Infectious Disease Flashcards
HPV Human Papilloma Virus “Pearls”:5
> The HPV serotypes in the Quadrivalent vaccine are responsible for 70 % of cervical cancer. The 5 additional serotypes in the Gardasil 9 vaccine account for 20% of cervical cancers.
Most 90% of patients will “clear” the HPV virus within 12 months. Meaning the pap test will revert to normal. However it’s felt that the HPV becomes latent (like TB) and doesn’t actually leave. The IgA and IgG can take over a year to turn (+). But “seroreversion” can occur and the antibodies disappear. 10% of patients will have persistent active HP»In these patients the virus has “evaded” the immune system.
> After infection the patient needs to be monitored as the virus can activate intermittently with pap test turning (+) intermittently
Regards acute Sinusitis:
What are the indications for amoxicillin-clavulelate 875 mg BID vs amoxicillin -clavulenate ER 1000/62.5 Two BID?
Amoxicillin-clavulanate rather than amoxicillin is recommended as empiric therapy for non-penicillin allergic adults. Amoxicillin-clavulanate is also preferred to a respiratory fluoroquinolone as initial empiric therapy. The dose of amoxicillin-clavulanate for most patients would be either 500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily.
●High-dose amoxicillin-clavulanate (2 g orally twice daily) is recommended in geographic regions with rates of penicillin-nonsusceptible S. pneumonia exceeding 10 percent and for patients who meet any of the following criteria: 65 years and older, recently hospitalized, treated with an antibiotic in the previous month, or immunocompromised.
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> What are the main causes of Traveler’s Diarrhea?
> What are the symptoms of TD?
> The majority of cases are due to bacteria, with
Enterotoxigenic E. coli(ETEC) the most common. Other common causes are Salmonella, Shigella, Campylobacter jejuni. Additional causes are Enteroaggritave E.coli(EAEC), Vibrio, Aeromonas hydrophilia, Pleisiomonas shigalloides, Entamoeba histolytica, Cryptosporidium,Giardia
> Giardia is the main protozoal pathogen found in TD. Entamoeba histolytica is a relatively uncommon pathogen in travelers. Cryptosporidium is also relatively uncommon. The risk for Cyclospora is highly geographic and seasonal: the most well-known risks are in Nepal, Peru, Haiti, and Guatemala. Dientamoeba fragilis is a low-grade but persistent pathogen that is occasionally diagnosed in travelers
> Rotaviruses are the most common viral cause followed by Noroviruses.
> Bacterial and viral TD presents with the SUDDEN ONSET OF BOTHERSOME SYMPTOMS THAT CAN RANGE FROM MILD CRAMPS AND URGENT LOOSE STOOLS TO SEVERE ABDOMINAL PAIN, FEVER, VOMITING, AND BLOODY DIARRHEA, ALTHOUGH WITH NOROVIRUS VOMITING MAY BE MORE PROMINENT. PROTOZOAL diarrhea, such as that caused by GIARDIA INTESTINALIS OR E. HISTOLYTICA, GENERALLY HAS A MORE GRADUAL ONSET OF LOW-GRADE SYMPTOMS, WITH 2–5 LOOSE STOOLS PER DAY. The incubation period of the pathogens can be a clue to the etiology of TD:
-BACTERIAL AND VIRAL PATHOGENS have an INCUBATION PERIOD OF 6–72 HOURS. PROTOZOAL PATHOGENS GENERALLY HAVE AN INCUBATION PERIOD OF 1–2 WEEKS and rarely present in the first few weeks of travel. An exception can be Cyclospora cayetanensis, which can present quickly in areas of high risk.
What is the chance(risk) of getting Travelers Diarrhea?
> Overall risk is 10-40% With the highest risk in South and Southeast Asia, Africa(with the exception of South Africa), South and Central America and Mexico.
Moderate risk (10 to 20 percent) — Caribbean Islands, South Africa, Central and East Asia (including Russia and China), Eastern Europe, and the Middle East, including Israel
Where are you more likely to have parasites as a cause of travelers diarrhea?
parasitic pathogens uncommonly cause travelers’ diarrhea [18-20]. However, there are a few locations where travelers are more likely to acquire parasites, including Nepal (where both G. lamblia and C. cayetanensis are common) and St. Petersburg (where G. lamblia remain hyperendemic). The mountainous regions of the West and Northeast United States are also highly endemic for G. lamblia, but travelers to these locations rarely request advice prior to travel. In these situations, it may be that environmental factors such as the juxtaposition of the water supply with the habitat of a certain animal species predispose the area to a hyperinfestation with the parasite.
