Infectious Diseases (5-10%) Complete Flashcards
(91 cards)
1
Q
CNS Infections: Meningitis vs Encephalitis
Meningitis
Predominantly starts with ______, ______, and ______ and can get ______ later into the course.
Encephalitis
Predominantly starts with _____ and _____ and can get _____, _____
A
CNS Infections: Meningitis vs Encephalitis
Meningitis
It predominantly starts with headache, neck stiffness, and fever and can get altered LOC later into the course.
Encephalitis
Predominantly starts with altered LOC/mental status and fever and can get seizures, focal neurological
changes associated.
2
Q
Meningitis:
Most sensitive sign?
A
Jolt accentuation – high sensitivity (97% in one study)
3
Q
Meningitis:
Most specific sign?
A
Kernig’s and Brudzinski’s signs – high specificity, poor sensitivity
4
Q
Basal skull meningitis:
– _________, _______ signs
– Organisms: Think _____, _____, _____, _____, _____
A
Basal skull meningitis:
– + CN palsies, long-tract signs
– Think TB (LEPTOMENINGEAL ENHANCEMENT), Listeria, Cryptococcus, Syphilis, Lyme in correct host
5
Q
Suspicion for Bacterial Meningitis:
When to do CT head?
A
6
Q
Individual CSF predictors for bacterial meningitis each with > 99% certainty:
- Glucose _____________
- CSF: blood glucose _____________
- Protein _____________
- WBC _____________
- PMNs _____________
A
Individual CSF predictors for bacterial meningitis each with > 99% certainty:
- Glucose < 1.9 mmol/L
- CSF: blood glucose < 0.23
- Protein > 2.2 g/L
- WBC > 2000 cells/mL
- PMNs > 1180 cells/mL
7
Q
Meningitis:
Age 18-50:
Common bacterial pathogens?
Antimicrobial Rx - Empiric?
Age > 50 or immunocompromised:
Common bacterial pathogens?
Antimicrobial Rx - Empiric?
A
8
Q
Meningitis: Antibiotic, and treatment duration
- S. pneumoniae?
- N.meningitidis
H. Flu - L.monocytogenes
A
9
Q
Steroids in Meningitis
Only helpful in __________
Dose?
Do not start if _____________
A
Only helpful in S. pneumoniae (50% reduction in mortality/morbidity)
Dose? Dexamethasone 10 mg IV q6h for 4 days PRIOR TO or WITH the first dose of antibiotics
Do not start if antibiotics have already been given to the patient
10
Q
Neisseria meningitis – CHEMOprophylaxis
Who?
____________
____________
____________
____________
____________
____________
When?
____________
What to give?
____________
OR ____________
OR ____________
A
Who?
– Household contacts
– Persons sharing sleeping arrangements
– Persons who have direct nose/mouth contamination w oral/nasal secretions (Kissing)
– Children and staff in childcare or nursery
– HCWs who have had intensive unprotected contact (without wearing a mask) (eg. intubating, resuscitating, closely examining the oropharynx)
– Airline passengers sitting immediately on either side of the case (but not across the aisle) when total time on aircraft > 8 hours
When?
– Within 10 days usually
What to give?
– Ciprofloxacin 500mg PO X 1 dose (increasing resistance concern)
– OR ceftriaxone 250mg IM X 1 dose
– OR rifampin 600mg PO BID X 2d
11
Q
N. meningitis – IMMUNOprophylaxis
Who?
____________
____________
____________
____________
What to give?
____________
A
Who?
– Household contacts of a case of invasive
meningococcal disease (IMD)
– Persons sharing sleeping arrangements with a case of IMD
– Persons who have direct nose/mouth contamination
with oral/nasal secretions of a case with IMD
– Children and staff in contact with a case of IMD in
childcare or nursery school facilities
What to give?
– Meningococcal vaccine (Men-C-ACYW or 4CMenB can be considered)
- If more than one year since the last meningococcal vaccine, then vaccinate again
12
Q
IE Workup:
Diagnostic workup
– at least ___ sets of blood cultures prior to _______
– Initial ____ for everyone
A
Diagnostic workup
– at least 2 sets of blood cultures prior to antibiotics (3 in 2015 IE statement)
– Initial TTE for everyone
13
Q
TEE
Class I indications?
