ORAL - ID Flashcards
GENERAL ABX COVERAGE
- Undifferentiated => piptaz + vanco
- Resp => ceftriaxone 2g + azithromycin 500mg + vanco
Critically with aspiration suspected => pip taz - Skin + soft tissue => ancef 2g + vanco 3.375g Q8H
- Abdominal => ceftriaxone 2g + flagyl 500mg
- **Meningitis **
Ceftriaxone 2g Q12
Vanco 15mg/kg Q6H (peds) Q12H (adults)
Elderly (>50), IC):
ampicillin 2g Q6H (listeria)
Viral: acyclovir 10-20mg/kg meningitic dosing
dex 10mg IV Q6H (0.6mg/kg/day Q6H)FOLLOW UP QUESTIONS - ABX effective against MRSA
ORAL: septra, clinda, doxy, linezolid, rifampin
IV: Vanco, dapto, linezolid - ABX effective against PSEUDO
piptaz, gentamycin/ tobramycin, ciprofloxacin, meropenem - ABX for VRE (DOLT)
daptomycin
oritavancin
linezolid
tigecycline - ABX for anaerobes
clindamycin
flagyl
amox/clav
ertapenum, meropenem
pip/taz - ABX for gram negative
piptaz
fluoroquinolones
carbapenems
aminoglycosides
later generation cephalosporins
FEVER IN RETURNING TRAVELER
- PPE/MOVID
BW: CBC, LFTs
thick/thin smears (q12H x3)
NP viral swabs, AFB
+/- stool cultures, viral serology, sputum
urine cultures
CXR - Malaria MGMT
ddx - thick + thin smears Q12H x3H (thick - dx, thin speciation)
**uncomplicated vs complicated **
=> uncomplicated - tolerate PO
=> complicate => not tolerate PO, EOD, >5% parasitemia
mgmt
prevention = malarone
uncomplicated/tolerate PO = malarone
requires IV = aresunate, exchange transfusion
non severe TX - ACT (artesunate, mefloquine)
severe TX - AM (artesunate, malarone), DQ (doxy, quinine)
exchange transfusion
avoid steroids (worse outcomes)
follow up questions
1. list airborne illnesses
measles
monkey pox
TB
Smallpox
chickenpox
COVID
- How to triage febrile illness at triage
PPE
sick contacts /travel hx
time line
HD - vitals - Questions to ask a returning traveller
where
how long, dates of travel
what’d you do there
when did symptoms start
how did you live (city, rural)
activities, sex, hospital / medical care, tattoo
ppx vaccination pretraval, malaria chemoppx - DDx for fever + returning traveller
malaria
viral hemorrhagic fever => ebola, chikungunya, dengue fever
infectious gastro (typhoid)
resp - MERS, TB
ARBOVIRUS + NEURO => Japanese encephalitis, Easter equine encephalitis, West Nile virus, St Louis encephalitis - Types of malaria
plasmodium
falciparum (bad - acidosis, RF, pulm edema, DIC, hypoglycemia, cerebral edema, jaundice)
ovale
vivax
malariae
knowlesi
(vector - anaphalodes) - Diagnostic features of severe malaria
FALCIPARUM isolated (+) PLUS
**Clinical (H2C2B3) **
=> Head - altered LOC, seizures
=> CV - CV collapse, resp failure
=> Blood - bleeding, jaundice, hemoglobinuria
LAB (GAAAL) and >10% parasitemia
=> glc 2.2
=> anemia HgB 70
=> acidosis
=> AKI (Cr >265)
=> lactate - complications of malaria
seizures
encephalopathy
ARDS
DIC/anemia
AKI
acidosis
BOTULISM CASE
CASE - descending weakness, symmetric
- floppy baby, poor feed
- B/L CN, bulbar involvement, symmetrical descending paralysis, constipation, urinary retention (normal sensory exam) => looks like anticholinergic
- U>L, P>D
- PPE/MOVID
exam - measure FVC/MIPS/MEPS (20/30/40) - MGMT
decontamination
consider gastric lavage if ingestion recent
elimination
enemas for toxin in GI tract (as long as NO ILEUS)
antidotes
ADULT - equine trivalent antitoxin 10cc
BABY - baby botulism IG, no antitoxin
WOUND - 1) surgical debridement
2) PenG 3mil U Q4H / Flagyl 500mg Q8H
confirm dx
toxin in blood, gastric contents, stool, wound
test food source if concerned for food borne - CONSULTS
ID consults
ICU for admission
public health
follow up questions
1. DDX for botulism
Polio
GBS
Diphtheria
