Internal infectious finals 6th Flashcards
מהם החיידקים האופיינים ל-
IE
**HACEK **
Haemophilus
Aggregatibacter
Cardiobacterium hominis
Eikenella Corrodens
Kingella kingae
+
Staph. aeurus
Enteroccoc
Strep. Viridents
Strep. Galolicitucus (bovis)
המופילוס אגר את הלב ויענקלה מלך
מהם החיידקים האופיינים לאנדוקרדיטיס עם מסתם תותב
בחודשיים האחרונים
חודשיים עד שנה
ומעל שנה
עד חודשיים- Coagulase negetive= Staph epidermedis + satph sapropyticus + Staph aureus, Gram negetive, mushrooms
חודשיים עד שנה- CoNs > Staph aurues
מעל שנה- כמו במסתמים נתיביים, המובילים סטרפים + סטאפ אארוס
איזה חיידק עלול שמזהם את מערכות החימום והקירור בחדר ניתוח עלול להוביל לאנדוקרדיטיס (ולא יצמח בתרבית דם)
Mycobacterium Chimere
איזה 3 קבוצות עיקירות של פתוגנים יכולים לזהם
TAVI
CoNs , Staph. aerus , Enteroccocs
מהו התסמין השכיח ביותר של אנדוקרדיטיס
חום
80-90%
מהם הקריטריונים המאג’ורים של דיוק, מהם באים לאבחן?
Duke
Major (for IE)
1. Positive blood culture
typical microorgnisms- only 2 seperate blood cultures (HACEK + Arus + Strep. galaticus + Strep. viridens , Enteroccoc)
Or
Positive Blood culture > 12 hrs apart / all of 3 or majority of >= 4 seperate blood culture with first and last drawn at least 1 hr apart
Or
single positive Blood culture with Coxiella (Qfever) or phase IgG Ab titer > 1: 800
2. Evidence of Endocardial involvment
Positive Echo- vagitation, abcess, Dehiscence of artificial valve, New regurgitaiton (no preexiting)
מבחינת קרטיריוני דיוק, כמה מספיק לאבחנהה וודאית?
- 2 Major
- 1 Major + 3 minor (from diff. groups)
- 5 minors
what is define as possible IE?
Duke criteria
- 1 Major + 1 minor
- 3 minors
most of the time will be treated as IE
מהו המשך הבירור ברמת חשדת גבוהה ואקוקרדיוגרפיה (TEE)
שלילי?
לחזור על הבדיקה לאחר 7-10 ימים
IE
איזה הדמייה נוכל לבצע בחולה שאינו ניתן לבצע לו TEE?
וחלפו מעל 3 חודשים מניתו במסתם תותב
CTA or PET-CT (pet mostly in pt with artifical valve)
What are the 5 minor criteria of Duke?
- Predisposition- גורמי סיכון כמו מחלה מסתמית, מזריקי סמים
- Fever > 38 C
- Vascular phenomenem- Emboli, Fraction, Bleedings, Janeway lesions, Mycotic anyrusm
- Immunologic phenomenem- Glomerulonephritism Osler’s node, Roth’s spots, Reumatohid Factor
- Microbiological evidence- not meeting major criteria
in IE : TEE and TTE:
- בחשד קליני נמוך ללא ממצאים-
- TTE with IE findings which not High risk-
- High risk pt or high clinical suspect
- TEE negitive with still high clinical supsect?
- בחשד קליני נמוך ללא ממצאים- TTE
- TTE with IE findings which not High risk- TEE
- High risk pt or high clinical suspect- TEE
- TEE negitive with still high clinical supsect- repeat TEE, after 2 TEE»_space; consider PET-CT or CTA
לפי מה נקבע משך הטיפול התרופתי ב-
IE
זמן התעקרות התרביות
מתי נתחיל טיפול אמפירי ב- (כלומר מתי נחליט שמכסים אמפירית)
IE
ואיזה טיפול ניתן ל
מזריקי סמים, מסתם תותב חדש, מסתם נטיבי / תותב מעל שנה, אנדוקרדיטיס עם תריבות שליליות
לא ניתן טיפול אמפירי במטופל יציב המודינאמית שנראה סבבה
במתן טיפול אמפירי
1. מזריקי סמים- ונקומיצין + גנטימצין ./ צפלוספורינים
2. מסתם תותב חדש (פחות משנה)- ונקומיצין + גנטמצין + צפלוספורינים
3. סאב אקוטי עם מסתם נטיבי / תותב מעל שנה- ונקומיצין ורוצפין
4. אנדוקרדיטיס עם תרביות שליליות- ונקומיצין, רוציפין / יוניצין + דוקסיציקלין
מהו הטיפול אנטיובטי לאנדוקרדיטיס ע”י סטרפטוקוקי
חיידק ללא עמידות
Sensetive- Penecillin G / Amoxicillin / Ampicillin / Rochiphin (Ceftriaxone- when no immidiate penicillin elergy)
if pt elergic to penecillin- Vancomycin
For 4weeks
or
Penicillin / Rociphin + gentamycin for 2 weeks- only if theres not risk for nephrotoxicity, artifical valve, complicated IE
מה טיפול בסטרפטוקוקי בעמידות חלקית ועמידות מלאה
Partial resistance- 4wks penecillin / rochephin + gentamycin for 2 wks / Vancomycin - 6 wks
Substential resistance- penecillin / rochephin + gentamycin for 6 wks / Vancomycin - 6 wks
מהו הטיפול באנדוקרדיטיס של סטאפ אארוס + CoNS
MSSA
MRSA
במסתם נטיבי ומסתם תותב
Native valve:
MSSA- Naficillin / Oxycillin /cefazoline (1st generation) if elergic Vancomycin - 4-6 wks
MRSA- Vancomycin / Deptomycin - 6 wks
Artifical valve- Always triple therapy
MSSA- Naficillin / Oxycillin /cefazoline (1st generation) + Rimpamfin 6-8 wks + Gentamycin
MRSA- Same as MSSA juts Vancomycin instead Penicillin / cafazoline.
