Infectious disease infectious disease exam

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Question Answer MC of all bacterial infections UTI UTI organism MC in young women that are sexually active (1) E. coli (2) S. aureus UTI organism MC in elderly men w/ prostate problems enterococcus faecalis UTI organism MC in young boys proteus mirabilis UTI organism MC in its w/ stones proteus mirabilis UTI organism MC in diabetics (esp if poorly controlled) (1) klebsiella(2) GBS(3) Candida asymptomatic bacteriuria, cystitis, prostatitis, pyelonephritisbacteria establish infection in the urinary tract by traveling from the urethra into the bladder and kidneys UTI – dysuria, frequency, urgency, cloudy malodorous urine- Positive nitrite or leukocyte esterase, bacteruria, pyuria- Tx w/ bacterium, cipro x 7days cystitis what is the treatment for a pregnant patient w/ cystitis (1) amoxicillin(2) cephalexin (3) nitrofurantoin x 7days what is the treatment for healthy females, females >65yo/diabetics or healthy men <50yo with cystitis Bactrim or cipro x 7 days (3 days healthy fem) fever, chills, nausea, vomiting, low back pain, CVA tenderness, tachycardia, pyuria on lab, bacteremia, occasionally septic shockOutpt TX: cipro, bactrim, amox/aug ~14dInpatient: cipro, ceftriaxone, amp/sulbactam, piper/tazo, imipenem pyelonephritis what is the outpatient treatment for pyelonephritis Outpatient: PO fluoroquinolones -7-14 days, TMP-SMX- 14 days, amoxicillin or augmentin for 14 days what is the inpatient treatment for pyelonephritis Inpatient: I.V fluoroquinolones, ceftriaxone or other 3rd generation cephalosporin, ampicillin/sulbactam, piperacillin/tazobactam or imipenem. Switch to oral when stable fever, chills, dysuria, urinary frequency and urgency, perineal/pelvic pain. On exam, enlarged, tender prostateTX: fluoroquinolone for 2 weeks, bactrim at least 4 weeks acute prostatitis variable low grade fever with pelvic or back discomfort. May cause asymptomatic bacteriuriaTX: bactrim or quinolone 4-6 weeks chronic prostatitis how do you diagnose prostatitis – Diagnosis made by microbiologic exam of expressed prostatic fluid or urine. Look for WBC (>10 per high powered field) what is the preventative treatment for asymptomatic bacteriuria in patients that have >3 episodes per year low dose bactrim, quinolone or nitrofurantoin for 6 months S. pneumonia MC pathogen, DX w/ blood cultures and LP and treat with dexamethasone and antimicrobial therapy, onset <24h to over 1wk, fever 95% pts, neck stiffness, meningeal irritation, lethargy, confusion, stupor, coma, seizures, focal sgs bacterial meningitis what are the lab findings in bacterial meningitis leukocytosis, pos blood cultures, CT scan in its w/ focal sxs, LP ASAP, latex agglutination positive, gram stain positive, CSF culture positive what are the lumbar puncture findings in a patient with bacterial meningitis (1) OP >180 mm/H20(2) CSF protein >40mg/dl (3) CSF glucose <40mg/dl (4) CSF WBC >100/mm3 what is the abx therapy for bacterial meningitis w/ s/ pneumonia with MIC <0.1 penicillin G (highly sensitive) what is the abx therapy for bacterial meningitis w/ s/ pneumonia with MIC 0.1-1.0 ceftriaxone (intermediate) what is the abx therapy for bacterial meningitis w/ s/ pneumonia with MIC >1.0 vancomycin (resistant) Bacteremia and meningitis caused by N. meningitidis–Predominantly a disease of college students living in dorms, military recruits in barracks, fulminant illness w/ rash, petechiae, ecchymosis, DIC, hypotension and death TX w/ penicillin meningococcal disease what is the abx therapy for bacterial meningitis w/ H. flu ampicillin for sensitive, otherwise ceftriaxone what is the abx therapy for bacterial meningitis w/ listeria monocytogenes ampicillin what is the abx therapy for bacterial meningitis w MSSA naficillin what is the abx therapy for bacterial meningitis w MRSA vancomycin what is the abx therapy for bacterial meningitis w/ gram negative bacilli (1) cefipime (2) ceftazidime (3) meropenem Localized microbial infection of cardiac valves or mural endocardium, – Primary lesion is a vegetation–Abn endocardial surface + high velocity turbulent blood flow across a defective valve or congenital defect favors platelet deposition infective endocarditis infected platelet fibrin thrombus vegetation what are the requirements for blood culture diagnosis of endocarditis o Blood Cultures (using 3 separate venipunctures, at 3 different sites taken over several hours. Ideal volume of each-15-20ml, incubated for 5 days) what kind of echo do you use to dx endocarditis TEE what are the three major dukes criteria (1) 2 pos cultures 12 hours apart (2) visualization of vegetation on TEE (3) new regurgitant murmur what are the 5 minor dukes criteria (1) T >100.4(2) predisposing heart condition(3) presence embolic disease/ hemorrhage (4) immuno phenomena (5) pos blood cultures but maj criteria not met (6) echo pos but maj criteria not met what combination of dukes criteria are needed to dx infective endocarditis (1) 2 major (2) 1 major 2 minor (3) 5 minor what is the mc organism for IE in patients w/ valves coats negative staph what are the top 3 mc organisms in endocarditis (1) s. viridian's (2) s. aureus (3) enterococci IE treatment for PCN susceptible strep (MIC <0.1) – penicillin