What are the precautions to avoid Travelers diarrhea?
> Basic advice for travelers to moderate or high-risk regions for travelers’ diarrhea includes eating only food that has been thoroughly COOKED AND SERVED HOT, fruits that the traveler PEELS just prior to eating, and PASTEURIZED dairy products. Beverages should be bottled or disinfected. Bottled drinks should be requested WITHOUT ICE and should be drunk from the bottle WITH A STRAW rather than from a glass. Hot tea and coffee are usually safe alternatives to boiled water
> FRUIT SALADS, LETTUCE, OR CHICKEN SALADS ARE EXAMPLES OF UNWISE FOOD CHOICES; the ingredients may have been improperly washed and/or may have been sitting for some time without proper refrigeration.
AVOID SAUCES, CONDIMENTS, “HOT BAR” BUFFET
How does the presentation of influenza differ in the elderly as opposed to younger patients?
Influenza CHARACTERISTICALLY BEGINS WITH THE ABRUPT ONSET OF FEVER, HEADACHE, MYALGIA, AND MALAISE [16,26-29], following an incubation period of one to four days (average two days) [3,9]. These symptoms are accompanied by manifestations of respiratory tract illness, such as nonproductive cough, sore throat, and nasal discharge. In some cases, the onset is so abrupt that patients can recall the precise time at which illness began.
> Older adult patients are particularly likely to have subtle signs and symptoms . Typical findings such as sore throat, myalgias, and FEVER MAY BE ABSENT AND GENERAL SYMPTOMS SUCH AS ANOREXIA, MALAISE, WEAKNESS, AND DIZZINESS MAY PREDOMINATE.
How many patients die each year from hospital acquired infections(often from central lines)?
- 75,000! Thats 200/day
How many people get antibiotic resistant infections in the U.S. yearly…..and what is the cost to society?
More than 2 million Americans contract antibiotic-resistant infections each year, resulting in more than 23,000 deaths, $20 billion in direct medical costs, and more than $35 billion in lost productivity
How many Americans get a food borne infectious illness yearly?
48 million Americans fall ill from a foodborne illness each year
What is best Rx for recurrent vulvovaginal candidiasis as of 1/1/2015?
, we believe that the optimal therapy for recurrent vulvovaginal candidiasis in nonpregnant women consists of initial induction therapy with fluconazole 150 mg every 72 hours for three doses, followed by maintenance fluconazole therapy once per week for six months [94]. Therapy is then discontinued, at which point some patients achieve a prolonged remission, while others relapse.
> Discuss the treatment of Travelers Diarrhea and considerations concerning
- antibiotics: indication and choice of
- use of Imodium
- diet
- indication for ORS
- definition of more severe diarrhea
> what should you tell patients about treatment of bloody diarrhea and the risk of antibiotics?
> Except for women, children and patients in South Asia the usual Rx is Cipro 500 mg BID
x 3 days. But some studies show good result with only 1 dose of cipro
> For women and children Azithromycin 1000 mg x 1 dose is preferable.
> For South Asian patients use Azithromycin as initial Rx because of widespread Chlamydia jejuni Quinolone resistance
> If diarrhea is very mild and Can eat lightly with TD and if it is mild can alternate between broth and juices.
> **If diarrhea is more severe or if frequency and amount of urination is low: use ORS.
(If patients are taking Imodium they may not realize how much fluid they are loosing in their intestines.)
> *We cautiously use of antimotility agents in the setting of travelers’ diarrhea. They SHOULD BE ADMINISTERED ONLY IN CONJUNCTION WITH EMPIRIC ANTIBIOTIC TREATMENT of the offending diarrheal pathogen, and travelers should be educated about the need to AVOID USAGE IN DYSENTERY (BLOODY STOOL AND/OR FEVERS). ANTIMOTILITY AGENTS SHOULD BE STOPPED IF ABDOMINAL PAIN OR OTHER SYMPTOMS WORSEN OR IF THE DIARRHEA CONTINUES TO BE INTRACTABLE AFTER TWO DAYS.