A
- TTE nondiagnostic or
- IE complications suspected or
- intracardiac leads
(TEE widely used these are just the Class I – eg consider if staphylococcal, enterococcal, fungal infections)
14
Q
IE – Diagnosis
A
15
Q
IE – Antibiotic Treatment:
- MSSA native valve
- MSSA Prosthetic valve
- MRSA native valve
- MRSA prosthetic valve
- CNST native
- CNST prosthetic
- Streptococcus viridans
Duration of treatment?
A
16
Q
In patients with _____-sided IE caused by Streptococcus, E. faecalis, S. aureus, or CNST deemed stable by the multi-D team on IV antibiotics
– ____ before the switch to oral therapy
– Follow-up ____ can be performed 1-3 days before the completion of the abx course
A
In patients with left-sided IE caused by Streptococcus, E. faecalis, S. aureus, or CNST deemed stable by the multi-D team on IV antibiotics
– TEE before the switch to oral therapy
– Follow-up TEE can be performed 1-3 days before the completion of the abx course
17
Q
Infective Endocarditis:
CLASS I Surgical Indications
A
18
Q
IE – Class II Surgical Indications
A
19
Q
IE - Prophylaxis;
Patient population
______________________ (Not indicated for ______)
______________________
______________________
______________________
Procedures
______________________
______________________
______________________
NOT FOR __/___/___ procedures
Regimen?
______________________
A
20
Q
CAP - Pathogens:
Most common?
Severe disease?
Post-influenza pneumonia?
A
21
Q
CAP – Outpatient Treatment
- Healthy outpatients without comorbidities or risk factors
________________________
________________________
________________________ - Outpatients with comorbidities
________________________
________________________
A
22
Q
CAP – Inpatient Treatment
- Inpatients, non-severe, without risk factors for MRSA or PsA: _________________
- Inpatients, severe CAP, without risk factors for MRSA or PsA: _________________
- Aspiration Pneumonia
- What about Legionella?
A
23
Q
CAP:
- Duration of treatment? _______________
- Steroids? _______________
- Influenza?
– __________ if hospitalized regardless of the duration of symptoms
A
24
Q
HAP/VAP:
Empirical Treatment? ___________________
Duration of treatment? ___________________
A
25
Diarrhea: Diagnosis
• Stool cultures:
for __________, __________, __________, __________, __________ in patient with diarrhea AND:
– __________
– __________
– __________
– __________
– __________ or __________
– (__________ in large volume rice water stools)
• Stool cultures:
for Salmonella, Shigella, Campylobacter, Yersinia, STEC in patient with diarrhea AND:
– Fever
– Bloody or mucoid stools
– Severe abdominal pain
– Sepsis
– Immunocompromise or outbreak exposure
– (V. Cholerae in large volume rice water stools)
26
Diarrhea: Diagnosis
C. difficile testing in patients with:
– __________
– Work in __________/__________ or __________
– __________ syndrome
– __________ flare
C. difficile testing in patients with:
– Recent antibiotics
– Work in healthcare/LTC or prison
– Compatible syndrome
– IBD flare
27
Diarrhea: Diagnosis
Blood cultures in patients with:
– __________
– __________
– Suspicion of __________
Blood cultures in patients with:
– Immunocompromise
– Sepsis
– Suspicion of enteric fever
28
Diarrhea: Diagnosis
Stool for Ova and Parasites in patients with:
– Diarrhea __________ days
– __________
– __________
– *Increased yield if ordered __________
– Repeat up to __________ to increase yield if high suspicion
Stool for Ova and Parasites in patients with:
– Diarrhea ≥ 14 days
– Immunocompromise e.g. HIV
– Travel
– *Increased yield if ordered daily x 3 days*
– Repeat up to 3x to increase yield if high suspicion
29
Diarrhea - Treatment
• Empiric therapy in adults with bloody diarrhea not recommended UNLESS:
1. _________________
2. _________________
3. _________________
Empiric therapy in adults with bloody diarrhea not recommended UNLESS:
1. Sick immunocompetent patients with bacillary dysentery (frequent scant bloody stools, abdominal pain, tenesmus, fevers), suggestive of Shigella
2. Recent travel with high fever (≥ 38.5) and/or sepsis
3. Sick immunocompromised patients
30
Diarrhea - Treatment:
Empiric antibiotic choice: __________ or __________
Empiric antibiotic choice: ciprofloxacin or azithromycin
31
Diarrhea - Treatment:
First choice:
1. Campylobacter: _____________________
2. S. enterica typhi or paratyphi: _____________________
3. Shigella: _____________________
4. Vibrio cholerae: _____________________
