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5th Year Revision > Y3 - Infection > Flashcards

Y3 - Infection Flashcards

1
Q

Define sepsis

A

Life-threatening organ dysfunction caused by a dysregulated host response to infection

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2
Q

define septic shock

A

a subset of sepsis with profound circulatory, cellular and metabolic abnormalities,

associated with greater risk of mortality than sepsis alone.

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3
Q

What are some high risk criteria in a case of suspected sepsis? (NICE)

A
  • RR>25
  • now need >40% O2 to keep sats >91% (or >87% in copd)
  • systolic bp <90mmHg or over 40mmHg< normal
  • HR>130bpm
  • Not passed urine in 16 hours
  • Catheterised = Passed <0.5ml/kg of urine per hour
  • Mottled or ashen appearance
  • cyanosis of skin, lips, tongue
  • Non-blanching rash of skin
  • New onset delirium
  • V,P,U on AVPU
  • Neutropenia or chemo within last 6 weeks
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4
Q

Sepsis six go

A
  • Take blood cultures (before antibiotics)
  • Take lactate
    • ABG, repeat after fluid challenge
  • Take urine output
    • catheterise if AKI/ SBP<90/ lactate >2
  • Give IV antibiotics
    • Meropenem IV 1g stat then if needed 2nd dose in 8hours
  • Give O2
    • (keep >94% or 88-92% in copd)
  • Give Fluids
    • fluid challenge of 500ml 0.9NaCl over 15 mins
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5
Q

What are some vital hx you need to take from a traveller returning with fever?

A
  • where within the past 12 months
  • dates and duration of stay (helps narrow down incubation periods)
  • time of onset and nature of signs and symptoms
  • accomodation (rural vs urban to identify how much exposure. visiting family/friends can result in high exposure)
  • recreational activities and exposures
    • eg. fresh water sports (schistosomiasis), Insects (malaria, rickettsia), animals (ticks, bites), canals or wells (leptospirosis)
  • Type of water and food (bottled, streetfood, etc)
    • asses risk of food-born or faecal-oral route illnesses
  • sexual history
    • condom use, sex worker, MSM
    • risk of HIV, Hep B/C, STI
  • PMHx, predisposition to infection due to diabetes or other immunosuppressive therapy
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6
Q

What kind of questions should you ask about pre-travel preparations to areas of disease?

A
  • Vaccinations for eg. hepaitis A and B, typhoid, tetanus
  • Childhood vaccinations eg. MMR
  • Yellow fever and rabies vaccines where appropriate
  • Malaria chemoprophylaxis
  • Protective measures eg. insect repellent and bed-net use
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7
Q

What investigations should you do for a traveller returning with a fever?

A
  • FBC
  • LFTs
  • U&Es, electrolytes
  • malaria smears and antigen detection dipstic (atleast 3 times over 24-48 hours)
  • urinalysis and culture
  • stool culture and investigation for ova, cysts, parasites
  • HIV, Hep B, Hep C, syphilis serology
  • acute serology to be saved in lab
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8
Q

What would you see on clinical examination and patient presentation of typhoid fever?

A
            • pulse rate that is slow for degree of fever = pulse temp dissociation
  • Rose spots (pink macules 2-3mm in diameter) on chest or abdo
  • Splenomegaly
  • sustained fever, anorexia, malaise, abdo discomfort, constipation, diarrhoea, dry cough
  • Recent Travel Hx to SE Asia, Southern or Central america
  • Do Typhidot serological test
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9
Q

How would you diagnose typhoid fever?

A
  • Non specific lab findings = leucopenia, lymphopenia, raised CRP
  • Blood cultures !!! (80% if 2 cultures taken)
    • stool, urine, bone marrow, duodenal aspirates
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10
Q

How would you treat typhoid fever?

A
  • IV ceftriaxone 2g OD (empirical)
  • Once sensitivities are known, switch to:
    • PO ciprofloxacin 500mg BD OR
    • PO azithromycin 500mg OD
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11
Q

What’s the parasite that spreads malaria?

A

night biting female anopheles mosquito

P.falciparum is the most serious one. There’s also P.vivax and P.ovale (mostly SE asia)

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12
Q

How does malaria present?

