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Infectious Diseases - MTB Flashcards

1
Q

B-lactam antibiotics

A
  • Penicillins
  • Cephalosporins
  • Cabapenems
  • Aztreonam
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2
Q

Penicillin: coverage

A
  • Strep viridins
  • S. pyogenes
  • Oral anaerobes
  • Syphillis
  • Leptospira
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3
Q

Ampicillin and amoxicillin: coverage

A
  • Penicillin bugs (S. viridins, S. pyogenes, Oral anaerobes, syphillis, leptospira)
  • E.coli
  • Lyme disease
  • Gram- negative bacilli
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4
Q

Amoxillin coverage

A

HELPS

  • H. influenzae
  • E.coli
  • Listeria
  • Proteus
  • Salmonella
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5
Q

Penicillin is the best initial therapy for?

A
  • Otitis media
  • Dental infection and endocarditis prophylaxis
  • Lyme disease limited to rash, joint, and CN VII
  • UTI
  • Listeria monocytogenes
  • Enterococcus infections
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6
Q

Penicillinase- resistant penicillins

A
  • Oxacillin
  • Cloxacillin
  • Dicloxacillin
  • Nafcillin
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7
Q

Penicilinase-resistant penicillins: Treatment

A

Skin infxns: cellulitis, impetigo, erysipelas
Endocarditis: Meningitis and Staph bacteriemia
Osteomyelitis and Septic arthritis
Not active against MRSA

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8
Q

Why is methicillin never the right answer?

A

Causes renal failure from allergic interstitial nephritis

- really means oxacillin sensitive or resistant

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9
Q

Penicillin drugs that cover gram negative bacilli (E.coli and Proteus) and pseudomonas

A
  • Piperacillin
  • Ticarcillin
  • Alzlocillin
  • Mezlocillin
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10
Q

Piperacillin, Ticarcillin, Alzocillin, Mezlocillin: best initial therapy for

A
  • Cholecystitis and ascending cholangitis
  • Pyelonephritis
  • Bacteremia
  • Hospital acquired and ventilator associated pneumonia
  • Neutropenia and fever
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11
Q

Which organisms are resistant to all forms of cephalosporins?

A
  • Listeria
  • MRSA
  • Enteroccocus
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12
Q

All cephalosporins cover will organisms

A
  • Group A Strep
  • Group B Strep
  • Group C Strep
  • Strep viridins
  • E. coli
  • Klebsiella
  • Proteus mirabilis
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13
Q

If pt complains of a rash when he takes penicillin?

A

Cephalosporins

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14
Q

If patient complains of anaphylaxis when he takes penicillin? Next step?

A

Non B-lactam antibiotic

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15
Q

1st generation cephalosporins: treatment

A
  • Staphylococci: METHICILLIN SENSITIVE = OXACILLIN SENSITIVE = CEPHALOSPORIN SENSITIVE
  • Streptococci (except Enterococcus)
  • Some gram (-) bacillin: E. coli NOT Pseudomonas
  • Osteomyelitis, septic arthritis, endocarditis, cellulitis
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16
Q

1st generation cephalosporins

A
  • Cefazolin
  • Cephalexin
  • Cephradrine
  • Cefadroxyl
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17
Q

2nd generation cephalosporins

A
  • Cefotetan
  • Cefoxitin
  • Cefaclor
  • Cefprozil
  • Cefuroxime
  • Loracarbef
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18
Q

2nd generation cephalosporin: coverage

A

Skin: MSSA = oxacillin sensitive = cephalosporin sensitive
Streptococci (except Enterococcus)
Gram (-) bacilli
Anaerobes
Osteomyelitis, Septic arthritis, Endocarditis, Cellulitis

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19
Q

When is cefotetan or cefoxitin the best initial therapy?

A

Pelvic inflammatory disease (PID) combined with doxycycline

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20
Q

Cefotetan and cefoxitin: adverse effects

A

Increase risk of bleeding and give disulfiramlike reaction w/ alcohol

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21
Q

When is cefuroxime, loracarbef, cefprozil, cefaclor the best initial therapy?

A

Respiratory infections such as bronchitis, otitis media, and sinusitis

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22
Q

3rd generation cephalosporins

A
  • Ceftriaxone
  • Cefotaxime
  • Ceftazidime
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23
Q

Ceftriaxone

A
  • 3rd generation cephalosporin
    1st line for pneumoccocus
  • treats meningitis, CAP (w. macrolides)
  • Lyme involving the heart or brain
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24
Q

Why do you avoid ceftriaxone in neonates?

A

Impaired biliary metabolism

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25
Q

Cefotaxime: uses

A
  • superior to ceftriaxone in neonates

- spontaneous bacterial peritonitis

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26
Q

Ceftazidime coverage

A

Pseudomonal coverage

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27
Q

Ceftaroline

A
  • 1st cephalosporin to cover MRSA
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28
Q

4th generation cephalosporin

A

Cefepime

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29
Q

Cefepime

A
  • 4th generation cephalosporin
  • has better Staph coverage compared to 3rd gen cephalosporins
  • used to treat neutropenia and fever
  • ventilator associated pneumonia
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30
Q

Cefoxitin and cefotetan: adverse effects

A

Deplete prothrombin and increase risk of bleeding

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31
Q

Carbapenems

A

Imipenem
Meropenem
Ertapenem
Doripenem

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32
Q

Carbapenems: mechanism of action

A

inhibit cell wall synthesis by binding to penicillin binding proteins

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33
Q

Carbapenem coverage

A

Gram (-) bacilli, including many that are resistant, anaerobes, streptococci, and staphylococci
- used to treat neutropenia and fever

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34
Q

How does ertapenem differs from other carbapenems?

