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Infection Flashcards

1
Q

Abx in appendicetomy, resection, biliary surgery?

A

Single dose 30 mins before surgery:

  • Tazocin 4.5mg IV
  • Gentamicin 1.5mg/kg and metronidazole 500mg IV
  • Co-amoxiclav 1.2g
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2
Q

Abx in oesophageal, gastric surgery?

A
  • Tazocin 4.5mg IV
  • Gentamicin 1.5mg/kg
  • Co-amoxiclav 1.2g
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3
Q

Abx in vascular surgery?

A
  • Tazocin 4.5mg IV
  • Flucloxicillin 1-2g + gentamicin 1.5mg

Add metronidazole if risk of anaerobes

  • Amputations, gangrene, diabetes
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4
Q

Abx in surgery at risk of MRSA?

A

For high risk patients add teicoplanin/vancomycin to normalregimens

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5
Q

Pathophysiology/aetiology of infectious mono?

A
  • Epstein-Barr Virus (human herpes virus 4)
  • More commonly young adults, incubation 4-8 weeks.
  • Virus targets B lymphocytes
    • Lifelong latent infection
    • Affects squamous epithelial cells of oropharynx
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6
Q

Signs/symptoms of infectious mono?

A

Symptoms

  • Usually asymptomatic infection in childhood
    • Sore throat, fever, anorexia, fatigue, malaise
    • Usually 2 week course, recurrence rare

Signs

  • Lymphadenopathy (posterior triangle), palatal petichiae, hepatomegaly, splenomegaly, jaundice
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7
Q

Complications of EBV/infectious mono?

A

Acute

  • Splenic rupture, upper airway obstruction, anaemia, kidney disease, neurological (CN palsy, Guillain-Barré, meningitis)

Oncogenic

  • Burkitts/Hodgkin’s lymphoma, B cell lymphoma if immunosuppressed, gastric/nasopharyngeal cancer
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8
Q

Investigations in infectious mono?

A

Bloods

  • Film - lymphocytosis, large irregular nuclei
  • FBC - high lymphocytes
  • LFTs - raised ALT
  • Serology - IgM if acute, IgG if past infection

Monospot antibody test (present in 85% of infection) - false +ve = pregnancy, AI disease, blood cancers

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9
Q

Management of infectious mono?

A

Supportive

  • Don’t give amoxicillin –> rash
  • Advice
    • Avoid contact sports for 3 weeks due to risk of splenic rupture
    • Avoid alcohol for duration

Usually self-limiting

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10
Q

What is SIRS criteria? Definitions of sepsis?

A

SIRS

  • HR >90
  • RR >20 or PaCO2 <4.3
  • Temp <36 or >38.3
  • WCC <4 or >12

Sepsis = SIRS + evidence of infection

Severe sepsis = sepsis + organ failure

Septic shock = sepsis + hypotension despite adequate fluid resuscitation

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11
Q

Markers of end-organ dysfunction in sepsis?

A
  • Lactate >2
  • Acute Resp failure requiring NIV or IV
  • AKI stage 2 or above
  • Platelets <100
  • INR >1.5
  • Hypotension/shock
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12
Q

Definition and causes of HAP?

A

Infection with symptoms >48 hours after admission

Less than 4 days

  • S.pneumonia, H.influenza, Moraxella catarrhalis

More than 4 days

  • Gram -ve bacilli/anaerobes
    • Pseudomonas - ITU/post srugery.
    • Klebsiella - rare - elderly, diabetc, alcoholic - cavitation i n upper lobe.
  • S.aureus
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13
Q

Treatment of HAP?

A

Local guidelines

  • Aminoglycoside (gent) IV + antipseudomonal penicillin IV
  • or 3rd gen cephalosporin

Prevent by mobilisation of surgical patients and adequate pain relief to allow deep breathing and prevention of atelectasis.

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14
Q

Pathophysiology of C.diff? Common causes?

A

Inhibition of C.diff overgrowth by other competing chronic flora lost due to antibiotic expsoure

Normal bacteria converts to a growth state, releases enterotoxins A and B –> colitis.

