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EM > ID & Immunizations > Flashcards

ID & Immunizations Flashcards

1
Q

Lyme Disease - bug and tick name

A
  • Borellia burgdoferi
  • Ixodes deer tick (black-legged tick)
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2
Q

Malaria Prophylaxis

A
  • malarone
    • 1 day before to 7 days after (daily)
    • don’t use in preg
  • chloroquine
    • weekly, 1 week before to 4 weeks after
    • OK in preg
  • mefloquine
    • 1 week before to 4 weeks after
    • OK in preg
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3
Q

Travel immunizations

A

Twinrix – Hep A/B

  • Regular schedule : day 0, 30 and 180
  • Accelerated schedule: day 0, 7, 21 and 365

Typhoid Fever – Salmonella

  • Typherix: single dose and repeat in 3 years
  • Typhim Vi: single dose and repeat in 3 years

Traveller’s Diarrhea - ETEC/V.cholera

  • Dukoral: two doses q weekly starting 2 weeks ac travel (6 years to adults) three doses q weekly starting 3 weeks ac travel (2 to 6 years)
    • Booster - if all pts have had their last dose within 5 years a single oral booster dose is needed; if the last dose was > 5 years then a complete primary vaccination series as per age is indicated

Tetanus/diphtheria

  • All travelers should have this UTD
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4
Q

Modified Centor Criteria

A

Presence of tonsillar exudates: 1 point

Tender anterior cervical adenopathy: 1 point

Fever by history: 1 point

Absence of cough: 1 point

Age less than 15 years,* add 1 point to total score

Age more than 45 years,* subtract 1 point from total score

0-1 = no treatment, no testing

2-3 = RAT, treat if +ve, send culture if -ve (in kids only)

4 = treat, send culture

If no RAT

0-1 = no treatment

2 = no treatment unless outbreak, or known recent gabs exposure

3-4 = treat

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5
Q

Treatment for GABS strep Pharyngitis

A

Peds: Amoxicillin 50 mg/kg PO daily X 10 days (max 1000 mg)

or Amoxicillin ER tablet 775 mg PO daily X 10 days (children >12)

Adult: Pen V 300 mg PO TID X 10 days

or

Peds: Clindamycin 20-30 mg/kg/day PO divided TID X 10 days

Clindamycin 300 mg PO TID X 10 days

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6
Q

Indications for Abx prophylaxis for IE

A
  1. Invasive Dental Procedure

AND

  1. Prosthetic heart valve, hx IE, or unrepaired congenital cyanotic heart defect
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7
Q

Uncomplicated UTI Tx options

A

Macrobid 100 mg PO BID X 5d

Cipro 250 mg PO BID X 3d

TMP-SMX (Septra DS) i tab PO BID X 3 d

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8
Q

Pyelonephritis (Inpatient) Treatment

A

Ceftriaxone 1-2g IV

or

Gentamicin 5 mg/kg IV

or

Cipro 400 mg IV

*add ampicillin 1-2 g IV if enterococcus suspected

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9
Q

Pyelonephritis (Outpatient) Treatment

A

Cipro 500 mg PO BID X 7d

or

Septra DS i tab PO BID X 10-14d

*add ampicillin 500 mg PO TID if enterococcus suspected

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10
Q

Pyelonephritis Tx in Pregnancy

A

Inpatient: Amp + Gent or Ceftriaxone

Outpatient: TMP/SMX* or Keflex

*Not for late third trimester due to risk of kernicterus

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11
Q

Outpatient Pneumonia Treatment

A

Amox/Clav 875/125 mg PO BID X 7d

Pen allergic:

levofloxacin 750 mg PO daily X 5d

or

moxifloxacin 400 mg PO daily X 5d

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12
Q

Pneumonia: Inpatient Treatment

A

Amox/Clav 875/125 mg PO BID +- Azithro 500 mg PO daily

or

cefotaxime 1g Q8h IV or ceftriaxone 1g q24h IV +- Azithro 500 mg IV daily

+- Vancomycin 15-20 mg/kg IV Q12h

Pen allergic:

levofloxacin 750 mg PO/IV daily

or

moxifloxacin 400 mg PO/IV daily

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13
Q

Cellulitis treatment

A

Nonpurulent: Keflex 500 mg PO QID X 5-7d

(levo/moxi/clinda if allergic)

Purulent: Septra DS i BID X 7d

(or doxycycline 100 mg PO BID)

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14
Q

Diabetic foot infections treatment

A

Minor (ulcer : Keflex +- Septra

Moderate to Severe:

