillin
- Monobactam: aztreonam
- Quinolones: Cipriofloxacin, levofloxacin, moxifloxacin, Gemifloxacin
- Aminoglycosides: gentamicin, tobramycin, amikacin
- Carbapenams: imipenem, ,meropenem, ertapenem*, doripenem
Exceptions
a. pseudomonas
b. gram neg rods, anaerobes, strep
c. pneumococcus
d. work synergistically with other agents for treatment
e. anaerobes. also strep and MSSA
f. MRSA and gram neg rods
g. multidrug resistant gram neg roads. renal toxicity
Beta Lactam Antibiotics
4 classes
mechanism
penicillins
caphalosporins
carbapenems
monobactam-aztreonam only
mech: inhibit cell wall binding by penicillin binding protein
4 Beta lactamase inhibitors
function
clavulanate, sulbactam, tazobactam, avibactam
combining beta-lactamase inhibitors with penicillins or cephalosporings broadens their spectrum to cover staph (not MRSA) and some gram neg rods
Anaerobic coverage
- GI
- Respiratory
- medications with no anaerobic coverage
- GI
- metronidazole (best for abdominal anaerobes)
- carbapenems, piperacillin, ticarcillin
- cefoxitin & cefotetan =only cephalosporins that covers anaerobes - Respiratory
clindamycin - medications with no anaerobic coverage
aminoglycosides, axtreonam, fluoroquinolones, oxacillin/nafcillin, all cephalosporings (except cefoxitin & cefotetan)
side effects linezolid daptomycin imipenem vancomycin
linezolid:thrombocytopenia
daptomycin: myopathy
imipenem: seizures
vancomycin; red man syndrome = red flushed skin from release of histamine. slow infusion rate
Antiviral Agents 1. Herpes Simplex, Varicella 2. Cytomegalovirus what's best for CMV retinitis side effects of vagancyclovir, gangcyclovir 3. chronic Hep C 4. Influenza A and B 5. RSV side effect 6. Chronic Hep B
- Herpes Simplex, Varicella:
Acyclovir, Valcyclovir, famcylcovir - Cytomegalovirus
Gangcyclovir, Valganciclovir, foscarnet
(can also cover HSV, varicella)
Vaganciclovir best for CMV retinitis
Vagan- & Gangcyclovir: neutropenia, BM suppression
foscarnet: renal toxicity
- chronic Hep C:
sofosbuvir-ledipasvir, elbasvir-grazoprevir, daclatasvir-sofosbuvir, ombitasvir-paritaprevir-dasabuvir, sofosbuvir - Influenza A and B: oseltamivir, zanamivir, peramivir
- RSV: ribavirin (side effect anemia)
- Chronic Hep B: lamivudine, interferon, adefovir, tenofovir, entecavir, terlbivudine
Antifungal Agents
- Fluconazole
- Voriconazole
- Echinocandins(caspofungin, micafungin, anidulafungin)
- Efinaconazole, tavaborole
- toxicity of all azoles
- Fluconazole: candida, cryptococcus
- Voriconazole: aspergillus, candida
voriconazole -visual disturbance - Echinocandins(caspofungin, micafungin, anidulafungin)
-neutropenic fever patients
-not for Cryptococcus
-no adverse effects
-candidemia - Efinaconazole, tavaborole (topical): onychonycosis
- toxicity of all azoles
Amphotericin
- 2 main indications
- adverse effects
- 2 main indications: cryptococcus, candida
- adverse effects: directly toxic to renal tubules causing renal tubular acidosis. distal RTA gives excess K and Mg loss and H+ retention. need to switch to liposomal amphotericin
Osteomyelitis -typical presentation -diagnostic testing -earliest finding of osteomyelitis on x-ray -how long do you know how to treat -treatment what is most common cause
-typical presentation: PAD, diabetes with ulcer or soft tissue infection. have to ask if it has spread to bone
-diagnostic testing?
x-ray first
MRI if x-ray negative but high clinical suspicion. MRI has greater sensitivity and NPV for diagnosis or exclusion of osteomyelitis of the foot
(x-ray might be negative b/c have to lose >50% Ca content of bone for xray to become abnormal)
-earliest finding of osteomyelitis on x-ray?
