JH IM Board Review - Infectious Disease IV Flashcards
1
Q
PID - Encompasses:
A
- Endometritis.
- Salpingitis.
- Tubo-ovarian abscess.
- Pelvic peritonitis.
2
Q
PID - MC etiology:
A
- N.gono.
- C.trachomatis.
==> Anaerobes, Gram(-) bacilli, streptococci, mycoplasma.
3
Q
PID - CP:
A
HALLMARKS = FEVER + BILATERAL LOWER ABDOMINAL PAIN.
- RUQ tenderness from perihepatitis (Fitz-Hugh-Curtis syndrome) is seen in 10%.
- Pelvic exam may reveal cervical motion tenderness, adnexal tenderness, or purulent endocervical discharge.
- A palpable adnexal mass suggests a tubo-ovarian abscess.
4
Q
PID - Dx - Clinical criteria for Dx:
A
ONE of the following:
- Uterine tenderness.
- Adnexal tenderness.
- Cervical motion tenderness.
5
Q
PID - Dx - Additional criteria:
A
- Mucopurulent cervicitis.
- Presence of WBCs in vaginal secretions.
- Documented N.gonorrhoeae or C.trachomatis.
- Oral temperature greater than 38.3C.
- Elevated ESR or CRP.
6
Q
PID - Dx - Definitive criteria include:
A
- Histopathologic evidence of endometritis.
- Radiologic evidence on transvaginal US.
- Laparoscopic evidence of PID.
7
Q
PID - Tx - Outpatient Tx:
A
Ceftriaxone + Doxycycline +/- MNZ.
==> Empirical Tx is broad spectrum to cover N.gono, C.trachomatis, anaerobes, Gram(-) bacteria, and strep.
8
Q
Inpatient Tx is provided when:
A
- Surgical emergencies cannot be excluded.
- Patient is pregnant.
- There is lack of response to or inability to take oral abx.
- Tubo-ovarian abscess is present.
9
Q
Epididymitis/Prostatitis - Epididymitis is defined as …?
A
Inflammation of the epidydimis caused by:
- Infection.
- Trauma.
10
Q
Epididymitis - Etiology:
A
In men <35 ==> N.gono (30%) + C.trachomatis (70%).
In men >35 ==> Gram(-) enterics (non STDs).
11
Q
Prostatitis - Acute/chronic:
A
- Acute ==> E.coli and occasionally N.gono.
2. Chronic ==> Gram(-) bacilli (incl. E.coli) + Enterococci.
12
Q
Epididymitis - CP:
A
UNILATERAL testicular pain and tenderness, edema, +/- hydrocele.
13
Q
Epididymitis - Must r/o:
A
Testicular torsion - Especially when onset of pain is sudden, and pain is severe.
==> PYURIA is generally seen in epididymitis.
==> Doppler US.
14
Q
Acute prostatitis - CP:
A
- Fever + Chills.
- Perineal pain.
- Back pain.
- Dysuria.
==> The prostate gland is tender on examination.
15
Q
Chronic prostatitis - CP:
A
Indolent.
16
Q
Epididymitis/Prostatitis - Dx:
A
- For epididymitis ==> Gram stain, culture, and/or NAA test of urethral exudates, intraurethral swabs, or urine.
- Dx ==> Of prostatitis is usually clinical ==> “Milking” the prostate by digital exam before voiding may induce pyuria.
17
Q
Epididymitis/Prostatitis - Tx of epididymitis:
A
- For epididymitis most likely caused by gonococcal or chlamydial infection, Tx should cover both organisms.
- For epididymitis in patients >35 without risk of gonococcal or chlamydial infection, Tx should cover E.coli.
18
Q
Tx of acute/chronic prostatitis:
A
- Tx of acute prostatitis ==> Ceftriaxone, quinolones, TMP-SMX for 14 days.
- Tx of chronic prostatitis ==> 4-6 weeks of a quinolone or 6-12 weeks of TMP-SMX.
19
Q
Vaginitis - 3 types:
A
- Bacterial vaginosis.
- Trichomoniasis.
- Vulvovaginal candidiasis.
