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Name some risk factors for HAI

Invasive procedures
Injectable drug therapies
Antibiotic overuse (C diff)
Poor hand hygiene
Poor environmental cleansing


Name some ways you can prevent HAI's through your behavior

Wash hands

Use gloves when appropriate

Abide by isolation precautions (masks with TB pt, etc)

Avoid overuse of antibiotics (C diff)

Speak up if you see a problem

Participate in quality improvement efforts

Get immunized

Treat latent TB

Participate in evidence based bundles such as with line insertion


When should periprocedural antibiotics be administered?

Within 60 minutes of skin incision

Usually one dose

Reducing makes sense for surgeries > 8 hrs

Post-operative courses of therapy, while you will see them, are inappropriate unless infection is present


What should you do if you get a mucosal exposure to patient blood or fluids?


Report to supervisor

See Occupational Medicine to learn if more needs to be done


If you are exposed to HIV via a needlestick or other means, how can you lower the likelihood of contracting the infection?

Wash/flush the site of exposure

Be evaluated to learn if post-exposure prophylaxis is indicated

(It's extremely effective, but does confer some toxicities, so the million dollar question if it occurs - I hope it doesn't! - is whether it is indicated


Where can I learn more about Geisel's policy on blood borne pathogen exposures?

Page 88 of the student handbook:


What is SIRS?

(I won't test you on the details but you should understand the general idea for clinical purposes.)

The criteria for SIRS are two or more of

(1) T >38.5ºC or 90,

(3) RR >20 or PaCO2 12,000 or 10% bands


What's the definition of sepsis?

SIRS + infection

(Add hypotension and you gotcherself septic shock)


What's the most common site of origin of sepsis?

Pneumonia and other lung infections

Followed by bloodstream infections, intraabdominal infections, urinary infections and skin/soft tissue infections (in that order).

So: guess the lung.


Describe the pathogenesis of sepsis

(1) Infection

(2) Failure to contain the infection and/or overly robust immune reaction and/or toxin release

(3) Systemic instability (e.g. SIRS)

(4) Epiphenomena like hyper coagulability, poor organ perfusion due to decreased systemic vascular resistance and (if present) hypotension

(5) Downstream inflammation from effects of the above, for example additional inflammation created by poor tissue perfusion

(6) Vicious cycle that can thwart therapy for the original focus


What kills people who are septic?

Sometimes hypotension itself kills people, particularly if they don't reach medical care in time, via poor brain or heart perfusion.

More commonly, hospitalized people with sepsis die from end organ dysfunction such as renal failure, or they succumb to complications of hospitalization like PE or MI, or they experience slow deterioration after failure to bounce back from the original homeostatic insult.


List some key tenants of sepsis resuscitation


Pressors if mean arterial pressure too low

Support failing organs (ventilator, dialysis, etc)

Good ICU care: avoid infections, clots, pressure ulcers, etc.


Usually it's obvious where sepsis is coming from - a big honking pneumonia is staring you in the face. But occasionally it's not clear, so you have to administer empirical antibiotics while you seek a clearer diagnosis. Name a couple of appropriate regimens for use in that context.

vancomycin + piperacillin/tazobactam

vancomycin + ceftazidime

(note that the second option above lacks anti-anaerobic coverage so would work for pneumonia - unless aspiration - but not for an intra-abdominal catastrophe such as if you suspect diverticulitis)


Which two pressor agents are most commonly used to treat sepsis?

Norepinephrine and vasopressin

Dopamine use was associated with greater toxicity such as cardiac arrhythmias


Contrast the typical presentation of bacterial meningitis and "aseptic" meningitis

Bacterial: more frequent in frail people at the extremes of age or immunocompromised, rapid onset, severe illness, high fever, severe headache, nuchal rigidity, clear mentation unless progressing toward coma, PMN predominance in CSF, low glucose is possible

"Aseptic": more frequent in healthy young people in the summer, less severe illness, less meningismus, clear mentation, lymphocyte predominance


What clinical features distinguish meningitis from encephalitis

Features that suggest meningitis: nuchal rigidity, sepsis, purpura fulminans

Features that suggest encephalitis: altered cognition (word salad, hallucinations, weird behavior) and seizures


Name some common causes of bacterial meningitis

Streptococcus pneumoniae

Neisseria meningitidis

Haemophilus influenzae (in unvaccinated people or from non-vaccine types)

Group B strep or E coli (infants)

Listeria (babies, >50 years, or immunocompromised [including pregnancy])

Cryptococcus (80% of the time in immunocompromised)


This CSF analysis pattern is suggestive of what kind of infection?

