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RACP Written Exam 2021 > Infectious Diseases > Flashcards

Infectious Diseases Flashcards

1
Q

Treatment for TB

A 
Two Months 
Rifampicin (Inducer of CYP/Yellow secretions) 
Isoniazid
Pyrazinamide
Ethambutol

Six Months
Rifampicin
Isoniazid

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2
Q

Duration of treatment for meningeal TB

A

12 months

Streptomycin replaces Ethambutol

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3
Q

Isonazid adverse effects

A

Peripheral neuropathy
Hepatitis
Rash

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4
Q

Rifampicin adverse effects

A

Febrile reactions
Hepatitis
Rash
GIT disturbance

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5
Q

Pyrazinamide adverse effects

A

Hepatitis
GIT disturbance
Hyperuricaemia

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6
Q

Streptomycin adverse effects

A

8th cranial nerve damage

Rash

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7
Q

Ethambutol adverse effects

A 
Retrobulbar neuritis (may present as colour vision loss) 
Arthralgia
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8
Q

TB Diagnosis

A

Two sputum samples (one early morning) for acid fast bacilli
Sputum culture = highest specificity

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9
Q

Chemoprophylaxis regimen for TB

A

Rifampicin + Isoniazid for 3 months
Isoniazid for 6 months

Offered to those who are positive for latent TB (TST/IGRA) or patients who are HIV infected and close contact with a smear positive individual.

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10
Q

Testing for latent TB

A

1) Turberculin skin test
- False +: BCG or infection with non-mycobacterium TB
- False -: immunosuppressed or overwhelming TB infection
2) IGRA

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11
Q

Testing for Syphilis

A

Non-Treponemal Tests: VDRL/RPR
(False positives from active infection with infectious mono, chickenpox and malaria as well as pregnancy)
(False negatives in secondary syphilis)
Treponemal Tests: Treponemal test remain positive even after treatment

Nb If Non-treponemal test + but treponema test - usually indicates a false positive finding.
If test positive in asymptomatic individual then needs to be repeated.

NB: Check treatment response at 3, 6 and 12 months with a nontreponemal test. Syphilis is considered cured if the nontreponemal titre falls by at least four-fold (two dilutions).

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12
Q

Brucellosis (Brucella) findings on culture and gram stain

A

Gram-negative coccobacilli
Nonencapsulated, nonmotile
Facultatively intracellular

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13
Q

Mechanism of action of neurominidase inhibitors

A

Neuraminidase inhibitors reduce viral shedding by interrupting the cleaving process of Neuraminidase.

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14
Q

Mechanism of action fo echinocandins

  • Anidulafungin
  • Caspofungin
  • Micafungin
A

Inhibit 1,3-beta-D-glucan synthase

Effect

  • Fungicidal against Candida
  • Fungistatic against Aspergillus
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15
Q

Mechanism of action of azoles

A

Impair the synthesis of ergosterol

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16
Q

Adverse effects of azoles

A

General: rash, headache, dizziness, nausea, vomiting, abdominal pain, diarrhoea, elevated liver enzymes

Specific: Thrombocytopenia and blue-green visual aura with voriconazole

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17
Q

Mechanism of action of Flucytosine

A

Converted to fluorouracil inhibits fungal DNA synthesis and is also incorporated into fungal RNA, affecting protein synthesis.

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18
Q

Adverse effects of flucytosine

A

Blood dyscrasias
Diarrhoea, nausea, vomiting, elevated liver enzymes (dose-related), rash

Nb: oxicity is associated with prolonged concentrations >100 mg/L. Need to undertake TDM

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19
Q

Amphotericin B mechanism of action

A

Binds irreversibly to ergosterol in fungal cell membranes causing cell death by altering their permeability and allowing leakage of intracellular components.

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20
Q

Amphotericin B adverse effects

A

nephrotoxicity
LFT derranagements: increased serum bilirubin, increased ALP,
Metabolic changes: hyperglycaemia, hyponatraemia
Other: tachycardia,

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21
Q

Linezolid mechanism of action

A

Inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit
Used for treatment of gram + and some anaerobes

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22
Q

Adverse effects of Linezolid

A 
Reversible myelosupression 
Serotonin syndrome (weak MAOI) 
Optic and peripheral neuropathy (interference with mitochondria activity) 
Lactic Acidosis (interference with mitochondria activity)
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23
Q

Mechanism of action of Guanine Analogue anti-virals

  • Aciclovir
  • Famciclovir
  • Ganciclovir
  • Valaciclovir
  • Valganciclovir
A