earliest finding = elevation of periosteum
will need bone biopsy/culture
-how long do you know how to treat?
follow sed rate. if ESR is still high after 4-6wks then further therapy and possible debridement is needed
-treatment
staphylococcus (most common cause) (NO ORAL meds)
MSSA: IV oxacillin, nafcillin
MRSA: IV vancomycin, linezolid, daptomycin
Gram-negative bacilli (Salmonella and pseudomonas)
ONLY GRAM NEGS CAN BE TREATED ORALLY
Otitis Externa
-treatment
cellulitis of the skin of the external auditory canal
- topical ciprofloxacin, ofloxacin, polymyxin/neomycin
- topical hydrocortisone to decrease swelling/itching
- acetic acid and water solution -reacidify ear
Malignant Otitis Externa
- common causative agent
- diagnosis
- treatment
osteomyelitis of skull–>brain abscess, skull destruction
- commonly caused by pseudomonas in diabetic
- CT, MRI first. biopsy is most accurate
- surgical debridement and antibiotics against pseudomonas (ciprofloxacin, piperacillin, cafepime, carbapenem, aztreonam)
Otitis Media
- diagnosis
- treatment
- common causative agents
- diagnosis: red, bulging, decreased hearing, loss of light reflex, IMMOBILE TYMPANIC MEMBRANE
- treatment: amoxicillin 7-10days
- no improvement after 3 days then amoxicillin-clavulunate, cefdinir
- persistent/recurrent: tympanocentesis & aspirate of tympanic membrane for culture - common causative agents: strep pneumo, Haemophilus, Moraxella
Sinusitis
- common causative agents
- diagnosis
- treatment
- common causative agents: strep pneumo, Haemophilus, Moraxella
- x-ray is best initial test. sinus aspirate for culture is most accurate
- amoxicillin + steroid nasal spray
amoxicillin-clavulunate if bad
Streptococcus Pharyngitis
- symptoms
- diagonosis
- treatment
Streptococcus Pharyngitis
1. exudate, adenopathy, sore throat, NO COUGH
2. diagnosis: rapid strep test detects Group A strep that can lead to rheumatic fever/glomerulonephritis
3.treatment: amoxicillin/penicillin.
penicillin allergy then azithromycin/clarithromycin
Influenza
- diagnosis
- treatment
- vaccine
- diagnosis: viral praid antigen detection
- treatment: oseltamivir or zanamivir if symptom onset within 48 hours. peramivir is available IV
- can get live if <50years without any medical conditions
Impetigo
-treatment
TOPIcals: mupirocin or retapamulin
severe: oral dicloxaciliin or cephalexin
MRSA: TMP/SMZ or doxycycline
Erysipelas
- causative agent
- symptoms
- diagnosis
- causative agent: group A (progenies) streptococcal infection of the skin.
- symptoms: skin bright read and hot (usually on face)
- blood cultures
- treatment: ORAL dicloxacillin or cephalexin
NO ROLE TOPICAL ANTIBIOTICS
Cellulitis
- causative agent
- diagnosis
- treatment for folliculitis, furuncles, carbuncles, boils
- causative agent: strep pyogenes and staph aureus
- diagnosis: if leg, r/o clot w/ lower extremity doppler
minor: oral dicloxaciliin, cephalexin, amoxicillin/clavulunate
severe: IV oxacillin, nafcillin, cafazolin, ampicillin/solbactam - treatment for folliculitis, furuncles, carbuncles, boils is same as above + drainage of boils. can develop post strep glomerulonephritis
Penicillin allergy
rash
anaphylaxis
rash: cephalosporin
anaphylaxis: vancomycin, linezolid, daptomycin
which infections can led to rheumatic fever or glomerulonephritis?
