INFECTIOUS DISEASES Flashcards
TROPICAL INFECTOLOGY TICK ANIMALS BORNE ANTIBIOTIC LADDER HIV/AIDS ENDOCARDITIS UTI ANTIFUNGALS ANTIVIRALS
OSTEO
BIT: XR IF NORMAL
SECOND: MRI
MAT: BONE BIOPSY CULTURE (REGLA DE ORO)
BONE SCAN LACK SPECIFICITY EQUAL SENSITIVITY THAT MRI
EARLIEST FINDING:
PERIOSTEAL ELEVATION
ESR 4-6 WKS = SEQUESTRUM
ORDER: BONE DEBRIDEMENT
IF MSSA IV NAFCILINA
IF MRSA VANCO DAPTO LINEZOLID CEFTAROLINE
SALMONELLA PSEUDOMONA ONLY OSTEO TX PO ABX
MALIGNANT OE
OSTEO SKULL BASE
OEA: TOPICAL POLYMIXIN + NEOMYCIN HYDROCORTISONE DROPS IN SEVERE CASES
BIT:
MRI
MAT:
BONE BIO
ORDER: CIPRO PIP TAZO CEFEPIME AZTREONAM
OMA
ETIOLOGY: MOPS
NON TYPABLE HINFLUENZAE NOT IN VACCINE
PE:
MOST SENSITIVE PRESENCE OF INMOBILE TYMP MEMBRANE
AMOXICILLIN 7-10 D
MAT: TYMPANOCENTESIS AND ASPIRATE FOR CULTURE IF PERSISTANCE AND FAIL TTX
AMOXICILLIN CLAVULANATE CEFDINIR CEFTIBUTEN CEFUROXIME CEFPROXIL CEFPODOXIME
SINUSITIS
SAME ETIOLOGY OMA SAME ABX
BIT: IF XR AND CT SELECT CT
MAT: SINUS ASPIRATE FOR CULTURE
SAME ABXs OMA
BUT ADD INHALED STEROIDS
STREP A
RHEUMATIC FEVER GLOMERULONEPHRITIS
CENTOR
EXUDATES
LAD
ABSENCE OF COUGH
PAIN/SORE THROAT
RAPID STREP TEST
PENICILLIN
ALLERGY:
AZYTHROMICIN OR CLARITHROMICIN
USE CEPHALEXIN IF ITS JUST A RASH
INFLUENZA
BIT: IF DX UNCLEAR
VIRAL RAPID ANTIGEN DETECTION IN NASOPHARYNGEAL SWAB
BEING AT HOME ISOLATE FOR 7 DAYS
OSELTAMAVIR ZANAMIVIR IN FIRST 48 HRS
PERAMIVIR IV NEURAMINIDASE INHIBITOR SIMILAR EFFICACY TO OSELTAMAVIR
AMANTADINE WRONG ANSWER
VACCINE: COPD CHF HEALTH CARE WORKERS DIALYSIS STEROID USERS OR MORE THAN 50 YEARS
INHALED LIVE ATTENUATED ONLY IN < 50 YRS
INACTIVATED IM FOR > 50 YRS
EGG ALLERGY NO CI
TOPICAL ANTIFUNGALS IF NO HAIR AND NAILS INVOLVEMENT
BEST INITIAL TEST:
ORDER KOH PREPARATION + CULTURE
TOPICAL CLOTRIMAZOL (STANDARD) MICONAZOL ECONAZOL KETOCONAZOL TERCONAZOL NYSTATINE CICLOPYROX
ANTIFUNGAL MEDICATION FOR SCALP AND NAILS
BEST INITIAL TEST:
KOH PREP
TERBINAFINE CHECK LFT’s FOLLOW UP
ITRACONAZOL
GRISEOFULVINE LESS EFFICACY
GU
GONOCOCCAL URETHRITIS
2 MEDICATIONS FOR URETHRITIS ALWAYS
CONFECTION
BEST INITIAL TEST:
SWAB FOR GRAM STAIN CULTURE WBC COUNT SINGLE BEST TEST FOR GONO CHLAMYDIA IN USMLE:
DNA PROBE: NAAT NUCLEIC AMPLIFICATION TEST COMPARABLE TO PCR AND CAN BE DONE IN URINE SAMPLE HIGHLY EFFECTIVE AS WELL
RECURRENT INFECTIONS:
TERMINAL COMPLEMENT DEFICIENCY FOR URETHRA AND SNC AS WELL
GONORRHEA: CEFTRIAXONA CHLAMYDIA: AZYTHROMICIN SINGLE PO DOSE USMLE TOC* DOXYCICLINE 7 DAYS PO
PREGNANT URETHRITIS TTX
GONORRHEA: CEFTRIAXONE
CHLAMIDIA: AZYTHROMICIN
PID
TREAT SAME URETHRITIS
THE IS THE BEST NEXT STEP:
BHCG
ROULE OUT ECTOPIC PREGNANCY
WHAT IS THE BEST SINGLE INITIAL: DNA PROBE NAAT NUCLEIC AMPLIFICATION TEST IN URINE
MAT: LAPAROSCOPY
OUT: CEFTRIAXONE/DOXY
INPATIENT: CEFOXITINE/DOXY/METRO