Spread by person to person contact or faecal oral route.

  • Pencillins, clindamycin, 3rd gen cephalosporins
  • IV higher risk than oral
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15
Q

Risk factors for C.diff?

A
  • Prolonged abx use
  • Multiple abx course
  • Increased age
  • Co-morbiditiy
  • Invasive GI procedure
  • Presence of NG
  • Long hospital stay
  • Immunocompromised
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16
Q

Complications of C.diff?

A

Ileus, toxic megacolon, dehydration, electrolyte disturbance, sepsis, perforation, death

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17
Q

Investigations in C.diff?

A

Bloods

  • FBC - raised WCC
  • U+E - check kidney function

Diagnosis

  • Stool sample for C.diff toxin
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18
Q

Management of C.diff?

A

Conservative (SIGHT)

  • Suspect
  • Isolate within 2 hours
  • Gloves and aprons
  • Hasnd wash with soap
  • Test immediately (stool sample)

Medical

  • Mild/moderate = metronidazole PO
  • Severe = vancomycin PO or fidaxomicin (expensive)
  • Non-responders = high dose vanc and IV metronidzole
  • Recurrent = vanc/fidaxomicin +/- faecal transplant
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19
Q

Prevention of C.diff?

A
  • No benefit in prophylactic antibiotics
  • Strict handwashing and rapid isolation of patients with diarrhoea
  • Responsible abx prescribing (minimal types, oral if possible, not prolonged course)
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20
Q

Definition of pyrexia of unknown origin?

A

Pyrexia >3 weeks with no identified cause, after evaluation in hospital for >3 days or >3 OP appointments.

(Pyrexia = >38.3)

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21
Q

Investigations in pyrexia of unknown origin?

A

Bloods

  • FBC, U+E, LFT, CRP, ESR
  • HIV test
  • CK, ANA, ANCA, RF, malaria, TB

MC+S

  • Blood cultures (multiple)
  • Urine, stool, CSF, sputum (including acid fast bacilli)

Imaging

  • CXR, abdo/pelvis USS, venous doppler

Other

  • Viral serology: hepatitis, CMV, EBV, toxoplasmosis, brucellosis
  • Temporal artery biopsy if suspect GCA
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22
Q

Differentials for pyrexia of unknown origin?

A

Infection/malignancy = 40%

  • HIV
  • Connective tissue disease, vasculitis, granulomatous disease
  • Elderly: PMR and GCA
  • Younger patients: adult onset Still’s disease
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23
Q

Situations in which empirical treatment is advocated in pyrexia of unknown origin?

A
  • Meet criteria for culture negative endocarditis
  • Suggestive of disseminated TB or other granulomatous infection
  • Temporal arteritis (with vision loss) suspected
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24
Q

Spread, incubation period and types of influenza?

A
  • Spread via aerosol droplets and contact
  • Incubation period = 1-4 days
  • Infective from 1 day prior to 7 days after symptoms
  • Three subtypes = A (H1N1 and H3N1), B and C
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25
Q

High risk groups for flu?

A
  • Chronic disease
  • Immunosuppression
  • Very young, elderly
  • Pregnant
  • BMI >40
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26
Q

Investigations for flu?

A
  • Viral PCR, rapid antigen testing
  • Viral culture (throat, nose, naso-pharyngeal, sputum)
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27
Q

Management of flu?

A

Uncomplicated

  • High risk = antivirals and symptomatic relief
  • Low risk = symptomatic relief only

Complicated (LRTI, exacerbation of underlying condition, hospital admission)

  • Oseltamavir (tamiflu) - 5/7 course. Not harmful in pregnancy.
  • Supportive therapy alongside.
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28
Q

Who should get flu vaccine?

A
  • High risk patients
  • Children >2 years
  • Healthcare workers
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29
Q

Cause and spread of measles?

A
  • Cause = morbillivirus (highly contagious)
  • Airborne via respiratory droplets
  • Incubation = 10-12 days
  • Infective from 4 days before until 4 days after rash
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30
Q

Presentation of mealses?

