Lecture 3 (ID)- Exam 2 Flashcards
(183 cards)
1
Q
- What is infectious disease?
- What is pathogenicity?
- What is virulence?
A
- Infectious Disease is the invasion of microorganisms into a host which harm that host’s tissue and disrupts the normal health function, leading to illness. Can be transmitted to others.
- Pathogenicity – ability to cause disease, used to compare species
- Virulence – the degree or extent of pathogenicity of a microorganism, used to compare strains within a species
2
Q
What is transimission?
A
- Transmission – the spread of an infectious agent by means of direct or indirect contact between an infected host and a noninfected host
3
Q
What is direct and indirect transmission?
A
- Direct transmission – immediate transfer of the disease agent by direct contact between the infected and the susceptible individual (touching, biting, licking, kissing, sex); direct projection (droplet) via coughing or sneezing within 3ft
- Indirect transmission – airborne, vehicle borne, vector borne does not require physical contact ( sneezing, coughing, talking >3ft)
4
Q
What are the indirect transmission types?
A
- Airborne – microbial aerosols to respiratory tract
- Vehicle borne – contaminated material/objects (fomites) : bedding, counters, utensils, surgical instruments,
food, water. [Any disease can be transmitted via vehicle even if primary mode is direct] - Vector – any agent which transmits infection from one organism to another (ticks, mosquitos, food, water)
5
Q
- What is incubation?
- What is epidemiology?
A
- Incubation – period of time between exposure and onset of symptoms
- Epidemiology – how often disease occurs in population and why
6
Q
A
7
Q
Direct Detection/ Microscopy:
* wet mounts: what is needed to be done prior to exam, what is it used for? What are examples?
A
- No fixation prior to exam
- Used for large &/or motile organisms visualized without staining
- Example:
* Giardia trophozoites
* Amebic cysts, or eggs
8
Q
What diagnosis process is this?
A
Direct Detection/ Microscopy: Wet Mounts
9
Q
When are wet monuts with KOH preparation used? What does the prep look like?
A
- Trichomonas
- Fungus
- Yeast
10
Q
When do we use wet mount applications with enhancing stains? What does it look like?
A
India ink to visualize encapsulated cryptococci in CSF
11
Q
Dark-field Microscopy:
* What it is used to examine?
* Examined under what?
* How does spirochetes appear?
A
- To examine lesions (chancres, mucous patches, condyloma lata, skin rash) for presence of Treponema pallidum or Borrelia burgdoferi
- Examined under a dark-field microscope at X40 or X100 power
- Spirochetes appear as motile, bright corkscrews against a black background
12
Q
Gram stain
* Obtain what?
* Requires what? (2)
A
- Obtain a sample of exudate or body fluid, answer in minutes
- Requires collection with appropriate devices
- Requires filling out laboratory request forms
Do not collect, do the walls of the tissue
13
Q
What is the likely bacteria in this slide?
A
Gram Negative Diplococci (Neisseria Gonorrhea) with oil emersion high powered lens
seen in sexaul active with genital discharge
14
Q
What is the likely bacteria in this slide?
A
Gram Positive Cocci in Clusters (Staph or MRSA)
15
Q
What is the likely bacteria in this slide?
A
Gram + Bacilli, single & in chains (Bacillus anthracis )
16
Q
What is the likely bacteria in this acid fast stain? Why do we use acid fast stains?
A
Bacteria: Mycobacterium
* Detects organisms such as that retain carbol fuchsin dye after acid/organic solvation (pink or red)
17
Q
For mycobacterium TB: acid fast organism appear what?
A
Acid-fast organisms appear pink or red against blue background of counter stain
18
Q
What is a giemsa or writght’s stain of blood, what is it used for?
A
Intra-or extracellular parasites(e.g., Borrelia recurrentis, Plasmodium, Babesia (tick born), or Trypanosoma)
picture is plasmodium vivax (malaria)
19
Q
Immunofluorescent Stains:
* What does it detect?
* What are examples of bacteria?
* What can be performed?
A
- Detect viruses within cultured cells or tissue specimens (herpes virus, rabies virus) or to reveal fastidious bacteria in specimens
* Legionella pneumophilia
* Pnemocystis jiroveci (PCP carinii) - Antibody stain could be performed
20
Q
What biological stain is this?
A
Immunofluorescent Stain
21
Q
Culture and sensitivity:
* usually what?
* How longs does it take for bacteria and for mycobacteria/fungus?
* Requires collection with what?
A
- Usually the “gold” standard
- Takes hours to days (culture) for bacteria, weeks for mycobacteria/ fungus
- Requires collection with appropriate devices, temperature and culture medium
- Requires filling out laboratory request forms
22
Q
Culture and sensitivity
* What is the kerby-bauer method
* Reported as what?
* What is MIC?
A
- Antibiotic discs placed on culture plate (Kirby-Bauer Method)
- Reported as: sensitive, resistant, intermediary
- MIC is a “Minimum Inhibitory Concentration” of antibiotic needed to inhibit growth of bacteria
23
Q
Macroscopic Antigen Detection:
* What it is used to identify?
* _ tests
* Typical test for what?
A
- Identify protein or polysaccharide antigen
- Color tests
- Typical test for blood type
24
Q
Detection by Serology:
* look for what?
* Used for what organisms?
A
- Looks for antibodies in blood
- Used for fastidious organisms; answer in hours to days
* Viruses
* Syphilis
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Detection by Serology:
* What is a paired serology?