CEFOTETAN /DOXY/METRO
PCN ALLERGY: CLINDA /GENTA
EPIDIDIMO ORCHITIS
AGE < 35 YO CEFTRIAXONE/DOXY GON/CLAM
AGE > 35 YO FLUOROQUINOLONE E. COLI
CONDUCTA A SEGUIR
GENITAL ULCER
DX
DOC
CHANCROID H. DUCREY "PAINFUL" NAIRIOBI OR MUELLER HINTON SWAB FOR GRAM STAIN IS DX SINGLE DOSE CEFTRIAXONE OR AZYTHROMINCIN
LGV CHLAMIDIA
L1-4
ASPIRATE THE BUBOE
DOXY/AZYTHRO
HSV GO STRAIGHT TO ACYCLO / VALACYCLO / FAMCICLOVIR 7-10d DO TZANCK IN UNCLEAR CASES
SYPHILIS
DO DARK FIELD X 3 = 100% SENSITIVE
DO NOT SEROLOGY PRIMARY FOR DX 75 %
PENICILIN G
GRANULOMA INGUINAL KLEBSIELLA BEEFY RED LESION THAT ULCERATES DO TOUCH PREP BIOPSY GRANULOMATIS DONOVANOSIS DOXY/TMP-SMZ/AZYTHROMIZIN
HSV TTX CONSIDERATIONS
CLEAR VESICULAR LESIONS
ULCERS OF UNCLEAR ETIOLOGY
MOST COMMON WRONG ANSWER FOR ACYCLOVIR RESISTANT HSV
CLEAR VESICULAR LESIONS: ACYCLO / VALACYCLO / FAMCICLOVIR 7-10d ULCERS OF UNCLEAR ETIOLOGY: TZANCK PREP BUT THE MOST ACCURATE IS PCR SEROLOGY HAS NO UTILITY
GANCYCLOVIR THIMINE KINASE MUTATION RESISTANCE IS CRUZADA TOO
ACYCLOVIR 40 tid VALACYCLOVIR 500 bid SAFE IN PREGNANCY USE AT 36 WKS WOMEN WITH FIRST EPISODE DURING PREGNANCY OR WITH FREQUENT RECURRENCES
IV ACYCLOVIR TO ALL PREGNANT WOMAN WITH SEVERE DISEASE
CHRONIC SUPRESSIVE TREATMENT FOR RECURRENCES
CMV
VALGANCICLOVIR
FOSCARNET
INFECTOUS MONONUCLEOSIS CCS CASE
17 YO CAME TO THE OFFICE C/O SORE THROAT FEVER MALAISE MYALGIA HEADACHE 2 DAYS AGO HE RECEIVED AMPICILLIN FOR PHARYNGITIS 39 C PETECHIA CERVICAL LAD LIVER ENLARGED 3 CM SPLENOMEGALY
CBC WBC >> LYMPHOCITOSIS ATYPICAL BMP CXR LFT BILIRRUBIN HIGH ALAT HIGH BLOOD CULTURES
ORDER:
HETEROPHILES ANTIBODIES
MONOSPOT
VIRAL CAPSIDE ANTIGEN IG M
ORDER: ACETAMINOPHEN AVOID CONTACT SPORT PREDNISONE IF THROMBOCITOPENIA OR HEMOLITC ANEMIA
GRANULOMA INGUNALE CCS CASE
24 YO MAN HAD AN PAINFUL ULCERATIVE GENITAL LESION FOR 3 DAYS THE LESION BEGAN AS PAPULE WITH ERYTHEMATOUS BASE .
Order
COMPLETE PE :
SOFT TENDER ULCER ON PREPUCE WITH INGUINAL LN.
ORDER • VDRL RPR • HIV • WRIGHT STAIN OR SCRAPING 2 TEST 4 GRANULOMA INGUINALE CAUSED BY DONOVANOSIS
•GRAM STAIN PLEOMORPHIC GRAM NEGATIVE ROD
IN “SCHOOL OF FISH” PATTERN
• DARK FIELD EXAMINATION
• CHLAMYDIAL ANTIBODY TESTING OF SCRAPPING.
ORDER
• CULTURE SCRAP: ➕ H. DUCREY
ORDER
AZYTHROMICIN 1 GR ONE SINGLE PO DOSE CEFTRIAXONE 250 MG IM SINGLE DOSE
SECONDARY LUES CCS CASE
24 YO MALE C/O MACULOPAPULAR RASH OVER ALL HIS BODY MILD FEVER HA SORE THROAT 2 WK AGO HAD A PAINLESS GENITAL ULCER THAT RESOLVED ON ITS OWN.
ORDER
COMPLETE PE
ALOPECIA
DIFUSE MP RASH DARK REDISH FEW PUSTULES GENERALIZED MODERTE ADENOPATHY
ORDER • CBC • BMP • UA • VDRL RPR: HIGH TITER • HIV • HbsAg, Anti HBc antibodies.
ORDER
• FTAA ➕
CULTURE OF PUSTULES NO GROWTH\
ORDER
• LP NORMAL
CSF VDRL, RPR, FTAA: ALL NON RACTIVE
ORDER
PCN G 2.4 MILLION SINGLE IM DOSE.