20
Q
Bacterial vaginosis - Organism:
A
Replacement of normal Lactobacillus spp. with anaerobes.
21
Q
Bacterial vaginosis - Discharge:
A
White, noninflammatory coating discharge..
22
Q
Bacterial vaginosis - Specific diagnosis:
A
Clue cells seen on microscopy.
==> Vaginal pH>4.5 + whiff test (fishy odor on addition of 10% KOH).
23
Q
Trichomoniasis - Organism:
A
T.vaginalis. (protozoan)
24
Q
Trichomoniasis - Discharge:
A
Foul-smelling, frothy, yellow-green discharge.
25
Trichomoniasis - Specific Dx:
1. Organism seen on microscopy of secretions (<70% sensitive).
2. Culture.
3. PCR now considered gold standard.
26
Vulvovaginal candidiasis - Discharge:
White, "cottage cheese" discharge.
27
Vulvovaginal candidiasis - Specific Dx:
Fungal elements seen on wet prep.
==> Vaginal pH 4-4.5.
28
Vaginitis - Tx - Bacterial vaginosis:
7-day MNZ 500mg twice daily.
29
Vaginitis - Tx - Trichomoniasis:
Single dose 2g oral MNZ.
30
Vaginitis - Tx - Sex partners of women with trichomoniasis should be treated ...?
With 2g MNZ.
31
Vulvovaginal candidiasis - Tx:
Topical and oral antifungal agents may be used to treat vulvovaginal candidiasis.
32
Proctitis - Definition:
Inflammation of the lining of the rectum.
33
Proctitis - Major causes:
1. N.gono.
2. C.trachomatis D-K.
3. C.trachomatis L1-L3 ==> LGN.
4. Early syph.
5. HSV-1/2.
34
LGV resurgence?
LGV has made resurgence in the USA and Western Europe in the last few years.
==> May cause strictures resembling Crohn disease.
35
Proctitis - All causes are ...?
INDISTINGUISHABLE based on symptoms.
==> Testing for all the previous pathogens should be considered.
36
Proctitis - Dx:
NAA tests have the highest Se to detect N.gono and C.trachomatis (even though NOT FDA cleared for extragenital sites).
==> Culture or PCR for HSV.
==> Serology for syph.
37
Empiric Tx of proctitis:
Ceftriaxone + Doxycycline.
==> May be considered until test results are available.
38
Condylomata Acuminata (Anogenital Warts) - Basic info:
1. HPV the cause.
2. MC viral STD in the USA ==> Most infections asymptomatic and self-limited.
3. High-risk types 16, 18, 31, 33, 35 ==> Cervical neoplasia (also dysplastic and neoplastic anal lesions).
==> Low risk HPV 6/11 RARELY associated with neoplasia, but cause 90% of warts.
39
Condylomata acuminata (Anogenital warts) - CP:
1. Most infections are asymptomatic.
2. Exophytic verrucous white or pigmented lesions.
3. Symptoms vary according to site and size of the lesions.
40
Condylomata acuminata - Dx:
Visual inspection.
==> Evaluation may include: Anoscopy, sigmoidoscopy, colposcopy, and/or vulvovaginal exam.
==> Acetic acid 5% can be applied to facilitate identification.
41
Condylomata acuminata - Bx:
Serves to evaluate for dysplasia.
42
Condylomata acuminata - HPV DNA used in conjunction with the ...?
PAP smear in women older than 30yr of age.
43
Condylomata acuminata - Tx:
1. Depends on size, location, patient and provider preference.
2. Tx include ==> Surgical removal, cryotherapy, or topical therapy with podophyllin, imiquimod, or trichloroacetic acid.
44
Condylomata acuminata - Prevention:
HPV virus-like-particle quadrivalent vaccine for types 6, 11, 16, 18 + Bivalent vaccine for types 16, 18 are recommended for ALL females ages 9-26.
==> Quadrivalent vaccine may be given to males ages 9-26yr.
==> Also effective in HIV-infected persons with CD4 counts greater than 200cell/mm3.
45
Condylomata acuminata - Vaccination does NOT ...?
ELIMINATE THE NEED FOR CERVICAL CANCER SCREENING.