Can be "paired serology" with an initial "acute" titer followed by a
"convalescent" titer in 2 weeks to determine a rise in antibody to
specific organism
* IgM antibodies for acute infection
* IgG antibodies persist for months to years; only gives an indication of some past infection.
* Toxoplasmosis
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Detection by Molecular “Probes” (genetic material markers)
* Uses what? What bacteria is used for?
* Polymerase chain reaction (PCR) identifies what?
* What is less sensitive than a PCR? But what does it allow?
* Uses markers for genetic material (DNA/ RNA) in microorganism
* Gonorrhea/ chlamydia probes
* Polymerase chain reaction (PCR) identifies minute quantities in a sample
* In situ hybridization less sensitive than PCR but allows localization of agent in a tissue section
* Fluorescent microscopy
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Dark field microscopy is used to detect:
1. Mycobacterium
2. Treponema palidum
3. Neisseria
4. Trichomonas
5. Chlamydia trachomatis
2. Treponema palidum
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KOH preparation is best to detect:
1. Candida
2. Plasmodium
3. Pneumococcus
4. Trichomonas
5. Chlamydia
Candida and Trichomonas
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Temperature Definitions:
* Hypothermia:
* Normal:
* Lower when? higher when?
* Pyrexia:
* Hyperpyrexia:
* Hypothermia (< 95 F or 35 C)
* Normal 98.6 F (37 C)->Lower in AM/ higher in PM – diurnal cycle
* Pyrexia (> 100.4 F-38 C)
* Hyperpyrexia (>106 F or 41 C)
* Usually heat stroke-> direct temp, stimulents
## Footnote
Temp is most senstitive in the morning
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Fever:
* Abnormal elevation of body temperature due to what?
* Caused by what?
* Many _
* Abnormal elevation of body temperature due to change in hypothalamic thermoregulatory center
* Caused by a resetting of hypothalamic “set point” by prostaglandin's (PGE 2)
* What is MOA of NSAIDs-> PDA occulsion in preg
* Many causes-> systemic, allergic and infection
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Clinical Manifestations of Fever:
* Elevated what?
* What are generalized symptoms?
* What are chills?
* What are Rigors?
* Elevated body temperature
* Generalized symptoms: myalgias, arthralgias, anorexia, & somnolence-> “I feel like c^@$!”
* **Chills**- a sensation of cold occur with most fevers +/- shivering (happens more with higher higher)
* **Rigors**: profound chills associated with piloerection, chattering teeth & severe shivering from bacterial infections or influenza
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Clinical Manifestations of Fever
* What are sweats
* Increases what?
* May precipitate what in cardiac compromised?
* Alterations in what?
* When does delirium and convulsions happen?
* Sweats: fever “breaks” and activation of heat-loss mechanisms
* Increases HR & O2 demand fever
* May precipitate HF in cardiac compromised failure-> CHF
* Alterations in mental status
* Delirium & convulsions: very young, elderly & debilitated
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**Hyperpyrexia**
* What is the temp?
* When does it happen? (4)
* Fever > 41.5°C (106. 7°F)
Causes:
* Severe infections
* CNS hemorrhages
* Heat stroke
* Substance abuse
* Reaction to anesthesia
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Hyperthermia:
* What is Exogenous Heat Exposure
* What is endogenous hear production?
Exogenous Heat Exposure
* Work or exercise in hot environments produces heat faster than peripheral mechanisms can lose it
Endogenous Heat Production
* Can cause hyperthermia despite physiologic & behavioral control of body temperature
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What are the differenital diagnosis of true fever?
* **Infection**
* **Immune phenomena/ collagen vascular disease**
* Vascular inflammation or thrombosis
* Infarction or trauma
* Granulomatous diseases (Sarcoid)
* IBD
* **Neoplasms** (Hodgkin's disease, lymphoma, leukemia, RCC & hepatoma)
* Acute metabolic disorders (thyroid storm, Addisonian crisis)
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Fever of Unknown Origin (FUO):
* What are the classifications (5)?
1. Classic FUO -> viral/ bacteria
2. Nosocomial FUO -> in hospital
3. Neutropenic FUO-> no immune system, chem therapy
4. HIV FUO
5. Undiagnosed or factitious-> faking or undiagnosed
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Fever of Unknown Origin:
* What is the etiology of developing counteries?
* What is the etiology of developed countries?
* In developing countries – infection is the primary etiology
* In developed countries – non-infectious inflammatory disease more common
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FUO: classic
* What is the criteria?
* T= 101° F on several occasions for at **least 3 weeks** with
* 3 outpatient visits or
* 3 days of "intelligent & invasive" ambulatory investigation and at least 2 days' incubation of cultures
* 3 days in hospital without elucidation of cause
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FUO-Nosocomial
* What is the criteria for nosocomial?
* T =101°F or > develops on several occasions in **hospitalized** patient receiving acute care & infection was not manifest or incubating on admission.
* 3 days of investigation, and at least 2 days' incubation of cultures
40
FUO-Neutropenic
* What is the criteria?
* **T =101°F** on several occasions and a neutrophil count <500/ L or is expected to fall to that level in 1 to 2 days
* Cause not identified after 3 days of investigation, including at least 2 days' incubation of cultures
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FUO-HIV associated
* What is the criteria?