5. Yersina enterocolitica: _____________________
6. Non-typhoidal S. enterica, STEC (inc. O157): _________
32
C. difficile Infection (CDI) Diagnosis
Testing:
– Stool ____________ test - combinations
• ____________
• ____________
– ____________ on colonoscopy
Testing:
– Stool toxin test - combinations
• EIA for GDH, toxin
• NAAT PCR for toxin
– Pseudomembranes on colonoscopy
33
C. difficile Infection (CDI) Diagnosis
Criteria for severe C. difficile:
– WBC _______ OR serum Cr ____ x premorbid level
Criteria for severe C. difficile:
– WBC > 15 OR serum Cr 1.5 x premorbid level
– Other risk factors: Age > 65, immunosuppression, T > 38, Albumin < 30
34
C. difficile Infection (CDI) Diagnosis:
Fulminant C. difficile:
– ________, ________, ________, ________, toxic megacolon (colon dilation >__________)
Fulminant C. difficile:
– Sepsis, Shock, Ileus, perforation, toxic megacolon (colon dilation >6cm)
35
C. difficile Infection
First Episode Treatment:
1.1st episode (non-fulminant)
_______________________
_______________________
2. 1st episode (Fulminant)
_______________________
36
C. difficile Infection Recurrence Treatment:
1. First relapse (Within _______ months of previous infection)
_______________________
_______________________
_______________________
2. ≥2nd relapse
_______________________
_______________________
_______________________
37
Typhoid is common in __________ Asia.
Presentation includes __________, “__________ spots”, __________ pain and can develop __________.
__________ is the most common presentation but can present with __________.
The preferred treatment, particularly in inpatients, is __________.
Typhoid is common in southeast Asia.
Presentation: includes fever, “rose spots”, abdominal pain, and can develop hepatosplenomegaly.
Constipation is the most common presentation but can present with diarrhea.
The preferred treatment, particularly in inpatients, is ceftriaxone.
38
Intraabdominal Infections (IAIs)
• __________ is #1 principle of management
– _________ if possible, _______ otherwise.
– Collections _____ cm or smaller can be attempted to be managed with antibiotics alone
• Initial antimicrobial coverage
Community-acquired, no previous hospitalization (Organisms: _____, _____) ->
1. __________ or __________ PLUS __________
(OR)
2. Amox-Clav
– Healthcare-associated or critically ill (Organisms: __________) ->
1. __________ OR
2. __________ OR
3. __________ OR
4. __________ PLUS __________
• __________ coverage for healthcare-associated or severe biliary infection
6. Intraabdominal Infections (IAIs)
• Adequate source control is #1 principle of management
– Percutaneous if possible, laparotomy otherwise.
– Collections 3cm or smaller can be attempted to be managed with antibiotics alone
• Initial antimicrobial coverage
Community-acquired, no previous hospitalization (E. coli, B. fragilis) ->
1. Ceftriaxone or Ciprofloxacin PLUS metronidazole
(OR)
2. Amox-Clav
– Healthcare-associated or critically ill (Pseudomonas coverage) ->
Piptazo, meropenem, ceftazidime OR cipro PLUS metronidazole
• Enterococcal coverage for healthcare-associated or severe biliary infection
39
Genitourinary Infections:
UTI:
Do NOT treat asymptomatic bacteriuria UNLESS:
– _________________________
– _________________________
Do NOT treat asymptomatic bacteriuria UNLESS:
– Pregnant
– Urologic procedure with mucosal transection
40
UTI – Empiric Treatment
First-line treatments and duration:
1. Acute Simple Cystitis
________________________
________________________
________________________
2. Complicated UTI OR Pyelonephritis (Oral)
________________________
________________________
3. Complicated UTI OR Pyelonephritis (IV)
________________________
________________________
41
Prostatitis:
• Do not treat if asymptomatic unless _____________, _______ or _______
• Do not treat if asymptomatic unless elevated PSA, planning for biopsy or infertility
42
Prostatitis:
Acute Prostatitis:
Presentation? _____________
Diagnosis? _____________
Antibiotics? _____________
Duration of antibiotics? _____________
Chronic Prostatitis:
Presentation? _____________
Diagnosis? _____________
Antibiotics? _____________
Duration of antibiotics? _____________
Acute Prostatitis:
Presentation: Fever, dysuria, pelvic pain, tender, and
edematous prostate
Diagnosis: – Obtain urinalysis + culture prior to abx
– Abx – empiric piptazo, 3rd gen ceph, FQ
– Duration 2-4 weeks
• Chronic:
Presentation? Subtle. Recurrent UTIs, obstructive symptoms.
