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Flashcards in infectious disease Deck (66)
1

clean surgical wound

no break techiniqueno inflammationclean areas: cardiac, vascular, neuro, ortho, ophtha

2

clean contaminated wound

POTENTIALLY colonized hollow viscus disrupted (head, neck, oral, abd, gym surg)minor break in procedure

3

contaminated wound

** penetrating trauma lt 4 hours old **inflammation already, MAJOR break in technique, major hollow organ spill

4

dirty wound

frank purulent drainage, abscess ** penetrating trauma gt 4 hours old **

5

clean areas of wounds

cardiac, vascular, neuro, ortho, ophtha

6

MRSA + central line relationship

87% bacteremic pts18-55% endocarditis ptshad central line

7

common MRSA sites

wounds, nares, trachea, perinum

8

MRSA - how resistance works

produce beta lactamasealtered penicillin-binding proteins (PBP) - rx efficacy needs high affinity between drug & PBP

9

* MRSA: at risk pops

aged / debilitatedmales/p surgery + lengthy hospymultiple invasive proceduresICU, trauma, burnindwelling cath, intravasc device, ET tube, ventprev hospyprior prolonged abx txpresence/size of wound

10

MRSA resistant to these meds

methicillinaminoglycosides: gentamicinerythromycintetracyclinescephalosporinsquinolones: cipro, floxin

11

what counts as epidemic

greater than 4 cases over baseline per month

12

MRSA + surgical pt care approach highlights

- tx remote infection prior to surgery (urine C&S + nasal swabs)- good control of glucose levels (150 ok, higher = increased infx risk)- special bathing protocol (air dry + chlorhexidine)- universal precautions always

13

MRSA + infected/colonized pt care highlights

CONTACT ISOLATION- gloves + hand wash most important- colonized + asymp + no surgical + no pna risk = NO NEED TO TREAT

14

MRSA: don't need to treat who

pts who are... colonized + symp + no surgery + no pna risk

15

** MRSA TREATMENT ** x4

vanc (IV) 15 - 20 mg/kg/dose Q8-12 hrs- bacteremia - vanc or dapto 2 wk- infective endocarditis: vanc 6 wk- CAP (one of the following)-- vanc IV 7-21 -- linezolid (zyvox) PO/IV -- clindamycin IV

16

vanc-resistant enterococcus

4th leading cause HAI in ICUintrinsic & acquired resistance possiblepoor prognosis w high mort rate

17

VRE key risk factors

- broad spectrum cephalosporins- parenteral vancomycin

18

** VRE TX OPTIONS **

newer abx: zyvoxcombo tx: pcn + vanc + gent

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vanc resis r/t heavy use 3rd gen cephalosporins

klebsiella pneumoniae

20

** skin infection tx **

ORAL- clindamycin- bactrim (sulfa-tmp)- tetracycline- linezolid (zyvox)

21

** cellulitis organisms ** common / less (x3 each)

BOOYEAH: gram pos cocci- beta hemolytic strep (A, B, C, G, F)- staph aureus- MRSAEHHH?- gram neggies- h flu- non-spore forming anaerobes

22

cellulitis at risk pops

diabeteselderlypedal edemavenous or lymphatic compromiseobese: abdominal wall cellulitis

23

cellulitis s/s** + intensification + toxic

** erythema w irregular borders but “spreading” **tenderness, warmth, pain, edemalymphadenopathyno vesicles or bullaeINTENSIFY RAPIDLY (edema, eryth spread 6-36 hours)TOXIC: tachy(cardic/pneic), hypotensive, septicemia

24

spread of cellulitis s/s

INTENSIFY RAPIDLYeryth + ede 6 - 36 hours spread

25

important ddx for cellulitis

VTE nec fasc (appears toxic - HAS BULLAE and cellulitis don't)

26

nec fasc s/s

skin necrosisbullaecrepitusanesthesia over skinrhabdomyolysisTOXIC!

27

** cellulitis w purulent drainage tx **

empirically for MRSA!!- clinda- bactrim- tetracycline (doxy)- linezolid (zyvox)

28

** non-purulent, no comorb cellulitis **

dicloxacillin 500 mg QIDcephalexin (keflex) 500 mg QIDclindamycin 300-450 mg q6 - 8 hrs ← pcn / cepha allergy

29

** acutely ill patient w cellulitis tx **

IV abxnafcillin (unipen or nafcil) 1-2 g IV q4hrscefazolin (ancef) 2 g IV q6hrsoxacillin 2gm IV q4hrsclindamycin 600-900 mg IV q8hr

30

cellulitis follow up

s/s resolved (typi within 24-48 hours)visible may take 72 hourslook for worsening

31

** recurrent cellulitis tx **

pcn 250-500 BID

32

tb transmission mode

airborne

33

primary TB

- infected but effective immune response not yet mounted- clinically & radiographically silent

34

progressive primary TB

5% infected, unable to contain organisms

35

** LATENT TB **

no active disease, cannot transmit10% progressive primary w/in 2 yearsactive tb will develop if immunocompromised or impaired (ex: prednisone)- pos ppd- neg CXR- no sx active tb

36

active TB

cough - at least 3 wks (dry to productive)fatigueweight lossanorexianight sweats***fever (low grade)blood streaked sputum (significant hemoptysis rare)bronchial breath soundsdullness to percussionRales, cracklesappears chronically ill, malnourished

37

gold standard tb diagnosis

CULTURE!!!!

