Week 2: Infectious diseases (1) (Antibiotics, fever in returned traveller, sepsis) Flashcards
staphylococci (stap. aureus) skin/ soft tissue infection
flucloxacillin (narrowest spec and easy to give)
streptococci (e.g. group A strep) skin/ soft tissue infection
benzylpenicillin
if penicillin allergy skin/ soft tissue infection
doxycyline, levofloxacin
IV ceftriaxone, meropenem
coagulase negative staph skin/ soft tissue infection
is often fluclox/peniccilin resistant –> need to get micro advice
MRSA skin/ soft tissue infection
Vancomycin, teicoplanin, linezolid
musculoskeleteal infection antibiotics
same as skin/soft tissue
TB musculoskeletal infection
quadruple threapy (RIPE)
respiratory infections e.g. S.pneumonia, H.influenzae
amoxicillin
pencillin allergy- doxycline
atypical resp infection e.g. legionella, mycoplasma
doxycycline, clarithonmycin
respiratory infection e.g. influenza
oseltamivir- antiviral
viral GI infection e.g. diarrhoea/enetrocolitis
N/A- virus
GI infection by Enterobacteriacae: Campylobacter, shigella, E.coli
if severe: ciprofloxacin, azithromycin
GI infection with salmonella spp e.g. S.typhi/parathyphi
IV ceftriaxone/azithromycin
treatment for GI infection with C.difficile
PO (not IV) metronidazole/vanc
GI infection: visceral infection/peritonitis usually with enterobacteriacae
Co-amox or Cipro or gentamicin or tazocin
+- anaerobe cover–> metronidazole or tazocin
if pen allergy–> meropenem
lower GU tract infection e.g. E.coli, klebsiella sp, proteus sp
nitrofurantoin/ trimethoprim
if UTI resistant to first line antibitoics
ciprofloxain or co-amox
GU tract infections : pseudomonas aerogenosis
ciprofloxcin, gen, tazocin
ESBL (Extended Spectrum Beta Lactamase) / resistant GU infections
carbapenem
GU infectio- gonorrhoea
For uncomplicated gonococcal infections:
- A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
- A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
GU infection- chlamydia
uncomplicated- doxycyline for 7 days
azithromycin (if preggo)
CNS ifnection e.g. meningitis (S. pneumoniae, N. meningitidis, H. influenzae
IV cephalosporin ( ceftrixone)
–> give dexamethasone with 1st dose in bacterial meningitis
*if in GP practice give peniciilin IM STATT–> reduce risk of deafness
CNS infection caused by listeria in >55/ imm.comp
amoxiciilin/ meropenem
CNS infection : TB
RIPE
CNS infection: Herpes simplex virus (encephalitis)
IV aciclovir
endocarditis : streptococci e.g. S. viridans
(may vary for prostethic vakve ednocarditiis vs native valve)
benzylpenicillin +- Gent
endocarditis : enterococci (E. faecalis)
amoxicillin
endocarditis: S. auerus e.g. IV drug users
flucloxacillin
“culture negative” endocarditis
ceeftriazone
MRSA/ pen allergy, pen resistant endocarditis
vancomycin
line infection
same as skin and soft tissue infection e.g. fluxclox
if MRSA- vancomycin
hospital acquired infection e.g. ENTEROBACTERIACAE (E.COLI, KLEBSIELLA)
Co-am/ Taz
hospital acquired infection e.g. pseudomonas
cipro, gent, tax, mero
hospital acquired infection e.g. C.difficile
metronidazole/ vancomycin
multi drug resistant HAI
meropenem
Principles of antibiotic use
- Simplest to use
- IV, PO
- Low frequency as possible
- Narrowest spectrum
- Drug drug interaction
- C.diff risk
- Cheapest
- Lowest conc as poss
common antibiotics
- beta lactam
- macrolides
- fluorquinolones
- tetracyclines
- nitroimidazoles
- aminoglycosides
- lincomycin
- glucopeptides
types of beta lactam
penicillin e.g. benzylpenicillin, fluxlocacillin
cephalosporins e.g. ceftriaxone
carbapenems e.g. meropenem
meropenem is very
broad spectrum and used for sepsis but does not cover meropenem MRSA
macrolides
erythromycin, clarithromycin, azithromycin
fluoroquinolones
ciprofloxacin, levofloxacin
tetracyclines
doxycycline
nitroimidazoles
metronidazole
→ can cause peripheral neuropathy on long term courses
→ disulfiram affect with alcohol
aminoglycosides
gentamicin
lincomycin
clindamycin
glycopeptides
vancomycin, teicoplanin
SEPSIS
“life-threatening organ dysfunction caused by a dysregulated host response to infection”
SEPTIC SHOCK:
“a subset of sepsis with profound circulatory, cellular and metabolic abnormalities, associated with greater risk of mortality than sepsis alone” (Mortality: Sepsis 10%, Septic shock >40%)
adult sepsis screening and immediate action tool
Much of travel-related illness will manifest as
- febrile illness,
- GI symptoms (diarrhoea +/- vomiting),
- jaundice,
- reticuloendothelial change (lymphadenopathy /hepatosplenomegaly),
- respiratory symptoms (cough, shortness of breath), or rash.