Diagnosis: – Ucx with prostatic massage
– Abx – FQ or TMP-SMX based on susceptibility
– Duration
4-6 weeks if FQ
8-12 weeks if other abx
43
Gonorrhea/Chlamydia Treatment:
Gonorrhea Treatment:
Anogenital or Pharyngeal: _____________
For DGI: _______________________________
Test of cure ______ weeks after treatment for all infections (PHAC)
Chlamydia Treatment
Anogenital or Pharyngeal: _____________
For LGV: ___________________________ for ___ days
Test of cure:
Gonorrhea Treatment:
Anogenital or Pharyngeal:
Ceftriaxone 250mg IM x 1 (Alt: Cefixime 800mg PO x 1)
PLUS
Azithromycin 1g PO x 1 (Alt: Doxycycline 100mg PO BID x 7d)
For DGI: Ceftriaxone 1-2g IM/IV q24h x 7 days
Test of cure 2 weeks after treatment for all infections (PHAC)
Chlamydia Treatment
Anogenital or Pharyngeal:
Azithromycin 1g PO x 1 OR Doxycycline 100mg PO x 7 days
For LGV: Doxycycline 100mg PO BID x 21 days
Test of cure:
Not routinely done
Indications for TOC (3-4w after
treatment) :
- LGV
- Unclear compliance
- Alternative regimen
- Pregnancy
44
Syphilis treatment:
1. PRIMARY, SECONDARY, EARLY LATENT: __________
2. LATE LATENT or UNKNOWN DURATION, TERTIARY
SYPHILIS: __________
3. NEUROSYPHILIS: __________
PRIMARY, SECONDARY, EARLY LATENT:
Benzathine penicillin G 2.4 mU IM x 1
LATE LATENT or UNKNOWN DURATION, TERTIARY
SYPHILIS: Benzathine penicillin G 2.4 mU IM weekly x3
NEUROSYPHILIS: Aqueous penicillin 4mU q4 hours IV x 14 days
45
Syphilis Test Interpretation
46
Skin and Soft Tissue Infections (SSTIs)
PURULENT: Organism?
NON-PURULENT
• Impetigo: Most often caused by ____________________
• Erysipelas: Most often caused by _________________, infecting _______________
• Cellulitis: Most often caused by _______________, infecting epidermis + dermis + SC tissue
• Necrotizing fasciitis
PURULENT: Staphylococcus aureus majority of the times
NON-PURULENT
• Impetigo: Most often caused by S. aureus
• Erysipelas: Most often caused by GAS, infecting epidermis + dermis
• Cellulitis: Most often caused by GAS, infecting epidermis + dermis + SC tissue
• Necrotizing fasciitis
47
Purulent (Furuncle/Carbuncle/Abscess)
– __________ and __________ should be performed
Empiric treatment:
1. Moderate infection?
2. Severe infection?
Purulent (Furuncle/Carbuncle/Abscess)
– I&D and C&S should be performed
48
Managing SSTIs: Non-Purulent
Non-Purulent (Impetigo/Erysipelas/Cellulitis) – Think _____________
Antibiotic treatment:
1. Mild severity
2. Moderate severity
Duration of antibiotics:
Generally, ____ days, extend up to ___ days if no improvement at completion (not if simply persistent _________)
Non-Purulent (Impetigo/Erysipelas/Cellulitis) – Think Strep!