A
  • Hx of 7-42 days incubation period (min 7)
    • if fever happens before 7th day of exposure to an endemic region, its probs not malaria
  • abrupt onset rigors
  • then high fevers, malaise, severe headache, myalgia, vague abdo pain, nausea, vomiting
  • Diarrhoea in 25%
  • Jaundice and hepatosplenomegaly
  • If untreated, P.falciparum = hypoglycaemia, renal failure, pulmonary oedema, neurologic deterioration
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13
Q

How would you investigate suspected malaria?

A
  • FBC = anaemia, thrombocytopenia, leukopenia, abnormal LFTs
  • Thick blood smear (highly sensitive) detects presence of parasites
  • Thin blood smear (highly specific) = can see parasites in RBC to determine the plasmodium species
  • Antigen test
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14
Q

How would you define a “Pyrexia of Unknown Origin”

A
  • Temp >38 on multiple occasions
  • Over 1 week of being an inpatient and still no diagnosis
  • >3 weeks duration of illness
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15
Q

How would you manage malaria?

A

Essentially remember

Quinine sulphate for uncomplicated

Quinine dihydrochloride or Artesunate IV for severe

Prophylaxis:

  • mosquito nets, barriers over sleeping areas
  • mosquito spray
  • take antimalarial medications as recomended Eg. Malarone, Doxycycline

uncomplicated Falciparum = chloroquine or hydroxychloroquine

  • SE = retinopathy, CNS agitation/anxiety/confusion, GI discomfort, pruritus most common in dark skinned

Severe falciparum = quinine PLUS doxycycline

  • quinine SE = CNS headache, Gi discomfort, fever, flushing, cinchonism
  • Doxycycline SE = photosensitivity, nephro/hepatotoxicity, damage to mucous membranes so drink loads of water
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16
Q

How do you get TB?

A
  • Mycobacterium tuberculosis (endemic to asia, africa, s america, eastern europe)
  • aerosol inhalation that causes pulmonary infection, then spreads via haematogenous spread all over body
  • can lie dormant for years = latent tb
    • can reactivate due to immunosuppression, advancing age, HIV, Vit D deficiency in immigrants moving to the UK, etc
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17
Q

How would you diagnose latent TB?

A
  • asymptomatic, not contagious
  • Chest Xray
  • Quantiferon
    • measures level of interferon-gamma released from T cells when exposed to mycobacteria proteins
    • does not differentiate between latent/active
    • immunosuppresed patients may produce false negatives
    • results in 24 hours
  • Tuberculin skin test or Mantoux test
    • intradermal injection of tuberculin
    • measure diameter of induration in 48-72 hours (>5mm is positive)
    • false positives in those who have had the BCG vaccine
    • false negative in immunocompromised, malnourised, elderly due to inadequate T cell response
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18
Q

When would you screen for latent TB?

A
  • do an interferon gamma test in asymptomatic patients with risk factors for latent TB
    • immigrants from high prevalence countries
    • healthcare workers
    • HIV positive patients
    • patients starting on immunosuppression
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19
Q

How would you treat latent TB?

A

3 months of rifampicin and isoniazid

OR

6 months rifampicin alone

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20
Q

What are the risks of the latent TB treatment?

A

you have to balance the risk of reactivation to the risk of hepatotoxicity

(>35 years old are at an increased risk of hepatotoxicity. Therefore it is advised to not treat latent TB unless they have other risk factors eg. HIV or work as a healthcare worker)

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21
Q

what are 4 common symptoms of active TB?

A
  • drenching night sweats
  • weight loss
  • unexplained persistent fever (low or high grade)
  • non-resolving cough
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22
Q

What are some examination signs of active TB?

A
  • clubbing, cachexia, lymphadenopathy, hepato-splenomegaly, erythema nodosum
  • crepitations or bronchial breathing if there are pulmonary changes/pleural effusions
  • pericardial rub if pericardial involvement
23
Q

How would you investigate active TB?