strep pharyngeal infection–>rheumatic fever and glomerulonephritis
strep skin infection–>glomerulonephritis
Fungal Infection of skin & nails
treatment
skin (no hair/nail): clotrimazole, miconazole, ketoconazole, econazole, nystatin, ciclopirox, terconazole
oral (scalp (tinea capitis) or nail (onychomycosis): terbinafine-increases LFTs
itraconazole
griseofulvin (capitis only)
Urethritis
- symptoms
- diagnosis
- treatment
Cervicitis
- symptoms
- diagnosis
- treatment
Urethritis
1.symptoms: urethral discharge +/- dysuria
2.diagnosis:
a. urethral swab: gram stain, culture, WBCs, DNAprobe
NAAT STI testing on urine
3.treatment: cover gonorrhea and chlamydia
Cervicitis
- symptoms: cervical discharge
- diagnosis: vaginal swab: gram stain, culture, WBCs, DNAprobe (NAAT)
- treatment cover gonorrhea and chlamydia
Medications for gonorrhea and chlamydia
gonorrhea IM ceftriaxone (ok in pregnancy)
chlamydia azithromycin once (ok in pregnancy) doxycycline 7 days (not in pregnancy)
Gonorrhea
disseminated
recurrent
dissem’d: polyarticular dx, petechial rash, tenosynovitis
recurrent: may have terminal complement deficiency
Pelvic Inflammatory Disease
- symptoms
- diagnosis
- treatment
- symptoms: lower abdominal pain, tenderness, fever, cervical motion tenderness
- diagnosis: leukocytosis measures dx severity. should do pregnancy test, then cervical culture and NAAT
lapascopy if recurrent/persistent
3.treatment
outpatient:
gonorrhea-IM ceftriaxone (ok in pregnancy)
chlamydia: oral doxycycline 7 days (not in pregnancy)
inpatient: cefoxitin & doxycycline +/- metronidazole
penicillin allergy: clindamycin & gentamicin
antibiotic safe during pregnancy
penicillins, cephalosporins, aztreonam, erythromycin, azithromycin
epididymo-orchitis
- presentation
- how does it differ from testicular torsion
- treatment
1.presentation:painful, tender testicle in NORMAL position
2.testicular torsion: testicle elevated & transverse position
3. treatment:
<35 years: ceftriaxone & doxycycline
>35 years: fluoroquinolone
Cancroid 1. causative agent 2. symptoms 3. diagnosis special medium 4.treatment
- Haemophilus ducreyi (gram neg coccobacilli)
- symptoms: painful genital ulcer, enlarged lymph nodes
- diagnosis: swab for gram stain & culture (Nairobi medium and Mueller-Hinton agar)
- IM ceftriaxone (ok pregnancy) or 1 dose azithromycin
Lymphogranuloma Venereum
- presentation
- diagnosis
- treatment
- BIG TENDER NODES (BUBOES) +/- drainage & ulcer
- diagnosis: serology for chlamydia
- aspirate bubo, then doxycycline or azithromycin
Erythromycin GI side effect
increases release of motilin hormone that increases GI motility between meals.
Herpes Simplex Virus
- diagnosis
- treatment
1.diagnosis: if there are clear vesicular lesions go right to treatment. if roofs come off of vesicles and lesion because an ulcer of unclear etiology than PCR is most sensitive. cultures provide sensitivities.
2.treatment: acyclovir, gangcyclovir, famicyclovir 7 days
recurrent/persistent then get viral cultures
resistant to acyclovir then use foscarnet not gangcyclovir
Syphilis 1. causative agent 2. symptoms, diagnosis treatment primary, secondary, tertiary Jarisch-Herxheimer Reaction
- treponema pallidum
a. primary
symptoms: painless chancre, adenopathy
diagnosis: darkfield, then VDRL/RPR
treatment: 1 IM shot benzathine penicillin. use doxycycline if penicillin allergy.
