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Step 3 > INFECTIOUS DISEASES > Flashcards

INFECTIOUS DISEASES Flashcards

1
Q

Cystic Fibrosis

common bacterial pathogens in CF pneumonia

A

gram (-):
pseudomonas aeruginosa*, burkholderia cepacia, stenotophomonas mmatlophilia

gram (-) coccobacilli: nontypeable Haemophilus influenzae

gram + cocci in chains: strep pneumo

gram + cocci in clusters: staph aureus*

staph: vancomycin

antipseudo:
tobramycin (aminoglycosisde) + antipsuedomonal penicillin (ticarcillin-clavulanate, piperacillin-tazobactam)
OR
3/4 gen cephalosporin (cefepime, ceftazidime)
OR
carbapenam (meropenan, imipenen/cilastatin

  • common combo: tobramycin, ticarcillin-clavulanate + vancomycin
  • most common. pseudo > staph as get older
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2
Q

Chronic Bacterial Prostatitis

-treatment

A

first line treatment is 6 weeks of fluoroquinolone (ciporfloxacin) or trimethorpim-sulfamethoxazole

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3
Q 
Cryptococcal Meningitis 
1. treatment:  
3 stages: 
a.induction
b. consolidation 
c. maintenance
  1. role of serial lumbar punctures
A
  1. treatment:
    3 stages:
    a.induction: amphotericin B and flucytosine for 2 weeks or more until symptoms abate and sterile CSF

b. consolidation: high dose oral fluconazole for 8 weeks
c. maintenance: lower dose oral fluconazole for 8 weeks
2. role of serial lumbar punctures: relieve increased ICP

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4
Q

Dengue Fever
Classic vs hemorrhagic
mgmt

A

classic: flu-like with myalgias, retro-orbital pain, rash

hemorrhagic dengue: increased vascular permeability, thrombocytopenia, spontaneous bleeding (leading to shock), positive tourniquet test (petechiae after BP cuff)

mgmt: supportive

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5
Q

Dengue Fever
Classic vs hemorrhagic
mgmt

A

classic: flu-like with myalgias, retro-orbital pain, rash

hemorrhagic dengue: increased vascular permeability, thrombocytopenia, spontaneous bleeding (leading to shock), positive tourniquet test (petechiae after BP cuff)

“dengue shock syndrome” circulatory failure

mgmt: supportive

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6
Q

BCG vaccination & PPD skin testing

A

shouldn’t cause induration > 15mm on PPD skin testing. effect decreases after 15+ years of receiving vaccine

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7
Q

Neisseria Meningitidis prophylaxis-who and what meds

A

household members, roommates/intimate contacts, daycare workers, those directly exposed to patients oral/respiratory secretions (kissing, mouth-to-mouth resuscitation, endotrach intubation/mgmt), airline travelers seated adjacent to affected person for more than 8 hours

rifampin-4 doses orally
ceftriaxone-once IM, safe when pregnant
ciprofloxacin-once orally, not kids

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8
Q

Vaccines for adults

A

annual flu, Td booster every 10 years with Tdap as one time substitute, PCV13 at 65 years follow by PCV23 in 6-12months.

if patient chronic heart, lung, liver dx, dbts, alcoholic or smoker give PCV23 alone before 65 years.
very gigh risk: SCD, immunocomp, CKD, give PCV 12 and 23 before 65 years

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9
Q

Tb

1. alternative treatment for latent if isoniazid resistant

A
  1. rifampin
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10
Q

infective endocarditis

-mycotic aneurysm

A

-infected arterial aneurysm can happen in systemic or cerebral circulation due to septic embolization and localized vessel wall destruction as complication of IE. intracerebral mycotic aneurysms can present as an expanding mass with focal neuron findings or with aneurysm rupture and subarachnoid hemorrhage

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11
Q

Staph aureus-treatment

  1. MSSA
  2. MRSA
A
  1. MSSA
    IV: oxacillin/nafcillin, or cezfazolin (1st gen cephalosporin)
    oral: dixloxacillin or cephalexin (1st gen cephalosporin)
  2. MRSA
    severe: vancomycin, linezolid (AE: thrombocytopenia), daptomycin (myopathy), tedizolid
    minor: TMP/SMX, clindamycin, doxycyline
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12
Q

Strep meds

A

penicillin, ampicillin, amoxicillin

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13
Q

gram negative rods
E. Coli, Enterobacter, Citrobacter, Morganella, Serratia, Pseudomonas

Exceptions:

a. ertapenem is the only cabapenem that doesn’t cover?
b. what do else do ticarcillin, piperacillin cover?
c. levo, gemi and moxi are excellent for?
d. aminoglycoside role in treatment staph& enterococcus
e. carbapenems excellent for?
f. what does tigecycline cover
g. use of polymyxin/colistin? toxicity?

