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Review for
Infectious D.
Comments
Answers.
Important to know the CX
but also w
AMS ,
encephalit
symptoms
Brain Inflammation
Initial workup for cx of Headache and Fever,
LP if safe.-Need to rule out high ICP using (FAILS) and
then CT.
Start ATB (Vanc. Piptazo. Asap.) after blood cultures
and LP (if you get them)
Treatment is always -?
Cx; photo phono phobia .
Dx: WBC PMN 1000s , GLu low. Proteins high.
fungal- glu low. Prot. High. Wbc. lymp.
TBIf Bacterial - neisseria . H. Flu. s. Pneumo -> PMN high.
Treat EMP. Standard.
If PMN not that high. -> something else.
1. RMSF - camper. Maculopapular rash centrifugal
spread. Dx. With serology and tx with doxy or ceftriaxone.
2. Lyme - if disseminated or late . With heart block.
Neural cx. Arthralgias - > dx. Serology tx: ceftriaxone.
3. TB- homeless. Tb risk factors. -> get cxr- AFB.
Dx. With CSF (tb?)
tx: RIPE.
4. Cryptococc.- HIV . Opening pressure is high..
CSF- ag. Tx. Ampho _flucytosine . Later (8weeks of
fluconazole)
Encephalitis
Dx: lp. Lymphocytes. GLu nl. Protein higher.
PCR - HSV TXl acyclorive iv.
Abscess or mass
Mass r/o cancer . If toxo signs . Periventricular calci. And
HIV.. serology TOxo.
Tx. Pyramethamine + sulfadiazine. \
Cryptococcal meningitis
Patients with HIV who have cryptococcal
meningitis require treatment in 3 stages as follows:
1. Induction - amphotericin B and flucytosine for >2
weeks (until symptoms abate and CSF is
sterilized)
2. Consolidation - high-dose oral fluconazole for 8
weeks
3. Maintenance - lower-dose oral fluconazole for >1
year to prevent recurrence
Meningoenhalitis Causes are HSV, West nile,
Adenovirus(coxsakie)
- Empiric fo
(acyclovir
Meningitis
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Answers.
HIV
Acute retroviral Illness Cx Mono like. But it differs from mono. mucocutaneous painful. Ulcers. Rash-palm and
soles.
Dx: p23 + elisa ( hiv ab.)
do PCR for virus.
Tx: start ART * NNRT 2 + 1 (protease. Integrase . Fusion . )
things to consider before starting therapy.
1. Viral load. CD count .
2. Genotype.
3. Comorbidities.
HepB. Hep C. TB.
other STD.
chronic dz. - cuz hiv ppl are inflammatory
have risk for CAD.
Opportunistic infections
CD 200 -> PCP ppx with Bactrim. -> Dapsone ->
atorvaqone + levocarine.
CD 100 > TOXO. - Bactrim. -> pentamidine.
CD 50 > CMV .. MAI -azithromycin.
Other problems?
* HIV lipodystrophy. consider statin for this.
Diagnoses
tell pt after confirmation and also contact partner .
Report to CDC.
screening . Screening for postexposure
May be negative in 4-8week repeat test. But start ppx (2+1)
asap within hours of exposure.
pregnancy and HIV
Vertical transcmission is highest risk. =- mom on
2+1 and give AZT during birth.
Sepsis
SIRS criteria.
2/4 - fever, WBC, RR, HR.
Sepsis
when there is infectious source.
Severe sepsis vs septic shock?
Bothe have organ dysfunction (lab values rise) . MAP <65,.
severe sepsis is responsive to fluid .
shock . Don’t respond.
Goals?- 6hr .
MAP - >65
U output >0.5ml / kg / hr.
CVP - 10-12
Sat Ven O2. >70%
Management?
ATB - empiric and IVF. Bolus.
pressors - norepi. Vasopressin - steroids.
Remove any source - lines. Plastic. Etc.
when to remove IV lines?
oxygen .
Follow ?
Lactate trending.
Pediatrics
Neonatal Sepsis
Antibiotics in pediatric sepsis
Age
Most common
organisms
Empiric
antibiotics
≤28
days
‣Group
B Streptococcus
‣Escherichia coli
‣Listeria
monocytogenes (a
ge <7 days)
‣Ampicillin +
gentamicin*
>28
days
‣Streptococcus
pneumoniae
‣Neisseria
meningitidis
‣Ceftriaxone
‣±
Vancomycin
(if meningitis
or MRSA is
suspected)
*Cefotaxime or ceftazidime can be used in place of
gentamicin for suspected meningitis due to superior
cerebrospinal fluid penetration.
