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Clinical Medicine 1 > Lecture 3 (ID)- Exam 2 > Flashcards

Lecture 3 (ID)- Exam 2 Flashcards

1
Q
  • What is infectious disease?
  • What is pathogenicity?
  • What is virulence?
A
  • Infectious Disease is the invasion of microorganisms into a host which harm that host’s tissue and disrupts the normal health function, leading to illness. Can be transmitted to others.
  • Pathogenicity – ability to cause disease, used to compare species
  • Virulence – the degree or extent of pathogenicity of a microorganism, used to compare strains within a species
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2
Q

What is transimission?

A
  • Transmission – the spread of an infectious agent by means of direct or indirect contact between an infected host and a noninfected host
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3
Q

What is direct and indirect transmission?

A
  • Direct transmission – immediate transfer of the disease agent by direct contact between the infected and the susceptible individual (touching, biting, licking, kissing, sex); direct projection (droplet) via coughing or sneezing within 3ft
  • Indirect transmission – airborne, vehicle borne, vector borne does not require physical contact ( sneezing, coughing, talking >3ft)
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4
Q

What are the indirect transmission types?

A
  • Airborne – microbial aerosols to respiratory tract
  • Vehicle borne – contaminated material/objects (fomites) : bedding, counters, utensils, surgical instruments,
    food, water. [Any disease can be transmitted via vehicle even if primary mode is direct]
  • Vector – any agent which transmits infection from one organism to another (ticks, mosquitos, food, water)
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5
Q
  • What is incubation?
  • What is epidemiology?
A
  • Incubation – period of time between exposure and onset of symptoms
  • Epidemiology – how often disease occurs in population and why
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6
Q
A
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7
Q

Direct Detection/ Microscopy:
* wet mounts: what is needed to be done prior to exam, what is it used for? What are examples?

A
  • No fixation prior to exam
  • Used for large &/or motile organisms visualized without staining
  • Example:
    * Giardia trophozoites
    * Amebic cysts, or eggs
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8
Q

What diagnosis process is this?

A

Direct Detection/ Microscopy: Wet Mounts

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9
Q

When are wet monuts with KOH preparation used? What does the prep look like?

A
  • Trichomonas
  • Fungus
  • Yeast
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10
Q

When do we use wet mount applications with enhancing stains? What does it look like?

A

India ink to visualize encapsulated cryptococci in CSF

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11
Q

Dark-field Microscopy:
* What it is used to examine?
* Examined under what?
* How does spirochetes appear?

A
  • To examine lesions (chancres, mucous patches, condyloma lata, skin rash) for presence of Treponema pallidum or Borrelia burgdoferi
  • Examined under a dark-field microscope at X40 or X100 power
  • Spirochetes appear as motile, bright corkscrews against a black background
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12
Q

Gram stain
* Obtain what?
* Requires what? (2)

A
  • Obtain a sample of exudate or body fluid, answer in minutes
  • Requires collection with appropriate devices
  • Requires filling out laboratory request forms

Do not collect, do the walls of the tissue

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13
Q

What is the likely bacteria in this slide?

A

Gram Negative Diplococci (Neisseria Gonorrhea) with oil emersion high powered lens

seen in sexaul active with genital discharge

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14
Q

What is the likely bacteria in this slide?

A

Gram Positive Cocci in Clusters (Staph or MRSA)

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15
Q

What is the likely bacteria in this slide?

A

Gram + Bacilli, single & in chains (Bacillus anthracis )

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16
Q

What is the likely bacteria in this acid fast stain? Why do we use acid fast stains?

A

Bacteria: Mycobacterium
* Detects organisms such as that retain carbol fuchsin dye after acid/organic solvation (pink or red)

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17
Q

For mycobacterium TB: acid fast organism appear what?

A

Acid-fast organisms appear pink or red against blue background of counter stain

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18
Q

What is a giemsa or writght’s stain of blood, what is it used for?

A

Intra-or extracellular parasites(e.g., Borrelia recurrentis, Plasmodium, Babesia (tick born), or Trypanosoma)

picture is plasmodium vivax (malaria)

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19
Q

Immunofluorescent Stains:
* What does it detect?
* What are examples of bacteria?
* What can be performed?

A
  • Detect viruses within cultured cells or tissue specimens (herpes virus, rabies virus) or to reveal fastidious bacteria in specimens
    * Legionella pneumophilia
    * Pnemocystis jiroveci (PCP carinii)
  • Antibody stain could be performed
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20
Q

What biological stain is this?

A

Immunofluorescent Stain

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21
Q

Culture and sensitivity:
* usually what?
* How longs does it take for bacteria and for mycobacteria/fungus?
* Requires collection with what?

A
  • Usually the “gold” standard
  • Takes hours to days (culture) for bacteria, weeks for mycobacteria/ fungus
  • Requires collection with appropriate devices, temperature and culture medium
  • Requires filling out laboratory request forms
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22
Q

Culture and sensitivity
* What is the kerby-bauer method
* Reported as what?
* What is MIC?

A
  • Antibiotic discs placed on culture plate (Kirby-Bauer Method)
  • Reported as: sensitive, resistant, intermediary
  • MIC is a “Minimum Inhibitory Concentration” of antibiotic needed to inhibit growth of bacteria
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23
Q

Macroscopic Antigen Detection:
* What it is used to identify?
* _ tests
* Typical test for what?

A
  • Identify protein or polysaccharide antigen
  • Color tests
  • Typical test for blood type
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24
Q

Detection by Serology:
* look for what?
* Used for what organisms?

A
  • Looks for antibodies in blood
  • Used for fastidious organisms; answer in hours to days
    * Viruses
    * Syphilis
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25
Q

Detection by Serology:
* What is a paired serology?