A

ALL of these:

  1. Cephalosporins: cefepime, ceftazidime
  2. Penicillins: Ticarcillin, piperacillin
  3. Monobactam: aztreonam
  4. Quinolones: Cipriofloxacin, levofloxacin, moxifloxacin, Gemifloxacin
  5. Aminoglycosides: gentamicin, tobramycin, amikacin
  6. Carbapenams: imipenem, ,meropenem, ertapenem*, doripenem

Exceptions

a. pseudomonas
b. gram neg rods, anaerobes, strep
c. pneumococcus
d. work synergistically with other agents for treatment
e. anaerobes. also strep and MSSA
f. MRSA and gram neg rods
g. multidrug resistant gram neg roads. renal toxicity

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14
Q

Beta Lactam Antibiotics
4 classes
mechanism

A

penicillins
caphalosporins
carbapenems
monobactam-aztreonam only

mech: inhibit cell wall binding by penicillin binding protein

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15
Q

4 Beta lactamase inhibitors

function

A

clavulanate, sulbactam, tazobactam, avibactam

combining beta-lactamase inhibitors with penicillins or cephalosporings broadens their spectrum to cover staph (not MRSA) and some gram neg rods

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16
Q

Anaerobic coverage

  1. GI
  2. Respiratory
  3. medications with no anaerobic coverage
A
  1. GI
    - metronidazole (best for abdominal anaerobes)
    - carbapenems, piperacillin, ticarcillin
    - cefoxitin & cefotetan =only cephalosporins that covers anaerobes
  2. Respiratory
    clindamycin
  3. medications with no anaerobic coverage
    aminoglycosides, axtreonam, fluoroquinolones, oxacillin/nafcillin, all cephalosporings (except cefoxitin & cefotetan)
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17
Q 
side effects 
linezolid
daptomycin 
imipenem
vancomycin
A

linezolid:thrombocytopenia
daptomycin: myopathy
imipenem: seizures
vancomycin; red man syndrome = red flushed skin from release of histamine. slow infusion rate

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18
Q 
Antiviral Agents 
1. Herpes Simplex, Varicella 
2. Cytomegalovirus
what's best for CMV retinitis 
side effects of vagancyclovir, gangcyclovir 
3. chronic Hep C
4. Influenza A and B
5. RSV
side effect 
6. Chronic Hep B
A
  1. Herpes Simplex, Varicella:
    Acyclovir, Valcyclovir, famcylcovir
  2. Cytomegalovirus
    Gangcyclovir, Valganciclovir, foscarnet
    (can also cover HSV, varicella)

Vaganciclovir best for CMV retinitis
Vagan- & Gangcyclovir: neutropenia, BM suppression
foscarnet: renal toxicity

  1. chronic Hep C:
    sofosbuvir-ledipasvir, elbasvir-grazoprevir, daclatasvir-sofosbuvir, ombitasvir-paritaprevir-dasabuvir, sofosbuvir
  2. Influenza A and B: oseltamivir, zanamivir, peramivir
  3. RSV: ribavirin (side effect anemia)
  4. Chronic Hep B: lamivudine, interferon, adefovir, tenofovir, entecavir, terlbivudine
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19
Q

Antifungal Agents

  1. Fluconazole
  2. Voriconazole
  3. Echinocandins(caspofungin, micafungin, anidulafungin)
  4. Efinaconazole, tavaborole
  5. toxicity of all azoles
A
  1. Fluconazole: candida, cryptococcus
  2. Voriconazole: aspergillus, candida
    voriconazole -visual disturbance
  3. Echinocandins(caspofungin, micafungin, anidulafungin)
    -neutropenic fever patients
    -not for Cryptococcus
    -no adverse effects
    -candidemia
  4. Efinaconazole, tavaborole (topical): onychonycosis
  5. toxicity of all azoles
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20
Q

Amphotericin

  • 2 main indications
  • adverse effects
A
  • 2 main indications: cryptococcus, candida
  • adverse effects: directly toxic to renal tubules causing renal tubular acidosis. distal RTA gives excess K and Mg loss and H+ retention. need to switch to liposomal amphotericin
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21
Q 
Osteomyelitis
-typical presentation
-diagnostic testing
-earliest finding of osteomyelitis on x-ray
-how long do you know how to treat
-treatment
what is most common cause
A

-typical presentation: PAD, diabetes with ulcer or soft tissue infection. have to ask if it has spread to bone

-diagnostic testing?
x-ray first
MRI if x-ray negative but high clinical suspicion. MRI has greater sensitivity and NPV for diagnosis or exclusion of osteomyelitis of the foot

(x-ray might be negative b/c have to lose >50% Ca content of bone for xray to become abnormal)

-earliest finding of osteomyelitis on x-ray?
earliest finding = elevation of periosteum
will need bone biopsy/culture

-how long do you know how to treat?
follow sed rate. if ESR is still high after 4-6wks then further therapy and possible debridement is needed

-treatment
staphylococcus (most common cause) (NO ORAL meds)
MSSA: IV oxacillin, nafcillin
MRSA: IV vancomycin, linezolid, daptomycin

Gram-negative bacilli (Salmonella and pseudomonas)
ONLY GRAM NEGS CAN BE TREATED ORALLY

