Step 2 Infectious Disease Frank P. Noto, MD Assistant Professor Mount Sinai School of Medicine Internal Medicine Clerkship Site Director
Remember, not freak out over ID. Best of luck!!!! It is not as bad as you think. Remember Think organ organism antibiotic Notice that I keep referring to the same themes over and over over again: MSSA: nafcillin, oxacillin, oxacillin, dicloxacillin, dicloxacillin, cloxaillin cloxaillin OR 1 st generation cephalosporins (cefazolin or cephalexin) MRSA: Vancomycin, daptomycin, if resistant or allergic to vanco (NOT for f or pneumonia, check CPK) bacteremia, endocarditis, cellulitis cellulitis linezolid, (do (do NOT give SSRIs, watch platelets) platelets) cellulitis, PNA tedizolid tigecycline (use for ESBL E coli that is resistant to imipenem, NOT cover pseudomonas) Quinupristin/dapfopristin Ceftaroline (5th generation) community acquired MRSA pneumonia and cellulitis telavancin, Dalbavancin IV one dose on day one and another does on day 8!! Oritavancin IV one one dose!! Skin infections Mild MRSA skin infections: TMP/SMX, doxy, clindamycin Group A strep strep throat penicillin, amoxicillin, amoxicillin, amp (cephalexin, clindamycin, clindamycin, macrolide for allergy) Serious skin infections due to Group A Strep
Enterococcus amp AND gent
penicillin AND clindamycin
Strep viridins penicillin or ceftriaxone plus gent
Gram-Positive Cocci
Penicillin G, VK, ampicillin, amoxicillin Effective against group A streptococcus, most anaerobes (not Bacteroides), actinomycosis, clostridium (not C. difficile), Listeria, syphilis Not staph: need beta-lactamase beta-lactamase inhibiters (sulbactam, (sulbactam, clavulinic acid)! Ampicillin is effective against E coli (resistance is rising) Ampicillin and amoxicillin effective for enterococci and Listeria Gram-Positive Cocci Semisynthetic penicillinase-resistant penicillins (oxacillin, cloxacillin, dicloxacillin, nafcillin) Exclusive Gram-positive coverage, staph and strep Drug of choice for MSSA, more effective than vancomycin If you see viridans, must be endocarditis Bone, heart, joint, skin *
Gram-Positive Cocci Cephalosporins Do not cover cover LAME LAME Listeria Atypicals MRSA - except ceftraoline Enteroccus
Strep viridins penicillin or ceftriaxone plus gent
Gram-Positive Cocci
Penicillin G, VK, ampicillin, amoxicillin Effective against group A streptococcus, most anaerobes (not Bacteroides), actinomycosis, clostridium (not C. difficile), Listeria, syphilis Not staph: need beta-lactamase beta-lactamase inhibiters (sulbactam, (sulbactam, clavulinic acid)! Ampicillin is effective against E coli (resistance is rising) Ampicillin and amoxicillin effective for enterococci and Listeria Gram-Positive Cocci Semisynthetic penicillinase-resistant penicillins (oxacillin, cloxacillin, dicloxacillin, nafcillin) Exclusive Gram-positive coverage, staph and strep Drug of choice for MSSA, more effective than vancomycin If you see viridans, must be endocarditis Bone, heart, joint, skin *
Gram-Positive Cocci Cephalosporins Do not cover cover LAME LAME Listeria Atypicals MRSA - except ceftraoline Enteroccus
1st Gen - cefazolin, cefdroxil, cephalexin, 2nd Gen –Cephamycins –Cephamycins : {cefoxitin, cefotetan} ONLY cephalosporin to cover
anaerobes
cefuroxime, cefprozil, cefaclor Coverage same as semisynthetic penicillins, plus some Gram-negative 1st proteus mirabilis, klebsiella, E coli 2nd - Providencia, P rovidencia, Haemophilus, Klebsiella, Enerobactor, Citrobacter, Morganella, indole-positive-Proteus, Moraxella catarrhalis Gram-Positive Cocci Cephalosporins If treating purely gram positive infection, use 1st generation, 2nd is too broad. Always narrow your coverage!
