0
Q
What does penicillin G, VK, benzathine treat?
A
Viridians strep Strep pyogenes Oral anaerobes Syphilis Leptospira
1
Q
What are the beta lactam antibiotics?
A
Penicillin
Cephalosporin
Carbapenems
Aztreonam
2
Q
What does ampillicin and amoxicillin cover?
A
Covers same as penicillin E. Coli Lyme Other gram - bacilli Amoxicillin - HELPS
3
Q
What does HELPS stand for in coverage by amoxicillin?
A
H - h. Influenzae E - e.coli L - listeria P - proteus S - salmonella
4
Q
Penicillins including amoxicillin and ampillicin are the best initial therapy for what?
A
OM
Dental infection & endocarditis prophylaxis
Lyme disease limited to joint, rash, CN 7
UTI in pregnant women
Listeria monocytes
Enterococcal infection
6
Q
What do Penicillinase resistant penicillins treat aka semisynthetic?
A
Skin infections - cellulitis, impetigo, erysipelas
Endocarditis, meningitis, bacteremia from staphy
Osteomyelitis, septic arthritis when organism is proven sensitive
* not active MRSA and enterococcus
- When Staphylococcus is sensitive to the semisynthetic penicillins and if concurrent Gram-negative infection is not suspected, these are the ideal agents. They are more efficacious than vancomycin is when the organism is sensitive.
7
Q
Penicillinase - resistant penicillins -name them?
A
Oxacillin Cloxacillin Dicloxacillin Nafcillin Methicillin belongs to this group of antibiotics as well and was one of the original drugs developed in the class. Methicillin is not used clinically, however, because it may cause interstitial nephritis.
7
Q
What are the penicillins that cover pseudomonas?
A
Piperacillin
Ticarcillin
Azlocillin
Mezlocillin
8
Q
What can you use to treat MRSA?
A
Vancomycin Linezolid Daptomycin Ceftaroline - Vanco derivative 5th generation tigecycline
9
Q
What are the anti pseudomonals best initial therapy for?
A
Cholescystitis & ascending cholangitis Pyelonephritis Bacteremia Hospital acquired and ventilator associated pneumonia Neutropenia and fever
10
Q
What are the gram - rods ( bacilli )?
A
C- citrobacter M - morganella S - serratia P - pseudomonas E - e.coli E - enterbacter
11
Q
If patient has rash to penicillin - what do you give?
A
Cephalosporin
12
Q
If patient has anaphylaxis to penicillin - what do you give?
A
Non beta lactam antibiotic
13
Q
What is the 2nd generation cephalosporin?
A
Cefotetan Cefoxitin Cefaclor Cefprozil Cefuroxime Loracarbef
14
Q
What are the 1st generation cephalosporin?
A
Cefazolin
Cephalexin
Cephradrine
Cefadroxyl
15
Q
What does cefuroxime, loracarbef, cefaclor?
A
Respiratory infections like bronchiolitis, OM, sinusitis
16
Q
Cefotetan & cefoxitin are best initial therapy?
A
PID with doxycycline
Cefotetan and cefoxitin increasing risk of bleeding and give disulfiram like reaction w alcohol
17
Q
What are the 3rd generation of cephalosporins?
A
Ceftiaxone
Cefotaxime
Ceftazdime
18
Q
What age group do you avoid ceftriaxone?
A
Neonates b/c impaired biliary metabolism
19
Q
What does ceftriaxone treat?
A
First line for pneumococcus Meningitis Cap pneumonia w macrolides Gonorrhea Lyme involving heart or brain
20
Q
What does cefotaxime treat?
A
Give to Neonates
SBP - spontaneous bacterial peritonitis
22
Q
What are the 4th generation cephalosporin? What do they treat?
A
Cefepine
Treats neutropenia and fever
Ventilation associated pneumonia
22
Q
What the Carbapenems? What do they cover?
A
Imipenem Meropenem Ertapenem Doripenem - covers gram - bacilli, neutropenia and fever
23
Q
What is the 5th generation cephalosporin treats MRSA?
A
Ceftaroline
24
What is the only Carbapenems that doesn't cover pseudomonas?
Ertapenems
25
What are the fluroquinolones?
Ciprofloxacin
Gemifloxacin
Levofloxacin
Moxifloxacin
26
What does azetronam cover?
Only gram - bacilli
| No cross reaction w penicillin
28
What do fluoroquinolones used to treat?
Best therapy for cap pneumonia including penicillin- resistant pneumococcus
Ciprofloxacin treats cystitis and pyelonephritis
Diverticulitis and GI infections - all will be combined w metro to treated anaerobes
28
What are the side effects of fluoroquinolones?
Bone growth abnormalities in children and pregnant women
| Tendonitis and Achilles tendon rupture
29
Which fluoroquinolones treats diverticulitis w/o combo metro?