G 12-18 million units/d IV – ceftriaxone 2 gms/d IV IE treatment for PCN resistant its vancomycin divided into 2xdaily doses x 4 weeks IE treatment for native valve, uncomplicated IE with susceptible strep viridans PCN G + gentamicin IE treatment for Relatively resistant strep (MIC 0.1-0.5): penicillin G 18 million units/d + gentamicin or vancomycin alone for 4 weeks IE treatment for enterococci or prosthetic valve PCN G + gents, ampicillin + gents or vancomycin + gents x 4-6 weeks IE treatment for HAECK ceftriaxone or ampicillin + getamycin IE treatment for MSSA infection of native valve – nafcillin or oxacillin 2 gms IV every 4 hours, – cefazolin 2 gms IV every 8 hours for 4-6 weeks- vancomycin for 4-6 weeks IE treatment for MSSA infection of prosthetic valve nafcillin or oxacillin + rifampin for 6-8 weeks (+gentamicin 1mg/kg IV for the first 2 weeks) IE treatment for MRSA infection of native valve vancomycin IE treatment for MRSA infection of prosthetic valve vancomycin and rifampin for 6-8 weeks (gentamicin) IE treatment for culture negative IE–both native and prosthetic valve vancomycin and gentamycin what are the indications for surgery for a patient with infective endocarditis o Moderate to severe HFo Vegetations > 1.0 cm that obstruct valveso Perivalvular invasion/abscess formationo Uncontrolled bacteremia o Fungal endocarditiso Prosthetic Valve Endocarditis (PVE) caused by Staph aureus or other hard to treat bugs what procedures require antibiotic ppx in its with valvular disease (amoxicillin 2g 30-40 mins before procedure) (1) Dental procedures (2) incision/biopsy resp tract mucosa (3) procedures on infected skin or mucous membrane structures what is the ppx for procedures for patients at risk of IE **Amoxicillin at a dose of 2 g– given to patients 30 to 60 minutes before the procedure. High-risk adults with penicillin allergy may receive cephalexin 2 g; clindamycin 600 mg or either azithromycin or clarithromycin 500 mg Organisms directly inoculated into the bone via: open fracture, penetrating wound, surgical procedure or from adjacent soft tissue infection, often polymicrobial, staph epi in prosthetic devices, pseudomonas puncture wounds, anaerobes decubitus ulcers continuous osteomyelitis Initial stage: fever, pain, swelling, erythema at the siteChronic stage: pain and drainage from ulcer or sinus tract. Patients may present with cellulitis or a superficial or deep wound infection continuous osteomyelitis Occurs in older pts w diabetes or vascular impairmento Skin breakdown & foot ulcers dev over wt bearing areaso develops by contiguous spread of infection and may lead to gangrene from S. AUREUS or polymicrobial with aerobes and anaerobes vascular osteomyelitis what is the pathology of osteomyelitis in infants <1 year old GBS, s. aureus, e. coli what is the pathology of osteomyelitis in children 1-16yo S. aureus, s. pyogenes, H. flu what is the pathology of osteomyelitis in adults >18 S. aureus, s. epidermis, E.coli, pseudomonas, serratia (IVDU), salmonella what organism is MC in osteomyelitis with IVDU pts serratia what organism is MC in osteomyelitis with sickle cell disease salmonella fever, local pain, decreased range of motion, blood cultures + in 50%, no drainage long bone osteomyelitis (kids) constant dull pain that progresses slowly, local tenderness, neurologic sx may suggest epidural abscess, < 50% have fever vertebral osteomyelitis (adults) useful in differentiating osteo from soft tissue infection in diabetics indium scan What is the treatment for Osteo from vascular insufficiency: Abx to treat staph aureus + debridement and wound care. Diabetics may need long term antibiotics What is the treatment for Acute hematogenous osteo in adults: abx for 4-6 weeks plus debridement • Beta lactam pencillin (pipercillin/tazobactam, ampicillin/sulbactam or ticarcillin/clavulante• Add vancomycin if MRSA is suspected: 8 weeks of tx is needed What is the treatment fo Acute hematogenous osteo in children ABx alone for 2-4 weeks• Beta lactam pencillin (pipercillin/tazobactam, ampicillin/sulbactam or ticarcillin/clavulante• Add vancomycin if MRSA is suspected: 8 weeks of tx is needed What is the treatment for acutely ill pt w/ osteomyelitis • Beta lactam pencillin (pipercillin/tazobactam, ampicillin/sulbactam or ticarcillin/clavulante• Add vancomycin if MRSA is suspected: 8 weeks of tx is needed What is the treatment for osteomyelitis seen post-surgery (GNB) (1) Cipro (2) ceftriaxone (3) ceftazidime What is the treatment for Vascular Osteo in diabetics or Contiguous Osteo in trauma- (1) ticar/ clave (2) imipenem (3)cipro + clinda What is the treatment for s. aureus naficillin, MSSA, vancomycin MRSA What is the treatment for GBS ampicillin or ceftriaxone what is the treatment for enterococci in diabetics ampicillin and gentamicin what are the normal antibacterial substances that protect someone from developing CAP from their normal flora of the upper respiratory tract IgA, AAT, lysozyme, alveolar macrophages how do these organisms cause pneumonia mycoplasma, legionella, chlamydia, Q fever, respiratory viruses, MTB inhalation of aerosolized droplets how do these organisms cause pneumonia : pneumococci, S. aureus, gram negative bacilli, anerobes aspiration of nasopharyngeal organism how do