* **T =101°F** on several occasions for >4 weeks for outpatients or >3 days for hospitalized patients and HIV + and not taking antiviral meds
* Appropriate investigation over 3 days, including 2 days' incubation of cultures, revealing no source
42
What are the infections that can make undergraduates die fast?
## Footnote
Wind, Water, Wound, Walking, and Wonder Drugs, Wing/Waterway and (W)abscess.
43
What are the causes of FUO lasting more than six months?
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Workup of FUO:
* What do you need to collect?
* Multiple blood samples (3-6) including samples for anaerobic culture, cultured for at least 2 weeks (periprosthetic infections)
* Blood, urine, or CSF tested/ stained/ cultures
* Perform CT/ MRI first before spinal tap
* PE & laboratory examination to R/O abscesses, hematomas, or infected foreign bodies
* Liver biopsy, even with normal LFT’s if Dx uncertain & specimens cultured for mycobacteria & fungi
* Bone marrow aspiration & biopsy for histology & culture
* Peripheral blood smear for Plasmodium, Babesia, Trypanosoma, Leishmaniasis, & Borrelia
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Work up of FUO
* What labs?
* What scopy exams?
* Repeat and do what?
* ESR, ANA, Antineutrophil cytoplasmic antibody (ANCA), RF, serum cryoglobulins
* Flexible colonoscopy/ endoscopy to R/O CA (cause of FUO & escapes detection by US & CT)
* Repeat CXR if new symptoms
* CT Chest & Abdomen
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Work up of FUO:
* What do you need to US?
* What do you need to do with patients over 50
* Exploratory what?
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Work-up of Nosocomial FUO:
* What is the source of infection?
* Sites of what?
* C. diff may be assoiciated with what/
* ~ 25% of patients have what?
* ~ 20 % of cases of nosocomial FUO are what?
* > 50% of patients with nosocomial FUO infected
* IV lines, septic phlebitis, & prostheses
* Sites of occult infections (sinuses of intubated patients)
* Clostridium difficile colitis may be associated with fever & leukocytosis before diarrhea (usually at least 3 days following admission)
* ~ 25% of patients have non-infectious cause (cholecystitis, DVT, PE, drug fever, transfusion reactions, ETOH/drug withdrawal, adrenal insufficiency, thyroiditis, pancreatitis, gout, & pseudogout)
* ~ 20 % of cases of nosocomial FUO undiagnosed
50
What is still's disease? What does it respond well to?
* Still's disease is inflammation with high spiking fevers, evanescent (transient) salmon-colored rash and/or arthritis Still's disease was first described in children, but it can occur in adults (adult-onset Still's disease).
* Responds well to NSAIDs
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Nosocomial FUO:
What is the Empirical antibiotic coverage for nosocomial FUO?
vancomycin for MRSA and broad-spectrum gram-negative coverage with piperacillin/tazobactam (Zosyn®), ticarcillin/clavulanate (Timentin®), imipenemicilastatin(Primaxin®), or meropenem (Merrem®)
52
Neutropenic FUO:
* Susceptible to what?
* What is the treatment?
* Susceptible to: focal bacterial & fungal infections, bacteremic infections, catheter infections & perianal infections
* Candida, Aspergillus, HSV or CMV
* Vancomycin plus ceftazidime or imipenem for bacterial sepsis empirical coverage
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What are the causes of HIV associated FUO?
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W/U of HIV-Associated FUO:
* What do you need to do?
* What type of x-ray
* > 80% of HIV patients with FUO are what?
* Consider what?
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Treatment of FUO’s:
* Continued what?
* Avoidance of what?
* What trials?
* Remember what?
* Continued observation & examination to identify source
* Avoidance of "shotgun" empirical Rx unless somewhat certain for source um
* Therapeutic medication trials
* Remember TB
* +PPD skin test or if granulomatous hepatitis
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Treatment of FUO’s:
* Response of what?
* Colchicine for what?
* When is prognosis generally good?
* Response of RF & Still's disease to ASA & other NSAID's
* Colchicine for familial Mediterranean fever
* When no underlying source of FUO is identified after prolonged observation (> 6 months), prognosis is generally good
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What groups of people do you need to be careful of infections without fevers?
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What is observed in patients with hypothermia?
* Hypothermia is observed in patients with septic shock
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Reasons not to treat fever that may aid diagnosis?
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What are relapsing fevers? What is an example of bacteria that causes this?
* Febrile episodes separated by intervals of normal temperature
* Borrelia infections (Lyme disease) (several day afebrile periods)
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What are tertian fevers? What bacteria causes this?
* Fever Paroxysms on 1st & 3rd days
* Plasmodium vivax
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What is quartan fevers? What is an example of bacteria that causes it?
* Paroxysms on first & fourth days
* P. malariae
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What is pel-ebstein fever? What is an example that causes it?
* Lasting 3 to 10 days then afebrile periods of 3 - 10 days
* Hodgkin's disease / lymphomas
| One week good, one week bad
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What is cyclic neutropenia fever?
* Every 21 days with neutropenia.
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What are indications & Regimens to Treat Fever
* Not certain fever helps
* Reduces HA, myalgias, & arthralgias
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Decision to Treat Fever:
* Reduce what? Increase what?
* Most fevers are what?
* What is a potent immunosuppressant?
* Reduce elevated set point and increase heat loss
* Most fevers are self-limited infections, viral
* PGE2 a potent immunosuppressant
– NSAID increases the anti-influenzal AB level (preferred over tyanol in flu)
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* When actaminophen preferred?