MRSA = methicillin-resistant Staphylococcus
aureus.
Neonates are at increased risk for serious bacterial
infection (eg, bacteremia, urinary tract infection [UTI],
meningitis) due to their immature immune systems,
and group B Streptococcus (GBS) and Escherichia
coli are the most common organisms found in the first
month of life.
Zoonosis
Lyme
cx. Early. Rash. .
early dissed - arthralgia. Cn 7 palsy . Hear block .
late. 0meningitis. Encephalitis.
???
DX. Clinical in early phase. . serology for early dissed and
late
Tx. DOxy . Ceftriaxone for diss. Or late.
GIT infections
C. Diff.
- watery diarrhea in ATB use pt.
cx; 3-4 times in 24hr. Pain. Fever. Wbc high.
dx. _ PCR. Stool .
tx. PO fidix. Po Vance.
f/u recurrence common cuz these re spores.
And diagnosis would be clinical with typical c diff. Cx.
Tx by severity.
- fido. Vanco.
- fulminant -> IV - metronidazole and Vance
enemas can be considered.
- if severe. Surgery . For mega colon.
Respiratory infections
Pneumonia
Aspiration Pneumonia
Old patient with massive parapneumonic effusion on chest x-ray.
Aspiration Pneumonia /
Pneumonitis
Concerning
features
•
•
Historical: smoke exposure
Physical: singed hair, facial
Strong indicators
of airway injury
•
•
Oropharyngeal blistering or
Retractions, respiratory distr
Management
CO = carbon monoxide.
Inhalation injury
CO and cyanide poisoning most common
Assess for airway edema or burn using bedside
fiberoptic bronchoscope and consider intubation
if burn present
If pt is unstable or unconscious just intubate.
And 100% O2.
Inhalation injury
Pathophysiology
•
•
Upper airway thermal injury ± lower airway chemical injury
Concomitant CO & cyanide poisoning common
•
100% oxygen to displace CO
•
Stable patients with concern
fiberoptic laryngoscopy
•
Unstable patients or patients
intubation
ENT
Otitis Media and Externa
Cx ‣ Acute Otitis Media +
Posterior bulging mastoid
‣ Ant. Rotated. Ear.
Otitis Media
Path
‣
‣
‣
‣
Cx
‣ Pulling of pinna (relieve
pain)
‣ Hx of recent URI
Dx
Otoscope -> bulging
tympanic membrane
- insufflation test - rigid.
Tx
- Amoxicillin
- Amoxi-clav
- Tympanoplasty - if
(>3/6mo or 4/yr)
Path ‣ Complication of URI ear
infection or tympasnoplasty
Dx ‣ Clinical
‣ CTscan (not needed)
Respiratory bugs
H.flu (non-tapeable)
St. Pneumo
Moraxella
Tx ‣ Surgical drainage +
‣ ATB same (amici. )
F/U
Pen allergy ->
cefdinir or
macrolide.
F/U
Otitis Externa
Path ‣ Swimmer’s ear - pseudomonas
‣ Digital trauma - Staph.
Cx ‣ Unilateral ear pain
‣ No relief with pulling ear.
‣ Red canal.
Dx ‣ Clinical
Tx ‣ Spontaneously resolves
F/U ‣ If Toxic, malignant otitis externa ->
use Cipro and Steroid ear drops.
Path ‣ URI bugs
‣ Mostly viral - no
treatment needed.
Cx ‣
‣
‣
‣
Congestion sym >10d
Purulent d/c
Painful facial tap.
Worsening.
Dx ‣ 2/4 criteria -> clinical dx.
‣ Transillumination test is
also possible if unsure.
Tx ‣ Amoxi-clav.
‣ Supportive if viral.
F/U ‣ CT scan for recurrence or
foreign body. For young
kids.
Cold - Rhinitis
Mastoiditis
Pharyngitis
Sinusitis
Croup
Path
Cx
Dx ‣ Centor (4)-> treat
‣ 3-> Rapid strep
Tx
F/U
Path
Cx
Dx
Tx
F/U
Infective endocarditis
Major Criteria
Major Criteria
1. Bacteremia
2. Echo -> new
murmur
3. Echo- confirm
vegetation
Minor
1. Risk factors
(IVDU, Hx,
prosthetic valve)
2. Fever
3. Vascular ( Septic
emboli, Splinter
hemorrhages,
Jane-lesions)
4. Rheum*immuno
(rothspots, osler
nodes.GN.)
