Week 11 Infectious Diseases Flashcards

1
Q

HIV transmission

A

Contact with body fluids which could contain HIV
- Body fluids: Blood, bloody fluids, genital secretions, and breast milk, CSF, synovial fluid, pleural fluid, peritoneal, pericardial, amniotic fluid
- Not detected in: urine, feces, sputum, nasal secretions, sweat, tears, vomit w/o blood - IF TINGED W/BLOOD, then yes can be transmitted

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2
Q

HIV risk Factors

A
  • Contact with body fluids that could contain HIV
  • Risk Activity – risk of acquiring HIV
    o I.e.: needle sharing
  • Prevalence – regional

Afrian MSM high and MSM

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3
Q

HIV Screening guidelines + Algorithm

A
  • CDC 2006: routine, voluntary HIV screening in all13- 64-year-olds as normal part of medical care without the prior requirement for signed consent or counseling.
  • USPSTF 2013: screen all 15-65 years old
  • Perceived risk: screen at least annually
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4
Q

HIV Progression

A

Antiviral markers → 0-14d detection, 14d-28d symptoms

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5
Q

Acute Retriviral syndrome conditions and SEs
Which days in HIV progression at risk for these?

A

Day 10-20 (HIV DETECTABLE)
* Fever lymphadenopathy, sore throat, rash, myalgia/arthralgia, headache
* “Mono”
* “Flu”
* Can be asymptomatic
Mononucleosis
* EBV–Ebstein Barr Virus
* CMV–Cytomegalovirus
* HIV
* Toxoplasmosis

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6
Q

Approach to HIV (+) patient:
What to ask? What do you need in HPI/Hx

A

Figure out how sick the patient is
* History, examination, lab tests
* Opportunistic infection prophylaxis
* Antiretroviral therapy
* Healthcare maintenance – immunizations, med hx, allergies, screenings, etc.

History
* Symptoms (extra-pulm TB; karposi’s sarcoma)
* Risk behaviors: range of when infection occurred, other infections one may be at risk of (TB? STDs?)
* Tobacco, alcohol, illicit drug use hx; sexual history
* Social support and psychiatric history – any identifying barriers
* Medications, including alternative meds
* Disclosure – from whom you might have gotten this from? Get partners tested

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7
Q

HIV Lab testing (general)
TB test considerations?

A
  • Comprehensive metabolic panel: renal, liver function
  • CBC with diff
  • Urinalysis (U/A)
  • Serologies of infections:
    • Which can reactivate: Cytomegalovirus (CMV), Toxoplasmosis IgG
    • Which can need immunization: Varicella (VZV) IgG, Hepatitis A IgG, Hepatitis B surface antibody, surface antigen
    • Which can complicate treatment: Hepatitis C Ab (and also Hepatitis B surface antibody, surface antigen)

A word on TB screening – test based on immune response
* Interferon gamma release assay (blood test)
* Tuberculin skin test (TST, or PPD)
– Lower cutoff for positive in HIV+ patients
– TST > 5 mm is positive in HIV+ patients
– If negative and patient’s CD4 count is < 200, repeat TST or IGRA after immune reconstitution

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8
Q

HIV specific lab testing

Labs AFTER initial HIV diagnosis

A
  • CD4 cell count: best predictor of risk of opportunistic infection or cancer
  • HIV RNA: “viral load”
  • HIV Genotyping

HIV disease test
* CD4 count
* HIV VL with genotype (RTI, PI, Integrase Inhibitor)
* HLA-B*5701Typing (if considering abacavir)
* Safety labs:
* CBC, CMP, U/A (Cr Cl), Lipids, HgA1C or fasting glucose, G6PD, pregnancy test

Coinfections
* Hep A Ab, Hep B (Surf Ab, Surg Ag, Core Ab), Hep C Ab
* TB (IGRA)
* Toxo, CMV, VZV – IgG
* STD screening
* RPR/FTA
* GC/CT
* Trichomonas
Other: assess readiness to start HAART

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9
Q

HIV specific monitoring labs and frequency

A

CD4 count
Every 3-6 months
* For first 2 yrs of ART
* If viremia develops on ART
* CD4 is ≤ 300
Every 12 months
* After 2yrs on ART with suppressed VL
* CD4 300-500
Optional Monitoring
* If CD4 count about 500 with suppressed VL

HIV Viral Load
* With ART initiation or modification
* 4-8 weeks after ART initiation or modification
* Every 3-6 months until pt has been suppressed on ART over 2yrs
* Every 6 months for pts stable on ART over 2yrs.