these organisms cause pneumonia: S.aureus, GNB, via bacteremia or endocarditis hematogenous seeding what three organisms cause lobar consolidation with pneumonia (1) s. pneumonia (2) h. influenza (3) m. catarrhalis what three organisms are hospital acquired for pneumonia that cause necrosis/ cavitation (1) s. aureus (2) GNB (3) p. aeruginosa what are the three common atypical (diffuse) pneumonia organisms (1) M. pneumonia (2) legionella (3) C. pneumonia what two organisms occur in CABP in presence of cardiopulmonary disease H. flu and M catarrhalis what organism follows influenza and causes CABP S. aureus who is GNB CABP commonly seen in immunosuppressed/ smokers hacking cough in CABP is usually what organisms mycoplasma/chlamydia/viral what is the CURB 65 criteria (1) Confusion (2) Uremia >7mmol?L(3) RR >30 (4) BP <90 Sys or dip <60 (5) age >65 what is the normal outpatient treatment for CAP o Macrolide (azithromycin 500mg, clarithromycin, or erythromycin) o Respiratory fluoroquinolone (levofloxacin, moxifloxacin or gemifloxacin)o Txis given for min of 5 d, pt should be afebrile for 48-72 hrs and show minimal signs of clinical instability what is the recommended treatment for CAP with patients with co morbidities (chronic heart/lung dz, alcoholism, malignancies, asplenia, immunosuppressed) o b-lactam plus a macrolide (strong recommendation; level I evidence) High-dose amoxicillin [e.g., 1gm 3 times daily] or amoxicillin-clavulanate [2gm 2 times daily] is preferredRespiratory fluroquinolones can also be used (moxi or levo) what is the inpatient treatment for CABP o Resp fluoroquinoloneso b-lactam plus macrolide ( cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patientso Tx for a min of 5 d, should be afebrile for 48–72 and w.out evidence of clinical instability before d.c what are the 7 criteria for clinical stability with CABP (1) T >37.8 (2) HR 100 (3) RR 24 (4) SBP 90 (5) O2 sat 90/ 60mmHg on RA (6) ability to maintain oral intake (7) normal mental status what is the treatment for MTB o Treatment of MTb- Isoniazid (INH), Rifampin, Ethambutol, vitamin B6o The treatment period is 6-9 months (for susceptible organisms)o Consider and screen for multi-drug resistant (MDR) organisms obligate aerobes that live in the soil , water, vegetables, and even in domestic animals and dairy products- Disease is usually seen in the immunosuppressed patient- Infections may manifest in lungs, blood, tissue atypical mycobacterial infections – Most commonly seen bugs include M. avium complex, M. kansaii, M. marinum, M. chelonae atypical mycoplasma seen in AIDS patients and severely immunosuppressed m. avium complex atypical mycoplasma seen in aquarium workers M. marinum atypical mycoplasma seen in transplant, immunosppressed M. kansaii atypical mycoplasma seen in post surgical procedures and procedures involving the eye m. chelonae Fiery red rash, Well demarcated margins, Intense pain with bullae formationo Group A strep usual pathogeno Rx –Penicillin erysipelas if S. aureus is suspected in a pt w/ erysipelas how do you tx them skin structure infection glycopeptide – Oritavancin- Dalbavancin- Tedizolid Infection of skin and subcutaneous tissue, Usually involves lower extremitieso Large area of skin involved that may progress for 24 hourso Bullae, lymphangitiso Group A strep, Staph aureus (consider CA-MRSA in NYC) enter via minor abrasions of skin cellulitis what is the most common drug for MRSA cellulitis bactrim what are the 5 drugs we use for MRSA cellulitis (oral) (1) bactrim (2) rifampin (3) clinda (4) Tetracyclines (5) linezolid what drug do you use to treat cellulitis if you dont think its MRSA keflex Papules progress to pustules & vesicles w honey brown crusts–Agent: Staph aureus or group A strepo Possible sequelae: Post streptococcal GN w/ GASo Topical tx: Mupirocin (Bactroban)o Systemic txt: Beta lactam (Augmentin- MSSA or TMP/SMX-MRSA) impetigo Infection of the hair follicle, Usually self-limitedo Staph aureus, pseudomonas (“hot tub” folliculitis)o Tx: Topical antibacterial soap/ good hygiene, warm compresses? If staph is suspected- Dicloxicillin or TMP/SMX (MRSA) folliculitis Medical emergency! Infection of tissues or fascia around muscleso Rapid progression, fever, rash, purplish discoloration, tissue damageo Grp A strep alone or with anaerobeso Antibiotics+ extensive debridement necrotizing fasciitis Papular rash with burrows involving finger webs, flexor surfaces, Intense pruritis, easy transmissionthe number of mites on a host is 10 to 15o Cause: S. scabeio Rx: topical permethrin, lindane or ivermectin scabies thick, hyperkeratotic crusts that can occur on almost any area of the body.o TX: soaks to loosen and remove crusts and administration of topical scabicidalwill have thousands to millions of mites. crusted norwegian scabies feed at night, usually an hr before dawn, – bites are painless, but pruritus & purpuric macules may appear. – do not usually require any tx – Creams w corticosteroids & oral antihistamines for allergic rxn. Abx cream/ointment if 2ndry infxn occurs bed bugs (cimix lectularis) caused by reactivated VZV infection, Dermatomal rash, painful vesicles- o Can be preceded (48-72 hours) by a prodrome of fatigue, malaise, abnormal sensation in the area of the HZ, tx to reduce time of