Internal medicine - Infectiology Flashcards
1
Q
Define FUO
A
Higher then 38C without any etiologic findings
2
Q
Classification of FUO
A
Classical
Nosocomial
Neutropenic
HIV associated
3
Q
Define Classical FUO
A
▪ > 38.3 C periodically
▪ Duration > 3 weeks
▪ No clear etiology despite investigation:
o 3 outpatient visits
o 3 days in the hospital
o 1 week of invasive ambulatory investigation
4
Q
Define Nosocomial FUO
A
▪ > 38.3 C periodically
▪ Hospitalized for > 24h
▪ No fever at admission
▪ Evaluation for at least 3 days
5
Q
Define neutropenic FUO
A
▪ > 38.3 C periodically
▪ Neutropenic count > 500
▪ Evaluation for at least 3 days
6
Q
Define HIV ass FUO
A
▪ > 38.3 C periodically
▪ Duration > 4 weeks for OP
▪ Duration > 3 days for IP
▪ Confirmed HIV disorder
7
Q
Large groups of etiology for FUO
A
Local pyogenic infection
IV infections
Mycobacterium
Immunological
Thermoregulatory
Other
8
Q
Name 5 drugs ass with FUO
A
Allopurinol
Heparin
Erythromycin
Isoniazid
Penicillin
9
Q
what is the MINIMUN diagnostic workup you have to do in FOU
A
Laboratory studies:
CBC with differential
Liver chemistries
Serum electrolytes
LDH
Creatine kinase
Urinalysis and urine culture
Blood culture (three sets) if bacteremia is suspected
Imaging:
X-ray or CT chest
Ultrasound or CT abdomen and pelvis
10
Q
Treatment in FUO
A
do NOT gibe AB, antipyretics or steroids unless:
Steroids in temporal arthritis
AB in neutropenia, tuberculosis or culture neg endocarditis
11
Q
Define URTI
A
Upper respiratory tract infection is any infection involving the paranasal sinuses, nasal cavity, pharynx or larynx, and is often caused by a virus.
Classified based on location involved
12
Q
Nasal sinuses?
A
maxillary sinus
ethmoidal sinus
sphenoidal sinus
frontal sinus
13
Q
lymphoid tissue as first line of defense?
A
Tonsils
14
Q
List the URTI and pathogen
A
Common cold - rhinovirus
Influenza - influenza virus
Covid - SARS covid
Sinusitis - rhinovirus, pneumonia, hemofilus
Tonsilitis/pharyngitis - Rhinovirus, s. pyogenes
Laryngitis - rhinovirus, pneumonia, hemofilus
Epiglottitis - Pyogenes, hemofilus, rhinovirus
Croup - parainfluenza virus
15
Q
Pathogen in mononucleosis?
A
Epstein-Barr virus (EBV) HSV-4
16
Q
mononucleosis transmission?
A
body secretions especially salvia - hence kissing disease
17
Q
what cells does EBV infect?
A
B-cells
18
Q
EBV incubation period?
A
6w
19
Q
signs and symptoms of mononucleosis
A
→ Splenomegaly, fever, fatigue, malaise
→ Pharyngitis and/or tonsillitis
→ Bilateral cervical lymphadenopathy
→ Abdominal pain
→ Possibly hepatomegaly and jaundice
→ Maculopapular rash (similar to measles): The rash is caused by the infection itself in about 5% of cases but is most commonly associated with the administration of aminopenicillin
20
Q
Diagnosis of mononucleosis
A
Monospot test with sheep RBC - agglutination is positive
Labs: liver transaminase and LDH
Peripheral smear 10-90% atypical B-lymphocytes
Serology Anti-VCA IgM- only 3 months/ IgG lifetime
21
Q
treatment of mononucleosis
A
Supportive only
No contact sport
22
Q
Define pneumonia
A
Pneumonia is a respiratory infection characterized by inflammation of the alveolar space and/or the interstitial tissue of the
lungs Pneumonia is most transmitted via aspiration of
airborne pathogens (primarily bacteria, but also viruses and fungi) but may also result from the aspiration of stomach
contents.
