Question book 4 Flashcards
73 year old with UTI
Why are they more common in elderly men?
urethral catheterisation normal-sized prostate increase of prostatic secretions dilation of ureter vesicoureteral reflux
urethral catheterisation - not that uncommon in men of this age to have a catheter. Usually for obstructive causes
prostate secretions decrease at this age. They are normally protective
Vesicoureteral reflux is common in children, not at this age
23 year old with UTI
what increases the risk of UTI?
use of spermicidal gel avoiding anal sex use of a condom consumption of cranberry juice post-coital micturition
use of spermicidal gel - disrupts normal flora
Other 3 factors reduce risk of UTI, cranberry juice has no evidence
55 year old presents with fever, no localising signs.
Urine culture has pure growth of an organism
Which bacteria are normally associated with haematogenous dissemination when found in mid-stream urine
Staph aureus Staph saprophyticus E. coli Salmonella Typhi Mycobacterium tuberculosis
Staph aureus - rare cause of primary UTI. So need to assess for bacteraemia spillover
E.coli/ Staph saprophyticus cause UTIs - but most likely ascending from outer urinary tract
Salmonella/ TB are rare in urine
22 year old presents with dysuria, frequency, urgency.
What is most common cause of community-acquired UTIs?
Klebsiella pneumoniae Staphylococcus saprophyticus E. coli Proteus mirabilis Enterococcus faecalis
E. coli - causes 70%-90% of infections
Klebsiella/ Proteus and Enterobacter are common causes, but mostly in relation to catheter associated UTIs
Enterococcus rarely causes UTIs
Staphylococcal UTI
How to discern if this is Staphylococcus aureus or Staphylococcus saprophyticus
Staphylococcus saprophyticus is:
- coagulase negative
- resistant to novobiocin
73 year old with UTI. Has long term catheter.
Which is true
- catheter associated UTI account for 40% of nosocomial infections
- bacteriuria is present in minority of patients with indwelling catheters at 30 days
- bacteriuria is frequently monomicrobial
- asymptomatic bacteriuria should always be treated
- patients with indwelling urinary catheters should receive antibiotic prophylaxis
catheter associated UTI account for 40% of nosocomial infections
- catheters become colonised quickly in most cases, so infections often polymicrobial. And asymptomatic cases should not be treated
- may be given antibiotics around time of insertion, but do not have an ongoing need for antibiotics
73 year old female with UTI
Why are UTIs more common in elderly women?
increased vaginal lactobacilli vesicoureteric reflux cognitive decline increased albumin in urine oestrogen replacement therapy
cognitive decline
risk factor itself due to poor hygiene
but also risk factor as delay in diagnosis - patient may be mildly confused, with bacteriuria, and unclear whether it needs treatment
23 year old pregnant woman has mid-stream urine submitted. how should it be interpreted?
asymptomatic bacteriuria develops 20-40% of women
asymptomatic bacteriuria is diagnosed with bacterial count higher than 1x10power5 CFU/ml
asymptomatic bacteriuria should always be treated in pregnancy
risk of pyelonephritis is comparable between pregnant and non-pregnant women
UTI in pregnancy have no effect on foetal development
asymptomatic bacteriuria is diagnosed with bacterial count higher than 1x10power5 CFU/ml.
Because vulvo-vaginal contamination can occur, recommended to send second urine sample before commencing treatment. Hence why we should not always treat asymptomatic bacteriuria in pregnancy
asymptomatic bacteriuria develops in about 10% of pregnant women, but higher risk of pyelonephritis developing in pregnancy
asymptomatic bacteriuria are more likely to have premature babies
23 year old symptomatic UTI, sample send shows sterile pyuria
Which condition is sterile pyuria not characteristic of?
renal tract Mycobacterium tuberculosis Chlamydia trachomatis urethritis antibiotic-treated E. coli UTI Neisseria gonorrhoea Staphylococcus saprophyticus UTI
Staphylococcus saprophyticus UTI would not be sterile as grows easily
Other organisms are fastidious, and difficult to grow
Also non-infectious causes of sterile pyuria e.g sarcoidosis, malignancy
54 year old with cirrhosis develops self-limtied diarrhoea after consuming raw oysters.
Two days later, presents with overwhelming sepsis, develops blistering skin lesions and dies.
What is most likely cause
Bacillus cereus Salmonella Heidelberg Salmonella Typhi Vibrio vulnifcus Cyclospora cayetanensis
Vibrio vulnifcus - causes enteritis, skin blistering or fulminant septicaemia.
Found in coastal waters, so ingestion of filter feeders causes contamination
35 year old male develops diarrhoea. He purchases two turtles illegally a week before symptom onset.
What is most likely pathogen?
Plesiomonas shigelloides Strongyloides stercocalis Salmonella typhi Salmonella Arizonae Vibrio cholerae
Salmonella enterica serotype Arizonae is associated with reptiles
23 year old male with diarrhoea.
Possible Plesiomonas shigelloides identified on blood culture
How is this differentiated from Shigella?