rash not to cure herpes zoster what is the most serious complication of herpes zoster post-herpetic neuralgia how do you treat herpes zoster Acyclovir 200mg 5x/ day x 7-10 days or Valacyclovir 1 gram 3x/day x 7 days or famciclovir 500mg 3x/day x 7 days to Painful vesicles in clusters on the skin, outbreaks last 7-10d w/ out treatment, types 1 and 2 cause skin lesions, others can cause cancers herpes simplex what is the initial treatment of herpes simplex o Txt: Acyclovir 200mg 5x/day or 400mg TID x 10 days, Valacyclovir 1 gram bid x 7-10 daysFamciclovir is NOT approved for treatment of initial episodes of HS what is the treatment for recurrent herpes simplex valcyclovir, famciclovir what is the suppressive treatment for genital herpes acyclovir 400mg BID, valacyclovir 1 gram daily, famciclovir 250mg twice daily inhalation of aerosolized droplets or ingestion of viral particleso SX-fever, fatigue, malaise, HA 1-3 d prior to rash– itchy vesicles in random distrib seen first on face, chest & back• Vesicles crust & scab, can cause scarso Illness lasts 5-10 d varicella zoster 24-48 hrs after ingestion of contam food or water- Each epi lasts only 24-72 hours. The onset can be abrupt or gradual- Sx: N/V Watery diarrhea (nonbloody), Abdominal cramps, Myalgias and malaise- Tx: hydration and support, avoid antimolility drugs symptomatic gastroenteritis person to person via direct contact, exposure to aerosols, or fecal–oral routes- are highly contagious, with infection requiring fever than 10 virions- resistant to freezing, heat, disinfection etc. – incubation 1-2d, sxs 1-3d- 96% viral gastroent norovirus large # cases diarrhea in winter, transmission fecal-oral – watery, non-bloody diarrhea, fever, vomiting, assoc resp infxn. Sxs usually last 3-4 days – Tx hydration and supportive rotavirus how do you diagnose human rotavirus (HRV) gastroenteritis rotazyme test Single most common cause of acute illness and physician visits in the U.S viral respiratory disease Causes URI and LRI, primarily in infants and childreno Can cause disease in immunocompromised adultso Transmission via inhaled respiratory particlesMC seen in spring, summer and fall parainfluenza parainfluenza associated with common URI symptoms and Croup in children HPIV-1 parainfluenza associated with broncholitis, bronchitis and pneumonia HPIV-2 ost common cause of broncholitis in children under 12 months in the US, most prevalent nov-april – runny nose, decreased appetite, cough, sneezing, fever–Recovery in 1-2 weeks- TX= symptomatic and respiratory support respiratory syncytial virus >100 serotypes–Main cause of the “common cold” (50%)–Usually affects the upper respiratory tract- nasal discharge, sneezing, sore throat, headache, cough, no fever, wheeze, sputum production rhinovirus what are the treatments for the common cold o Antihistamines- diphenhydramine (sedating), loratadine, cetirizine, fexofenadine, chlorpheniramine (less sedating) o Decongestants- pseudoephedrine, phenylephrine to loosen nasal congestiono Mucolytic- guiafenesin, dextromethrophan all are transmitted by direct contact with respiratory secretions-small particle aerosols, late winter, spring, early summero Syndromes: pharyngitis, conjunctivitis, tracheobronchitis, pneumonia adenovirus what are the four syndromes that accompany adenovirus (1) pharyngitis (2) conjunctivitis (3) tracheobronchitis (4) pneumonia how do you treat and prevent adenovirus o No specific treatment or vaccine available. Strict attention to good infection-control practices is effective for stopping nosocomial outbreaks of adenovirus-associated disease Mod sized, enveloped RNA virus with 3 antigenic types + SARS Co virus, transmission via inhalation of large particle droplets– more often in the winter- runny nose, sore throat, cough, HA, fever & chills- symptomatic tx, dx test only if suspect SARS coronavirus are there any effective antivirals or vaccines for coronavirus no form of viral pneumonia where infection with a serotype of coronavirus encompasses the lower respiratory tract, pts can dev ARDS, fever, nasal congestion, cough, sneezing Tx= plasma transfer and support of respiratory function w/ O2 and mech vent SARS what are the serologic tests done for SARS indirect fluorescent antibody testing and enzyme linked immunosorbent assays to detect ab's against virus when can you determine someone is negative for coronavirus Although some patients have detectable coronavirus antibody within 14 days of illness onset, definitive interpretation of negative coronavirus antibody tests is possible only for specimens obtained >21 days after onset of fever. what molecular testing is done to detect SARS reverse transcriptase-polymerase chain reaction (RT-PCR) tests specific for the RNA from this novel coronavirus. This can detect infection within the first 10 days after the onset of fever in some SARS patients fever, cough, and shortness of breath, o Pneumonia is a common finding on examination. Gastrointestinal symptoms, including diarrhea, have also been reported. Can progress to organ failure, shock, respiratory failure that needs tx in ICU MERS-COV how is MERs transmitted -The virus does not seem to pass easily from person to person unless there is close contact, such as occurs when providing unprotected care