A
  • does not cover Pseudomonas
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35
Q

Aztreonam

A
  • only drug in the class of monobactams
  • exclusively for gram- negative bacilli including Pseudomonas
  • no cross reaction w/ penicillin
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36
Q

Fluoroquinolones

A
    • block DNA topoisomerases
  • Ciprofloxacin
  • Gemifloxacin
  • Levofloxacin
  • Moxifloxacin
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37
Q

Best therapy for community acquired pneumonia, including penicillin-resistant pneumococcus

A

Fluoroquinolones (e.g ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin)

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38
Q

Fluoroquinolones: uses

A
  • gram negative rods for urinary and GI tracts (including Pseudomonas)
  • best tx for CAP
  • Neisseria
  • Some gram positive organisms
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39
Q

Fluoroquinolone: treatment uses

A
  • Diverticulitis and GI infxns (must be combined w metronidazole) b/c they don’t cover anaerobes
  • MOXIFLOXACIN can be used as single agent for diverticulitis and doesn’t need metronidazole
  • CIPROFLOXACIN for cystitis and pyelonephritis
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40
Q

Fluoroquinolones: adverse effects

A
  • BONE GROWTH ABNORMALITIES: in children and pregnant women
  • TENDONITIS and Achilles tendon rupture
  • Gatifloxacin removed b/c glucose abnormalities
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41
Q

Aminoglycosides

A

Gentamicin, Tobramycin, Amikacin

  • inhibit formation of initiation complex and cause misreading of mRNA
  • require oxygen for uptake thus ineffective w/ anaerobes
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42
Q

Aminoglycoside coverage

A
  • gram (-) bacilli (urine, bowel, bacteremia)
  • synergistic w/ B-lactam antibiotics for enterococci and staphylococci
  • not effective against anaerobes since need to oxygen to work
  • NEPHROTOXIC AND OTOTOXIC
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43
Q

Doxycycline

A

Bacteriostatic: bind to 30S and prevent attachment to aminoacyl-tRNA
- fecally eliminated and can be used in patients w/ renal failure

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44
Q

Doxycycline

A
  • Chlamydia
  • Lyme disease limited to rash, joint or CN VII palsy
  • Ricksettia
  • MRSA of skin and soft tissue
  • Primary and secondary syphillis in those allergic to penicillin
  • Borrelia, Ehrlichia, and Mycoplasma
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45
Q

Doxycycline: adverse effects

A
  • Tooth discoloration (children)
  • Fanconi syndrome (type II RTA proximal)
  • Photosensitivity
  • Esophagitis/ulcer
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46
Q

Nitrofurantoin : indication

A

Cystitis especially in pregnant women

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47
Q

Trimethoprim/Sulfamethoxazole

A
  • Cystitis
  • Pneumocystis pneumonia treatment and prophylaxis
  • MRSA of skin and soft tissue (cellulitis)
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48
Q

Trimethoprim/Suldamethoxazole: adverse effects

A
  • Rash
  • Hemolysis (with G6PD deficiency)
  • Bone marrow suppression (b/c folate antagonist)
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49
Q

Beta-lactam/B-lactamase combinations

A
  • Amoxicillin/clavulanate
  • Ticarcillin/ clavulanate
  • Ampicillin/ Sulbactam
  • Piperacillin/Tazobactam
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50
Q

Beta-lactamase coverage

A
  • against sensitive staphylococci to these agents
  • cover anaerobes
  • first choice for mouth and GI abscess
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51
Q

Best initial therapy for gram positive cocci

A
  • Oxacillin, Cloxacillin, Dicloxacillin, Nafcillin
  • 1st gen cephalosporins: cefazolin, cephalexin
  • Fluoroquinolones
  • Macrolides (e.g. azithromycin, erythromycin) - 3rd line
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52
Q

Oxacillin (Methicillin-Resistant) Staphylococcus

A

Best treated with:

  • vancomycin
  • linezolid: reversible bone marrow toxicity
  • daptomycin: elevated CPK
  • tigecycline
  • ceftraroline
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53
Q

Minor MRSA infections of skin are treated w/

A
  • TMP/SMX
  • Clindamycin
  • Doxycycline
  • Linezolid
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54
Q

Anaerobes

A

Oral (above diaphragm)

  • Penicillin (G, VK, ampicillin, amoxicillin)
  • Clindamycin

Abdominal/ gastrointestinal
- Metronidazole, beta-lactam/lactamase combinations

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55
Q

Gram Negative Bacilli

e.g. E.coli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Citrobacter

A
  • cause infections of bowel (peritonitis, diverticulitis)
  • urinary tract (pyelonephritis)
  • liver (cholecystis, cholangitis)
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56
Q

Gram- negative bacilli: treatment

A
  • Quinolones
  • Aminoglycosides
  • Carbapenems
  • Piperacillin, Ticarcillin
  • Aztreonam
  • Cephalosporins
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57
Q

Most appropriate tx for E.coli bacteremia.