Moxifloxacin
31
Name the aminoglycosides?
Gentamicin, Tobramycin, Amikacin
31
What are the side effects of aminoglycosides?
Nephrotoxic and ototoxic
32
What do aminoglycosides treat?
Gram-negative bacilli (bowel, urine, bacteremia)
Synergistic w beta-lactam antibiotics for enterococci & staphylococci
no effect on anaerobe
33
What does doxycycline treat?
Chlamydia
Lyme disease limited to rash, joint, or seventh cranial nerve palsy
Rickettsia
MRSA of skin and soft tissue -cellulitis
Primary and secondary syphilis in those allergic to penicillin
Borrelia, Ehrlichia, and Mycoplasma
34
What is the side effects of tetracyclines?
tooth discoloration (children), Fanconi syndrome (Type II RTA proximal), photosensitivity, esophagitis/ulcer
35
TRP-SMX used to treat?
Cystitis
Pneumocystis pneumonia & prophylaxis
MRSA - skin & soft tissue - cellulitis
36
What are the beta lactam/beta-lactamase combo drugs?
amox/clavulanate
ticarcillin/clavulante
ampicillin/sulbactam
piperacillin/tazobactam
37
What are side effects of TRP-SMX?
rash, hemolysis in G6PD def
| bone marrow suppression due to folate antagonist
38
What these combo drugs cover?
First choice for anaerobes for the mouth & GI abscess
39
What is the best initial therapy for gram +
oxacillin, cloxacillin, dicloxicillin, nafcillin
1st - gen cephalo - cefazolin, cephalexin
fluoroquinolones
macrolides (last choice b/c less effective)
41
What treats minor MRSA skin infection?
```
all oral
TRP-SMX
Clindamycin
Doxycycline
Linezolid
```
41
Most common causes of meningitis? Bugs...
Streptococcus pneumonia (60%), group B streptococci (14%), Haemophilus injluenzae (7%), Neisseria meningitidis (15%), and Listeria
42
What will cover gram - bacilli?
```
Quinolone
aminoglycosides
carbapenems
piperacillin, ticarcillin
azetronam
cephalosporin
```
43
What are S/S of meningitis? How do you know when to do CT?
fever, headache, neck stiffness (nuchal rigidity), & photophobia
Do CT if presence of papilledema, seizures, focal neurological abnormalities, confusion
44
Meningitis
Name Epidemiology, RFs, Criteria
Epi = MC in neonates> adults, Streptococcus pneumoniae is the most common cause of meningitis for all patients beyond the neonatal period.
- Haemophilus influenzae was the most common cause in children (decreased due to vaccine)
- Neisseria meningitidis is spread by respiratory droplets and is the most common cause of meningitis in adolescents.
- Listeria monocytogenes is more common in those with immune system defects, particularly of the cellular (T-cell) immune system and sometimes neutrophil defects.
RFs = nonimmunized, asplenia, VP shunts
Criteria - isolation of n. meningitis from CSF,
blood, joint, scrapings of purpuric lesions
45
What is the CSF profile for bacterial, viral, TB?
Bacterial - Cell ct = 1000, neutrophils, protein level incr, glucose decr, do culture & stain
Viral = 10-100s lymphocytes, normal pressure, normal glucose
TB = 10-100 lymphocytes, highly elevated, normal to low glucose, neg stain & culture
46
What is the best initial test & most accurate test?
LP for both
47
When do you add treatment for listeria? what drug? alt?
Add ampicillin....alt = TRP-SMX Elderly, neonates, steroids, AIDs & HIV, immunocomp including ETOH, pregnant
48
What is the treatment of meningitis? alt if allergic?
Bacterial initially treated w/ ceftriaxone or ceftaxime and vancomyocin + steriods
alt to cephalo = carbapenem, meropenem, chloramphetical, aminoglycosides
49
What are the long term complications of meninigtis? Prevent?
CN8 deafness, cogn/behavorial impairment
| Prevention w/ meningococcal vaccine, Hib vaccine
50
Encephalitis - what is it? Epi? RFs? Dx initial and accurate? Bug that causes? Complications? prevention?
```
Epi = 50 likely due to infectious, HSV
RF’s = organ transplant, immunodef
Dx = clinical Dx, most accurate = PCR
Tx = acyclovir
Complication - dealth, neuro sequelae
Prevention - MMR vaccine, BCG for TB
```
51
If HSV is resistant to acyclovir, what can you give instead?
Foscarnet
52
What is the SE of foscarnet?
renal toxicity, acyclovir is less renal toxic
53
OM - define? epi? etiology? RF's? Hx & PE?
