MTB infectious disease Flashcards
What type of hepatitis is treated, acute or chronic hep A,B or C?
Acute hep C
What is the treatment for acute Hep C?
interferon
Ribaviron
Boceprevir or Telaprevir
(BIRT)
Treatment decreases the likelihood of developing chronic hepatitis C
What is the criteria for dx of chronic Hep B?
What are the treatment options (6)?
Presence of surface Ag >6 mo If e-Ag is present and DNA polymerase is elevated treat with ONE of the following 1. Entecavir 2. Adefovir 3. Lamivudine 4. Telbivudine 5. Interferon 6. Tenofovir
What are the side effects of interferon?
arthralgia/myalgia
leukopenia and thrombocytopenia
depression and flu-like symptoms
What is the goal of chronic hep therapy?
- reduce DNA polymerase levels to undetectable levels
- convert someone who is e-Ag positive to anti-hepatitis e-Ab
What is the role of liver biopsy in hepatitis management?
Presence of fibrosis indicates need to start treatment immediately for hep B or C
if there is active viral replication, fibrosis will progress to cirrhosis which is not reversible
Do most people have symptoms with acute hepatitis C infection?
No
How do you treat genotype 1 hepatitis C?
How are other genotypes treated?
Genotype 1: ledipasvir/sofosbuvir (Harvoni) - orally x12 weeks
Other: Sofosbuvir (Sovaldi) and ribavirin orally
What is the goal of treatment of Hep C?
achieve undetectable viral load
How do you treat hep C that has failed other treatments?
interferon
What is the only type of acute hepatitis that is treated?
acute hepatitis C
What is a major side effect of Ribavirin?
anemia
Everyone born between ____ and ____ must be tested for hepatitis C.
1945 and 1965
What are the cure rates for hep C?
exceeding 90%
What is one way to differentiate between urethritis and cystitis?
urethral discharge
What are 4 causes of urethritis?
gonorrhea
chlamydia
mycoplasma genitalium
ureaplasma
What are the 3 most accurate tests for gonorrhea/chlamydia?
urethral culture
DNA probe
NAAT
What is the treatment for cervicitis?
azithromycin and ceftriaxone as a single dose
azithromycin and doxycycline have equivalent efficacy - but doxy is harder to use
What are the 5 presenting sx of someone with PID?
- lower abdominal tenderness
- lower abdominal pain
- fever
- cervical motion tenderness
- leukocytosis
What is the most accurate testing for PID?
Laparoscopy - only do this if the dx is unclear, sx persist despite tx, recurrent episodes for unclear reasons
What test can be done to confirm the dx of PID?
cervical swab for culture, DNA probe, or NAAT
These tests will clarify the need to treat the partner for an STD
What are the inpatient and outpatient treatments for PID?
What organisms are being targeted when treating for PID?
If pt is allergic to PCN (anaphylaxis), what can be used?
inpatient: Cefoxitin or cefotetan + doxy
outpatient: ceftriaxone and doxy - possibly with metronidazole
treatment is targeting chlamydia and gonorrhea
allergy to PCN
- inpatient: clindamycin, doxycycline, gentemycin
- outpatient: levoquin and metronidazole
A pt presents with tender lymph nodes that are suppurating, what is the most likely dx?
lymphogranuloma venereum
What are dx tests are performed to dx syphilis?
Dark-field microscopy –> if this is positive for spirochetes, no further testing is needed.
VDRL or RPR - 75% sensitive in primary syphilis
FTA (fluorescent treponemal antibody absorption test) or MHA-TP (microhemagglutination test for treponemal pallidum) - confirmatory
What dx test is used for chancroid?
stain and culture on specialized media
What dx is used for lymphogranuloma venereum?
complement fixation titers in blood
NAAT pm swab
What dx test is used for herpes simplex?
- what is the best initial test
- what is the most accurate test
Tzanck prep - best initial test
viral culture is most accurate
What is the treatment for syphilis? (1)
What if they are allergic to the initial tx?
intramuscular benzathine PCN
If allergic: Doxycycline
What is the treatment for Chancroid?
What organism is being targeted?
tx: azithromycin - single dose
org: Haemophilus ducreyi
What is the treatment for lymphogranuloma venereum?
Docycycline
What is the tx for herpes simplex?
What is the treatment if resistant to first line therapy?
acyclovir
valacyclovir
famcyclovir
- Foscarnet for acyclovir-resistant herpes
If VDRL or RPR are negative - does this rule out neurosyphilis?
nope!