WBC 400
Percent polymorphonuclear cells 90%
Glucose 30 (concurrent blood glucose 100)
Protein 45
Gram stain pending

Bacterial meningitis, because the PMN count is high and (less sensitive) the glucose is low


How does the clinical presentation of a brain abscess differ from that of meningitis?

Brain abscess and meningitis can have some similarities. Headache is common in both as is fever.

But brain abscess is a focal infection, so more likely to show focal symptoms such as asymmetric weakness or numbness. Also, since brain abscess is often secondary to hematogenous spread to the brain there can be an associated syndrome of bacteremia, perhaps with some common source like a dental abscess or injection drug use or a skin/soft tissue infection history


Name some causes of aseptic meningitis




West Nile virus


TB meningitis (can show up like this, and as chronic meningitis)

Lyme disease


Drugs (NSAIDS for example)
Cancer (carcinomatous meningitis)


What is the standard empirical antibiotic regimen for a health 25 year-old with bacterial meningitis?

The standard regimen against meningitis while awaiting cultures is vancomycin (to cover resistant Streptococci) and ceftriaxone (to cover Streptococci plus Gram negatives like Neisseria).


What drug should you give to treat viral encephalitis

Acyclovir, while awaiting results of the HSV PCR


Why should you add ampicillin to your empirical antibiotic regimen against bacterial pneumonia in infants, adults >50 years, and immunocompromised patients?

To cover Listeria monocytogenes against which their T cell immunity is likely to be inadequate.


List some interventions proven to reduce the risk of HIV infection

HIV testing and linkage to care

Antiretroviral therapy

Condoms and sterile syringes

Prevention programs for high risk people like partners of people living with HIV

Substance abuse treatment

Screening and treatment for other STI's

(These are listed in the CDC page to which the chapter links)


List some interventions that our HIV clinic uses to maximize effective therapy for people with HIV

Respectful and non-judgmental communication style

Efforts to redress barriers to accessing care e.g. transportation difficulties, mistrust, work conflicts, poverty, etc.

Substance abuse resources

Provision of therapy that aligns with the patient's social context, for instance not prescribing drugs that need to be refrigerated to a homeless patient without consistent access to refrigeration


What is the "HIV treatment cascade?"

Only a quarter of people with HIV in the United States know it, access care consistently, get drugs and take the drugs consistently enough for them to work. At each of these steps there is a drop off in participation influenced in large part by social determinants of health such as poverty, drug use, mistrust, ignorance, and other forms of social chaos.

For a depiction and explanation, please visit this website:


Name some obstacles to redressing the social determinants of poor outcomes in HIV prevention or treatment services

Ignorance of the factors that influence patient outcomes

Failure to connect with patients across cultural, racial or other differences

Focus on the assignment of blame to patients for behaviors that may have complex origins

Inadequate funding

Inflexible clinic schedules and other barriers to easy access to care for people with either chaotic schedules or schedules not under their control

Inadequate psychiatric services

Implementation of biomedical interventions without understanding the social context in which they occur


Define structural violence and give a few examples of it

Structural violence occurs when a social structure avoidably prevents people from meeting their basic needs.

Examples include racism, poverty, war and stigma.


A defect of which arm of the immune response is suggested by recurrent thrush, shingles and Pneumocystis jiroveci?

T cells


What infections predominate among people with abnormal antibody defects that are characteristic of common variable immunodeficiency?

Sinopulmonary infections from Streptococcus pneumoniae and persistent gastrointestinal infection with Giardia lamblia