38

tb dx

exposure hx, predisposing factors, s/sppd CXR: infiltrates, nodular densities in apical region of upper lobes3 early morning sputum specimens- acid-fast bacilli on smear- positive sputum culture bronchoscopy (bronchoalveolar lavage)gastric morning aspirate (after an overnight fast) - culture only, can’t smear

39

may have diminished reaction to PPD testing x4

malnourishedimmunosuppressedunderlying bacterial/viral infection

40

HIV patients + tb

anergistic

41

considered PPD conversion

wheal increases 10 mm+ within 2 years - needs follow up

42

** tb test interp: high

greater than 5HIV/AIDSclose contact tb positiveCXR = “old” healed tb

43

** tb test interp: moderate

greater than 10persons from high incidence country (asia, africa, latin america)IVDUunderserved, low incomeinsititutionalizedgastrectomy, jejunoileal bypass10% under IBWCKD, DMcorticosteroids or immunosuppressantleukemia, lymphoma, other cancers

44

** tb test interp: low

greater than 15everyone else

45

** CDC TB TX RECS **

4 rx = prevent resistance development- INH- rifampin- PZA- ethambutolmonitor liver & renal fxn- weekly culture + sputum smear x6 weeks then mo- mo f/u s/s AE

46

tb rx AE

INH, rifampin, PZA - hepatotoxicPZA - ↑ uric acid levelsethambutol - optic neuritis

47

ethambutol monitoring

visual acuity & red/green color perception (causes optic nerve damage)

48

protease inhibitor and rifampin

CONTRAINDICATEDalt: rifabutin

49

FUO criteria

illness - 3 wks durationgt 100.4 F / 38.3 C several occasions undx after 3 office visits / 3 days in hospital3x s/s severe enough to require evaluation

50

hospital associated FUO

over 38.3 C (several occasions)admission cultures negativeundx after 3 days

51

neutropenic FUO

THINK CHEMOover 38.3 Cneutrophils less than 500neg culturesundx after 3 daysdifferentials: fungal, occult bacterial infx

52

HIV-associatied FUO

over 38.3 C- 4 wk outpt- 3 days inptwill see CMV, fungal infection, pneumocystis pneumonia

53

common causes of FUO

tuberculosisendocarditis (recent dental work? murmur?)gallbladder diseaseHIV (primary or opportunistic infection)systemic infection: tb, endocarditis, CMV, Epstein Barrinfection: 25-40% cancer: 25-40% (lymphoma, leukemia)undx: 10-15%

54

common abscess sites/sources

liver, spleen, kidney, brain, bonegall bladder (cholecystitis)UTIdental abscess paranasal sinuses

55

big tx no no with FUO

NO STEROIDSmasks fever, exacerbates infectious process

56

anion gap + FUO

Na - (CO2 + Cl)normal: 10 - 1216+ -- losing bicarb or retaining H

57

fever 101+ tx

NSAID: naproxen 250 mg BIDget blood cultures first - remember, can take 3 to 5 days to grow

58

when to admit FO

1. appears “toxic”2. declining rapidly with / without weight loss3. neutropenic (chemo)4. s/p transplant within 6 mo

59

PIs, NNRTIs - interactions

metabolized by Cyp450 system, can be inhibitor, inducer, and substrate

60

Ritonavir, Cobicistat - interactions

avidly bind Cyp34A enzyme & can yield very high levels of competing compounds

61

*HIV drugs: key drugs resulting in interactions*

Versed
Statins
Cafergot
Rhythmol
Viagra
Rifampin
Fluticasone

62

viral load & CD4 count: goals & use

viral load
- monitor this value!
- goal: undetectable @ under 20 - 75 copies/mL

CD4 count
- AIDS defining: under 200/uL (level at which ↑ risk opportunistic infection)
- reference range: 500 - 2000 cells/uL

63

HIV: ELISA

enzyme-linked immunosorbent assay - rapid test

most commonly used screening method

64

HIV: western blot

most widely accepted confirmatory assay for detection of ab to HIV retrovirus

65

*kernig's sign*

straighten bent leg = pain
sign of meningitis

66

*brudzinski sign*

flex neck = flex knee
sign of meningitis