FOLLOW UP6 -12-24 MONTHS LATER TITTERS VDR PRP TO LOW
LATENT SYPHILIS EARLY SAME RX 1ry 2ry SYPHILIS LATE PCN G BENZATINA ONCE/WK X 3 WK 2.4 M DOXICICLYNE PO 100 mg DY X 4 wk TETRACICLINE 500 mg 4 XDY X 4 wk
NEUROSYPHILIS
PCN OR PCN IF ALLERGY
DESENSITIZES
SUSPECT:
HIV
NEURO SYMPTOMS
INNITIALLY > 1:32 TITERS FAIL TO DECLINE AFTER TX FOUR FOLD
LATER FU: CSF EVERY 6 MOS FOR WBC COUNT AND VDRL RPR TITERS 2 YRS AFTER REPEAT IF CSF WBC DO NOT NORMALIZES
VZV
SHINGLE CCS CASE
HZV SHINGLE CASE ORDER WRIGHT OR GIEMSA STAIN OF UNROOFED LESION (TZANCK PREP) VIRAL CULTURE OR PCR ORDER: ACYCLOVIR/VANCYCLOVIR/GANCYCLOVIR GABAPENTIN POST HERPETIC NEURALGIA TCA VZ VACCINE 65- OLDER
CCS CASE DISSEMINATED GONORRHEA DX LYME REITER VIRAL DISEASES
37 YO WOMAN HAS 3 DAYS OF PROGRESSIVE JOINT PAIN IN HER ANKLES KNEES AND WRIST THERE IS ALSO PAIN IN THE BACK OR HER HAND AND FOREARMS AS SHE FLEXES OR EXTENDS HER FINGERS
ORDER:
COMPLETE PE TEMP 38.7 PHARYNGEAL INJECTION SKIN PETECHIAL RASH SWOLLEN RED TENDER KNEE ANKLE WITH DECREASED RANGE OF MOTION.
ORDER:
• CBC • BLOOD CULTURE • PT, PTT • UA • URINE CULTURE • SWAB RECTAL ORAL URETHRAL • ARTHROCENTESIS • JOINT FLUID C S AND CELLS • THAYER MARTIN MEDIA CULTURE • VAGINAL C S, DNA PROBE FOR CHLAMYDIA AND GONORRHEA
ALL STD/IVD USER: • RPR, VDRL • HbsAg, anti Hbc Ab. • HIV
ORDER:
• IV CEFTRIAXONE 1 g Q DAY FOR 7 - 10 days IS TOC
FOR DISSEMINATED GONORRHEA
PO CHOICES:
CEPODOXIME
CEFIXIME
ALL STD:
NOTIFY PUBLIC HEALTH
SAFE SEX
TREAT PARTNER
CCS CASE CHOLANGITIS POSS HEPATIC ABSCESS
54 YO MAN WITH DM COMES TO THE OFFICE HE BEGAN HAVE RUQ PAIN CHILLS FEVER
PH: KNOWN BILIARY TRACT DISEASE
Order
Complete PE» 38.9 temp, vitally tachycardia , N. BP, mild icterus, RUQ Tenderness, no masses. No peritoneal signs,
Order
• CBC» leukocytosis, • BMP
• Abd ultrasound : dilated common bile duct with stone and mass lesion in right lobe of liver, consistent with hepatic abscess.
• Abd x-ray acute series. • Alkaline phosphatase • LFT»> total bilirubin 3. • PT,PTT
• UA • Blood culture
• U culture
• CXR»> fluid in Right costophrenic angle,
• Amylase • Lipase Order
• Send PT to ER
• NPO
• Iva • NSS
• CT scan of the abdomen : dilated CBD, 5X3 cm mass in right lobe of liver» abscess.
• Stool for (ova, parasite, culture, G stain)
• IV ampicillin/ sulbactam + doxycycline or Cephtriaxone + metronidazole.
• Surgical consult, reason : cholangitis for possible hepatic abscess.
• Percutaneous drainage of liver.
CCS CASE CEREBRAL ABSCESS
55 yo man comes to your office with almost 2 wks of progressive worsening headache, fever, and 2 days of left hand and leg weakness. There has been nausea and some vomiting.
Order complete PE >> temp 39, bulging red right tympanic members. Left Upper and lower extremely weakness. Intact sensory exam. Order • CBC • BMP • U-a • Urine culture • Blood culture • CXR • Brain CT with and without contrast >> hypodense area on right tempropariatal lobe. Marked enhancement with contrast. >> consistent with brain abscess Order
- Send to ED
- NPO
- PT, PTT • Fibrinogen
- FDP
- Stereotactic CT guided needle biopsy of the lesion.»_space; G positive cocci in chain and G negative rod»_space; culture»_space; strep viridans and bacteriodes melaninognicus.
Order
• IV Penicillin + metronidazole for 8 wks, or phetriaxone + metro
• Repeat CT after 3 wks.
• Surgical drainage if resistant to antibiotic.
CCS CASE INFLUENZA
25 YO MALE RETURN FROM NICKING TRIP WITH SEVERE EXCRUCIATING HEADACHE FEVER CHILLS MYALGIA
Order»_space; complete PE»_space; fever 38, mild enlarged cervical LN, erythematous pharynx, scattered rahles bilaterally.
Order
• CBC» • BMP • Blood culture • Urine analysis • Urine culture • CXR» bilateral interstitial markings. • ABG»_space;> 7.48/30/70. O2 sat 93%. • Sputum G stain»_space; few leucocytes • Sputum culture for bacteria, viral, mycobacterium fungi»_space; viral ag detected. Order
• Admit to hospital • Respiratory support ( oxygen, humidified air) if her ABG deteriorating do intubation • Ozeltamivir/ zanamivir • Antibiotic if there is bacteria, infection detected in culture
LYME DISEASE CCS CASE
25 YO MAN RETURN FROM NICKING TRIP WITH
HA FEVER MYALGIA
Order
complete PE»_space; Nuchal rigidity, right facial palsy. Temp 39.