A
  • Quinolones
  • Aminoglycoside
  • Carbapenems
  • Piperacillin, Ticarcillin
  • Aztreonam
  • Cephalosporin
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58
Q

Pt presents w/ fever, stiff neck, photophobia, meningismus. Likely dx?

A

Meningitis

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59
Q

Pt presents with fever and confusion. Likely dx?

A

Encephalitis

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60
Q

Pt presents with fever and focal neurological findings. Likely dx?

A

Abscess

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61
Q

Meningitis

A
  • infection or inflammation of covering or meninges of CNS
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62
Q

Common causes of meningitis

A
  • S. pneumonia (60%)
  • Group B Strep (14%)
  • Haemophilus influenzae (7%)
  • N. meningitides (15%)
  • Listeria (2)
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63
Q

Meninigitis bug associated with neurosurgery

A

S. aureus

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64
Q

Meningitis: presentation

A
  • Fever, headache, neck stiffness (nuchal rigidity) and photophobia
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65
Q

Meningitis with AIDS patient < 100 CD4 cells. Likely organism?

A

Cryptococcus

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66
Q

Meningitis with camper/hiker, rash shaped like target, joint pain, facial palsy, tick remembered in 20%. Likely organism?

A

Lyme disease

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67
Q

Meningitis w/ camper/hiker, rash moves from arms/legs to trunk, tick remembered in 60%. Likely organism?

A

Rocky Mountain spotted fever (Ricksettia)

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68
Q

Meningitis w/ pulmonary TB in 85%. Likely organism?

A

Tuberculosis

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69
Q

Meningitis with no presentation.

A

Viral

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70
Q

Meningitis in adolescent with petechial rash. Likely organism?

A

Neisseria

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71
Q

Best initial and most accurate test for meningitis

A

Lumbar puncture

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72
Q

Bacterial meningitis: CSF

A
  • 1000s, neutrophils
  • elevated protein
  • decreased glucose
  • stain: 50 - 70%
  • culture: 90%
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73
Q

Cryptococcus, Lyme, Ricksettia: CSF

A
  • 10s - 100s lymphocytes
  • possibly elevated protein
  • possibly decreased glucose
  • negative stain and culture
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74
Q

Tubercolosis: CSF

A
  • 10s - 100s lymphocytes
  • markedly elevated protein
  • may be low glucose
  • negative stain and culture
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75
Q

Viral meningitis: CSF

A
  • 10s - 100s lymphocytes
  • usually normal protein
  • usually normal glucose
  • negative stain and culture
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76
Q

When is head CT the best initial test for meningitis?

A

Head CT prior to an LP only if there is the possibility that a space occupying lesion may cause herniation

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77
Q

Head CT first when any of the following present:

A
  • Papilledema (blurred, fuzzy disc margin from intracranial pressure)
  • Seizures
  • Focal neurological abnormalities
  • Confusion interfering w/ neuro examination
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78
Q

If there is a contraindication to immediate LP in meningitis patients, what’s the next step?

A

Antibiotics

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79
Q

Bacterial Antigen Detection (Latex Agglutination Tests)

A
  • similar to gram stain
  • antigen detection methods are positive, they are specific
  • if antigen detection methods are negative, person could still have infecition
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80
Q

When is a bacterial antigen test indicated?

A

Pt has received antibiotic prior to LP and culture may be falsely negative

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81
Q

What is the most accurate test for TB meningitis

A
  • Acid fast stain and cx on 3 high volume LP
  • centrifuge the specimen to concentrate the organisms
  • has highest CSF protein level
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82
Q

Most accurate for Lyme and Rickettsia meningitis?

A

Specific serologic testing
ELISA
Western blot
PCR

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83
Q

Most accurate test for cryptococcus meningitis

A 
India ink (60 - 70% sensitive)
Cryptococcal antigen is more than 95% and specific
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84
Q

Most accurate test for viral meningitis

A

Generally a diagnosis of exclusion

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85
Q

Best initial treatment for bacterial meningitis

A
  • Ceftriaxone, vancomycin, and steroids
  • base your treatment answer on cell count*
  • *** Gram stain is good if positive, protein and glucose levels are too nonspecific **
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86
Q

Thousands of neutrophils on CSF. Tx?

A

Ceftriaxone, Vancomycin, and Steroids

- add ampicillin if immunocompromised for Listeria

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87
Q

Listeria monocytogenes

A
  • resistant to all cephalosporins but sensitive to penicillins
  • add ampicillin to ceftriaxone and vancomycin if case describes risk factors for Listeria
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88
Q

Risk factors for Listeria monocytogenes

A
  • Elderly
  • Neonates
  • Steroid use
  • AIDS or HIV
  • Immunocompromised
  • Pregnant
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89
Q

Neisseria meningitides: Additional management

A
  • ceftriaxone
  • respiratory isolation
  • rifampin, ciprofloxacin, or ceftriaxone to close contacts (household contacts, kissing, or sharing cigarettes, or eating) to decrease nasopharyngeal carriage
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90
Q

Man comes to ED with fever, severe headache, neck stiffness and photophobia. On exam, he is found to have weakness of is left arm and leg. Most appropriate next step in management of patient?