A

Can be “paired serology” with an initial “acute” titer followed by a
“convalescent” titer in 2 weeks to determine a rise in antibody to
specific organism
* IgM antibodies for acute infection
* IgG antibodies persist for months to years; only gives an indication of some past infection.
* Toxoplasmosis

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26
Q

Detection by Molecular “Probes” (genetic material markers)
* Uses what? What bacteria is used for?
* Polymerase chain reaction (PCR) identifies what?
* What is less sensitive than a PCR? But what does it allow?

A
  • Uses markers for genetic material (DNA/ RNA) in microorganism
    * Gonorrhea/ chlamydia probes
  • Polymerase chain reaction (PCR) identifies minute quantities in a sample
  • In situ hybridization less sensitive than PCR but allows localization of agent in a tissue section
    * Fluorescent microscopy
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27
Q

Dark field microscopy is used to detect:
1. Mycobacterium
2. Treponema palidum
3. Neisseria
4. Trichomonas
5. Chlamydia trachomatis

A
  1. Treponema palidum
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28
Q

KOH preparation is best to detect:
1. Candida
2. Plasmodium
3. Pneumococcus
4. Trichomonas
5. Chlamydia

A

Candida and Trichomonas

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29
Q

Temperature Definitions:
* Hypothermia:
* Normal:
* Lower when? higher when?
* Pyrexia:
* Hyperpyrexia:

A
  • Hypothermia (< 95 F or 35 C)
  • Normal 98.6 F (37 C)->Lower in AM/ higher in PM – diurnal cycle
  • Pyrexia (> 100.4 F-38 C)
  • Hyperpyrexia (>106 F or 41 C)
    * Usually heat stroke-> direct temp, stimulents

Temp is most senstitive in the morning

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30
Q

Fever:
* Abnormal elevation of body temperature due to what?
* Caused by what?
* Many _

A
  • Abnormal elevation of body temperature due to change in hypothalamic thermoregulatory center
  • Caused by a resetting of hypothalamic “set point” by prostaglandin’s (PGE 2)
    * What is MOA of NSAIDs-> PDA occulsion in preg
  • Many causes-> systemic, allergic and infection
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31
Q

Clinical Manifestations of Fever:
* Elevated what?
* What are generalized symptoms?
* What are chills?
* What are Rigors?

A
  • Elevated body temperature
  • Generalized symptoms: myalgias, arthralgias, anorexia, & somnolence-> “I feel like c^@$!”
  • Chills- a sensation of cold occur with most fevers +/- shivering (happens more with higher higher)
  • Rigors: profound chills associated with piloerection, chattering teeth & severe shivering from bacterial infections or influenza
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32
Q

Clinical Manifestations of Fever
* What are sweats
* Increases what?
* May precipitate what in cardiac compromised?
* Alterations in what?
* When does delirium and convulsions happen?

A
  • Sweats: fever “breaks” and activation of heat-loss mechanisms
  • Increases HR & O2 demand fever
  • May precipitate HF in cardiac compromised failure-> CHF
  • Alterations in mental status
  • Delirium & convulsions: very young, elderly & debilitated
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33
Q

Hyperpyrexia
* What is the temp?
* When does it happen? (4)

A
  • Fever > 41.5°C (106. 7°F)

Causes:
* Severe infections
* CNS hemorrhages
* Heat stroke
* Substance abuse
* Reaction to anesthesia

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34
Q

Hyperthermia:
* What is Exogenous Heat Exposure
* What is endogenous hear production?

A

Exogenous Heat Exposure
* Work or exercise in hot environments produces heat faster than peripheral mechanisms can lose it

Endogenous Heat Production
* Can cause hyperthermia despite physiologic & behavioral control of body temperature

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35
Q

What are the differenital diagnosis of true fever?

A
  • Infection
  • Immune phenomena/ collagen vascular disease
  • Vascular inflammation or thrombosis
  • Infarction or trauma
  • Granulomatous diseases (Sarcoid)
  • IBD
  • Neoplasms (Hodgkin’s disease, lymphoma, leukemia, RCC & hepatoma)
  • Acute metabolic disorders (thyroid storm, Addisonian crisis)
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36
Q

Fever of Unknown Origin (FUO):
* What are the classifications (5)?

A
  1. Classic FUO -> viral/ bacteria
  2. Nosocomial FUO -> in hospital
  3. Neutropenic FUO-> no immune system, chem therapy
  4. HIV FUO
  5. Undiagnosed or factitious-> faking or undiagnosed
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37
Q

Fever of Unknown Origin:
* What is the etiology of developing counteries?
* What is the etiology of developed countries?

A
  • In developing countries – infection is the primary etiology
  • In developed countries – non-infectious inflammatory disease more common
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38
Q

FUO: classic
* What is the criteria?

A
  • T= 101° F on several occasions for at least 3 weeks with
  • 3 outpatient visits or
  • 3 days of “intelligent & invasive” ambulatory investigation and at least 2 days’ incubation of cultures
  • 3 days in hospital without elucidation of cause
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39
Q

FUO-Nosocomial
* What is the criteria for nosocomial?

A
  • T =101°F or > develops on several occasions in hospitalized patient receiving acute care & infection was not manifest or incubating on admission.
  • 3 days of investigation, and at least 2 days’ incubation of cultures
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40
Q

FUO-Neutropenic
* What is the criteria?

A
  • T =101°F on several occasions and a neutrophil count <500/ L or is expected to fall to that level in 1 to 2 days
  • Cause not identified after 3 days of investigation, including at least 2 days’ incubation of cultures
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41
Q

FUO-HIV associated
* What is the criteria?

A
  • T =101°F on several occasions for >4 weeks for outpatients or >3 days for hospitalized patients and HIV + and not taking antiviral meds
  • Appropriate investigation over 3 days, including 2 days’ incubation of cultures, revealing no source
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42
Q

What are the infections that can make undergraduates die fast?