Order
•CBC • BMP • Fibrinogen • Blood culture • Brain CT • Lumbar puncture» as usual add antibodies against Burrelia burgedorferi ( ELIZA and western blot), bacterial and viral culture. Order
• Burrelia burgedorferi Serum IgM level ( ELIZA )» high titer • Serum Western blot Order
Cephtriaxone for 3 wks.
“2 min screen”
deet Diethiltoluamide Permethrine repellent to clothes wear protective clothes
CCS CASE COMPLICATED OMA MASTOIDITIS
27 MALE COME TO THE OFFICE A WEEK AFTER INITIAL VISIT FOR EAR PAIN AND DECREASE HEARING . HE WAS COMPLIANT WITH AMOXICILLIN THAT YOU HAD PRESCRIBED IT TO HIM FROM WEEK AGO. HE COMES NOW BECAUSE WORSENING PAIN AND DETERIORATION AF HEARING.
Order»_space;
complete PE»_space; temp 38, bulging red tympanic membrane, intact membrane, tender Pinna, which displaced inferiorly and laterally. Area abive the pinna is tender and Small fluctuate mass.
Order
• CBC • BMP • Plain x ray of mastoid process»> obliteration of mastoid air cells and destruction of trabecular mesh work. • CT of mastoid process»_space; massive destruction and subperiosteal collections. • Tympanocentesis and culture»_space; Strep. pneumonia. • Mastoid biopsy is the most sensitive test. Order
• IV penicillin only for pen sensitive pneumococcal infection • Pen resistant»_space; cefotaxime or Ceftriaxone • Vancomycine for one resistant.
CCS CASE ASCENDING CHOLANGITIS
78 YO WOMAN BROUGHT TO THE ED WITH FEVER CHILLS RUQ PAIN LIGHT STOOLS COLOR AND DARKER COLOR OF URINE HTN ON BETA BLOCKER
ORDER COMPLETE PE
38.6 C BP 90/60, HR 100, SCLERAL ICTERIC, RUQ TENDERNESS,MILD REBOUND TENDERNESS WELL HEALED SCAR IN RIGHT HYPOC
ORDER:
• Oxy, Pulse oxy • IV access, NSS • NPO
• IV AMPICILLIN/SULBACTAM if allergic to pen use
AZTREONAM + METRONIDAZOL COVER GRAM NEG
• EKG
• CARDIAC MONITORING
• CBC
• BMP» BUN high,
• FIBRINOGEN
• BLOOD CULTURE
• URINE ANALYSIS
• URINE CULTURE
• LFT» bilirubin 4 (hi) , alk 300 (hi), rest are N.
•ABDOMINAL USG»_space; DILATED COMMON BILE DUCT»_space; NO MASSES.
ORDER:
- ADMIT TO WARD
- CONSULT SURGERY
- Order ERCP TO REVIEW THE STONE FROM BILE DUCT IF FAILED EXPLORATORY LAPAROTOMY
CCS CASE SUB ACUTE ENDOCARDITIS
32 YO MALE COMES TO THE ER ROOM CO 5 DAYS OF PRODUCTIVE COUGH PLEURITIC CHEST PAIN HE IS AN ACTIVE IV DRUG USER LAST USE ON THE DAY BEFORE PRESENTATION
Order
Complete PE»> Temp 39, thin, lying on stretcher, petechia on his mouth and conjunctiva. Bilateral clear.thin red lines on his fingernails.
Order
• Pulse oxy • Oxygen • IV access»_space;> Normal saline • Cardiac monitoring
Order
• CBC • BMP • UA • Blood culture»_space;> MSSA»_space;> • Urine culture • IV Vancomycin + gentamycin • CXR»_space;> multiple Nodular lesion bilateral
• Echo»_space;> vegetation
Order
• Admition • Nafcillin+Genta for 6 wks coz vegetations.
CCS SKIN INFECTION CASE
6 YO BOY IS BROUGHT TO THE OFFICE WITH RASH THAT STARTED AS SUPERFICIAL ACCUMULATION OF SEVERAL SMALL VESICLES ON HIS LEGS BELLOW THE KNEE NO FEVER OR CHILLS.
ox honey down crusted lesions on erythema tours base
Nothing to be done»_space; this is classical distribution of impetigo causative organism strep pyogenes
ORDER:
Topical Mupirocin if not oral dicloxacillin & nafcillin. Pen allergy erythromycin s or azithromycin.