A

Ceftriaxone, vancomycin, and steroids

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91
Q

Most common neuro deficit of untreated bacterial meningitis

A

Eighth cranial nerve deficit or deafness

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92
Q

Encephalitis

A
  • acute onset of fever and confusion
  • herpes simplex is by far the most common cause
  • must do head CT first b/c of presence of confusion
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93
Q

Most accurate test for herpes encephalitis?

A

PCR of CSF

** blood serology from routine cold sore, genital herpes, or encephaltis**

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94
Q

Encephalitis: Treatment

A

Acyclovir - best initial therapy for herpes encephalitis

** Foscarnet used in acyclovir-resistant herpes**

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95
Q

Woman is admitted for herpes enecephalitis confirmed by PCR. After 4 days of acyclovir her creatinine level begins to rise. Most appropriate next step in management?

A

Reduce the dose of acyclovir and hydrate

– can’t use foscarnet because has more renal toxicity

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96
Q

Otitis Media

A
  • presents with redness, immobility, bulging, and decreased light reflex of tympanic membrane
  • pain is common
  • decreased hearing and fever also occur
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97
Q

Most sensitive physical finding for otitis media?

A

Immobility

- fully mobile TM essentially excludes otitis media

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98
Q

Otitis Media: Diagnostic Tests

A
  • Tympanocentesis - if there are multiple recurrents or if no response to multiple abx
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99
Q

Otitis Media: Treatment

A

Amoxicillin (best initial therapy)

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100
Q

If patient w/ otitis media doesn’t respond to amoxicillin, what’s the next best therapy?

A
  • Amoxicillin/ clavulanate
  • Azithromycin, clarithromycin
  • Cefuroxime, loracabef
  • Levofloxacin, gemifloxacin, moxifloxacin
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101
Q

34 y/o women presents w/ facial pain, discolored nasal discharge, bad taste in mouth, and fever. On physical exam, she has facial tenderness. Which of the following is most accurate diagnostic tests?

A

Sinus biopsy or aspirate

  • need microbiological diagnosis for treatment
  • ** never culture nasal discharge **
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102
Q

Sinus biopsy in sinusitis is needed only if:

A
  • infection frequently recurs

- no response to different empiric therapies

103
Q

34 y/o F presents w/ facial pain, a discolored nasal discharge, bad taste in her mouth, and fever. On physical exam, she has facial tenderness What is the most appropriate next step OR action OR management?

A

Amoxicillin/clavulanic acid and decongestant

** Amox/Clav, doxycycline, and TMP-SMX**

104
Q

Pharyngitis

A

Presents w/

  • pain on swallowing
  • enlarged lymph node in neck
  • exudate in the pharynx
  • fever
  • no cough and no hoarness
    • when these features are present, likelihood of step exceeds 90%**
105
Q

Pharynigitis: Diagnostic Test

A
  • Rapid strep test
  • when criteria suggesting infection are present, abx are needed until culture
    • Positive strep test = positive pharyngeal culture
106
Q

Pharyngitis w/ small vesicles or ulcers.

A

HSV or herpangina

107
Q

Pharyngitis w. membranous exudates

A

Diphtheria
Vincent angina
EBV

108
Q

Pharyngitis: Treatment

A
  1. Penicillin or AMOXICILLIN (best initial therapy)
  2. Penicillin allergic pts are treated w/ cephalexin if reaction is only a rash. If allergy is anaphylaxis, use clindamycin or macrolide
109
Q

Strep pharyngitis is treated because

A

to prevent rheumatic fever

110
Q

Influenza

A

Presents w/

  • arthralgia/myalgia
  • cough
  • fever
  • headache and sore throat
  • nausea, vomiting, or diarrhea esp in children
111
Q

Most appropriate next step in management for influenza

A

Depends on time course from presentation

- if within 48 hrs: perform nasopharyngeal swab or wash to detect the antigen associated w/ influenza

112
Q

Influenza: Treatment

A
  • < 48 hrs: oseltamivir, zanamivir
  • neuraminidase inhibitors shorten duration of symptoms
    • treat both influenza A and B
  • > 48 hrs: symptomatic treatment only
113
Q

Bloody infectious diarrhea associated w/ poultry

A

Salmonella

114
Q

Bloody infectious diarrhea associated with GBS

A

Campylobacter

115
Q

Bloody infectious diarrhea associated with HUS

A

E.coli 0157:H7

116
Q

Bloody infectious diarrhea associated with second most common cause of HUS

117
Q

Blood infectious diarrhea associated with shellfish and cruise ships

A

Vibrio parahaemolyticus

118
Q

Bloody infectious diarrhea associated with shellfish, hx of liver disease, and skin lesions

A

Vibrio vulnificus

119
Q

Bloody infectious diarrhea associated w/ high affinity for Fe, hemochromatosis, blood transfusions

120
Q

Bloody infectious diarrhea associated w/ white and red cells in stool

A

C. difficile

121
Q

Best initial test for bloody infectious diarrhea

A

Test for blood and leukocytes

- lactoferrin&raquo_space; fecal leukocytes

122
Q

If infectious diarrhea is nonbloody, what are common causes of diarrhea

A
  • Viral
  • Giardia
  • Cryptosporidiosis
  • Bacillus cereus
  • Staphylococcus
123
Q