to a patient. o No sustained community transmission has been documented how do you treat MERS No vaccine or specific treatment is currently available. Treatment is supportive and based on the patient’s clinical condition how do you prevent MERS Good hand hygiene, limit contact with bats, camels in the Middle East, eat well cooked foods & consistent infxn control practice for HCW who treat patients with MERS-CoV what kind of virus is influenza RNA enveloped virus what are the two surface proteins that influenza A subtypes are based on hemagglutinin (HA) and neuraminidase (NA) surface proteins how many types of hemagglutinin (HA) influenza A subtypes are there 3 (H1, H2, H3) how many neuraminidase (NA) surface proteins are there 2 (N1, N2) who do influenza A, B, and C infect o Influenza A infects humans and other species (swine, horses, birds)o Influenza B and C infect only humans how is influenza transmitted o Transmission via inhalation of large and small aerosolized particleso Epidemics occur annually from Dec–March in temperate areas refers to minor changes in HA and less often in NA that occurs frequently (usually every few years) as a result of point mutations due to selective immunologic pressure in the population. Result- minor antigenic change antigenic drift occurs only in influenza A as a result of acquisition of new gene segments of HA and/or NA (occurs every few decades). Result: major antigenic change causing pandemics. Examples- H1N1(1918), H2N2(1957), H3N2(1968), H1N1(1976) and H1N1 (2009) antigenic shift fever (100-1040 F), sore throat, myalagia, headache, cough (usually non-productive)- Dx: nasopharyngeal swabs or pharynx swabs for viral culture influenza what two drugs are used to treat and shorten the course of influenza Oseltamivir 75mg po bid x 5 days or Zanamivir 5mg inhalation bid x 5 days 3 inactivated injectable vaccineso 1 nasal mist approved by the FDA for seasonal o vaccine in the U.S. is changed every yr to combat the prevalent serotype found in Asia influenza vaccine what are the new influenza vaccine recommendations ? All persons 6 months or older should have a seasonal influenza vaccine in the 2012-13? Vaccination should occur before influenza occurs in the community and continue until the end of the influenza season in the community How is the Live Attenuated influenza Vaccine (LAIV)—administered via inhalation how is the trivalent inactivated influenza vaccine administered IM injection or SubQ when should adults receive the pneumococcal vaccine Adults aged ?65 years who have not prev received pneumococcal vaccine or whose hx is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23. The dose of PPSV23 should be given 6–12 months after a dose of PCV13. vaccine routinely recommended for childrenvaccines are interchangeable; however, if different brands of vaccines are admin for dose #1 & #2, a total of 3 doses are nec to complete the primary series in infants. Vaccine NOT given if child is over 5. H. influenza B vaccine pneumococcal vaccine recommended for children ages 2-23 month1 dose to healthy children 2-5 not previously vaccinated. heptavalent pneumococcal vaccine recommended for elderly and others with diabetes, heart or lung disorders1 dose to adults may be repeated every 5-7 years for <65 at risk or >65 at risk 23 valent vaccine (Pneumovax) recommended for college bound students, military recruits and others (Menomune, Menactra). Does not cover group B meningococcus meningococcal vaccine (menacer–1 dose) when should long adults receive a meningococcal group B vaccine Young adults aged 16-23 yrs who are healthy and not at incr risk for serogroup B meningococcal dz a 2-dose series of MenB-4C at least 1 mo apart or a 2-dose series of MenBFHbp at 0 & 6 mos for short-term protection campylobacter, shigella, salmonella, (responsible for >90% of all cases) yersinia, invasive E coli, clostridium difficle, aeromonas, entamoeba histolytica inflammatory infectious diarrhea bacteria vibrio cholerae, vibrio parahemolyticus, enterotoxigenic E coli, rotavirus, norwalk agent non-inflammatory infectious diarrhea bacteria o Results from either an imbalance in the absorptive- secretory processes of the bowel or intestinal hypermotilitymay be classified as inflammatory (organisms invade the bowel mucosa) or noninflammatory (pathogens elaborate enterotoxins) infectious diarrhea Infection caused by ingestion of contaminated food, exposure to infected dogs, unpasteurized milk, SXS=crampy and pain, profuse foul smelling, watery diarrhea, stool bloodyDX: small, motile comma shaped on gram stain campylobacter how do you treat campylobacter ? Rx: hydration, abx for pts w/ moderate to severe disease in immunocompromised pts • Macrolides, quinolones (resistance increasing) • Avoid anti-motility drugs (diphenoxylate, loperimide) type of campylobacter that invades intestinal epithelial cells c. jejuni -acquired from ingestion of contaminated food (eggs, cheese, fruit, poultry), water, drugs SX= N/V, fever, watery diarrhea, abd pain after 6-72 hours of injection, DX stool exam, culture on selective media non-typhoidal salmonella (S. typhimurium and enteriditis) how do you treat non-typhoidal salmonella ? Rx: ABx recommended for infants, patients• >50 yrs, those with cardiac valve abnormalities