RETAPAMULIN TOPICAL ABX ONLY FOR IMPETIGO
USMLE QUESTION:
A MAN COMES WITH A PAINLESS GENITAL ULCER
SYPHILIS
SENSITIVITY
TTX: NOTE IM TO IV SINGLE TO MULTIPLE
NON TREPONEMAL
VDRL and RPR
TREPONEMAL
ROULE IN SPIN CONFIRMATE /EXPENSIVES TO SCREENNING
EIA; ENZYME LINKED IMMUNOABSORBENT ASSAY
TPHT: TREPONEMA PALLIDUM HEMAGGLUTINATION TEST
FTA abs; FLUORESCENT TREPONEMA Abs
PRIMARY
ANSWER:
DO DARKFIELD 25% IN PRIMARY LUES SERONEGATIVES
DARK FIELD MOST SENSITIVE VDRL RPR 75% FTA-Abs TTX: SINGLE IM PCN G ALLERGY: DOXY
SECONDARY
DARK FIELD VDRL RPR 99% FTA TTX: SINGLE IM PCN G ALLERGY: DOXY
TERCIARY
DARK FIELD VDRL RPR 50 % FTA SENSITIVITY 100% EN CSF 75% IN BLOOD TTX: IV PENIC G ALLERGIES:DESENSITIZE
CCS “2 MIN” SCREEN
FOLLOW UP: “LATER” RPR/VDRL TO LOW
DO NOT USE TREPONEMAL TEST FTABS EIA LIFELONG REACTIVITY
PCN ALLERGY DESENSITIZE IS THE ANSWER 2 SCENARIOS SYPHYLIS
NEUROSYPHILIS
PREGNANT
BASIC SCIENCE HPV:
IMIQUIMOD
STIMULATES CYTOKINES
INTERFERON
TNF ALPHA IL-6
ALSO NK SYSTEM
ALSO USE: BASAL CELL
ACTINIC QUERATOSIS
MINOR SQUAMOUS CELL
WARTS:
PODOFILOX: CITOXIC ANTIMYCOTIC
IMIQUIMOD
IF NO RESUELVE:
PODOPHILIN RESIN
TCA
THEN: SURGERY: IF> 1CM REDUCE W/ TCA PODOPHILIN THEN EXCISION CRYO, LASER, TRICHLOROACETIC ACID.
FU: RECURRENCE
PREGNANCY: TCA SURGERY
DO NOT USE PODOPHILIN, PODOFILOX, FU TEERATOGENIC
PEDICULOSIS AND SCABIES
PERMETHRINA: BOTH
IVERMECTINE: SCABIES
LINDANE : BOTH
PYRETHRINES PEDICULOSIS
UTI
FOSFOMYCIN NITROFURANTOIN 3d SAFE IN PREGNANCY CLASS B
E COLI RESISTANCE >20% LEVO OR CIPRO
COMPLICATED MEANS STONE STRICTURE TUMOR OBSTRUCTION: TMP-SMT 7 d
ASYMPTOMATIC BACTERIURIA
DO NOT TREAT
JUST IN PREGNANCY AND PREVIOUS AN INSTRUMENTATION
PYELO 7 DYS DOES NOT RESOLVE
DO US R/O PERINEPHRIC ABSCESS BIOPSY COVER SELECTED OUT GRAM POSITIVES VANCO NAFCILLIN OXACILLIN
PROSTATITIS IS LIKE AN ABSCESS
BEST INITIAL TEST: UA
MAT: WBC PROST MASSAGE
CIPRO
TMP-SMT
FOSFOMYCIN
NGU 5 TO 10 dys AFTER
AZYTHRO TOC*
NO MEJORA ?
IF COMPLIANCE NOR REINFECTION
DO METRONIDAZOL TRICHOMONAS
NO MEJORA ?
RESISTANT NGU
ERYTHROMYCIN 800 MG / 6 TIMES A DAY
RMSF
HIKING AND CAMPING IN LONG ISLAND 2 DYS ago + FINE PETECHIAL RASH OVER WRIST AND LEFT ANKLE =TICK BORNE
ORDER:
INDIRECT FLUORESCENT ANTIBODY TESTING INMUNOASSAY OR COMPLEMENT FIXATION NEGATIVES
REPEAT SEROLOGY FOR RSMF IN ONE WEEK?
ERLICHIOSIS; CENTRAL RASH NO ERIPHERY
NO!
ABS ARE TYPICALLY SEEN IN n 7-10 DYS AFTER ONSET
REPEATING WOULD DELAY
TREAT EMPIRICALLY
DOXY
PREGNANCY CLORANFENICOL
HIV/AIDS
WHEN TO START THERAPY?
CD4 < 500 -350 CD4 > 500 VIRAL LOAD DETECTABLE - 50,000 BY PCR PREGNANCY ANY CD4 ANY STAGE NEEDLE STICK INJURY SYMPTOMATIC PTS ANY CD4 OR VIRAL LOAD
ADVERSE EFFECTS GENERIC
HAVE YOU DINE WITH YOUR NUCLEAR FAMILY?
NAVIR TEASE A PROTEASE INHIBITOR
NUCLEOSIDE: LACTIC ACIDOSI
PI HYPERGLICEMIA HYPERLIPIDEIMIA
NON NUCLEOSIDE DROWSISSNESS AVOID MENTAL ILNESS
INTEGRASE INHIBITORS
ADVERSE EFFECTS SELECTIVE
NUCLEOSIDES: ZIDOVUDINE: ANEMIA DIDASONIDE/ STAVUDINE: PANCREATITIS NEUROPATHY ABACAVIT HLA B 5701 RASH TENOFOVIR RTA RENAL TOX NEUROPATHY BONE DEMINERALIZATION
PI: INDINAVIR: KIDNEY STONES
ADVERSE EFFECTS GENERIC
HAVE YOU DINE WITH YOUR NUCLEAR FAMILY?