49
Necrotizing Fasciitis (NF):
Presentation? ___________________________________________
First step? ___________________________________________
Empiric antibiotics treatment? __________________________
– Consider ________ if shock or pre-operative
Types? _________________________________________________
_________________________________________________
50
Toxic Shock Syndrome (TSS):
Organism: _________, sometimes __________ – tampons, nasal packing
Diagnostic Criteria?
Management?
• __________ and __________ precautions*
• Antibiotics: __________ PLUS __________
• Chemoprophylaxis – __________ x __________days (__________ if PCN allergy)*
Organism: Group A Strep, sometimes S. aureus – tampons, nasal packing
51
Osteomyelitis
Patient Population and Organisms
All patients: ____________________________________________
Foreign body, prosthetic infection: _____, _____
Diabetes: _____, _____, _____
Immunocompromised: _____, _____, _____
Patient Population Organism
All patients = S. aureus
Foreign body, prosthetic infection = CNST, Cutibacterium acnes
Nosocomial = Pseudomonas, Enterobacterales, Candida
Diabetes = Streptococcus, Gram-negative bacilli, anaerobes
Immunocompromised = Candida, Aspergillus, Mycobacterium
52
Non-Vertebral Osteomyelitis (w/o hardware)
- Empiric Therapy?
- Duration of treatment?
__________ weeks from the last debridement if a residual infection
__________ post complete source control
Empiric Therapy?
Ceftriaxone +/- Vancomycin (if MRSA risk factors) +/- Metronidazole (if sacral). Tailor based on organism if possible
Duration?
6 weeks from the last debridement if residual infection
48 hours post complete source control
53
Native Vertebral Osteomyelitis
• Etiology? ___________
• Microbiology: – Most common?
Diagnosis?
– ______________________________
– ______________________________
– ______________________________
- *If S. aureus bacteremia in prior 3 months, __________
Treatment:
1. if no sepsis/neuro compromise?
2. Empiric treatment?
3. Duration?
4. if neuro deficits, spinal cord compression,
progression/recurrence despite appropriate
antibiotics. Next step?
Native Vertebral Osteomyelitis
• Etiology: hematogenous seeding disc à bone
• Microbiology: – Most common: S. aureus*
Diagnosis:
– Blood cultures (50% Pos if S. aureus), biopsy
– ESR, CRP (sensitivity 94-100%)
– MRI (SN 97%, Sp 93%)
- *If S. aureus bacteremia in prior 3 months, biopsy likely not needed
Treatment:
– **Hold ABx until biopsy result** if no sepsis/neuro compromise (dx 50-60% of time with 1st bx)
– Empiric: ceftriaxone + vancomycin
– Duration: 6 weeks
– **Surgery** if neuro deficits, spinal cord compression, progression/recurrence despite appropriate antibiotics
54
Prosthetic joint infection?
Empiric treatment? ______________, add _______ for staphylococcal
When to remove the prosthesis?
Duration of treatment?
55
What type of foot ulcer is it?
– Neuropathic: __________, ________ appearance, ___________ ulcer, ________ pain, ____________ foot
– Arterial: _______ malleolus, ________, _______ pulses, ____________ foot
– Venous: _______ malleolus, ______ margins, ______________ depth, _____ pain, __________ dermatitis/________________
What type of foot ulcer is it?
– Neuropathic: Pressure points, punched-out appearance, deep ulcer, minimal pain, warm and dry foot
– Arterial: Lateral malleolus, dry and punctate, decreased pulses, cold and dry foot
– Venous: Medial malleolus, irregular margins, shallow depth, mildly painful, venous stasis dermatitis/lipodermatosclerosis
56
Diabetic Foot Wounds
Antibiotic Management:
• Mild-Mod, no recent Abx: target organism: __________ (ABX: _________)
• Severe Infection: _________ coverage (ABX: ____________)
• Duration: Dependent on ________: ________ weeks
• If source control (e.g. amputation) can ________
Diabetic Foot Wounds
Antibiotic Management
• Mild-Mod, no recent Abx: target aerobic GPC (E.g Cefazolin)
• Severe Infection: Broad spectrum coverage (E.g. CFtx + Metronidazole)
• Duration: Dependent on severity/bone involvement: 3-6 weeks
• If source control (e.g. amputation) can stop Abx
57
HIV – Initiation of ARV
ARV recommended for ________ with HIV, regardless of _______ to __________________ associated with HIV infection
ARV regimen should include ________ PLUS
______ OR
______ OR
______
First-line therapy?