Gram-Positive Cocci . Clindamycin Excellent strep, staph and anaerobe coverage Use in penicillin allergy Use for anaerobic infections above diaphragm Metronidazole
Use for below diaphragm infections Use for C. difficile(use Metronidazole for the FIRST recurrence PO vancomycin taper for 2nd (Fidaxomicin after the 3rd recurrence) PPIs can lead to recurrent c diff Stop PPIs in a patient with C idff
Gram-Positive Cocci Cephalosporins Allergic cross-reactivity Only < 5% risk Ok if rash Never if anaphylaxis If minor infection - use macrolide or new fluoroqinlones
Serious infections - aztreonam for gram negative, plus vancomycin, linezolid, daptomycin for gram-positive Daptomycin, linezolid, tigecycline can be used for VRE Extended-Spectrum Beta-Lactamases (ESBL): E coli and Kleseilla Aci netobacter baumanni i
Very resistant gram negatives :
First line is imipenem: but now have some resistance
Use Tigecycline for resistance to these organisms Tigacyline covers ESBL gram-negative, not pseudomonas. Ceftolazone/tazobactam ESBL and MDR pseudomonas, complicated UTIs and intraabdominal infections Ceftazidime/avibactam ESBL KPC carbapenemase (very resistant) GI and serious skin infections Macrolides Mild gram-positive infections Atypical infections Do not use for serious gram-positive infection
Invasive Aspergillus
In patients with neutropenic fevers after 5 DAYS on antibiotics with new pneumonia Treatment: 1st line Voriconazole Caspofungin and Amphotericin B may also be used Neutropenic Fever ANC less than 500 Monotherapy with an antibiotic that covers pseudomonas only
If indwelling catheter, add vancomycin for MRSA Gram-Negative Bacilli
Penicillins (piperacillin, ticarcillin, mezlocillin) Full range of gram-negative Enterobacteriaceae (E coli, Enterobacter, Klebiella, Citrobacter, Morganella, Proteus, Serratia), plus pseudomonas Add beta-lactamase inhibitor, tazobactam or clavulanate) to add activity against staph Gram-Negative Bacilli Fluoroquinolones Ciprofloxacin GOOD: gram-negative coverage, including Pseudomonas NO: gram-positive coverage New fluoroquinolones (levofloxacin, gemifloxacin, moxifloxacin) Very good gram-positive coverage, gram-negative, and atypical (mycoplasma, chlamydia, Legionella) Gram-Negative Bacilli 3rd/4th generation Cephalosporins Full coverage of gram-negative bacilli, such as Enterobacteriaceae (E. coli, Proteus mirabilis, indole-positive Proteus, Klebsiella, Enterobacter, Serratia, Citrobacter), Neisseria, and H. influenzae Only ceftazidime and cefepime (4th gen) will cover pseudomonas Ceftazidime is not reliable for staph/strep PO: cifixime = gonorrhea PO: cefpodoxime Gram-Negative Bacilli Aminoglycosides Good Gram-negative coverage, including pseudomonas Synergistic with penicillin in treatment of staph Use for endocarditis Nephrotoxic and ototoxic Aztreonam Only Gram-negative coverage, use in serious infections with severe penicillin allergy Gram-Negative Bacilli Carbapenems (imipenem, meropenem, doripenem, ertapenem) Full coverage of Enterobacteriaceae, plus Pseudomonas Plus excellent gram-positive and anaerobic coverage Not MRSA, Enterococcus faecium, or Stenotrophomonas maltophila
Gram-Negative Bacilli Ertapenem Does not cover pseudomonas Approved for intra-abdominal and soft tissue infections Lower seizure threshold, especially imipenem Gram-Negative Bacilli Doxycycline Early lyme - rash, joint problems, facial palsy Rikettsiea Chlamydia Ehrlichiosis Trimethoprim-sulfamethoxazole PCP Uncomplicated cystitis
Meningitis
Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes: HIV, steroids, lymphoma, leukemia, chemo, neonates and elderly (> 50) Cryptococcus Rocky Mountain Spotted fever mid-Atlantic Tb, Lyme disease, syphilis Viruses: entero, HIV, HSV, West Nile, St. Louis Meningitis:
Fever, photophobia, headache, nuchal rigidity, N/V AMS, seizures 8th cranial nerve Petechial rash: Neisseria CT head if: focal motor deficits, seizures, papilledema, severe AMS, immunocompromised (HIV, transplant, immunosuppressive meds)
DO NOT delay treatment: start empiric antibiotics Meningitis
Normal cell count is < 5 Bacterial: cell count in thousands all neutrophils High protein and low glucose Gram stain is positive only 50 to 70% Cell count of several dozen to hundreds with lymphocytes: viral, Lyme, Tb, syphilis, fungal, Rikettsia Meningitis Treatment
Ceftriaxone and vancomycin Ampicillin if over 50 or 3 months old, HIV, steroids, hematologic malignancies, pregnancy Meningitis Cryptococcus: amphotericin B, followed by fluconazole in HIV for life or until increase in CD4 count to > 100 for 3 to 6 months on HAART Cryptococcus neoformans: India ink and crypto antigen titer Tb, treat for 9 -12 months Meningitis Steroids in Tb and streptococcus meningitis Dexamethasone 15-20 minutes before or with antibiotics Neurocysticercosis
Ingestion of Taenia solium, also called the pork tapeworm China, Southeast Asia, India, sub-Saharan Africa, and Latin America Prevalence of cysticercosis in Mexico is between 3.1 and 3.9 percent CT scan: calcified and uncalcified cysts, as well as distinguishing active and inactive cysts. Cystic lesions can show ring enhancing and focal enhancing lesions. Albendazole Brain Abscess
Spread from mastoiditis, dental infections, sinusitis, otitis media, bloodstream Streptococcus: 60 to 70% (viridans streptococci, Streptococcus milleri, microaerophilic streptococci) Bacteriodes fragilis: 20 to 30% (high resistance to clindamycin) Enterobacteriaceae: 25 to 35 %,
Staphylococcus 10% Headache and fever, focal deficits in 60 %, seizures CT scan or MRI Aspiration or excision in essential for gram stain and culture Brain Abscess In HIV, 90% are toxoplamosis vs. lymphoma Treat with pyrimethamine and sulfadiazine for 10 to 14 days Always need surgical drainage and medical therapy Combination with penicillin or a third generation cephalosporin and metronidazole Third generation cephalosporin and Metronidazole (NOT clindamycin) and vancomycin for sinusitis Penetrating trauma or after neurosurgery Vancomycin and a third generation cephalosporin
Encephalitis
Viral: HSV-1, varicella-zoster, CMV, enteroviruses, Eastern and Western equine, St. Louis, West Nile Headache and fever with AMS Lethargy or coma, focal deficits, seizures. Need LP: PCR for HSV has 98 % sensitivity and 95 % specificity CT may show temporal lobe involvement. IV acyclovir Sinusitis
Maxillary is most common Facial pain, headache postnasal drainage, purulent drainage, fever, tooth pain Imaging not usually needed CT scan if no response to therapy 90% to 98% are caused by viruses NSAIDs and decongestants
Antibiotics if: Symptoms last for at least 10 days If symptoms are severe: fever over 102° and facial pain for three to four successive days If symptoms worsen, usually after a viral upper respiratory infection of five Sinusitis Haemophilus influenzae and Moraxella catarrhalis Amoxicillin-clavulanate Doxycycline or new fluoroquinolone
Pharyngitis
Strep pyogenes, group A beta-hemolytic strep 15 to 20% Majority are viral Rapid strep test is 60 to 100% sensitive, but 95% specific If negative, should confirm with culture Penicillin, ampicillin or amoxicillin Macrolides, 1st generation cephalosporins, clindamycin
Influenza
Fever, myalgias, headache, fatigue, coryza, nonproductive cough, sore throat Rapid antigen detection, swab of nasopharyngeal secretions Symptomatic therapy Neuraminidase inhibitors: oseltamivir and zanamivir (48 hours) Amantadine and rimantadine effective against Influenza A NOT used much Vaccinate Everyone! Bronchitis Acute bronchitis NO antbiotics!!!!