NAVIR TEASE A PROTEASE INHIBITOR
GRAVIR: INTERGRASE INHIB
NUCLEOSIDE: LACTIC ACIDOSIS
PI HYPERGLYCEMIA HYPERLIPIDEIMIA
NON NUCLEOSIDE DROWSINESS AVOID MENTAL ILLNESS
INTEGRASE INHIBITORS
ADVERSE EFFECTS SELECTIVE
USMLE FREQ QUESTIONS
NUCLEOSIDES:
ZIDOVUDINE: ANEMIA DIDASONIDE/ STAVUDINE: PANCREATITIS NEUROPATHY ABACAVIT TEST FOR HLA B 5701 = RASH TENOFOVIR RTA RENAL TOX NEUROPATHY BONE DEMINERALIZATION
PI: INDINAVIR: KIDNEY STONES
MARAVIROC
COBICISTAT
RITONAVIR
MFAGE: CCR5 - Gp 120 ENTRY INHIBITOR
BOST DRUG LEVELS
ADD TO HARRT BOOST LEVEL OF OTER PI s BY P450 INTERACTION
HAART EXAMPLES
2 NUCLEOSIDE + 1 INTEGRASE INHIBITOR PRINCIPLE
+ BOOSTER.
TENOFOFOVIR EMTRICITABINA+ PI ATRAZANAVIR + RITO
TENOFOVIR EMTRICITABINA+ INTEGRASE INHIBITOR
LAMIVUDINE ABACAVIR + INTEGRASE INHIBITOR
USMLE FAVORITE
HIV + FND
RING OR CONTRAST ENHANCING LESIONS
PYRIMETAMINE + SULFADIAZINE
REPEAT CT SCAN 2 WK
IF NOT
LYMPHOMA CNS
BIOPSY IT
CAN USE ATOVAQUONE INSTEAD PYRIMETHAMINE
PCP
PCPPr: CD4 200 TMP-SMX BY FAR
USMLE FAVORITES PrSCENARIOS:
ATOVAQUONE IF RASH TMP-SMX
DAPSONE G6PD
PENTAMIDINE AEROSOLIZED LESS EFFICACY
PCP CCS:
IV TMP-SMX IV PENTAMIDINE CLINDAMICINA PRIMAQUINA IF RASH ATOVAQUONE FOR MILD CASES PaO2 70 mm 35 A-a STEROID
NEUROTOXOPLASMOSIS
USMLE FAVORITE
HIV + FND
Pr TOXOPLASMOSIS
CD4 < 100
DO IgG SEROLOGY FOR TOXOPLASMOSIS
GIVE TMP/SMX
RING OR CONTRAST ENHANCING LESIONS
DO IgG SEROLOGY TOXOPLASMA
EMPIRIC
PYRIMETHAMINE + SULFADIAZINE
REPEAT CT SCAN 2 WK
RESOLUTION?
FU
LIFELONG TMP/SMX
D/C IF CD4> 200
RING ENHANCING LESIONS PERSISTS
LYMPHOMA CNS
BIOPSY IT
CAN USE ATOVAQUONE INSTEAD PYRIMETHAMINE
MAI
CD4 < 50 AZITHRO MAI
Pr = AZITHRO 1200 mg ONCE /WK PO
DX ORDER:
BLOOD CULTURE LEAST SENSITIVITY
BONE MARROW MORE SENSITIVE
LIVE BX THE MOST SENSITIVE
TTX- CCS MAI AZYTHROMICIN OR CLARYTHROMCIN INSTEAD RIFAMPICIN ETHAMBUTOL ADD RIFABUTIN
PPD >5 mm
EVALUATE AND TREAT FOR EITHER ACTIVE OR LATENT TB
SIGHT THREATENING CMV
ORAL CANDIDIOSIS/ESOPHAGI
DX: DILATED FUNDOSCOPIC EXAM ORDER: IV GANCICLOVIR : LOW WBC FOSCARNET :HIGH CREATININE
Pr VALGANCYCLOVIR UNLESS HART CD4 RISES
PO FLUCONAZOL
PO DIFLUCAN REFRACTORY PERSISTENT
HIV < 50
HA FEVER
NECK STIFFNESS AND FOTOPHOBIA
DX:
CSF ANALYSIS : LYMPHOCYTES SENSITIVITY INDIA INK 60% CRYPTOCOCAL ANTIGEN 95%
AMPHOTERICINE + 5 FC FOLLOWED BY FLUCONAZOL
Pr LIFELONG FLUCONAZOL UNLESS CD4 RAISES
PME
HIV< 50 BEST NEXT STEP MRI-CT SCAN FOR WHITE MATTER LESIONS PCR CSF FOR CJ HAART
INFECTIVE ENDOCARDITIS
MAJOR CRITERIA 2 BLOOD CULTURES + POSITIVE ECHO = INFECTIVE ENDOCARDITIS BEST NEXT STEP USMLE: FEVER+ NEW MURMUR+ BLOOD C S IF BLOOD CS POSITIVE DO ECHO-CARDIOGRAM IF TTE ECHO IS NEGATIVE DO TEE SENSITIVITIES 60% VS 95% SPECIFICITY EQUAL 95%
USMLE MYTH FAVORITES
COXIELLA
BARTONELLA
ARE MCC CULTURE NEGATIVE ENDOCARDITIS THAN HACEK
CLOSTRIDIUM SEPTICUM MCC THAN STREP BOVIS ORDER COLONOSCOPY
ENDOCARDITIS TTX MCO: S aureus MRSA VIRIDANS Strep
DO 4-6 WK IV TTX
DO NOT NEED TO COVER GNR
EMPIRIC: VANCO+GENTA OR (CEFTRIAXONE)
LEARN ONE: IN MRSA VANCO DAPTOMICIN IN MSSA NAFCILLIN
ONLY CARDIAC DEFECTS THAT NEEDS PROPHYLAXIS