ACUTE
Subacute
2 major
1 major + 3 minor
- Bacteremia
- Murmur
- Echo shows vegetation
Signs: FROM JANE
Fever, Roth spots, Oslers, Murmur.
Janeway lesions , Anemia, Nailbed
hemorrhages, emboli
Minor criteria:
1. Risk factor
- IVDU
- Hx of endocarditis.
- Prosthetic Valve
2. Fever
3. Vascular signs:
- Septic emboli
- Splinter , nailed hemorrhages
- Janeway lesions.
4. Immune signs
- Roth spots
- Osler nodes,
- GN.
Treatment
4-6weeks Vanco
Native - Vanco + Gent
Prosthetic - Vanc + gent
- <60days + Cefipime
- 1yr + Ceftriaxone
Subacute - no Vanco. - Gent + Ceft.
Major Criteria
Minor
1. Bacteremia
1. Risk factors
2. Echo -> new
(IVDU, Hx,
murmur
prosthetic valve)
3. Echo- confirm
2. Fever
vegetation
3. Vascular ( Septic
emboli, Splinter
hemorrhages,
Jane-lesions)
4. Rheum*immuno
(rothspots, osler
nodes.GN.)
ACUTE
Path ‣ Staph
‣ Strep
Subacute
•
HACEK
Cx ‣
‣
‣
‣
CHF,
Bacteremia
TOxic
- immunologic
signs
Dx ‣ 2 blood cultures
‣ Follow until neg.
‣ TEE.
- Fever - on and off.
- Non-toxic
- Blood cultures 3 until
you get positive don’t
start ATB
- TEE
Tx ‣ Vanco
F/U
No Vanc but Genta +
Ceft.
Acute
SKIn and Soft Tissue
Infections
1. Cellulitis
Path Strep Infection into Lymph.
Cx Red, defined, (tracks or lines)
+/- fever
Dx ‣ Clinical
Tx Amoxicillin (beta lactase) cuz its strep.
F/U
Erysipelas
Path P. Acnes
Cx Zit
Path:
St. Aureus or S. Progenies
Cx
Dx
Tx
Treatment is either
Cef (2/1 gen) or amoxicilin -> pip/tazo or amoxiclav.
TMX-SMX or Clinda -> Vanco.
F/U
- DM-> Pip/tazo and Vanco.
Dx
Tx ‣
‣
‣
‣
Comedones - Top retinoids
Inflamed - Top _ Benz peroxide.
Severe- pustular - + doxy .
Resistant - Isoret.
F/U UPT - before isotret.
Path Strep Pyogenes
Staph Aureus (bulbous)
Cx Child
Honey-crusted lesion on face
Dx
Clinical
Tx Local - Mupirocin
Lots of dz -> Amoxi (strep)
Refractory - clindamycin
(staph)
F/U Can cause PSGN .
Impetigo
Acne Vulgaris
2.
Osteomyelitis
Path: recurrent or non-resolving
Cx
Dx: probe
Xray, MRI.
BEST : biopsy.
Tx :
Debridement + ATB(targeted based on
biopsy) for 4-6 weeks.
F/U- ESR and CRP (to follow resolution of
inflammation)
3. Gas Gangrene
Path:
Cx
Dx
Tx : PCN + clindamycin.
F/U
4. Necrotizing Fasciitis
Path: mcc is S. Pyogenes in healthy
DM- polymicrobial (due to poor peripheral
circulation (PAD)
Cx: look toxic. In shock.
Dx
Tx - Debride
Ceftriaxone + Clinda + Ampl-sulbac.
F/U
6. Key concepts and HY points
MCC osteo is staph (for all pt groups)
DM - polymicrob
Perforated wounds - pseudomonas.
Sickle cell - salmonella
Vibrio vulnificus
Bite wounds - amoxi-clav.for all.
Human bites-> eikinella species. (Gram neg)
Pastuerella -> cellulitis + osteomyelitis 1-2 days after a
dog/cat bite
Cat-scratch Disease
Vs. papule -> LAD
Urinary Tract Infections
Urethritis
Path: STD - Gono or chlam
Cx: discharge +
Dx: NAAT for Gono and Chlam
Tx: Ceftri - Gono
Doxy or Azithro - Chlam
Treat for both if present !
