Infectious Diseases Flashcards
(59 cards)
1
Q
UTI Facts
A
- Cystitis: Infection of bladder (lower urinary tract)
- Pyelonephritis: Infection of the kidney (Upper UT)
- UTI is 2nd most common UT problem in children, behind enuresis
- 2nd only to URI as most common infection in adults
2
Q
UTI S/S
A
- Dysuria
- Frequency
- Urgency
- Suprapubic pain
- Hematuria
- Fever
- ** May be asymptomatic
3
Q
Pyelonephritis S/S
A
- May or may not have s/s or UTI
- Fever and chills
- Flank pain
- CVAT
- N/V
- Presentation may mimic PID
4
Q
Honeymoon Cystitis
A
- UTI during or shortly after a honeymoon or vacation
- Sexual activity can push bacteria back into urethra
5
Q
UTI Diagnosis
A
- 75-95% of cystitis and pyelo- is E. coli
- UA for pyuria - present in almost all women with acute cystitis or pyelo-
- WBC casts are pathognomic for pyelonephritis
- Hematuria is NOT a predictor of complication
6
Q
Enterobacteriaceae
A
- Group of gram-negative rods
- Salmonella, E. coli, Y. pestis, Klebsiella, and shigella
7
Q
Pyuria
A
- presence of pus (leukocytes and WBC)
- Alone is asymptomatic
8
Q
Urine volume
A
- Normal=600-1500mL
- Polyuria= >2L
- Oliguria= <200mL
9
Q
Polyuria causes
A
- DM
- DI
- Polycystic kidney
- CRF
- Diuretics
- IV NaCl or glucose
10
Q
Oliguria causes
A
- Dehydration
- Renal ischemia
- Acute tubular necrosis
- Obstruction
- ARF
11
Q
Urine color: Yellow
A
- Normal: Pale-light amber
- Milky: UTI
- Orange urine
- Meds: rifampin, sulfasalazine, phenazopyridine, some laxatives, some chemo
- Hx: Blockage, infection or Dz of the liver or bile duct –> Esp. w/ light colored stools, dehydration, fever
12
Q
Urine color: Blue or Green
A
- Blue or green:
- Dyes: food dyes, kidney/bladder tests
- Meds: amitriptyline, indomethacin, propofol
- Hx: Hypercalcemia, “blue diaper syndrome” (rare); UTI caused by pseudomonas
13
Q
Urine color: Orange
A
- Orange urine
- Meds: rifampin, sulfasalazine, phenazopyridine, some laxatives, some chemo
- Hx: Blockage, infection or Dz of the liver or bile duct –> Esp. w/ light colored stools, dehydration, fever
14
Q
Urine color: Dark amber or Tea-colored
A
- Liver dysfunction
- Increased muscle damage –> adverse Rx to statin, hepatitis, rhadomyolysis
- Food: Large amounts of fava beans, rhubarb, or aloe
- Meds: antimalarial drugs, metronidazole, nitrofurantoin, laxatives containing cascara or senna, and methocarbamol
15
Q
Urine color: red or pink
A
- blood
- secondary to UTI, BPH, neoplasms, cystic kidneys, long-distance running, renal calculi
- Food: beets, blackberries, and rhubarb
- Meds: rifampin, laxatives containing senna
Toxins: chronic lead or mercury poisoning
16
Q
Urine pH
A
- Normal: 4.6-8
- Acidic pH: Ketosis*, starvation, fever, acidosis, UTI E. coli
- Alkaline: strict vegetarian, systemic alkalosis, UTI proteus
17
Q
Urine Odor
A
- Normal: little to no odor
- Highly concentrated: ammonia
- Food/meds: asparagus, vitamins (esp. B6)
- Pathologic:
- acute liver failure, UTI, dehydration, DKA, metabolic disorders
- Maple sugar urine disease (Branched-Chain Ketoaciduria): body has trouble breaking down amino acids
- rectovaginal fistula
18
Q
Urine specific gravity
A
- Normal: 1.002-1.030
- High SG: Adrenal insufficiency; hepatorenal syndrome, CHF, dehydration; glycosuria; renal artery stenosis; shock; SIADH
- Low: DI, Renal failure; pyelonephritis, acute tubular necrosis, psychogenic polydipsia; hypoaldosteronism