Guanine analogues
phosphorylated by virally-encoded cellular enzymes –> acyclovir triphosphate, which competitively inhibits viral DNA polymerase

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24
Q

Treatment of Syphilis

A

Penicillin

If allergic and non-pregnant doxycycline

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25
Q

Mechanism of action of Tetracyclines

- Doxycycline

A

Bacteriostatic; inhibit bacterial protein synthesis by reversibly binding to 30S subunit of the ribosome

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26
Q

Adverse effects of tetracyclines

A

Photosensitivity
Photo-onycholysis and nail discolouration
Teratogenic post 18 weeks gestation (inhibit bone growth)

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27
Q

Glycopeptides mechanism of action

  • Vancomycin
  • Teicoplanin
A

Bactericidal; inhibit bacterial cell wall synthesis by preventing formation of peptidoglycan polymers.

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28
Q

Mechanisms of resistance of enterococcus species to vancomycin

A

Alteration of the peptidoglycan synthesis pathway

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29
Q

Daptomycin Mechanism of Action

A

Gram-positive bacterial cytoplasmic membranes in the presence of calcium, causing depolarisation, potassium efflux (impairing potassium-dependent DNA, RNA and protein synthesis) and cell death.

Treatment of systemic and life-threatening infections caused by Gram-positive organisms

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30
Q

Interaction between HIV and CD4 cells

A

Attachment occurs by interaction of GP120 on the surface of the virus and the CD4 antigen receptor on the surface of the host cell
Binding then occurs via a co-receptor
- CCR5 on Macrophages
- CXCR4 on CD4 cells

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31
Q

Red man syndrome

A

Occur from infusion of glycopeptide (note vancomycin > teicoplanin)
Related to rate of infusion
Note an allergic reaction although histamine release involved
Treat with antihistamine (promethazine)

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32
Q

Mechanism of action of carbapenems

  • Meropenem
  • Etrapenem
  • Imipenem
A

Inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins. Usually bactericidal

Febrile neutropenia
Gram negative or Gram positive
Anaerobes

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33
Q

Treatment for New Delhi metallo-beta-lactamase 1 (NDM-1)

A

Colistin or tigecycline

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34
Q

Colisitin mechanism of action

A

Bactericidal; interacts with lipopolysaccharides in the outer bacterial membrane changing its permeability.

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35
Q

Tigecycline mechanism of action

A

Binds to 30S ribosomal subunit preventing incorporation of amino acids into bacterial peptides; bacteriostatic.

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36
Q

Treatment regimen in HIV

A

2NRTI
+
NNRTI/PI/Integrase Inhibitor

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37
Q

When using a protease inhibitor why is ritonvair also used in the treatment of HIV

A

Ritonavir (a protease inhibitor in itself) interacts with both P-glycoprotein (reducing efflux) and inhibitors CYP3A leading to increased concentration and elimination half lives of other PIs.

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38
Q

Which form of malaria can result in the severest haemolysis

A

P Falciparum (invades red cells of all ages)

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39
Q

Criteria for severe P Falciparum malaria infection

A

Parasite count > 2%

Complication of malaria

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40
Q

Treatment for severe Falciparum malaria

A

IV Artesunate
or
IV Quinine

If >10% circulating erythrocytes consider exchange transfusion

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41
Q

Empiric treatment for suspected bacterial meningitis

A

1) 3rd generation cephalosporin - Ceftriaxone/Cefotaxime
2) Dexamethasone
3) Ben pen - if alcoholic, older than 50, immunocompromised, pregnant or debilitated (to cover for Listeria)
4) Vancomycin - if concern for Strep pneumoniae (Gram-positive diplococci)

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42
Q

Main risk factors for HIV associated lipoatrophy/dystrophy

A

Stavudine but also zidovudine (NRTIs)
Older age
Low baseline triceps skin fold values

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43
Q

Prevention of hepatitis B when contaminated by source +HBV

A

Not vaccinated: Immunoglobulin + Hepatitis B vaccine

Non responder to vaccine: Check source HBsAg is positive or if it cannot be obtained, the HCP should receive two doses of hepatitis B immunoglobulin (HBIG). The second dose of HBIG should be given one month after the first dose.