* What do you use in children and why
Acetaminophen preferred
* NSAIDs and ASA cause GI symptoms
* Blocks PGE2 centrally
In children, use acetaminophen
* No ibuprofen until 6mo old
* ASA increases risk of Reye's syndrome
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Indications & Regimens to Treat Fever
* What drugs are more effective together?
* What are different ways of giving the drug
* What is indicated for hyperpyrexia?
* Acetaminophen and NSAIDs are more effective together
* Parenteral preparations of NSAIDs & rectal suppository preparations
* Dantrolene – indicate for hyperpyrexia
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Definitive Indications to Treat Fever:
* Fevers increase demand for what? What does this cause?
* Worsening what?
* Children with a hx of what? Treating with antipyretics has not been shown to do what?
* What is DOC for hyperpyretic patients >105-106°F?
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What is Systemic Inflammatory Response Syndrome (SIRS)
* SIRS is a body response to a stressor: Infectious or noninfectious
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For SIRS, what is the criteria?
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What is bacteremia?
* Bacteria in blood and + blood cultures
* Can be septic without documented bacteremia
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* What is sepsis/septicemia?
* What is severe sepsis?
Sepsis/septicemia:
* SIRS + bacteremia (microbes or their toxins in blood)
Severe sepsis
* Sepsis and one organ dysfunction or Lactic Acid >2 but <4
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What is septic shock?
* Severe sepsis and shock
* BP of < 90mmHg or 40 points less than pt’s normal BP AND unresponsive to fluid resuscitation (30cc/kg NS) OR Lactate >4
* Organ dysfunction indicating need for vasopressors
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What is refractory septic shock?
Septic shock lasting longer than 1 hour with no response to fluid or vasopressors (use higher doses)
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What is Multiple-organ dysfunction syndrome (MODS)?
* Dysfunction of more than one organ
* requiring intervention to maintain homeostasis
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* Systemic inflammation and bacterial infection=
* Sepsis and organ(s) not working=
* Sepsis and low blood pressure=
* Systemic inflammation and bacterial infection = sepsis
* Sepsis and organ(s) not working = severe sepsis
* Sepsis and low blood pressure = septic shock
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What are the s/s of early phase sepsis?
Tachycardia, skin warm and dry, hyperventilation, decrease in urine output, hypoxia, hypothermia
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What are the s/s of late phase sepsis?
Restless,anxiety, hypotension, oliguria, edema, fever, cold and clammy skin
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What is the sepsis mortality?
* Increases 8 % for each hour without antibiotics
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What are the risk factors for gram - bacteremia?
* DM
* Lymphoproliferative disease
* Cirrhosis
* Burns
* Invasive procedures or devices
* Neutropenia
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What are the risk factors for gram + bacteremia?
* IV catheters or mechanical devices (valves)
* Burns
* IVDA
* Children, elderly
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Clinical Manifestations of Sepsis
* What are the cutaneous signs?
* Cyanosis & ischemic necrosis of peripheral tissue
* Cellulitis (sores)
* Pustules
* Bullae
* Hemorrhagic lesions
* Generalized erythroderma
* Petechial or purpuric lesions (DIC)
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Clinical Manifestations of Sepsis:
* What are the signs for GI?
– N/V
– Diarrhea
– Ileus
– Gastric ulceration with bleeding
– Cholestatic jaundice
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Clinical Manifestations of Sepsis:
* What are the signs with renal?
– Oliguria, azotemia, proteinuria, & nonspecific renal casts
– ARF 2/2 acute tubular necrosis
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Clinical manifestations of sepsis:
* What are hematologic signs?
– Thrombocytopenia 10-30%
– Profound thrombocytopenia (< 50,000) usually reflects DIC
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Clinical Manifestations of Sepsis:
* What are the ARDS signs?
– Pulmonary capillary microvascular injury
– 20-50%
– Causes diffuse pulmonary infiltrates/hypoxemia
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Clinical Manifestations of Sepsis:
* What happens to BP?
Hypotension
* Misdistribution of blood flow & blood volume from hypovolemia due to diffuse capillary leak
* After fluid, CO increase and SVR falls
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Clinical Manifestations of Sepsis:
* What is Multiple-organ dysfunction syndrome (MODS)
* Widespread endovascular injury with high fatality rates
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What does the hematologic lab levels in sepsis?
* Leukocytosis with left shift or leukopenia
* Thrombocytopenia
* INR >1.5
* DIC
* Microangiopathic (DIC)
* Hemolysis (clostridial bacteremia, malaria, DIC)
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What is shown in ABG in early and late sepsis?
* Early- hyperventilation-induced respiratory alkalosis
* Late- metabolic acidosis /hypoxemia
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What does CXR show in sepsis?
* ARDS
* Underlying pneumonia
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Sepsis labs:
* High or low bilirubin?
* High or low protein?
* High or low procalcitonin?
* high or low CRP?
* high or low Lactate?
* Hyperbilirubinemia
* Proteinuria
* ↑ > 2 SD above normal Procalcitonin (nl <0.05ug/L)
* ↑CRP> 2 SD above normal
* ↑ Lactate (>2 mmol/L)
| usually just look at lactate
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Lab values of sepsis:
* What is the urine issue?
Urine is <0.5 ml/kg/hour for >2 hours despite adequate fluid resuscitation
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Definitive Diagnosis of Sepsis:
* What is there not of?