19
Q
Prerenal ARF
A
- most common type of ARF
- can be a complication of almost any disease, condition, or medication that causes a decrease in the normal amoutn of blood volume
- Blood loss, hypotension, sepsis, ACE’s, NSAID’s, severe dehydration or burns, pancreatitis and liver Dz
- Tx: Correct the cause
- Often reverses itself in 2-3d
- If left untreated, can lead to intrinsic acute renal failure
20
Q
Renal Failure (AKA renal insufficiency or chronic renal insufficiency)
A
- 2 types:
1) Acute: 2/t acute kidney injury
2) Chronic: 2/t chronic kidney Dz
Detected by: - Elevated serum creatinine and decrease in GFR
- S/S: abnormal fluids levels; deranged acid-base balance; abnormal K, Ca, and Phos; hematuria; anemia
21
Q
Postrenal failure
A
- occurs when there is an obstruction, causing waste to build up
- Causes: Calculi; BPH; neurologic insult to the spinal nerve or neurologic disorders (Parkinson’s, CVA, MS); blood clots; neoplasm
22
Q
Proteinuria causes
A
- Prerenal: heavy exercises, fever, HTN, multiple myeloma, eclampsia
- Renal: acute/chronic glomerulonephritis, renal tubular dysfunction, polycystic kidney, nephrotic syndrome
- Post renal: acute/chronic cystitis, tuberculosis cystitis
23
Q
Microalbuminuria
A
- ** Cannot be detected by dipstick
- Detected by 24hr specimen
- Most common risks: DM & HTN
- Other risks: meds, trauma, toxins, infections, immune disorders, obesity, age >65, family Hx, preeclampsia, race & ethnicity
- Increased production of proteins can cause it: multiple myeloma, amyloidosis
- ** Orthostatic proteinuria: more proteinuria standing than lying
24
Q
Bence-Jones proteins
A
- A type of proteinuria usually associated with multiple myeloma
- detected in 24hr specimen
- can also occur with: amyloidosis; CLL; lymphoma
25
Creatinine
- Waste product of muscle metabolism
| - Produced from creatine, which is important in energy production
26
BUN
- Measures the amount of nitrogen in blood that comes from the waste product urea
- a by-product of protein metabolism, made in the liver, and excreted through kidneys
* High: HF, dehydration, high protein diet
* Low: Liver Dz or damage, 2nd or 3rd trimester of pregnancy
27
Microscopic exam of urine
* RBC's
- Inflammation, injury, or Dz in kidney or UT
- Can be a contaminant from hemorrhoids or menstruation
* WBC
- infection or inflammation
* Epithelial cells
- from bladder or external urethra
* Microorganisms
- bacteria, yeast, trichomonads
* Casts
- Identified by substances in them: RBC, WBC, hyaline casts
* Crystals
- formed in excessively alkaline or acidic urine, temperature also promotes formation
28
UA Dipstick analysis
- Glucose
- Ketones
- Hgb
- Leukocyte esterase: suggests WBCs in urine
- Nitrites: evidence of bacteria
- Bilirubin/urobilinogen: liver Dz or RBC breakdown
29
UTI Treatment
- TMP-SMX DS 160/800mg PO q12hr
* Bactrim, septra
* Avoid if prevalence of resistance is >20%
* Avoid if patient has taken TMP-SMX for cystitis in 3mo
- Nitrofurantoin: 100mg PO q12hr x 5d
* Macrobid, Macrodantin
- Fosfoycin trometamol: 3g PO x1 dose
* Monurol
* Not as effective as others
30
UTI Alternative treatment
If TMP-SMX, nitrofurantoin, and fosfomycin can not be used, move to fluoroquinolones
31
How to ease dysuria
- Phenazopyridine (Pyridium)
* Treats symptoms
* NO effect of infection
* Turns urine BRIGHT orange
* Take with lots of water