and prosthetic vascular grafts• quinolones, TMP/SMX, ceftriaxone HIGHLY INFECTIOUS—ingestion of only 10-100 organisms causes disease via invasion of proximal small bowel, spread by contaminated food and water–SX fever, abd cramps, watery diarrhea followed by blood & mucus, rectal urgency, tenesmus, freq small vol diar shigella how do you dx shigella stool exam+ cultures, blood cultures how do you tx shigella hydration, ABx (TMP/SMX, quinolones) to shorten the course of clinical illness are gram-negative bacilli that live in salinated water, produce multiple extracellular cytotoxins and enzymes that are associated with extensive tissue damage explosive watery diarrhea, crampy abd pain , N/V. vibrio species toxigenic-01 strain of vibrio: only sporadic cases in the U.S. vibrio cholera common cause of diarrhea in the U.S from vibrio, 25% p/w bloody stool vibrio parahemolyticus associated with 94% of all vibrio deaths. vibrio vulnificus how do you tx vibrio fluid and electrolyte replacement use doxy or quinolone in severely ill cause of traveler's diarrhea, watery diarrhea without polymorphonuclear (PMN) leukocytes. acts on the GI mucosa, leading to an outpouring of copious fluid from the small bowel. Large fluid loss may result in dehydration enterotoxigenic E. coli (ETEC) what kind of e. coli is inflammatory and what isnt enterotoxigenic E. coli is non-inflammatory and enteropathogenic and enterohemorrhagic are inflammatory how do you treat enterotoxigenic coli doxycycline, trimethoprim/sulfamethoxazole (TMP/SMZ), or fluoroquinoloneso Abx may shorten the duration of diarrhea by 24-36 h o Symptomatic/Supportive treatment (fluids, pepto-bismol) cause of childhood diarrhea, underdev countries or nursery outbreaks – watery non-bloody diarrhea, fever, the child may be dehydrated, no inflammation cells found in the diarrheal fluid, may last longer than 2 weeks enteropathogenic E. coli what treatment is contraindicated in enteropathogenic e. coli in children anti-motility agents • Dysentery- fever, bloody diarrhea, abd cramping, tenesmus lasting 5-7 do PMN leukocytes• HUS (serotype 0157:H7) fever, watery to bloody diarrhea, dehydration, hemolysis, thrombocytopenia, & uremia requiring dialysis enterohemorrhagic E. coli (EHEC) fever, bloody diarrhea, abdominal cramping, tenesmus lasting 5-7 do PMN leukocytes, Intestinal mucosa produces a significant inflammatory response. caused by EHEC dysentery what is the serotype for HUS serotype 0157:H7) fever, watery to bloody diarrhea, dehydration, hemolysis, thrombocytopenia, and uremia requiring dialysiscaused by EHEC hemolyticc uremic syndrome (serotype 0157:H7) not useful in enterohemorrhagic E coli (EHEC) infection and may predispose to development of HUS antibiotics what are the three intestinal protozoal diseases giardiasis lamblia, entamoeba histolytica, cryptosporidia mode of transmission—contaminated water, fecal-oral o Sx: Nausea, bloating, gas, diarrhea, anorexia o Tx: Metronidazole 250mg PO/IV tid or Paromomycin 500-750mg PO tid giardiasis lamblia Mode of Transmission- Contaminated water, fecal-oral, contaminated foodo Sx: Colitis, dysentery, diarrhea, liver abscesso Tx: Iodoquinol 650 mg PO tid; Metronidazole 500-750 mg PO/IV tid: Paramomycin 500-750 mg PO tid entamoeba histolytica Mode of Transmission- Contaminated water, swimming pools, fecal-oralo Sx: immunocompetent patients: Self-limited diarrhea ; Immuno- suppressed patients: Severe and interminable diarrheao Tx: No tx nec in immunocomp pts; immunosuppressed-Nitazoxanide cryptosporidiosis what is the treatment for giardiasis lamblia metronidazole and paromomyicin what is the treatment for entamoeba histolytic iodoquinol, metronidazole, paramomyicin what is the treatment for cryptosporidiosis No treatment necessary in immunocompetent patients; immunosuppressed-Nitazoxanide 500 mg PO bid for 3 d Ascariasis, hookworm, trichuriasis, stronylodiasis, onchocerciasis, lymphatic filariasis, Loisis, Guinea worm nematodes : schistosomasis, Food-borne flukes, cysticercosis platyhelminths what are the 5 most common helminthiases are those caused by infection with intestinal helminths (1) ascariasis (2) trichuriasis (3) hookworm (4) shistosomiasis (5) LF systemic infection caused by the spirochete Borrelia burgdorferi. The bacteria are inoculated into the skin by a tick bite, nearly always from hard-bodied ticks of the genus Ixodeso distinct affinity for skin, heart, CNS, joints, and eyes. lyme disease early) erythema migrans rash, low-grade fever, non-specific flu-like illness ( fatigue, headache, myalgias, and arthralgias ), Dx w/ acute and convalescent phase serologic testing lyme disease what are the 4 abx you can use to treat lyme disease Amoxicillin , Doxycycline , Cefuroxime, Ceftriaxone – for CNS disease) venereal disease caused by infection with the spirochete Treponema pallidum. It can also be acquired via exposure to infected bloodDx: RPR screen and confirm with FTA syphilis what is seen in primary syphilis chancre Characterized by morbilliform erythematous rash but lesions can be pustular, annular, or scaling• All of these lesions contain treponemes• Typically seen in the palms and soles secondary syphilis lesion of late syphilis. The lesion is easily confused with HPV-associated genital or anal warts. These