A
  • CXR
    • mediastinal lympahdenopathy, cavitating pneumonia, pleural effusion
  • CT
    • lymphadenopathy
    • nodes with central necrosis are very suggestive
    • lesions in viscera
  • MRI
    • leptomeningeal enhancement in TB meningitis
  • Bacterial Culture = gold standard
    • can take 6 weeks so start ATT after cultures taken
    • Pulmonary TB = sputum culture (if can see TB using simple microscopy, start ATT immediately as this is “smear positive”. A high bacterial load and high infectivity)
      • If “smear negative” then proceed to bronchoscopy and endobronchial US guided biopsy of pulmonary lymph nodes. Then start ATT
    • Meningeal TB = lumbar puncture for culture then TB PCR
    • Lymph node TB = core biopsy of lymph node
    • Pericardial TB = pericardiocentesis
    • GI = colonoscopy and bowel biopsy or US guided omentum biopsy

Histology shows caseating/necrotising granulomatous inflammation

24
Q

What is a paradoxical reaction to TB treatment?

A

Sometimes there is increased inflammation as bacterial die. This can cause worsening symptoms and swelling.

(usually occurs at the start of treatment)

Therefore give steroids at the start of treatment especially for TB in places that can’t tolerate swelling (eg. meningeal, spinal, pericardial)

25
Q

How would you diagnose a TB meningitis or CNS TB? What special things should you consider in terms of treatment?

A
  • Do a LP in all patients with miliary TB to exclude TB meningitis
  • Symptoms can be subtle like personality change and headache, but will progress to meningitis and become comatose over several weeks
  • MRI = leptomeningeal enhancement
  • LP = high protein, low glucose, lymphocytosis
  • paradoxical reaction to ATT in TB meningitis can be fatal so give steroids with treatment!!! Treatment is also longer (12 months)
26
Q

What sort of thing do you have to look out for in pericardial TB? How is the treatment different?

A
  • pericardial effusion and tamponade
  • Signs = pericardial rub or kussmauls sign
  • Paradoxical reaction to ATT = tamponade
  • Treatment is 6 months + steroids
27
Q

How should you investigate and treat miliary TB?

A
  • Neuroimaging (CT/MRI) head
  • Lumbar puncture to rule out CNS
    Don’t delay ATT awaiting biopsies! just start it
28
Q

When should you keep in mind Multi-Drug Resistant TB? What special measures are taken?

A

Keep in mind in:

  • patients who have had incomplete treatment for TB previously
  • patients from abroad

Special Treatment:

  • infection control!!!
  • manage in negative pressure room
  • staff should wear masks and PPE at all times dealing with them
29
Q

What is standard ATT (Anti-TB Therapy)?

This is used for all TB except CNS TB

A

2 months (intensive phase)

  • Rifampicin
  • Isoniazid
  • Ethambutol
  • Pyrazinamide

These are available in a combined tablet called RIFATER

    • pyridoxine (Vitamin B)

Then 4 months (continuation phase)

  • rifampicin
  • isoniazid

These are available in a combined tablet RIFINAH

    • pyridoxine (vit b)
30
Q

What are the side effects of the TB drugs?

A

Rifampicin

  • urine/tears turn orange
  • drug induced hepatitis +

Isoniazid

  • peripheral nephropathy (reduced by the pyridoxine)
  • colour blindness
  • drug induced hepatitis ++

Ethambutol

  • optic neuropathy/ reduced visual acuity

Pyrazinamide

  • drug induced hepatitis +++

Therefore measure basline LFTs and visual acuity before treatment!!!

Continue to monitor LFTs throughout treatment.

If LFTs are deranged, stop and gradually reintroduce drugs once they have normalised, or try a liver friendly regimen (amikacin, levofloxacin, ethambutol) for 24 months.