ההבדל בין מסתם נטיבי ותותב זה בתותב 3 תרופות והמשך 6-8 שבועות לעומת עד 6 שבועות
מבחינת התחלת הטיפול בזיהומים של אנדוקרדיטיס עם MSSA
עם איזו תרופה כדאי להתחיל את הטיפול
Start Tx with Antistaphiloccocl penicillins and switch to cefazoline after few days.
מדוע מוסיפים ריפמפין בזיהומי מסתם תותב?
חודרת ביופילם ומונעת הישנות- נותנים לאחר כמה ימים רק לאחר שהעומס הבקטיראלי יורד (חיידקים מפתחים אליהם עמידות)
התרופה לא עוזרת מבחינת הקלירנס או הטיפול בזיהום הנוכחי
מהו הטיפול באנדוקרדיטיס של
Q fever
ומה נצפה במעקב אחרי טיטר הנוגדנים- אינדיקציה להצלחה?
Doxy + Hydroxychloroquine
at least-
Artifical valve- 24 months
Native valve 18 month
Phase I IgG- reduciton multipe 4
Phase II IgM- become negetive
מהו הטיפול באנדוקרדיטיס ע”י אנטרוקוק?
Penicillin G / Ampicillin + Gentamycin (AG) 4-6 wks
(if penecillin elergic- switch to Vanco) for 6 wks
Enteroccoc Fecalis- Ampi + rochipin - 6wks (less nephrotoxicity)
מהו הטיפול באנדוקרדיטיס של
HACEK
Rociphin or Ampi- sulbactam ( unicyin)- 4 wks
מהי הפרוגנוזה של ווגיטציות באנדוקרדיטיס לאחר 3 חודשי טיפול
50% ישארו באותו גודל
25% יקטנו
25% יגדול מעט
מהי הגישה לאנדוקרדיטיס עם קוצב לב
הוצאת כלל המערכת מהר ככל הניתן- ללא תלות במחולל
ניתן להשתיל חדשה תוך 10-14 יום
מהו הטיפול הפרופילקטי הניתן לפני פרוצדורה דנטלית פולשנית?
מוקסיפן (Amoxicillin) 2 gram 1hr before
for elergic:
1. Clarithromycin
2. Azenil (Azitromycin = macrolide) 500 mg / 3. Doxycycline 100 mg / Cehpalexin (not immidiate reaction to penecillin)
Cannot take OP:
1. Ampicillin- 2g IV/ IM 1 hr before
or (elergic)
2. Cefazolin / Ceftriaxone 1 gr IV/ IM 30 min before
most common pathogen in CAP (Comunnity pneumonia)
Pneumoccoc
most common 3 patohens in Outpatietns, non-ICU, ICU
Pneumonia
Outpt- Pneumoccoc > M.pneumonia > HiB
Non-ICU- pneumoccoc > M. pneumonia, C.pneumonia
ICU- Pneumoccoc > Staph.aureus, Lagionella
Which bacteria love to ceuase pneumonia after Influenza infection?
Staph. aureus
Which patogen a/w pneumotocella? (Lung cavitation)
Staph. arueus
common patohgen for pneumonia in alcholic users
Pneumoccoc, oral anerobes, klabsella, acyntobacter, TB
Which pathogen is a/w pneumonia and birds
Clymedia pystaci, Histoplasma capsolutum
How pneumonia diagnosed?
Clinical presentaiton with new finding on CXR
What is the criteris of good sputum culture? what is the effectivess of this method?
Criteria:
PMN > 25
Squemous cell epithelum < 10
Yelid- only 50% when bactermia is present
only take in HR pt
When we will use PCR in pneumonia
For viral cuases + a-typical
Which pneumonic pathogen can be tested trough urine test
Lagionella- only idnt. serogropu 1 (sens 70%, specif. 90%)
pneumoccoc- sens 70%, sensetivity 90%
could identify pathogen even after Abx Tx started
מהם 2 המדדים לפיהם נקבע האם חולה עם פניאומוניה יאושפז או ינוהל בקהילה?