Jarisch-Herxheimer reaction: fever, headache, myalgia within 24 hrs of treatment due to release of pyrogens from dying treponema. give aspirin & continue treatment.
b. secondary
symptoms: rash, mucous patch, alopeci areata, condylomata lata
diagnosis: RPR and FTA
treatment: 1 IM shot benzathine penicillin. doxycycline if penicillin allergy.
c. tertiary
symptoms: neuro (tabes dorsalis, argyll-robertson pupil, general paresis), gumma, aortitis
diagnosis: RPR & FTA, LP (test CSF with VDRL and FTA)
treatment: IV aq. penicillin. desensitize if penicillin allergy
patients with CD4<350 and RPR titer >1:32 higher risk neurosyphilis
Granuloma Inguinale
- symptoms
- diagnosis, typical causative agent
- treatment
- symptoms: beefy, red ulcerating genital lesion
- diagnosis: biopsy or touch prep, klebsiella granulomatis, donovan bodies
- treatment: doxycycline, TMP/SMX, azithromycin
scabies treatment
permethrin, ivermectin, lindane
Cystitis
treatment
uncomplicated: oral fosfomycin or nitrofurantion 3 days
E coli resistance >20% locally then ciprofloxacin or levofloxacin
complicated: TMP/SMX or ciprofloxacin 7 days
Central line associate bloodstream infection
commonly due to coag negative staph, staph aureus, candy, aerobic gram neg bacilli
prevent infection: maximal barrier precautions, avoid femoral site, skin cleansing with chlorhexidane, prompt catheter removal when no longer needed
Infectious Mononucleosis
usually due to EBV. systemic viral infection
presents with fever, extreme fatigue, oxidative pharyngitis/tonsillitis, lympadenopathy (including posterior cervical) and hepatosplenomegaly
atypical reactive lymphocytes (predominant cytoplasm, irregular nucleus) on peripheral blood smear.
Lactational Mastitis
oral dicloxacillin (anti staph penicillin) and cephalexin.
no Trimethoprim-sulfamethoxazole while breast feeding
if doesn’t resolve then u/s to r/o inflammatory breast ca, breast abscess
HIV lidodystrophy
presents as lipoatrophy, fat accumulation or both in different areas. a pattern with increased fat tissue deposition on the back of the neck and abdomen along with thin extremities. closely related to diabetes and dyslipidemia.
HIV infected patients frequently have dyslipidemia, particularly hypertriglyceridemia, which can be exacerbated by antiretroviral therapy. first line usually statin but use vibrate in triflyverise >500mg/dL
Schistosomiasis
parasitic fluke infection common in sub-saharan africa. chronic urinary schistomiasis can cause dysuria, urinary frequency, terminal hematuria, peripheral eosinophilia.
diagnosis: i.d. parasite eggs by urine sediment microscopy
Ecythma Gangrenosum
most commonly seen in immunocompromised patient with pseudomonas aeruginosa bacteremia. manifestations: rapid evolution of >1 skin lesion from an erythematous macule to a pustule or bull and then into a non painful gangrenous ulcer. fever and systemic sign common.
treatment:
antipseudonomal beta lactam (piperacillin-tazobactam) AND amonoglycoside (gentamicin)
HIV
Cutaneous Cryptococcosis
usually occurs in advanced HIV CD4<100. marker of disseminated dx.
manifestations: rapid onset multiple papular lesions with central umbilification and central hemorrhage/necoris
diagnose with lesion biopsy
treat with 2+ weeks of IV amphotericin B and oral flu cytosine then 1 year of oral fluconazole
Diptheria Epidemiology Manifestations Diagnosis Treatment
Epidemiology: toxigenic strains of corynebacterium diphtheriae. kids <15yrs. vaccine decreases risk.
Manifestations:
pharyngitis -grey patches/pseudomembranes that bleed when scraped.
toxin mediated myocarditis
Diagnosis: culture resp secretions, toxin assay
Treatment: erythromycin or penicillin G. diphtheria antitoxin if severe
Chagas Disease
dilated cardiomyopathy
if azithromycin isn’t effective for nongonococcal urethritis, what else should be suspected?
trichomonas
treat with metronidazole
Chlamydia in pregnancy screening risk factors OB complications fetal complications treatment
screening: universal 1st trimester, agin in 3rd trimester if high risk
risk factors: <25 yrs, hx of STI, new partner, multiple partners, unprotected sex
OB complications: preterm, premature rupture of membranes, preterm labor, postpartum endometritis
fetal complications: neonatal conjunctivitis, neonatal pneumonia
treatment: azithromycin
can you work at hospital with latent Tb infection
healthcare workers with latent Tb should be counsel about the risk of developing active Tb and offered preventative therapy with isoniazid for 6-12 months. they shouldn’t be excluded from the workplace if they refuse to accept recommended therapy.