What is the most sensitive test for dx neurosyphilis?
FTA
- if this is negative, it means the person does not have neurosyphilis
What are 7 causes of false positive VDRL/RPR?
- infection
- older age
- injection drug use
- AIDS
- malaria
- antiphospholipid syndrome
- endocarditis
What is the treatment for all stages of syphilis? What if the pt is allergic?
- primary and secondary syphilis - tx = PCN IM or doxycycline if allergic
- tertiary syphilis tx = PCN IM or desensitize to PCN if PCN allergic.
What is the treatment for neurosyphilis in a pregnant women?
Desensitization
What rxn can occur within the first 24 hours following treatment of syphilis?
Jarisch-Herxheimer rxn
fever and worse sx after tx
give aspirin and antipyretics –> it will pass
What is the viral etiology of genital warts?
papilllomavirus
How is condylomata acuminata dx?
visual appearance
- NOT biopsy, serology, stain, smear, or culture
What are the uses of Imiquimod?
- genital warts
- actinic keratosis
- basal cell cancer
it is an immunostimulant that leads to the slough off of the lesion
it does not burn or damage skin
What are 3 ways to treat genital warts?
- cryotherapy - liquid nitrogen
- surgery
- podophyllin
- trichloacetic acid
- Imiquimod - immunostimulant that leads to the sloughing off of the lesion
What 2 treatments are available for pediculosis (crabs)?
- permethrin - first line
- lindane - more toxic
What is the treatment for scabies?
- permethrin
- ivermectin - is used for widespread disease and severe disease which needs repeat dosing
What is the best initial treatment for pyelonephritis?
quinolones
What are the presenting sx of cystitis?
dysuria
suprapubic pain/discomfort
mild or absent fever
What is the best initial test for UTI?
What is the most accurate test?
initial: UA with >10 WBC
accurate: urine culture
note: when the sx are clear for cystitis and there are WBCs in the urine –> just treat - no need for urine culture or imaging
List 5 meds that can be used to tx cystitis.
- Nitrofurantoin –> uncomplicated tx for 3 days, if anatomic abnormality tx for 7 days
- fosfomycin
- TMP/SMX
- ciprofloxacin - not used routinely in order to avoid resistance
- cefixime
When should you do a urine culture or imaging with cystitis?
When there are frequent episodes that do not respond to treatment
What are teh presenting sx of pyelonephritis?
- flank or costovertebral tenderness
- high fever
- may have abdominal pain d/t inflamed kidney
- UA shows increased WBCs
- perform CT or sonogram to check for anatomical abnormalities
What meds can be used to tx pyelonephritis?
- ceftriaxone or ertapenem –> ceftriaxone is the first tx for pyelonephritis
- until culture is known - ampicillin and gentamicin
- ciprofloxacin - oral for outpatient tx
Any group of drugs for gram negative bacilli would be effective for pyelonephritis
How do you increase the dx yield of urine culture with acute prostatitis?
prostate massage
What is the tx for prostatitis?
Same tx used for pyelonephritis
6-8 wks of ciprofloxacin or TMP/SMX for acute prostatitis
The difference between pyelonephritis tx and prostatitis tx is time. Pyelo tx = 7 days of TMP./SMX, cipro or fluoroquinolones.
Prostatitis is for 6-8 weeks depending on the chronicity
The degree of endocarditis is proportional to what?
the degree of damaged valve.
What kind of valve is associated with the most severe endocarditis?
prosthetic valves
How would you treat endocarditis caused by
- Strep viridens
- S. aureus (susceptible)
- Fungal
- S. epi or resistant staph
- Enterococci
viridens - ceftriaxone x 4 wks aureus - oxacillin, nafcillin, cefazolin Fungal - amphotericin and valve replacement epi or resistant staph - vancomycin Enterococci - ampicillin and gentimicin
How do you treat a tx resistant endocarditis?
aminoglycoside and extend the duration of treatment
What treatment is added for prosthetic valve endocarditis with staph?
rifampin
When is surgery needed to tx endocarditis?
- CHF from ruptured valve or chordae tendineae
- Prosthetic valves
- Fungal endocarditis
- abscess
- AV block
- recurrent emboli with abx
What organisms are difficult to grow in regular media and cause culture negative endocarditis?
What are the 2 most common causes of culture negative endocarditis?
How do you treat infection with these orgs?