A

Wind, Water, Wound, Walking, and Wonder Drugs,Wing/Waterway and (W)abscess.

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43
Q

What are the causes of FUO lasting more than six months?

A
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44
Q
A
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45
Q

Workup of FUO:
* What do you need to collect?

A
  • Multiple blood samples (3-6) including samples for anaerobic culture, cultured for at least 2 weeks (periprosthetic infections)
  • Blood, urine, or CSF tested/ stained/ cultures
    * Perform CT/ MRI first before spinal tap
  • PE & laboratory examination to R/O abscesses, hematomas, or infected foreign bodies
  • Liver biopsy, even with normal LFT’s if Dx uncertain & specimens cultured for mycobacteria & fungi
  • Bone marrow aspiration & biopsy for histology & culture
  • Peripheral blood smear for Plasmodium, Babesia, Trypanosoma, Leishmaniasis, & Borrelia
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46
Q

Work up of FUO
* What labs?
* What scopy exams?
* Repeat and do what?

A
  • ESR, ANA, Antineutrophil cytoplasmic antibody (ANCA), RF, serum cryoglobulins
  • Flexible colonoscopy/ endoscopy to R/O CA (cause of FUO & escapes detection by US & CT)
  • Repeat CXR if new symptoms
  • CT Chest & Abdomen
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47
Q

Work up of FUO:
* What do you need to US?
* What do you need to do with patients over 50
* Exploratory what?

A
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48
Q
A
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49
Q

Work-up of Nosocomial FUO:
* What is the source of infection?
* Sites of what?
* C. diff may be assoiciated with what/
* ~ 25% of patients have what?
* ~ 20 % of cases of nosocomial FUO are what?

A
  • > 50% of patients with nosocomial FUO infected
    * IV lines, septic phlebitis, & prostheses
  • Sites of occult infections (sinuses of intubated patients)
  • Clostridium difficile colitis may be associated with fever & leukocytosis before diarrhea (usually at least 3 days following admission)
  • ~ 25% of patients have non-infectious cause (cholecystitis, DVT, PE, drug fever, transfusion reactions, ETOH/drug withdrawal, adrenal insufficiency, thyroiditis, pancreatitis, gout, & pseudogout)
  • ~ 20 % of cases of nosocomial FUO undiagnosed
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50
Q

What is still’s disease? What does it respond well to?

A
  • Still’s disease is inflammation with high spiking fevers, evanescent (transient) salmon-colored rash and/or arthritis Still’s disease was first described in children, but it can occur in adults (adult-onset Still’s disease).
  • Responds well to NSAIDs
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51
Q

Nosocomial FUO:
What is the Empirical antibiotic coverage for nosocomial FUO?

A

vancomycin for MRSA and broad-spectrum gram-negative coverage with piperacillin/tazobactam (Zosyn®), ticarcillin/clavulanate (Timentin®), imipenemicilastatin(Primaxin®), or meropenem (Merrem®)

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52
Q

Neutropenic FUO:
* Susceptible to what?
* What is the treatment?

A
  • Susceptible to: focal bacterial & fungal infections, bacteremic infections, catheter infections & perianal infections
  • Candida, Aspergillus, HSV or CMV
  • Vancomycin plus ceftazidime or imipenem for bacterial sepsis empirical coverage
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53
Q

What are the causes of HIV associated FUO?

A
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54
Q

W/U of HIV-Associated FUO:
* What do you need to do?
* What type of x-ray
* > 80% of HIV patients with FUO are what?
* Consider what?

A
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55
Q

Treatment of FUO’s:
* Continued what?
* Avoidance of what?
* What trials?
* Remember what?

A
  • Continued observation & examination to identify source
  • Avoidance of “shotgun” empirical Rx unless somewhat certain for source um
  • Therapeutic medication trials
  • Remember TB
    * +PPD skin test or if granulomatous hepatitis
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56
Q

Treatment of FUO’s:
* Response of what?
* Colchicine for what?
* When is prognosis generally good?

A
  • Response of RF & Still’s disease to ASA & other NSAID’s
  • Colchicine for familial Mediterranean fever
  • When no underlying source of FUO is identified after prolonged observation (> 6 months), prognosis is generally good
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57
Q

What groups of people do you need to be careful of infections without fevers?

A
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58
Q

What is observed in patients with hypothermia?

A
  • Hypothermia is observed in patients with septic shock
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59
Q

Reasons not to treat fever that may aid diagnosis?

A
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60
Q

What are relapsing fevers? What is an example of bacteria that causes this?

A
  • Febrile episodes separated by intervals of normal temperature
  • Borrelia infections (Lyme disease) (several day afebrile periods)
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61
Q

What are tertian fevers? What bacteria causes this?

A
  • Fever Paroxysms on 1st & 3rd days
  • Plasmodium vivax
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62
Q

What is quartan fevers? What is an example of bacteria that causes it?

A
  • Paroxysms on first & fourth days
  • P. malariae
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63
Q

What is pel-ebstein fever? What is an example that causes it?

A
  • Lasting 3 to 10 days then afebrile periods of 3 - 10 days
  • Hodgkin’s disease / lymphomas

One week good, one week bad

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64
Q

What is cyclic neutropenia fever?

A
  • Every 21 days with neutropenia.
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65
Q

What are indications & Regimens to Treat Fever

A
  • Not certain fever helps
  • Reduces HA, myalgias, & arthralgias
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66
Q

Decision to Treat Fever:
* Reduce what? Increase what?
* Most fevers are what?
* What is a potent immunosuppressant?