Acute inflammation of tacheobroncheal tube Mostly viral, M. pneumonia, C. pneumoniae
Chronic bronchitis COPD exacerbation: Streptococcus pneumonia, H. influenzae, Moraxella Cough with sputum May have low grade fever Discolored suggest bacterial etiology Bronchitis Cough with sputum, no fever and a normal CXR
Acute exacerbations of chronic bronchitis can be treated with amoxicillin, doxycycline, TMP/SMZ Repeat infections should get amoxicillin/clavulinate, macrolide, 2nd or 3rd generation cephalosporin, new fluoroquinolones
Lung Abscess
90% have anaerobes involved Peptostreptococus, Prevotella, Fusobacterium are most common 85 to 90% have periodontal disease or aspiration Fever, cough, sputum, chest pain Putrid, foul-smelling sputum and a more chronic cough Several weeks of weight loss, anemia, fatigue Lung Abscess CXR will show thick-wall cavity Need aspiration of abscess for diagnosis Clindamycin is first line Penicillin Most respond to antibiotics and do not need drainage Pneumonia
Sixth leading cause of death Risk factors: DM, ETOH, smoking, malnutrition, immunosuppression Most common: Community-acquired pneumonia Strep pneumonia (15-35%) Haemophilus (2-10%) Atypical Legionella (15%)
Mycoplasma (10%) Chlamydia (5-10%) Viral Pneumonia Haemophilus influenzae - smokers, COPD Mycoplasma -healthy Legionella - air conditioning Pneumocystis jiroveci - HIV Coxiella burnetti (Q-fever) - exposure to animals Klebsiella - alcoholics Staphylococcus aureus - post influenza Coccidioidomycosis - southwest (Arizona) Pneumonia Chlamydia psittaci - birds Histoplasma capsulatum - bird droppings, spelunking, bats Bordetella pertussis - cough with whoop and post-tussive vomiting Francisella tularensis - hunters, rabbits Avian infuenza - Southeast Asia Bacllus anthracis, Yersina pestis Francisella tularensis - bioterrorism Pneumonia Cough, fever, sputum production, dyspnea Klebsiella - current jelly Rales, rhonchi, dullness to percussion, egophony RR, hypoxia leads to hyperventilation CXR-lobar PNA S. pneumonia Interstitial infiltrates - PCP, viral, atypical Sputum for Gram stain and culture Pneumonia Treatment Severity: Hypoxia, PO2 < 60 (< 94%), RR > 30 Confusion, uremia, hypotension High fever, leukopenia, tachycardia, hyponatremia Outpatient →
empiric therapy Macrolide or new fluoroquinolone
Pneumonia Treatment: Inpatient New fluorquinolones, or 2nd or 3rd generation cephalosporins (ceftriaxone, cefuroxime) with macrolide or doxy, or Beta-lactam/beta-lactamase combination, with macrolide or doxy
Community-Acquired MRSA pneumonia
Think about it and cover it when you have: Necrotizing or cavitary pneumonia IV drug users Severe pneumonia requiring admission to the ICU Empyema Gram-positive cocci in clusters on sputum Gram stain Recent antimicrobial therapy Recent influenza-like illness (they love this on USMLE, almost as much I love beer!!) Community-Acquired MRSA pneumonia use ONE of the following :
Ceftriaxone and Vancomycin and azithromycin
OR Linezolid and ceftriaxone and azithromycin OR Clindamycin and ceftriaxone and azithromycin OR Ceftaroline (the one and only cephalosporin to cover MRSA) and azithromycin
Hospital (ventilator) -Acquired Pneumonia
After 48-72 hours in the hospital After 5 days, you must cover MDR organisms Pseudomonas, Klebsiella, E coli MRSA MUST give 2 for pseudomonas and one for MRSA 3 antibiotics total!! Ceftazidime OR Cefepime OR Pipercillin/tazobactam OR Ticarcillin/clavulinate OR Imipenem, meropenem, doripenem OR Aztreonam the answer when serious gram negative infection with anaphylactic reaction to penicillin PLUS