- Extrapulmonary Tb
kids & infants
how to treat Tb meningitis
kids & infants should be treated for 12 months . treat Tb meningitis with isoniazid, rifampin, and pyrazinamide for 2 months then INH and rifampin for 10 months
HIV meds during pregnancy
first line zidovudine/lamuvudine
efavirenz preferred after 8 weeks . if woman already on it then leave . if not then don’t begin until after 8wks
in general should try to avoid discontinuing/modifying effective regimen as can lead to viral failure and drug resistance
pneumocystis pneumonia
- role of corticosteroids in patients with HIV
- what is sputum culture is negative but suspicion is high
- if ABG show alveolar-arterial oxygen gradient >35 and or arterial oxygen tension <70 on room air . these patient often have respirator decompensation during the first 2-3 days of treatment due to organism lysis, which stimulates inflammatory response. steroid reduce risk of intubation
- do bronchial lavage
disseminated gonococcal infections
- how do you confirm diagnosis when suspected
- unique finding
- culture joint fluid and mucosal surfaces (urethral, cervical, rectal, oral mucosa)
- tenosynovitis -painful tendons along the ankle & toe joints
Mucomycosis
rhinocerebral -typically present in which patients? treatment?
DKA patients, requires surgical debridement and IV liposomal amphotericin B
Infectious Mono
what happens if give amoxicillin
gernalized maculopapular rash that will resolve spontaneously after withdrawal of antibiotic and observation
uncomplicated pediatric pneumonia
- most common cause preschool age or focal lung findings? treatment?
- most common cause older child or well appearing with bilateral lung findings
- strep pneumo, amoxicillin
2. mycoplasma pneumoniae, azithromycin
Pyelonephritis
- presentation
- diagnosis
- treatment
- cystitis symptoms+flank pain, tenderness, fever
- diagnosis: urinalysis & culture
- treatment: cover for gram neg bacilli
outpatient : ciprofloxacin
inpatient: ceftriaxone, amp, gent, quinolones
Periphrenic Abscess
- presentation
- diagnosis
- treatment
- rare complication of pyelonephritis
suspect if pt doesn’t respond to treatment for pyelo within a 1week, persistent WBCs on U/A & fever - need u/s or CT kidneys
biopsy abscess - treat with quinolone and add staph coverage (oxacillin, naficillin, vanc)
Prostatitis
- presentation
- diagnosis
- treatment
- freq, urgency, dysuria, perineal/sacral pain “boggy” prostate
- diagnosis: U/A
- treatment: TMP/SMX or cipro
same as cystitis just longer. 2 wks for acute, 6 wks for chronic . can also use fosfomycin
HIV
HAART
when is ritonavir added? why?
cobicistat?