* Requires what?
* What NEEDS to be obtained?
* If blood cultures (Negative in 30%), Dx. depends on what?
* No reliable lab test for early diagnosis
* Requires isolation of microorganisms from blood or local site of infection
* At least 2 blood cultures from different venipuncture sites (ideally from ports)
* If blood cultures (Negative in 30%), Dx. depends on Gram’s stain & C/S of primary site of infection or secondary infected cutaneous tissue
## Footnote
With overwhelming bacteremia, smears of peripheral-blood buffy coat may reveal microorganisms
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How many blood cultures do you need with endocarditis sepsis?
3
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What is the treatment of Sepsis “Call a Code (SRT)”
* Medical emergency
* Sequester support
* Complete in first one-six hours
* Goal directed therapy
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Resuscitation Bundle for sepsis
* What do you need to give (2)
* What labs?
* What do you need to monitoring? What might do you have to give?
* Fluids (NS vs LR)
* Labs with
* Lactate levels
* Blood cultures
* Broad spectrum antibiotics
* Central venous monitoring
* Oxygen saturation monitoring/ high flow O2/ Endotracheal intubation
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Resuscitation Bundle for sepsis:
* Vasopressors: What is the DOC?
* Hydrocortisone: only give if what? What is the drug?
Vasopressors
* Norepinephrine is the drug of choice, carefully titrated to maintain mean BP > 60 mmHg
* Epinephrine
* Not first line: Dopamine/ vasopressin
Low dose hydrocortisone
* Only if hypotensive with fluids and vasopressors
* 50 mg/ every 6 hours
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Treatment of Sepsis-> eliminate offedning microorganism
* Treat what
* Give antibiotics when?
* Empirical therapy based on what?
* Therapy against both what?
* Gram stain of primary site of infection directs what?
* Treat local site of infection (ie surgery)
* Antibiotics given as soon as blood & other sites cultured and within 1 hour of presentation
– Empirical therapy based on information about pt & antimicrobial susceptibility patterns in community & hospital (Antibiograms)
– Therapy against both gram - & +
– Gram stain of primary site of infection directs antimicrobial therapy
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What is the empiric antibioitic txt for immunocompetent adult with no obvious source in adults with normal renal function:
If patient is allergic to lactam agents, ciprofloxacin (400 mg q12h) + clindamycin (600 mg q8h)
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Treat Local Site of Infection for sepsis
* What do you need to remove
* What imaging nees to be done?
* What needs to be collected?
* What drainage?
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When do you do a blood transfusion?
* Start at HgB of 7-8 except in MI, ischemic CAD, or acute hemorrhage
* Platelets, FFP or Cryoprecipitate or whole blood if needed
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Ventilation-sepsis
* What do you give? except?
* Intubation can cause what?
* What do you give?
* What is great?
* High flow O2 except in COPD (takes away respiratory drive)
* Mechanical ventilation (intubated): easy to hurt them
* “low” tidal volume (6 mL/kg) with end respiratory plateau pressures less than 30 cm of water
* Noninvasive ventilation is great (BiPAP or less commonly CPAP)
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IV Antimicrobial Therapy for Severe Sepsis:
* What do you switch?
* one or two agents for what?
* treat for how long?
* Switch to susceptibility directed antibiotic, even if improved
* Use C/S data
* One or two agents for gram negative infections
* Use only one agent except if Pseudomonas or neutropenia
* Treat 7-10 days
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What is the prognosis of sepsis?
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Prevention of Septic Shock:
* What should you minimize the number of
* limiting use or duration of what?
* Reducing incidence/ duration of what before shock?
* Aggressively treating what?
* immunizations?
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* A cancer patient with a central line port develops a fever. The cancer has been remitting for 1 week, and there are no signs that it is spreading. There is currently no fever. The basic work up for fever is negative. What should you next do for this patient?
* Begin low dose steroids
* Perform exploratory laparotomy
* Remove the central line and send tip for C & S
* Start empiric IV antibiotics
* Give some tylenol
* Remove the central line and send tip for C & S
* Start empiric IV antibiotics (broad septrum)
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The proper treatment of septic shock include:
* Using WBC enhancers when neutropenic
* Using a broad-spectrum antibiotic when culture results are pending
* Limitation of IV fluids
* Waiting for culture result to start antibiotics
* Tylenol 1000mg PO once
Using a broad-spectrum antibiotic when culture results are pending
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What are the different types of STD infections?
* Parasitic (Pubic lice, scabies, trichomoniasis)
* Bacterial (Chlamydia, LGV, Gonorrhea, Syphilis)
* Viral (HSV, Hepatitis B, HIV, HPV)
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What are STIs?
Sexually transmitted infections (STIs) are infections that are passed from person to person through sexual contact, primarily through bodily fluids (e.g., blood, breast milk, vaginal or anal fluids, semen/copulation and pre-copulation/excitation fluids). While STIs are generally curable or treatable, they can cause serious health problems if left ignored and untreated.
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What type of STDs are constiuted as abuse? What must you do?
Childhood STDs constitute abuse:
* MUST BE REPORTED AND PROPERLY DOCUMENTED WITH TESTS
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Parasitic - Pubic Lice
* What is this also called?
* What is it?
* How is it transmited? How long can they live off a human?
* aka crabs, Pthirus Pubis; ectoparasite of humans.