31
Q

Describe NICE’s views on infection control with TB

A
  • after diagnosis, patients need to be referred to TB nurse to perform contact tracing.
    • household contacts with have CXR or quantiferon and any latent TB will be treated
  • Patients with non-resistant pulmonary TB should have a side room
  • After 2 weeks of treatment, patients are considered non-infectious to immunocompetent individuals
  • If there are immunocompromised patients on that ward, resp TB patients must have a side room until discharge regardless of if they are smear positive or negative
  • Smear positive patients can be discharged home but must isolate at home until they have completed 2 weeks of treatment
  • staff do not need to wear masks/aprons unless MDR TB is suspected or they are performing aerosol generating procedures like nebulisers
  • Smear positive TB patients need to wear masks when leaving their rooms until they complete 2 weeks of treatment
32
Q

When should you screen for bacterial STI?

A
  • all patients who are known to have a sexually transmitted/transmissible infection
  • all patients who request testing
  • any patient identified to be at high risk of STI from their hx
33
Q

How would you screen an asymptomatic patient for Gonorrhoea (GC) or Chlamydia (CT)?

A

NAATs (PCR) from sites identified

  • Urethral GC/CT = first pass urine (men)
  • Vaginal/Cervical GC/CT = Vulvo-vaginal swab (as far into vagina as possible)
  • GC/CT of throat = pharyngeal swab
  • Rectal GC/CT = rectal swab (2cm into rectum and rotated)
34
Q

What additional tests would you perform on symptomatic patients?

Eg. urethral discharge, vaginal discharge, oral/genital ulceration, anal discharge, conjunctivitis

A

Urethral discharge = charcoal swab to microbiology requesting Gonococcal culture

Vaginal discharge = charcoal swab from cervical os for Gonococcal culture.

Additional charcoal swab from posterior fornix for Trichomas vaginalis and Candida culture

Oral/genital ulceration = green viral swab for HSV1 and 2 (PCR)

Anal discharge = charcoal swab for gonococcal culture, hsv swab if significant anorectal discomfort

Conjunctivitis = GC/CT NAAT from conjunctiva.

Additional charcoal swab for Gonococcal culture if significant purulent discharge

35
Q

What investigations would you do for someone newly diagnosed with HIV?

A
  • confirmatory HIV test
  • CD4 count
  • HIV viral load
  • HIV resistance profile
  • HLA B*5701 status
  • serology for syphilis, hep B (sAg, cAb, sAb), hep C, hep A
  • Toxoplasma IgG, Measles IgG, Varicella IgG, Rubella IgG
  • FBC, U&Es, LFTs, bone profile, lipid profile
  • Schistosoma serology if >1 month spent in sub-saharan africa
  • Annual cervical cytology in women
36
Q

How would you support someone with a new HIV diagnosis?

A

Refer to HIV clinical nurse specialist team for contact tracing, advice, education, support and links to community support groups.

Can suggest Clinical Psychology Department for assesment if there are psychological difficulties related to their HIV diagnosis.

37
Q

How would you treat HIV patients with low CD4 counts?

A

They are at risk from opportunistic infections!!!

CD4 <200

  • Co-trimoxazole 480mg PO OD as primary prophylaxis against Pneumocystis Pneumonia (pneumocystis jirovecii)

CD4 <50

  • Azithromycin 1250mg PO once weekly to protect against Mycobacterium Avium-Intracellulare
  • assess by Opthalmology with dilated fundoscopy to look for evidence of intra-ocular infections such as Cytomegalovirus Retinitis
38
Q

What is the main complication with the antiretroviral medications?

A

Drug interactions!!!

Also do not miss meds or get the wrong dose of antiretrovirals, as this coudl result in drug resistance.

39
Q

What is the next step if someone eg. a member of staff on IDU is concerned about being exposed to HIV?

A

contact the consultant on call or Occupational Health or the on-call Genitourinary Medicine about the need for PEP

PEP should be commenced within 72 hours = Combination of ART therapy (Truvada + Raltegravir for 28 days)

Test in 3 months to confirm -ve status

abstain from unprotected sex for a min of 3 months until confirmed -ve

40
Q

Case 1

Patient comes in after swimming in a freshwater lake in malawi.

Haematuria, dysuria, urinary frequency, rash.

What is this and how would you investigate/treat it?

A

Schistosomiasis

Xray shows calcifications of egg clusters in the bladder.

Treat with single dose of oral praziquantel

Monitor as Schistosomiasis can cause SCC bladder cancer.