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22
Q

Otitis Externa

-treatment

A

cellulitis of the skin of the external auditory canal

  1. topical ciprofloxacin, ofloxacin, polymyxin/neomycin
  2. topical hydrocortisone to decrease swelling/itching
  3. acetic acid and water solution -reacidify ear
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23
Q

Malignant Otitis Externa

  1. common causative agent
  2. diagnosis
  3. treatment
A

osteomyelitis of skull–>brain abscess, skull destruction

  1. commonly caused by pseudomonas in diabetic
  2. CT, MRI first. biopsy is most accurate
  3. surgical debridement and antibiotics against pseudomonas (ciprofloxacin, piperacillin, cafepime, carbapenem, aztreonam)
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24
Q

Otitis Media

  1. diagnosis
  2. treatment
  3. common causative agents
A
  1. diagnosis: red, bulging, decreased hearing, loss of light reflex, IMMOBILE TYMPANIC MEMBRANE
  2. treatment: amoxicillin 7-10days
    - no improvement after 3 days then amoxicillin-clavulunate, cefdinir
    - persistent/recurrent: tympanocentesis & aspirate of tympanic membrane for culture
  3. common causative agents: strep pneumo, Haemophilus, Moraxella
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25
Q

Sinusitis

  1. common causative agents
  2. diagnosis
  3. treatment
A
  1. common causative agents: strep pneumo, Haemophilus, Moraxella
  2. x-ray is best initial test. sinus aspirate for culture is most accurate
  3. amoxicillin + steroid nasal spray
    amoxicillin-clavulunate if bad
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26
Q

Streptococcus Pharyngitis

  1. symptoms
  2. diagonosis
  3. treatment
A

Streptococcus Pharyngitis
1. exudate, adenopathy, sore throat, NO COUGH
2. diagnosis: rapid strep test detects Group A strep that can lead to rheumatic fever/glomerulonephritis
3.treatment: amoxicillin/penicillin.
penicillin allergy then azithromycin/clarithromycin

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27
Q

Influenza

  1. diagnosis
  2. treatment
  3. vaccine
A
  1. diagnosis: viral praid antigen detection
  2. treatment: oseltamivir or zanamivir if symptom onset within 48 hours. peramivir is available IV
  3. can get live if <50years without any medical conditions
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28
Q

Impetigo

-treatment

A

TOPIcals: mupirocin or retapamulin
severe: oral dicloxaciliin or cephalexin
MRSA: TMP/SMZ or doxycycline

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29
Q

Erysipelas

  1. causative agent
  2. symptoms
  3. diagnosis
A
  1. causative agent: group A (progenies) streptococcal infection of the skin.
  2. symptoms: skin bright read and hot (usually on face)
    • blood cultures
  4. treatment: ORAL dicloxacillin or cephalexin
    NO ROLE TOPICAL ANTIBIOTICS
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30
Q

Cellulitis

  1. causative agent
  2. diagnosis
  3. treatment for folliculitis, furuncles, carbuncles, boils
A
  1. causative agent: strep pyogenes and staph aureus
  2. diagnosis: if leg, r/o clot w/ lower extremity doppler
    minor: oral dicloxaciliin, cephalexin, amoxicillin/clavulunate
    severe: IV oxacillin, nafcillin, cafazolin, ampicillin/solbactam
  3. treatment for folliculitis, furuncles, carbuncles, boils is same as above + drainage of boils. can develop post strep glomerulonephritis
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31
Q

Penicillin allergy
rash
anaphylaxis

A

rash: cephalosporin
anaphylaxis: vancomycin, linezolid, daptomycin

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32
Q

which infections can led to rheumatic fever or glomerulonephritis?

A

strep pharyngeal infection–>rheumatic fever and glomerulonephritis
strep skin infection–>glomerulonephritis

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33
Q

Fungal Infection of skin & nails

treatment

A

skin (no hair/nail): clotrimazole, miconazole, ketoconazole, econazole, nystatin, ciclopirox, terconazole

oral (scalp (tinea capitis) or nail (onychomycosis): terbinafine-increases LFTs
itraconazole
griseofulvin (capitis only)

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34
Q

Urethritis

  1. symptoms
  2. diagnosis
  3. treatment

Cervicitis

  1. symptoms
  2. diagnosis
  3. treatment
A

Urethritis
1.symptoms: urethral discharge +/- dysuria
2.diagnosis:
a. urethral swab: gram stain, culture, WBCs, DNAprobe
NAAT STI testing on urine
3.treatment: cover gonorrhea and chlamydia

Cervicitis

  1. symptoms: cervical discharge
  2. diagnosis: vaginal swab: gram stain, culture, WBCs, DNAprobe (NAAT)
  3. treatment cover gonorrhea and chlamydia
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35
Q

Medications for gonorrhea and chlamydia

A 
gonorrhea
IM ceftriaxone (ok in pregnancy)
chlamydia  
azithromycin once (ok in pregnancy)
doxycycline 7 days (not in pregnancy)
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36
Q