Pneumonia severiy index (PSI)- prognostic scale to indentify pt with high mortality risk- grouped 1-4, from 3 they will be hospitellized
CURB65- Confusion, urmia > 20, RR > 30, BP 90/60, age > 65
*in CURB65 everything is equal to or above/ under
score 0- realse
Score 1-2 Hospitelized
score > 3- 22% mortality rate. moght need ICU
במצב של פניאומוניה, למעט מדדים:
PSI
CURB65
להחלטה על אשפוז,
אילו 3 מצבים נוספים תתקבל החלטה על אשפוז בכלמקרה?
- Can’t take PO
- Complient might be a problem
- O2 saturaiton < 92% in Room air
What is the common treatment in CAP? (W/co-morbidiy or risk factors)
Amoxicillin + macrolide / Doxycycline
or
Doxycycline (1st option as monotherapy)
or
Macrolide
What is the common treatment in CAP? (with co-morbidiy or risk factors)
Combinataion therapy:
1. Amoxicillin- Calvulanate/ Cefuroxime
2. mono- with flueroquinolone
- Chronic heart, liver, lung, kideny disease, DM, alcoholism, aspleniam, melignency
- Abx treatment in < 3 months
- contact with health services
What is the Tx for inpatient with/without risk factors
Pneumonia
Severe vs non.severe
Everyone will get Beta-lactam + Macrolide or respiratory Fluroauinolone (לא ציפרו ולא אופלו = לא ציפור ולא עוף)
no risk factors- as mention
prior respiratory isloation- add MRSA or pseudomonas coverge
Recent hospetilaziton,
Abx treatment- add MRSA or pseudomonas coverge only if culture is positive
Pseudomonas- Tazo, cefatizim. penem (mero, imi)
MRSA- vanco/ lenazolid
macrolide- azytro, clarithro, beta lactam- ampicillin or sulbactam (unicyn)
Aspiration pneumonia
מתי נכסה אנארוביים?
הגיינה דנטלית ירודה
אבצס ריאתי
נקרוטיזינג פניאומוניה
טיפול:
Ogmentin / clyndamycin- עד לרזולוציה הדמייתית 3-14 שבועות
מהו משך הטיפול ב-
CAP
5 days w/o complicaiton
no metter PO, IV, In-patient or out-patient
MRSA or psuedomonas- prolong treatment
כיצד נגדיר כשלון טיפולי בטיפול בפניאומוניה
אי הגבה לטיפול לאחר 72 שעות
Ventilation Associated pneumonia
When most of them occured after starting of ventilation
most in first 5 days of ventilation
What is the ampiric Tx in VAP?
No risk factors for resistent Gram negetive pathogen Pipercillin- Tazobectem / Cefepime /Levofloxacin
Risk factor- 2 Abx - Pipercillin- Tazobectem / Cefepime /Ceftazedime/ imipenem/ meropene, + Amikacin/ Gentamicin/ Torbamycin/ Ciprofloxaxin/ Levofloxacin/ Colistin /polymyxin
משך הטיפול האנטיביוטי 7-8 ימים
HIV
מהו הסיכון להידבק דרך עירוי דם
מהו הסיכון להדבקה במגע מיני
סיכון הדבקה ללידה באם לא מטופלת
דרך עירוי דם- 92.5%
דרך מגע מיני- < 2%
הדבקה בלידה באם לא מטופלת- 15-25% במדינות מפותחות, 25-35% במדינות מתפתחות
מהו הגורם הסיכון העיקרי להעברת איידס בלידה?
רמת הוירמיה של האם
מהו הסיכון להעברה מהאם ליילוד באישה החולה ב-HIV
תחת טיפול ART
< 1%
ההמלצה לטפל בכל אישה בהריום עם ART
By the CD4 count in HIV,
what are the 3 stages of HIV?
Stage I - CD4 < 500
Stage II- 499-200
Stage III CD4 < 200 - AIDS
What are the AIDS definig illness?
Infectious
* ** Esophagitis / URI- Candida
* CMV- CREEP (Colonitis, retinitis, esophagitis, pulmonitis, Encephalitis)
* Cryoptoccoucos neoformans- meningitis
* HSV- chronic > 1 mont or in Resp.tract or esophagitis
* **Mycobacterium- TB any site, other mycobacteria (MAC**) dissemenited or Extra-pulmonary
* PCP pneumonia- reccurent
* Toxo
* Chronic diarrhea- Cryptosprasium, isosphorea
Malignency:
1. KAposki Sarcoma -HHV8
2. Lymphoma- Burkitt, immunoblastic or Primay CNS lymphoma
3. Cervical carcinoma
Others:
HIV enchepalopathy
PML - JC virus
Wasting syndrome- HIV associated
מה כוללת בדיקת
ELISA 4th generation for HIV?
P24 + IgG + IgM (for virus envelope)
after 2 wks can be detected
sensetivirt 100%, Specifity 99.5%
what the algorithm to diagnose HIV?