Epi - MC in kids
Etio - caused by viruses mainly or bacteria
s. pneumoniae > h. influenza > morxella cata
RFs - daycare, lack of breast feeding, Native
American & Alaskan
Hx & PE = pain, redness, immobility (most important factor), bulging, decrease light reflex of TM
54
OM - what Dx studies? Criteria? Tx?
Dx = clinical, most accurate tympanocentesis
Criteria - mild bulging of TM + recent onset
of ear pain, intense erythema of TM OR
mod/severe bulging of TM
Tx - only give antibiotics if no improvement in
2-3days, amoxicillin 10d
55
OM - how to prevent? what are the complications?
Prevention - BR feed, no smoking
Complications - OM w/ effusion - should
resolve in 3m otherwise drained
56
Brain abscess - define? Etio? S/S? Dx?
Brain abscess - collection of infected material with the brain parenchyma
Etio = due to Strep > Bacteriodes > Enterobacteriaceae, often polymicrobial
S/S = headache, focal neurologic deficit
Dx = initially CT scan, MRI more accurate - gram stain & culture fluid if bacterial
57
How do you treat brain abscess?
aspiration + surgical excision, antibiotics need to specific
Penicillin - covers strep
metro - covers anaerobes
ceftazidime - covers gram - bacilli
58
What is Otitis Externa? RFs? Epi? Hx & PE?
```
inflammation of external ear
(mostly inflammation of ear canal) caused
by Pseudo/s. aureus (polymicrobial)
RF’s - cerum impaction, swimmers ear,
diabetics
Epi - usually in kids 7-12 yo
Hx & PE = ear pain, tragus tenderness,
ear canal swelling + erythema
```
59
How do Dx OE? Tx?
```
Dx = clinical
Tx = clear ear canal —> pain control —>
antibiotic ear drops for bacteria (1st line)
- neomycin/polymycin B
- if gram +/- then give ciprofloxacin +
steroids (decrease inflammation)
```
60
Sinusitis - define? Epi? RFs? Hx & PE? Criteria?
```
Sinusitis - infection of sinuses (MC - maxillary
then ethmoid, frontal, sphenoid)
Epi - females, adults & kids
RFs - URT infection, allergic rhinitis
Hx & PE - facial pain/headache/
post nasal drainage/ purulent nasal discharge
Criteria = s/s 10 d then
possibly bacterial, give antibiotics
```
61
How would Dx Sinusitis? Tx?
Dx - clinical
Tx - mild/uncomp - decongestant
pseudoephedrine (3-5day otherwise rebound)
and oxymetazoline
severe - give antibiotics - amox/clavulate
62
Pharyngitis - Etio? RFs? Hx & PE?
Most commonly due to viruses, Group A strep (s.pyogenes)
RFs - nasal colonization, Group A strep, viral infection early spring - winter months
Hx & PE = pain on swallowing, enlarged lymph nodes in neck, exudate on pharynx, fever, NO COUGH & HOARNESS
63
What is the Dx of pharyngitis? Tx? Complication? Prevention?
Best initial test = rapid strep test
most accurate = culture
Tx = penicillin or amoxicillin 10 days; if allergic w rash then tx w cephalexin; if anaphylaxsis use macrolide & clindamycin
Complication - rheumatic fever & GN
Prevention if prophylaxis if Hx of rheumatic
fever
64
Influenza - Etio? RFs? Hx & PE?
```
Influenza - acute resp infection caused
by viral - influenza A & B, transmitted
by inhalation of infected resp secretion
RFs - > 65 yo, chronic disease, health
care workers
Hx & PE = arthralagia/myalgias, nonprod cough, fever, headache & sore throat
N/V/D in children
```
65
Influenza Dx? Tx? Prevention? Complication?
```
Dx - clinical, rapid Ag detection via naso
swab if w/in 48 hrs
Tx - symptomatic - give acetominophen
and anti-tussives
Criteria = if s/s within 48h then give oseltamir, zanamivir, if >48h then tx symptoms
Prevention - vaccine to DM, elderly,
preg women, health care workers
Complication - OM/pneumonia
```
66
Pneumonia Community Acquired- Etio? Epi? RFs? Hx & PE?
CAP - MC is s. pneumoniae, however viruses are MC in kids 65 yo, recent resp infection, HIV, smoking
Hx & PE - cough, fever, sputum production, puritic chest pain (assoc w lobar pneumonia seen in pneumococcus) tachycardia, crackles/rales on ausculatation
67
Pneumonia CAP- Dx? Tx? Prevention? Complication
Dx - sputum culture - most specific test, CXR
Tx - empiric tx = azithromycin and clarithromycin; alt is new quinolones - moxi, levo, gemifloxacin
if hospitalized then pt gets new quinolone or 3rd gen cephalo + macrolide (or doxy)
Prevention - pneumococcal vaccine in >65 yo; 19-64 with chronic disease, functional asplenia, give influenza vaccine to elderly, health care workers
Complications - empyema, pleural effusion,
68
Pneumonia - HAP - Etio? RFs? Hx & PE? Dx? Criteria?