* Tiny crab-like insects that nest in pubic hair & bite their host to feed on blood
* Transmitted direct contact or off bedding, clothing, towels; Can live off human host x24-48h
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What are the sx and dx of pubic lice?
* Sxs: pruritis in pubic area, visible nits or lice on hair; secondary sores and infection 2◦ intense scratching
* Dx: presence of nits or lice (Presence on eyebrows/eyelashes of children, suspect sexual abuse)
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What is the txt of pubic lice?
Tx: Wash all clothing, towels, bedding: Hot (103F+) water and machine dry; store other unwashable items in sealed plastic bag x 14 days
Medicated creams & lotions
* Permethrin cream->twice 7 days apart
* Lindane – not recommended for first line (hepatic metabolism)
* Toxic to brain and nervous system-> avoid in infants and toddlers <2yo, epileptic, pregnant/breast-feeding women, elderly, <110lb
* Ivermectin – topical US approved, not oral
Evaluate for other STIs; notify all partners, avoid sexual contact until fully cleared
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Parasitic - Scabies:
* What is another term?
* How is it tranmitted? How long do they live off human
* Sarcoptes scabiei var hominis; microscopic mites
* Primarily through direct prolonged skin to skin contact; rarely off bedding, clothing, towels; live off human for 48-72 hrs
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Parasitic - Scabies:
What are the sx?
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Scabies
* What is the dx?
* what is seen in immunocompromised?
Dx: based on history and exam; presence of mites, eggs, or feces found on microscopic evaluation of skin scraping
* Norwegian (crusted) scabies – in immunocompromised
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What is the txt of scabies?
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Parasitic - Trichomoniasis
* What are other names?
* Most common what?
* aka, Trich, Trichomonas Vaginalis, protozoan parasite
* Most common curable sexually transmitted parasitic infection
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Parasitic - Trichomoniasis
* what are the sxs?
* What is the dx?
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Trichomoniasis
* What is the txt? (first line, alt and intravag)
Metronidazole 2G, partner txt. (may even be given in gel form)
* Alt: Tinidazole/Ornidazole – non-pregnant/breastfeeding women
* Intravaginal: paromomycin, furazolidine, acetarsol, nonoxynol-9
* Evaluate for other STIs
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* What are the bacterial STI's?
* What can they be treated?
* What can they cause if untreated?
* Bacterial STI’s include Chlamydia, LGV, gonorrhea & syphilis
* Can be treated and cured with antibiotics
* Untreated infection can cause PID, infertility, & epididymitis
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* What are the viral STI's?
* What can they be treated?
* What can happen?
* Viral STI’s include HPV, HIV, Herpes, & Hepatitis A,B,C
* Medication available to treat symptoms only
* There is NO cure
* Can pass onto others for the rest of your life
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Bacterial - Gonorrhea
* What are other names and what are their bacterial structure
* most common cause of waht?
* How is it transmitted?
* aka “clap”, ”drip”, Neisseria gonorrhoeae, oxidase+, gram -, diplococci, obligated bacteria
* Most common cause of gonococcal urethritis; ~106 million/ yr, US ~1.4 million/yr
* Direct contact with infected tissue/fluid, vertical transmission
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What are the sx of gonorrhea?
* Copious mucopurulent green, yellow, white d/c 1-14 days post exposure), dysuria, cervicitis/orchitis/epididymitis/penile lymphangitis/penile edema, testicular/scrotal pain; urethral strictures, rectal itching, discharge, soreness, bleeding, abdominal pain, painful bowel movements, postcoital or intermenstrual bleeding; pharyngitis, mucopurulent exudates, conjunctivitis
* Untreated can lead to ectopic pregnancy and infertility, first trimester abortion, disseminated gonococcal infection (DGI):arthritis, tenosynovitis, dermatitis, septicemia, vasculitis, endocarditis
* Infants – (vertical transmission) conjunctivitis/blindness, joint infection, septicemia
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What is the dx of gonorrhea?
Dx: Clinically, plus labs
* NAAT testing: urine or swabs– Gold standard
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What is the txt of gonorrhea? What about resistant strains?
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Chlamydia:
* What is it called?
* Most common cause of what? Who does it affect more?
* how is it transmitted?
* aka “The Clam”, Chlamydia Trachomatis, gram -, anaerobic, intracellular obligate bacteria
* Most common cause of nongonococcal urethritis and infertility in women
* Females 2x>males; Females15-24 y/o, males 20-24y/o
* Direct contact with infected tissue/fluid
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What are the sx of chalmydia?
* Scant yellow d/c, dysuria, postcoital or intermenstrual bleeding,cervicitis/urethritis/proctitis/epididymitis/prostatitis, pruritus, phlegm, PID, perihepatitis
* Untreated can lead to ectopic pregnancy and infertility, reactive arthritis
* Multiple serologically variant strains -> multiple medical conditions
* Trachoma – ocular illness, blindness (Asia/Africa)
* Lymphogranuloma venereum – severe proctocolitis, painful LAD, painless genital ulcers
* Infants – (vertical transmission) conjunctivitis, pneumonia
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What is the dx of chlamydia?
Clinically, plus labs
* NAAT testing: urine or swabs– Gold standard
* Culture – sexual assault cases, rule out LGV
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What is the txt of chlamydia?
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Disseminated GC/Chlamydia Disease:
* What is it?
* What are the 2 clinical syndromes?
* Tenosynovitis often found where?
* What also might occur?
