W3P2 Flashcards

Question

Treatment for Trichomonas Vaginalis

Answer 1

Metronidazole | aka flagyl, used for parasites

Answer 2

“ I can see something down there…” “ I have a rash” ``` DDx: HSV 1, 2 Treponema pallidum Lymphogranuloma venereum (= serovars L1, L2, L3 of Chlamydia trachomatis) ```

Answer 3

Herpesviridae family (DNA viruses) Very common (seroprevalence studies: 15-50% positive) Classically: HSV-1 = orolabial disease, HSV-2= genital: *not true* any more Most transmission is during asymptomatic shedding Establishes latent infection in the sacral sensory ganglia → periodic reactivation Infection is for life

Answer 4

Cluster of vesicles on an erythematous base: painful Lesions anywhere in ‘boxer short’ area ``` Primary genital herpes Sometimes extensive vesiculo-ulcerative lesions: lesions are PAINFUL! Systemic symptoms (fever, muscle aches) Tender lymphadenopathy Meningitis (rare) ```

Answer 5

Culture [not anymore] PCR Direct fluorescent Antibody (DFA) staining

Answer 6

It is NOT curable Medical treatment for clinically important first episodes and recurrences with either Acyclovir, Famciclovir or Valacyclovir Can consider daily suppressive therapy for people with frequent recurrences (this also decreases transmission to partners)

Answer 7

Least common of the 3 provincially reportable bacterial STIs Incidence rising Transmission via vaginal, anal, and oral sexual contact

Answer 8

different stages of disease (primary, secondary, latent, tertiary, etc). Can live in body and cause problems for decades! different clinical manifestations at each stage of disease (“the great masquerader”), because it can spread to many organs in body diagnosis can be complicated (no culture, PCR not widely used)

Answer 9

Transmission: sexual, congenital + Primary Syphilis Secondary Syphilis: disseminated in skin, lymph nodes, etc commonly and classically found on the palms and soles Latents syphilis is ASYMPTOMATIC Early latent [within 1 year]: no symptoms Late latent [over 1 year] low transmissibility, no symptoms Tertiary Syphilis [years later] = aortitis, neurosyphilis

Answer 10

Primary Syphilis | this is a PAINLESS ulcer

Answer 11

Teriary Syphilis - Serpiginous Gummata of forearm like full mouth bite mark shape

Answer 12

Mostly based on serology | Dark field microscopy of chancres

Answer 13

1. Screen with non-treponemal test (VDRL, RPR) and confirm with treponemal test 2. Screen with treponemal test (EIA), then perform non-treponemal test, then confirm with another treponemal test

Answer 14

measure antibodies in patients serum to cardiolipin antigen 1. Venereal Disease Research Lab test (VDRL) 2. Rapid Plasma Reagin (RPR) Aggregation of Cardiolipin antigen in presence of antibody = positive test result for syphilis this type of test is NON specific, so you get a lot of false positives*

Answer 15

Syphilis Serology measure antibodies against specific T. pallidum antigens These tests are very SPECIFIC for T. pallidum Enzyme-linked Immuno-Assay (EIA) agglutination tests eg. Treponema Pallidum Particle **Agglutination assay (TPPA)** Line immunoassay (LIA)

Answer 16

Interpretation: Syphilis (any stage) Previously treated disease (soon after trtmnt)

Answer 17

False Positive

Answer 18

No syphilis | Very early disease (need to repeat VDRL in 2-4 weeks)

Answer 19

Some cases of late stage disease | Previously treated disease (late after trtmnt)

Answer 20

1. Start with non-treponemal test (RPR, VDRL) then confirm positives with treponemal test

Answer 21

Start with treponemal test (EIA), then if positive perform non-treponemal test. (If discordant, confirm with a second treponemal test)

Answer 22

Penicillin is the treatment, dosage changes/increases Primary, Secondary, or early latent: Penicillin IM x 1 Late Latent, tertiary: Penicillin IM weekly x 3 doses Neurosyphilis: Penicillin IV for 10-14 days

Answer 23

Chlamydia trachomatis serovars L1, L2 and L3 Relatively rare Outbreaks starting in 2003 (risk factor: MSM) Clinical Presentation; genital warts often single painless papule weeks later: tender adenopathy