4th generation ELISA:
Negetive- done
Positive»_space; return test »_space; if positive »_space; RNA load by Western Blot if positive - HIV
if negetive/ uninclusive- reapet
מהו הבירור הראשוני שמבוצע לאחר אבחנת HIV
- Routine blood work- include glucose and lipids
- CXR
- CD4 + VIral load
- resistence of virus
- Co-infections- STI, Shypilis
- PAP- every year
- Toxo serology- if IgG positive need PPX when CD < 100
-
Viral hepatitis- HAV, HBC, HCV
9. Latent TB- PPD/ IGRA test - HLA B57:01- C/I in Abacavir
- b-HCG- Tx in Efavirenz
What are the 3 major groups of HIV pahramcological Tx?
- NRTI- neculoside RT inhibitor - samse site as necloside attach
- NNRTI- Non-nucleoside RT inhibitor- connect to a different site (not active site) in RT
- INSTI- Integrase strands inhibitors- prevent viral DNA to integrate with host genome
- protease inhibitor- prevent maturation of virus
כיצד ניתן את הטיפול התרופתי ב-HIV
Combination of 2 medications from the NRTI group + Third medication (most common integrase inhibitor)
איזה משלב תרופות של
NRTI
בד”כ מקובל בטיפול ב-HIV
Tenofovir + Emtricitabin
Which HLA is a/w Abacavir and skin adverse effect (rash»_space; steven jhonson or TEN)
HLA B57:01
מהם 2 תופעות הלוואי העיקריות של טנופוביר
(Tenofovir)
- CKD (also Fanconi syndrome= PCT)
- Bone reabsoprtion
Which medication is given for HIV + HBV?
Tenefovir
Lamivudin
Adefovir
Entecavir
HIV- NRTI, NNRTI, Potease inhibitor, INSTI
- מבחינת פיתוח עמידויות:
1. איזו תרופה מאוד לא סלחנית- כלומר מספיק לפספס מנה אחת כדי לפתח עמידות/ מוטציה אחת
2. איזו תרופה מאוד סלחנית - כלומר ניתן לפספס יחסית הרבה ועדיין לא תתפתח עמידות
- NNRTI- תרופה לא סלחנית לפספוס של טיפול ופיתוח עמידויות בקלות
- Protease inhibitors- מאוד סלחנית בטיפול, קו 2 לחולים שנכשלים ומפתחים עמידויות
איזו קבוצת תקופות לטיפול באיידס מהוות קו 2 לחולים שנכשלים ומפתחים עמידות
Protease inhibitors
in which Cytochrome P450 subtype all of HIV protease inhibitor medication are metabolized?
CYP3A4
all of them metabolize + all of them inhibit Cyp3A4
What is the boosting principle when Treating HIV with Protease inhibitor
giving combine PI- Ritonovir + other PI
Inhibit Cyp3A4»_space; elevate Bio-availibilty of the active PI
The following medicaiton are belong to which HIV group type?
Dolbutegravir, Elvitegravir reltegravir
INSTI- all have Tegra = Terra for inTEGRAs
Dolbutegravir- elevete risk for NTD (pregnent womens- early pregnancy)
Elvitegravir
Raltegravie
HIV related:
What is PEP and PREP
which medicaiton include
PEP = pre exposure prophylaxis- נתנת באופן קבוע לאנשים בסיכון להידבק
Tenofovie + Emticitabin
PREP = Post exposure ppx- ניתן עד 72 שעות מהחשיפה פוטנציאלית לוירוס. טיפול זהה לטיפול באיידס= 2 NRTI + 1 integrase inhibitor- for 4 weeks
HIV
What is IRIS?
Immune reconstitution inflammatory syndrome
סיבוך של טיפול רטרו-ויראלי, החמרה במצב סביב התחלת הטיפול
הידרדרות פרדוקסלית כתוצאה מירידה בעומס הויראלי והתאוששות מע’ החיסון שגורמת לתגובה אימונית שלא התאפשרה לאנטיגנים שנשארו בדם מזיהום
more common in HIV pt with low CD4 or with drastic decrease in viral load
HIV
IRIS
whats the treatment?
Mild cases- Symtomatic
Severe- Steroids
PCP and HIV
מתי ניתן טיפול פרופילקטי
מהו הגולד סטנדרט לאבחון
מהו הטיפול
PPx- CD4 <200
Gold standart- Culture from sputum/BAL/ lung biopsy
Tx- Resperim for 21d (s.e- rash and BM deprresion, hyperkalemia)
Blood gas PaO2 < 70 (hypoxemia) - Add steroids
Cryptoccocus neoformans
below which levels of CD4 accour?
Dx?
Tx?
CD4 < 100
CSF stain with india ink- cryptoccocal Ag.
Tx- first stage- Amp B+ Flucytosin 2wks»_space; Amp B alone until negetive CSF cultures»_space; fluconazole until CD4 > 200 for 6months
Toxoplasmosis
Dx?
Tx?
PPx?
