Lecture 4 (ID)-Exam 2 Flashcards
1
Q
Bacterial Meningitis:
* Most likely organism that what?
* What is key to decrease long-term sequelae?
* What is ideally done before antibiotics?
A
- Most likely organism varies by age
- Rapid diagnosis and treatment is key to decrease long-term sequelae
- Ideally blood cultures and lumbar puncture (LP) should be completed before antibiotic treatment
* Do not delay initiation of therapy for LP / neuroimaging
2
Q
When should CT be done in bacterial meningitis?
A
Neuroimaging (CT) indicated for patients with focal neurologic deficits, seizures, immunocompromised, papilledema, altered consciousness to rule out mass or increased intracranial pressure prior to LP
3
Q
Bacterial Meningitis
When should empiric therapy be based on and how long should they be on it
A
- Empiric therapy should be based on most likely organism and antibiotic ability to penetrate the CNS
- Empiric therapy should continue for 48 to 72 hours; until bacterial meningitis is ruled out – culture or PCR
4
Q
- What does inflamation of the meninges cause?
- What antibiotic characterics increase CNS penetration?
A
5
Q
Meningitis
Newborn to one month:
* What are the most common organisms? (4)
* What is the empiric therapy?
A
Organisms: GElH
* Group B streptococci
* E. coli
* Listeria monocytogenes
* Herpes simplex virus (HSV)
Txt:
* Amipicllin plus cefriazone or cefotamine or aminoglycosides and +/- acyclovir (HSV)
6
Q
Meningitis
1 month to 50 years
* What are the most common organisms? (2)
* What is the treatment?
A
Organisms:
* S. pneumoniae
* N. meningitidis
Treatment:
* Vanco plus cefriazone plus dexamethasone (start at or before first abx dose)
7
Q
Meningitis
> 50 years or co- morbidities
* What are the mc organisms (3)
* What is the treatment?
A
Organisms:
* N. Meningitidis (~50%)
* S. Pneumoniae (~40%)
* Listeria monocytogenes (~5%)
Treatment:
* Vancomycin plus ampicillin plus ceftriaxone plus dexamethasone
8
Q
- How is neonatal HSV encephalitis happen?
- What is the presentation?
- How do you dx it?
A
- perinatal transmission of HSV (1 or 2); often no history of maternal herpes infection; maternal disease may be asymptomatic-> Most commonly seen within first month of life
- SEIZURES, INCREASED LIVER ENZYMES, fever, lethargy, poor feeding
- Diagnosis: PCR of CSF
9
Q
What is the treatment of neonatal hsv encephalitis?
A
- Acyclovir until HSV ruled-out or 21 days minimum
- Test for cure via CSF PCR at 21 days; if positive treat 7 more days
- Suppressive therapy with acyclovir continued for 6 months
10
Q
A
11
Q
Erysipelas vs cellulitis?
A
12
Q
What is this? What organisms (2) is this caused by?
A
Impetigo-Strep or staph
Common in kids, can be local or diffused
13
Q
What is this?
A
Lymphangitis
14
Q
What are the primary skin and soft tissue infections? What is there organism?
A
- Erysipelas: Group A Strep (GAS)
- Impetigo: S. aureus, GAS
- Lymphangitis: GAS; occasionally S. aureus
- Cellulitis: GAS, S. aureus, rarely other gm +/g m -, anaerobes
15
Q
What are the secondary skin and soft tissue infections and the organsims that causes them (2)?
A
- Bite wounds animal: Pasteurella spp (multocida), S. aureus, Capnocytophaga spp, Bacteroides spp
- Bite wounds human: Eikenella, same as animal bites
16
Q
What is the first line txt of Erysipelas? What is the second line (lower yield)
Facial?