Answer 24

Very common (~70% adults have at least 1 HPV genital infx) [More than 130 HPV types] Types 6 and 11 commonly cause condyloma acuminata (genital warts) Types 16 and 18 commonly cause (pre)cancerous lesions: cervical CA, anal CA Vaccine now given in all provinces in grades 4-7

Answer 25

Cryotherapy Topical agents Cervix: Colposcopy +/- excision procedures for pre-malignant/malignant lesions

Answer 26

1. Direct infection of blood and its components Bacteremia, viremia, fungemia Ehrlichia/Anaplasma Plasmodium, Babesia, Trypanosoma, Leishmania 2. Infection of endovascular device Prosthetic cardiac valve, PPM, ICD, CVL, AV fistula/mesh, vascular graft, LVADs, mechanical heart 3. Direct infection of vasculature and structures Suppurative thrombophlebitis Endarteritis Endocarditis

Answer 27

Abrupt toxic course lasting days to weeks

Answer 28

Indolent protracted course featuring systemic symptoms often lasting longer than weeks

Answer 29

Change in the nature of underlying heart diseases: rheumatic → DEGENERATIVE Population is aging, aged with heart disease survive longer Aged with heart disease benefitting from PROSTHETIC VALVE replacement surgeries “health-care associated” IE due to increased uses of endovascular technologies - IV catheters, hyperalimentation lines, dialysis lines/shunts, - PPMs/ICDs Biofilm formation

Answer 30

1. Native Valve (i.e the valves with which you are born) Rheumatic heart disease Congenital heart disease (some but not all) Degenerative heart disease Mitral valve prolapse - Uncontrolled bacteremia and/or history of prior endocarditis 2. Prosthetic Valve (i.e the synthetic valve placed during cardiac surgery) 3. Endovascular device utilization Intravenous access: long standing CVAD >>>> peripheral IV Implanted devices, surgical materials 4. IVDU intravenous drug use

Answer 31

Adherence -> Colonization [bcterial division, fibrin deposition, platelet aggregation, extracellular proteases, protection from neutrophils] -> Mature vegetation Many things can lead to adherence: trauma, turbulence, metabolic changes Bacteriocins, IgA protease, bacterial adhereance

Answer 32

Mitral Valve: 30-45% Aortic: 5-35% other two quite rare

Answer 33

When heavily colonized mucosal surfaces are traumatized Degree of bacteremia is proportional to the burden of colonization and degree of trauma Typically “low grade” and “transient” - ≤ 10 CFUs/ml - Blood stream sterilized within 30 minutes - Function of “serum susceptibility” of the organism Sufficient to infect a NBTE valvular lesion

Answer 34

Complex extracellular polysaccharide, “glycocalyx” Role in dental caries (S. mutans) Prominent among certain Streptococcus spp. Promotes adherence to platelet-fibrin matrix (NBTE)

Answer 35

Fibronectin - S. aureus binding and uptake into “normal” endothelium, followed by triggered apoptosis - Clumping factor, coagulase

Answer 36

- Staphylococcus spp. (surface receptor-fibrinogen-platelet receptor, or via vWF system) - Streptococcus spp. (surface Antigens-IgG-platelet FcR) ↓ rate of removal of organism ↑ adherence and aggregation on vegetations

Answer 37

Utility of prophylactic antibiotics - Even sub-inhibitory (prophylactic) antibiotics may prevent IE by a. Decreasing expression of adhesion virulent factors b. Direct cell killing

Answer 38

Minimal phagocyte infiltration Protected from circulating immune factors Environment for major proliferation Deeper dormant/inert bacterial forms  (may represent up to 90% of bacterial burden)

Answer 39

Native Valve Community acquired - Staphylococcus aureus / viridans Streptococcus spp. - Lesser extent Enterococcus spp. Nosocomial - Staphylococcus aureus - Lesser extent Enterococcus spp. IVDU - Staphylococcus aureus - Lesser extent other bacteria

Answer 40

Early post surgical, intermediate Post surgical (2-12 months) coagulase NEGATIVE STAPH > staph aureus

Answer 41

Considered in microbiology of culture negative endocartitis HACEK - Gram negative organisms with unusual growth charcteristics - Not truly “culture negative” using modern techniques HACEK is an acronym for a group of organisms that are small, fastidious gram-negative bacilli. 1. The HACEK organisms include Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae.