==> Because not all cancer-causing HPV types are included in the vaccine.
46
UTIs:
Represent a broad spectrum of clinical illness, from uncomplicated cystitis to pyelonephritis with bacteremia.
47
UTIs - Pregnancy increases the risk because:
1. Dilation of ureters.
2. Decr. ureteral peristalsis.
3. Decr. bladder tone.
48
Approx. ...-...% of patients with untreated bacteriuria early in gestation progress to pyelonephritis later in pregnancy.
20-40%.
49
Pyelonephritis has been associated with ...?
Premature delivery.
==> Urine culture is therefore a ROUTINE part of prenatal screening.
50
Complicated UTI is defined by the presence of:
1. Pregnancy.
2. Male sex.
3. Immunosuppression.
4. Catheter or urologic instrumentation.
5. Stone or abnormal structure of the GU tract.
6. Functional abnormality of the GU tract.
51
Development of perinephric abscess?
Suggested by an acute pyelonephritis-like illness with persistent fever and symptoms despite medical therapy.
52
Asymptomatic bacteriuria:
More than 10^5 CFU/mL BUT NO SYMPTOMS.
53
UTIs - Dx - Lab EVALUATION:
Microscopic exam of the urine for pyuria and hematuria, or urine dipstick test for leukocyte esterase and nitrites.
54
Urine culture for uncomplicated UTI?
NOT necessary.
55
Microbiology of complicated UTI is ...?
LESS PREDICTABLE and requires:
1. Urine gram stain.
2. Urine culture.
56
Dx of pyelonephritis is supported by ...?
>10^5 CFU/mm3 of bacteriuria + Pyuria of >10 WBC/mm3.
57
Dx of pyelonephritis - Leukocyte casts are seen in ...?
20-50% of cases.
58
Pyelonephritis - Blood cultures:
NOT required but are positive in 20% of cases.
59
Dx of perinephric abscess should be confirmed by ...?
US or CT.
60
UTIs - Tx of UNCOMPLICATED UTIs:
Empirical:
1. TMP-SMX DS 1tb twice daily for 3 days = 1st line in areas where resistance is <20%.
2. Nitrofurantoin for 5 days or single-dose fosfomycin (avoid if any concern for pyelonephritis).
3. FQ but resistance and collateral damage a concern. Beta-lactams also, but have lower efficacy than other agents.
==> Amoxil and ampicillin SHOULD NOT BE USED due to relatively POOR efficacy.
61
Tx for COMPLICATED UTI:
Abx selection is based on culture data.
==> Duration of therapy is generally 7-14 days depending on the chosen antimicrobial agent.
62
For pyelonephritis, Tx is based on severity of illness and is guided by urine and/or blood culture results:
In MILD cases ==> Tx includes ORAL quinolones for 7 days or TMP/SMX for a 14-day course.
MODERATE to SEVERE ==> IV FQ, 3rd gen cephalosporins, or aminoglycosides.
63
Catheter-associated bacteriuria should only be treated ...?
In the setting of:
1. SYMPTOMATIC infection.
2. Suspected sepsis.
3. Renal transplantation (controversial).
4. Immunocompromise.
==> In the catheterized patient, pyuria ALONE is not an indication for abx therapy.
==> The presence, absence, or degree of pyuria should NOT be used to differentiate infection from asymptomatic bacteriuria.
64
Catheter-associated bacteriuria - If possible, ...?
REMOVAL of catheter during Tx is advised.
65
When long-term catheterization is required ...?
Intermittent catheterization rather than an indwelling catheter reduces the risk of infection.
66
When to treat asymptomatic bacteriuria?
1. In pregnant women.
2. Before an invasive urologic procedure.
3. In persons with renal transplant (controversial).
4. If neutropenia is present.
==> DO NOT Tx IN DIABETICS AND ELDERLY PERSONS.
67
World population infected with TB?
1/3 ==> Most have latent TB (LTBI).
68
TB - Risk factors:
1. HIV.
2. Systemic illness (DM, CKD).
3. Nutritional status (LOW BMI and LOW vitD).
4. Immunosuppression by TNF-alpha inhibitors.
69
TB - HIV infected?