A
  • Reduce elevated set point and increase heat loss
  • Most fevers are self-limited infections, viral
  • PGE2 a potent immunosuppressant
    – NSAID increases the anti-influenzal AB level (preferred over tyanol in flu)
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67
Q
  • When actaminophen preferred?
  • What do you use in children and why
A

Acetaminophen preferred
* NSAIDs and ASA cause GI symptoms
* Blocks PGE2 centrally

In children, use acetaminophen
* No ibuprofen until 6mo old
* ASA increases risk of Reye’s syndrome

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68
Q

Indications & Regimens to Treat Fever
* What drugs are more effective together?
* What are different ways of giving the drug
* What is indicated for hyperpyrexia?

A
  • Acetaminophen and NSAIDs are more effective together
  • Parenteral preparations of NSAIDs & rectal suppository preparations
  • Dantrolene – indicate for hyperpyrexia
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69
Q

Definitive Indications to Treat Fever:
* Fevers increase demand for what? What does this cause?
* Worsening what?
* Children with a hx of what? Treating with antipyretics has not been shown to do what?
* What is DOC for hyperpyretic patients >105-106°F?

A
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70
Q

What is Systemic Inflammatory Response Syndrome (SIRS)

A
  • SIRS is a body response to a stressor: Infectious or noninfectious
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71
Q

For SIRS, what is the criteria?

A
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72
Q

What is bacteremia?

A
  • Bacteria in blood and + blood cultures
  • Can be septic without documented bacteremia
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73
Q
  • What is sepsis/septicemia?
  • What is severe sepsis?
A

Sepsis/septicemia:
* SIRS + bacteremia (microbes or their toxins in blood)

Severe sepsis
* Sepsis and one organ dysfunction or Lactic Acid >2 but <4

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74
Q

What is septic shock?

A
  • Severe sepsis and shock
  • BP of < 90mmHg or 40 points less than pt’s normal BP AND unresponsive to fluid resuscitation (30cc/kg NS) OR Lactate >4
  • Organ dysfunction indicating need for vasopressors
75
Q

What is refractory septic shock?

A

Septic shock lasting longer than 1 hour with no response to fluid or vasopressors (use higher doses)

76
Q

What is Multiple-organ dysfunction syndrome (MODS)?

A
  • Dysfunction of more than one organ
  • requiring intervention to maintain homeostasis
77
Q
  • Systemic inflammation and bacterial infection=
  • Sepsis and organ(s) not working=
  • Sepsis and low blood pressure=
A
  • Systemic inflammation and bacterial infection = sepsis
  • Sepsis and organ(s) not working = severe sepsis
  • Sepsis and low blood pressure = septic shock
78
Q
A
79
Q
A
80
Q

What are the s/s of early phase sepsis?

A

Tachycardia, skin warm and dry, hyperventilation, decrease in urine output, hypoxia, hypothermia

81
Q

What are the s/s of late phase sepsis?

A

Restless,anxiety, hypotension, oliguria, edema, fever, cold and clammy skin

82
Q

What is the sepsis mortality?

A
  • Increases 8 % for each hour without antibiotics
83
Q

What are the risk factors for gram - bacteremia?

A
  • DM
  • Lymphoproliferative disease
  • Cirrhosis
  • Burns
  • Invasive procedures or devices
  • Neutropenia
84
Q

What are the risk factors for gram + bacteremia?

A
  • IV catheters or mechanical devices (valves)
  • Burns
  • IVDA
  • Children, elderly
85
Q

Clinical Manifestations of Sepsis
* What are the cutaneous signs?

A
  • Cyanosis & ischemic necrosis of peripheral tissue
  • Cellulitis (sores)
  • Pustules
  • Bullae
  • Hemorrhagic lesions
  • Generalized erythroderma
  • Petechial or purpuric lesions (DIC)
86
Q

Clinical Manifestations of Sepsis:
* What are the signs for GI?

A

– N/V
– Diarrhea
– Ileus
– Gastric ulceration with bleeding
– Cholestatic jaundice

87
Q

Clinical Manifestations of Sepsis:
* What are the signs with renal?

A

– Oliguria, azotemia, proteinuria, & nonspecific renal casts
– ARF 2/2 acute tubular necrosis

88
Q

Clinical manifestations of sepsis:
* What are hematologic signs?

A

– Thrombocytopenia 10-30%
– Profound thrombocytopenia (< 50,000) usually reflects DIC

89
Q

Clinical Manifestations of Sepsis:
* What are the ARDS signs?

A

– Pulmonary capillary microvascular injury
– 20-50%
– Causes diffuse pulmonary infiltrates/hypoxemia

90
Q

Clinical Manifestations of Sepsis:
* What happens to BP?

A

Hypotension
* Misdistribution of blood flow & blood volume from hypovolemia due to diffuse capillary leak
* After fluid, CO increase and SVR falls

91
Q

Clinical Manifestations of Sepsis:
* What is Multiple-organ dysfunction syndrome (MODS)

A
  • Widespread endovascular injury with high fatality rates
92
Q
A
93
Q

What does the hematologic lab levels in sepsis?

A
  • Leukocytosis with left shift or leukopenia
  • Thrombocytopenia
  • INR >1.5
  • DIC
  • Microangiopathic (DIC)
  • Hemolysis (clostridial bacteremia, malaria, DIC)
94
Q

What is shown in ABG in early and late sepsis?

A
  • Early- hyperventilation-induced respiratory alkalosis
  • Late- metabolic acidosis /hypoxemia
95
Q

What does CXR show in sepsis?

A
  • ARDS
  • Underlying pneumonia
96
Q

Sepsis labs:
* High or low bilirubin?
* High or low protein?
* High or low procalcitonin?
* high or low CRP?
* high or low Lactate?

A
  • Hyperbilirubinemia
  • Proteinuria
  • ↑ > 2 SD above normal Procalcitonin (nl <0.05ug/L)
  • ↑CRP> 2 SD above normal
  • ↑ Lactate (>2 mmol/L)

usually just look at lactate

97
Q

Lab values of sepsis:
* What is the urine issue?