Shares some antigens with Shigella sonnei, so mis-diagnosis can occur due to cross-reacting antisera
Plesiomonas is oxidase pos
Shigella is oxidase neg
Associated with water or animal exposure
Children’s nursery has outbreak of diarrhoea.
10 children agred between 4 and 7 have become symptomatic in past 2 weeks with diarrhoea. Low volume, but with blood and mucus
What is most likely cause
Shigella spp Enterotoxigenic E. coli Giardia intestinalis Rotavirus Norovirus
Shigella
Shigella sonnei is most frequent shigella infection, and does not require treatment
Enterotoxigenic E.coli is common cause of travellers diarrhoea in places with lower hygiene standards. Less likely, but not impossible in our case
49 year old goes to nearby farm and eats pork chitterlings for lunch.
5 days later has diarrhoea (no blood or mucus) with abdominal pain and fever
What is most likely cause?
Shigella Enterotoxigenic E. coli Campylobacter coli Yersinia entercolitica Vibrio parahaemloyticus
Yersinia entercolitica
Can present with abdominal pain which may be mis-interpreted as appendicitis
Is a zoonosis
Campylobacter and E. coli do not usually have fever. Fever suggests significant systemic infection
Shigella would normally have bloody diarrhoea
Vibrio parahaemolyticus is related to sea-food
29 year old presents 33rd week of gestation with temp 38.8degC, with diarrhoea
Which organism is a particularly dangerous potential cause of this presentation?
Salmonella typhimurium Listeria monocytogenes Giardia intestinalis Taenia saginata Plesiomonas shigelloides
Listeria monocytogenes
Before 20 weeks associated with miscarriage. After 20 weeks associated with pre-term labour. If delivery occurs, risk of neonatal sepsis and meningitis
Identified with tumbling motility at room temperature (not 37degC)
29 year old 33rd week gestation, with temp 38.2degC. PROM.
Which of following organisms most likely to be isolated?
Gardenerlla vaginalis Ureaplasma urealyticum Bacteroides fragilis E. coli Streptococcus agalactiae
Ureaplasma urealyticum
Immediately at PROM, ureaplasma is most commonly isolated as is the most common cause of PROM
Following rupture of the membranes, Strep agalactiae and E. coli are most commonly isolated, as they cause chorioamnionitis and foetal infection
65 year old with IE due to Enterococcus faecalis in blood cultures
Which statement is true
More common in young females than old males
Treatment with vancomycin and gentamicin is optimal
Treatment with amoxicillin and gentamicin is optimal even where there is low-level gentamicin resistance
Where there is high level gentamicin resistance, testing for tobramycin and amikacin is indicated
Where there is a vanB phenotype treatment with vancomycin rather than teicoplanin is advocated
Treatment with amoxicillin and gentamicin is optimal even where there is low-level gentamicin resistance
older males are most common patients to have IE
Most Enterococci are resistant to amikacin and tobramycin, so no need to test
Enterococcus faecium endocarditis - use vancomycin and gentamicin
Enterococcus species isolated with van genes
What protection to they confer to bacteria
vanA
vanB
vanC
vanA - resist vancomycin and teicoplanin
vanB - resist vancomycin
vanC - resist vancomycin (low level)
77 year old with stroke. Admission CXR clear
7 days later fever, SOB, and significant lobar pneumonia
What is likely cause?
Clostridium perfringens Staphylococcus aureus Mycobacterium tubcerculosis Fusobcaterium necrophorum Klebsiella pneumoniae
Staphylococcus aureus
Acute cavitating pneumonia due to Staph aureus, Klebsiella, Pseudomonas, Proteus.
PVL can be implicated in Staph infection
Unsure why answer is not klebsiella - no history of aspiration, but has had stroke
32 year old female with fever, rigors, hypotension. Urine culture grow E.coli
Resistant to amoxicillin, cefoxitin, cefuroxime, ciprofloxacin
What is best initial treatment pending sensitivities?
Nitrofurantoin Meropenem Ceftazidime Ceftriaxone Co-amoxiclav
Meropenem
Fever/ hypotension means sepsis - so rules out nitrofurantoin
Resistance pattern suggests ESBL or AmpC - so need to avoid other choices
18 year old with cystic fibrosis complains of worsening SOB. Has been colonised with Pseudomonas aeurginoas and Staphylococcus aureus, but not needed treatment in past year
Sputum culture grows isoalte of Stenotrophomonas maltophilia
What treatment is advised?
amoxicillin gentamicin co-trimoxazole meropenem Tazocin
co-trimoxazole is first line treatment for Stenotrophomonas
resistant to meropenem, tazocin
Other options include colistin, doxycline
23 year old with URTI and drooling symptoms.