1. Incr. risk of progression to active TB after infection.
2. Incr. risk of reactivation of LTBI.
3. Incr. mortality from TB.
==> HAART decr. the risk of active TB.
70
MDR TB - Defined as:
Resistance to at least INH and Rifampin.
71
MDR TB - Clusters in geographic areas:
1. Russia.
2. India.
3. China.
4. Peru.
5. South Africa.
72
MDR TB - Risk factors:
1. Previous TB Tx.
2. Poor adherence with TB Tx.
3. Adding one drug to a failing TB Tx regimen.
73
Extensively drug-resistant (XDR TB) - Defined:
Resistance to AT LEAST:
INH + Rifampin + At least 1 FQ + At least 1/3 injectable 2nd-line drugs (amikacin, canamycin, capreomycin).
74
TB - Transmission:
Airborne transmission from patients with pulm. TB disease.
75
Primary infection:
Usually ASYMPTOMATIC.
==> >90% of immunocompetent people control initial infection and develop clinical silent LATENT infection.
76
Primary infection - A minority of patients present with:
1. Pleural effusion.
| 2. Pneumonia in mid- or lower lung fields with HILAR/Mediastinal LAN.
77
Primary infection - HIV:
High risk of progression to active TB after initial infection, even with NORMAL CD4 count.
==> Can present with ANY CXR pattern (including NORMAL CXR).
78
Reactivation TB disease:
Typically subacute illness over weeks or months with fever, sweats, weight loss, cough.
79
Reactivation TB - Although pulm. disease is most common ...?
Nearly ANY organ system can be involved and clinical manifestations are PROTEAN.
==> A high index of suspicion is essential.
80
Tuberculin skin test (TST) - False POSITIVES:
1. Infection with non tuberculous mycobacteria (NTM).
| 2. Previous BCG vaccination.
81
TST - False NEGATIVE:
Immunosuppression.
82
Positive TST with remote BCG (greater than 10 yr):
More difficult to interpret.
83
IGRAs:
Whole-blood tests that can be used to diagnose TB infection.
==> Measures a person's immune reactivity to TB.
84
IGRAs - Measure of disease activity or cure?
NO.
85
IGRAs instead of TST?
May be used in most instances in place of the TST.
==> IGRAs may be preferred in persons who have received BCG vaccine.
==> TST is preferred in young children.
86
Like the TST, IGRA cannot distinguish ...?
LTBI from active TB.
87
Previous BCG vaccination and IGRA?
Vaccination will NOT cause a false(+) IGRA.
88
As with TST, so IGRA:
Should not be relied upon as a test for active TB infection.
==> A negative result does NOT rule out active disease.
89
Detection of Active TB - Lab:
Microscopic exam of sputum or other clinical specimen stained for acid-fast bacilli (AFB smear).
==> For pulm. TB ==> Obtain 3 MORNING SPUTUM SPECIMENS (sent for AFB smear and mycobacterial culture).
==> AFB smear not sensitive and not specific for TB (but POSITIVE smear is highly predictive of TB in TB-endemic settings).
90
Detection of TB - Culture:
1. Sensitive and specific (in combination with other tests done on cultured material) for M.tuberculosis.
2. Slow: Takes 3 to 6 weeks for M.tuberculosis to grow in culture.
3. Cannot check TB drug susceptibilities without culture.
91
Detection of TB - NAA tests:
1. Used to evaluate resp. specimens from untreated patients.
2. Detects TB DNA, so highly specific for M.tuberculosis.
3. Highly sensitive in AFB smear-positive patients. Only 50% sensitive in AFB smear-negative patients.
==> IF TB IS SUSPECTED AND NAA IS NEGATIVE ==> TB NOT EXCLUDED.
==> NAA TEST DOES NOT REPLACE SMEAR OR CULTURE.
92
Xpert MTB/RIF:
New, rapid test that can be used to diagnose TB and detect rifampin resistance from a sputum sample.
==> Drug resistance detected with genetic test must be confirmed by culture with susceptibility testing.