Giardia: infectious diarrhea

A
  • Camping/hiking and unfiltered fresh water
124
Q

Cryptosporidiosis

A

unbloody infectious diarrhea

- AIDS less than 100 CD4 cells; detect w/ modified acid fast stain

125
Q

Scombroid

A
  • most rapid onset on diarrhea
  • wheezing, flushing, rash
  • found in fish
  • treat with antihistamines
126
Q

Treatment of mild infectious diarrhea

A

Oral fluid replacement

127
Q

Giardia: treatment

A

Metronidazole, tinidazole

128
Q

Cryptosporidiosis: tx

A

Treat underlying AIDS, nitazoxanide

129
Q

Viral diarrhea: treatment

A

Fluid support as needed

130
Q

B. cereus, staphylococcus: treatment

A

Fluid support as needed

131
Q

Hepatitis

A
  • infection of inflammation of liver
132
Q

Hepatitis C

A
  • rarely presents w/ an acute infection and is found as a “silent” infection on blood tests or when patients present with cirrhosis
  • transmitted via sex, perinatal, or blood
133
Q

Hepatitis D

A
  • exists exclusively in those who have active viral replication of Hep B
  • transmitted via sex, perinatal, or blood
134
Q

Hepatitis A

A
  • transmitted via food and water
135
Q

Hepatitis E

A
  • typically the worst in pregnancy, esp among patients from East Asia
  • transmitted via food and water
136
Q

Acute hepatitis: presentation

A
  • jaundice
  • fever, weight loss, and fatigue
  • dark urine
  • hepatosplenomegaly
  • nausea, vomiting, and abdominal test
137
Q

Hepatitis: Diagnostic Tests

A
  • increased direct bilirubin
  • increased ratio of ALT to AST
  • increased alkaline phosphatase
138
Q

Which of following correlates the best w/ an increased likelihood of mortality in acute hepatitis?

A

Prothrombin time

- if elevated, there is markedly increased risk of fulminant hepatic failure and death

139
Q

Best initial diagnostic tests

A

IgM antibody for acute infection

IgG anitbody to detect of resolution of infection

140
Q

Hepatitis C

A
  • assessed w/ PCR for RNA level, which tells the amount of active viral replication
  • PCR are the 1st change as indication of improvement w/ treatment
141
Q

Acute/Chronic Hep B infection

A
  • positive HBsAg
  • positive HBeAg
  • positive IgM or IgF
  • negative HBsAb
142
Q

Hep B: resolved, old, past infection

A
  • negative HBsAg
  • negative HBeAg
  • positive IgG
  • positive HBsAb
143
Q

Hep B: vaccination

A
  • negative HBsAg
  • negative HBeAg
  • negative core antibody
  • positive HBsAb
144
Q

Hep B “window period”

A
  • negative HBsAg
  • negative HBeAg
  • positive IgM, then IgG
  • negative HBsAB
145
Q

Which of the following will become abnormal first after acquiring Hep B infection?

A

Surface antigen

146
Q

Which of the following is the most direct correlate w/ amount or quantity of active viral replication?

A

Envelope antigen

147
Q

Which of the following indicates that a patient is no longer a risk for transmitting infection to another person (active infection has resolved)?

A

No surface antigen

- as long as surface antigen is present, there is still replication

148
Q

Which of the following is the best indication of the need for treatment w/ anti-viral medications in chronic disease?

A

Hep B e-antigen

- strongest indicator of active viral replication

149
Q

Which of the following is the best indicator that a pregnant woman will transmit infection to her child?

A

E-antigen

- perinatal transmission is the most common method of transmission worldwide

150
Q

Hepatitis: Treatment

A
  • Hep A and E resolve spontaneously
  • Hep B becomes chronic in 10% of patients
  • Hep C trated w/ interferon, ribavirin and boceprevir, telaprevir
151
Q

Chronic Hepatitis: Treatment

** chronic = persistence of surface antigen for > 6 months

A
  • if patients have (+) e-antigen and elevated DNA polymerase treat w/ entec
152
Q

Interferon: adverse effects

A
  • Athralgia/myalgia
  • Leukopenia
  • Depression and flu-like symptoms
153
Q

Goal of chronic hepatitis therapy

A
  • Reduce DNA polymerase to undetectable levels

- Convert those patients with e-antigen to having anti-hepaitis e-antibody

154
Q

Liver bx for hepatitis B or hepatitis C

A

If there is active viral replication, fibrosis will progress to cirrhosis

155
Q

Hep C Treatment

A
  • No way to determine duration of infection
  • most patients don’t have acute symptoms
  • goal of therapy is undetectable viral load
156
Q

Urethritis

A
  • look for urethral disharge

- give dysuria w/ urinary frequency and burning]

157
Q

Cystitis

A
  • NO urethral discharge

- give dysuria w/ urinary frequency and burning

158
Q

Best initial test for urethritis

A
  • Urethral swab for Gram stain
  • ## urine testing for nucleic amplification can detect gonorrhea and chlamydia
159
Q

Most accurate test for urethritis

A

Urine culture, DNA probe or nucleic acid amplifications for chlamydia and gonorrhea

160
Q

Causes of urethritis

A
  • Gonorrhea/chlamydia
  • Mycoplasma genitalium
  • Ureaplasma
161
Q

N. gonorrhoae

A
  • causes gonorrhea

- treat with cefixime or ceftriaxone (3rd cephalosporins)