Answer 42

FEVER 80% Chills Weakness Dyspnea SIGNS: fever 90% heart murmur 85% * important to do cardiac Auscultation

Answer 43

Most important diagnostic test is BLOOD CULTURE When bacteremia present, first two cultures yield agent > 90% of the time Can be altered if ABX are given prior to culturing Recommended 3 sets, only 2 bottles per stick in first 24 hours At least 10 ml of blood in each bottle May need prolonged incubation

Answer 44

TTE- transthroacic echo? Utility in all patients suspected of having endocarditis (usually by agent and syndrome) May be technically inadequate in up to 20% of individuals Variable sensitivity Negative study cannot R/O IE Highest in right sided IE due to positioning of the heart False positive studies are rare TEE- trans esophageal echo? Invasive More sensitive than TTE (65% vs 95%) Should be considered in suspected cases where TTE was negative Especially useful for prosthetic heart valves, intracrdiac abscesses and fistulae Negative results do not exclude IE May repeat TEE in 7-10 days

Answer 45

Used to diagnose Definite vs Possible IE Definite IE: Pathologic Criteria Microorganisms: demonstrated by culture or histology in a vegetation, OR in a vegetation that has embolized, OR in an intracardiac abscess, OR Pathologic lesions: vegetation or intracardiac abscess present, confirmed by histology showing active endocarditis Clinical criteria 2 major OR 1 major and 3 minor OR 5 minor Possible IE: - 1 major and 1 minor or 3 minor Rejected: Firm alternative diagnosis, OR Resolution of manifestation of IE with ABX for 4 days or less, OR No pathologic evidence of IE at surgery or autopsy, after ABX therapy for 4 days or less Does not meet criteria for possible IE

Answer 46

1. Blood culture positive for IE (at least one of:) a. Typical microorganisms consistent with IE from 2 separate blood cultures: - Viridans streptococci, S. bovis, HACEK group, S. aureus - Community acquired enterococci, without primary focus b. Microorganisms consistent with IE from persistently positive blood cultures Evidence of Endocardial Involvement a. Echocardiogram positive for IE (TEE recommended in patient with prosthetic valves, rated at “possible IE” by clinical criteria, or complicated IE/paravalvular abscess) b. New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient)

Answer 47

a. Predisposition: predisposing heart condition or injection drug use b. Fever: T>38C c. Vascular phenomenon: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions d. Immunologic phenomenon: GN, Osler nodes, Roth spots, and positive RF e. Microbiological evidence: positive blood culture but does not meet a major criterion as noted above, or serological evidence of active infection with organism consistent with IE Echocradiographic minor criteria eliminated

Answer 48

1. Destruction of underlying heart valve - Healing by fibrosis and calcification 2. Acute IE Vegetation is larger, softer, more friable Associated with more suppuration, more necrosis Less healing Valve perforation Rupture of chordae tendonae, interventricular septum, papillary muscle Perivalvular abscess Fistula into pericardium, myocardium Myocarditis, myocardial infarction, and pericarditis 3. Involvement of conduction system