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44
Q

Amoebic Liver Abscess Treatment

A 
Metronidazole 8-hourly for 7 days
or
Tinidazole 2 g orally, daily for 5 days
and
Paromycin 500 mg orally, 8-hourly for 7 day to eradicate cysts in the gut and prevent recurrence
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45
Q

Use of bactrim prophylaxis

A

PJP

Toxoplasmosis

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46
Q

HIV prophylaxis for patients with CD4 count
<200
<50

A

<200: PJP prophylaxis with Bactrim (if allergic give damson. atovaquone or aerosolised pentamidine)
<50: MAC prophylaxis with Azithromycin (unless on ART)

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47
Q

Cause of bullous impetigo

A

Staphylococcus aureus

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48
Q

Antibiotics for Streptococcal or Enterococcal Infective Endocarditis

A

Gentamicin and Benzylpenicillin

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49
Q

Antibiotics for Staphyloccocal Endocarditis

A

MSSA: Flucloxacillin 2g 4 hourly for 4-6 weeks
MRSA: Vancomycin for 6weeks

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50
Q

Antibiotics for HACEK endocarditis with Beta Lactamase

A

Ceftriaxone 2g daily for 4-6 weeks

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51
Q

Important parameter for effectiveness of beta lactam antibiotics

A

Time over minimum inhibitory concentration (time dependent)

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52
Q

Important parameter for effectiveness of amino glycoside antibiotics

A

Concentration max/MIC (concentration dependent)

53
Q

Important parameter for effectiveness of vancomycin

A

AUC/MIC is most important.

54
Q

Treatment for severe tropical pneumonia (north of Tenant Creek) in patients considered at risk (diabetes, hazardous alcohol consumption, CKD, COPD or Immunosuppressive therapy) or Gram Negative Bacilli identified on culture

A

Meropenem + IV azithromycin

55
Q

How does HIV gain entry to the CD4 cell?

A

Glycoprotein 120 and 41 attach to CD4 molecules changing their shape and the attaches to CCR5 or CXCR4
Virus is then allowed to enter the cell

56
Q

Abacovir delayed hypersensitivity

A

HLAB*57.01

57
Q

Window period in which HIV cannot be identified by ELISA antigen antibody testing

A

2-3 weeks (15 days)

58
Q

Tenofovir mechanism of action

A

Reverse Transcriptase Inhibitor

59
Q

Preferred treatment regimens for HIV

A

Integrase Inhibitor

2 Nucelotide reverse transcriptase inhibitors

60
Q

Mechanism of action of Nucleoside Reverse Transcriptase Inhibitors

A

Bind to viral reverse transcriptase at deoxynucleotide binding site and block DNA synthesis

61
Q

Mechanism of non-nucleoside RTIs

A

Bind viral reverse transcriptase but not at deoxynucleotide binding site and alter the confirmation of enzyme blocking DNA synthesis

62
Q

Protease Inhibitor mechanism of action

A

Block viral protease preventing maturation of the virus during and after budding
Ritonavir/Lopinavir/Atazanavir/Darunavir

63
Q

Use of ritonavir for HIV

A

Inhibits CYP3A4 which boosts other protease inhibitors

64
Q

Integrase inhibitors

A

Block viral integrate preventing integration of viral DNA into host DNA

Rategravir
Elvitegravir
Dolutegravir
Bictregravir

65
Q

When to commence PEP for HIV

A

Within 72hrs (best within 24hr)

66
Q

Who to give post-exposure prophylaxis

A

Non-occupational: If HIV load is unknown or detectable
- 3 drug regimen

Occupational:

  • HIV load unknown or detectable: 3 drug regimen
  • HIV load known to be undetectable: 2 drug regimen
67
Q

Prep regimen

A

Tenofovir + Emtricitabine

68
Q

PEP regimen

A
  • 2 Drug regimen: 28 days of Tenofovir + Emtricitabine or Lamivudine
  • 3 Drug regimen: 28 days Dolutegravir/Raltegravir/Rilpivirine
69
Q

Monitoring while on Prep

A

6monthly: eGFR and ACR
12monthly: Hepatitis C

70
Q

CD4 count and opportunistic infections

A

<250: PJP
<150: Cryptococcal/Toxoplasma
<50: MAC/Cytomegalovirus

71
Q

Clinical presentation of PJP

A

Fever
Non productive cough
Marked exertion dyspnoea (well when sitting but drop sats on walking)

CXR: Diffuse bilateral infiltrates (Basal and apical sparing)
CT: Widespread ground glass changes

72
Q

Diagnosis of PJP

A

CXR: Bilateral infiltrates with basal and apical sparing
CT: Ground glass

PCR of sputum
BAL (>90% diagnostic yield)

73
Q

Treatment of PJP

A

Cotrimoxazole 15-20mg/kg/day
Allergy: IV Pentamidine, Dapsone or Atovaquone, Clindamycin + Primaquine
If hypoxic consider adding steroids