162
Q

Chlamydia

A
  • azithromycin

- doxycycline

163
Q

Cervicitis

A
  • presents with cervical discharge and inflamed “strawberry” cervix on physical exam
  • do nucleic acid amplfication
164
Q

Using cefixime to treat gonorrhea

A
  • cannot be used alone

- must use with azithromycin or doxycycline

165
Q

Pelvic Inflammatory Disease (PID)

A

Presents with

  • lower abdominal tenderness
  • lower abdominal pain
  • fever
  • cervical motion tenderness
  • leukocytosis
166
Q

PID evaluation

A
  • must exclude pregnancy in a woman with lower abdominal pain or tenderness or cervical motion tenderness
167
Q

Pelvic Inflammatory Disease (PID): Diagnostic Test

A
  • Cervical swab for culture, DNA probe, or nucleic amplification confirm PID etiology
  • need to clarify need to treat STD
168
Q

Most accurate test for PID

A
  • Laparoscopy

* * rarely needed – only if diagnosis is unclear

169
Q

PIDL Treatment

A
  • combination of meds for gonorrhea and chlamydia

Inpatient: cefoxitin or cefotetan combined w/ doxycycline

Outpatient: cefriaxone and doxycycline (possibly w/ metronidazole)

170
Q

PID treatment w. anaphylaxis to penicillin:

A

Levofloxacin and metronidazole for outpatient tx

Clindamycin, gentamicin, and doxycycline as inpatient

171
Q

Ulcerative genital disease w/ painless ulcer. Likely dx?

172
Q

Ulcerative genital disease w. painful ulcer. Likely dx?

A

Chancroid (Haemophilus ducreyi)

173
Q

Ulcerative genital disease w/ lymph nodes tender and suppurative. Likely dx?

A

Lymphogranuloma venerum

174
Q

Ulcerative genital disease w/ vesicles prior to ulcer and painful. Likely dx?

A

Herpes simplex

175
Q

Syphillis: Diagnostic Tests

A
  • Dark-field microscopy
  • VDRL or RPR (75% sensitive)
  • FTA or MHA-TP (confirmatory)
176
Q

Chancroid (haemophilus ducreyi): diagnostic tsts

A

Stain and culture on specialized media

177
Q

Lymphogranuloma venereum: diagnostic tests

A

Complement fixation titers in blood

Nucleic acid amplification testing on swab

178
Q

Herpes simplex: diagnostic tests

A

Tzanck prep is the best initial test

Viral culture is the most accurate tests

179
Q

Syphillis: treatment

A

Single dose of IM bethazine penicillin

Doxycycline if penicillin allergic

180
Q

Chancroid (Haemophilus ducreyi): Treatment

A

Azithromycin (single dose)

181
Q

Lymphanogranuloma venereum: treatment

A

Doxycycline

182
Q

Herpes simplex: treatment

A

Acyclovir, valacyclovir, famicyclovir

** Foscarnet for acyclovir-resistant herpes

183
Q

Woman comes to clinic w/ multiple painful genital vesicles. Next step in management?

A

Oral acyclovir

    • topical acyclovir is worthless
    • viral culture is necessary if presentation is clear
184
Q

Primary Syphillis: presentation

A
  • painless genital ulcer w/ heaped indurated edges (it becomes painful if it becomes secondarily infected w. bacteria)
  • painless adenopathy
185
Q

Secondary syphillis: presentation

A
  • rash (palms and soles)
  • alopecia areta
  • mucous patches
  • condylomata lata
186
Q

Tertiary syphillis: presentation

A

NEUROSYPHILLIS
- Meningovascular (stroke from vasculitis)
- Tabes dorsalis (loss of position and vibratory sense)
- General paresis (memory and personality changes)
- Argyll Robertson pupil ( reacts to accomodation, but not light)
AORTITIS (Aortic regurgitation, aortic aneurysm)
GUMMAS (skin and bone lesions)

187
Q

False positive VDRL / RPR

A
  • infection
  • older age
  • injection drug use and AIDS
  • malaria
  • antiphospholipid syndrome
  • endocarditis
188
Q

Primary and secondary syphillis: treatment

A
  • Single IM injection of penicillin

- Oral doxycycline if penicillin allergic

189
Q

Tertiary syphillis: treatment

A

IV penicillin

- desensitize to penicillin if penicillin allergic

190
Q

Jarisch-Herxheimer reaction

A
  • fever and worse symptoms after treatment

- give aspirin and antipyretics; it will pass

191
Q

Genital Warts (Condylomata Acuminata)

A
  • from papillomavirus
  • diagnosed on visual appearance
  • tx w/ cryotherapy w/ liquid nitrogen, surgery for large ones, or “melting” them podophllin or trichloroacetic acid
  • imiquimod = locally applied immunostimulant that leads to sloughing off the lesion
192
Q

Pediculosis (Crabs)

A
  • found on hair-bearing areas (axilla, pubis)
  • causes itching
  • visible on the surface
  • treat w/ premethrin; lindane is equal in efficacy, but more toxic
193
Q

Scabies

A
  • found in WEB SPACES btwn fingers and toes at or at elbows or genitalia
  • found around the nipples or near the genitals
  • BURROWS visible (they dig) but smaller than pediculosis
  • SCRAPE and magnify
  • Treat w/ PREMETHRIN
  • Widespread disease is “crusted” or hyperkeratotic and responds to ivermectin; server disease needs repeat dosing
194
Q