Answer 49

``` 1. Embolic phenomenon 15-35% of cases have clinical events 70-95% of cases had clinical events in pre-antibiotic era Kidney, spleen, coronaries, brain Immune phenomenon ``` 2. Immune complex deposition Complement activation Autoimmune process activated by increased circulating antibodies

Answer 50

During active IE, all biopsies are found to have abnormal architecture - Abscess - Infarction - GN

Answer 51

Mycotic aneurysm - Can be prominent clinical presentation, or discovered at autopsy years later - More common with viridans Streptococcus Mechanism - Direct invasion of arterial wall, abscess and/or rupture - (Septic) emboli occluding vasa vasorum - IC deposition and injury to the vascular wall Tend to occur at bifurcation points

Answer 52

Cerebral emboli Most common neurologic event in IE – 20% MCA and branches most commonly involved Hemorrhagic transformation of ischemic event is leading CNS related cause of death in IE Other (non-exhaustive list) Purulent meningitis – S. pneumoniae Microabscesses – S. aureus

Answer 53

Enlargement Immune stimulation, follicle engorgement Infarction 44% of autopsies, usually clinically silent Abscess Surgical indication, or percutaneous drainage Spontaneous Rupture

Answer 54

Typically associated with right sided IE (right heart supplies to lungs) - PE (septic or “bland”) ± infarction - Acute pneumonia - Pleural effusion - Empyema

Answer 55

1. Petechiae – 20-40% 2. Osler nodes (Immunologically mediated) IC deposition in blood vessel - arteriollar intimal proliferation with extension to venules and capillaries, may be accompanied by thrombosis or necrosis - Tender, at pulp of fingers 3. Janeway lesions (Vascular event) Septic emboli - feature subcutaneuous abscesses - Non-tender, palms and soles

Answer 56

1. Roth Spots - Lymphocytes, edema and hemorrhage in nerve fibre layer of the retina 2. Conjunctival petechiae/hemorrhage 3. Flame hemorrhages

Answer 57

All components of immune system are deficient c/w immune system of older children/adults Degree of deficiency is inversely related to gestational age and birth weight, but even term are deficient Protection Placenta, filters microorganisms Maternal Ab, but mostly transferred in 3rd trim Breast milk, contains secretory IgA

Answer 58

Most important is the time during gestation that the transmission of infection occurs - During 1st trimester, while the fetus is being formed, the most devasting effects occur Three types of effects: 1. Interference with normal development 2. Inflammatory reaction to the infection 3. Placental insufficiency leading to poor growth

Answer 59

THE MOTHER Recognizing exposure of a pregnant woman - Most of the time the pregnant woman are not symptomatic - Detection of specific IgM Ab to an offending agent or rising titre of IgG are helpful in assessing risk - Baseline immunity will help to exclude dx I.e. was the mother already immune to Rubella, CMV, parvo, etc…

Answer 60

IgG crosses placenta, so not helpful - Would be measuring mother’s Ab Presence of specific IgM or rising IgG titre indicates fetal infection Isolation of offending agents if possible - Viral cultures of urine and other body secretions for CMV, Rubella, HSV - PCR amplification if possible, ie. Toxo - Pathology of placenta - Darkfield microscopy from lesions for T. pallidum (syphillis)

Answer 61

``` Limited number of treatable infections. Don’t want to miss these: Toxoplasmosis Syphillis HSV HIV CMV ``` No effective treatment Rubella

Answer 62

Toxoplasmosis Avoid cat litter boxes, gardening, eating raw or undercooked meat Rubella Prenatal vaccination, or if non immune post delivery to protect future offspring CMV Meticulous handwashing Syphillis Serologic testing early on, and repeated if at risk for exposure. Of course treat pregnant mother to prevent infection in the fetus Listeria (gram+) Avoid Deli meats

Answer 63

CBC: yees has look for abnormalities (i.e. platelets are low) Blood culture/Urine culture: bacterial infections would present acutely and this is not an acute presentation CSF culture^ Torch screen: misconception, not effective THERE IS NO SUCH THING** Immunoglobulins, specifically IgM (it doesn't cross the placenta)

Answer 64

TORCH: Toxo, Other, Rubella, CMV, Herpes ^ just an acronym for screening general stuff The common misconception There is no ONE test that will screen for congenital infections Congenital infections of different causes have many clinical similarities The acronym “TORCH” should be expanded. “O”ther now includes Syphillis, TB, Listeria, leptospirosis, Hepatitis B, enteroviruses, Varicella, Parvovirus, HIV…and most recently ZIKA!! Nothing replaces a good clinical accumen and directed specific testing

Answer 65

Go by your index of suspicion! Always start with your clinical history, and getting the OB/GYN report - Ultrasounds, serologies AND when they were done. You will save a lot of time, effort and cost A full work up should always include and ophthamology assessment