Unvaccinated
What symptoms do you not see in diptheria
Cardiomyopathy Peripheral neuropathy Asphyxia Septicaemia Cervical lymphadenopathy
Septicaemia
cervical lymph nodes cause bulls neck, and possible asyphxia
toxin causes neuropathy and cardiomyopathy
28 year old presents to GUM clinic with urethra discharge and dysuria
RPR neg
TPHA pos
What is most likely explanation
primary syphilis secondary syphilis tertiary syphilis Treated syphilis Treponema pallidum spp. pertenue infection
treated syphilis
clinical symptoms suggestive of chlamydia or gonorrhoae
primary syphilis - painless ulcer
secondary syphilis - rash over palms and soles
tertiary syphilis - destructive gummas, meningitis, aortitis
Treponema pallidum spp. pertenue infection causes yaws - mucocutaneous lesions
28 year old with urethral discharge and dysuria. Gram neg diplococcus seen on urethral smear. Patient leaves without treatment
What is the likely outcome?
septic arthritis urethral stricture epididymo-orchitis prostatitis septicaemia
urethral stricture
Untreated gonococcal infection:
males develop urethral stricture, epidiymo-orchitis or prostatitis. Urethral stricture is most common sequale
females develop PID, infertility
septic arthritis is uncommon, and is due to septicaemia. But much rarer than urethral stricture
24 year old male with rash on foot
no foreign travel
Frequently goes barefoot in park
What is most likely cause?
Strongyloides sterocralis Ancylostoma braziliense Necator americanus Borrelia burgdorferi Clostridium perfringens
Ancylostoma braziliense (hookworm) Presents with CLM - soil transmitted helminth. Cannot penetrate skin layers
Ancylostoma duodenale - hookwork which can penetrate skin layers, and move to small intestine
Necator americanus - hookworm which can penetrate skin layers, and move to small intestine
Strongyloides causes larva currens - a fast moving pruritic rash. No history of foreign travel
37 year old IVDU presents with actuely swollen and painful right leg.
Marked tachycardia and hypotension.
On examination of leg, no areas of necrosis
CT shows grosslyswollen leg
Blood culture - gram pos bacilli
What is most likely cause?
Bacillus anthracis Clostridium perfringens Clostridium sordellii Staphylococcus aureus Streptococcus pyogenes
Clostridium sordellii
Clostridia exotoxins cause significant oedema. No necrosis makes Clostridium perfringens and Bacillus antrhacis less likely
Staph are gram pos cocci
31 year old with recurrent tonsillitis - 8 episodes in past year, each needing antibiotics
What is most appropriate course of action
prescribe lifelong penicillin V orally
prescribe a further course of 1 week of amoxicillin
refer to ENT specialists for tonsillectomy
prescribe further 10 days of amoxicillin
watch and wait approach
refer to ENT specialists for tonsillectomy
Particularly if:
- 7 or more episodes in 1 year or
- 5 episodes a year for 2 years
antibiotics do reduce duration of symptoms, and risk of peri-tonsillar abscess. But do not prevent further episodes
29 year old with cerebral abscess
Which organism is least likely to cause a cerebral abscess
Staph aureus Peptostreptococcus spp Neisseria meningitidis Nocardia brasiliensis Actinomyces isrealii
Neisseria meningitidis
Abscesses arise from haematogenous spread, or direct extension from surround structures
38 year old 18 weeks pregnant
Admit fever, RUQ pain, looks unwell
Short admission in Greece for pyelonephritis 6 weeks ago
Blood culture grows Klebsiella pneumoniae
resistant to amoxicillin, cephalexin, cefotaxime, ciprofloxacin, amikacin, meropenem, temocillin
sensitive to nitrofurantoin, colistin, tigecycline
rapid PCR for detection of carbapenemase enzymes detects presence of KPC (Klebsiella pneumoniae carbapenemase)
Which treatment would you recommend
colistin colistin and meropenem colistin and tigecycline nitrofurantoin colistin and fosfomycin
colistin and tigecycline
resistant to meropenem
sepsis - so rules out nitrofurantoin
fosfomycin is excellent for E.coli, less so for klebsiella. Also patient septic which makes it less likely choice
tigecycline is recommended if benefits outweigh risks, as little information on teratogenicity
unclear why not using colistin monotherapy
66 year old had non-bloody diarrhoea which was self-limiting.
Two weeks later had swollen painful knee, presents to A&E
Joint aspiration was sterile
Raised CRP, HLA B27 positive
Which of the following is least likely to be the cause?
Yersinia entercolitica Shigella Salmonella Campylobacter Giardia lamblia
Giardia lamblia
All others implicated in reactive arthritis
Old term Reiter’s syndrome used to be urethritis, arthritis, and conjunctivitis following UTI commonly
what criteria compose the qSOFA score?
respiratory rate heart rate hypotension lactate altered mentation raised inflammatory markers
respiratory rate RR>22
altered mentation GCS <15
hypotension <100mmHg
Which disease is commonly caused by Coxsackie A or Coxsackie B
Conjunctivitis Herpangina HFNM Meningitis Myocarditis/ pericarditis Pleurodynia (Bornholm disease)
Coxsackie A Conjunctivitis Herpangina HFNM - Enterovirus 71 can also cause HFNM Meningitis Myocarditis/ pericarditis
Coxsackie B
Meningitis
Myocarditis/ pericarditis
Pleurodynia (Bornholm disease)
Woman with discharge
What is causative organism
- thick white discharge
- cottage cheese discharge
- fishy discharge
thick white discharge - trichomonas vaginalis
cottage cheese - candida albicans
fishy discharge - Bacterial Vaginosis - Gardnerella