Etio - pneumonia acquired after 48 hours of admission to the hospital; caused by gram - bacilli Pseudomonas,E.coli, Klebsiella, and Acinetobacter species
RFs - poor infection control, intubation
Hx & PE - same as pneumonia but with recent hospital admission
Dx - sputum, CXR
Criteria - HAP requires positive imaging plus 2 of 3 clinical features: fever >100.4°F (38°C), leukocytosis or leukopenia, or purulent secretions
69
Pneumonia - HAP - Tx? Prevention? Complication?
Monotherapy with ampicillin/sulbactam, ceftriaxone, ciprofloxacin, ertapenem, levofloxacin, or moxifloxacin
Prevention - wash hands
Complication - empyema, abscess
70
Bronchitis (acute & chronic) - Define? Etio? Epi? RFs?
Define - lower resp tract,
Epi - highest incidence in fall and winter
Etio - MCC of acute bronchitis is viral (coronavirus, rhinovirus, RSV); nonviral cases think Mycoplasma, c. pneumoniae; chronic - MCC s.pneu > h. infl > moraxella
RFs - viral and atypical bacterial exposure
71
Bronchitis - Hx & PE? Dx? Criteria? Tx? Prevention?
Hx & PE - cough w sputum (discolored sputum)
Dx - clinical dx
Criteria - An acute illness of <21 days, Cough as the predominant symptom, At least 1 other lower respiratory tract symptom such as sputum production, wheezing, chest pain
Tx - symptomatic treatment if viral - bronchodilators & cough suppressant
acute exacerbation - amox or doxy or TMP-SMP; complication - pneumonia/chronic cough
Prevention - no smoking
72
Lung Abscess - Define? Etio? RFs?
Define - most are anaerobes (oral)
Etio - assoc w peridonal disease or aspiration
RFs - chronic illness, poor dental hygiene, aspiration of gastric contents
Hx & PE = foul smelling sputum, fever, cough
73
Lung Abscess - Dx? Tx? Complication? Prevention?
Dx - CT/CXR, LL most common in upright position, post segment of RUL is MC in supine
Tx - best initial tx clindamycin
Complication - empyema, hemoptysis
Prevention - good oral hygiene
74
TB- define? Etio? RFs?
caused by mycobacterium tuberculosis
Etio - half the cases due to recent immigrants
RFs - alcoholics, health care workers, prisoners, homeless, weak immune systems
Hx & PE = wieght loss, night sweats, cough,fever, extrapulm manifestations
Dx - best initial - CXR; most specific test - culture
Tx - RIPE for 2 months, until sensitivity known then INH + rifampin for 6 more months; Tx meningitis (w steriods) for longer (12), pregnancy (9) and osteomyelitis
75
What is the SE of Ethambutol? PZA?
ethambutol causes optic neuritis
| PZA - benign hyperuricemia (don't treat unless gout assoc)
76
What is the PPD test guidelines for positive test?
>5mm = close contacts w active TB, HIV +, abnormal CXR w healed TB, steriod/organ transplant
>10mm = health care workers, prisoners, nursing homes, recent immigrants
>15mm = low risk pts
+ PPD --> CXR ---> abnormal -->3 sputum AFB done to see if active disease -->if + then treat w RIPE; if +PPD --> normal CXR or neg AFB smear then give 9m of INH + B6
77
What is the MCC of food poisoning?
Campylobacter
78
What bug causes food poisoning with
1. poultry & eggs
2. travelers diarrhea
3. undercook hamburger meat
4. fried rice
5. fresh water on camping trip
6. HIV patient
1. samonella
2. e. coli
3. e. coli 0157:H7
4. bacillus cereus
5. giardia
6. cryptosporidiosis
79
What organisms give bloody diarrhea?
```
Samonella
Shigella
Yersenia
invasive e.coli
Campylobacter
```
80
What organism associated w HUS?
E. coli 0157:H7
81
What protozoan is assoc w bloody diarrhea?
Entamoeba histolytica
82
What do NOT give bloody diarrhea (protozoan)?
Giardia
Cryptosporiodium
Cyclospora
83
What is the best initial Dx test for infectious diarrhea?
Stool for WBCs via methylene blue test
| Culture - most specific for organism
84
What Dx do you do for Giardia & cryptosporidia?
AFB stain for Cryptosporidia
| Stool ELISA for Giardia
85
Tx for infectious diarrhea?