Gonorrhea
disseminated
recurrent

A

dissem’d: polyarticular dx, petechial rash, tenosynovitis

recurrent: may have terminal complement deficiency

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37
Q

Pelvic Inflammatory Disease

  1. symptoms
  2. diagnosis
  3. treatment
A
  1. symptoms: lower abdominal pain, tenderness, fever, cervical motion tenderness
  2. diagnosis: leukocytosis measures dx severity. should do pregnancy test, then cervical culture and NAAT

lapascopy if recurrent/persistent

3.treatment
outpatient:
gonorrhea-IM ceftriaxone (ok in pregnancy)
chlamydia: oral doxycycline 7 days (not in pregnancy)

inpatient: cefoxitin & doxycycline +/- metronidazole
penicillin allergy: clindamycin & gentamicin

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38
Q

antibiotic safe during pregnancy

A

penicillins, cephalosporins, aztreonam, erythromycin, azithromycin

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39
Q

epididymo-orchitis

  1. presentation
  2. how does it differ from testicular torsion
  3. treatment
A

1.presentation:painful, tender testicle in NORMAL position
2.testicular torsion: testicle elevated & transverse position
3. treatment:
<35 years: ceftriaxone & doxycycline
>35 years: fluoroquinolone

40
Q 
Cancroid 
1. causative agent 
2. symptoms
3. diagnosis 
special medium
4.treatment
A
  1. Haemophilus ducreyi (gram neg coccobacilli)
  2. symptoms: painful genital ulcer, enlarged lymph nodes
  3. diagnosis: swab for gram stain & culture (Nairobi medium and Mueller-Hinton agar)
  4. IM ceftriaxone (ok pregnancy) or 1 dose azithromycin
41
Q

Lymphogranuloma Venereum

  1. presentation
  2. diagnosis
  3. treatment
A
  1. BIG TENDER NODES (BUBOES) +/- drainage & ulcer
  2. diagnosis: serology for chlamydia
  3. aspirate bubo, then doxycycline or azithromycin
42
Q

Erythromycin GI side effect

A

increases release of motilin hormone that increases GI motility between meals.

43
Q

Herpes Simplex Virus

  1. diagnosis
  2. treatment
A

1.diagnosis: if there are clear vesicular lesions go right to treatment. if roofs come off of vesicles and lesion because an ulcer of unclear etiology than PCR is most sensitive. cultures provide sensitivities.
2.treatment: acyclovir, gangcyclovir, famicyclovir 7 days
recurrent/persistent then get viral cultures
resistant to acyclovir then use foscarnet not gangcyclovir

44
Q 
Syphilis 
1. causative agent 
2. symptoms, diagnosis treatment
primary, secondary, tertiary 
Jarisch-Herxheimer Reaction
A
  1. treponema pallidum

a. primary
symptoms: painless chancre, adenopathy
diagnosis: darkfield, then VDRL/RPR
treatment: 1 IM shot benzathine penicillin. use doxycycline if penicillin allergy.

Jarisch-Herxheimer reaction: fever, headache, myalgia within 24 hrs of treatment due to release of pyrogens from dying treponema. give aspirin & continue treatment.

b. secondary
symptoms: rash, mucous patch, alopeci areata, condylomata lata
diagnosis: RPR and FTA
treatment: 1 IM shot benzathine penicillin. doxycycline if penicillin allergy.

c. tertiary
symptoms: neuro (tabes dorsalis, argyll-robertson pupil, general paresis), gumma, aortitis
diagnosis: RPR & FTA, LP (test CSF with VDRL and FTA)
treatment: IV aq. penicillin. desensitize if penicillin allergy

patients with CD4<350 and RPR titer >1:32 higher risk neurosyphilis

45
Q

Granuloma Inguinale

  1. symptoms
  2. diagnosis, typical causative agent
  3. treatment
A
  1. symptoms: beefy, red ulcerating genital lesion
  2. diagnosis: biopsy or touch prep, klebsiella granulomatis, donovan bodies
  3. treatment: doxycycline, TMP/SMX, azithromycin
46
Q

scabies treatment

A

permethrin, ivermectin, lindane

47
Q

Cystitis

treatment

A

uncomplicated: oral fosfomycin or nitrofurantion 3 days
E coli resistance >20% locally then ciprofloxacin or levofloxacin

complicated: TMP/SMX or ciprofloxacin 7 days

48
Q

Central line associate bloodstream infection

A

commonly due to coag negative staph, staph aureus, candy, aerobic gram neg bacilli
prevent infection: maximal barrier precautions, avoid femoral site, skin cleansing with chlorhexidane, prompt catheter removal when no longer needed

49
Q

Infectious Mononucleosis

A

usually due to EBV. systemic viral infection
presents with fever, extreme fatigue, oxidative pharyngitis/tonsillitis, lympadenopathy (including posterior cervical) and hepatosplenomegaly

atypical reactive lymphocytes (predominant cytoplasm, irregular nucleus) on peripheral blood smear.