74
Q

Prophylaxis for PJP

A

CD <200

Cotrimoxazole daily or thrice weekly
Pentamadine three weekly nebulised

75
Q

Cryptococcal Infection in HIV

A 
Commonly meningitis (sub acute headache and fever)
Pulmonary Cryptococcus
76
Q

Cryptococcal infection in HIV diagnosis

A

LP: Raised opening pressure, Low glucose and raised WCC and protein
India ink and CRAG positive

77
Q

Treatment of cryptococcal meningitis in HIV

A

LP/VP shunt
Amphotericin and flucytosine for 1-2 weeks followed by 8 weeks of high dose fluconazole

Ensure secondary prophylaxis until the CD 4 count rises

78
Q

Treatment for IRIS

A

Steroids

79
Q

Primary Prophylaxis in HIV (ETG)

A

CD4 <200: PJP –> Cotrimoxazole (Bactrim) either once daily or thrice weekly options
CD4 <100: Toxoplasma –> Cotrimoxazole (Bactrim) either daily or thrice weekly
CD4 <50: MAC –> Azithromycin 1.2gram once weekly or Clarithromycin 500mg BD

80
Q

Live Vaccines contraindications

A

Should not be given to patients on anti-TNF or Rituximab

Need to give 4 weeks prior to commencement of same

81
Q

Flu vaccine in immunosuppressed host

A

Twice in the first season and then twice thereafter

Caution with giving when patient on checkpoint inhibitor due to cytokine storm thereafter

82
Q

Screening prior to Anti-TNF/DMARDS

A

Interferon Gamma assay

83
Q

Treatment for latent TB infection on a patient pre anti-TNF or DMARD

A

9 month of isoniazid

84
Q

Treatment/prophylaxis for patients pre commencement of rituximab with evidence of previous Hep B infection

A

HbSag+/- with Anti-Hbcore positive: Prophylaxis with Entecavir/tenofovir for 12 months after cessation go B cell depletion

85
Q

When to commence PJP prophylaxis with cotrimoxazole?

A
  • High dose corticosteroids >16-25mg/day or >4mg dexamethasone for >4weeks
  • TNF alpha inhibition
  • HIV with CD4<200
  • Chemotherapy or monoclonal antibodies which cause prolonged lymphopenia
86
Q

The ESCAPPM organisms

A 
E: Enterobacter
S: Serratia
C: Citrobacter
A: Acinetobacter
P: Pseudomonas
P: Porteus Valgaris
M: Morganella Morganii
87
Q

Mechanism of ESCAPPM antibiotic resistance

A

Inducible beta-lactamases (AmpC-cephalosporinases) which lead to resistance to third generation cephalosporins

I.e When you give someone with enterobacter ceftriaxone it will induce the beta lactamase and then become resistant

88
Q

Mechanism of ESBL antibiotic resistance

A

Plasmid mediated inactivation of all cephalosporins

89
Q

Treatment for ESBL infections

A

Meropenem or Cotrimoxazole

90
Q

Mechanism of Vancomycin action

A

Binds to peptidoglycan terminus D-ala-D-ala in cell walls sequestering the substrate from transpeptidase and inhibiting cell wall cross linking

91
Q

Mechanism of Vancomycin Resistant Enterobaciae

A

D-ala-D-ala is changed to D-ala-D-lac si tgar vancomycin cannot bind.

92
Q

Treatment for VRE

A

Ampicillin (If sensitive)
Daptomycin
Linezolid

93
Q

Mechanism of Beta-Lactams

A

Bind to PBP and inhibit cell wall synthesis/repair

Bacteriocidal

94
Q

Aminoglycosides mechanism of action

A

Inhibit protein synthesis by binding to the 30S ribosomal subunit

Gentamicin, Tobramycin, Amikacin

95
Q

Macrolides mechanism of action

A

Inhibit protein synthesis by preventing peptidyltransferase from adding the growing peptide attached to tRNA to the next amino acid

Erythromycin, clarithromycin, roxithromycin, azithromycin

96
Q

Tetracycline mechanism of action

A

Inhibit protein synthesis by binding to the 30s ribosomal subunit

Doxyxycline, minocycline, tigecycline and tetracycline

97
Q

Trimethoprim mechanism of action

A

Binds to dihydrofolate reductase and inhibits the reduction of dihydrofolic acid to tetrahydropholic acid

98
Q

Sulfamethoxazole mechanism of action

A

Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid (PABA)

99
Q

Fluoroquinolones mechanism of action

A

Interfere with DNA synthesis by inhibiting topoisomerase thereby preventing bacterial DNA from unwinding and duplicating.

