Infectious Diseases

Question 1

Most common CAP vs Nosocomial pneumonia

Answer 1

CAP=Strep. Pneumo

Nosocomial=E. coli, Pseudo, and S. Aureus

Question 2

Atypical pneumonia common bugs and signs

Answer 2

Mycoplasma pneumonia, Chlamydia pneumonia, Coxiela, legionella, influenza

Dry cough, headache, sore throat
Normal pulse with high fever

Question 3

Legionella common demographics

Answer 3

Organ transplant recipeients, renal failure, patients with chronic lung disease, and smokers

Question 4

Nursing home residents common infection

Answer 4

Psuedomonas predilection for upper lobes

Question 5

CD4 count less than 500 infections

Answer 5

Tb, recurrent pneumonias, vaginal candidiasis, and herpes zoster

Question 6

CD4 count less than 200 infections and prophylaxis

Answer 6

pneumocystis jirovecii, cryptococcis (treat with IV amphotericin B plus flucytosine and chronic suppression with fluconazole, frequent lumbar punctures), histoplasmosis, or cryptospordiosis

Prophylaxis with TMP-SMX for pneumocystis one double strength tablet daily
P02 less than 70 and A-a gradient more than 35 have poor prognosis and should be given prednisone before TMP-SMX

Question 7

CD4 count less than 50 infections

Answer 7

Mycobacterium aviium intracellulare complex, disseminated histoplasmosis, CMV retinitis, colitis, adrenalitis, and esophagitis (IV ganciclovir, foooscarnet or cidofovir), CNS lymphoma (diagnose with stereotactic brain biopsy or with CSF for epstein barr virus)

Question 8

MAC with CD4 count less than 50 treatment

Answer 8

Clarithromycin, ethambutol, and rifabutin for weeks

MAC prophylaxis-clarithromycin 500 mg twice daily
Azithromycin 1200 mg weekly

Don’t need concomitant HAART therapy with prophylaxis once CD4 counts recover

Question 9

CD4 count less than 100

Answer 9

Prophylaxis with daily dosing of TMP-SMX

toxoplasmosis (sulfadiazine and pyrimethamine)

Question 10

CURB 65 guidelines

Answer 10

Confusion
Uremia >20 BUN
RR >30
BP less than 90/60
>65
More than 2= inpatient
More than 4=ICU

Question 11

Outpatient younger than 60 with pneumonia bugs and treatment

Answer 11

S. pneumo, Mycoplasma, Chlamydia or legionella

Treatment: Macrolides (azithromycin or clarythromycin)
or doxycycline

For 5 days

Question 12

Older than 60 or with comorbidiites outpatient pneumonia treatment

Answer 12

Fluroquinolone (levofloxacin, moxifloxacin)
Second or third cephalosporin
For 5 days

Question 13

Co morbidities to consider for pneumonia

Answer 13

Heart disease, sickle cell, pulmonary disease, diabetes, alcoholic cirrhosis

Question 14

Inpatient CAP treatment

Answer 14

Macrolides + cephalosporin

Or fluorquinolone

Question 15

ICU CAP treatment

Answer 15

Cephalosprin + macrolide (IV)

Cephalsoprin + flluoroquinolone

Question 16

Hospital acquired pneumonia (in hospital for >72 hours)

Answer 16

ceftazidime or cefepime
Imipenem
piperccillin/tazobactam

Question 17

Ventilator associated pneumonia diagnosis and treatment

Answer 17

Diagnosis: new inflitrate on CXR, purlent secretion from endotracheal tube
Bronchoalveolar lavage

Treatment: 3 drugs

1. ceftazdimine/cefipime OR pipercillin/tazobactam OR carbapenem (Pseudo)
2. Aminoglycoside or fluoroquinolone (Pseudo)
3. Vanco or linezolid (gram +)

Question 18

Lung abscess treatment

Answer 18

Postural drainage
Antibiotics:
Gram positive: ampicillin or amoxicillin/clavulanic acid, ampicillin/sulbactam, or Vanco
Anaerobes: clinda or metro
Gram negative: fluoroquinolone or ceftazidime

Continue until cavity is gone or until CXR have improved considerably

Question 19

Results of PPD test results and treatment

Answer 19

Used for latent TB not active TB (active TB order a sputum culture)
Positive if >15 mm in patients with no risk factors

High risk (high prevelance areas, immigrants, health care workers, nursing home residents, close contact with TB, alcoholics, diabetics)=10 mm positive

HIV, steroid users, organ transplant, close contact with active TB, radiographic evidence of primary TB=5 mm is positive

Never have had a PPD test before do another test in 1-2 weeks

If positive use chest X ray to rule out active disease-if excluded use 9 months of isoniazid (even if have had BCG vaccine)

Question 20

Treatment of TB

Answer 20

2 months of RIPE (or streptomycin) and then 4 months of INH and rifampin

Question 21

Ages and treatment of suspected meningitis

Answer 21

less than 4 weeks: aminoglycoside
Infants (less than 3 mos): cefotzxime +ampicillin +vanco
3 mos to 50 years: ceftriaxone or cefotaxime + vanco
greater than 50: ceftriaxone or cefotaxime+vanco+ampicilin
Impaired cellular immunity: ceftazidime +ampicilin +vanco