Dx- MRI with ring enhencment leisons.defenitive- brain biopsy
Tx- Pyrimethamine + Sulfaiazine + Leucovorin for 4-6wks. until CD4 > 200 for 6 months
PPx- TMP-SMX (Resperim) when CD4 < 100 + positive IgG toxo
Progressive multifocal leukoeneephalapthy (PML)
1. Who is the pathogen
2. Tx?
JC virus
DNA of JC virus in CSF- higlu specific (100%) but less sensetive (76%)
No Tx- only ART to improve prognosis
TB
Diagnosis?
Tx- and the effect on ART Tx.
PPX?
Dx- Culture from involve site. in fulminant disease PPD or IGRA are not trustfall.
Tx- RIPE (ripamfin, Isoniaside, Pyranizamid, Ethembutol) + chekc resistence.
PPx- Positive IGRA / PPD > 5 mm / close contact with active TB - 9 months of isoniaside + pyaniazmid
Starting of ART + TB Tx »_space; IRIS . therefore if CD > 50, we will strart ART after 2-4 wks follow the RIPE Tx. if CD4 < 50- start ART ASAP
HIV
מהו הפרופילקסיס שניתן לכל אחד מהמזהימים הבאים ובאילו רמות של
CD4
PCP
Toxo
MAC
PCP CD4 < 200 - TMP-SMX (resperim). stop when CD4 > 200 for 3 moths
Toxo CD4 < 100 + IgG positive for toxo TMP-SMX. stop when CD4 > 200 for 3 moths
MAC CD4 < 50 Azytromycin . stop when ART start
MAC (mycobacteria avium complex)
CD4 levels when activate?
Dx?
Tx?
PPx?
CD4 < 50
Tx- Macrolide (clarithromycin) + Ethembutol until no symptoms, negetive culture, CD4 > 100 for 3-6 months
PPx- Macrolide in CD4 < 50 who are not starting ASAP ART
When CT/ MRI should be done before LP?
- immunocompremised
- recent Head trauma
- low consinouss levels
- focal nuerologic defecit (inclu. siezures)
CSF in bacterial meningitis:
* Opening pressure
* WBC
* RBC
* Glucose
* CSF/ Serum glucose
* Protein
- Opening pressure > 180
- WBC > 10-10K, PNM dominance
- RBC- abcsent or few
- Glucose < 40
- CSF/ Serum glucose < 0.4
- Protein > 45 mg/dL
empirical Tx for Community acquired meningitis?
Dexa- 20min before Abx started
Chephalosproines- Ceftriaxone / Cefotaxime / Cefepime
Vancomycin
Acyclovir
Ampicillin- Pt > 55yrs or immunocompremised (chronic, transplent, pregnency, malignency. ) ** if elergic- TMP-SMX (resperim)**
if otitis / mastoidits/ sinusitis- metronidazole for gram negetive anerobes
Hospital aquired meningitis Ampiric Tx?
Vancomycin
Ceftazidime / Meropenem
for staph and pseudomonas
What is the common CSF profile seen on viral meningitis?
glucose, cells, opening pressure, protein
Pleocytocis- Lymp dominance
Protein- normal/ slightly eleveted
Glucose normal
opening pressure- slightly eleveted to normal
What is the PPx Tx for close contact of meningocooc?
Rifampim or Azytromycin (macrolide) or Rochipin IM
What is the cheractristics of TB CSF and whats the Tx?
CSF
High opening pressure
WBC- Lymp dominance
High protein
low glucose
Diagnosis- AFB positive , culture from CSF. PCR also recommend
Tx
RIPE
Rifampim
Isoniazide
Pyrazinamide / Pyridoxime
Ethenmbuthol
Pt without HIV will be also given Dexamethasone for 3 weeks
Cryptococcus neoformans (meningitis)
What is the cheractristics CSF and whats the Tx?
CSF
WBC- Lymp dominance
High protein
low glucose
Dx- Cryptoccocal antigen / india ink / culture
Tx
Flucytosine + Amp B - 4 weeks
after
fluconazole - 8 weeks (if HIV- cont. until CD4 > 100)
Which Abx are the with high associations to Clostridium Diff. ?
CACF = קקי כיף
Clindamycin
Ampicillin
Cepalosphorin 2-3
Fluroquinolon
מה % ההשינות של זיהום חוזר בקלוסטרידיום דפיצילי?
15-30%
Which sub-type of C.diff is associaited with increase indicance with increase mortality
NAP1 / BI / 027
what are the criteria to Dx of Colistridum Diff. ?
Diarrhea- 3 or more for at least 4 hours
plus one of the follow:
1. Toxin A/B in stool
2. Stool PCR- pathogenic C.diff species
3. Psuedomembranous appreance
בנוכחות חשד קליני גבוה יש להתחיל טיפול אמפירי
מהו הטיפול לקלוסטרידיום דפיצילי
1. Primary CD
2. Recombinanct / complicated CD
3. Reccurent CD infectios
- primary- 1st line: Fidaxomicin / Vancomycin PO. 2nd line: Fluroquinolone (flahyl) PO
- Recombinant/ complicated- Shock, Toxic Megacolon, Paralytic iluis Vancomycin + IV metronidazole
- Reccurent - Fidaxomicin or Vancomycin (slow tapering for weeks)
מתי נשקול השתלת צואה במטופלים עם קלוסטרידיום?