100
Q

Rifamycin mechanism of action

A

Inhibit bacterial DNA-dependent RNA polymerase

101
Q

Nitromidazole mechanism of action

A

Reduction of the nitro group on the antibiotic by nitroreductases produced by susceptible bacteria.

(Metronidazole/Tinidazole)

102
Q

Lincosamide mechanism of action

A

Bind to the 50S subunit of bacterial ribosomes

Clindamycin

103
Q

Mechanism of action of Linezolid

A

Binds to 50s subunit prevention of the formation of 70s subunit

104
Q

Daptomycin mechanism of action

A

Binds to bacterial membranes and causes a rapid depolarisation which leads to cell death

105
Q

Side effect of Daptomycin

A

Elevated CK and myalgias

106
Q

Control of TB replication is dependent on which factors?

A

TNF alpha
Interferon Gamma
T cells

107
Q

What affects the specitity to Mantoux

A

previous BCG

exposure to other non-TB mycobacteria

108
Q

Advantage of interferon gamma release assay over Mantoux test

A

No cross reactivity with BCG or other Non-TB Mycobacterium

109
Q

What does IGRA test

A

Previous exposure to TB

110
Q

Gold standard for TB diagnosis

A

Culture

111
Q

TB Meningitis CSF findings

A

High WCC (lymphocytic)
Elevated protein
Low glucose

112
Q

Can IGRA determine between antibodies and latent infection?

A

No - therefore need to treat as if they are latent if IGRA positive

113
Q

Risk factors for progression to active TB

A
  • HIV (therefore test all patient with TB for HIV)
  • Transplant
  • Silicosis
  • Chronic renal failure
  • Biologic therapy (esp TNF alpha antagonist)
  • Prednisone <15mg/day
  • Diabetes
114
Q

Treatment for latent TB

A 
- 9 months Isoniazid 
or
- 4 months Rifampicin
or
- 3 month Rifampicin and Isoniazid
115
Q

Side effects of Isoniazid

A

Hepatotoxicity in 2% (increase with age)

116
Q

Standard short course TB treatment

A

2 months RIPE –> 4 months RI

117
Q

Adverse reactions from TB drugs

A

R: drug interactions, hepatitis, hypersensitivity
I: Hepatisis, peripheral neuropathy (give with pyridoxine)
E: Optic neuropathy
P: Hepatitis, skin, polyarthralgia and gout

Nb Hepatitis P>I>R

118
Q

Hepatitis in TB

A

> 2 ULN/Assymptomatic: Monitor
5 ULN or >3ULN with symptoms - stop

If unable to stop TB treatment adopt in amikacin, moxifloaxcin

119
Q

Most significant TB monoresistance

A

Isoniazid.

Treatment for Isoniazid resistant TB: 6 months RPE+Levofloxacin

120
Q

What is MDR-TB

A

TB resistant to Isoniazid and Rifampicin

121
Q

Treatment for MDR TB

A

10% can have short course treatment

Levo/Moxi
Bedaquiline
Linezolid
\+
Clofazimine/Cycloserine
122
Q

New treatment for TV

A

Bedaquiline: Oral diarylquinoloe
Delamanid: Nitromidazole, inhibits mycolic acid synthesis

123
Q

HIV and TB dependent on CD4 count

A

CD4>200: Typical reactivation of TB

CD4<200: Atypical manifestations including diffuse lung infection (cavitation uncommon) and extra pulmonary TB

123
Q

HIV and TB dependent on CD4 count

A

CD4>200: Typical reactivation of TB

CD4<200: Atypical manifestations including diffuse lung infection (cavitation uncommon) and extra pulmonary TB

124
Q

Early ART treatment for patients with TB outcome

A

Improves mortality

If
CD4 0-50: Early ART (within two weeks)
CD4>50: ART 8 weeks after starting TB treatment

125
Q

HIV, TB and IRIS

A

10-40% of patient with TB/HIV starting ART experience IRIS

Can consider prophylactic prednisone in those with CD4<100

126
Q

Interaction between TB treatment and HIV

A

Rifampicin (TB) will increase the metabolism of protease inhibitors and therefore a high dose of a protease inhibitor may need to be used

127
Q

Specific change to TB treatment for TB meningitis

A

Substitute moxifloxacin for ethambutol due to high CSF penetration
Give dexamethasone at commencement of treatment

Treat for 9-12 months

128
Q

TB and Biologics

A

Higher rates of disseminated disease
Can have rebound disease when biologic removed

Adalimumab>Infliximab>Etanercept

RACP Written Exam 2021 (18 decks)

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