A
Oral:
1. Penicillin or amoxicillin
2. Cephalexin (not IgE)
IV:
1. Penicillin or ampicillin
2. Cefazolin (not IgE) or vancomycin (IgE)
Vanco for facial erysepelas
17
Q
What is the first line txt of impetigo? What is the second line (lower yield)
A
Oral :
1. Penicillin or Trimethoprim-sulfamethoxazole or mupirocin
topical (if local)
2. Cephalexin
18
Q
What is the first line txt of Cellulitis? What is the second line (lower yield)
A
Oral:
1. Cephalexin or dicloxacillin
2. TMP-SMX or clindamycin
IV:
1. Vanco
19
Q
What are the organisms and treatment of cat BITE?
A
Organisms:
* Pasteurella multocida (MAIN)
* Staphylococcus aureus
* Capnocytophaga spp
* Bartonella henselae
Txt: Amoxicillin/clavulanate
20
Q
What are the organisms (4) and first line treatment of a dog BITE? What is the second line (low yield)?
A
Organisms:
* Pasteurella canis (Dr. Sereda had this one in his PP)
* Staphylococcus aureus
* Capnocytophaga spp
* Bacteroides spp
Treatment:
* First-line: Amoxicillin / clavulanate
* Second-line: Clindamycin plus TMP/SMX or a fluoroquinolone
21
Q
What are the 3 mc organisms in human bite and what is the first line early, first line infected?
A
Organisms:
* Streptococci
* Staphylococcus aureus
* Eikenella corrodens
Txt:
* First-line early: Amoxicillin / clavulanate
* First-line infected: ampicillin / sulbactam or cefoxitin or piperacillin / tazobactam
22
Q
FOR ALL BITE WOUNDS WHAT IS FIRST LINE?
A
amoxicillin/clavulanate
23
Q
What is acute osteomyelitis?
A
Typically presents with a symptom duration of a few days or weeks
* Radiographic changes not evident
24
Q
What is chronic osteomyelitis?
A
characterized by long- standing infection over months or years
* Bone ischemia and necrosis common
* Fistula tracts from bone to skin = pathognomonic
25
What is nonhematogenous OM and Hematogenous OM?
Nonhematogenous osteomyelitis
* Trauma, surgery, soft-tissue infection
Hematogenous osteomyelitis
* Bacteria seed bone in the setting of bacteremia
* Vertebral osteomyelitis MCC – poly microbial
26
What is the most common organisms for hematogenous and vertebral OM? What is the empiric therapy?
Organism:
* S.aures
* Strep pyogenes
* Salmonella with a pt of sickle cell
Txt:
* Vanco + 3rd/4th gen cephalosporin
27
What is the mc organisms and empiric therapy for chronic OM?
Organism:
* S. Aureus
* Enterobacteriaceae
* Pseudomonas
Empiric therapy:
* No recommended because you need to wait for results
28
OM treatment:
* What is essential?
* What is the empiric therapy?
* What is the duration of therapy?
* Bone culture essential unless pathogen isolated from blood
* Vancomycin + ceftriaxone OR ceftazidime OR cefepime
* Duration: 6 to 8 weeks acute infection; longer with chronic infections– exact course dictated by infectious disease specialist-> Conversion to oral therapy once patient stabilizes
29
OM pathogen specific therapy:
* What is first line for MSSA?
* What is second line?
First line:
* Nafcillin 2gm IV Q4H
* Oxacillin 2gm IV Q4H
* Cefazolin 2gm IV Q8H (first gen)
Alternative
* Clindamycin 600 mg IV Q8H
* Ciprofloxacin 400 mg IV Q8H
* Levofloxacin 750 mg IV Q24H
30
OM pathogen specific therapy:
* MRSA: what is the first line and second line?
* First: Vancomycin 15 to 20 mg/kg
* Second: Linezolid or Daptomycin
31
OM pathogen specific therapy:
* Pseudomonas aeruginosa: what is the first line?
* Cefepime 2gm IV Q12H
* Ceftazidime 2gm IV Q8H
32
SEPTIC ARTHRITIS – ACUTE MONOARTICULAR
* What is is?
* What are the most common organisms?
* Bacterial infection of joint space associated with rapid joint destruction (days)
* MC in healthy adults or prosthetic joints: S.aureus
* Strept pyogenes
* Gram negative is rare ( immunocompromised, IV drug users, elderly)
* +/- N. honorrhea in young adults with STD risk
33
What are the s/s of septic arthritis?