A

Urine is <0.5 ml/kg/hour for >2 hours despite adequate fluid resuscitation

98
Q

Definitive Diagnosis of Sepsis:
* What is there not of?
* Requires what?
* What NEEDS to be obtained?
* If blood cultures (Negative in 30%), Dx. depends on what?

A
  • No reliable lab test for early diagnosis
  • Requires isolation of microorganisms from blood or local site of infection
  • At least 2 blood cultures from different venipuncture sites (ideally from ports)
  • If blood cultures (Negative in 30%), Dx. depends on Gram’s stain & C/S of primary site of infection or secondary infected cutaneous tissue

With overwhelming bacteremia, smears of peripheral-blood buffy coat may reveal microorganisms

99
Q

How many blood cultures do you need with endocarditis sepsis?

A

3

100
Q

What is the treatment of Sepsis “Call a Code (SRT)”

A
  • Medical emergency
  • Sequester support
  • Complete in first one-six hours
  • Goal directed therapy
101
Q

Resuscitation Bundle for sepsis
* What do you need to give (2)
* What labs?
* What do you need to monitoring? What might do you have to give?

A
  • Fluids (NS vs LR)
  • Labs with
    * Lactate levels
    * Blood cultures
  • Broad spectrum antibiotics
  • Central venous monitoring
  • Oxygen saturation monitoring/ high flow O2/ Endotracheal intubation
102
Q

Resuscitation Bundle for sepsis:
* Vasopressors: What is the DOC?
* Hydrocortisone: only give if what? What is the drug?

A

Vasopressors
* Norepinephrine is the drug of choice, carefully titrated to maintain mean BP > 60 mmHg
* Epinephrine
* Not first line: Dopamine/ vasopressin

Low dose hydrocortisone
* Only if hypotensive with fluids and vasopressors
* 50 mg/ every 6 hours

103
Q

Treatment of Sepsis-> eliminate offedning microorganism
* Treat what
* Give antibiotics when?
* Empirical therapy based on what?
* Therapy against both what?
* Gram stain of primary site of infection directs what?

A
  • Treat local site of infection (ie surgery)
  • Antibiotics given as soon as blood & other sites cultured and within 1 hour of presentation
    – Empirical therapy based on information about pt & antimicrobial susceptibility patterns in community & hospital (Antibiograms)
    – Therapy against both gram - & +
    – Gram stain of primary site of infection directs antimicrobial therapy
104
Q

What is the empiric antibioitic txt for immunocompetent adult with no obvious source in adults with normal renal function:

A

If patient is allergic to lactam agents, ciprofloxacin (400 mg q12h) + clindamycin (600 mg q8h)

105
Q

Treat Local Site of Infection for sepsis
* What do you need to remove
* What imaging nees to be done?
* What needs to be collected?
* What drainage?

A
106
Q

When do you do a blood transfusion?

A
  • Start at HgB of 7-8 except in MI, ischemic CAD, or acute hemorrhage
  • Platelets, FFP or Cryoprecipitate or whole blood if needed
107
Q

Ventilation-sepsis
* What do you give? except?
* Intubation can cause what?
* What do you give?
* What is great?

A
  • High flow O2 except in COPD (takes away respiratory drive)
  • Mechanical ventilation (intubated): easy to hurt them
  • “low” tidal volume (6 mL/kg) with end respiratory plateau pressures less than 30 cm of water
  • Noninvasive ventilation is great (BiPAP or less commonly CPAP)
108
Q

IV Antimicrobial Therapy for Severe Sepsis:
* What do you switch?
* one or two agents for what?
* treat for how long?

A
  • Switch to susceptibility directed antibiotic, even if improved
    * Use C/S data
  • One or two agents for gram negative infections
    * Use only one agent except if Pseudomonas or neutropenia
  • Treat 7-10 days
109
Q

What is the prognosis of sepsis?

A
110
Q

Prevention of Septic Shock:
* What should you minimize the number of
* limiting use or duration of what?
* Reducing incidence/ duration of what before shock?
* Aggressively treating what?
* immunizations?

A
111
Q
  • A cancer patient with a central line port develops a fever. The cancer has been remitting for 1 week, and there are no signs that it is spreading. There is currently no fever. The basic work up for fever is negative. What should you next do for this patient?
  • Begin low dose steroids
  • Perform exploratory laparotomy
  • Remove the central line and send tip for C & S
  • Start empiric IV antibiotics
  • Give some tylenol
A
  • Remove the central line and send tip for C & S
  • Start empiric IV antibiotics (broad septrum)
112
Q

The proper treatment of septic shock include:
* Using WBC enhancers when neutropenic
* Using a broad-spectrum antibiotic when culture results are pending
* Limitation of IV fluids
* Waiting for culture result to start antibiotics
* Tylenol 1000mg PO once

A

Using a broad-spectrum antibiotic when culture results are pending

113
Q

What are the different types of STD infections?

A
  • Parasitic (Pubic lice, scabies, trichomoniasis)
  • Bacterial (Chlamydia, LGV, Gonorrhea, Syphilis)
  • Viral (HSV, Hepatitis B, HIV, HPV)
114
Q

What are STIs?

A

Sexually transmitted infections (STIs) are infections that are passed from person to person through sexual contact, primarily through bodily fluids (e.g., blood, breast milk, vaginal or anal fluids, semen/copulation and pre-copulation/excitation fluids). While STIs are generally curable or treatable, they can cause serious health problems if left ignored and untreated.

115
Q

What type of STDs are constiuted as abuse? What must you do?

A

Childhood STDs constitute abuse:
* MUST BE REPORTED AND PROPERLY DOCUMENTED WITH TESTS

116
Q
A
117
Q

Parasitic - Pubic Lice
* What is this also called?
* What is it?
* How is it transmited? How long can they live off a human?