- lamivudine & abacavir + integrase inhibitor
- tenofovir&emtricitabine + integrase inhibitor
- tenofovir & emtricitabine + atazanavir (protease inhibitor)
when is ritonavir added? why? if use protease inhibitor at ritonavir to boost levels of other protease inhibitors
cobicistat? boost drug levels
Adverse effect of classes
- NRTI (-dine, -sine, -bine, -vir)
- protease inhibitors (-navir)
- NNRTI (-pine, rine, efavirenz)
- integrase inhibitors (gravir)
- lactic acidosis
- hyperglycemia, hyperlipidemia
- drowsiness, don’t use in mentally ill
- no major
AE:
- tenofovir
- efavirenz
- abacavir
- tenofovir: RTA, fanconi’s syndrome
- drug resistance,avoid preg. & mentally ill
- only use if neg for HLA-B*5701 mutation
PreP
PEP
PrEP: tenofovir + emtricitabine
PEP: tenofovir + emtricitabine + integrase inhibitor
Tenofovir
2 forms
disoprovil form is toxic to bone and kidneys
alafenamide form is less toxic
HIV
Prophylaxis:
1. Pneumocystitis Jiroveci Pneumonia (PCP)
2. Mycobacterium Avium-Intracellulare
- CD4<200
TMP/SMX
if rash than dapsone or atovaquone
no dapsone if G6PD deficiency - CD<50, oral azithromycin once a week
HIV Opportunistic Infections
presentation, diagnosis, treatment
- PCP
- Toxoplasmosis
- Cytomegalovirus
- Cryptococcus
- Progressive Multifocal Leukoencephalopathy
- Mycobacterium Avium-Intracellulare
- PCP
presentation: shortness of breath, dry cough, hypoxia, increased LDH
diagnosis:CXR: incresed interstitial markings
if neg but high suspicion then bronchoalveolar lavage
treatment: IV TMP/SMX
if rash switch to IV pentamidine
not dapsone because not IV
severe (pO2<70, A-a gradient >35): steroids
- Toxoplasmosis
presentation: headache, n/v, focal neuro findings
diagnosis: CT head “ring enhancing lesions”
treatment: pyrimethamine & sulfdiazine for 2 wks. repeat CT if lesions smaller than confirmative. if lesions not responding then brain biopsy
- Cytomegalovirus (CD4<50)
presentation: blurry vision
diagnosis: appearance of lesion on PE
treatment: ganciclovir or foscarnet
maintenance therapy with oral valganciclovir forever, unless CD4 increases
- Cryptococcus (CD<50)
presentation: fever and headache
diagnosis: LP- increase CSF lymphocytes
india ink stain 60% sensitivity
crypto antigen test 95% sen and specific
treatment: amphotericin & 5-FC then fluconazole lifelong unless CD4 rises
- Progress.Multifocal Leukoencephalopathy (CD<50)
presentation: focal neuro abnorms
diag:CT head or MRI. no ring enhancement, no mass effect
PCR of CSF for JC virus most accurate
treatment: none. take HAART, as CD4 increases PML will resolve
- Mycobacterium Avium-Intracellulare (CD<50)
presentation: wgt loss, fever, fatigue, anemia, high all phase, high GGTP with normal bilirubin
diag:
blood culture -least sensitive
bone marrow- more sensitive
liver biopsy-most sensitive
treatment: clarithromycin and ethambutol
Infective Endocarditis
1.empiric therapy
- vancomycin and gentamicin to cover most organism (s. aureus, MRSA, viridans group strep). treat 4-6weeks
Endocarditis Prohpylaxis:
- cardiac defects that need prophylaxis
- procedures that require prophylaxis
- what drugs for prophylaxis
- cardiac defects that need prophylaxis
- prosthetic valves
- unrepaired cyanotic heart disease
- previous endocarditis
- transplant recipients with valve disease - procedures that require prophylaxis
- dental procedures that cause bleeding
- respiratory tract surgery
- surgery of infected skin - dental/oral:
- amoxicillin
- rash: cephalexin
- anaphylaxis: azithromycin, clarithromycin, clindamycin
skin:
cephalexin
allergic to penicillin: vanc
Animal Borne diseases
presentation, diagnosis, treatment
- Leptospirosis
- tularemia
- Cysticercosis
- Leptospirosis (spirochete) animal pee
presentation: fever, abdominal pain, myalgia
diagnosis: serology
treatment: ceftriaxone or penicillin - tularemia–rabbits in the summer
presentation:
ulcer at contact site, big lymph nodes, conjunctivitis
pneumonic : deadly
diagnosis: serology. taking culture releases spores!