Amox/Clav + Septra

or

Ceftriaxone + Flagyl + Vanco

or

Pip-Tazo + Vanco

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15
Q

SIRS Criteria

A

Two of:

T >38.3 or

HR > 90

RR >20 or PCO2

WBC 12,000, or >10% immature forms

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16
Q

Triggers for treating AOM

A

>6 months with otorrhea OR severe (mod otalgia/>48h/T>39) X 10d

6-23 months with bilat AOM X 10d

6-23 months unilat, not severe = Obs or Abx X 10d

>2 years, not severe = Obs or Abx X 5-7d

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17
Q

Persistent Symptoms of AOM after 48-72h

A

Initiate or change Abx therapy, consider IM ceftriaxone, clinda, or tympanocentesis

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18
Q

AOM Abx Choice

A

1st line: Amoxicillin 80-90 mg/kg divided BID or Amox/Clav 90 mg/6.4 mg/kg

Pen Allx: Cefuroxime 30 mg/kg divided BID

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19
Q

Dose of Acyclovir for suspected HSV Encephalitis

A

10 mg/kg IV q8h X 10-14 d (assuming normal renal function)

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20
Q

Stages of Lyme Disease

A
  • first stage: erythema migrans, sometimes malaise/LAN, resolves 3-4 weeks
  • second stage: fever, LAN, neuropathies, heart block, arthralgias, multiple target lesions. Unilateral or bilateral facial nerve palsy.
  • late disseminated stage: months/years later. Chronic arthritis, myocarditis, polyneuropathy, subacute encephalopathy.
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21
Q

What to do with a tick bite?

A
  • no need to test serum or tick if no EM
  • IDSA recommends prophylaxis (200 mg doxy or 4 mg/kg up to 200 mg in children > 8 as single dose) if all of:
    • ixodes tick
    • engorged or > 36 h attached
    • within 72 h of bite
    • if doxy contraindicated, do not offer alternative abx
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22
Q

Rocky Mountain Spotted Fever (read-through)

A
  • rickettsia rickettsii
  • fever, malaise, conjunctivitis
  • rash (80%) days 2-4 of fever
    • small blanching erythematous macules –> becomes petechial
    • begins on hands/feet, centripetal spread up the trunk
  • Labs
    • normal WBC + Hb
    • Low Plt
    • mild + LFTs
    • Low Na
    • acute + convalescent serum
  • Tx
    • Doxy
    • Risk of teeth staining low, recommended for children of all ages
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23
Q

Rabies incubation period

A
  • 20-90 days, but cases up to 5 years
  • stays localized in soft tissues during incubation, but rapidly spreads to CNS thereafter
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24
Q

Rabies Clinical Features

A
  • encephalitis
  • 80% encephalitic, 20% paralytic
  • 50% have hydrophobia - drinking causes choking/spasms
    • aerophobia - grimacing when air blown on face
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25
Q

What does/does not constitute a rabies exposure?

Which animals are low/high risk?

A
  • petting a rabid animal or contact with urine/blood/feces is not an exposure (unless fresh wound on skin)
  • being in same room as bat with no known bite is NNT ~2.7 million, but PEP often still recommended
    • If asleep, if child, if mentally disabled, then PEP
  • healthy cat/dog –> observe animal for 10 days before offering vaccine
    • 2x vaccinated cat/dog no reported cases
  • skunks, raccoons, foxes, most carnivores, and bats need prophylaxis
  • squirrel, rats, rabbits, rodents almost never require prophylaxis (no reported cases)
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26
Q

Ehrlichiosis

A
  • tick-borne illness
  • WBC infection
  • lone-star tick, southeastern US
  • 30% get nonspecific rash
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27
Q

Anaplasmosis

A
  • tick-borne illness
  • ixodes tick, common in Lyme endemic areas
  • fever, malaise
  • no rash
  • doxy
28
Q

Tularemia

A
  • Francisella tularensis
  • transmitted by ticks and flies
  • several forms
    • ulceroglandular (most common)
    • glandular
    • typhoidal
    • oculoglandular
    • pneumonic
  • doxy, cipro, gent if severe
29
Q

Babesiosis

A
  • malaria-like parasite
  • co-infection with lyme common
  • 7-10 days atovaquone + azithromycin
30
Q

West Nile Virus

A
  • arbovirus
  • transmitted by mosquitoes
  • 20% infected develop symptoms, 1% severe infection
  • Ab testing available, not specific
  • treatment supportive
31
Q

Anthrax

A
  • bacillus anthracis
  • unsterilized, imported animal hides/raw wool
  • pulmonary
    • generally fatal inhaled mediastinitis
  • cutaneous
    • most common
    • painless macule –> ulcerative site with serosanguineous vesicles – > painless black eschar
      • untreated mortality 5-20%
32
Q