```
oral fluids & electrolytes
if severe (high fever, abd pain, tachy & hypotension) then give IV fluids & oral antibiotics
```
86
UTI - define? etio? epi? RFs?
infection of kidney/bladder/urethra, divided into complicated (structual impairment that decreases in efficacy) and uncomplicated (healthy nonpreg, w/o UT abnormalities)
Epi - MC in females, >18 yo
Etio - majority are uncomplicated caused by e. coli others are Proteus, Enterobacteriae, Klebsiella; complicated caused by citrobacter, enterobacter, pseudo, s. aureus
RFs - sex/foreign body, Hx of recurrent UTI, postmen women
87
UTI - Hx & PE? Dx? Tx? complication?
Hx & PE = dysuria, fever, frequency, urgency, burning
Dx = initial UA best initial test, most accurate is urine culture
Tx = uncomp = nitrofuratoin x5day, TRP-SMX x3day
comp = 7d w/ quinolone (cipro)
Complications = pyelonephritis/perirenal abscess
88
What if the patient is resistant to TRP-SMX for UTI - what do you give?
quinolone for 3 days as 1st line
89
What do you give to preg women w UTI?
Nitrofuratoin
Amox/clavulate
cephalexin
90
Urethritis - Etio?Epi? RFs? Hx & PE?
STD presenting w urethral d/c, dysuria and or puritis @ end of urethra
Epi - c. tracho is MC, 2nd = n.gono
Etio - divided into gonococcal and nongonoccal (caused by c. tracho/ureaplasma/mycoplasma)
RFs - 15-24 yo females/multi sex parters/prior hx of STD, no condom use
Hx & PE - urethral d/c dysuria, urethra itching
91
Urethritis - Dx? Criteria? Tx? complication?
Dx - best initial = urethral swab for gram stain (UA) most accurate = urine culture
Criteria = urethral d/c + >5 PMNs on UA
Tx = for gono = IM single dose ceftriaxone or oral cefixime; c. tracho = azithromycin or doxy
complications = GU abscess/ disseminated gonococcal, urethral stricture/fistula
92
Cervicitis - Etio?RFs? Hx & PE? Criteria? Dx? Tx?
due to inflammation of cervix, prurulent endocervical exudate or easily induced endocervical bleeding
Etio = divided into infectious (n. gono & c. tracho) and noninfectious
RFs = 15-25 female, multiple sex partners, BV, hx of STD
Hx & PE - purulent cervical d/c, intermenstrual bleeding, dysuria, urinary freq,
Criteria - easily induced cervical bleeding +mucopurulent d/c
Dx - urethral swab then urine culture
Tx - same as urethritis
93
PID - etio? epi? RF's? Hx & PE?
inflammation of female upper genital tract (endometritis/salpingitis/tubo ovarian abscess/pelvic peritonitis)
Epi - young/single/sexually active F w hx of STD
Etio - polymicrobial infection esp c. tracho & n. gono
RFs - prior infection w c. tracho/n.gono, young age of onset of sex, prior hx of PID, IUD use
Hx & PE? - lower abd tenderness/lower abd pain/fever/ cervical motion tenderness/ leukocytosis
94
PID - Criteria? Dx? Tx?
Criteria - young sexually active F w lower abd pain + >1 of (adnexal tenderness, uterine tenderness, cervical motion tenderness)
Dx - cervical swab/DNA probe/ PCR confirms etiology; most accurate - laproscopy
Tx - rest & analgesics --> antibiotics - outpt gets ceftriaxone + azithromycin 100mg BID 14d and if no response then hospitalize and give IV (cefotetan or cefoxitin) +doxycycline
95
What if they have anaphylaxsis to penicillin if they have PID?
Give outpt = levofloxacin + metro
| inpatient = clinda + gentamycin
96
Syphilis - define? Etio? RFs?
STD infection caused by spirochete, treponema palladium
Etio - acquired through sex or congenital
RFs - sex w infected pt, men sex w men, multiple sex partners, illicit drug use
97
Primary syphilis? Secondary syphilis? Tertiary?
Primary - chancre - painless genital ulcer w heaped indurated edges, painless lymphadenopathy
Secondary - 4-8wk after primary = rash (palms & soles) alopecia acreta, mucous patches, condylomata lata
Tertiary - if untreated then neurosyphilis - tabes dorsalis, general paresis, argyll robertson pupil, aortitis, gumma
98
How do you Dx? Tx? syphilis
Dx - VDRL/RPR - initial, confirmed w FTA-ABS
Tx - primary & secondary w/o neurosyphilis tx w IM benzathine Pen G, if allergic to Pen then give doxy but if tertiary or neurosyphilis give pen & desensitize if allergic
99
What does congenital syphilis cause?