MC monoarticular joint pain, swelling, erythema, warmth, **limited ROM**
* +/- systemic symptoms – fever, chills, rigors
34
What is the txt plan include of septic arthritis?
Treatment plan should include joint aspiration and drainage, antibiotic therapy and orthopedic consult
35
* What should you do with with synovial fluid aspiration and drainage? What suggestive of septic arthritis?
* Rapid initiation of treatment imperative to prevent
* Cell count, gram stain, culture (gold standard)
* Multiple daily aspirations / surgery may be required
* Purulent fluid with WBC ≥ 50, 000 suggestive of septic arthritis
* Rapid initiation of treatment imperative to prevent joint damage
36
Acute monoarticular empiric txt is dictated by what?
gram stain and STD risk
37
ACUTE MONOARTICULAR
* What do you treat if std risk with gram stain negative/gram negative diplococci or gram stain positive?
38
ACUTE MONOARTICULAR
* What do you treat if no/low std risk with gram stain negative or gram stain positive?
39
How long is septic arthritis txt?
* When can IV be converted to oral?
40
Cat scratch disease
* What is the sxs?
* What is the bacteria that causes it?
* Most common in who?
sx: Febrile illness with subacute regional lymphadenopathy
* Self-limited regional lymphadenitis
* 90% patients with high fever and lymphadenopathy
* Spontaneous resolution within 2 to 4 weeks in most cases
* Rarely severe, disseminated disease
Bacteria
* Bartonella henselae - intracellular gram-negative rod
Common in:
* 50% < 18 years of age
41
How do you diagnosis cat scratch disease?
* ± history of cat contact
* Positive antibody test for Bartonella henselae
42
What is the txt for cat scratch disease (KNOW THE DOSES) for adults and pediatrics?
First-line: Azithromycin
* Adults: 500mg PO day 1, then 250mg PO daily x 4 days (THINK 500 years old-adult)
* Pediatric patients: 10mg/kg PO day 1, then 5mg/kg PO daily x 4 days (THINK 10 yo kid)
43
Tooth infections:
* What is the mcc?
* What is the etiology?
* MCC = dental caries or periodontal disease (gingivitis / periodontitis)
* Etiology: polymicrobial including viridians group streptococcus, Peptococcus, Peptostreptococcus, Prevotella
44
* What is the first line txt for tooth infections (3)?
* What is the txt if penicillin allergic?
First-line:
* **Amoxicillin** (better gram - coverage)
* Penicillin
* Amoxicillin/clavulanate
Penicillin allergic: Azithromycin or clindamycin
45
What are the complications of tooth infections?
* Cellulitis
* Abscess formation
* Sinusitis
* **Ludwig’s angina – bilateral infection of submandible causing posterior displacement of tongue**
* Surgical drainage of abscess required if present
* Watch airway
46
What is ludwig's angina in tooth infections?
Ludwig’s angina – bilateral infection of submandible causing posterior displacement of tongue
* Surgical drainage of abscess required if present
* Watch airway
47
STREPTOCOCCAL PHARYNGITIS
* What is the mc organism? What age group?
* Streptococcus pyogenes AKA Group A Streptococcus (GAS)
* MCC of bacterial pharyngitis (viral MC overall)
* MC in children > 2 years and adolescents
48
What are the txt goals of streptococcal pharyngitis (3)?
* Reduce duration and severity of symptoms
* Prevent acute and delayed complications-> Rheumatic fever
* Prevent the spread of infection to others
49
* What is the DOC for strep pharyngitis? What are the alternatives?
* When can people return to work or school?
DOC: penicillin or amoxicillin PO x 10 days
Alternatives:
* Penicillin G benzathine IM
* Cephalexin
* Clindamycin x 10 days
* Azithromycin x 5 days
Return to school or work 24 hours after first dose of antibiotic
50
What are the post streptococcal complications?