Q6 months
* CMP
* CBC/CBCd

Q12 months
* HCV Ab
* Based on risk behaviors
* Lipids (if normal at measurement)
* Hgb A1C/fasting glucose (if normal at last measurement)
* UA w/microalbumin
* RPR (at minimum, more frequent based on risk behaviors)

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10
Q

List of diseases during course of HIV infection

A
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11
Q

Recommended regimens for HIV+ tx
When to start?

A

ART recommended for all HIV+ individuals regardless of CD4 cell count
Commonly used medications for HIV (out of > 25 options)

NRTIs
* Tenofovir (TDF or TAF) + Emtricitabine (FTC)
* Abacavir (ABC) + Lamivudine (3TC)

NNRTIs
* Rilpivirine (RPV) (if VL <100K, CD4>200)
* Efavirenz (EFV)

Boosted PI
* Darunavir/r (DRV/r)
* Atazanavir/r (ATV/r)

Integrase inhibitor
* Raltegravir (RAL)
* Elvitegravir (EVG)/cobicistat
* Dolutegravir (DTG)
* Bictegravir (BIC)

START ASAP - BUT assess readiness to take treatment
Get HIV genotype to help determine which HIV drugs pt is susceptible to

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12
Q

When to screen for CVD prevention (lipid management) for HIV+ pts
Statin contraindications

A

Screening: fasting lipids
* At HIV diagnosis
* Start of ART
* Change of ART
* Q6-12mos

Lipid Management
* Beware of drug interactions between statins and PIs or cobistat

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13
Q

Immunization schedule for HIV+ infected adults
Why?

A

Routine vaccines:
* MMR
* Polio
* Chickenox (Varicella)
* Flu (influenza)
* Tdap
* COVID-19 (if pt opts for vaccine)

Hepatitis A
* 2 doses, 6-18 months apart

Hepatitis B
* HeplisavB – 2 doses; ONE month apart

TwinRix (Hep A&B combo)
* 3 doses, 0, 1 month, 6 months after dose 1

Human Papilloma Virus (HPV)
* Adults up to age 45
* 3 doses; 0, 1-2 months, 6 months.

Meningococcal B (MenB)
* Typically given prior to college
* May need if no functioning spleen

Meningococcal ACWY (MenACWY)
* 2 doses are given 8 weeks apart, then booster every 5 years.

Pneumococcal (PPSV23, PCV15, PCV20)
* PCV20 alone, or PCV15 followed 8 weeks later by PPSV23.
* If only received PPSV23, may receive PCV20 or PCV 15 ≥1year after their last PPSV23 dose.
* Zoster (Shingles) ≥ 19 y/o: 2 doses; given 2-6 months apart

Increased risk for vaccine-preventable infections
Increased cancer risks
CVD risk

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14
Q

HIV workup and health maintenance summary
Screenings

A

Breast, Prostate, Colon, Lung
DEXA: postmenopausal women AND men ≥ 50 y/o

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15
Q

PrEP
What is it? How is it taken?
Labs to monitor? Frequency?