Aseptic is supportive

Question 22

Diagnosis and treatment of encephalitis

Answer 22

CSF PCR
MRI of brain-T2 signal in frontotemporal region=HSV encephalitis
EEG=tempral lobe discharges

Treatment: HSV=acycylovir for 2-3 weeks
CMV=ganciclovir or foscarnet

Question 23

Importance of HBeAg, HBsAg, anti-HBs, anti-HbC

Answer 23

HbeAg: indicates infectivity
HbsAg: earliest to arrive
anti-HBs-natural or vaccine induced immunity
Anti-HbC: present during window period

Question 24

diagnosis of Hep C

Answer 24

PCR detects viral load

Question 25

Diagnosis Treatment of botulism

Answer 25

Diagnosis: ID toxin in serum, stool or gastric contents (bioassay) gastric lavage if within several hours High suspicion=antitoxin Wounds=penicillin and wound cleansing

Question 26

Complicated UTI

Answer 26

extends beyond blader: pyelo, prostatits, urosepsis) Risks: men, diabetes, pregnancy, RF, history of pyelo, obstruction, catheter, resistant organism, immunocompromised

Question 27

Treatment of UTI

Answer 27

``` uncomplicated: TMP/SMX (bactrim): 3 days nitrofurantoin: 5-7 days Fosfomycin: single dose Ciprofloxacin: 3 days ``` Pregnant: ampicllin, amoxicciln or oral cephalosporins: 7-10 days Men: same as uncomplicated but for 7 days Recurrent: 2 more weeks of treatment and culture 2+ UTIs per year: TMP/SMx after sex or at first symptoms or low dose TMP/SMX for 6 months Phenzopyridine: urinary analgesic

Question 28

Treatment of Pyelonephritis

Answer 28

Uncomplicated TMP/SMX or fluroquinolone for 10-14 days Amoxcillin Single dose of ceftriaxone or gentamicn Ill, elderly, pregnant, unable to tolerate orals, urosepsis Hospitalize and give IV fluids Ampicillin plus gentamicn or cipro-parenterally Treat until patient is afebrile for 24 hrs then 14-21 day course Urosepsis: IV antibiotics for 2-3 weeks Recurrent: same organism: 6 week treatment dif. organism: 2 week treatment

Question 29

Treatment of acute and chronic prostatits

Answer 29

Acute: IV TMP/SMX if extremely ill Mild: TMP/SMX or fluoroquinolone or doxycycline for 4-6 weeks Chronic: fluroquinolone

Question 30

HPV treatment

Answer 30

ticholracetic acid, podophyllin, inqiquimoid, surgery

Question 31

Diagnosis and treatment of HSV

Answer 31

Diagnosis: Tzanc smear is quickest test shows multinucleated giant cells Culture of HSV is gold standard-swab base of ulcer Elisa- minutes to hours encephaltiis: PCR of CSF is gold standard, EEG prominent intermittent high amp with slower waves oral or topical acyclovir for 7-10 days Foscarnet for resistant or immunocompromised Disseminated: hospitalize and parenteral acyclovir

Question 32

When is syphilis not contagious?

Answer 32

late latent phase if serology has been positive for >1 year

Question 33

Diagnosis and treatment of syphilis

Answer 33

Diagnosis: start with VDRL or RPR if positive then do a FTA-ABS Test for HIV Treatment: Benzathine penicillin (one dose IM) if allergic doxycycline for 2 weeks Latent or tertiary: penicclin 3 doses IM once per week

Question 34

Chancroid diagnosis and treatment

Answer 34

haemphoilus ducreyi Diagnosis: painful genital ulcer, unilateral tender inguinal lymphadenopathy Rule out syphilis and HSV Treatment: azithormycin or ceftriaxone (IM) (one dose)

Question 35

Lymphogranuloma venereum

Answer 35

C. Trachomatis Painless ulcer, tender inguinal lymphadenopathy, constitutinal symptoms Can lead to perianal fissures, andretal stricture or elephantiasis of genitals Diagnosis: serology-complement fixation, immunofluorescnce Treatment: doxy for 21 days

Question 36

Pediculosis Pubis

Answer 36

Pubic lice diagnosis: examination of hair under the microscope Treatment: permethrin 1% shampoo (Elmite)

Question 37

``` Cellulitis:treatment Local trauma- wounds. abscesses Immersion in water Acute sinusitis ```

Answer 37

trauma-Strep. pyogenes wounds-S. aureus immersion-pseudo, aeromonas hydrophila, Vibrio vulnificus Sinusitis-H. influenza Treatment: Oxacililn/nafcillin or cephalosporin-IV until infection improves then 2 weeks of oral antibiotics

Question 38

Erysipelas

Answer 38

Cellulits confined to dermis and lymphatics Caused by Strep. pyogenes Fiery red, well demarcated, painful lesion High fever and chills Predisposing factors: lymphatic obstruction, local trauma, fungal infections, diabetes, alcoholism Complications: sepsis, local spread to subQ tissues, necrotizing fasciitis Treatment: IM or oral penicillin or erythromycin