A

Rash

  • Morbilliform - maculopapular blanching rash - face –> trunk –> limbs
  • Fades after 3-4 days in order of appearance

Fever

  • With at least 1 of 3 Cs - cough, coryza, conjunctivitis.

Prodrome

  • 2-4 days with fever, cough, runny nose, mild conjunctivitis and diarrhoea.

Kolpik’s spots

  • Small red spots with blue/white speck in centre - buccal mucosa.
31
Q

Complications of measles?

A

Common = bronchopneumonia, otitis media

Post-measles encephalitis = drowsiness, vomiting, headahce, convulsions

Subacute sclerosing pan encephalitis = slow progressive neurological degeneration

Death

32
Q

Investigations and management of mealses?

A

Investigations

  • Salivary swab or serum sample for measles specific IgM taken within 6 weeks of onset

Management

  • Often self-limiting: paracetamol, ibuprofen and plenty of fluids
  • MMR vaccine within 72hrs of exposure if not had it
  • If immunocompromised/pregnant immunoglobulin within 5 days of exposure
33
Q

Spread of mumps?

A
  • Respiratory droplet spread
  • Incubation = 14-21 days
34
Q

Presentation of mumps?

A

Symptoms

  • Fever, myalgia, headahce

Signs

  • Tender swelling of salivary glands
  • Parotid > submandibular
35
Q

Complications of mumps?

A
  • Meningoencephalitis
  • Epididymo-orchitis if pubertal/post-pubertal –> subfertility
  • Oophoritis
  • Pancreatitis
  • Deafness
36
Q

Investigations and management of mumps?

A

Investigations

  • Mumps specific IgM/IgA

Management

  • Supportive therapy
37
Q

Cause and spread of rubella?

A

AKA german measles

  • Respiratory droplet spread
  • Incubation 14-21 days
  • RNA virus of togaviridae family
38
Q

Presentation of rubella?

A

Lymphadenopathy

  • Occipitral, cervical, post-auricular

Maculopapular rash

  • H+N –> trunk and extremities over 3-5 days
39
Q

Complications of rubella?

A

Childhood

  • Neuritis and arthritis

Congenital

  • 90% risk of foetal malformation in 1st trimester
  • Congenital heart defects, learning difficulties, sensorineural deafness, cataracts
40
Q

What is TORCH syndrome?

A
  • Toxoplasmosis
  • Other: syphilis, parvovirus, VSV
  • Rubella
  • CMV
  • Herpes simplex

Features = hepatosplenomegaly, fever, lethargy, difficult feeding, anaemia, petechiae, purpura, jaundice

41
Q

Investigations and management of rubella?

A

Investigations

  • Offer IgM/IgG testing
  • Rubella PCR from oral fluid sample

Management

  • Notifiable disease
  • Usually self-limiting (5-7 days)
  • Supportive therapy unless immunocompromise (specialist advice)
42
Q

Cause and spread of chicken pox?

A

Varicella zoster virus

  • Incubation period = 7-14 days
  • Infectivity is from a few days before the onset of lesions until the crust falls off.

Reactivation of dormant virus -> shingles (dermatomal)

43
Q

High risk groups for chicken pox?

A
  • Pregnant Women
  • Immunocompromised
  • Systemic disease
  • Patients on high dose steroids
  • Neonates
44
Q

Presentation of chicken pox?

A

Symptoms

  • Headache, malaise, abdominal pain
  • Crops of vesicles over 3-5 days
  • Lesions very itchy

Signs

  • Pyrexia
  • Rash - papule –> vesicle –> pustule –> crust
  • Excoriations from scratching
45
Q

Complications of chicken pox?

A
  • Scarring
  • Secondary bacterial infections: Necrotising fasciitis, toxic shock syndrome
  • Encephalitis: Cerebellar signs with ataxia
  • In pregnancy: fetal varicella syndrome
46
Q

Management of chicken pox?