93
Detection of TB - CXR:
1. Reactivation pulm. disease typically involves upper lobe(s) or upper segments of lower lobe(s).
2. Cavitation is classic, but infiltrates may be ==> Lobar, Nodular, Interstitial.
94
Criteria for positive TST, by risk group - >5mm:
1. HIV.
2. Recent contact with ACTIVE TB.
3. Fibrotic changes on CXR consistent with previous TB.
4. Immunosuppression, including organ transplant or prednisone >15mg/day.
5. Use of anti-TNF-a drugs.
95
Criteria for positive TST, by risk group - >10mm:
1. Recent immigrants (<5yr) from a high prevalence country.
2. Injection drug users.
3. Residents and employees of high-risk congregate settings ==> Long-term care facilities, health care facilities, homeless shelters, prisons, or jails.
4. Mycobacteriology lab workers.
5. Persons with medical conditions that put them at risk ==> silicosis, DM, CKD, some malignancies, gastrectomy or jejunoileal bypass, underweight.
6. Children <4.
7. Infants, children, or adolescents exposed to adults at high risk for TB.
96
Criteria for positive TST, by risk group - >15mm:
Persons without any of above risk factors (TST NOT recommended in this group).
97
Recommended Tx for active TB disease, based on disease site:
ALL 4-drug regimen for 2 months = INH + RIF + Pyrazinamide + Ethambutol/Streptomycin.
1. Most forms of pulm. and extrapulm. TB ==> Continue INH + RIF until 6 months.
2. Cavitary pulm. TB with delayed culture conversion. Consider for bone and joint TB ==> Continue INH + RIF until 9 months.
3. CNS TB ==> Continue INH + RIF until 9-12months.
98
INH - Major toxicities:
1. Hepatotoxicity.
| 2. Peripheral neuropathy.
99
INH - Monitoring:
1. Baseline liver chemistries.
| 2. Repeat if baseline is abnormal or if other hep risk factors or symptoms of hepatotoxicity are present.
100
RIF - Major toxicities:
1. Hepatotoxicity.
2. Fever.
3. Flulike syndrome.
4. Thrombocytopenia.
5. Drug-drug interactions.
101
RIF - Monitoring:
1. Baseline liver chemistries and CBC.
| 2. Repeat if baseline is abnormal or if other hep risk factors or symptoms of adverse reaction are present.
102
Pyrazinamide - Major toxicities:
1. Hepatotoxicity.
2. Arthralgia.
3. Rash.
103
Pyrazinamide - Monitoring:
1. Baseline liver chem.
2. Uric acid.
3. Repeat if baseline is abnormal or if other hep risk factors or symptoms of adverse reaction are present.
104
Ethambutol - Major toxicity and monitoring:
Optic neuritis ==> Baseline and monthly tests of visual acuity and color vision.
105
Alternative regimens for LTBI:
1. Rifampin daily for 4 months.
| 2. Rifapentine plus INH ONCE-WEEKLY for 3months.
106
Rifapentine + INH once-weekly for 3 months - Restrictions:
A. Must use directly observed therapy.
B. Cannot be used in:
1. HIV-infected patients on antiretroviral therapy.
2. Children under 2.
3. Pregnant women.
4. Women attempting to get pregnant.
107
If INH used, what should be given?
B6 - Pyridoxine.
108
Pyrazinamide and pregnancy:
Generally NOT recommended.
109
Tx of MDR TB:
Duration is 18-24 Months, with complex multidrug regimen.
==> Toxicity is common.
110
Tx of TB in HIV:
1. Duration is not affected.
2. Worsening of TB signs or symptoms can be seen in 1st several weeks after starting HIV and/or TB treatment ==> Paradoxical worsening or IRIS.
3. Monitoring for drug tox important.
4. RIF stimulates CYP450 ==> Interaction with HIV drugs.
111
Prevention of TB transmission:
1. Respiratory isolation should be initiated for all persons suspected of having pulm. TB who are hospitalized or in otherwise congregate setting (eg prison, nursing home).
2. Resp. isolation can be discontinued once 3 sputum specimens collected more than 8h apart are smear negative.
3. Care providers (for persons having or suspected of having infectious pulm. TB disease) should use resp. protection (eg N-95 mask).