רק אחרי 2 חזרות למרות טיפול אנטיביוטי
מהו הטיפול האדגונבטי שניתן למטופלים בסיכון גבוה למניעת הישנות של קלוסטירידום?
Bezkitixumab
monoclonal Ab against toxin B
+
Abx treatment (Fidaxomicin most likley)
מהם השיטות לאבחון של שחפת ריאתית?
- Sputum surface (משטח כיח) with Acid fast stainning
- Sputum culture- gold standart- 4-8 weeks until grows + 3 samples
- PCR Xpert MTB/RIF- תוך שעות עם ספציפיות ורגישות קרובה לזאת של תרבית
נוזלי קיבה- באלו שלא מסוגלים לתת כיח, נשלח לתרבית /PCR - יותר FP
מהי בדיקת הסקר המובילה לשלילה של שחפת חוץ ריאתית בפלאורה
ומהי הבדיקה הנדרשת לאבחנה?
ADA- if very low = rule out TB
For Dx- Biopsy of pleura
what is the name of Spinal TB?
Pott’s disease
What is the primary test for suspected HIV + TB infections?
PCR XPERT
Gold Standart is still culture
Which supplament should be given with Isoniazid Abx Tx?
B6 (pyrodoxin)
Which Abx is associated with orange urine ?
Rifampin
Which Abx is associated with Gout?
Pyranizamide
Which Side effect is common to all 3 Abx?
Isoniazid
Rifampin
Pyranizamide
Eleveted liver enzymes
In TB, A resistance to Isoniazid will be replaced by————-
Fluroquinolone
Which Side effect under TB treatment require stop treatment?
Eleveted liver enzymes > 3X + symptoms or >X5
ITP (R)
Gout (Z)
Optic neuritis (E)
RIPE
Which 2 types of Test are used to detect latent TB?
TST (mantu)- low specifity
IGRA- INF-y reaction to specific Ag of TB, more specifity then TST
רגישות נמוכה במדוכאי חיסון, לא יודע להבדיל בין מחלה פעילה ללא פעילה.
Tx for latent TB that Rq Tx?
daily Isoniazid for 6-9 months
טיפול הבחירה, יש עוד אופציות לא נכנסתי
Which pathogens are the only ones that will be positive for nitrates in the urine stick test?
Enterobacteriaceae
when do we start Tx for cystitis in mans and women
womens- classic clinical presentation and based on Hx.
men- if UTI symptoms are present, always take a urine culture. if first UTI + fever = US or CT
Tx for cystitis in:
1. women
2. pregnant
3. men
- women- phosphomycin (1 dose), Resperim (3 days) or Nitroporentoin (P > R > N). 2nd line- beta lactams (Chephalosporins)
- pregnant- Ampicillins / Cepahlosporins (beta-lactams)
- men- quinolones or resperim (SMX- TMP)
Tx for pyelonephritis
PO vs IV
PO- 1st line- Quinolone (if sensetive TMP-SMX can be given = resprim)
IV- Quinolone , Chephalosporin 3-4, with/out aminoglycosides or carbapenem
Unlike Cystitits this ones involve Fever
A man present with fevfer, dysurea, urgency and peri-anal pain
whats the likely diagnosis?
whats the Tx?
acute bacterial Parostatitis
Tx- Quinolone or resperim (TMP-SMX ) 2-4 weeks
like Cystitis treatment in men just there it will be for 7-14 days
Which population should be treated for asymptomatic bacteriruria?
pregnant womens, pt before orologic procedure
posibble- Kidney transplants and neutopenic pt.
Catheter Associated UTI
Tx
Tx:
Switch catheter + Abx Tx based on culture
Which types of Pt can present with Candidurea?
3 main populations
ICU pt
Pt under broad spectrum Abx
Pt with DM
> 50% are non-albicans types
Whats the Tx for candidurea and when we treat
Treat only:
1. symptomatic pts
2. pt with High risk for systemc disease (immunodepressent, unstable.. )
Tx:
1st line- Fluconazole
* if resistance– Flucytosine or Amph B
Whats the Df of reccurent UTI?
And what can be a possible Tx?
2 options of Tx
> 2 episodes in 1 year
Tx:
1. low dose of resperim or Nitroporentoin for 6 months
2. Pt- initiated Therapy- Abx + cup for culture in home. when pt feels episode is started, give urine to culture and start Abx
In which time frame after BM transplation CMV, PCP and toxo are most common?
1-4 months
how long after BM translpent a capsular pathogen infection is most common?
> 6 months
Pneumoccoc
Hib
meningoccoc
* and nocardia- actinomycin and not that capsular
Which infection can inhibit the engrafment of the BM transplent and cause encephalitis?
HHV-6 reactivation
Which systemic menefistaion HSV can casue in BM transplents
Mucositis, Esophagitis, pneumonia
Acyclovir Tx.