Hutchinson teeth, saber shins (bony abnormalities), scars of intestinal keratitis
100
Chancroid - define? Etio? Hx & PE? Dx? Tx?
painful genital ulcers w fluctuant lymphadenitis (bubo) caused by H. ducreyi (gram - bacillus)
Hx & PE = painful papules become shallow ulcers, inguinal nodes are tender and painful
Dx = clinically, gram stain initially then confirm w culture
Tx = azithromycin single dose OR IM ceftriaxone
101
Lymphogranuloma Venereum -define?Etio? Hx & PE? Dx? Tx?
STD having transitory primary lesion followed lymphangitis
Etio - c. tracho
Hx & PE = transient lesion that ulcerates and heals quickly w unilateral enlargement of inguinal lymph nodes
Dx - clinically, c. tracho serology, confirm w PCR
Tx - doxy (erythromycin alt)
102
Granuloma Inguinale - define? Etio? Hx & PE? Dx? Tx?
chronic granulomatous condition
Etio = donovania granulomatis; c. granulomatis
Hx & PE = painless, red nodule w elevated granulomatous mass
Dx - clinically, do Giemsa or Wright stain (Donovan bodies)
Tx = doxy or ceftriaxone or TMP-SMZ
103
Genital Herpes - etio? Hx & PE? Dx? Tx?
Etio - due to HSV
Hx & PE - vesicles on skin, painful circular ulcers
Dx - Tzanck and culture
Tx - acyclovir, famiciclovir, valacyclovir
Prevention - but treat the partner
104
Genital warts - Etio? Epi? RFs? Hx & PE?
Etio - common STD, caused by HPV esp 6 & 11,
Epi - peak 16-25 yo
Hx & PE - found in moist areas in genital areas, veruccus papules
Dx - clinically, no initial test
Tx - patient applied = podophyllin/imiquimod
clinician applied = cryotherapy/destruction (currettage/sclerotherapy/TCA)
105
Cystitis - define? Etio? Epi? RFs? Hx & PE?
infection of the urinary bladder in young/sexual active
Epi - F > M; 18-24 yo
Etio = e.coli
RFs - freq sex/ Hx of UTI/urinary catheter/pregnancy/ diabetes
Hx & PE = dysuria (urgency/freq), suprapubic pain, barely fever
106
Cystitis - Dx? Tx? Complication? Prevention?
Dx - UA - look for WBCs; Nitrate + = gram - bac
confirm w culture
Tx = uncomplicated TRP-SMX 3d/ nitrofuratoin 3day if there's resistance then use cipro
Complication - pyelonephritis/ urinary retention
Prevention - wipe front to back
107
Pyelonephritis - define? Epi? Etio? RFs? Hx & PE?
inflammation of renal parenchyma/calcies/ pelvis
Epi - gram - bac; MC e. coli > proteus > klebsiella
Etio - divided into uncomplicated (younger women) & complicated (older men, preg women, diabetics)
RFs - freq sex/ UTI/ DM/ stress incontinence, obstruction in kidneys/ anatomical urinary abnormality/preg
Hx & PE - CVA tenderness/flank, fever
108
Pyelonephritis - Dx? Tx?
Dx - UA, culture (MC)
Tx - indication for hospitalization (hypotension/vomiting/dehydration), fever >102, increase WBCs, severely ill w comorbidity
use ampicillin + gentamycin until cultures come back (w genta - pts w renal dysfunction decrease dosage)
110
Perinephric Abscess - Etio? Hx & PE? Dx? Tx?
collection of infected material surrounding kidney
Etio - predisposing to pyelonephritis - like stones;
Hx & PE - persistant pyelonephritis not responding to treatment
Dx - UA/culture - best initial; confirm w imaging either CT/MRI; aspiration needed for bac etio
Tx - antibiotics that cover gram - rods (3rd gen cephalo or antipseudo penicillin or ticarillin/clavulanate + amino
Drainage is needed
111
Endocarditis - etiology? Hx & PE?
```
Endocarditis is an infection of the valve of the heart leading to a fever and a murmur.
Etio = Regurgitant and stenotic lesions confer increased risk. Prosthetic valves are associated with the highest risk, IV drug users
Hx & PE = fever, new murmur
- Splinter hemorrhages
- Janeway lesions (flat and painless)
- Osler nodes (raised and painful)
- Roth spots in the eyes
- Brain (mycotic aneurysm)
- Kidney (hematuria, glomerulonephritis)
- Conjunctival petechiae
- Splenomegaly
- Septic emboli to the lungs
```
112
Endocarditis Dx & Tx?
Best initial test = blood culture
Most accurate = TEE
CRITERIA =
1. Oscillating vegetation on echocardiography
2. Three minor criteria:
- Fever >100.3°F (38°C)
- Risk such as injection drug use or prosthetic valve - Signs of embolic phenomena
Tx = best empiric therapy is vancomycin and gentamicin
113
Endocarditis assoc w organism and treatment?