A
  • aka crabs, Pthirus Pubis; ectoparasite of humans.
  • Tiny crab-like insects that nest in pubic hair & bite their host to feed on blood
  • Transmitted direct contact or off bedding, clothing, towels; Can live off human host x24-48h
118
Q

What are the sx and dx of pubic lice?

A
  • Sxs: pruritis in pubic area, visible nits or lice on hair; secondary sores and infection 2◦ intense scratching
  • Dx: presence of nits or lice (Presence on eyebrows/eyelashes of children, suspect sexual abuse)
119
Q

What is the txt of pubic lice?

A

Tx: Wash all clothing, towels, bedding: Hot (103F+) water and machine dry; store other unwashable items in sealed plastic bag x 14 days

Medicated creams & lotions
* Permethrin cream->twice 7 days apart
* Lindane – not recommended for first line (hepatic metabolism)
* Toxic to brain and nervous system-> avoid in infants and toddlers <2yo, epileptic, pregnant/breast-feeding women, elderly, <110lb
* Ivermectin – topical US approved, not oral

Evaluate for other STIs; notify all partners, avoid sexual contact until fully cleared

120
Q

Parasitic - Scabies:
* What is another term?
* How is it tranmitted? How long do they live off human

A
  • Sarcoptes scabiei var hominis; microscopic mites
  • Primarily through direct prolonged skin to skin contact; rarely off bedding, clothing, towels; live off human for 48-72 hrs
121
Q

Parasitic - Scabies:
What are the sx?

A
122
Q

Scabies
* What is the dx?
* what is seen in immunocompromised?

A

Dx: based on history and exam; presence of mites, eggs, or feces found on microscopic evaluation of skin scraping
* Norwegian (crusted) scabies – in immunocompromised

123
Q

What is the txt of scabies?

A
124
Q

Parasitic - Trichomoniasis
* What are other names?
* Most common what?

A
  • aka, Trich, Trichomonas Vaginalis, protozoan parasite
  • Most common curable sexually transmitted parasitic infection
125
Q

Parasitic - Trichomoniasis
* what are the sxs?
* What is the dx?

A
126
Q

Trichomoniasis
* What is the txt? (first line, alt and intravag)

A

Metronidazole 2G, partner txt. (may even be given in gel form)
* Alt: Tinidazole/Ornidazole – non-pregnant/breastfeeding women
* Intravaginal: paromomycin, furazolidine, acetarsol, nonoxynol-9
* Evaluate for other STIs

127
Q
  • What are the bacterial STI’s?
  • What can they be treated?
  • What can they cause if untreated?
A
  • Bacterial STI’s include Chlamydia, LGV, gonorrhea & syphilis
  • Can be treated and cured with antibiotics
  • Untreated infection can cause PID, infertility, & epididymitis
128
Q
  • What are the viral STI’s?
  • What can they be treated?
  • What can happen?
A
  • Viral STI’s include HPV, HIV, Herpes, & Hepatitis A,B,C
  • Medication available to treat symptoms only
    * There is NO cure
  • Can pass onto others for the rest of your life
129
Q

Bacterial - Gonorrhea
* What are other names and what are their bacterial structure
* most common cause of waht?
* How is it transmitted?

A
  • aka “clap”, ”drip”, Neisseria gonorrhoeae, oxidase+, gram -, diplococci, obligated bacteria
  • Most common cause of gonococcal urethritis; ~106 million/ yr, US ~1.4 million/yr
  • Direct contact with infected tissue/fluid, vertical transmission
130
Q

What are the sx of gonorrhea?

A
  • Copious mucopurulent green, yellow, white d/c 1-14 days post exposure), dysuria, cervicitis/orchitis/epididymitis/penile lymphangitis/penile edema, testicular/scrotal pain; urethral strictures, rectal itching, discharge, soreness, bleeding, abdominal pain, painful bowel movements, postcoital or intermenstrual bleeding; pharyngitis, mucopurulent exudates, conjunctivitis
  • Untreated can lead to ectopic pregnancy and infertility, first trimester abortion, disseminated gonococcal infection (DGI):arthritis, tenosynovitis, dermatitis, septicemia, vasculitis, endocarditis
  • Infants – (vertical transmission) conjunctivitis/blindness, joint infection, septicemia
131
Q

What is the dx of gonorrhea?

A

Dx: Clinically, plus labs
* NAAT testing: urine or swabs– Gold standard

132
Q

What is the txt of gonorrhea? What about resistant strains?

A
133
Q

Chlamydia:
* What is it called?
* Most common cause of what? Who does it affect more?
* how is it transmitted?

A
  • aka “The Clam”, Chlamydia Trachomatis, gram -, anaerobic, intracellular obligate bacteria
  • Most common cause of nongonococcal urethritis and infertility in women
  • Females 2x>males; Females15-24 y/o, males 20-24y/o
  • Direct contact with infected tissue/fluid
134
Q

What are the sx of chalmydia?

A
  • Scant yellow d/c, dysuria, postcoital or intermenstrual bleeding,cervicitis/urethritis/proctitis/epididymitis/prostatitis, pruritus, phlegm, PID, perihepatitis
  • Untreated can lead to ectopic pregnancy and infertility, reactive arthritis
  • Multiple serologically variant strains -> multiple medical conditions
    * Trachoma – ocular illness, blindness (Asia/Africa)
    * Lymphogranuloma venereum – severe proctocolitis, painful LAD, painless genital ulcers
  • Infants – (vertical transmission) conjunctivitis, pneumonia
135
Q

What is the dx of chlamydia?

A

Clinically, plus labs
* NAAT testing: urine or swabs– Gold standard
* Culture – sexual assault cases, rule out LGV

136
Q

What is the txt of chlamydia?

A
137
Q

Disseminated GC/Chlamydia Disease:
* What is it?
* What are the 2 clinical syndromes?
* Tenosynovitis often found where?
* What also might occur?