ARV recommended for all individuals with HIV, regardless of CD4 count to reduce morbidity and mortality associated with HIV infection
ARV regimen should include TWO NRTIs PLUS
INSTI (Integrase Strand Transfer Inhibitor) OR
NNRTI OR
PI
58
HIV – OI Primary Prophylaxis:
PJP:
When to start?
Preferred agent?
Dapsone (check ______)
Dapsone OK for _____ allergy, NOT OK for ______________ to TMP-SMX
SJS/TEN is clear contraindication to re-challenge/continuation – give ____________
Bactrim and Pregnancy?
Continue prophylaxis until CD4 count stabilizes _____ for at least __________
When to start? CD4 < 200
Preferred agent? TMP/SMX 1 DS PO daily
Dapsone (check G6PD)
Dapsone OK for sulfa allergy, NOT OK for SJS/TEN to TMP-SMX
SJS/TEN is clear contraindication to rechallenge/continuation – give atovaquone
Prophylaxis with TMP-SMX is recommended during pregnancy – supplement with folic acid during the first trimester (NT defects)
Continue prophylaxis until CD4 count stabilizes >200 for at least 3 months
59
HIV – OI Primary Prophylaxis:
Toxoplasma (if Toxo IgG positive):
When to start?
Preferred agent?
MAC:
When to start?
Preferred agent?
Toxoplasma (if Toxo IgG positive):
When to start? CD4 < 100
Preferred agent? TMP/SMX 1 DS PO daily
MAC: NO LONGER RECOMMENDED
60
HIV – OI Treatment
PJP:
Moderate – Severe PJP: PaO2 _____ or A-a gradient _____
Preferred Rx? ______ 15-20mg/kg ____ x _____ days (any severity)
PLUS (FOR SEVERE ONLY): ___________
ALTERNATIVE RX: Moderate to Severe:
_____________
_____________
ALTERNATIVE RX: Mild to Moderate:
______________
______________
______________
Check G6PD prior to using ______ or ______
Moderate – Severe PJP:
PaO2 < 70 or A-a gradient ≥ 35mmHg
Preferred Rx? TMP-SMX 15-20mg/kg IV [TMP
component] x21 days (any severity)
PLUS (FOR SEVERE ONLY): Prednisone taper
ALTERNATIVE RX: Moderate to Severe
• Primaquine* + Clindamycin IV
• Pentamidine IV
ALTERNATIVE RX: Mild to Moderate
• Dapsone* + TMP
• Primaquine* + Clindamycin PO
• Atovaquone 750mg PO BID
Check G6PD prior to using dapsone or primaquine
61
HIV – OI Treatment:
Toxoplasma: Preferred treatment?
MAC: Preferred treatment?
Toxoplasma: Preferred treatment? Sulfadiazine + pyrimethamine (AI) x 6wk. NOT AVAILABLE IN CANADA SO WE USE TMP-SMX
MAC: Preferred treatment? Clarithromycin + ethambutol OR Azithromycin + ethambutol x12 mos
62
HIV in Pregnancy:
All HIV + women contemplating pregnancy need ______ and _________ prior to conception
• Intra-partum care
– If VL > 1000 copies/mL (or unknown) near delivery, give _________ and recommend ____________
– If VL suppressed, _______________________
Post-partum care
– If maternal VL suppressed within 4 weeks of delivery: Infant given ___________________
– If maternal VL not suppressed at birth, infant given ___________________
All HIV + women contemplating pregnancy need ARV and undetectable VL prior to conception
• Intra-partum care
– If VL > 1000 copies/mL (or unknown) near delivery, give IV zidovudine and recommend scheduled C/S
– If VL suppressed, no increased risk of vaginal delivery
Post-partum care
– If maternal VL suppressed within 4 weeks of delivery: Infant given AZT x 4wks (zidovudine (AZT))
– If maternal VL not suppressed at birth, infant given presumptive 3-drug ART
63
HIV, Pregnancy, and breastfeeding
Breastfeeding NOT recommended for mothers living with HIV in [US/Canada], as safe alternatives are available
64
Preventing HIV: PrEP
Regimen?