Urinary Tract Infections

A
  • can present with DYSURIA (frequency, urgency, burning) and a FEVER
  • U/A shows INCREASED WBCs
  • E.coli is most common cause
195
Q

Best initial therapy for UTI

A

Quinolones are best initial therapy

196
Q

Anatomic defects lead to UTIs

A
  • Stones
  • Strictures
  • Tumor or prostate hypertrophy
  • Diabetes
  • Foreign body (including foley catheter)
  • Neurogenic bladder
197
Q

Urinary frequency

A
  • multiple episodes of micturation
198
Q

Polyuria

A

increase in the volume of urine

199
Q

Cystitis

A

presents w/ dysuria

  • SUPRAPUBIC PAIN/ discomfort
  • mild or absent fever
200
Q

True or False? Men with UTIs have anatomic abnormalities

201
Q

Best initial test for UTI

A
  • Urinanalysis with more than 10 WBCs
202
Q

Most accurate test for UTI

A

Urine culture

203
Q

UTI: Treatment

A
  • NITROFURANTOIN or fosfomycin
  • TMP/SMX (Bactrim) if local resistance is low
  • Ciprofloxacin - reserved from routine use to avoid resistance
  • Cefixime
204
Q

36 y/o generally healthy woman comes to the office w/ urinary frequency and burning. The U/A shows more than 50 WBCs per HPF. What is the most appropriate next step in management?

A

Nitrofurantoin for 3 days

  • 3 days is enough for uncomplicated cystitis
  • 7 days if there is anatomic anatomic abnormality is found
205
Q

Pyelonephritis

A

dysuria with

  • flank or CVA tenderenss
  • high fever
  • occasionally with abdominal pain from inflamed kidney
206
Q

Pyelonephritis: Diagnostis

A

U/A shows increased WBCs

CT or U/S are done to show anatomic abnormality

207
Q

Pyelonephritis: Treatment

A
  • Ceftriaxone, ertapenem
  • AMPICILLIN and GENTAMICIN until cx results are known
  • Ciprofloxacin (for outpatient treatment)
208
Q

Acute Prostatitis

A

presents with dysuria with

  • perineal pain
  • tender prostate on examination
209
Q

Acute Prostatitis: diagnostic tests and

A

Prostate massage aided urine culture

  • treat the same as you would pyelonephritis
    • ceftriaxone, ertapenem
    • ampicillin and gentamicin
    • ciprofloxacin
210
Q

Chronic Prostatitis: treatment

A

Long term therapy w/ TMP-SMX for 6-8 weeks

211
Q

Perinephric Abscess

A
  • look for pyelonephritis that doesnt resolve with appropriate therapy
  • if pyelonephritis is associated with persistent fever after 5-7 days of therapy, perform imaging study (e.g. CT or U/S)
  • MUST DRAIN ABSCESS
212
Q

Endocarditis

A
  • infection of valve of heart leading to fever and a murmur

- diagnosed with vegetations seen on echo and positive blood cultures

213
Q

Endocarditis: etiology

A
  • risk of endocarditis is proportional to damage of valves
214
Q

Risk factors for endocarditis

A
  • Prosthetic valves have highest risk
  • Regurgitant and stenotic lesions have increased rect
  • Bacteremia caused by injection drug users and S. aureus
  • Dental procedures offer mildly increased, but small risk
215
Q

Endocarditis: presentation

A
  • fever

- new murmur or change in murmur

216
Q

Complication of endocarditis

A
  • Splinter hemorrhages
  • Janeway lesions (flat and painless)
  • Osler nodes (raised and painful)
  • Roth spots in eyes
  • Brain (mycotic aneurysm)
  • Kidney (hematuria, glomerulonephritis)
  • Conjunctival petechiae
  • Splenomegaly
  • Septic emboli to lungs
217
Q

Endocarditis: Diagnostic Tests

A

Blood culture (BEST INITIAL TEST)
TTE
TEE
EKG (may show AV block if dissection into conduction system)

218
Q

Mam comes into ED with fever and murmur. Blood cx grow S. bovis. TTE shows vegetation. Next appropriate step in management?

A

Colonoscopy

- S. bovis associated with colonic pathology (diverticulitis to polyps to colon cancer)

219
Q

Diagnosis of Culture Negative Endocarditis

A
  1. Oscillating vegetation
  2. Three minor criteria
    - Fever > 100.3 F
    - Risk of injection drug use or prosthetic valve
    - Signs of embolic phenomena
220
Q

Best empiric treatment for endocarditis

A

Vancomycin and gentamicin

221
Q

Endocarditis caused by S. viridans: tx

A

Ceftriaxone for 4 weeks

222
Q

Endocarditis caused by S. aureus (sensitive): tx

A

Oxacillin, nafcillin, or cefazolin

223
Q

Endocarditis caused by S. epidermidis or resistant Staphylococcus: tx

A

Vancomycin

224
Q

Endocarditis caused by enteroccocci: tx

A

Ampicillin and gentamicin

225
Q

Treatment of resistant organisms for endocarditis

A
  • Add aminoglycoside and extend duration of treatment
226
Q

Surgical indications for endocarditis

A
  • CHF or ruptured valve
  • Prosthetic valves
  • Fungal endocarditis
  • Abscess
  • AV block
  • Recurrent emboli while on antibiotics
227
Q