Although an uncommon cause of travelers’ diarrhea, BLOODY DIARRHEA CAN REFLECT AN ENTEROHEMORRHAGIC E. COLI INFECTION, for which antibiotic TREATMENT HAS BEEN ASSOCIATED WITH AN INCREASED RISK OF HEMOLYTIC-UREMIC SYNDROME, ESPECIALLY IN CHILDREN. Treating diarrhea that impairs daily activities or complicates travel responsibilities likely outweighs this minor risk, but travelers should be advised of this.
> What are the recommendations for prophylaxis for Travelers Diarrhea?
> What is the treatment for TD?
Prophylactic antibiotics are effective in the prevention of some TD. Controlled studies have shown that diarrhea attack rates are reduced by 90% or more by the use of antibiotics.trimethoprim-sulfamethoxazole and doxycycline are no longer considered effective antimicrobial agents against enteric bacterial pathogens. The fluoroquinolones have been the most effective antibiotics for the prophylaxis and treatment of bacterial TD pathogens, but increasing resistance to these agents, mainly among Campylobacter and Shigella species, may limit their benefit in the future.
A nonabsorbable antibiotic, rifaximin, is being investigated
At this time, prophylactic antibiotics should not be recommended for most travelers. Prophylactic antibiotics afford no protection against nonbacterial pathogens and can remove normally protective microflora from the bowel, which could make a traveler more susceptible to infection with resistant bacterial pathogens. A traveler relying on prophylactic antibiotics will need to carry an alternative antibiotic to use in case diarrhea develops despite prophylaxis. Additionally, the use of antibiotics may be associated with allergic or adverse reactions in a certain percentage of travelers and may potentially contribute to drug resistance. The use of prophylactic antibiotics should be weighed against the result of using prompt, early self-treatment with antibiotics when TD occurs, which can limit the duration of illness to 6–24 hours in most cases. Prophylactic antibiotics may be considered for short-term travelers who are high-risk hosts (such as those who are immunosuppressed) or who are taking critical trips (such as engaging in a sporting event) during which even a short bout of diarrhea could affect the trip.
Both as empiric therapy or for treatment of a specific bacterial pathogen, first-line antibiotics include fluoroquinolones, such as ciprofloxacin or levofloxacin. Increasing microbial resistance to the fluoroquinolones, especially among Campylobacter isolates, may limit their usefulness in some destinations, such as Thailand, where Campylobacter is prevalent. Increasing cases of fluoroquinolone resistance have been reported from other destinations and in other bacterial pathogens, including Shigella and Salmonella. A potential alternative to the fluoroquinolones in these situations is azithromycin, although enteropathogens with decreased azithromycin susceptibility have been documented in several countries.
**Single-dose or 1-day therapy for TD with a fluoroquinolone is well established, both by clinical trials and clinical experience. The best regimen for azithromycin treatment is not yet established. One study used a single dose of 1,000 mg, but side effects (mainly nausea) may limit the acceptability of this large dose. Azithromycin, 500 mg per day for 1–3 days, appears to be effective in most cases of TD.
Imodium: Can be used but Antimotility agents are not generally recommended for patients with bloody diarrhea or those who have diarrhea and fever.
What is Tropical Sprue?
Tropical sprue is a syndrome of persistent TD often associated with malabsorption, steatorrhea, and folate and vitamin B12 deficiency. Tropical sprue is rare in short-term travelers, and recent surveys of returned travelers suggest that it is occurring less frequently worldwide. Although exhaustive searches to identify the etiologic agent of tropical sprue have been futile, it bears all the hallmarks of an infectious disease. Exclusion of other diarrheal etiologies is required for diagnosis. Treatment with tetracycline 250 mg 4 times daily and folate 5 mg daily for at least 6 weeks is generally successful. Patients with concomitant vitamin B12 deficiency may require parenteral vitamin B12.
What is the hallmark of the development of secondary bacterial pneumonia in a patient with influenza?
The hallmark of the clinical presentation in patients with secondary bacterial pneumonia is the exacerbation of fever and respiratory symptoms after initial improvement in the symptoms of acute influenza. Fever may abate for one or more days of acute influenza, but, instead of continuing to improve, the patient with secondary bacterial pneumonia relapses with higher fevers, cough, production of purulent sputum, and radiographic evidence of pulmonary infiltrates.