TDF/FTC 1 tablet daily (Tenofovir disoproxil and emtricitabine)
65
Preventing HIV: PEP (Post-exposure prophylaxis)
Start _______ within __________
Regimen? all for _____ days
- ___________________
Start as soon as possible, within 72hours
• Regimens – all for 21 days:
– TDF/FTC + Raltegravir
– TDF/FTC + Dolutegravir
– (TDF/FTC + Darunavir/ritonavir)
66
TB
Updated Terminology:
Latent TB = ____________
Active TB = ____________
Latent TB = TB Infection
Active TB = TB Disease
67
Latent TB – Diagnosis
• Two accepted tests: ____ and ____
• ____ can separate LTBI from active TB
TST – Tuberculin Skin Test:
• May be affected by BCG _____ infancy
• ___ patient visits
• Maybe (-) if ___________
IGRA – Interferon Gamma Release Assay:
• _____ affected by BCG
• Maybe (-) if ___________
Latent TB – Diagnosis
• Two accepted tests: TST and IGRA
• Neither can separate LTBI from active TB
TST – Tuberculin Skin Test:
• May be affected by BCG after infancy
• 2 patient visits
• Maybe (-) if immunosuppressed
IGRA – Interferon Gamma Release Assay:
• Not affected by BCG
• Maybe (-) if immunosuppressed
68
TST Result and Situation in which reaction is considered positive
0-4mm: __________________
5mm:_____________________
> or equal to 10mm: ___________
0-4mm: Generally considered negative
69
Latent TB – Treatment:
FIRST-LINE REGIMENS: __________________
SECOND LINE REGIMENS: __________________
FIRST-LINE REGIMENS:
Rifampin (4R), Daily, for 4 Months. Consider Rash, Drug Interactions
SECOND LINE REGIMENS:
Isoniazid (9H), Daily, 9 Months. Consider Hepatotoxicity, peripheral neuropathy
70
TB disease:
Total duration of treatment?
INTENSIVE PHASE (2 Months): RIPE
CONTINUATION PHASE (min 4 Months): INH/RMP
71
Latent TB and HIV
• Preferred regimens?
– _____________________________ for ____ months
– _____________________________ for ____ months
– _____________________________ for ____ months
• Preferred regimens:
– 3HP: **Weekly** INH + Rifapentine for 3 months
– 3HR: **Daily** INH + Rifampin for 3 months
– (Alternative: INH x 6-9 months)
72
Active TB and HIV
73
Fever in Returned Traveler: Post-Travel:
• Timing of fever / clinical symptoms
in relation to international travel
– Short incubation periods < 2 weeks =
___________
___________
___________
___________
___________
___________
– Longer incubation periods > 2 weeks =
___________
___________
___________
___________
___________
– Short incubation periods < 2 weeks = Malaria, Dengue, Chikungunya, traveller’s diarrhea, viral URTI, influenza
– Longer incubation periods > 2 weeks = Malaria, TB, hepatitis, HIV, enteric fever due to Salmonella spp.
74
Fever in Returned Traveler: Post-Travel:
• Pattern of fever
– Daily:
___________
___________
___________
___________
– Biphasic:
___________
___________
– Relapsing:
___________
___________
• Pattern of fever
– Daily: Malaria, traveler’s diarrhea, viral RTI, enteric fever
– Biphasic: Malaria, Dengue
– Relapsing: Malaria, enteric fever
75
Malaria – Diagnosis
Species:
• Plasmodium falciparum
– Can be severe
– Present within ___________
– Infects RBCs of ______ stages
• P. ovale and P. vivax
– May present ______ due to ________ in liver
Malaria – Diagnosis
Species:
• Plasmodium falciparum
– Can be severe
– Present within 3 months
– Infects RBCs of all stages
• P. ovale and P. vivax
– May present years later due to hypnozoites in liver
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Malaria – Diagnosis
Diagnostic Techniques:
1. ____________________ x ___, separated by at least __________ over 24 hour period
2. ____________
highest Sensitivity for ____________
Malaria – Diagnosis
Diagnostic Techniques:
Thick and thin blood smear x3, separated by at least 6 hours over 24 hour period
Rapid detection test (RDT)
highest Sensitivity for P. falciparum
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Malaria – Management:
Treatment of complicated Malaria?