F/U- HIV. And partner treatment .
Asymptomatic Bacteruria
Path: not routine, only for pregnancy and urologic
procedures.
Cx:
Dx: UA
U-culture positive => 10^5
Tx: amoxiclav. Or Cephalexin.
Nitrofurantoin
F/U
Pyelonephritis in pregnancy:
manage with IV ceft.
no tetracyclines, Bactrim.
Floroquinolones
Gyne UTI
Recurrent UTI is >2 in 6mo or >3 in yr.
Tx with postcoital ATB.
Cystitis
Path: complicated vs non-compl
Non-comp - non-pregs. (3daystx)
Comp - Penis, Plastic, Procedure, Pyelo.
(5day tx)
Gram neg. Ecoli.
Cx: U/F/D.
Dx: UA -> nitrites + Leuk esterase.
U-culture not necessary here
Tx : Nitrofurantoin or Bactrim (3 or 5 days)
Amoxicillin for pregs.
F/U: f/u to check for resolution.
Pyelonephritis
Path:
Same G-neg.
Cx:
F/U/D + fever. Chills.
Dx
UA + U-culture
Tx
Ceftriaxone (target gram-negs) for 7days
Cipro - also alternative .
F/U - follow in 3 days to see improvement .
If not improving , ATB not working or
abscess.
Pyelonephric Abscess
Path: - not improving in 3 days.
Cx :
Dx : US or CT- abd.
Tx: Drain + ATB 14 days.
F/U
Recurrent UTI
If associated with sex-> manage with postcoital ppx
bactrim or nitrofurnatoin
Not associated with sex can have daily low dose ATB.
Lactational Mastitis
Syphillis in Pregnancy
Most Common pathogen? And treatment?
- ant-staph. (Dicloxacilin or cephalexin)
What is a common complication that can occur and how
to solve this?
- breast abscess
- Do US, then drain it.
Treat all Syphillis with Pen-IM (desensitize if allergic)
UTI in pregnancy
- All women are screened for asymp bacteriuria during
first prenatal visit (12-16weeks)
-
Pregnancy and obstetrics
Antenatal screening (36-38)
What are the exceptions to universal screening of GBS?
1. Hx of GBS bacteriuria,
2. Invasive early onset GBS in prior child.
You just treat with intrapartum ppx IV PCN.
STD
Genital Ulcers
* syphillis
* LGV
* Chancroid
* HSV
‣ What is important to know?
‣ Number
‣ Painful or not
Syphillis
Dx
NAAT
Tx •
Doxycycline
Path Spirochete,
Fu
Cx ‣ 1. Chancre- Painless, single ulcer or basically asymptomatic.
‣ 2. Fever, systemic signs + Targetoid rash on palm and soles,
‣ 3. Organs, bones, gammas, Neuro. //Tabes Dorsalis -, Arg. Rob. Pupil.
Chancroid
Dx 1. Primary - dark field micro
2. RPR -> confirm with FTA ABS
3. Neuro - CSF -> RPR -> FTA ABS
Path H. Ducreyi
Tx 1.
Cx Painful single Ulcer
PCN IM ( 1/2/ early Latent <1yr)
LAD is tender..
PCM IM 3 times . ( Latent - late or unknown )
PCN IV - (14days ) for neurosyphilis
Dx
Gram stain + culture
Tx Macrolide or Cipro.
Fu Follow treatment with RPR - titers.
HIV and other STD tests.
F/U
Lymphgranuloma Venorum LGV.
Path Clamydia. Trachoma (rare in US) ,
Cx Painless . Singles Ulcer
But LAD is painful and suppurative, ulcerate, drain.
Herpes (HSV)
Quic
k
revie
w
TOPI
CS
Path HSV 1 or HSV 2
Com
ment
s or
Answ
ers.
Cx Painful. Prodrme
Painful vesicles
Red base,
Coalesce and become ulcer.
Dx
PCR
Tx Acyclovir or Valacyclovir
F/U
- Herpes
in pregnancy?
Other
STDs
to note
Path
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Cx
Dx
Tx
F/U
Trichomonas
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Comme
P
a
t
h
C
x
D
x
T
x
F
/
U
Trichomonas
Funfact about treating during
breastfeeding?
•
Why important to treat both
partners regardless of symptoms?
- !! Risk
Stop
24hrs
cause
in high
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Template
Path
Cx
Dx
Tx
F/U
?? = Question to check cuz I’m unsure
!! - important HY stuff.