Cipro (or levofloxacin) Or Gentamycin (or any aminoglycoside) not in renal failure PLUS
Vancomycin OR Linezolid Pneumonia Pneumonia Vaccine > 65, serious underlying lung, cardiac, liver, renal disease, steroids, HIV, splenectomized, diabetics, hematological malignancies. Re-dose in 5 years if severely immunocompromised Tuberculosis Mycobacterium tuberculosis
Tuberculosis Active: Productive cough, fever, weight loss, night sweats Lymph node, meningeal, GI, GU - extrapulmonary sites CXR - apical infiltrates or cavities, effusions, calcified nodules Sputum staining for acid-fast bacilli (need 3 negative to rule out Tb), culture takes 4-6 weeks Tuberculosis Treatment Isoniazid, rifampin, pyrazinamide, ethambutol for 2 months or when sensitivity is back Continue INH and rifampin for 4 more months Tuberculosis Latent Tb positive PPD or positive quantiferon gold or the interferon-gamma release assays (IGRAs) (check this instead of PPD in patients who received the BCG) With a negative chest X-ray > 5 mm: close contacts, HIV, abnormal CXR consistent with old Tb, steroid use or organ transplant recipients
> 10 mm: healthcare workers, prisoners, NH residents, immigrants (5 years), homeless, immunocopromised (hematologic malignancies, DM, dialysis, IV drug users) > 15 mm: low risk Positive PPD and negative CXR: 9 months of INH If positive CXR, collect sputum for AFB * Viral Hepatitis Hepatitis A and E Oral/fecal route Incubation 2-6 weeks, Acute infection for days to weeks Hepatitis B, C, D Parental route B and C can be chronic
Viral Hepatitis Presentation Acute - jaundice, dark urine, light stools, fatigue, malaise, tender enlarged liver
Hep C can cause cryoglobulinemia Hep B associated with PAN Hep D can only be co-infected with B Viral Hepatitis Diagnosis ALT higher than AST High bilirubin Alkaline phosphatase and GGT less elevated High PT in severe disease Check pcr-RNA viral load for hep C to access activity Hepatitis B Surface Ag = infected Surface Ag + IgM Core Ab = acute infection Surface Ag + IgG Core Ab= chronic infection Core Ab: IgM = acute infection IgG = 1) chronic infection (if Hep Bs Ag), or 2) recovery (if Hep Bs Ab) Hepatitis B Surface Ab = vaccinated Resolution of infection = Hep Bs Ab, IgG Hep Bc Ab (exposed, recovered, and immune - 95%) Window period = Hep Bc IgG antibody and Hep Be antibody (2-6 weeks between the loss of surface antigen and development of surface antibody) Hep Be Ag = high replication rate and highly infectious
Viral Hepatitis Treatment Acute hepatitis - supportive care. Chronic hep B – Tenofovir (can cause fanconi syndrome) and Entecavir preferred. interferon, adofovir, lamivudine, telbivudin (these agents have more resistance) Cirrhosis - liver transplant Needle stick hep B - hep B Immunoglobulin and vaccine if not immune
Chronic Hepatitis C • Antibody to hepatitis C with elevated viral load for hepatitis C RNA by PCR • Genotype 1 and 4:
• Ledipasvir-sofosbuvir or sofobuvir-simeprevir+/- ribavirin • Genotype 2 and 3: • sofosbuvir and ribavirin
Sexually Transmitted Infections (STIs) Urethritis Purulent discharge, dysuria, urgency, frequency Neisseria gonorrhea Nongonococcal Chlamydia trahcomatis (50%) Ureaplasma urealyticum (20%) Mycoplasma hominis (5%) Trichomonas (1%) HSV (rare) * * STIs: Gonorrhea Disseminated Gonorrhea Classic triad of dermatitis, migratory polyarthritis, and tenosynovitis Skin findings Small macules or hemorrhagic pustules on an erythematous base located on palms and soles or on the trunk AND elsewhere on the extremities
STIs: Gonorrhea