A

Low Risk

  • Fluids, minimise scratching, PCM for fever and pain relief
  • Calamine lotion/antihistamines for scratching
  • Avoid contact with high risk groups

High Risk

  • Check for varicella antibodies
  • If not immune –> immunoglobulin (<10 days post-exposure)
  • Oral aciclovir if they present <24 hours post-onset of rash
47
Q

5 causes of infective gastroenteritis (without blood)?

A
  1. Norovirus
  2. Rotavirus
  3. Enterotoxigenic E.coli
  4. Clostridium Perfringens (A)
  5. Vibrio cholerae (cholera)
48
Q

What is commonest cause of traveller’s diarrhoea?

A

Enterotoxigenic E.coli

49
Q

Management of cholera

A
  • Rapid dipstick and culture confirmation
  • ORS with safe water - NG/IV if low intake
50
Q

What are you looking for in the stool to diagnose norovirus?

A

Reverse transcriptase

51
Q

Advice for travellers to avoid enterotoxigenic e.coli?

A
  • Boil water
  • Avoid ice/shellfish/salads
  • Handwashing
52
Q

5 causes of dysentery?

A
  1. Shigella
  2. E.coli 0157
  3. Campylobacter
  4. Salmonella
  5. Yersinia
53
Q

Transmission of the dysentery organisms?

A
  1. Shigella - faecal-oral
  2. E.coli 0157 - raw beef
  3. Campylobacter - raw meat/poultry, contaminated H2O
  4. Salmonella - meat, eggs, poultry, milk
  5. Yersinia - uncooked pork
54
Q

Complication of E.coli 0157?

A

HUS

  • Anaemia (haemolytic)
  • AKI (uraemia)
  • Thrombocytopenia

Avoid abx with this bacteria as it increases risk of HUS

55
Q

Investigations in dysentery?

A

Stool culture

PCR immunoassay (shiga toxin, etc)

56
Q

What to avoid in dysentery?

A

Avoid antidiarrhoeals - risk of toxic dilatation

57
Q

Abx in dysentery?

A

If septic/severe/immunosuppressed

  • Cipro/azithro

Usually just supportive management

58
Q

Cause and spread of whooping cough?

A

Bordatella pertussis (gram +ve)

  • Droplet spread
  • RFs = unvaccinated/immunocompromised
59
Q

Presentation of whooping cough?

A

Catarrhal Period (1-2 weeks)

  • Insidious onset, low grade pyrexia, cough, coryzal symptoms

Paroxysmal (1-6 weeks)

  • Paroxysms of coughing - worse at night
  • Inspiratory whoop at end of coughing
  • Fever; vomiting after paroxysm

Convalescent

  • Decreased intensity of cough, gradual recovery
60
Q

When does whooping cough stop being infectious?

A

3-4 weeks after paroxysms (household contacts)

61
Q

Management of whooping cough?

A

Investigations

  • PCR nasal/throat swab

Management

  • Macrolides (erythro, clarithro, azithro) - reduces infectivity
  • Exclude from nursery/school for 3-5 days after commencing treatment
62
Q

In whom should you consider malaria?

A

Anyone with a fever who has previously visited an area with prevalence, regardless of prophylaxis

63
Q

Aetiology of malaria?

A

Transmission through bite by female anopheles mosquito - sub-saharan Africa has 90% of cases.

Malaria belt = tropical and subtropical areas.

Plamodium Falciparum

  • Most prominent in africa, most deaths worldwide

Others

  • Vivax (Asia, Americas, Africa, Middle East)
  • Malariae (Africa, Americas, SE asia)
  • Ovale (Africa)
  • Knowlesi (SE asia)
64
Q

Presentation of Malaria?

A

3 months after visiting area

Signs

  • Fever
  • Late - jaundice, confusion, seizures, splenomegaly

Symptoms

  • Non-specific
    • Fever, extreme fatigue, headache, malaise, myalgia, diarrhoea, cough
  • Fevers
    • Paroxysms - relate to rupture of RBCs and release of inflammatory cytokines.
    • Variable for falciparium, every 2 days for vivax, ovale.
65
Q

Complications of severe malaria?