* Limits doses, may mask worsening infection
- Do not prescribe for more than 2 days
32
UTI Special populations
* DM more prone to UTI
* Pregnancy is a risk factor for UTI
* Due to the protective effect of estrogen, after menopause, women are more prone to UTI
33
UTI Follow-Up
* Urine Culture
| - Not needed unless patient has s/s after 48-72hrs of ABX or recurrent symptoms within a few weeks of treatment
34
Tickborne Dz Facts
- Anaplasmosis --> Black-legged Dz: Northeast, upper midwest, & Pacific coast
- Babesiosis --> Black-legged tick: Eastern US
- Ehrlichiosis --> Lone Star tick: south-central and eastern US
- Lyme Dz --> Black-legged tick: Northeastern, upper midwest, and pacific coast
- Rickettsia --> Gulf Coast Tick
- Rocky Mountain Spotted Fever --> American dog tick, Rocky mountain wood tick, & brown dog tick in US
- Souther tick-associated rash illness (STARI) --> lone star tick: southeastern and eastern US
- Tickborne relapsing fever (TBRF) --> soft ticks
- Tularemia --> dog tick, wood tick, and lone star tick: throughout US
- 36D Rickettsiosis --> Pacific coast tick
35
STARI
* STARI
- Rash: red, expanding bulls-eye lesion that develops around bite
- Appears within 7d of bite (shorter onset than lyme)
- c/o fever, fatigue, HA, and myalgia (less likely to have other s/s than lyme)
- Redness at bite does not necessarily indicate infection
- pts. more likely to recall bite
- Same Tx as lyme with faster recovery
36
Lyme Dz
- Erythema migrans ("bulls-eye" rash)
- -- Occurs in about 70-80%
- -- begins at the site of tick bite in 3-30d (~7d)
- Rash expands over several days (more likely to have multiple lesions than with STARI)
- May measure up to 30cm (12in)
- Usually feels warm to touch
- Rarely itchy or painful
- May appear on any part of body
37
STARI/ Lyme Tx
- Usually same regimen as lyme
1) Doxycycline 100mg PO BID x 12-21d
2) Amoxicillin 500mg PO TID x 14-21d
3) Ceftin (cefuroxime axetil) 500mg PO BID x 14-21d
* For Lyme with Neuro s/s:
- Ceftriaxone IV
- PCN IV
38
Lyme: Early Localized stage (3-30d after bite)
- EM Rash
- Fatigue, chills, fever, HA, muscle and joint aches, and lymphadenopathy (HIV, mono, both have similar s/s)
- REMEMBER, some people may not develop rash, and some people have tick bite with no lyme Dz
ns and dizziness
39
Lyme: Early disseminated stage (days-to-weeks after bite)
- If untreated, may spread systemically and produce intermittent s/s
- Additional EM lesions
- Severe HA and nuchal rigidity (meningitis)
- Pain and swelling in large joints
- shooting pains that may interfere with sleep
- Heart palpitations
40
Lyme: Late Disseminated stage (months-to-years after bite)
- ~60% have intermittent bouts of arthritis, with severe joint pain and swelling
- Large joints most often affected, particularly knees
- ~5% may develop chronic neurologic s/s
- -- shooting pains, numbness/tingling in hands or feet, & problems with short-term memory
41
Complications of Lyme: Post-treatment Lyme disease syndrome (PTLDS)
~10-20% have s/s that last for months-to-years after treatment
- S/S: muscle/joint aches; cognitive defects; sleep disturbance; fatigue
- May be caused by autoimmune disorder
42
Other complications of Lyme
- Chronic joint inflammation (knees)
- Lymphocytic meningitis
- Neuritis
- Myocarditis
- Transient AV blocks
- Neurologic s/s (fascial palsy, neuropathy)
- Cognitive defects (impaired memory)