23
Q
3 groups of pneumonia
A
Community-acquired pneumonia
Hospital-acquired pneumonia (HAP)
Ventilator-associated pneumonia (VAP)
24
Q
typical pathogens causing pneumonia
A
Streptococcus pneumoniae (most common)
Hemophilus influenzae
Moraxella catarrhalis
Klebsiella pneumoniae
Staphylococcus aureus
25
atypical pathogens causing pneumonia
▪ Mycoplasma pneumoniae
▪ Chlamydophila pneumoniae
▪ Chlamydophila psittaci
▪ Legionella pneumophila
▪ Coxiella burnetiid → Q fever
▪ Francisella tularensis → tularemia
26
Virus causing pneumonia
▪ RSV
▪ Influenza viruses, Parainfluenza viruses
▪ CMV
▪ Adenovirus
▪ Coronaviridae (SARS-CoV-2)
27
Symptoms of pneumonia
Severe malaise, high fever and chills
Productive cough with purulent sputum (yellow-greenish)
Crackles and bronchial breath sound on auscultation
Dullness on percussion
Tachypnea and dyspnea (nasal flaring, thoracic retractions)
Pleuritic chest pain when breathing, often accompanying pleural effusion
28
what can PCT tell us?
Levels > 0.25ug indicates bacterial infection
Continue or discontinue AB
29
CURB65 stands for
Confusion
Urea > 7 mmol/L
RR: < 30
BP: SBP <90
Age > 65
If 2 or more then inpatient
30
what desides ICU or not in pneumonia patient?
Need vasopresser - ICU
Need ventilatory support - ICU
31
What divides the treatment approach in an outpatient pneumonia?
Comorbidities yes or no
Yes: Combination therapy
No: monotherapy
32
Inpatient treatment in pneumonia
ONE IV B-lactam (Ampicillin-tazobactam or ceftriaxone)
ONE PO DAC (doxycycline, azithromycin, Clarithromycin)
33
Etiology of Nosocomial pneumonia
Pseudomonas aeruginosa
Enterobacteriaceae
Acinetobacter spp
Staphylococci (Staphylococcus aureus)
Streptococcus pneumoniae
34
risk factors of nosocomial pneumonia
1. Old age and immobility of any cause
2. Chronic disease: (bronchial asthma, COPD, heart failure)
3. Immunosuppression: HIV, diabetes, immunosuppression, alcoholism
4. Environmental factors: crowded living conditions
5. Specific medications (e.g., amiodarone, bleomycin)
6. Surgical procedures: upper abdominal surgery, chest surgery
35
Define UTI
Urinary tract infections (UTIs) are infections of the bladder, urethra, ureters, or kidneys that are most commonly caused by bacteria, especially E. coli.
36
Define upper and lower UTI
Upper UTI: kidney + ureter
Lower: bladder and urethra
37
Bacterial etiology of UTI
o Escherichia coli: leading cause of UTI (approx. 80%)
o Staphylococcus saprophyticus: 2nd leading cause of UTI in sexually
o Klebsiella pneumoniae: 3rd leading cause of UTI
o Proteus mirabilis
o Nosocomial bacteria: Serratia marcescens, Enterococci spp., and Pseudomonas aeruginosa are associated with increased drug resistance.
o Enterobacter species
o Ureaplasma urealyticum
38
Viral etiology of UTI
Only in immunocompromised and children
- Adenovirus
- CMV
- BK virus
These cause hemorrhagic cystitis!!!
39
Classification of UTI
By clinical presentation
By location
By severity
By source
BY frequency
40
What is urosepsis?
UTI with a dysregulated immune response that can lead to MOF sepsis
41
Define complicated UTI
Men
Pregnancy
Postmenopausal
Children with atypical UTI
Immunosuppressed
Renal failure
42
what is healthcare ass UTI
UTI due to catheter CAUTI
43
Clinical signs of an upper UTI
→ Symptoms of lower UTI
→ Fever
→ Flank pain
→ Fatigue/malaise
→ Nausea and vomiting
44
Diagnosis of UTI
o Positive urinalysis (proof of pyuria and bacteriuria): Initiate treatment.
o Negative urinalysis but persisting suspicion: Obtain urine culture.