A

Cerebral Malaria

  • Low GCS, seizures, coma

Bilious Malaria

  • Diarrhoea, jaundice, liver failure

Lungs, Kidneys Spleen

  • AKI, spontaneous bleeding, pulmonary oedema/ARDS, acidosis

Overall, a sepsis-like picture that can lead to death - complicated malaria.

66
Q

Why is falciparium the worst malaria?

A
  • Because it causes cytoadherence (clumping of RBCs)
  • Stops blood flow to spleen so spleen can’t clear infected cells
  • Also causes ischaemic damage
  • Ischaemic damage + haemolytic anaemia = organ failure
67
Q

What confers resistance to malaria?

A
  • Sickle cell anaemia
  • G6PD deficiency
  • Thalassaemia

Lack of Duffy antigen on RBCs

68
Q

Investigations in malaria?

A

Thick and Thin Blood Film

  • Thick = view parasites in RBCs, Thin = identifies plasmoidum species
  • >5% RBCs affected –> worse outcomes
  • If negative film, repeat at 12 and then 24 hours - malaria unlikely with 3 negative smears.

Others

  • FBC, U+E, LFTs, clotting, glucose
    • Low plts, high LDH (haemolysis), normochromic normocytic anaemia
  • ABG
  • Urinalysis
69
Q

Prevention of malaria?

A

Vector Control

  • Reduction of breeding sites (stagnant water)
  • Insecticidal nets
  • Indoor residual spraying

Bite Prevention

  • Mosquito repellent (50% DEET) - apply after sunscreen.

Chemoprophylaxis

  • Kills sporozoites before they infect hepatocytes.
70
Q

Management of active malaria infection?

A

Uncomplicated

  • Artemisinin combination therapy (ACT) to clear parasites
  • Atovaquone proguanil/Oral quinine sulphate if not available

Severe

  • Urgent parenteral treatment
  • Artesunate IV, then full dose ACT
  • Quinine regime IV
  • Manage in high dependency setting - monitor BMs, Hb, clotting, U+E, daily parasite levels.
71
Q

Malaria chemoprophylaxis?

A

Chloroquine

  • 1 week before, 4 weeks after.
  • GI disturbance, headahce. CI in epilepsy.

Proguanil

  • Diarrhoea, antifolate (care if possibly prego)

Mefloquine

  • 2-3 weeks prior, 4 weeks after.
  • Neuropsychiatric SEs, dizziness

Doxycycline

  • 1-2 days prior, 4 weeks after
  • Hepatic impairment, photosensitivity, teratogenic
72
Q

Things to ask in febrile traveller history?

A

Exclude malaria and HIV in all travelers. Don’t forget normal differentials for fever.

Geography of Travel

  • Urban, rural

Symptoms

  • Onset, duration

Activities

  • Bites, diet, fresh water exposure (schisto, leptospirosis), sexual activity, dust exposure, game parks, farms, caves, unwell contacts.
73
Q

Febrile traveller differentials?

(Undifferentiated, rash, jaundice, hepato/splenomegaly, GI symptoms, respiratory symptoms, CNS symptoms)

A

Undifferentiated fever: Malaria, amoebic liver abscess, chikungunya, dengue, enteric fever, leptospirosis, schistosomiasis

Fever with rash: Dengue, VHF, schistosomiasis

Fever with jaundice: leptospirosis, viral hepatitis, VHF, yellow fever

Fever with hepato/splenomegaly: malaria, amoebic liver abscess, brucellosis, leptospirosis, trypanosomiasis, leishmaniasis

Fever with gastrointestinal symptoms: E. coli, Campylobacter, Salmonella, Shigella

Fever with respiratory symptoms: influenza, Streptococci, H. influenzae, TB

Fever with CNS symptoms: malaria, meningococcal, Japanese encephalitis, rabies, African trypanosomiasis.

- FINALS (24 decks)

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