50
Q

Lactational Mastitis

A

oral dicloxacillin (anti staph penicillin) and cephalexin.

no Trimethoprim-sulfamethoxazole while breast feeding

if doesn’t resolve then u/s to r/o inflammatory breast ca, breast abscess

51
Q

HIV lidodystrophy

A

presents as lipoatrophy, fat accumulation or both in different areas. a pattern with increased fat tissue deposition on the back of the neck and abdomen along with thin extremities. closely related to diabetes and dyslipidemia.

HIV infected patients frequently have dyslipidemia, particularly hypertriglyceridemia, which can be exacerbated by antiretroviral therapy. first line usually statin but use vibrate in triflyverise >500mg/dL

52
Q

Schistosomiasis

A

parasitic fluke infection common in sub-saharan africa. chronic urinary schistomiasis can cause dysuria, urinary frequency, terminal hematuria, peripheral eosinophilia.
diagnosis: i.d. parasite eggs by urine sediment microscopy

53
Q

Ecythma Gangrenosum

A

most commonly seen in immunocompromised patient with pseudomonas aeruginosa bacteremia. manifestations: rapid evolution of >1 skin lesion from an erythematous macule to a pustule or bull and then into a non painful gangrenous ulcer. fever and systemic sign common.

treatment:
antipseudonomal beta lactam (piperacillin-tazobactam) AND amonoglycoside (gentamicin)

54
Q

HIV

Cutaneous Cryptococcosis

A

usually occurs in advanced HIV CD4<100. marker of disseminated dx.

manifestations: rapid onset multiple papular lesions with central umbilification and central hemorrhage/necoris

diagnose with lesion biopsy
treat with 2+ weeks of IV amphotericin B and oral flu cytosine then 1 year of oral fluconazole

55
Q 
Diptheria 
Epidemiology
Manifestations 
Diagnosis 
Treatment
A

Epidemiology: toxigenic strains of corynebacterium diphtheriae. kids <15yrs. vaccine decreases risk.

Manifestations:
pharyngitis -grey patches/pseudomembranes that bleed when scraped.

toxin mediated myocarditis

Diagnosis: culture resp secretions, toxin assay

Treatment: erythromycin or penicillin G. diphtheria antitoxin if severe

56
Q

Chagas Disease

A

dilated cardiomyopathy

57
Q

if azithromycin isn’t effective for nongonococcal urethritis, what else should be suspected?

A

trichomonas

treat with metronidazole

58
Q 
Chlamydia in pregnancy 
screening 
risk factors 
OB complications 
fetal complications 
treatment
A

screening: universal 1st trimester, agin in 3rd trimester if high risk

risk factors: <25 yrs, hx of STI, new partner, multiple partners, unprotected sex

OB complications: preterm, premature rupture of membranes, preterm labor, postpartum endometritis

fetal complications: neonatal conjunctivitis, neonatal pneumonia

treatment: azithromycin

59
Q

can you work at hospital with latent Tb infection

A

healthcare workers with latent Tb should be counsel about the risk of developing active Tb and offered preventative therapy with isoniazid for 6-12 months. they shouldn’t be excluded from the workplace if they refuse to accept recommended therapy.

60
Q
  1. Extrapulmonary Tb
    kids & infants
    how to treat Tb meningitis
A

kids & infants should be treated for 12 months . treat Tb meningitis with isoniazid, rifampin, and pyrazinamide for 2 months then INH and rifampin for 10 months

61
Q

HIV meds during pregnancy

A

first line zidovudine/lamuvudine
efavirenz preferred after 8 weeks . if woman already on it then leave . if not then don’t begin until after 8wks

in general should try to avoid discontinuing/modifying effective regimen as can lead to viral failure and drug resistance

62
Q

pneumocystis pneumonia

  1. role of corticosteroids in patients with HIV
  2. what is sputum culture is negative but suspicion is high
A
  1. if ABG show alveolar-arterial oxygen gradient >35 and or arterial oxygen tension <70 on room air . these patient often have respirator decompensation during the first 2-3 days of treatment due to organism lysis, which stimulates inflammatory response. steroid reduce risk of intubation
  2. do bronchial lavage
63
Q

disseminated gonococcal infections

  1. how do you confirm diagnosis when suspected
  2. unique finding
A
  1. culture joint fluid and mucosal surfaces (urethral, cervical, rectal, oral mucosa)
  2. tenosynovitis -painful tendons along the ankle & toe joints
64
Q

Mucomycosis

rhinocerebral -typically present in which patients? treatment?