The most common tropical infections we diagnose in the unit are:
- malaria,
- dengue fever, and
- typhoid (enteric) fever.
Incubation period
Knowing when potential exposures occurred allows the determination of an incubation period. Most of the severe, rapidly progressive infections (such as falciparum malaria and haemorrhagic fevers) acquired in tropical or developing countries become apparent within one to two months after return.
useful time-frames when thinking about incubation period
- 0-10 days: Dengue, rickettsia, viral (including infectious mononucleosis), gastrointestinal (bacteria / amoeba)
- 10-21 days: Malaria, typhoid, primary HIV infection
- >21 days: Malaria, chronic bacterial infections (e.g. brucella, coxiella, endocarditis, bone and joint infections); TB; parasitic infections (helminths/protozoa)
which hepatitis has vaccines
against hepatitis A, hepatitis B,
common vaccinations for travellers
against hepatitis A, hepatitis B, typhoid, tetanus, childhood vaccinations (e.g. MMR) + yellow fever and rabies when appropriate
prophylaxis for malarious areas
drugs: Atovaquone/proguanil (Malarone), doxycycline, and mefloquine
non-drugs:
nets and DEET spray
history: fever in a returning traveller
- Geographic region of travel within the last 12 months (especially tropics)
- Dates of travel and duration of stay (helps identify incubation periods of infection)
- Careful documentation of time of onset and nature of various signs and symptoms
- Types of accommodations + rural vs urban stays.
- Modern hotels generally have fewer exposures than backpackers or volunteer workers who spend significant time in rural areas.
- Persons who visit family and friends while abroad may also be at risk of illness (especially if rural areas)
- Recreational activities and exposures – e.g. insects (malaria, rickettsia), animals (bites/ticks), freshwater lakes and streams (schistosomiasis), well/canal water (leptospirosis)
- Type of food and water consumed (bottled, hotel, street food). Helps asses risk for food-borne illnesses (faeco-oral route)
- Sexual history, including sexual exposure while abroad (include condom use, sex with commercial sex worker, MSM). Helps to assess risk of HIV, Hep B/C and other STI acquisition
- Past medical history and predisposition to infection (e.g. diabetes, on immunosuppressive therapy)
- Vaccinations and preventative measure
clinical examination for fever in the returned traveller
- vital signs
- skin
- eyes
- spleen
- neuro
vtial signs to look out for in returned traveller
a pulse rate that is slow for the degree of fever e.g. typhoid
skin signs to look out for in the returned traveller
- A maculopapular rash (dengue fever, leptospirosis, rickettsia, infectious mononucleosis (EBV, CMV), childhood viruses (rubella, parvovirus B19), primary HIV infection
- Rose spots (pink macules, 2 to 3 mm in diameter) on chest or abdomen (typhoid fever).
- Black necrotic ulcer with erythematous margins – rickettsia (tick exposure)
- Petechiae, ecchymoses, or hemorrhagic lesions - dengue fever, meningococcemia and viral hemorrhagic fever
eye signs to look out for in the returned traveller
The eyes should be examined for evidence of conjunctival suffusion - leptospirosis.
spleen signs to look out for int he returned traveller
splenomegaly: mononucleosis, malaria, visceral leishmaniasis, typhoid fever, brucellosis.
neurologic systems to look out for in the returned traveller
Fever and altered mental status in the returned traveler may represent meningo-encephalitis and is a medical emergency. E.g. cerebral malaria, Japanese encephalitis and West Nile Virus encephalitis. Do not forget common infective causes (N. meningitis, Strep. Pneumonia, Herpes simplex virus (HSV)).
bacterial vaginosis
metronidazole
thrush
fluconazole
general management of STI
- Co-infections are common
- May be asymptomatic
- Consider screening for others
- Start with presenting complaint
STIs
- Chlamydia
* doxycyline
* azithromycin if preggo - Gonorrhoea
* IM ceftriaxone - Syphillis
- benzylpenicillin IM