Treatment to choose for uncomplicated P. falciparum Malaria?
Treatment to choose for uncomplicated
NON-P. falciparum Malaria?
If P. vivax or P. ovale, add _______ (check ___________ first) to treat the hypnozoite stage
Malaria – Management:
Treatment of complicated Malaria?
IV artesunate X 48h then PO
• Atovaquone-proguanil OR
• Doxycycline OR
• Clindamycin
Treatment to choose for uncomplicated P. falciparum Malaria?
CR (most common) Atovaquone-proguanil
Treatment to choose for uncomplicated
NON-P. falciparum Malaria?
CS (most common) Chloroquine
If P. vivax or P. ovale, add primaquine (check G6PD level first) to treat hypnozoite stage
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Candidemia management:
C. albicans/dubliniensis/tropicalis: Choose?
C. glabrata: Choose?
Management:
• Stable, no recent azole exposure → ________
• Unstable, neutropenic, or recent azole exposure → ________
• Pregnancy → ________
• CNS infections → __________
Duration:
Treat for _____ weeks from first negative blood culture (if no metastatic focus)
Candidemia management:
C. albicans/dubliniensis/tropicalis: Choose? Fluconazole
C. glabrata: Choose? Echinocandins
Management:
• Stable, no recent azole exposure →fluconazole
• Unstable, neutropenic, or recent azole exposure → echinocandin
• Pregnancy → amphotericin B
• CNS infections → amphotericin B +/-flucytosine
Duration:
Treat for two weeks from first negative blood culture (if no metastatic focus)
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Invasive aspergillosis:
Opportunistic infection seen in _______________
Diagnosis using _________, ________ or ______
Rx: _______
Duration:_________
Invasive aspergillosis:
Opportunistic infection seen in neutropenia/ cellular immunocompromise
Diagnosis using imaging (CT chest), indirect tests (galactomannan of serum and sputum), or direct tests (fungal culture or pathology)
Rx: Voriconazole x ≥6 weeks or longer
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Monkeypox Vaccination:
Indication for pre-exposure vaccination?
Indication for post-exposure vaccination?
81
Lyme Disease - Dx
82
Lyme Disease Management Pearls
• Do not test ________ patients
• Erythema migrans – _____ diagnosis, no need for ______
• No Lyme diagnosis without _________
• CNS Lyme disease (meningitis, radiculoneuritis, mono neuritis multiplex. C palsy, spinal cord inflammation) – Diagnosis by _____________
• Screen patients for Lyme disease if admitted for ________ in an appropriate epidemiologic setting
• Consider ___________ especially if ongoing fevers while on antibiotics
Lyme Disease Management Pearls
• Do not test asymptomatic patients
• Erythema migrans – clinical diagnosis, no need for serology
• No Lyme diagnosis without positive testing from an accredited reference lab (ie. Public Health Ontario)
• CNS Lyme disease (meningitis, radiculoneuritis, mononeuritis multiplex. C palsy, spinal cord inflammation) – Serum antibody testing (not PCR or culture of CSF)
• Screen patients for Lyme disease if admitted for acute myocarditis/pericarditis in an appropriate epidemiologic setting. Consider the need for admission (e.g. high grade HB, PR over 300, myopericarditis, symptomatic bradycardia)
• Consider coinfection (Babesia, Anaplasma), especially if ongoing fevers while on antibiotics
83
Lyme Disease – Rx
84
Immunomodulating Therapy Work-up
Workup before starting prolonged steroids?
85
Line Infections
Treatment
– ______ line if possible – ALWAYS for ________, ________, ________ (ie. ________, ________, ________)
– Directed therapy x ____ d (minimum ___ days if S. aureus / Candida)
Line Infections
Treatment
– Remove line if possible – ALWAYS for S.aureus, Candida spp, complicated infection (ie. thrombophlebitis, IE, OM)
– Directed therapy x 7d (minimum 14 days if S. aureus / Candida)
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Prevention Strategies:
VAP
CLABSI (Central Line-associated Bloodstream Infection)
CAUTI
87
Precautions
88
Precautions (2)
89
Tetanus prophylaxis in wound management
90
• Rabies post-exposure prophylaxis
91
Test
Test