lesions are highly contagious and contain treponemes condyloma lata (2ndary syph) characterized by multi-organ disease (gumma) especially cardiovascular (80-85%) and CNS (5-10%) • Sx: Fever, jaundice, anemia, and nighttime skeletal pain tertiary/late syphilis manifests as an insidious and progressive loss of mental and physical functions and is accompanied by mood alterations in tertiary/late syphilis neurosyphilis what is the TOC in primary and secondary syphilis Benzathine penicillin G (Bicillin) 2.4 million units IM x 1 or x 3 (1 per week/ 3 weeks) characterized by fever, myalgia and headache after treatment for syphilis. Usually seen in patients treated early in the infection. Possibly related to elevated treponema levels. Jarisch-Herxheimer Reaction what happens to RPR and FTA testing when immunocompetent patient is successfully treated In immunocompetent patients-RPR should revert to negative but FTA may remain detectable indefinitely what RPR level is considered positive cure in immunocompromised patients treated for syphilis In immunocompromised patients- RPR may remain positive but cure is considered RPR at 1:2 or 3 fold decrease from highest level what should pregnant women with syphilis be treated with bazathine penicillin what is the treatment for latent syphilis Penicillin G Procaine (Crysticillin)-2.4 million U IM qd for 17-21 d what is the treatment for neurosyphilis Penicillin G Procaine (Crysticillin)-2.4 million U IM qd for 17-21 dAdd probenecid 500 mg PO qid for 17-21 d tick borne disease caused by Rickettsia rickettsia coccobacilli, spring/early summer, incr risk w/ exposure to dogs and wooded areas w/ high grassSX: fever, severe HA, rash of palms/soles late finding, myalgia, malaise, N/ abd pain, V rocky mountain spotted fever what are the three most common vectors for rocky mountain spotted fever (1) american dog tick (2) brown dog tick (3) rocky mountain wood tick what do you treat pts with RMSF doxycycline what do you treat pregnant pts with RMSF chloramphenicol what are 4 common bugs that lead to skin findings in sepsis Meningococcemia, purpura fulminans, erythremaderma toxic shock syndrome, RMSF, steven Johnson-syndrome (1) N. meningitides, (2) Strep A, (3) Staph aureus, (4) rickettsia spp. what are 3 common bugs that lead to soft tissue findings in sepsis –: necrotizing fasciitis, clostridial infection GAS, MRSA, clostridia perfringens what are 2 common bugs that leads to neurologic findings in sepsis (bacterial meningitis) N. meningitis, s. pneumonia – Humans acquired HIV-1 from ____, and HIV-2 from the ____ 1) chimpanzees 2) mangabey monkey retroviruses that belong to the family of lentiviruses – HIV-1, HIV-2 phylogenetically related to HIV viruses- HIV was probably transmitted into humans as this – SIV (simian immunodeficiency virus) who is PrEP pre-exposure prophylaxis recommended for (1) sexually-active adult MSM (men who have sex with men) at substantial risk of HIV acquisition (IA)(2) adult heterosexually active men and women who are at substantial risk of HIV acquisition. (IA)(3) IDU at substantial risk of HIV acquisition. (IA) what combination has been proven successful for pre-exposure prophylaxis to HIV Daily oral PrEP with the fixed-dose combination of tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg has been shown to be safe and effective in reducing the risk of sexual HIV acquisition in adults; therefore – HIV infection should be assessed at what intervals while patients are taking PrEP so that those with incident infection do not continue taking it. at least every 3 months a mono or influenza like illness occurs in HIV pts – Sx: fever, fatigue, rash, HA, myalgias, arthralgias, lymphadenopathy, pharyngitis- Labs: nonspecific, ELISA + in 4 wks, plasma p24 antigen & HIV RNA + earlier acute retroviral infection when do you treat HIV patients that develop an acute retroviral infection Rx: ASAP because patients are highly infectious, may have a long interval of asymptomatic infection, and there is a unique opportunity to preserve HIV directed CD4+ and CD8+ cells looks for antibody to HIV-1 (and sometimes HIV-2) – Can be done using serum or saliva – Rapid testing (20 minutes for a result) has revolutionized testing – Home testing kits are also available hiv antibody testing – The conventional serum test for diagnosing HIV infection is the repeatedly reactive immunoassay followed by confirmatory Western blot or immunofluorescent assay. The test is highly accurate (sensitivity and specificity, >99.5%), and results are available within 1 to 2 days from most commercial laboratories. may use either blood or oral fluid specimens and can provide results in 5 to 40 minutes. The sensitivity and specificity of test are also both greater than 99.5%; however, initial positive results require confirmation with conventional methods. rapid hiv testing what are the USPSTF recommendations for screening patients for HIV – The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. looks for HIV-1 antigen in plasma. PCR, bDNA, Taqman are the most popular. Different levels of sensitivity.