A
  • One pill once daily for HIV-negative patients, taken to prevent transmission of HIV

Before PrEP – basic labs needed
* Renal panel: CrCl > 50
* LFTs
* HIV neg (test for this)
* No s/s acute HIV
* HBV sAg neg, opportunity to vaccinate (check sAb)
* Urine pregnancy testing

PrEP
* Tenofovir diisproxil fumarate / emtricitabine (TDF/FTC)
* Tenofovir alafenamide/emtricitabine
* Brand name: Truvada
* Dose: 1 tab per mouth daily

Monitoring
* (First 3 months: renal panel + LFTs)
* HIV test, risk assessment and counseling q 2-3
* months
* STI screen q 3-6 months (q3 for MSM at risk for recurrent bacterial STI)
* Renal panel q 6 months
* Provide condoms and education
* Pregnancy testing q3 months
Undetectable = unt-ransmittable → combatting stigma

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16
Q

NPEP

A

Non-occupational postexposure prophylaxis
* All primary care providers should feel comfortable prescribing NPEP!!
* Provide nPEP regimen to an individual (HIV-) after sexual contact in which there is concern/risk for HIV acquisition.
* Unprotected anal? Unprotected vaginal? Drug use?
* Medication regimen MUST be started within 72hrs of the possible contact.
* Preferred Regimen:
* Tenofovir disoproxil fumarate (TDF) 300mg with emtricitabine (FTC) 200mg [Truvada] once daily PLUS dolutegravir (DTG) 50mg [Tivicay] once daily by mouth for 28days
* Follow-up: 28days; consider transition to PrEP pending sexual preferences/behaviors
* Occupational regimen – same F/U

17
Q

Post-exposure to HIV chart and which test to use

A
18
Q

U = ________

HOW LONG THO

A

UNDETECTABLE

Need to be undetectable for at least 6 months
* HIV+ individual can achieve being undetectable by being on HAART/HIV med regimen
* Studies have shown those HIV+ who are undetectable (virally suppressed) have significantly lower number of virus particles in the body, such that they are unable to transmit during sexual practice.
* So few virus particle, such that lab testing unable to detect.
* Studies only been done for sexual contact, not for IV drug use or breastfeeding, etc.

19
Q

Prior to starting PrEP, what to ask?

A
  • Get a detailed sexual history from the patient prior to starting PrEP.
    • Partners?
    • Last sexual contact?
    • Type of sex they engage in?
    • Condom use?
    • Risk for HIV acquisition?
  • Obtain all appropriate lab work and sexual health testing (as noted in lecture slides) prior to starting PrEP.
    • Patient must be HIV (-) before starting PrEP
  • Ensure appropriate follow-up Q 3 months for routine sexual health labs/testing/adherence.
    • Kidneys functioning on Truvada
    • STDs can be asymptomatic – shedding it to other ppl
20
Q

Hepatitis B
What is it and transmission

A
  • Hepatotoxic, acute, and chronic disease
  • Epi: Est worldwide 240 million people are chronically infected with hepatitis B
  • > 686 000 deaths/y from complications of hepatitis B (cirrhosis, HCC)
  • Virus: hepadnavirus, cccDNA
  • Transmission: contact with the blood or other body fluids of an infected person (HIGHEST RISK OF TRANSMISSION BETWEEN MOM & BABY)
21
Q

Hep B Pathogenesis

A
  • HBV hijacks hepatocyte machinery to reproduce cccDNA
  • Difficult to extract
  • Immune response (body’s own response) causes hepatotoxicity, instead of virus
  • Constant battle between viral replication and host immune response
  • Some skip cirrhosis phase and → chronic (Progression to chronic HBV varies by age at acquisition)
22
Q

Phases of Chronic Hep B infection

A
23
Q

Hep B Treatment Goals

A
  • Prevent transmission
  • Prevent complications of chronic liver disease
  • Prevent reactivation (cancer chemotherapy, immunosuppression, bone marrow transplantation)
24
Q

HBV Screening: WHO

A
  • PWID - persons who inject drugs
  • MSM
  • Persons needing immunosuppressive therapy, chemo, organ transplantation
  • Elevated AST/ALT of unknown origin
  • Hemodialysis
  • Pregnant women
  • Needlestick exposure
  • HIV+
25
Q

What to order to test Hep B?
Interpretation chart

A
  • hepatitis B surface antigen (HBsAg)
  • hepatitis B surface antibody (anti-HBs)
  • Total hepatitis B core antibody (anti-HBc):
  • Hepatitis B surface antigen (HBsAg):
    • +HBsAg indicates infection (acute or chronic); 6 mos or <, chronic
    • +HBsAg person is infectious
26
Q