Viridans streptococci - Ceftriaxone for 4 weeks
Staphylococcus aureus (sensitive) - Oxacillin, nafcillin, or cefazolin
Fungal - Amphotericin and valve replacement
Staphylococcus epi or resistant Staph - vanco
Enterococci - Ampicillin and gentamicin
114
For endocarditis - what do you add for resistant organisms
aminoglycoside
115
When is surgery the answer for endocarditis?
* CHForrupturedvalveorchordaetendineae
* Prostheticvalves
* Fungal endocarditis
* Abscess
* AV block
* Recurrentemboliwhileonantibiotics
116
What are the organisms that are difficult to culture for endocarditis? tx?
```
• Haemophilus aphrophilus
• Haemophilusparainfluenzae • Actinobacillus
• Cardiobacterium
• Eikenella
• Kingella
Tx = use ceftriaxone
```
117
When do you give prophylaxis for endocarditis?
```
1.Significant cardiac defect
Prosthetic valve
Previous endocarditis
Cardiac transplant
Unrepaired cyanotic heart disease
2. Risk of bacteremia
- Dental work with blood
- Respiratory tract surgery that produces bacteremia
best initial management is amoxicillin prior to the procedure, if pen allergic =clindamycin or azithromycin or clarithromycin
```
118
Lyme disease? etio? PE?
Lyme disease is an arthropod-borne disease from the spirochete Borrelia burgdorferi transmitted via deer tick (Ixodes)
Etio = found in northeast states, CT, NY, NJ, Mass
PE = rash MC manifestation = ash is erythema migrans. It is a round red lesion with a pale area in the center; most common long term complication is joint pain (if no tx then 60% get joint pain); neuro = Seventh cranial nerve or Bell palsy is the most common neurological manifestation of Lyme disease and cardiac = AV block is the most common cardiac
119
Lyme disease - dx? tx?
Dx - clinical
Criteria - ELISA/IFA if neg then do Western blot,
prophylaxsis started w/in 72 hr of tick bite, tick bite>36 hr, doxy contraindicated for children <8 yo, pregnancy, lactation give amoxicillin instead
Tx - single doxy or amox or cefuroxime for CVS/CNS s/s give IV ceftriaxone
120
When do you give single dose of doxy within 72 hours?
- Ixodes scapularis clearly identified as the tick causing the bite
• Tick attached for longer than 24 to 48hours
• Engorged nymph-stage tick
• Endemic area
121
HIV - stages? stucture?
```
gp 41/120 - envelope proteins
gp 24 - capsid protein
RT - makes dsDNA from RNA, dsDNA
integrates into host genome
HIV - Criteria
Stages
1. Acute HIV syndrome
2. asymptomatic stage - 10y post infectious
stage
3. symptomatic stage
4. AIDS
- HIV + and AIDs defining illness
- HIV + and CD4 ct <200
```
122
What are the opportunistic infections according CD4 count in HIV?
Opportunistic infections according CD4
200-500 = oral thrush, Karposi, TB, Zoster,
lymphoma, Herpes, bacteria pneumonia,
100- 200 = PJP, dementia, PML, disseminated
histoplasmosis, coccidiomycosis
<50 = CMV, MAC, PML, CNS lymphoma
123
Best initial test for HIV? confirm?
best initial test for HIV is the ELISA test, confirmed with Western blot testing
infants are diagnosed with PCR or viral culture - which detects DNA of HIV
124
When do you use viral load testing?
* Measure response to therapy (decreasing levels are good)
* Detect treatment failure (rising levels are bad)
* Diagnose HIV in babies
125
Treatment for HIV?
choice of medications to select 3 drugs from 2 different classes to which the patient's virus is susceptible, best initial drug regimen is a combination of emtricitabine, tenofovir, and efavirenz.
126
What are the NNRTIs? SE?
```
- Zidovudine = leukopenia
• Didanosine = pancreatitis, peripheral neuro
• Stavudine
• Lamivudine
• Emtricitabine
• Abacavir = hypersen rxn
• Tenofovir
- zalcitabine - pancreatitis, perineuropathy, lactic acidosis
```
127
What are the NRTIs? SE?
* Efavirenz = neuro s/s
* Etravirine
* Nevirapine = rash
* Rilpivirine
128
What are the protease inhibitors? SE?
```
PI = SE include hyperlipidemia, hyperglycemia, lipodystrophy
• Darunavir
• Atazanavir
• Ritonavir
• Saquinavir
• Nelfinavir
• Amprenavir
• Fosamprenavir
• Lopinavir
• lndinavir = renal stones, hyperbilirubinemia
• Tipranavir
```
129
PJP - s/s? Dx? Tx? Prophylaxis?