45
urinalysis findings
Pyuria: presence of WBC - Positive leukocyte esterase ≥ 5 WBC/HPF
Bacteriuria: presence of bacteria in the urine
Leukocyte casts may indicate pyelonephritis
Presence of squamous epithelial cells can be a sign of contamination
46
treatment of UTI
First-line treatment
❖ Nitrofurantoin for 5 days
❖ Fosfomycin (single dose)
Second-line treatment: beta-lactam antibiotics for 5–7 days
❖ Amoxicillin/clavulanic acid
47
treatment of UTI in men
UTIs in men can involve the prostate, AB should be able to penetrate prostate (fluoroq)
48
Drug that can cause cystitis
cyclophosphamide
49
Define Pyelonephritis
Pyelonephritis is an infection of the renal pelvis and parenchyma that is usually associated with an ascending bacterial infection of the bladder
50
Risk factors for pyelonephritis
Pregnancy
Urinary obstruction
cystitis (most common cause)
Recent AB use
Immunosuppression
Renal transplant
51
Classification of pyelonephritis?
Uncomplicated: Immunocompetent, non-pregnant, normal anatomy
Complicated
52
Complicated pyelonephritis when
o Failure of outpatient therapy
o Sepsis
o Male sex
o Age > 60 years
o Urinary tract abnormalities (e.g., obstruction, indwelling catheter)
o History of surgery to the urinary tract or kidneys
o Hospital-acquired infection
o Renal impairment
o History of nephrolithiasis
o Immunosuppression
o Pregnancy
53
pH in UTI pyelonephritis
> 7.5-8.0
54
when to take blood cultures in UTI
Blood cultures (2 sets): Should be performed in all patients with suspected complicated pyelonephritis
55
can complicated pyelonephritis be outpatient
never, always to hospital
56
Indications for imaging in pyelonephritis
What type of imaging?
New GFR decrease to < 40
known or suspected urolithiasis
recurrent pyelonephritis
CT abdomen
57
Define Sepsis
Sepsis is an acute life-threatening condition characterized by organ dysfunction due to a dysregulated immune response to infection
58
Diagnostic criteria for sepsis
→ Persistent hypotension: Vasopressors are required to maintain MAP ≥ 65 mm Hg.
→ Persistent lactic acidosis: lactate > 2 mmol/L (18 mg/dL) despite adequate fluid resuscitation
59
qSOFA to predict sepsis
o Altered mental status
o Systolic BP < 100 mmHg
o Respiratory rate > 22/min
60
SIRS criteria for sepsis
≥ 2 PLUS a suspected or confirmed underlying infection
o Temperature: > 38°C or < 36°C
o Heart rate: > 90/min
o Respiratory rate: > 20/min or PaCO2 < 32 mm Hg
o White blood cell count: > 12,000/mm3 or < 4000/mm3
61
Symptoms of organ dysfunction SOFA
→ CNS impairment: altered mental status
→ Cardiovascular failure: hypotension
→ Coagulopathy → DIC → petechiae, purpura
→ Liver failure: jaundice
→ Kidney failure: oliguria
→ Respiratory failure: symptoms ARDS
62
target MAP when sepsis?
Try to keep > 65 mmHg
63
Define endocarditis
Infection of the endocardium, typically affects one or more heart valves. Usually a result of bacteremia.
64
Pathogens in infective endocarditis?
Staph aureus 40%
Strep viridians 20%
Staph epidermis 15%
Enterococci 10%
Gran neg HACK 5%
Fungal < 5%
Coxiella and bartonella < 5%
65
Cardiac risk factors for infective endocarditis?
→ Acquired valvular disease
→ Prosthetic heart valves
→ Congenital heart defects
→ Previous IE
→ Cardiac implantable electronic device (CIED)
66
Non-cardiac risk factors for endocarditis
→ Poor dental status
→ Dental procedures
→ Nonsterile venous injections (e.g., in IV drug use)
→ Intravascular devices
→ Surgery
→ Chronic hemodialysis
→ Immunocompromise (e.g., HIV infection, diabetes)
67
frequency of valve involvment
Mitral > Aortic > tricuspid > pulmonary
68
General presentation of endocarditis (VERY IMPORTANT)
→ Fever and chills (seen in ∼ 90% of patients)
→ Tachycardia
→ General malaise, weakness, weight loss, night sweats
→ Dyspnea, cough, pleuritic chest pain
69
New cardiac manifestations indicating endocarditis?