Question 39

Tetanus treatment

Answer 39

Admit to ICU and provide respiratory support Diazepam for tetany Neutralize unbound toxin with passive immunization-give single dose of tetanus immune globulin (if large wound and unknown tetanus status, >10 yrs since boster or less than 3 Td) Provide active immunization with tetanus/diptheria toxoid Thoroughly clean and debride wounds with tissue necrosis Give metroniadzole or penicillin G If have greater than 3 doses of Td do not have to provide passive or active immunity

Question 40

Osteomyelitis diagnosis and treatment

Answer 40

Diagnosis: ESR and CRP useful in monitoring response to therapy Needle aspiration or bone biopsy: most direct and accurate means of diagnosis MRI: most effective imaging study Treatment: IV antibiotics for 4-6 weeks only after etiology is based on cultures Empircally: Penicillinase resistatn penicillin-oxacillin or 1st gen cephalosporin-cefazolin Aminoglycoside and B-lactam Ab if possilbility of gram- Surgical debridement

Question 41

Organisms and acute infectious arthritis

Answer 41

S. Aureus-most common overall Young sexually active-gonorrhea sickle cell, immunodefiency, IV drug abuse-salmonella, pseudo

Question 42

Diagnosis and treatment of acute infectious arthritis

Answer 42

Diagnosis Joint aspiration->50,000 WBC with 80% PMNs PCR of fluid if gonorrhea suspected Elevated ESR Elevated CPR-mointoring clinical improvement CT or MRI-sacroiliac or facet joints involved Treatment: Daily aspiration or surgical drainage Healthy adult: (S. aureus)-Parenteral, oxacillin and cephazolin for 4 weeks Immunocompromised or other gram-indications: parenteral ceftriaxone or aminoglycoside for 3-4 weeks tazobactam+pipercillin if pseudo Gonnorrhea: parenteral ceftriaxone until improvement then cipro for 3-10 days orally also doxy

Question 43

Diagnosis and treatment of Lyme disease

Answer 43

Diagnosis: Clinical-treat empirically IgM Abs peak 3-6 weeks after onset of symptoms Serologic studies: ELISA (serum IgG and IgM) during first month of illness Western blot ``` Treatment: Localized disease 10 days of antibiotics Early Lyme disease: Oral doxcycline-21 days Amoxicclin and cefuroxime if pregnant or less than 12 ``` facial nerve palsy, arthritis, or cardiac disease (30-60 days) of antibiotic therapy CNS: treat antibioticcs for 4 weeks

Question 44

Treatment of Rocky Mountain spotted fever

Answer 44

Doxycycline for 7 days orally or IV if vomiting CNS manifestations or pregnant: chloramphenicol

Question 45

Treatment of malaria

Answer 45

Chloroquine phosphate unless resistance is suspected (pretty much everywhere) Qunine sulfate and tetracycline or atovaquone-proguanil and mefloquine P. faliciparum (no remission of fever) may require IV quinidine and doxycycline P. Vivax and ovale may requrie primaquine phosphate for hypnozoites in liver Prophylaxis: mefloquine or chloroquine if not going to resistant areas

Question 46

Diagnosis and treatment of rabies

Answer 46

Diagnosis: virus or viral Ag in infected tissue Serum Ab titers Negri bodies histologically PCR detection of virus RNA Treatment Clean the wound thoroughly Wild animal bites: find animal capture and destroy them and send to lab for immunofluorescen of brain tissue Healthy dog or cat: capture animal and observe for 10 days Known exposure Passive immunization: Administer human rabies immunoglobulin into the wound and gluteal region Active immunization: administer antirabies vaccine in three IM doses into deltoid or thigh over a 28 day period

Question 47

HIV prophylaxis s/p needle stick

Answer 47

Tenofovir-emtricitabin, raltegravir for 4weeks | Serology: immediately, 6wk, 3m, 6m

Question 48

Candidiasis Treatment

Answer 48

oropharyngeal candidiasis: clotrimazole troches five times per day Nystatin mouthwas: three to five times per day Oral ketoconazole or fluconazole Vaginal: miconazole or clotrimazole Cutaneous: oral nystatin powder Systemic: amphotericin B or fluconazole or vorinconazole or caspfungin

Question 49

Treatment for leptospirosis

Answer 49

oral: tetracycline or doxycycline if severe IV penicillin G

Question 50

Diagnosis and treatment of cryptococcosis

Answer 50

Diagnosis: LP is essential if meningitis suspected Latex agglutiation detects cryptococcal Ag in CSF Tissue biopsy is characterized by lack of inflammatory response Treatment: amphotericin B with flucytosine for approx. 2 weeks followed by oral fluconazole

Question 51

Catheter related sepsis organisms

Answer 51

S. aureus and S. epidermidis

Question 52

Precautions for neutropenic patients

Answer 52

Reverse isolation precuations: positive pressure room, masks, and strict handwashing

Question 53

amount of time to wait after mono to play sports

Answer 53

3-4 weeks after symptoms onset