* Tonsillopharyngeal cellulitis or abscess
* Scarlet fever
* Acute rheumatic fever – prevented by treatment
* Acute glomerulonephritis – not prevented by treatment
* Post-streptococcal reactive arthritis
* TSS
* Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS) – s**udden onset tics / obsessive compulsive disorder**
51
What is the difference between pans and pandas?
52
GIARDIASIS
* What are all the offical names? Mc cause of what?
* How do you get it?
* Giardia lamblia (aka G. duodenalis, G. intestinalis); MC intestinal parasite responsible for diarrhea worldwide
* MC intestinal parasite in the US
* Ingestion: **contaminated water; fresh water; usually history of camping or hiking**
53
What is the first line for girardiasis and alternatives?
First-line treatment:
* Metronidazole 250 mg PO three times daily x 5 to 7 days OR
* Tinidazole 2 gm PO x 1 dose
Alternatives:
* Nitazoxanide (Alinia)
* **ParoMOMycin** (DOC pregnancy – not readily available)
54
Toxoplasmosis:
* What is it caused by?
* Most common what?
* What is the txt for immunocompetent pt that is not preg?
* toxoplasma gondii – intracellular protozoan
* Most commonly opportunistic infection in immunocompromised host
* Immunocompetent – **generally no treatment** if not pregnant
55
What is the treatment for Immunocompetent: active ocular retinochoroiditis MC?
* Pyrimethamine +Sulfadiazine + Leucovorin
* Prednisone if threat of vision loss
* Treat for 1-2 weeks past symptom resolution
56
How do you treat chronic toxoplasmosis?
TMP-SMX-> up to year
57
What is common sx of toxoplasmosis for immunocompromised? What do you txt it with?
* Immunocompromised: brain abscess, encephalitis MC
* Ring enhancing lesions on CT or MRI of brain
Treatment:
* FIRST LINE: TMP-SMX for 6 weeks
* Pyrimethamine +Sulfadiazine + Leucovorin and Prednisone if threat of vision loss
58
Pyrimethamine
* What is the MOA?
* What are the adverse effects?
* When do you not use?
59
Under helminths
* What are cestodes?
* What are trmatodes?
* What are nematodes?
60
# These are the mc so I would consider high yield
ANTINEMATODAL AGENTS
* What is the MOA, indication and Adverse effects of Albendazole and Mebendazole
61
ANTINEMATODAL AGENTS
* What is the MOA, indication and adverse effects of pyrantel pamoate?
62
ANTINEMATODAL AGENTS
* What is the MOA, indication and adverse effects of Ivermectin?
63
COMMON NEMATODES
* What is the name for round worm and DOC?
* What is the name for pinworm and DOC?
PIN WORM: TREAT WHOLE FAM
64
Neurocysticercosis
* What is the DOC?
Albendazole ± praziquantel ± dexamethasone PLUS anti-seizure medication
65
CESTODES (TAPEWORMS)
* Two different diseases depending on what?
route of transmission
66
CESTODES (TAPEWORMS): Intestinal tape worms
* Transmitted how?
* Growth where?
* What are the sx?
* What is the tx?
67
CESTODES (TAPEWORMS): Cysticercosis
* How do you get it?
* What does this infect?
* What are the symptoms?
68
What is the txt of cysticerosis
Albendazole + praziquantel x 10 days; ± dexamethasone
* PLUS anti-seizure medication up to two years
69
TREMATODES (FLUKES)
* What is the mc reservior?
* What is the treatment?
* Snail MC reservoir
* txt: Praziquantel
70
What is the MOA, SE and alternative Praziquantel in flukes?
71
CUTANEOUS LARVA MIGRANS
* What is it?
* What are the sx?
* Common in where?
* What is the dx?
* Cutaneous penetration of dog or cat hookworm
* Pruritic, serpiginous, cutaneous migratory tract
* Common in topical / subtropical climates with beach exposure
* Dx: clinical
72
What is the txt of Cutaneous larva Migrans?