```
causes pneumonia, dry cough, fever
Dx - bronchoscopy w BAL for direct ID
CXR - bilateral interstitial infiltrate
Tx - TRP-SMX
steriods used for severe pneumonia -
PaO 35 mmHg
PROPHYLAXSIS - TRP-SMX > dapsone >
atovaquone
```
130
CMV - s/s? dX? Tx? prophylaxis?
causes retinitis - blurry vision, visual
disturbance in HIV + w low CD4; esoghagitis
endoscopy shows shallows ulcers in distal
esophagus Dx - via fundoscopy
Tx - valganciclovir; foscarnet for alt
CMV prophylaxis is valganciclovir for life until CD4 ct 200
Foscarnet SE is renal toxicity
131
MAC ? Dx? Tx? Prophylaxis
inhalation results in fever, NS, wasting,
bacteremia, anemia
Dx - blood culture, biopsy of BM, liver biopsy
Tx - clarithromycin + ethambutol +/- rifabutin
PROPHYLAXIS - azithromycin (oral)1x/wk
132
Toxoplasmosis - Dx? Tx? Prophylaxis?
brain mass lesions
DX - ring enhanced lesions on CT w contrast
surrounded by edema; trial of treatment for
2 weeks is given and then re-CT to see if
lesion shrank; if no shrinkage then biopsy
needed to r/o cancer
Tx - pyrimethamine & sulfadiazine (alt is
clindamycin) leucovorin prevents BM supression
PROPHYLAXSIS - TMP-SMZ or dapsone +
pyrimethamine
133
Cryptococcosis - Dx? Tx? Prophylaxis?
causes meningitis - fever,
headache and malaise
Dx - LP w India ink stain then confirm w
cryptococcal Ag
worse prognosis - high Ag titer, high opening
pressure, low CSF cell ct
Tx - amphotericin IV 10-14 days w flucytosine
followed by fluconazole for oral maintence
PROPHYLAXIS - fluconazole - not usually
given
134
What vaccines do you give HIV + pt?
Pneumococcus
Influenza
Hep B
135
If HIV drug resistance occurs what are the next choices?
either atazanavir, darunavir, or raltegravir combined with emtricitabine / tenofovir
136
When do you do C - section for HIV + ?
Cesarean delivery is performed to prevent transmission of virus if the CD4 is low (below 350) or the viral load is high
Remember: Pregnant HIV-positive persons should be treated with anti-retrovirals during the whole pregnancy. Do not wait for the second trimester, and always use at least 3 drugs.
137
Q fever? etio? PE? Tx?
Q fever - caused by Coxiella burnetti - transmission by aerosol
Hx & PE - febrile illness, atypical pneumonia, hepatits
Dx - serology
Tx - doxy
138
RMSF? PE? Dx? Tx?
caused by Rickettsi transmitted by wood tick around midwest area
Hx & PE - fever, rash, headache - rash starts in wrist & ankles
spread centripetally
Dx - serology, biopsy of skin lesion
Tx - doxy
139
Leptospirosis - Dx? Tx?
caused by exposure to animal urine, results
fever & abd pain
Dx - serology, blood Ag
Tx - ceftriaxone or penicillin
140
TSST - Etio? PE? Dx? Tx?
caused by s. aureus (TSST-1) acquired from wound
and tampons
Hx & PE = hypotension, fever, sepsis, desquamative rash on
hands and feet
Dx - clinically
Tx - beta - lactam penicillin (naficillin, oxacillin)
141
Aspergillosis - etio? RF? PE? Dx? Tx?
pulm infection in immunocomp
Etio - due to A. fumigatus
RF - neutropenia, steriod use, cytotoxic drugs (azathioprine, cyclophosphamide)
Hx & PE - allergic bronchopul like asthma - fever, cough, wheezing
Myectoma - fungal ball - resides in pre-existing cavity w/ hemoptysis as CC
Dx - CXR - halo sign, biopsy confirm
Tx - voriconazole superior to Amp B (give if systemic s/s)
142
Blastomycosis - etio? RF? PE? Dx? Tx?
multiple nodules in lungs, broad budding yeast,
Etio - southeast area
Epi - inhalation of decaying wood
Hx & PE - pulm w fever/cough/chest pain/weight loss, skin lesions,
osteolytic bone lesion
Dx - sputum, biopsy confirms
Tx - amp B 8-12 wks; itraconazole/ketoconazole for mild disease
143
Coccidomycosis - etio? RF? PE? Dx? Tx?
pulm disease, hilar adenopathy, pleural effusion
Etio - southwest area - california
Hx & PE - fever, bone lesion, maculopap lesion
Dx - sputum, biopsy confirms
Tx - Amp B (systemic) and azoles for mild disease
144
Histoplasmosis - PE? Dx? Tx?
PE = palate ulcers, HSM, bat droppings hx
Etio - wet areas - Midwest area
Dx - urine Ag detection
Tx - Itraconazole
Internal Medicine
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