A

DKA patients, requires surgical debridement and IV liposomal amphotericin B

65
Q

Infectious Mono

what happens if give amoxicillin

A

gernalized maculopapular rash that will resolve spontaneously after withdrawal of antibiotic and observation

66
Q

uncomplicated pediatric pneumonia

  1. most common cause preschool age or focal lung findings? treatment?
  2. most common cause older child or well appearing with bilateral lung findings
A
  1. strep pneumo, amoxicillin

2. mycoplasma pneumoniae, azithromycin

67
Q

Pyelonephritis

  1. presentation
  2. diagnosis
  3. treatment
A
  1. cystitis symptoms+flank pain, tenderness, fever
  2. diagnosis: urinalysis & culture
  3. treatment: cover for gram neg bacilli
    outpatient : ciprofloxacin
    inpatient: ceftriaxone, amp, gent, quinolones
68
Q

Periphrenic Abscess

  1. presentation
  2. diagnosis
  3. treatment
A
  1. rare complication of pyelonephritis
    suspect if pt doesn’t respond to treatment for pyelo within a 1week, persistent WBCs on U/A & fever
  2. need u/s or CT kidneys
    biopsy abscess
  3. treat with quinolone and add staph coverage (oxacillin, naficillin, vanc)
69
Q

Prostatitis

  1. presentation
  2. diagnosis
  3. treatment
A
  1. freq, urgency, dysuria, perineal/sacral pain “boggy” prostate
  2. diagnosis: U/A
  3. treatment: TMP/SMX or cipro
    same as cystitis just longer. 2 wks for acute, 6 wks for chronic . can also use fosfomycin
70
Q

HIV
HAART
when is ritonavir added? why?
cobicistat?

A
  1. lamivudine & abacavir + integrase inhibitor
  2. tenofovir&emtricitabine + integrase inhibitor
  3. tenofovir & emtricitabine + atazanavir (protease inhibitor)

when is ritonavir added? why? if use protease inhibitor at ritonavir to boost levels of other protease inhibitors

cobicistat? boost drug levels

71
Q

Adverse effect of classes

  1. NRTI (-dine, -sine, -bine, -vir)
  2. protease inhibitors (-navir)
  3. NNRTI (-pine, rine, efavirenz)
  4. integrase inhibitors (gravir)
A
  1. lactic acidosis
  2. hyperglycemia, hyperlipidemia
  3. drowsiness, don’t use in mentally ill
  4. no major
72
Q

AE:

  1. tenofovir
  2. efavirenz
  3. abacavir
A
  1. tenofovir: RTA, fanconi’s syndrome
  2. drug resistance,avoid preg. & mentally ill
  3. only use if neg for HLA-B*5701 mutation
73
Q

PreP

PEP

A

PrEP: tenofovir + emtricitabine
PEP: tenofovir + emtricitabine + integrase inhibitor

74
Q

Tenofovir

2 forms

A

disoprovil form is toxic to bone and kidneys

alafenamide form is less toxic

75
Q

HIV
Prophylaxis:
1. Pneumocystitis Jiroveci Pneumonia (PCP)
2. Mycobacterium Avium-Intracellulare

A
  1. CD4<200
    TMP/SMX
    if rash than dapsone or atovaquone
    no dapsone if G6PD deficiency
  2. CD<50, oral azithromycin once a week
76
Q

HIV Opportunistic Infections
presentation, diagnosis, treatment

  1. PCP
  2. Toxoplasmosis
  3. Cytomegalovirus
  4. Cryptococcus
  5. Progressive Multifocal Leukoencephalopathy
  6. Mycobacterium Avium-Intracellulare
A
  1. PCP
    presentation: shortness of breath, dry cough, hypoxia, increased LDH

diagnosis:CXR: incresed interstitial markings
if neg but high suspicion then bronchoalveolar lavage

treatment: IV TMP/SMX
if rash switch to IV pentamidine
not dapsone because not IV
severe (pO2<70, A-a gradient >35): steroids

  1. Toxoplasmosis
    presentation: headache, n/v, focal neuro findings

diagnosis: CT head “ring enhancing lesions”
treatment: pyrimethamine & sulfdiazine for 2 wks. repeat CT if lesions smaller than confirmative. if lesions not responding then brain biopsy

  1. Cytomegalovirus (CD4<50)
    presentation: blurry vision

diagnosis: appearance of lesion on PE

treatment: ganciclovir or foscarnet
maintenance therapy with oral valganciclovir forever, unless CD4 increases

  1. Cryptococcus (CD<50)
    presentation: fever and headache

diagnosis: LP- increase CSF lymphocytes
india ink stain 60% sensitivity
crypto antigen test 95% sen and specific

treatment: amphotericin & 5-FC then fluconazole lifelong unless CD4 rises

  1. Progress.Multifocal Leukoencephalopathy (CD<50)
    presentation: focal neuro abnorms

diag:CT head or MRI. no ring enhancement, no mass effect
PCR of CSF for JC virus most accurate

treatment: none. take HAART, as CD4 increases PML will resolve

  1. Mycobacterium Avium-Intracellulare (CD<50)
    presentation: wgt loss, fever, fatigue, anemia, high all phase, high GGTP with normal bilirubin

diag:
blood culture -least sensitive
bone marrow- more sensitive
liver biopsy-most sensitive

treatment: clarithromycin and ethambutol

77
Q

Infective Endocarditis

1.empiric therapy

A
  1. vancomycin and gentamicin to cover most organism (s. aureus, MRSA, viridans group strep). treat 4-6weeks
78
Q

Endocarditis Prohpylaxis:

  1. cardiac defects that need prophylaxis
  2. procedures that require prophylaxis
  3. what drugs for prophylaxis
A
  1. cardiac defects that need prophylaxis
    - prosthetic valves
    - unrepaired cyanotic heart disease
    - previous endocarditis
    - transplant recipients with valve disease
  2. procedures that require prophylaxis
    - dental procedures that cause bleeding
    - respiratory tract surgery
    - surgery of infected skin
  3. dental/oral:
    - amoxicillin
    - rash: cephalexin
    - anaphylaxis: azithromycin, clarithromycin, clindamycin

skin:
cephalexin
allergic to penicillin: vanc

79
Q

Animal Borne diseases
presentation, diagnosis, treatment

  1. Leptospirosis
  2. tularemia
  3. Cysticercosis
A
  1. Leptospirosis (spirochete) animal pee
    presentation: fever, abdominal pain, myalgia
    diagnosis: serology
    treatment: ceftriaxone or penicillin
  2. tularemia–rabbits in the summer
    presentation:
    ulcer at contact site, big lymph nodes, conjunctivitis
    pneumonic : deadly

diagnosis: serology. taking culture releases spores!
treatment: streptomycin, doxycycline, gentamicin

  1. Cysticercosis–infected pork
    presentation: calcifications and seizures
    diag: CT head: thin walled calcified cysts
    treatment: abendazole
80
Q

Tick Borne Diseases

  1. Lyme Disease
  2. Babesiosis
  3. Erlichia/Anaplasma
  4. Malaria
A
  1. Lyme Disease
    caused by spirochete Borrelia Burgdorferi carried by Ixodes tick
presentation: 
erythema migrans, camping
long term manifestations: 
joint involvement- late
cadiac: AV conduction block/defect
Neurologic: 7th cranial nerve palsy (bell's) most common

Diag: serology (IgM, IgG, ELISA, western blot,or PCR)

Treatment:
rash, joint, palsy: doxycycline, amoxiciliin, or cefurozime
CNS or cardiac involvement: IV ceftriaxone

  1. Babesiosis- transmitted by ixodes tick
    presents: hemolytic anemia
    diagnosis: peripheral blood smear looking for tetrads of intraerythrocytic ring forms or do a PCR
    treatment: azithromycin and atovaquone
  2. Erlichia/Anaplasma-ixodes tick
    NO RASH, elevated LFTs,thrombocytopenia, leukopenia

diag: “morulae” (inclusion bodies in WBCs on peripheral blood smear or PCR
treatment: doxycycline

  1. Malaria
    traveler from endemic area, hemolysis, GI complaints
    diagnosis: blood smear
    treatment:
    acute: mefloquine or atovaquone/proguanil
    (same drugs for prophylaxis)
    mefloquine: neuropsych, sinus brady, QT prolongation

severe: quinine/doxycycline or artesunate

quinine-QT prolongation
no cardiac precautions with artesunate

severe defined as: >5% parasitemia, renal insuff, metabolic acidosis, CNS involvement, hypoglycemia

81
Q

Atypical Respiratory Diseases

  1. Norcardia
  2. Actinomyces
  3. Histoplasmosis
  4. Coccidiodomycosis
  5. Blastomycosis
A

1.Norcardia (pt immunocomp’d) (branching, filamentous)
presentation:
respiratory/pulmonary dx can disseminate to any organ (skin, brain most common)

diag: CXR first, culture most accurate
treatment: TMP/SMX

  1. Actinomyces (not immunocomp’d, normal oral flora)
    presentation: facial/dental trauma
    diag: gram stain (branching, filamentous), confirm with anaerobic culture
    treatment: penicillin
  2. Histoplasmosis (bat droppings)
    - wet areas (OH, MS)
    presents: oral & palate ulcers, splenomegaly. pt might feel like they have viral illness

diag:
best initial test: histoplasmosis urine and serum anitgen
most accurate: biopsy with culture

4.Coccidiodomycosis (dry areas-Arizona)
acute respiratory illness, joint pain, erythema nodosum
treatment: itraconazole

  1. Blastomycosis (rural southeast)
    presents: acute resp illness, skin lesions, bone lesions
    diag: culture, broad budding yeast
    treatment: amphotericin or itraconazole
82
Q

Fungal Infections

  1. Mucomycosis (Zygomycosis)
  2. Aspergillus
A
  1. Mucomycosis (Zygomycosis) (immunocompromised)
    immunocompromised, DKA
    deferoxamine increases the risk by mobilizing iron
    eats through nasal canals, eyes, brain

diag: biopsy
treatment: emergency surgery! IV amphotericin

  1. Aspergillus
  2. Allergic bronchopulmonary
    present: asthmatics, CF pts. coughing brown mucous plug, abnormal CXR

diag: confirm with aspergillus precipitin antibodies and IgE in serum or skin plugs. high eosinophilia

treatment: oral prednisone
oral itraconazole or voriconazole

2.Invasive aspergillus
severely immunocompromised–neutropenic, leukemic
progresses rapidly

diag:
biopsy
CT & CXR severe lung infiltrates
serum galactomannan assay, beta-D glucan level, PCR