Answer 66

Classic Triad: Hydrocephaly, diffuse intracranial calcifications, chorioretinitis (inflammation in the eye) Do maternal serology (IgG) NEG: excludes Congenital Toxoplasmosis, mom was never infected. POS: Titre and Avidity help us with timing Only infection while pregnant will affect the baby Do Toxo IgM, but stays positive for 6-18 months NEG: Does not totally exclude, but unlikley POS: Increases the likelihood, but + for >6 months

Answer 67

CHILD Ophthamology: assess for chorioretinitis Head imaging: CT vs Ultrasound vs Xray PCR on whole blood, and CSF MOM Toxoplasmosis suspected during pregnancy Seroconversion documented Work up to assess if baby infected/affected PCR on amniotic fluid Serial ultrasounds, looking for ventricular dilatation Placental histology If work up indicates infection, then important to treat mom, which will also treat the fetus Baby will need to continue treatment once born

Answer 68

Once the baby is born: Check Mom’s rubella status PRIOR to the current pregnancy POSITIVE: excludes Rubella NEGATIVE/ or unknown - Check Rubella IgG on Mom and/or baby If negative: excludes Rubella, immunize Mom If Positive: Do Rubella IgM on both Mom and baby If IgM Positive: Congenital Rubella If Negative: Do Rubella Viral Cultures Isolation of the virus in the baby is proof positive

Answer 69

Once the baby is born: Urine viral culture/PCR for CMV POSITIVE: If done within first 2-3 weeks of birth, then can diagnose Congenital CMV NEGATIVE: excludes CMV While mother is still pregnant: Serology IgG not helpful as most women have antibody (60-80%), indicating infection at some point during her life. Complicated and controversial on how to diagnose in mother, but includes IgM and PCR

Answer 70

3 distinctive syndromes in the baby: Majority of infections start during delivery with incubation of 2 days to 6 weeks 1. Skin, eye, mucous membrane “SEM” 2. Encephalitis 3. Disseminated If there are skin lesions: test the lesion (special stain, or PCR, or viral culture) POSITIVE: Confirms Diagnosis If there are no lesions: - Culture mouth, eye, urine, rectum - CSF and Blood for HSV PCR

Answer 71

SYPHILIS Check maternal serology, and recheck at time of delivery, or thereafter NEGATIVE: exclude POSITIVE: Review history, prior treatment This is not something you want to miss, as this plus congenital Toxo, HIV, HSV, CMV are really the only treatable causes!

Answer 72

Maternal primary CMV in pregnancy ``` 43-58% transmit to fetus 15-20% of infected newborns are symptomatic - Mortality: 20-30% - Sequelae: 90% of survivors - Severe psychomotor delay 50-60% - Hearing loss 30-60% ``` 80-85% are asymptomatic at birth 12-15% hearing loss, behavior or learning problems

Answer 73

17% of seropositive pregnant women shed virus at some point during the pregnancy 0.8-3.4% transmit to fetus Symptoms and severe sequelae: extremely rare Hearing loss: 5% (unilateral or mild)

Answer 74

Baby may have become infected at time of delivery or anytime afterwards. Only infection during pregnancy causes the hearing problems. Therefore must find the virus when the baby is a newborn to say that this happened.

Answer 75

if exposed to this virus, must tell pregnant women: About 30-60% of adults are immune So if she was immune, there is no risk to the baby In pregnancy: ?spontaneous abortion in 1st trimester; fetal anemia and hydrops in 2nd and 3rd trimester; ? Stillbirth Causes bone marrow aplasia, resulting in severe anemia in the baby, and congestive heart failure - Hydrops fetalis: abnormal accumulation of fluid in two or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema. Other infectious causes of nonimmune hydrops: Toxoplasmosis, rubella, CMV, syphilis

Answer 76

Diagnosis: Serology on mom at time of exposure If IgG positive: She is immune, and baby not at risk If IgG negative, check and follow IgM, IgG If there is seroconversion, then need to follow fetus, and can do fetal blood transfusions if necessary