A
  • Gonococci disseminates into the bloodstream
  • 2 clinical syndromes – purulent arthritis or a triad of rash, tenosynovitis and arthralgias
  • Tenosynovitis often found in hands, wrists, feet, ankles
  • Arthritis may occur in one or more joints and be migratory
138
Q

Gonorrhea Conjunctivitis:
* What is it?
* Must treat when?
* How do you tx?

A
  • Purulent discharge
  • Must treat urgently
  • Single 1 g dose of ceftriaxone
139
Q
  • What are DDx with STIs?
  • What is txt of PID?
  • What is Txt of disseminated?
A
140
Q

Sore Throat:
* Always consider what?
* What do you need to do?
* Should test for what?

A
  • Always consider an STI in a sexually active patient or even young child with risk factors for sexual abuse
  • Swab test is exactly the same as for genitalia
  • Should test for refractory cases of pharyngitis to symptomatic and empiric ABX
141
Q

Syphilis:
* What is it also called and what is it?
* What are the primary sx?

A
  • Aka “lues”, “syph”, treponema pallidum, a spirochete bacteria which causes a 3 phase infection that progresses in stages with periods of asymptomatic latency, without treatment invades CNS
  • Sxs: Primary: (3 days – 3 months) starts as a small, painless indurated ulcer called a chancre associated w/ LAD; goes away on it’s own [2-6 wks]
142
Q

What are the sxs for secondary syphilis?

A

Secondary: (2 – 24 weeks) morbilliform rash on the body, dark spots on palms and soles, hair loss, feeling ill, condyloma lata (Flat-topped papules and plaques that occur at the mucocutaneous junctions of the nares, angles of the mouth, and in the anogenital region), HA, myalgia, arthralgia, hepatosplenomegaly, alopecia, malaise

143
Q

What are the sxs of latent and tertiary syphilis?

A
  • Latent: asymptomatic stage, tests +, lesions or rashes can recur- but not present on exam
  • Tertiary: years later - effect neurological system: blindness (Argyll-Robertson pupil), different paralyzed, cognitive decline, meningitis, hearing loss, aphasia, stroke, seizures, tabes dorsalis; gummas = infiltration of organs w/destruction; aortic aneurysm, valvulopathy, Charcot’s join
144
Q

What is the dx of syphilis?

A

Dark field microscopy- allows direct examination of spirochetes
* Serological testing: Treponemal/Nontreponemal
* Nontreponemal: detects Ab - RPR, VDRL
* If +, followed by Treponemal Ab Absorption assay (TPA) or FTA-ABS (fluorescent treponemal Ab)
* Neuro patients: CSF fluid evaluation
* Imaging studies depend on organ involved

145
Q

What is the txt of syphilis?

A

primary, secondary or early latent (<365 d), exposure: single dose of IM Bicillin 2.4 million units; reinfection w/4 fold increase (1:8 to 1:32. 1:1 to 1:4)
* OR Doxycycline 100mg po BID x 14d; Tetracycline 100mg po QID x 14d

Tertiary, Late latent: weekly dose of IM Bicillin 2.4 million units x 3 wks
* OR Doxycycline 100mg po BID x 28d; Tetracycline 100mg po QID x 28d

Neurosyphilis: IV Pen G 18-24 million units daily x 14d

146
Q

Syphilis:
* When do you need to follow up?
* What do you need to do with partner? what does the patient need to do?
* Complications 24h post treatment is what?

A
  • F/u: 3, 6, 9, 12, and 24 months with serial retesting -> 4 fourfold decline (1:265 to 1:64, 1:64 to 1:16)= successful treatment
  • Partner notification & txt; Abstain from sex duration of treatment, Evaluate for other STIs
  • Complications 24h post treatment is Jarisch Herxheimer Reaction
    * HA, myalgia, fever, tachycardia, malaise- tx supportive.
147
Q
A
148
Q

HPV (Human Papilloma Virus)
* What is it?
* What is the low and high risk?
* What are the rates?
* How is it transmitted?

A
149
Q

What are the sxs of HPV?

A

Asymptomatic
* Genital warts flat or raised veruccated lesions often time flesh colored, slightly pruritic along genitalia or orally
* Bleeding during sexual activity
* Common warts – rough raised bumps on hands and fingers; Plantar warts – hard, grainy with central dot on soles of feet; Flat warts – flat topped, face, bearded areas, legs

150
Q

What is the dx of HPV?

A

Clinically, based on visible lesions, but often times also routine screening
* Pap smear, anal pap, colposcopy, anoscopy

151
Q

What is the txt of HPV?

A

There is NO CURE, but vaccination is available to prevent certain types of HPV (Gardasil)
* Symptom control: mechanical removal via cryotherapy, electrocautery, laser, surgical excision; topically antimitotics, caustics, interferon inducers (imiquimod)
* Relapse frequent
* Monitor for cervical/anal/colorectal/oral cancer
* Partner notification, Safe sex practices, Evaluation of other STIs

152
Q

HSV (Herpes Simplex Virus)
* What is it?
* How is it transmitted?

A
  • Oral or Genital Herpes/ HSV1 and 2, belongs to Alphaherpesviridae subfamily, lies dormant in dorsal root ganglia and can reactivate
  • ~30% of the world has symptomatic HSV, ~90% worldwide asymptomatic w/ ~65% in US
  • Direct contact with contaminated saliva or bodily secretions, and sexual contact with infectious tissue.
153
Q

What are the sxs of HSV?