Guidelines for chronic Hep B testing

A
27
Q

Hepatitis C
What is it and transmission

A
  • Epi: Est worldwide >170 million people are chronically infected with hepatitis C
  • Virus: ss RNA virus, flavivirus
  • Transmission: parenteral; needlestick, transfusion, transplantation of infected organs, sharing contaminated needles (blood)

Needlestick Rule of 3’s
* HIV: 0.3%
* HCV: 1.8%
* HBV: 30%

28
Q

Labs to monitor and diagnostics prior to treatment of Hep C

A
  • HCV viral load
  • HCV genotype
  • Renal panel
  • AST, ALT, GGT, T Bili, Alk Phos CBC
  • Platelet Albumin PTT
  • Liver biopsy
  • Elastography
  • Noninvasive serologic marker screen
  • Fib-4 scoring
29
Q

Treating Hep C

A
  • Goal: CURE, defined as sustained virologic response (SVR)
  • > 95% cure rates for all genotypes, excellent safety profiles, well-tolerated
  • Monitor for drug interactions
  • Special populations: decompensated cirrhosis, renal disease, acute infection, people who inject drugs - Call GI or ID
30
Q

Important Take home points

A
  • HIV epidemic continues to grow
  • Identify asymptomatic patients to get them linked, engaged, treated and suppressed
  • Stop transmission of disease with treatment as prevention, and with preventative medication
  • HIV is a survivable, chronic illness
  • Start ART in everyone
  • Rates of heart disease, stroke, cancers are increased in HIV-positive patients and the PCP is incredibly valuable
  • HIV treatments impact bone health
  • Hepatitis B: screen those at risk – that’s more people that you think
  • Stratify hepatitis B disease so you can treat those who need it
  • Hepatitis C: screen those at risk
  • CURE hepatitis C!
  • Co-morbid polysubstance use disorder is not a contraindication to treatment
31
Q

Gonorrhea
Symptoms and location

A
  • Can affect: genitalia, throat, rectum
    Symptoms:
    • Dysuria
    • Urethral/vaginal discharge
    • Painful/swollen testicles
    • Rectal sx:
      • Discharge, itching, bleeding, soreness, painful bowel movements
32
Q

Gonorrhea treatment

A
  • Ceftriaxone 500mg IM single dose.
  • If chlamydial infection cannot be excluded, concurrent treatment: Doxycycline 100mg bid for 7 days.
  • > 300lbs – 1g of ceftriaxone
    * 500mg IM ceftriaxone & Doxy 100mg bid x 7days
33
Q

Gonorrhea test of cure

A

o Throat: 7-14days – NAAT testing
o Urogenital/Rectal: 3 months

34
Q

Chalmydia
Location and symptoms

A
  • Can affect: genitalia, throat, rectum
  • Symptoms:
    • Dysuria
    • Urethral/vaginal discharge
    • Painful/swollen testicles

Rectal sx:
* Discharge, rectal pain, bleeding

35
Q

Chlamydia Treatment and test of cure

A

Doxycycline 100mg bid for 7 days.
Alt regimen: Azithromycin 1gram PO x1.

Test of cure: Consider in 3 months.

36
Q

Syphilis manifestations

A

PAINLESS HSV

Clinical Manifestations: hands, feet, belly
* Primary- painless chancre- lasts 3-6 weeks
* Secondary – rash, lymphadenopathy
* Latent- asymptomatic (> 1yr between testing)
* Tertiary- after 10-30 years of untreated syphilis

37
Q

Syphilis diagnosis & treatment
F/U testing
Testing for neuro syphilis?

A

Diagnosis: RPR with FTA-ABS confirmatory
Treatment- Bicillin (Penicillin) or Doxycycline if pcn allergic
Treat contacts/exposures
Repeat testing 3 months to follow RPR trends.
Neuro syphilis – LP gold standard