New murmur
Heart failure (regurgitation)
Arrhythmias
70
Extracardiac manifestation of endocarditis
o Petechiae, splinter hemorrhages (hemorrhages underneath fingernails)
o Janeway lesions: Small, nontender, erythematous macules on palms/soles and hemorrhage caused by septic micro emboli
o Osler nodes: painful nodules fingers and toes caused by immune complex deposition
o Roth spots: round retinal hemorrhages with pale centers
71
Classification of endocarditis
By onset: acute, subacute, prostatic vale
By location: left or right
72
Definite diagnosis criteria in endocarditis
> 2 major
1 major + > 3 minor
> 5 minor
73
Possible diagnostic criteria in endocarditis
1 major and 1 minor
> 3 minor
74
Major criteria for endocarditis
Positive blood culture
Characteristic echo findings
New valvular regurgitation
75
Minor criteria in endocarditis
Predisposing factors
Fever
Vascular abnormalities
Immunologic phenomena
Blood culture positive but uncommon pathogen
76
Treatment of endocarditis
Native valve: Vancomycin + Beta-lactam
Prosthetic valve: add Rifampin + gentamycin to above
77
Define Lymes disease
Tick born infection due to Borrelia genus spirochete causing Borrelioses
78
Pathogen, vector and host in Lymes disease?
Borrelia Burgdorferi, Afzeii, Garanii
Vector is Ixodes tick
Host is deer, cattle, white footed mouse
79
Highest season for Lymes and who is at increased risk?
April to October
Outdoor enthusiasts and workers
80
Stages and timing of Lymes?
Stage 1 - Early localized: after 7-14 days of incubation
Stage 2 - Early disseminated: after 3-10 weeks
Stage 3 - Late Lyme disease: months to years after
81
Describe Lyme stage 1
Erythema migrans (EM) 70-80% of cases
Flue like symptoms
82
Define erythema migrans
▪ Occurs in approx. 70–80% of infected individuals of Lymes
▪ Slowly expanding red ring around the bite site with central
clearing (“bull's eye rash”)
▪ Typically warm, painless; possibly pruritic
▪ EM is often the only symptom.
▪ Self-limiting (typically subsides within 3–4 weeks)
83
Describe 2 stage in Lyme disease
Migratory arthralgia - bursa and tendons
Early neuroborreliosis (facial nerve palsy)
Lyme carditis
Cutaneous Borrelia lymphocyte
84
Describe stage 3 of Lymes disease
Lyme arthritis - bacteria colony in joints
Late neuroborreliosis - meningitis, encephalitis, gait, psychiatric
85
Diagnostic approach in Lyme?
1. Tick bite there
2. EM or not? If yes - AB treatment
1. Tick bite there
2. EM er not? If No - are there symptomes - YES
3. Do ELISA+WB - AB if positive
4. If no EM and no symptoms then ruled out
86
Treatment of Lymes
First like: PO Doxycyclin/Amoxicillin/Cefuroxime
Don't give Doxy in pregnancy
87
Treatment of Lyme if neuroborreliosis?
Hospitalize and give IV ceftriaxone
88
What types of immunization do we have with vaccines?
Passive and active (Live attenuated/Inactivated)
89
Mechanism in passive immunization?
Injection of preformed antibodies induces a RAPID response (specific)
Provides TEMPORARY protection (Ab half-life of ∼ 3 weeks their titers)
90
Examples of passive immunization
▪ Antitoxins
▪ Humanized monoclonal antibodies
▪ Maternal transmitted via breast milk (IgA) or cross the placenta (IgG)
91
When do we give passive immunization
ACUTE, post-exposure elimination of a pathogen
Viruses: rubella, rabies, hepatitis B
Toxins: tetanus, botulinum, diphtheria
92
Mechanism in active immunization
Vaccine has antigens so body produce antibodies in response
SLOW onset, but immunity usually LASTS for years or even a lifetime.
This is the way natural infections lead to active immunization as well.
93
Examples of active immunization
Every infection we get
Measles, mumps, rubella (MMR combined vaccine)
Covid vaccine
94
Vaccines in Adults
1. Influenza every year
2. TDaP if not when a child (tetanus, diphtheria, pertussis)
3. HPV for 12–13-year-olds
4. Pneumovax and Prevenar (if immunocompromised)
95
Vaccines during pregnancy?