DENTAL PROCEDURES THAT CAUSES BLEEDING
RESPIRATORY TRACT
SURGERY OF INFECTED SKIN
TRANSPLANTS PATIENT WHO DEVELOPED VALVULAR DZ
PROSTHETIC VALVES
UNREPAIRED CARDIAC CYANOTIC MALFORMATIONS
PREVIOUS ENDOCARDITIS
DOC:
AMOXICILLIN
ALLERGIES: CLINDAMYCIN or AZITHRO/CLARITHRO
JUST RASH: CEPHALEXIN
TO MUCH INFORMATION FOR ONLY ONE CARD
RECREAR MEJOR ESTO
ULTRA HY INFECTOLOGY
Aedes Mosquito: Chikungunya Dengue and Yellow Fever
NST: No specific treatment
HF: Hemorrhagic fever
IC: Inmunocompromising
Criptococcus Neoformans resistant to Echinocandins Caspofungin Micafungin Candida auris is resistant to Fluconazol Voriconazol
TULAREMIA TRICHINELLOSIS Under-cooked meat Myalgia Dx (Eosinophils + CK MM + ELISA) Albendazol Mebendazol PLAGUE Fever HA Myalgia Massive LAD Buboes Aspirate MAC Culture Streptomycin Gentamycin Doxycicline. Lung is fatal STRONGILOIDES CYSTICERCOSIS Albendazol BRUCELLAS CHAGAS ANTHRAX BARTONELLA
TICK: RMSF LYME BABESIA ERLICHIA/ANAPLASMA MALARIA
FUNGAL AND ATYPICAL
NOCARDIA ACTYNOMICES HYSTOPLASMOSIS COCCIDIOMYCOSIS BLASTOMYCOSIS MUCORMYCOSIS DKA Deferoxamine Surgery + IV Amphotericin FU: Posaconazol Isavuconazol ASPERGILLUS CANDIDA auris Bloodstream IC Resistant Fluconazol Voriconazol Tx: Echinocandins Caspofungin Micafungin
TROPICAL DISEASE AND PARASITES
DENGUE HF NST ELISA
EBOLA HF Airborne? NO!!! Direct Contact PCR
CHIKUNGUYA RNA virus Toga Aedes Joint Pain Arthralgia y Rash PCR NST
ZIKA Microcephaly GB association Acetaminophen and Fluids NST
CRIMEAN CONGO RNA HF Ticks ELISA PCR Rivabirin
LEISHMANIOSIS Direct + PCR to confirm liposomal Anphothericine Miltefosine
ECHINOCOCCUS Albendazol Alcoholization cyst
BEDBUG
MID EASTERN RESPIRATORY SYNDROME Coronavirus Airborne Middle East Arabia Saudi ARDS fatal
CHOLERA OK
LYME
CAMPING / HIKING + RASH = LYME = DOXYCICLINE
RASH IS ENOUGH
PO alternatives: Pregnant: Amoxicillin Cefuroxime
MANIFESTATIONS NEED CONFIRMATION:
IgM IgG ELISA confirm WESTERN BLOT OR PCR
JOINT
CARDIAC
CNS
4 USMLE:
RASH JOINT BELL PALSY DOXYCICLNE
CNS OR CARDIAC (AV BLOCK) CEFTRIAXONE
MALARIA
MILD MALARIA AND Pr MALARIA :
MEFLOQUINE Neuropsychiatric effects bradycardia and QT prolongation
ARTOVAQUONE/PROGUANIL
IV QUININE/DOXYCICLINE
TREAT SEVERE MALARIA WITH ARTEMISINS DERIVATES ARTEMETHER ARTHESUNATE AS IV QUININE PROLONGS QT AND HAS LESS EFFICACY
SEVERE MALARIA: ARTEMETHER ARTHESUNATE
PARASITEMIA > 5 % HYPOGLYCEMIA CNS HIGH CREATININE METABOLIC ACIDOSIS
USMLE FAVORITE:
G6PD BEFORE PRIMAQUINE
REMEMBER DAPSONE IN PCP
ANTIBIOTICS
ANTIVIRALS
ANTIFUNGALS
/
LADDER FOR STAPH STREP
CELL WALL PETIDO GLICAN
D Ala-D Ala: TELAVANCIN DELVAVANCIN ORITAVANCIN= VANCOMYCIN
PBP = PCN CEPHALOSPORINS CARBAPENEM MONOBACTAM (EXCEPTION AZTREONAM)
RIBOSOMAL BUY AT 50 CELL AT 30
AMINOGLICOSIDE
TETRACICLINES
CLINDA
ERITHRO
LINEZOLID
QUINOLONES DNA GYRASE TOPOISOMERASE II = ETOPOSIDO TOPO I
TELAVANCIN DELVAVANCIN ORITAVANCIN
TMP-SMX: - FOLATE DHFR INHIB
MSSA
OXACILLIN
NAFCILLIN
CEPHAZOLIN
MRSA
BLOOD STREAM: LINEZOLID: LOW PLATELETS DAPTOMICIN: MYOPATHY VANCOMICIN CEFTAROLINE
MINOR CLINDAMICIN TMP-SMZ DELAFLOXACIN TIGECYCLINE