What is the Tx for Brain abcess
**IV Abx- **
Community Aqu (immunocompetent)»_space; Chepalosporins 3-4 (Ceftriaxone, cefepim, cefotaxim) +Metronidazole (flagyl)
After brain trauma / surgical- Ceftazidim / meropenem (psuedomonas ) + Vanco (staph)
Surgical drainage
Anti-epileptic Ppx
*if edema or mass effect present- add steroids
LP is C/I
Whats the Tx for Human/ monkey bite?
Beta- lactam + Beta lactamase (augmintin or unicyn)
Every moneky / humen bite rq ppx tx
Whats the most likely Diagnosis?
Monoarthritis with fever with dull sample from involve joint, on test shows WBC > 25K , PMN dominance
Septic arthritis
in 90% of cases only 1 joint would be involve
Which pathogen is the most common for Septic arthritis
Staph Areus
Genoccoc- part of systemic STI
Which pathogen can cause Septic arthritis after surgical procedure / IVDU in spine?
Candida
Which pathogen can cause sub acute/ chronic septic artherits in immunosupressent with involvment of 1 large joint in lower extrimites?
TB
Whats the Tx for non-genoccocal septic artheritis?
- source control- drainge from joint
- Abx:
positive cocci - if MRSA- vanco, otherwise- cephazolin, oxycillin or naficillin
Gram negetive bacilli- Chephalosporins 3 = Ceftriaxone
*at high risk for pseudomonas- cefepim or ceftazidim. in critical pt- Aminoglycosides or Ciprofloxacin (flueroquinolones)
Tx for 2-4 weeks accodring to cultures.
A young pt present with** fever, rash and migratory arthritis**. the pt mentioned she is sexully active and does not use any STI protection.
what is the most likely Dx?
what is the Tx?
Diseminated gonococcal infetion
Tx:Ceftriaxone (rocephin)
if bactria is sensetive- moxipen or quinolone can be use
**add 1 dose of azytromycin for clamydia coverage **
Which site is the most commont site for Osteomyalitis in adults?
Spinal column
What is the most common location of Spinal OM?
Where will we see TB OM?
Lumbar 60% > Thoracic 30% > Cervical 10%
in TB - mostly thoracic
Which are the most common pathogens to acute OM and subacute OM
acute- Staph areus (40-50%), Streptococci 12%
**Sub-acute- ** TB, Brucella, Strep.viridens (mostly second to IE)
How to Dx Spinal OM?
- ** Blood Culture-** not sensetive but if positive = diagnosed
- if blood culture negetive»_space; Bone biopsy and cultures (if also negetive PCR)
Additional test:
MRI- best when neurological defecit are present (if MRI cannot consider PET-CT)
Imaging is not part of Dx test but can help when theres a DDx and suspicion of complication
What is the Tx for spinal OM?
Abx, length of Tx, Surgical, Empiric Tx
לא מתחילים טיפול אמפירי עד לזיהוי של הפתוגן
can give PO or IV.
If quinolones consider- short IV course to prevent resistance
length of Tx- 6 weeks (prolong if abcess present or implants in spinal colounm
Surgical Tx- not needed at hematogenic spread. always needed when theres implants»_space; below 30 days hatraya, above- remove implants
which population is more prone to foot OM?
DM
PAD, Periphareal nuropathy, after foot surgery
How to Dx OM of the feet?
Clinical Dx
Probe to bone test- if can touch the bone withour the need of imaging
most common as exogenous sources such as ulcers, surgical wound…
What is the Tx for feet OM and how we decide on the Tx?
Tx Desicion- based only on Bone biopsy if cannot»_space; Start empiric tx
MRSA»_space; Vanco
No recent Abx use- Clindamycin + unicyn
Recent Abx use- Clindamycin + Quinolones
psuedomonas- Tazosin,cefapim
Tx include surgical debris removal + 6 weeks Abx course
Erysipelas
pathogen
bounderis
pain
progression
Tx?
GAS
Define bounderis
Very painful
Rapid progression
without penetrating to deep tissue
Tx penecillin
Cellulitis
pathogen
Tx?
Pathogens- bacterial from skin flora = Staph areaus (more puralent) , GAS (less puralent)
Tx- Oxacillin, Nafcillin , Cefazolin, Vancomycin (MRSA)
Necrotizing fasciitis
2 common pathogens
alarming sighs
- GAS, Clostirsium perfringens
alarming sighs - unproportional pain to the skin findings
- bullos with blue / purple liquids
What is Fourniers gangerne
Fasciitis of the perineum area with swelling of the scortum and penis with contaminaiton of surrounding tissues.
What is the Tx for Necrotizing Fasciitis
- Surgical exploration- removal of all necrotic tissue with hatraya + sample for culture
- **Abx- Clindamycin always.