Answer 77

Hepatitis B If mother is sAg and eAg positive: 70-95% transmission, and 90% of infants will become chronic carriers THEREFORE GIVE HBIG to the baby (HepB immuneglobulin), AND FIRST DOSE OF VACCINE AT BIRTH (then at 1, 6 months) protective in 85-95% VACCINE ALONE protective in 70-80% Hep C Perinatal tranmission Less than 5% Increased if co-infected with HIV (18-20%) Diagnosis in infant? Follow serology at 6, 12, 18 months ?PCR

Answer 78

Highest risk of transmission if First episode of maternal infection in pregnancy - 40-50% transmission, versus 0-5% if recurrent Multiple cervical lesions Rupture of membranes > 6 hours Instrumentation, scalp electrodes Prematurity, no maternal antibody Clinical presentation: 1. Skin-eye-mucous membrane (SEM) 2. Encephalitis 3. Disseminated 20 % HAVE NO SKIN LESIONS!!

Answer 79

Varicella Zoster Infection ``` VZV embryopathy: - Limb scarring and atrophy - Bony defects - CNS abnormalities - Eye, chorioretinitis Development of Zoster early in life Congenital varicella syndrome: 1-2% ``` Unlikely that VZIG (varicella immuneglobulin) is protective to fetus Give VZIG to newborn if maternal varicella 5 days before, to 2 days after delivery - Severe disease in newborn: mortality of 5 %

Answer 80

``` Up to 20% of women experience by age 30 >50% have at least 1 in a lifetime 10% of women have recurrent infections Up to 20% chance of the cause of fever in feverish newborns - High if uncircumcised male (20%) - Approx 7% otherwise ```

Answer 81

Infections at any site: Bladder, kidney or protate Cystitis Infection at level of bladder Pyelonephritis Infection involving renal parenchyma (kidney) Renal abscess Pus collection with severe pyelo or spread from blood stream Bacterial Prostatitis Infection of the Prostate gland

Answer 82

Higher incidence in females because of shorter distance from urethra to bladder - Most of the time bacteria is “flushed out” with the next void - Transport from bladder to kidney can result in pyelonephritis ``` Ascent to kidney facilitated by: Pili of the bacteria (E. coli) Obstruction Neurologic disease leading to a poorly functioning bladder Pregnancy Reflux (urine going up the ureters) ```

Answer 83

E.coli accounts for 85% (due to pathogenic factors) - P Fimbriae/pili allow for bacteria to attach Staph. Saprophyticus isolated in 5-15% of young women with UTIs Other Enterobacteriaceae, enterococcus, yeast, Group B strep, account for the minority Urea splitting organsims may form struvite stones - Proteus, Morganella and Providencia All bets are off in there is indwelling plastic, such as catheters - Biofilm forms and traps unusual organisms

Answer 84

Most important is periodic, complete and normal voiding Washes out bacteria, and cells to which they are attached Behavioral risks Sexual intercourse Mechanically allows bacteria to ascend. Occurs 30% of encounters, but voiding clears the bacteria Patients with structural or functional abnormalities of the Urinary tract that compromise voiding. - Obstruction to flow - Increased access (catheters) - Pregnancy (urinary stasis)

Answer 85

``` Uncomplicated Cystitis or Pyelonephritis Lower tract symptoms Dysuria (pain on voiding) Frequency (frequent urination) Urgency (“I need to go NOW!) Discomfort in suprapubic or lower back area Gross hematuria Upper tract or Pyelonephritis High fever CVA (costo-vertebral angle) tenderness Unlikely UTI if symptoms are in between voids and if there are vaginal symptoms ```

Answer 86

Young infants cannot complain of the typical symptoms Fever, irritablility Afebrile, but poor feeding; vomiting; diarrhea; jaundice; poor weight gain

Answer 87

Leukocyte esterase: detects esterase, an enzyme released by white blood cells. Most sensitive 94% when UTI suspected Specificity: 64-92% (due to other infection/inflammation of tract, urethera, vaginitis..) Nitrite: Bacteria that cause a UTI make an enzyme that changes urinary nitrates to nitrites. Sensitivity: 16-82% Specificity: 95-100%, good to Rule-In [Blood and/or protein Poor sensitivity and specificity]