Albendazole or Ivermectin
73
A 4-year-old girl is brought by her mother complains of genital and anal itching, especially at night when she is going to bed. The girl is otherwise healthy and her vaccinations are up to date. Her temperature is 97.8°F, blood pressure is 110/75 mmHg, pulse is 88/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for excoriations over the girl's anus and near her vagina. Which of the following is the most likely infectious etiology?
A Ascariasis
B Candida albicans
C Gardnerella vaginalis
D Herpes simplex virus
E Enterobius vermicularis
E Enterobius vermicularis
74
Malaria:
* What does treatment depend on?
75
Malaria txt-quinoline:
* What is the MC first line of quinoline derivative?
* What is CI in pregnancy?
* Used in combination of what?
* Chloroquine
* CI in preg: Primaquine
* Used in combo with doxy, clindamycin for sereve infection
| Multiple adverse effects
76
Malaria txt-artemisinin derivatives:
* DOC for severe malaria?
* Effective?
* Used in combination to do what?
* Artesunate
* Effective against all strains of malaria with little resistance
* Used in combination to reduce resistance-> Artemether-lumefantrine (Coartem)
## Footnote
Safe in preg and minimal SE
77
A 35-year-old male is brought to the emergency department by his male partner presenting with fever, headache, altered mental state, and left hemiparesis. The patient is HIV positive, and his CD4+ count one month ago was 73 cells/μL. He has not been adherent to his antiretroviral and prophylactic therapy. An MRI of the head demonstrates ring-enhancing lesions and surrounding edema. Enzyme-linked immunoassay (ELISA) is positive for anti-toxoplasma IgG antibodies. The treatment of choice is:
A TMP-SMX
B Pyrimethamine + sulfadiazine
C Clindamycin
D Atovaquone
E TMP-SMX + pyrimethamine
B Pyrimethamine + sulfadiazine
78
79
BACTERIAL VAGINOSIS
* Not a what? What is the offical name?
* What ar the sxs?
* Not an STI but can be transmitted sexually
* Gardnerella vaginalis
80
* What is the treatment for BV? (KNOW DOSE)
* What do you use for pregnancy?
* What do you do for refractory/recurrent infections?
* DOC: **Metronidazole 500 mg PO BID x 7 days**
* Preg: Oral metronidazole or oral clindamycin x 7 days
* Refract/recurrent infections: Boric acid capsules 600 mg intravaginally daily x G21 days after initial antibiotic treatment complete-> CONDOM
* 50% increase in cure rate if patients abstain from intercourse or use condoms during treatment
81
CANDIDA VULVOVAGINITIS
* What is the caused by?
* What are the risk factors?
* What are sxs?
* How is it dx?
* Fungal infection usually caused by Candida albicans
* Risk factors – broad-spectrum antibiotics, pregnancy, diabetes, immune compromise, silk underwear
Signs:
* Pruritis may be severe, and is most prominent symptom
* Thick, adherent curd like white discharge in vaginal vault
* Not malodorous and pH is normal (<4.5)
Diagnosed by clinical appearance or KOH prep of slide with microscopy
82
Candida vulvovaginitis treatments
* What are topcial therapies? What are oral therapys (who is this not recommended to)
Topical therapies: 1-to-7-day regimens
* Antifungal tablets or creams
* Butoconazole
* Clotrimazole
* Miconazole
* Terconazole (not OTC but more effective
Oral therapy:
* Fluconazole 150mg x 1 to 3 doses (q 72 hours)
* Not recommended in first trimester
83
TRICHOMONAS VAGINALIS: sxs
84
Trich vaginalis:
What is the treatment for men and women (know doses)?
What is the alternative?
85
N. gonorrhoeae:
* What is the txt? (doses)
Chalamydia:
* What is the txt? (doses)
* Gon: Ceftriaxone 500mg IM one time (be careful because Dr. S has ceftriaxone and doxy for txt)
* Chlamydia (d-k): Doxy 100 PO BID for 7 days (Clams on the doc)
86
What is the sxs and txt for C.trachomatis serovar L1-L3 (Lymphogranuloma venereum)?
* sx: Small, painless genital ulcer that resolves before lymphadenopathy; unilateral buboes
* txt: Doxycycline 100mg PO BID x 21 days
87
* What do you give for a patient over a 150kg or for conjunctivitis (n.gon)?