Influenza r (inactivated)
COVID-19
TDaP once every pregnancy (third trimester)
96
Vaccines in high risk individuals
HepA vaccine
HepB vaccine
Meningococcal
Travel vaccines
97
Vaccination in HIV individuals
NO live attenuated vaccines
NO influenza vaccine
VZ and MMR can be given if CD4 is over 200
98
Define influenza
Highly contagious viral infection, typically occurs during winter. It is caused by influenza A, B, and C viruses
99
What type of virus causes influenza?
RNA viruses of the family orthomyxoviruses
100
How is influenza transmitted?
Person-to-person transmission: directly via respiratory droplets (sneezing or coughing) or indirectly through contact with contaminated surfaces
101
Which is most common and which is mildest? (influenza)
Influenza A is common but stronger
Influenza B is mild
102
Why do we need to develop new influenza vaccines frequently
Because of Antigen shift and antigen drift by the virus creating new strands
103
What is Antigen DRIFT by influenzas virus?
Minor changes in antigenic structure (hemagglutinin and/or
neuraminidase) via random point mutation
104
What is Antigen SHIFT by influenzas virus?
Two subtypes of viruses infect the same cell and exchange genetic segments
105
Influenza diagnosis?
Clinical diagnosis - General symptoms
May rule out infections like pneumonia if very severe
RT-PCR
Rapid Ag test
106
Define neutropenic fever
Neutropenic fever is an oncologic emergency common in patients receiving chemotherapy. A decrease in a patient's absolute neutrophil count (ANC) can lead
to potentially life-threatening infections, and the risk of serious infection is directly associated with the extent and duration of neutropenia
107
Neutrophil count in neutropenia
Neutropenia: ANC < 500/uL
108
Pathogens in neutropenic fever
Gram positive
▪ Staphylococcus aureus, including MRSA
▪ Viridans group streptococci
▪ Streptococcus pneumoniae
▪ Streptococcus pyogenes
Gram-negative
▪ Escherichia coli
▪ Klebsiella species
▪ Enterobacter species
▪ Pseudomonas aeruginosa
▪ Acinetobacter species
109
Immediate management if neutropenic fever
Risk stratify patients using the MASCC score.
Establish IV access and obtain 2 blood cultures
Start empiric antibiotic therapy
Consult the patient's oncologist
Provide supportive care: IV fluids, antipyretics, pain management, antiemetics
110
AB in neutropenic fever low risk patients
If not taking fluoroquinolones as prophylaxis
o Ciprofloxacin or Levofloxacin
PLUS amoxicillin/clavulanate
111
AB in neutropenic fever in high-risk patients
Monotherapy with one of the following
▪ Piperacillin/tazobactam
▪ Cefepime
▪ Meropenem
112
How to treat low risk neutropenic fever when already on fluoroquinolones?
Treat as high risk!!
113
what scoring is used in neutropenic fever?
MASCC score
114
Define systemin mycosis?
Fungal infections that affect internal organs of the body and are not confined to skin, subcutaneous tissues, or mucus membranes.
115
types of Mycosis?
Aspergillosis - respiratory and endocarditis
Invasive Candidiasis - hematologic and esophagitis
Cryptococcosis - pulmonary or meningoencephalitis abscess
Pneumocystis pneumonia - pneumonia
Mucormycosis - orbital cellulitis or sinusitis
116
Antifungals given in mycosis?
o Caspofungin: Preferred for suspected candidiasis
o Voriconazole: Preferred for invasive mold infections (aspergillosis)
o Amphotericin: Preferred for suspected mucormycosis, Aspergillosis
117
Define meningitis
Meningitis is a serious infection of the meninges in the brain or spinal cord that is most commonly viral or bacterial in origin
118
Cause of meningitis < 1 month
Streptococci agalactia
E. coli
Listeria
119
cause of meningitis 2-50 years
Streptococci pneumoniae
Neisseria meningitidis
120
Leading cause of viral meningitis?
Enterovirus
HSV
121
Pathway of infection in meningitis
Most pathogens colonize the nasopharynx or upper airways before entering the CNS via:
o Hematogenous dissemination.
o Contiguous spread of infections in nose, eyes, and ears
o Retrograde transport along or within peripheral or cranial nerves
Direct infection (e.g., due to trauma or head surgery)
122
Meningitis incubation time
Bacterial 3-7 days
Viral 2-14 days
123
Classical triad of meningitis symptoms
Fever
Headache
Neck stiffness
124
More meningitis symptoms
▪ Altered mental status
▪ Photophobia
▪ Nausea, vomiting
▪ Malaise
▪ Seizures
▪ Possibly cranial nerve palsies
125
special symtomes for Neisseria meningitis?