- PCR< 50 copies or <400 copies- bDNA< 75 copies- Taqman< 20 copies or <48 copies HIV PCR viral load testing how many copies in PCR testing for viral load <50 copies or <400 copies how many copies in bDNA testing for viral load <75 copies how many copies in Taqman testing for viral load <20 copies or <48 copies what tests need to be monitored in HIV patients and patients on ART every 3-6 months (1) viral load (2) CBC (3) chemistries (4) LFT/bili how often do fasting lipids need to be monitored in HIV patients and patients on ART annually if nl at last measurement, every 6 months if abnormal how often do fasting glucose need to be monitored in HIV patients and patients on ART annually if nl at last measurement, every 6 months if abnormal how often does a pt need to have a urinalysis if they have HIV or are on ART every 6 months if on tenofovir when does the WHO recommend starting treatment for pts w/ HIV – WHO (September 2015) recommends starting treatment immediately for all HIV infected persons (regardless of CD4 count or viral load) DHHS guideline states – Antiretroviral therapy (ART) is recommended for all HIV-infected pts to reduce risk of dz progression. o strength and evidence for this recommendation vary by pretreatment CD4 cell count: CD4 count <350 cells/mm3 (AI); CD4 count 350 cells/mm3 to 500 cells/mm3 (AII); CD4 count >500 cells/mm3 (BIII). what is the normal ARV therapy for HIV pts (1) Two NRTI's in combo w/ (2) 3rd active antiretroviral drugs from one of three classes 1. integrase strand transfer inhibitors 2. NNRTI, 3. PI w/ pharmacokinetic enhancer what is the DHHS recommendation for ARV naive patients who are HLA-B*5701 negative – Dolutegravir/abacavir/lamivudinea what is the DHHS recommendation for ARV naive patients DTE – Dolutegravir plus tenofovir/emtricitabinea,b (AI) what is the DHHS recommendation for ARV naive patients ECTE – Elvitegravir/cobicistat/tenofovir/emtricitabineb (AI) what is the DHHS recommendation for ARV naive patients RTE – Raltegravir plus tenofovir/emtricitabinea,b (AI for tenofovir disoproxil fumarate, AII for tenofovir alafenamide)a,b what are the 4 NNRTI's (1) delavirdine (2) efavirenz (3) nevirapine (4) rilpilvirine what are the 3 integrase inhibitors (1) raltegravir (2) elvitegravir (3) dolbutegravir what is the booster (can be used with a PI) cobicstat fusion inhibitor enfuvirtide (1) abacavir (2) didanosine (3) emtricitabine (4) lamivudine (5) stavudine (6) zidovudine (7) tenofovir (8) tenofovir alafenamide NRTI's CCR5 maraviroc (1) amprenavir (2) atazanavir (3) darunavir (4) fosamprenavir (5) indinavir (6) lopinavir (7) nelfinavir (8) ritonavir (9) saquinavir (gel/tablet) (10 ) tirpanavir PI what 4 meds are in genvoya (1) tenofovir alafenamide (2) emtricabine (3) elvitegravir (4) cobicstat what meds are in complera (1) tenofovir (2) emtricitabine (3) rilpilvirine what meds are in odefsey (1) rilpilvirine (2) emtricitabine (3) tenofovir alafenamide what meds are in stribild (1) tenofovir (2) emtricitabine (3) elvitegravir (4) cobicstat what meds are in triumeq (1) abacavir (2) lamivudine (3) dolbutegravir what meds are in atripla (1) tenofovir (2) emtricitabine (3) efavirenz – Hypersensitivity: rash, fever, nausea, oral lesions, cough in 3% of patients treated with this NRTI abacavir ADR mild in 20%, severe in 3% with NRTI’s lactic acidemia 3 ADR's in 15% with protease inhibitors (PI’s) insulin resistance and hyperglycemia, hyperlipidemia, lipodystrophy what two ARV drugs cause elevated creatinine clearance tenofovir, cobicstat what two ARV drugs cause neuropsychiatric effects Efavirenz, rilpivirine (NNRTI's) what is the definition of aids A person infected with HIV and a CD4 cell count below 200 or a person infected with HIV an opportunistic infection what common opportunistic infection in HIV pts is seen in eyes CMV what common opportunistic infection in HIV pts is seen in mouth and throat candidiasis what common opportunistic infection in HIV pts is seen in skin herpes simplex, shingles what common opportunistic infection in HIV pts is seen in brain toxoplasmosis, cryptococcal meningitis what common opportunistic infection in HIV pts is seen in the lungs PCP pneumonia, MAC, TB, histoplasmosis what common opportunistic infection in HIV pts is seen in the gut CMV, cryptosporidiosis what common opportunistic infection in HIV pts is seen in the genitals herpes simplex, HPV, candidiasis in patients who have never had an O.I but are likely to get one depending on their CD4 cell count primary prevention prevention in patients who have already had an O.I secondary prevention when can you stop primary and secondary opportunistic infection in hiv patients – Both primary and secondary prophylaxis can be stopped in patients who have had a sustained improvement in their CD4 cell count sustained above 200 on antiretroviral treatment what is the ppx regimen for PCP bactrim 1x daily CD4 <200 what is the ppx regimen for toxoplasma TMP/SMX in patients with IgG antibody and CD4 cell count <100/ul what is the ppx regimen for MTB exposure PPD >5 mm) INH 300 mg + B6 for 9 months what is the ppx regimen for MAC azithromycin 1200 mg/ weekly in patients with CD4 count <50/ul what is the ppx regimen for cryptococcus after documented disease- fluconazole 200 mg orally daily what is the ppx regimen fo CMV ganciclovir I.V, foscarnet I.V, valganciclovir P.O or ocular implants after documented infection treated

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