A

Recurrent (possible) outbreaks of painful sores and blisters in same area as initial inoculation
* Primary infection: 3d -1wk after exposure, viral prodrome: malaise, anorexia, fever, tender LAD, orolabial – cold sore, fever blister, pain, halitosis, dysphagia, pharyngitis, mono like syndrome, vesicular eruption [2-6wk]; follicular papules; herpetic whitlow: deep blisters, LAD; keratoconjunctivitis; encephalitis
* Secondary: milder, 24 prodrome: tingling, burning, pruritis, vesicular eruption
* Neonatal: scalp, trunk rash; oral and ocular involvement; CNS: bulging fontanelle, lethargy, poor feeding, irritability, seizures
* Asymptomatic or subclinical shedding between recurrences ~70%

154
Q

HSV dx?

A

Dx: Viral Culture – Gold standard
* PCR – HSV DNA, gold standard for CSF infections
* Serologic testing via Western blot

155
Q

What is the txt of HSV?

A

Antivirals
* Initial outbreak: Acyclovir 400mg TID x7-10d OR Valacyclovir 1G BID x7-10d OR Famciclovir 250mg TID x7-10d
* Recurrent: Acyclovir 400mg TID x 5 days (HIV x 10d) OR Valacyclovir 500mg BID x 3d OR Valacyclovir 1G QD x 5d (HIV 1G BID x5-10d)
* Suppressive: Acyclovir 400mg BID (HIV 800mg BID) OR Valacyclovir 500 mg QD (HIV BID) OR Valacyclovir 1G QD (HIV BID)
* Safe sex practice; Evaluation of other STIs; Partner notification

156
Q

HIV:
* What are the types?
* What type of virus?
* Dependent on what?

A
157
Q

HIV/AIDS:
* HIV is a virus that destroys what?
* Once the immune system is weakened, what can happen?
* The virus is present in what?
* What is the most common race?
* Male transmission:
* Female transmission:
* What are the high risks?

A
158
Q

HIV Infection:
* HIV enters the body by infecting what cells?
* What cells are the among the first to deal with HIV?
* What can be given to prevent replication?
* When is HIV not detectable?

A
159
Q

Replication:
* Each infected CD4 cell produced how many new viruses?
* Each replication cycle lasts how long?
* Increased number of virions =
* Higher viral load means what?

A
  • Each infected CD4 cell produces about 300 new infectious viruses – called virions.
  • Each replication cycle only lasts 1 to 2 days.
  • Increased number of virions = Viral load or the amount of virus in the blood.
  • Higher viral load means more immune suppression
160
Q

HIV presentation:
* 1 to 3 weeks after exposure, some people experience what?

A

1 to 3 weeks after exposure, some people experience mild flu-like symptoms that may last a few weeks, then disappear
* Fever/Chills
* Extreme Fatigue
* Decreased appetite/stomach discomfort
* Body aches
* Swollen lymph nodes

161
Q

HIV presentation:
* Many people present when? why?
* What is the only way to know?

A
  • Many people have NO symptoms until years after exposure
    * Because they shrug off short lived viral symptoms prior to seroconversion and get identified with superbugs and low CD4 counts years after exposure
  • The only way to know is to get TESTED!
  • Mean time 10 years from exposure to real severe sympto
162
Q

Explain the timeline of ELISA, antibodies detected using western blot and proviral dna?

A
163
Q

HIV Disease Progression
* Couple weeks after infection, HIV becomes detectable with what?
* Acute Viral Infection symptoms can last how long
* What has reaches peak
* What level drops?
* What test?

A

Couple weeks after infection, HIV becomes detectable with p24 Antigen testing and patients are usually symptomatic
* Acute Viral Infection symptoms can last 2 weeks + (although not everybody will experience)
* Viral load reaches its peak – upwards of 1 million copies / mL of blood
* CD4 counts drop
* + Rapid test requires ELISA/ Western Blot confirmatory test

164
Q

HIV:
* Why is transmission high during the first couple of weeks?
* ~28 days after infection (viral symptoms resolve), what test can be done?

A
  • Transmission of HIV to others is very high due to high VL count in bodily fluids and mucosal tissue
  • ~28 days after infection (viral symptoms resolve), HIV Ab tests become positive ( “4th gen Ab/Ag test), i.e. seroconversion occurs
    * p24 levels start to drop as HIV Ab bind to p24 creating Ab/Ag complexes in effort to eliminate
165
Q

HIV:
* What is the screening test and teh confirmatory test?
* Waht is the combined sensitivity and specificity?
* What is the window period?

A
166
Q

HIV
* >6 weeks Ab only tests will detect how many infections?
* HIV levels start to fall as what starts to rise?
* What will stabilize and when?

A
167
Q

What is the timeline to detect HIV ab and ag?

A
168
Q

HIV lab:
* What is viral load? What it is good for?
* What is chronic goal?
* treat?

A
169
Q

What is the naturally course of HIV disease?

A
170
Q

WHO Stages of HIV Infection->T4/ CD4 lymphocyte Count
* Normal level?
* Immunodeficient? (what are the 4 stages?

A
171
Q
  • What are opportunistic infections?
  • How is the HIV disease measured by?
    *
A
172
Q
A
173
Q

What are the AIDs defining conditions?

A
174
Q

What is this (HIV +)?

A

Kaposi Sarcoma- human herpes virus type 8

175
Q

Disease Risk Outcomes for HIV?

A
176
Q

What is the lab workup for HIV/AIDs patients?

A
177
Q

What is the HIV txt?
* When do you start and why?
* What is an important things about ART?

A
178
Q

Fill in the drugs for HIV

A
179
Q

HIV med

A
180
Q

STI and HIV Prevention:
* What is the only effective method?
* Avoid what?
* What should patients have?
* Get tested when?
* What should you use?
* Get onto what when in high risk activities?

A
181
Q

What are the HIV Preventive measures?

A
182
Q

Who needs to be screened for HIV

A
183
Q
  • Studies have shown that CD4 count is usually lower when?
  • Acute infection, for example, influenza, pneumonia, hepatitis B, cytomegalovirus, and chemotherapy, may lead to what?
A

Clinical Medicine 1 (8 decks)

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