Petechia
Purpuric rash
Myalgia
126
Meningitis test?
Kernig
Brudzinski
Nuchal rigidity
127
what specific symptoms can give you an indication of meningitis is due to rocky mountain fever or meningococcal?
Presence of a non-blanching rash (does not go away with pressure)
128
Indications of unsafe lumbar puncture?
FAILS
Focal neurological defect
Altered mental status
ICP
Lesions in the brain or skin near LP site
Seizure
129
what to do if lumbar puncture cannot be done in a suspected meningitis?
CT head - if it shows no signs of increased ICP then do a lumbar puncture
130
Labs indicating viral vs bacterial meningitis
Bacterial:
Cloudy, purulent CSF
high WBC
High Lactate
High protein
Low glucose
Viral
Clear CSF
Low WBC
Normal Lactate
Normal protein
Normal glucose
131
Empiric therapy in meningitis?
Ceftriaxone + Vancomycin + Dexamethasone
If Listeria ad ampicillin
If history of tick bite add Doxycycline
132
Most common cause of formation of brain abscess (spread)
o Can be otogenic (e.g., otitis media, mastoiditis)
o Sinus (sinusitis): caused by Streptococcus milleri
o Oral (e.g., dental infection)
o Meningeal (e.g., meningitis)
133
Most common pathogens in brain abscess? is it only one?
Mostly POLYMYCROBIAL
o Viridans streptococci (often secondary to sinusitis)
o Staphylococcus aureus
o Coagulase-negative staphylococcus
134
stages of brain abscess development
Early cerebritis the first 3–5 days - neutrophils and cerebral edema
Late cerebritis after 2–3 weeks
▪ Necrosis, liquefaction, and infiltration of macrophages
▪ Result in fibrotic capsule around the lesion
135
symptoms of brain abscess
Dull persistent headache
Focal neurological deficits (oculomotor or abducens nerve palsy
Symptoms of increased intracranial pressure
Fever
Generalized or focal seizures
136
Brain abscess treatment
❖ Early surgical drainage and biopsy of the abscess
❖ Empiric AB for pyogenic brain abscess: IV antibiotic therapy 6–8 weeks
137
when do we not drain a brain abscess
If brain abscess < 2.5 cm, history of symptoms < 1 week, no signs of ICP
138
What is diarrhea
Acute onset of excessive bowel movements caused directly or indirectly by microbial pathogens.
139
Define acute onset diarrhea
▪ New onset of ≥ 3 unformed stools during a 24h period.
▪ Duration is always < 14 days.
140
Define food paisoning
Acute enteric infection caused by bacteria or toxins getting into the gastrointestinal tract by food consumption or by infected water. Usually not serious and will pass within 24-48 hours.
141
Define Acute inflammatory diarrhea
fever, bloody diarrhea colonic tissue damage due to invasion
142
Bacteria causing acute inflammatory diarrhea
Campylobacter jejuni
E. coli
Salmonella
Shigella
Yrsinia enterocolitica
Vibrio Cholera
Bacillus Cereus
143
Virus causing non-inflammatory diarrhea
Adenovirus
Rotavirus
Norovirus
144
What does clostridium difficile cause?
Gram-positive bacillus causing antibiotic-associated Pseudomembranous colitis
Very resistant
Associated with AB treatment
145
two types of C. diff
Toxigenic or non-toxigenic; toxigenic strains cause C. difficile infection (CDI)
146
C. diff rounte of transmission
Community-acquired CDI: fecal-oral route
Hospital-acquired CDI: via contaminated surfaces and medical equipment
147
C. diff viral factors?
Toxin A (enterotoxin: Binds to brush border of enterocytes → receptor-mediated endocytosis → change of conformation → increase in epithelial
permeability and apoptosis → diarrhea
Toxin B (cytotoxin) Same as in toxin A, but also pore formation
148
Treatment of C. diff?
1. Stop causing AB
2. Give fluids
3. Metrodidazole/Vancomycin
149
C. dill diagnosis?
Medical history
Stool PCR
Stool immunoassay
Stool culture - take a long time