treatment: streptomycin, doxycycline, gentamicin
- Cysticercosis–infected pork
presentation: calcifications and seizures
diag: CT head: thin walled calcified cysts
treatment: abendazole
Tick Borne Diseases
- Lyme Disease
- Babesiosis
- Erlichia/Anaplasma
- Malaria
- Lyme Disease
caused by spirochete Borrelia Burgdorferi carried by Ixodes tick
presentation: erythema migrans, camping long term manifestations: joint involvement- late cadiac: AV conduction block/defect Neurologic: 7th cranial nerve palsy (bell's) most common
Diag: serology (IgM, IgG, ELISA, western blot,or PCR)
Treatment:
rash, joint, palsy: doxycycline, amoxiciliin, or cefurozime
CNS or cardiac involvement: IV ceftriaxone
- Babesiosis- transmitted by ixodes tick
presents: hemolytic anemia
diagnosis: peripheral blood smear looking for tetrads of intraerythrocytic ring forms or do a PCR
treatment: azithromycin and atovaquone - Erlichia/Anaplasma-ixodes tick
NO RASH, elevated LFTs,thrombocytopenia, leukopenia
diag: “morulae” (inclusion bodies in WBCs on peripheral blood smear or PCR
treatment: doxycycline
- Malaria
traveler from endemic area, hemolysis, GI complaints
diagnosis: blood smear
treatment:
acute: mefloquine or atovaquone/proguanil
(same drugs for prophylaxis)
mefloquine: neuropsych, sinus brady, QT prolongation
severe: quinine/doxycycline or artesunate
quinine-QT prolongation
no cardiac precautions with artesunate
severe defined as: >5% parasitemia, renal insuff, metabolic acidosis, CNS involvement, hypoglycemia
Atypical Respiratory Diseases
- Norcardia
- Actinomyces
- Histoplasmosis
- Coccidiodomycosis
- Blastomycosis
1.Norcardia (pt immunocomp’d) (branching, filamentous)
presentation:
respiratory/pulmonary dx can disseminate to any organ (skin, brain most common)
diag: CXR first, culture most accurate
treatment: TMP/SMX
- Actinomyces (not immunocomp’d, normal oral flora)
presentation: facial/dental trauma
diag: gram stain (branching, filamentous), confirm with anaerobic culture
treatment: penicillin - Histoplasmosis (bat droppings)
- wet areas (OH, MS)
presents: oral & palate ulcers, splenomegaly. pt might feel like they have viral illness
diag:
best initial test: histoplasmosis urine and serum anitgen
most accurate: biopsy with culture
4.Coccidiodomycosis (dry areas-Arizona)
acute respiratory illness, joint pain, erythema nodosum
treatment: itraconazole
- Blastomycosis (rural southeast)
presents: acute resp illness, skin lesions, bone lesions
diag: culture, broad budding yeast
treatment: amphotericin or itraconazole
Fungal Infections
- Mucomycosis (Zygomycosis)
- Aspergillus
- Mucomycosis (Zygomycosis) (immunocompromised)
immunocompromised, DKA
deferoxamine increases the risk by mobilizing iron
eats through nasal canals, eyes, brain
diag: biopsy
treatment: emergency surgery! IV amphotericin
- Aspergillus
- Allergic bronchopulmonary
present: asthmatics, CF pts. coughing brown mucous plug, abnormal CXR
diag: confirm with aspergillus precipitin antibodies and IgE in serum or skin plugs. high eosinophilia
treatment: oral prednisone
oral itraconazole or voriconazole
2.Invasive aspergillus
severely immunocompromised–neutropenic, leukemic
progresses rapidly
diag:
biopsy
CT & CXR severe lung infiltrates
serum galactomannan assay, beta-D glucan level, PCR
treatment: voriconazole, isavuconazole, caspofungin
Tropical Diseases
- Dengue
- ebola
- Chikungunya
- Zika
- Leishmaniasis
- Echinococcus
- Dengue (Aedes mosquito)
severe bone pain, headache, retro-orbital pain
thrombocytopenia, petechiae, capillaries leak
diag: ELISA serology
treatment is supportive
2. ebola (RNA filovirus) hemorrhagic fever get from direct contact with bodily fluids NOT AIRBORNE diag: serology or PCR treatment supportive