Brucellosis

A
  • unpasteurized dairy, slaughterhouse workers
  • endemic in Mediterranean basin
  • nonspecific symptoms
33
Q

Psittacosis

A
  • chlamydophila psittaci
  • from birds
  • pneumonia + endocarditis, hepatitis, CN palsies, AIN
34
Q

Q Fever

A
  • coxiella burnetii (rickettsial infection)
  • inhalation or arthropod from cattle, sheet, goats
35
Q

Hantavirus

A
  • inhalation from rodents
  • 3-4 d flu-like illness –> APE, hypotension, metabolic acidosis
  • supportive treatment
36
Q

Cutaneous Larva Migrans

A
  • migrating cutaneous hookworm larva from contaminated soil
  • single-dose ivermectin
37
Q
A

Disseminated Gonorrhea

38
Q

(painless)

A
  • chancre or primary syphilis
39
Q

Rash of secondary syphilis

A
  • dull red-pink papular
  • starts on trunk, spreads to flexor surfaces, palms + soles
40
Q

(painful)

A
  • chancroid
    • haemophilus ducreyi
41
Q

(painless chancre —> painful LAN)

A
  • lymphogranuloma venereum
42
Q

Nongonococcal Urethritis

A
  • usually chlamydia
  • sometimes ureaplasma urealyticum, mycoplasma genitalium, HSV, adenovirus (no need to treat)
  • if WBC >5/HPF –> treat for chlamydia
  • if symptoms persist, culture for trichomonas vaginalis + treat with Flagyl 2 g PO x 1
43
Q

Syphilis

A
  • treponema pallidum
  • primary
    • painless chancre, indurated borders
  • secondary
    • 3-6 weeks after end of primary phase
    • rash, lymphadenopathy, sore throat/fever/headaches/malaise
      • dull red-pink, papular
      • starts on trunk, spreads to palms/soles, flexor surfaces
  • tertiary
    • 3-20 years later, in 1/3 of patients
    • widespread granulomatous lesions (gummata)
    • meningitis, dementia, neuropathy (tabes dorsalis), thoracic aneurysm
44
Q

Genital Herpes

A
  • genital usually HSV-2, but indistinguishable from HSV-1
  • prodrome of pain/tingling x 24h
  • vesicles heal within 3 weeks
  • shedding for 10-12 days after onset of rash
  • to culture, deroof/puncture vesicle and scrape base with swab
  • first episode (primary) treated longer than second episode
45
Q

Chancroid

A
  • Haemophilus ducreyi
  • painful genital ulcers + lymphadenitis (may lead to buboes if untreated)
  • dx clinical (cultures poor, no PCR available)
  • single dose zithromax or ceftriaxone tx
46
Q

Lymphogranuloma Venereum (tropical bubo)

A
  • painless chancre x 2-3 days
  • unilateral suppurative inguinal LAN 1-3 wks later
    • scarring linear depressions parallel to inguinal ligament
    • somtimes rectal ulcers, bleeding, discharge
  • dx clinical, no great tests
  • doxy x 21 days
47
Q

Granuloma Inguinale (Donavanosis)

A
  • Klebsiella granulomatis
  • endemic in India, south Africa
  • painless subcutaneous nodules –> painless beefy red, fragile ulcers
  • dx clinical, no great test
  • doxy x 3 weeks
48
Q

Cognitive Force

WBC > 20

A
  • CXR
  • Urine
  • Skin check
49
Q

Sporotrichosis

A
  • Sporothrix schenckii fungus
  • mostly in tropical zones, in soil, common among florists
  • dx fungal cultures/tissue biopsy cultures
  • tx itraconazole x 3-6 months
50
Q

Acute Herpetic Gingivostomatitis

A
  • common primary infection at 6 mo. - 5 yrs
  • 90% HSV 1, 10% HSV 2
  • abrupt high fever, drooling, swollen + friable gingiva + vesicular oral lesions, tender cervical LAN
  • lasts 1-3 weeks
  • acyclovir 15 mg/kg PO divided 5x/day x 7d
51
Q