Meningitis
Hypothyroid
Tick paralysis
MG
Lambert eaton
CVA
Paralytic shellfish
TETATNUS CASE
CASE - nasty laceration
- PPE/MOVID
- SUPPORTIVE
=> benzos
=> consider MgSO4
=> +/- rocuronium
=> NM blockade - but may also have laryngospasms - Antidote - NEUTRALIZE
HTIG 5000U into prox wound wound
TDAP 0.5cc IM - Antidote - prevent more toxin
flagyl 500mg IV TID (can consider PCN, however is GABA antagonist)
debride wound - Treat complications
rhabdo
HTN
Fracture, d/c
hyperthermia - CONSULTS
ID, ICU
Public health
follow up questions
1. Pathophys of tetanus
clostridium tetani
binds GABA irreversibly + blocks post synaptic release of GABA
toxin moves retrograde
- Tetanus Prophylaxis
clean wound: 10yrs immunized (nothing), >10yrs (dTAP, no TIG), incomplete vac (dTAP + TIG)
dirty wound: 5yrs immunized (nothing), >5yrs (dTAP), no immunization (DTAP, TIG) - DDX for tetanus
Strychnine
Black Widow
Dystonic reaction
Hypocalcemia
Rabies
Status epilepticus - List types of tetanus
generalized - trismus, opisthotonus, autonomic hyperreactivity
local - muscle spasms at site
cephalic - CN palsies
neonatal - generalized tetanus in newborn - Describe risk factors for tetanus
unimmunized
wound: >6hrs, >1cm,
stellate, denervated
ischemic
infected
contaminated w dirt
burns, frostbite
DIPTHERIA CASE
CASE - bull neck, soft palate paralysis, neuritis, cardiomyopathy, renal failure, organ necrosis
- PPE/MOVID
PPE - droplet precautions
consider intubation (difficult airway)
B/W - trop/ECG (myocarditis) - MGMT
diptheria anti-toxin 20 000 IM
erythromycin 500mg QID
debride blisters
immunization => TDAP (>5yrs since last)
prophylaxis (close contacts) => erythromycin 7d - Consults
ID, ICU
public health
follow up questions
1. list ddx for tetanus
mono
GAS
epiglottitis
MENINGITIS CASE
- PPE/MOVID
=> contacts (droplet contact) - LP (post CT) results
=> GR rods (E coli)
=> GR bacilli (H influenza)
=> GR diplococci (N meningitides)
=> GR + pairs ( S pneumo)
=> GR + chains (listeria) - MGMT
Ceftriaxone 2g Q12H
Vanco 15mg/kg q6H (PEDS) Q12H (ADULTS)
elderly - Ampicillin 2g IV
viral - acyclovir 10mg/kg IV Q8H
Cryptococcal - Amphotericin B, 5-flucytosine
Toxo - folic acid, pyramethamine and sulfadiazine - Meningitis chemoprophylaxis
Meningococcal
WHO: household, intimate contacts, HCW + direct mucosal contact w secretions
WHAT: Rifampin 600mg PO BID X4 / Cipro 500mg x1 / preg: CTX 250mg IM
H influenza
WHO: non preg household contacts (if kids 4yrs younger)
WHAT: Rifampin 600mg PO X4 - Indication for CT > LP
Previous CNS pathology
Altered LOC
Seizure
Signs of incr ICP
Immunocompromised
Focal neuro deficit
RABIES CASE
CASE - patient bit by a bat
- PPE/MOVID
=> determine vaccination to rabies status - Wound care
=> scrub wound with soap + water
=> rinse with povidone - MGMT
HRIG 20U/kg around wound => remainder IM in prox
vaccine => opposite limb to the IG
TDAP
HIV CASE
CLINICAL - B/L infiltrates + hypoxia in HIV
- PPE/MOVID
BW - CD4 counts, LDH, ABG (hypoxia) - MGMT
=> Septra 15mg/kg of TMP component divided by Q6H then 2 tabs Q8H
=> steroids if 1) A-a >35, 70>PaO2, resp distress
prophylaxis of CD4
MAC (CD4 50) - azithromycin
TOXO (CD4 100) - septra
PJP (CD4 200) - septra
Crypto / Histo - not recommended
- Consults
ID, ICU
FOLLOW UP QUESTIONS
1. AIDS defining illness
toxoplasmosis
CMV retinits
CNS lymphoma
PJP
Esophageal candidiasis
Kaposi sarcoma
MAC
PML - reactivation of the JV virus, demyelinating disease
HSV esophagitis
- 5 ring enhancing lesions
toxoplasmosos
crypotococcus
CNS lymphoma
Abscess
Tuberculoma
Glioblastoma
Neurocysticercosis - What are 5 derm findings of HIV
chronic HSV ulcers
Kaposi sarcoma