treatment: voriconazole, isavuconazole, caspofungin

83
Q

Tropical Diseases

  1. Dengue
  2. ebola
  3. Chikungunya
  4. Zika
  5. Leishmaniasis
  6. Echinococcus
A
  1. Dengue (Aedes mosquito)
    severe bone pain, headache, retro-orbital pain
    thrombocytopenia, petechiae, capillaries leak
    diag: ELISA serology
    treatment is supportive
2. ebola (RNA filovirus)
hemorrhagic fever
get from direct contact with bodily fluids NOT AIRBORNE
diag: serology or PCR
treatment supportive
  1. Chikungunya (RNA togavirus)
    headache, fevers, fatigue, JOINT PAIN/ARTHRALGIAS, sometimes rash
    diag: serologyand PCR
    treatment supportive
  2. Zika (aedes mosquito)
    fever, rash, conjunctivitis
    PREGNANT WOMEN: MICROCEPHALY
    supportive treatment -acetaminophen & fluids
  3. Leishmaniasis (protozoa spread by sandflies)
    skin/mucosal or visceral form or liver, spleen, and fever
    diag:
    direct visualization on liver/spleen/BM/ WBC aspirates
    confirm with culture and PCR

treatment: liposomal amphotericin, miltefosine

  1. Echinococcus
    dog and sheep, eggs eaten by humans
    spreads to liver, lung, brain forming hyatid cysts
    see cysts on sonogram, CT, MRI
    can confirm with ELISA
    aspirate of cyst can spread it accidentally

treatment albendazole or inject EtOH into cyst

84
Q 
CSF
WBC, glucose, protein
bacterial meningitis
TB meningitis 
Viral meningitis 
guillain-Barre
A

normal
WBC 0-5
glu 40-70
protein <40

bacterial meningitis
WBC >1000
glu <40
protein >250

TB meningitis
WBC 5-1000
glu <10
protein >250

Viral meningitis
WBC 100-1000
glu 40-70
protein <100

Guillain-Barre
WBC 0-5
glu 40-70
protein 45-1000

85
Q

HIV

immune reconstitution inflammatory syndrome

A

HIV+ patents can develop transient worsening of infectious symptoms for several weeks after initiation of antiretroviral therapy due to immune reconstitution inflammatory syndrome. IRIS arises due to the potent immune recovery that quickly occurs after initiation of antiretroviral therapy. its self limited.

86
Q

empiric treatment of community acquired pneumonia

A

outpatient:
1. macrolide or doxyclycline (healthy)
2. flouroquinolone (levo or moxi) or beta-lactam + macrolide (comorbitdities)

inpatient (nonICU)

  1. flouroquinolone (IV)
  2. beta lactam + macrolide IV

inpatient (ICU)

  1. beta lactam + macrolide IV
  2. beta lactam + flouroquinolone IV
strep pneumo=beta lactam (ceftriaxone)
atypical CAP (legionella) = macrolide or FQ
87
Q

complications of cat scratch disease

A

bartonella henselae
complications: 10% ppl supporative lymph nodes, visual loss due to neuroetinitis, encephalopathy, FUO, hepatosplenomegaly

88
Q

most common pathogens for acute otitis media

A

strep pneumo, nontypeable haemophilus influenzae, moraxella catarrhalis.

H influenzae causes otitis-conjunctivitis syndrome

89
Q

Serum Sickness

A

immune
serum sickness in prodromal phase of acute Hep B that is caused by complement activation by circulating immune complexes. other manifestations of Hep B infection explained by circulating immune complexes are polyarteritis nods and glomerulonephritis

90
Q

what are most common cause of viral meningitis or encephalitis in

  1. kids
  2. adults
A
  1. enteroviruses or arboviruses
    (EEE, WEE, SLE, colorado tick fever, california encephalitis)
  2. adults herpes simplex
91
Q

toxoplasmosis

A

cat feces, contaminated soil on fruits and veggies, undercooked meat. usually asymptomatic in immunocompetent adult, but to newborn or fetus: choriorytinitis, near findings (hydrocephalus, intracranial calcifications) and hearing impairment

92
Q

HIV

Virologic failure

A

failure to achieve a viral load <200 copies/mL within 6 months of ART.

goal of ART: decrease VL <50 copies/mL within 6 months

93
Q

PEdiatric Sepsis

A

<28days: most likely E coli, Group B strep
give ampicillin + cefotaxime

> 28days most likely strep pneumo, N. men.
ceftriaxone or cefotaxime +/- vanc

94
Q

Cystitis

pregnancy

A

treat with nitrofurantoin, cephalexin, amoxicillin-clavulanate 3-7 days.
FQs & tetracyclines contained.
TMP-SMX cause neural tube defects b/c folate antagonist properties. 1st line in non-pregnant

95
Q

Contraindications to varicella vaccine, MMR

A

anaphylaxis to neomycin or gelatin
pregnancy
immunodeficient state

96
Q

Human Bites
bugs
mgmt

A

eikenella corrodens, alpha-hemolytic strep, staph aureus

wound irrigation and wound care, no closure except on face, antibiotics, maybe tetanus booster

Step 3 (22 decks)

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