Treatment of Varicella + Shingles

A
  • Varicella
    • h/a, malaise, fever
    • 2-3 crops of lesions focused on torso/face over 1 week
    • consider PO acyclovir if > 12 y old, chronic skin or lung disorder, or immunocompromised
    • acyclovir 20 mg/kg PO QID x 5 days
    • start within 24h of rash if possible
    • pregnancy
      • ​30% varicella pneumonia, mortality 40%
    • congenital varicella syndrome
    • usually in first 20 weeks of pregnancy
    • <2% risk at < 20 weeks, lower after
    • diagnosis
      • clinical
      • 4x rise in varicella-specific IgG Ab over 14-21d period
    • management
      • if history of chickenpox –> reassure
      • if unknown, and able to get results within 96h, draw VZV IgG Ab
      • if unable to get labs within 96h or if no immunity
      • give VZIG 625 units IM
      • if develops severe disease
      • acyclovir 10 mg/kg IV Q8h or 800 mg PO QID x 5 d
  • Shingles
    • valacyclovir 1 g PO TID x 5 days for adolescents/adults
    • maternal HZV not harmful but exposure to HZV without varicella immunity is
52
Q

Poor Man’s CD4 Count

A
  • < 200 is ~ < 1700 cells/mm^3 total lymphocyte count
  • < 200 CD4 and viral load > 50 k is associated with AIDS-defining illnesses and is common cutoff for antiretroviral therapy
53
Q

oral hairy leukoplakia (OHL)

A
  • oral hairy leukoplakia (OHL)
    • EBV infection
    • lateral border tongue white plaques, cannot scrape off
    • acyclovir
54
Q

HIV Optho Emergency

A
  • CMV Retinitis
  • low CD4 count (often < 50) + ssx retinal detachment
55
Q

PJP Pneumonia

A
  • fever, nonproductive cough, SOB
  • Xrays diffuse infiltrates but 25% neg
  • sometimes elevated LDH
  • ABG –> increase in Aa gradient
  • walk test –> desat
  • septra DS 2 TID x 3 weeks
  • prednisone 40 mg BID and 21 day taper if PaO2 < 70 mm Hg or Aa > 35 mm Hg
56
Q

Endocarditis

A

Review Evernote

57
Q

Tetanus

A

Review Evernote

58
Q

Occ Health and HIV PEP

A

see note “Occ Health”

59
Q

C. Diff Infection

A
  • symptom onset usually 7-10 days post abx, but up to 60d
  • sometimes two-step test
    • step 1: test for glutamate dehydrogenase (present in all strains)
    • step 2: if +ve, test for toxin A/B which is present only in toxic strains, treat if step 2 positive
  • initial mild episode: Flagyl 500 mg PO TID x 14 d
  • initial moderate episode: Vanco 125 mg PO QID x 14 d
  • severe: Flagyl 500 mg IV + Vanco 500 mg PO
  • Relapse: see stanford
  • fidaxomicin 200 mg PO BID x 10 d (alternative to vanco for moderate)
  • treatment does not eradicate, so do not test/treat asymptomatic patients
60
Q

Scombroid Poisoning

A
  • tuna, mackerel, bonito, mahi-mahi
  • histadine in fish transformed into histamine by bacteria when stored too warm
  • 30 min-24h after eating
    • flushing, headache, abdo cramping, vxdx
  • self-limited
  • tx with H1 + H2 blockers
61
Q

Ciguatera Poisoning

A
  • large reef predator fish contaminated with Gambierdiscus toxicus –> ciguatoxin
  • grouper, snapper, amberjack, barracuda
  • heat resistant
  • acts on Na channels causes depolarization
  • nxvxdx –> hypesthesias, paresthesias, numbenss, weakness
  • temperature sensitivity +- heat/cold reversal
  • supportive treatment
62
Q

Tetrodotoxin

A
  • puffer fish
  • paresthesias, h/a, vx, ddx, ascending paralysis
  • death in 4-6 h
  • anticholinesterases such as neostimine and edrophonium
63
Q

Tetanus Clinical Syndromes

A
  • uncontrolled muscle spasms
    • may start with mild trisumus –> risus sardonicus
    • opisthotonos
  • hypersympathetic state
    • HTN, fever, sweating
  • normal LOC
  • localized tetanus
    • rigid just muscles prox to wound
    • may progress to generalized
  • neonatal tetanus
    • improper stump care, born to unimmunized mother
    • weak cry, poor suck
  • cephalic tetanus
    • from HI or otitis
    • CN 7th and other CN palsies
64
Q

Who needs airborne precautions?

A
  • Measles
  • Tuberculosis (primary or lanryngeal)
  • Varicella (airborne + contact)
  • Zoster (disseminated or immunocompromised patient; (airborne and contact )
  • SARS (Contact+airborne )
65
Q

Sexual Assault

A

See Evernote

66
Q

Treatment of First Stage vs. Second Stage Lyme

A

See Evernote

67
Q

Asplenic patient with fever

A
  • start broad spectrum abx
  • consider admission

EM (27 decks)

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