- Chikungunya (RNA togavirus)
headache, fevers, fatigue, JOINT PAIN/ARTHRALGIAS, sometimes rash
diag: serologyand PCR
treatment supportive - Zika (aedes mosquito)
fever, rash, conjunctivitis
PREGNANT WOMEN: MICROCEPHALY
supportive treatment -acetaminophen & fluids - Leishmaniasis (protozoa spread by sandflies)
skin/mucosal or visceral form or liver, spleen, and fever
diag:
direct visualization on liver/spleen/BM/ WBC aspirates
confirm with culture and PCR
treatment: liposomal amphotericin, miltefosine
- Echinococcus
dog and sheep, eggs eaten by humans
spreads to liver, lung, brain forming hyatid cysts
see cysts on sonogram, CT, MRI
can confirm with ELISA
aspirate of cyst can spread it accidentally
treatment albendazole or inject EtOH into cyst
CSF WBC, glucose, protein bacterial meningitis TB meningitis Viral meningitis guillain-Barre
normal
WBC 0-5
glu 40-70
protein <40
bacterial meningitis
WBC >1000
glu <40
protein >250
TB meningitis
WBC 5-1000
glu <10
protein >250
Viral meningitis
WBC 100-1000
glu 40-70
protein <100
Guillain-Barre
WBC 0-5
glu 40-70
protein 45-1000
HIV
immune reconstitution inflammatory syndrome
HIV+ patents can develop transient worsening of infectious symptoms for several weeks after initiation of antiretroviral therapy due to immune reconstitution inflammatory syndrome. IRIS arises due to the potent immune recovery that quickly occurs after initiation of antiretroviral therapy. its self limited.
empiric treatment of community acquired pneumonia
outpatient:
1. macrolide or doxyclycline (healthy)
2. flouroquinolone (levo or moxi) or beta-lactam + macrolide (comorbitdities)
inpatient (nonICU)
- flouroquinolone (IV)
- beta lactam + macrolide IV
inpatient (ICU)
- beta lactam + macrolide IV
- beta lactam + flouroquinolone IV
strep pneumo=beta lactam (ceftriaxone) atypical CAP (legionella) = macrolide or FQ
complications of cat scratch disease
bartonella henselae
complications: 10% ppl supporative lymph nodes, visual loss due to neuroetinitis, encephalopathy, FUO, hepatosplenomegaly
most common pathogens for acute otitis media
strep pneumo, nontypeable haemophilus influenzae, moraxella catarrhalis.
H influenzae causes otitis-conjunctivitis syndrome
Serum Sickness
immune
serum sickness in prodromal phase of acute Hep B that is caused by complement activation by circulating immune complexes. other manifestations of Hep B infection explained by circulating immune complexes are polyarteritis nods and glomerulonephritis
what are most common cause of viral meningitis or encephalitis in
- kids
- adults
- enteroviruses or arboviruses
(EEE, WEE, SLE, colorado tick fever, california encephalitis) - adults herpes simplex
toxoplasmosis
cat feces, contaminated soil on fruits and veggies, undercooked meat. usually asymptomatic in immunocompetent adult, but to newborn or fetus: choriorytinitis, near findings (hydrocephalus, intracranial calcifications) and hearing impairment
HIV
Virologic failure
failure to achieve a viral load <200 copies/mL within 6 months of ART.
goal of ART: decrease VL <50 copies/mL within 6 months
PEdiatric Sepsis
<28days: most likely E coli, Group B strep
give ampicillin + cefotaxime
> 28days most likely strep pneumo, N. men.
ceftriaxone or cefotaxime +/- vanc
Cystitis
pregnancy
treat with nitrofurantoin, cephalexin, amoxicillin-clavulanate 3-7 days.
FQs & tetracyclines contained.
TMP-SMX cause neural tube defects b/c folate antagonist properties. 1st line in non-pregnant
Contraindications to varicella vaccine, MMR
anaphylaxis to neomycin or gelatin
pregnancy
immunodeficient state
Human Bites
bugs
mgmt
eikenella corrodens, alpha-hemolytic strep, staph aureus
wound irrigation and wound care, no closure except on face, antibiotics, maybe tetanus booster