* Gonococci disseminates into the bloodstream
* 2 clinical syndromes – purulent arthritis or a triad of rash, tenosynovitis and arthralgias
* Tenosynovitis often found in hands, wrists, feet, ankles
* Arthritis may occur in one or more joints and be migratory
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Gonorrhea Conjunctivitis:
* What is it?
* Must treat when?
* How do you tx?
* Purulent discharge
* Must treat urgently
* Single 1 g dose of ceftriaxone
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* What are DDx with STIs?
* What is txt of PID?
* What is Txt of disseminated?
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Sore Throat:
* Always consider what?
* What do you need to do?
* Should test for what?
* Always consider an STI in a sexually active patient or even young child with risk factors for sexual abuse
* Swab test is exactly the same as for genitalia
* Should test for refractory cases of pharyngitis to symptomatic and empiric ABX
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Syphilis:
* What is it also called and what is it?
* What are the primary sx?
* Aka “lues”, “syph”, treponema pallidum, a spirochete bacteria which causes a 3 phase infection that progresses in stages with periods of asymptomatic latency, without treatment invades CNS
* Sxs: Primary: (3 days – 3 months) starts as a small, painless indurated ulcer called a chancre associated w/ LAD; goes away on it’s own [2-6 wks]
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What are the sxs for secondary syphilis?
Secondary: (2 – 24 weeks) morbilliform rash on the body, dark spots on palms and soles, hair loss, feeling ill, condyloma lata (Flat-topped papules and plaques that occur at the mucocutaneous junctions of the nares, angles of the mouth, and in the anogenital region), HA, myalgia, arthralgia, hepatosplenomegaly, alopecia, malaise
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What are the sxs of latent and tertiary syphilis?
* Latent: asymptomatic stage, tests +, lesions or rashes can recur- but not present on exam
* Tertiary: years later - effect neurological system: blindness (Argyll-Robertson pupil), different paralyzed, cognitive decline, meningitis, hearing loss, aphasia, stroke, seizures, tabes dorsalis; gummas = infiltration of organs w/destruction; aortic aneurysm, valvulopathy, Charcot’s join
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What is the dx of syphilis?
Dark field microscopy- allows direct examination of spirochetes
* Serological testing: Treponemal/Nontreponemal
* Nontreponemal: detects Ab - RPR, VDRL
* If +, followed by Treponemal Ab Absorption assay (TPA) or FTA-ABS (fluorescent treponemal Ab)
* Neuro patients: CSF fluid evaluation
* Imaging studies depend on organ involved
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What is the txt of syphilis?
primary, secondary or early latent (<365 d), exposure: single dose of IM Bicillin 2.4 million units; reinfection w/4 fold increase (1:8 to 1:32. 1:1 to 1:4)
* OR Doxycycline 100mg po BID x 14d; Tetracycline 100mg po QID x 14d
Tertiary, Late latent: weekly dose of IM Bicillin 2.4 million units x 3 wks
* OR Doxycycline 100mg po BID x 28d; Tetracycline 100mg po QID x 28d
Neurosyphilis: IV Pen G 18-24 million units daily x 14d
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Syphilis:
* When do you need to follow up?
* What do you need to do with partner? what does the patient need to do?
* Complications 24h post treatment is what?
* F/u: 3, 6, 9, 12, and 24 months with serial retesting -> 4 fourfold decline (1:265 to 1:64, 1:64 to 1:16)= successful treatment
* Partner notification & txt; Abstain from sex duration of treatment, Evaluate for other STIs
* Complications 24h post treatment is Jarisch Herxheimer Reaction
* HA, myalgia, fever, tachycardia, malaise- tx supportive.
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HPV (Human Papilloma Virus)
* What is it?
* What is the low and high risk?
* What are the rates?
* How is it transmitted?
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What are the sxs of HPV?
Asymptomatic
* Genital warts flat or raised veruccated lesions often time flesh colored, slightly pruritic along genitalia or orally
* Bleeding during sexual activity
* Common warts – rough raised bumps on hands and fingers; Plantar warts – hard, grainy with central dot on soles of feet; Flat warts – flat topped, face, bearded areas, legs
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What is the dx of HPV?
Clinically, based on visible lesions, but often times also routine screening
* Pap smear, anal pap, colposcopy, anoscopy
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What is the txt of HPV?
There is NO CURE, but vaccination is available to prevent certain types of HPV (Gardasil)
* Symptom control: mechanical removal via cryotherapy, electrocautery, laser, surgical excision; topically antimitotics, caustics, interferon inducers (imiquimod)
* Relapse frequent
* Monitor for cervical/anal/colorectal/oral cancer
* Partner notification, Safe sex practices, Evaluation of other STIs
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HSV (Herpes Simplex Virus)
* What is it?
* How is it transmitted?
* Oral or Genital Herpes/ HSV1 and 2, belongs to Alphaherpesviridae subfamily, lies dormant in dorsal root ganglia and can reactivate
* ~30% of the world has symptomatic HSV, ~90% worldwide asymptomatic w/ ~65% in US
* Direct contact with contaminated saliva or bodily secretions, and sexual contact with infectious tissue.
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What are the sxs of HSV?