43
Staphylococcus aureus facts
- Community-acquired MRSA (CA-MRSA, CMRSA)
- Hospital-acquired or health-care-acquired MRSA (HA-MRSA or HMRSA
- epidemic MRSA (EMRSA)
44
MRSA colonization
- Individuals can serve as a reservoir
- The anterior nares are the most common site
- If the nares are colonized, transmission can be spread more readily with URI or sinus infection
45
MRSA Treatment wound
- If a patient has a fluctuant or purulent SSTI:
* Should have I&D
* Send debrided material for culture
- I&D may be sufficient for abscess I&D + ABX
46
MRSA Treatment PO
- Unknown what is best choice
* Clindamycin 300-450mg PO q6-8hr
* TMP-SMX x2 DS tabs PO q12hr
* AVOID tetracyclines
* Linezolid ONLY for patients who can't take clinda or TMP-SMX
- -- Costly; high toxicity
47
Alternative MRSA Tx
- Rifampin
* Shows great activity vs. MRSA
* Used in combination with first line agents
* Use of rifampin alone is contraindicated (rapid development of resistance
- Fluoroquinolones
* ABSOLUTELY contraindicated
* Highly resistant to cipro
* MRSA fluoroquinolone resistance prevalent in many regions of US
48
Community-Acquired Pneumonia (CAP)
* Prevention
- Pneumococcal vaccine
- Influenza vaccine
* Who should get vaccine?
- 65+ yo
- High risk patients age 2-64; chronic illnesses, Heart, lung Dz, HIV, Immunocompromised, smokers
49
PNA Vaccine
* Pneumococcal polysaccharide (PPSV23)
- 1 or two doses between ages 19-64 with other risk factors
- 1 dose at 65
* Pneumococcal 13-valent conjugate (PCV13)
- 1 dose
50
CAP Fact Dx
- ONLY definitive way to diagnose PNA is with CXR
51
CAP Predicting mortality
- Pneumonia severity index (PSI) - more complex
- CURB-65 --> Assign one point for each variable
* Confusion
* Uremia: BUN >20
* Respiratory rate >30
* low Blood pressure: SBP 65
* **CRB-65 can be used in community
* ** Hospitalize for 2-3pts.
- SMART-COP --> CXR, tachypnea, O2 sats, RR, BP, Albumin, mental status, ABG
52
Reasons to admit for CAP
- Complication of PNA: sepsis; cavitary PNA;
- Exacerbation of underlying Dz: COPD
- Inability to reliably take meds or follow-up
- Multiple risk factors: COPD, heart dz, smoking, etc.
53
CAP most common organism
- Streptococcus pneumoniae
54
When to culture sputum?
- Before ABX given
- Hx of travel
- Hx of MRSA
55
CAP Epidemiology
- Hx of COPD or HIV=increased risk
- High fever >104, male sex, multilobar involvement, GI and neurologic abnormalities--> Associated with Legionella
- Presentation more subtle in older adults
* ** If AMS in older adult, always get UA and CXR
- REMEMBER influenza often overlaps
56
CAP Treatment: Outpatient
- Patient previously healthy, no ABX in last 3mo, & no risk factors for drug resistant S. Pneumoniae
* Macrolide
* ** Azithromycin 250mg: 500mg day 1, 250mg x4d; Clarithromycin or erythromycin
- -- Now commonly given 500mg Azithromycin PO qd x3d
* ** Doxycycline: BID
57
CAP Treatment: Outpatient with comorbidities
- A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin)
- A beta-lactam: (1st: high-dose amoxicillin, augmentin, 2nd: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, erythromycin)
58
CAP Outpatient follow-up
1) In office in 2-5d
| 2) Follow-up CXR in 6-8wk
59
Risk factors for Penicillin-resistant PNA
- Age >65, beta-lactam or macrolide therapy in past 6mo, ETOH, medical comorbidities, immunosuppressive illness or therapy; exposure to child in day care center