41
Q

What vaccines are live attenuated?

A
  • BCG
  • MMR
  • Influenza (intranasal)
  • oral rotavirus
  • oral polio
  • yellow fever
  • oral typhoid
42
Q

How long should someone wait if they recently had a varicella zoster vaccine, to get a yellow fever vaccine?

A

4 weeks

as both are live attenuated.

43
Q

Case 2

Patient comes back from Sri Lanka with:

  • severe 10/10 joint pain in the right wrist and ankle
  • range of movement limited by severe pain but no swelling
  • fatigue, headache, malaise and feeling unwell for the past 3 days
  • pyrexia
  • widespread blanching maculopapular rash

What are some differentials?

A

Chikungunya

  • mosquito spread, presents similar to dengue BUT more debilitating joint pain
  • abrupt high fever, flu like symptoms, arthralgia, myalgia, fatigue, Joint pain, rash
  • Africa, asia, india
44
Q

Case 3

HIV patient presents with dyspnoea, dry cough, fever, exercise induced desaturation

What do you think it is?

What investigations would you do and how would you manage it?

A

Pneumocystis jiroveci pneumonia is common in HIV with low CD4

CXR shows lobar consolidation, bilateral interstitial pulmonary infiltrates.

Bronchoalveolar Lavage demonstrates PCP (silver stain shows characteristic cysts)

Management = Co-trimoxazole

Common complication = pneumothorax.

45
Q

How would you treat an atypical pneumonia returning from Turkey with weird air conditioning?

A

Urinary antigen test for Legionella!

Give Clarithromycin

46
Q

What are 5 classical features of meningitis?

A
  • Neck stiffness
  • Headache
  • Photophobia
  • Nausea/Vomitting
  • Fever
47
Q

What is your immediate management for meningitis? (He has a non-blanching rash)

A

Immediately give Benzylpenicillin IV or IM if a vein is not available.

If there is no non-blanching rash, just wait until they get to hospital and then they will be put on the empiric antibiotic.

48
Q

What investigations would you do to confirm meningitis?

A
  • Blood culture within 1 hour of arrival to hospital, prior to giving antibiotics
  • Serum Pneumococcal and Meningococcal Polymerase Chain Reaction
  • FBC, Blood glucose, U&Es, creatinine
  • VBG for lactate in sepsis
  • Lumbar Puncture
    • Shows low glucose, high protein, high WBC
49
Q

Meningitis is a notifiable disease.

What is a notifiable disease?

A

If a doctor suspects a patient is suffering from a notifiable disease, they have a statutory duty to notify the Consultant for Communicable Disease Control.

Important infections eg. Meningococcal meningitis & septicaemia is one of the ones that requires prompt Public Health Intervention.

(Others are Legionnaires disease, Meningitis, Typhoid fever, Anthrax)

50
Q

Complications of meningitis

A
  • Sepsis!!!!!!
    • shock, kidney problems, etc.
  • Cognitive, behavioural, academic problems
  • seizures (treat with benzodiazepines)
  • H.Influenzae type b meningitis = hearing loss, subdural effusion
51
Q

What are some AIDS defining illnesses ?

A

Kaposis sarcoma

Pneumocystis jirovecii pneumonia

Cytomegalovirus infection

Candidiasis (oesophageal or bronchial)

Lymphomas

TB

52
Q

How would you test and monitor for HIV?

A
  • antibody blood testing = p24 antigen or PCR testing

Monitor

  • CD4 count (500-1200 is normal)
  • Viral Load (HIV RNA per ml of blood)
53
Q

How would you manage HIV?

A
  • should be started at GUM or HIV specialist cen tres
  • Antiretroviral Therapy is offered to everyone
    • Tenofovir + Emtricitabine + 3rd agent
  • Also give the meds for opportunistic infections eg co-trimoxazole for pneumocystis jirovecii pneumonia
  • annual cervical smears for women (higher risk of HPV cervical infection)
  • up to date with vaccinations
  • sexual education eg condoms, birth via caesrian unless viral load is undetectable, give ART to newborns for 4 weeks post birth, don’t breast feed

5th Year Revision (14 decks)

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