GAS/ C. perfingens- Penecillin G + clindamycin
Aerobes + anaerobes (if break GI / GU mucose)- Ampicillin + Ciprofloxacin + Clindamycin
Which 2 pathogens can ceuase Enteric Fever
Yersinia enterolitica
Salmonella thypi
Which 2 pathogens cause the fastest food poisning (1-6h)
- Staph aureus
- Bacilius cereus- fried rice
Which 2 patogens can cause 8-16hours watery diarrhea food posioning after exposure?
C. perfingens
Bacillus cereus- meats, veg, other things not rice
Bloody diarrhea without fever?
pathogen
EHEC
What is the likely pathogen?
Framer present with peunonia with dry cough and headace.
on Labs there is Thrombocytopenia
which is the most common pathogen?
Q-fever
Coxiella burnetti
How to Dx Q-fever?
Serologic test:
1. Acute phase = seroconversionphase II IgG is eleveted pi 4
2.Chronic phase- IgG phase I > 1:80 titers
Tx for Coxcella burnetii
* for acute disease
* pregnant women
* chronic disease
- acute disease- Doxycyclin 14 days (if risk factors for IE- add hysroxycholoquin and treat for 6-12 months)
- pregnant women- TMP-SMX (resperim) for all pregnancy
- chronic disease- Hydroxychroloquin + Doxy for at least 18 months (if not native valve- 24 months)
When follow up on Q fever unfection is done
Without clinical sighs + Phase I titer < 1024
in high risk pt- follow up for at least 2 years, every 3-6 months (PCR + serology)
Which nerve is involve in Zoster opthalmicus
CN V (Tragiminal) - opthalmic branch
נגזרות של איזה חומר משתמשים לטיפול במלריה חמורה?
Artemisin
Whats the treatment for Lyme disease in early diases and late disease
Early disease (skin- erythema migrnas), joints, AV block I-II»_space; doxycycline
late disease - AV block III / neurologic menefstaitons- Ceftriaxone
Which systems involvment are define as tetrietry syphilis
CNS
Cardiovascular
Skin
Bones
In which stage of syphilis Neurosyphilis occurs?
Can occur in any one of the stages.
asymptomatic- detect by LP if positive VDRL
Symptomatic- CN VII,VIII involvment. meningieal… (mainly HIV pt)
How to diagnose Syphilis (Trepimona palladium)
Non Treponomal tests- VDRL test. RPR
if positive continue
Trepomonal Test- TPPA + FTA-ABS
if CNS involvment suspicion»_space; complete LP
What is the treatment for the following:
1. Syphilis 1st, 2nd and early latent (< 1 year) stage?
2. late latent (> 1 year) and 3rd stage shypilis
3. Nuerosyphilis
- 1-2 stage + early latent - 1 dose penecillin IM
- late latent + 3rd stage- 3 doses of Penicilln IM (1 each week)
- neurosyphilis- Penecillin IV 10-14 days
What would be the treatment for syphilis if pt is elergic to penecillin?
and what if also have HIV or pregnancy?
Only elergic- use Doxycycline
if Pregnancy / HIV + latent and above / neurosyphilis - Desensetization »_space; use penecillin
what are the 2 options of vaccine to pneumoccoc?
PVC (prabvner) 10/13/20- recommended by WHO for children
PPSV23 pneumobax- polysaccharide vaccine of 23 species. above > 65 or 2-64 + high risk for pneumoccocal inf.
Regarding pneumoccoc vaccination.
what is the reccomandation for immunosupressent pt. (include MM)
PVC13»_space; 2 month later»_space; PPSV23»_space; after 5 years »_space; PPSV23
Which malignancy are related to EBV
5
- Burkkit
- Hodjkins
- CNS lymphoma in HIV (100% with EBV positive)
- transplant organ pt- post transplant lymphoproliferative disorder
- Nasophyrnx carcinoma
Which malignanct is associated with each pathogens:
HHV8
Helicobacter pylori
HTLV-1
HCV
HHV8- Kaposki sarcoma, cavity-based lymphoma
Helicobacter pylori- MALT lymphoma, Gastric carcinoma
HTLV-1- Adult T cell lymphoma
HCV- Waldenstorm macroglobulinemia
What kind of Exposure safety all of the following pathogen needing?
Measles, TB, COVID19, VZV
Aerosoles transmitted- needed N95 + חדר בידוד עם תת לחץ
What is the fundemental principels of empirical Tx for oncolgic pt with neutropenic Fever?
Cover gram positive and negetive + pseudomonas:
Tazosin/ meropenem/ ceftazidim/ cefapim
fever after 4-7 days of Abx- Add Anti-fungal
PPx for neutropenic pt- Quinolones
Which Abx can ceause Red men syndrome?
Vancomycin.
low the IV rate and give anti-histamines
Which Side effect can happen with Rifampin
orange body fluid
ITP
AIN (kidney)
What is the empirical Tx for Urethritis in males?
Ceftriaxone IM- for gonoccocal
+
Doxycycline - for clamydia
In Tx for TB in HIV.
Which Abx will be change to which other type and why?
Rifampin to Rifbotin beacuse of the interaciton of Rifampin with CYP450»_space; activate it»_space; less affective HIV drugs