Endocarditis with infected prosthetic valve by Staphylococcus

A

Add rifampin

228
Q

Culture negative endocarditis: common bugs

A 
HACEK
- Haemophilus aphrophilus
- Haemophilys parainfluenzae
- Actinobacillus
Cardiobacteruium
- Eikenella
- Kingella
229
Q

Strongest surgical indication for endocarditis

A

CHF and acute valve rupture

230
Q

Most common bugs associated with culture negative endocarditis

A

Coxiella

Bartonella

231
Q

Features needed to establish prophylaxis for endocarditis

A
  1. SIGNIFICANT HEART DEFECT
    - Prosthetic valve
    - Previous endocarditis
    - Cardiac transplant recipient w/ valvuloplasty
    - Unrepaired cyanotic disease
  2. RISK OF BACTEREMIA
    - Dental work WITH BLOOD
    - Respiratory tract surgery that produces bacteremia
232
Q

Best initial management for endocarditis prophylaxis

A

Amoxicillin prior to procedure

- if patient is penicillin allergic, use clindamycin, azithromycin or clarithromycin

233
Q

Procedures that don’t abx prophylaxis area:

A
  • Flexible endoscopies even w/ bx
  • Ob/Gyn proceudures
  • Uro procedures
  • Gi prodecures including ERCP
  • Valvular heart disease including MVP even w/ murmur
  • MR, MS, AR AS, HOCM, and atrial septal defect
234
Q

Lyme disease

A
  • arthropod-borne disease from the spirochete Boriella burdorferi.
  • results most often in a fever and a rash
  • untreated infxn can recur as joint pain, cardiac disease, or neuro disease
235
Q

Lyme disease: etiology

A
  • transmitted by deer tick (Ixodes scapularis) typically in northeast (CT, MA, NY, NJ)
  • most don’t notice tick bite
  • patient recall being outdoors (hiking or camping)
  • ## tick must be attached for > 24 hrs to transmit organism
236
Q

Lyme disease: presentation

A

RASH: 5 - 14 days after bite as target lesion (red round lesion with pale area in center)
JOINT PAIN:
- knee most common joint.
- joint fluid has about 25,000 WBCs
NEURO:
- meningitis, encephalitis, or cranial nerve palsy
CARDIAC:
- damage to myocardium or pericardium (e.g myocarditis or ventricular arrhythmia)

237
Q

Most common neuro manifestation of Lyme disease

A

Bell palsy or seventh cranial palsy

238
Q

Most common cardiac manifestation of Lyme disease

A

Transient AV block

239
Q

Lyme disease: diagnostic testing

A
  • typical target rash is enough to start treatment

- serological testing is enough for joint, neuro, or cardiac manifestations

240
Q

Tx for asymptomatic tick bite for Lyme disease

A

No treatment routinely

241
Q

Tx for Lyme disease rash

A

Doxycycline

Amoxicillin or cefuroxime

242
Q

Tx for Lyme disease: joint, Bells palsy

A

Doxycycline

Amoxicillin or cefuroxime

243
Q

Tx for cardiac and neuro manifesations other than Bells palsy

A

Intravenous ceftriaxone

244
Q

Asymptomatic Tick Bite

A
  • if no Lyme symptoms, then no treatment
245
Q

Indications for treatment of tick bite (single dose of doxycycline)

A
  • Ixodes scapularis clearly identified as tick cause of bite
  • Tick attached longer than 24 - 48 hrs
  • Engorged nypmh-stage tick
  • Endemic area
246
Q

HIV

A
  • retrovirus infecting CD4 cell
  • drop from 600 - 1000 at a rate of 50 to 100 per year in untreated persion
  • depletion of CD4 cell count takes btwn 5- 10 years
247
Q

HIV: Etiology

A

Transmitted through

  • injection drug use with contaminated needles
  • sex, particuarly MSM
  • transfusion (extremely rare since 1985)
  • perinatal
  • needlestick or blood-contaminated sharp instrument injury
248
Q

HIV: Presentation

A
  • infections occur w/ profound immunosuppression when CD4 count fall below 50/ microL
  • ## PCP occurs below 200 / microL or under 14%
249
Q

Infections at increased frequency w/ HIV

A
  • Varicella zoster (shingles)
  • Herpes simplex
  • Tuberculosis
  • Oral and vaginal candidiasis
  • Bacterial pneumonia
  • Kaposi sarcoma
250
Q

Best initial test for HIV

A

ELISA test

- positive test confirmed with Western blot testing

251
Q

HIV: Diagnostic Test

A
  • ELISA Test (Confirmed w. Western blot testing)

- Infected infants diagnosed with PCR or viral culture

252
Q

Diagnosing HIV in infants

A

Infected infants diagnosed with PCR or viral culture

- ELISA testing is unreliable b/c maternal HIV Ab may be present for up to 6 months

253
Q

HIV Viral Load Testing is useful for:

A
  • Measure response to therapy (decreasing levels are good)
  • Detect treatment failure (rising levels are bad)
  • Diagnose HIV in babies
254
Q

Goal of HIV treatment

A

To drive viral load to undetectable (< 50 cells / micro L)

- CD4 counts have more chance to r

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