Recurrent (possible) outbreaks of painful sores and blisters in same area as initial inoculation
* Primary infection: 3d -1wk after exposure, viral prodrome: malaise, anorexia, fever, tender LAD, orolabial – cold sore, fever blister, pain, halitosis, dysphagia, pharyngitis, mono like syndrome, vesicular eruption [2-6wk]; follicular papules; herpetic whitlow: deep blisters, LAD; keratoconjunctivitis; encephalitis
* Secondary: milder, 24 prodrome: tingling, burning, pruritis, vesicular eruption
* Neonatal: scalp, trunk rash; oral and ocular involvement; CNS: bulging fontanelle, lethargy, poor feeding, irritability, seizures
* Asymptomatic or subclinical shedding between recurrences ~70%
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HSV dx?
Dx: Viral Culture – Gold standard
* PCR – HSV DNA, gold standard for CSF infections
* Serologic testing via Western blot
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What is the txt of HSV?
Antivirals
* Initial outbreak: Acyclovir 400mg TID x7-10d OR Valacyclovir 1G BID x7-10d OR Famciclovir 250mg TID x7-10d
* Recurrent: Acyclovir 400mg TID x 5 days (HIV x 10d) OR Valacyclovir 500mg BID x 3d OR Valacyclovir 1G QD x 5d (HIV 1G BID x5-10d)
* Suppressive: Acyclovir 400mg BID (HIV 800mg BID) OR Valacyclovir 500 mg QD (HIV BID) OR Valacyclovir 1G QD (HIV BID)
* Safe sex practice; Evaluation of other STIs; Partner notification
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HIV:
* What are the types?
* What type of virus?
* Dependent on what?
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HIV/AIDS:
* HIV is a virus that destroys what?
* Once the immune system is weakened, what can happen?
* The virus is present in what?
* What is the most common race?
* Male transmission:
* Female transmission:
* What are the high risks?
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HIV Infection:
* HIV enters the body by infecting what cells?
* What cells are the among the first to deal with HIV?
* What can be given to prevent replication?
* When is HIV not detectable?
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Replication:
* Each infected CD4 cell produced how many new viruses?
* Each replication cycle lasts how long?
* Increased number of virions =
* Higher viral load means what?
* Each infected CD4 cell produces about 300 new infectious viruses – called virions.
* Each replication cycle only lasts 1 to 2 days.
* Increased number of virions = Viral load or the amount of virus in the blood.
* Higher viral load means more immune suppression
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HIV presentation:
* 1 to 3 weeks after exposure, some people experience what?
1 to 3 weeks after exposure, some people experience mild flu-like symptoms that may last a few weeks, then disappear
* Fever/Chills
* Extreme Fatigue
* Decreased appetite/stomach discomfort
* Body aches
* Swollen lymph nodes
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HIV presentation:
* Many people present when? why?
* What is the only way to know?
* Many people have NO symptoms until years after exposure
* Because they shrug off short lived viral symptoms prior to seroconversion and get identified with superbugs and low CD4 counts years after exposure
* The only way to know is to get TESTED!
* Mean time 10 years from exposure to real severe sympto
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Explain the timeline of ELISA, antibodies detected using western blot and proviral dna?
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HIV Disease Progression
* Couple weeks after infection, HIV becomes detectable with what?
* Acute Viral Infection symptoms can last how long
* What has reaches peak
* What level drops?
* What test?
Couple weeks after infection, HIV becomes detectable with p24 Antigen testing and patients are usually symptomatic
* Acute Viral Infection symptoms can last 2 weeks + (although not everybody will experience)
* Viral load reaches its peak – upwards of 1 million copies / mL of blood
* CD4 counts drop
* + Rapid test requires ELISA/ Western Blot confirmatory test
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HIV:
* Why is transmission high during the first couple of weeks?
* ~28 days after infection (viral symptoms resolve), what test can be done?
* Transmission of HIV to others is very high due to high VL count in bodily fluids and mucosal tissue
* ~28 days after infection (viral symptoms resolve), HIV Ab tests become positive ( “4th gen Ab/Ag test), i.e. seroconversion occurs
* p24 levels start to drop as HIV Ab bind to p24 creating Ab/Ag complexes in effort to eliminate
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HIV:
* What is the screening test and teh confirmatory test?
* Waht is the combined sensitivity and specificity?
* What is the window period?
166
HIV
* >6 weeks Ab only tests will detect how many infections?
* HIV levels start to fall as what starts to rise?
* What will stabilize and when?
167
What is the timeline to detect HIV ab and ag?
168
HIV lab:
* What is viral load? What it is good for?
* What is chronic goal?
* treat?
169
What is the naturally course of HIV disease?
170
WHO Stages of HIV Infection->T4/ CD4 lymphocyte Count
* Normal level?
* Immunodeficient? (what are the 4 stages?
171
* What are opportunistic infections?
* How is the HIV disease measured by?
*
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173
What are the AIDs defining conditions?
174
What is this (HIV +)?
Kaposi Sarcoma- human herpes virus type 8
175
Disease Risk Outcomes for HIV?
176
What is the lab workup for HIV/AIDs patients?
177
What is the HIV txt?
* When do you start and why?
* What is an important things about ART?
178
Fill in the drugs for HIV
179
HIV med
180
STI and HIV Prevention:
* What is the only effective method?
* Avoid what?
* What should patients have?
* Get tested when?
* What should you use?
* Get onto what when in high risk activities?
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What are the HIV Preventive measures?
182
Who needs to be screened for HIV
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* Studies have shown that CD4 count is usually lower when?
* Acute infection, for example, influenza, pneumonia, hepatitis B, cytomegalovirus, and chemotherapy, may lead to what?