extra pulm TB
extra pulm cryto - Cryptococcus meningitis
Clinical - subacute, fever, HA, progressive ICP elevation
DX - serum, CSF cryptococcal antigen, india ink stain
mgmt - amphotericin B - Toxo presentation
dx - IgM + and No IgG (new infection)
mgmt - pyrimethamine, sulfadiazine, add leucovorin (prevent heme tox of pyrimethamine)
steroids (if mass effect/edema)
tx abx for meningitis
HEMORRHAGIC FEVERS CASE
CASE - fever, HA, arthralgias, pancytopenia
- PPE/MOVID
PPE - DDX of hemorrhagic fevers
dengue
yellow fever
chikungunya
ebola
Marburg - Dengue fever
incubation 4-7days
dengue fever => self limited, bone pain, desquam rash, periorbital pain
dengue hemorrhagic fever => vascular permeability, thrombocytopenia, spon bleeding
dengue shock syndrome
mgmt - supportive - Ebola fever
recent travel to africa, HA/N/V/D, weak, myalgias, hemorrhage
PPE = isolate (contact + droplet)
safety => ID, public health. do not handle until handling procedure
tx - IVF, blood, plt, FFP
HSV MGMT
Primary Oral or Genital
- Valacyclovir 1 g BID x 7 days
Recurrent oral
- Valacyclovir 1 g BID x 1 day
**Recurrent Genital **
- Valacyclovir 1g BID x 5 days
Whitlow
- Acyclovir 400 TID x 10 days
Encephalitis
- 10mg/kg q8
MEASLES CASE
- PPE/MOVID
airborne isolation x4 days after rash onset - mgmt
abx for complications (OM, PNA)
monitor for complications (encephalitis)
Vit A supplement (deficiency prolong recovery + risk of complications) - Consults
ID
public health
CHICKENPOX CASE
- PPE/MOVID
airborne isolation - Antiviral
=> valacylovir 1g TID (adults) / 20mg/kg TID (peds) - Shingles MGMT
PAIN control
within 72hr onset / >72h with new lesions = Valacyclovir 1g TID x7d
>72h + NO new lesions = no tx
preg + IC => tx
complications => post herpetic neuralgia, reye syndrome, necrotizing fascitis - Ramsey Hunt MGMT
Pain control
valacyclovir 1g TID x7d
prednison 1mg/kg x5d - VZV ophthalmicus
optho
pain control
valacyclovir
topical steriod w optho
Follow up questions
1. criteria for antivirals
(peds)
Unvaccinated adolescent
Secondary cases in household
Chronic cutaneous or pulm disorder
Inhaled steroids
Chronic asa
- List complications of chickenpox
pneumonia
Superinfection- GAS particularly with NSAID use
Encephalitis
Hepatitis
Reye syndrome
Pregnancy
AOM
TICK CASE
CASE = patient presenting with erythema migrans
- ddx for erythema migrans
Cellulitis
Fungal infection
Plant dermatitis
Drug eruption
Erythema multiforme
Erythema Nodosum
Erythema marginatum - MGMT
doxy 100mg PO BID X21d
=> no neuro sx (except bells)
=> no more than 1st deg AVB
If child (8) - amox 500mg TID X21d
neuro/meningitis CTX 2g IV x28d
prophylaxis doxy 200mg x1 dose
follow up questions
1. criteria for doxy prophylaxis
>8yrs
ixodes
attached >36H + engorged
start tx within 72H of tick rmoval
no c/I to doxy
- What is Jarish Herheimer
systemic inflammatory response following treatment of a disease caused by spirochetes (toxin released from lysed bacteria)
=> lyme
=> syphilis
=> leptospirosis - RMSF
presentation - fever, HA, arthralgia, vasculitic, myocarditis, ARDS
MGMT = Doxy 100mg BID
RPA
- PPE/MOVID
- MGMT
airway protection - awake intubation db set up
CTX, vanco
ENT
FOLLOW UP QUESTIONS
1. XR findings of RPA
Enlarged prevertebral soft tissues (C2 7mm, C7 14mm)
reversal of cervical lordosis
air / fluid level in pre vertebral tissue
FB
Soft tissue mass
VB destruction
GRAM STAINS
GRAM POSITIVE
- S aureus => cocci, clusters
- S pneumo => cocci, pairs (pneumo = 2lungs/pairs)
- Listeria => rods / chains
GRAM NEGATIVE
- N meningitidis => cocci (pairs)
- H flu => coccobacilli
- Pseudomonas => gram neg rods
- E coli => gram neg rods