ESBL HA INFECTIONS CARBAPENEM CEPHALOSPORIN BETALACTAMASE INHIB CEFOLOZANE-TAZO CEFTAZIDIMA-AVIBACTAM
STREPTOCOCCUS
PCN
AMPICILLIN
AMOXICILLIN
GEMIFLOXACINO
DELAFLOXACINO
QUINOLONE FOR PNA
MRSA SKIN
GNR
LADDER FOR GNR ESSENTIALLY EQUAL EFFICACY
CEFEPIME
CEFTAZIDIMA
PIPERACILINA
TICARCILINA
AZTREONAM
CIPROFLOXACINO
LEVOFLOXACINO
MOXIFLOXACINO
GEMIFLOXACINO
GENTAMYCIN
TOBRAMYCIN
AMIKACIN
IMIIPENEM
ERTAPENEM
MEROPENEM
DORIPENEM
ANAEROBES
BELLOW DIAPHRAGM
METRONIDAZOL
SAME EFFICACY THAN METRONIDAZOL:
CARBAPENEM: IMIPENEM SEIZURES
TICARCILINA
PIPERACILLIN
ONLY CEPHALOSPORIN COVERS ANAEROBES CEFOXITINA
CEFOTETAN
ABOVE DIAPHRAGM:
RESP ANAEROBES STREP
CLINDAMYCIN
HPV
Papanicolau
Liquid base cytology
For woman > 30 YO combine Liquid Cytology with HPV DNA testing
3 YEARS AFTER THE ONSET OF SEXUAL INTERCOURSE OR 21 YO WHICHEVER EARLIER
IF 3 CONSECUTIVE NEGATIVES CONSIDER INCREASING THE INTERVAL BETWEEN CYTOLOGY SCREENING 2 TO 3 YRS IF NOT CIN 2 OR CIN 3 -IMMUNE COMPROMISE -HIV INFECTION OR IN UTERO EXPOSITION TO DIETILETHILBESTROL
DO NOT SCREEN WOMAN WHO ARE NEGATIVE FOR BOTH HP DNA AND CYTOLOGY BEFORE 3 YRS
REPEAT HPV DNA TESTING AND CYTOLOGY
EVERY 6 -12 MONTHS IN HIGH RISK WOMAN OR HPV DNA POSITIVE.
DISCONTINUE:
HYSTERECTOMY FOR BENIGN PROCESS OR 65 TO 70 YO WITH NEGATIVE RECENT ADEQUATE CERVICAL CYTOLOGY SCREENING
CCS CASE
ACUTE RETRO VIRAL SYNDROME
DIFFERENTIAL DX
INFECTIOUS MONONUCLEOSIS-LIKE CASE SECONDARY SYPHILIS ACUTE EARLY HEPATITIS B or A INFLUENZA ACUTE TOXOPLASMOSIS ROSEOLA ACUTE HSV INFECTION STILL DISEASE
SCREEN FOR
VDRL / RPR
CHLAMYDIA
GONORRHEA DNA PROBE NAAT URINE
BASELINE GENOTYPE
HAART IS OPTIONAL IN ARS
DON’T FORGET CCS 2 MIN SCREEN
HEPATITIS A HEP B
PNEUMOCOCCAL VACCINES EVERY 5 YR
INFLUENZA ANNUAL
NOTIFY HEALTH PUBLIC
HIV SUPPORT GROUP
SAFE SEX
TREAT PARTNER
PREVENTING MOTHER CHILD TRANSMISSION
USE C-SECTION
NO BREASTFEEDING ONLY FORMULA FEEDING
HAART THERAPY DURING PREGNANCY AND LABOR
MENINGITIS
CCS APPROACH
VANCOMYCIN + CEPHALOSPORIN THIRD GENERATION CEFTRIAXONE CEFEPIME CEFTAZIDIME MEROPENEM
COVER LISTERIA MONOCYTOGENA IN >50 YO AND < 1 MONTH
IV AMPICILLIN
ORDER
BLOOD CULTURES AND LUMBAR PUNCTION STAT
AVANCE CLOCK 1 MIN
NOT IN THE SAME SCREEN
DEXAMETHASONE 15 MIN BEFORES 1 ST DOSE OF EMPIRIC ANTIBIOTICS
ORDER
PROTEIN GLUCOSE CELL COUNT GRAM STAIN AND BACTERIAL CULTURES
CSF PCR FOR ENTEROVIRUS AND HSV IF BACTERIAL GRAM STAIN AND CULTURE ARE NEGATIVE “ASEPTIC MENINGITIS”
CT SCAN BEFORE LP IF:
IMMUNE COMPROMISED HISTORY OF CNS DISEASE NEW ONSET SEIZURE PAPILEDEMA ALTERED LEVEL OF CONSCIOUSNESS FND
NEGATIVE CT SCAN»_space;> PERFORM LUMBAR PUNCTURE
CSF ANALYSIS:
CSF FINDINGS CONSISTENT WITH BACTERIAL MENINGITIS
CONTINUE OR STOP ABXS
NEUTHROPENIA FEBRILE
ABSOLUTE NEUTROPENIA < 500
COVER GRAM NEGATIVE WITH CEFEPIME OR IMIPENEM
IF VERY CRITICALLY ILL OR MRSA RISK ADD VANCOMYCIN
IF NO RESPONSE I 48 HOURS ADD ANTIFUNGALS
NEUTHROPENIA FEBRILE
ABSOLUTE NEUTROPENIA < 500
COVER GRAM NEGATIVE WITH CEFEPIME OR IMIPENEM
IF VERY CRITICALLY ILL OR MRSA RISK ADD VANCOMYCIN
IF NO RESPONSE I 48 HOURS ADD ANTIFUNGALS