Answer 88

Microscopy: Technologist dependant #WBC/HPF: Sensitivity: 32-100%; Specificity: 45-97% Bacteria: Sensitivity: 15-96%; Specificity: 11-100% If analyzed > 3 hours after collection: The sensitivity drops by 35%

Answer 89

Combination of tests maximize the Sensitivity and the Specificity LE or nitrite +: Sens: 83-100%; Spec: 68-98% Microscopy for WBC and bacteria: - Sensitivity: 99% Anything positive on dip/microscopy - Sensitivity of 100%; Specificity poor If dip/microscopy all negative - Negative Predictive Value: 100%

Answer 90

Empiric therapy may need to be modified based on susceptibility testing Antimicrobials excreted in urine are preferred For cystitis, only urinary antibacterial activity is necessary For Pyelonephritis, need adequate drug level in urine and tissue, and possible blood level

Answer 91

Usually treated empircally based on symptoms and dipstick result, and often cultures are not sent (adult medicine) It takes 2-3 days to get urine culture results,and many treat for only 3 days Send a culture if symptoms are uncertain, history of frequent relapse, or if pregnant Most use TMP/SMX (Septra) for 3 days Alternatives: Quinolone (Cipro) also for 3 days, or Nitrofurnatoin (local bacteriostatic) for 7 days

Answer 92

Can have bloodstream extension, so blood and urine cultures are indicated before treatment Empiric therapy is based on severity, i.e oral vs. initial IV then oral or all IV. Usually start with Ampicillin (to cover possible enterococcus) and aminoglycoside (To cover gram negatives: Genta/Tobra), and tailor based on urine C&S For oral treatment, many use Septra or quinolone Because both are extremely well absorbed (bioavailable) If no improvement by day 3, consider a complicated infection (obstruction, abscess

Answer 93

Should not be treated except - Pregnancy: Can go onto pyelonephritis, which can precipitate premature labor - About to have a urological procedure: compromise of the mucosa can lead to the complication of spread to the bloodstream

Answer 94

2 episodes every 6 months, or 3 every year Some refer to it as “Honeymoon cystitis” Can try daily or alternate day low dose TMP/SXT, or following intercourse - Reduces gram negative flora in periurethral area, but increase incidence of resistant UTIs Nitrofurantoin has less of an impact on colonizing flora, but can intermittently sterilize the urine through high urinary antimicrobial levels

Answer 95

UTIs under 3 months - quite common! - higher if infant is febrile - uncircumsized males = higher

Answer 96

Incidence decreases in boys and increases in females during the first 6 months, and by age 1 females outnumber boys 3-10:1.

Answer 97

WORSE IN CHILDREN May have no symptoms attributable to the urinary tract Higher likelihood of having blood spread, and complications as meningitis (neonates) Higher likelihood of having some malformation of the urinary tract Therefore needs more extensive workup initially and in follow-up

Answer 98

Neonates have lower grade fever or afebrile Fever is of shorter duration, and disappears more promptly on treatment May just have poor feeding, lethargy, grunting, poor weight gain and no fever OR fulminant sepsis Asymptomatic other than jaundice

Answer 99

Ascending vs Hematogenous - not sure which comes first, chicken vs egg situation A substantial proportion of newborns with UTI have bacteremia

Answer 100

Septra and Quinolone

Answer 101

If under 6-8 weeks of age: all have a septic workup including a lumbar puncture Treated all IV if under 1 month All newborns should have an ultrasound to rule out congenital malformations of the urinary tract Consider radiographic work up with VCUG to detect reflux from bladder up the ureter, if the UTI is considered “atypical” - Recurrent; Non E.coli; abnormal ultrasound; bacteremia May require prophylaxis if there is high grade reflux, at least until the time they are toilet trained

Answer 102

Higher the grade, higher up the infection = worse

Answer 103

To detect dilatation, obstruction, anomalies If a late prenatal ultrasound has been done, is this still a necessary test? NEJM: Jan.16,2003 Hoberman et al Ultrasound did not change management, nor did it differentiate those with or without reflux There is no role for an U/S for every repeat UTI if the anatomy is known, and there is no unexpected response to treatment

W3P2 Flashcards

(127 cards)