* What do you give to a preg person for chlamydia?
* Ceftriazone 1000mg IM x 1 dose if ≥ 150kg or for conjunctivitis
* Azithromycin 1gm one dose
88
89
Fill in for syphilis
90
* What is the txt of syphilis for primary, secondary or early latent?
* What do you use for pen allergic?
91
# HIV txt
* What do NRIT/NnRTI do?
* What do EI/mAbs, cCr5 and FI do?
* What do PI do?
* What do Insti do?
92
* HIV in all patients but especially in patient who have what?
* What should patients have done prior to starting therapy?
* What is high therefore most patients should be txt with what?
93
What is the guideline for starting HIV meds?
INSTI plus 2 NRTIs
94
Who should be on HIV prep?
* HIV positive partner
* Bacterial STI in last 6 months
* History of no or inconsistent condom use
* IV drug use
95
What must one meet for starting PREP?
* Documented HIV Ag/Ab negative 1-week prior to starting therapy
* No symptoms of HIV
* Estimated CrCL ≥ 30 ml/min
* No medication contraindications
96
What are the different regimens for PREP?
97
HIV PEP – POST EXPOSURE: Occupational or nonoccupational
* Exposure to what?
* PEP is not effective if started when?
* What should one obtain?
* Exposure to potentially infectious fluids; known HIV positivity or unknown status
* PEP unlikely to be effective if started > 72 hours post-exposure
* Obtain rapid tests when available; do not hold treatment for prolonged results
| Regimens low yeild
98
99
100
Topical candidasis:
* What do you txt for cuatenous and vulvovaginal?
101
What is th DOC for diaper dermatitis from candidias?
Topical nystatin
102
What is the txt of thrush and espophageal candidaisis?
103
What is the first line for histoplamosis? (mild/mod and servere)
104
What is the first line for blastomycosis? (mild/mod and servere)
* Liposomal preferred
105
What is the first line for coccidoimycosis? (mild/mod and servere)
106
CRYPTOCOCCUS:
* What is it?
* What population?
107
What is the txt of crytococcus for pulmonary disease/
Fluconazole
108
What is the txt of crytococcus meningitis/disseminated disease?
* Induction
* consolidation
* maintenance
* Induction: Liposomal amphotericin and flucytosine
* consolidation: fluconazole (400mg for 10 week) then lower dose fluconazole for maintenance (200mg for 12 m)
109
Who do you see with pneumocystis jirovecii?
110
pneumocystis jirovecii txt?
111
A 32-year-old man with a two-week history of fever and dry, nonproductive cough. For the past five days, he has been having shortness of breath. There is no history of pleuritic chest pain or rigors. Past medical history is significant for HIV. His temperature is 100.4°F (38°C), the pulse is 92/min, O2 saturation is 92%, respirations are 18/min, and blood pressure is 120/70 mmHg. An ABG is performed and reveals a PaO2 of 64 mmHg. Purified protein derivative (PPD) is negative. CD4 cell count is 190. The chest exam reveals bibasal crackles. The chest radiograph shows interstitial infiltrates bilaterally. HAART therapy and IV trimethoprim-sulfamethoxazole are initiated. What other treatment is recommended for this patient?
A dapsone
B rifabutin
C prednisone
D atovaquone
E mechanical ventilation
C prednisone
112
A 29-year-old woman with a history of asthma comes to the emergency department complaining of weakness for the past three days. She reports fever, malaise, a non- productive cough, and muscle soreness. Physical examination shows a temperature of 101.3F, BP of 124/80, P88, and a SpO2 of 99% on RA. She appears tired but otherwise well. She has no focal weakness, and auscultation of her lungs is normal. A chest x-ray is negative for an acute process. Rapid flu testing is positive for influenza A, and nasal wash cultures are pending. Which of the following is the best treatment for this patient?
A amantadine Q
B oseltamivir
C influenza vaccination
D supportive care and reassurance
E zanamivir
D supportive care and reassurance