HACEK
- Haemophilus aphrophilus
- Haemophilus parainfluenza
- Actinobacillus
- Cardiobacterium
- Eikenella
- Kingella
Most common = coxiella and Bartonella
Tx = Ceftriaxone
What meds are used to prophylax a patient for endocarditis?
- amoxicillin - prior to surgery
- if allergic - clindamycin, azithromycin, clarithromycin
What is the causative organism of Lyme disease?
borrelia burgdorferi - carried by the ixoides scapularis deer tick
What joint is most commonly affected in lyme disease?
Knee
What are 3 neurological manifestations of lyme disease?
- meningitis
- encephalitis
- cranial nerve palsy = most common neuro presentation 7th CN or Bell’s palsy
What is the most common cardiac manifestation of lyme disease?
transient AV block
What 5 serologic tests can be used to test for lyme?
IgG, IgM, ELISA, western blot, PCR testing
What is the treatment for the following presentations of lyme disease
- rash
- joint, nerve palsy
- cardiac and neuro manifestations other than 7th cranial nerve
Rash - doxycycline, Amoxicillin or cefuroxime
Joint/7th cranial nerve palsy - Doxycycline, Amoxicillin or cefuroxime
Cardiac/neuro other than 7th CN palsy - IV ceftriaxone
What is the initial and what is the confirmatory test for HIV in an adult?
initial test: ELISA
confirmatory: Western Blot
Infant - PCR or viral culture. ELISA is not accurate b/c mom’s antibodies can be present in infant up to 6 months following delivery.
What are 3 ways in which viral load testing by PCR-RNA is helpful in HIV dx?
- measure response to tx
- detect tx failure
- Dx HIV in babies
Goal is to drive levels below 50 microliters - this is a good indication that CD4 levels will rise
Life expectancy of someone with undetectable levels of HIV virus is the same as someone not infected with HIV
When should you do genotyping/viral resistance testing of a pt infected with HIV?
How many medications and from how many different classes of medications should be used to treat HIV?
- prior to tx start
- when pt is not responding to tx
3 meds from 2 different classes.
List 3 different reasons for which HIV treatment would be started.
- CD4 count below 500 in asymptomatic pt
- Very high viral load >100,000
- Opportunistic infections are present
Antiretroviral meds are acceptable to start even if CD4 count is above 500
Note: CD4 count rising lags behind decrease in viral load
What is the best treatment to start in an HIV pt?
What is an alternate to this, if the pt is resistant?
Atripla = emtricitabine, tenofovir, efavirenz
Either: atazanavir, darunavir, raltegravir combined with emtricitabine/tenofovir
What med is given to boost levels of darunavir or atazanavir?
Ritonivir
What are the 3 classes of the first line antiretroviral medications?
- Nucleoside and nucleotide reverse transcriptase inhibitors
- Non-nucleoside RTI
- Protease inhibitor
What are the 2 classes of 2nd line HIV antiretrovirals?
- Entry inhibitors
Enfuvirtide
Maraviroc
- Integrase inhibitor
Raltegravir
Dolutegravir
Elvitegravir with cobicistat (cobicistat inhibits the metabolism of elvitegravir - increases levels)What is the postexposure prophylaxis regimen for someone with a significant HIV needle stick or sexual exposure?
combo therapy x 4 weeks
List the adverse effects of the following meds
- Zidovudine
- Stavudine and didanosine
- Abacavir
- Protease inhibitor
- indinavir
- Tenofovir
- Zidovudine –> anemia
- Stavudine and didanosine –> peripheral neuropathy and pancreatitis
- Abacavir –> hypersensitivity (determined by HLA B5701), SJS
- Protease inhibitor –> hyperlipidemia, hyperglycemia
- Indinavir –> Nephrolithiasis
- Tenofovir –> Renal insufficiency
What antiretroviral should be avoided in pregnancy?
What are the treatment guidelines for a pregnant HIV + mother?
No Efavirenz - teratogenic in animals –> replace with protease inhibitor
- Mom needs to be on treatment throughout pregnancy regardless of viral load and CD4 count - to prevent perinatal transmission
- Administer Zidovudine during delivery
- make sure viral load is controlled by time of parturition
- must do C-section if viral load is >1000
- CD4 count and viral load have no bearing on HIV treatment of pregnant woman - always always always treat with antiretrovirals
What med should an infant born to a mother positive for HIV be given and for how long?
Zidovudine during delivery and for 6 weeks following delivery.