Diagnosis Blood smear shows gram-negative, coffee bean-shaped intracellular diplococci Culture for gonorrhea Serology for Chlamydia by swabbing urethra, or Ligase chain reaction test of urine STIs: Gonorrhea Treatment One dose of ceftriaxone IM or cefixime PO and azithromycin PO Alternative is doxycycline for 7 days (NOT FQ)
Fever, discharge, leukocytosis, lower abd pain CERVICAL MOTION TENDERNESS, adnexal tenderness or uterine tenderness!! Diagnosis Culture on Thayer-Martin for gonococcus and Gram stain of discharge STIs: PID Treatment Single dose IM ceftriaxone and oral doxycycline for 2 weeks OR Ofloxacin and metronidazole (both oral) for 2 weeks Hospitalize if high WBC or fever Treat with doxycycline and cefoxitin or cefotetan
Syphillus
Spirochetes are Gram-negative bacteria that are long, thin, helical and motile via axial filaments (a form of flagella) Primary infection Chancre in 3rd week and disappears in 10-90 days, painless lymphadenopathy Secondary infection Cutaneous rash during 6-12 weeks - symmetric, more on flexor and volar surfaces,
condylomata lata, papaules at mucocutaneous junctions STIs: Syphilis (Treponema Pallidum) STIs: Syphilis Latent Asymptomatic, 1/3 develop tertiary Tertiary or late 3-20 years later - gumma in any tissue Neurological and CV manifestations (aortitis) STIs: Syphilis
Other long-term sequelae Argyll Robertson pupil Small, irregular, reacts to accommodation, but not to light Tabes dorsalis 3 to 20 years after infection Pain, ataxia, sensory changes, loss of tendon reflex STIs: Syphilis Diagnosis Screening = VDRL, RPR More specific FTA-ABS (Fluorescent Treponemal Antibody absorption) MHA-TP Darkfield of chancre Neurosyphilis FTA of CSF is more sensitive than a VDRL Treatment Primary/secondary/early latent (less than one year) Penicillin G, IM times one Tertiary (gummas, CV manifestations) / Late latent (more than one year, VDRL or RPR titers elevated >1:8 without symptoms) Penicillin G, IM once a week for 3 weeks STIs: Syphilis Treatment (cont’d)
Neurosyphilis (includes ocular syphilis) Penicillin IV for 10 to 14 days
Doxycycline for penicillin G-allergy in primary and secondary Pregnant or neurosyphilis must be desensitized STIs HSV Vesicles become eroded and painful Itching and soreness precede PCR (NOT tzanck culture) Acyclovir, valacyclovir, famciclovir UTIs Cystitis Dysuria, frequency, urgency, suprapubic pain Urinalysis for WBC, RBC, nitrites, Gram-neg infxn Urine culture with >100,000 is confirmation, but not necessary Trimethoprim/sulfamethoxazole, nitrofurantoin, or quinolone for 3 days 7 days if DM or complicated-stones, strictures, obstruction, pregnant, men No quinolones in pregancy UTIs Pyelonephritis Obstruction due to tumor, stricture, calculi, PBH, neurogenic bladder, or vesicoureteral reflux E. coli most common. Also Proteus, Klebsiella, Enterococcus. Candida in immunocompromised or with Foley cath Symptoms: Fever, chills, flank pain, n/v, CVA tenderness, urinary complaints Diagnosis: urinalysis and urine cultures Always get cultures before starting antibiotics! UTIs Treatment 3rd generation cephalosporin, fluoroquinolone, amp and gent 10-14 days of antibiotics Do not use TMP/SMZ for empiric therapy due to up to 20% resistance
Skin Infections Cellulitis
Infection involving subcutanous tissue Localized pain, erythema, edema, warmth Most commonly: Staph and group A Strep (GAS), Strep pyogenes Dicloxacillin or cephalexin If life-threatening diabetic foot infection: must cover gram negatives and anaerobes: Use imipenem and vanco!! If CA-MRSA think about when you see: purulent drainage/abscess, MSM, prisoners, athletes, American Indians Treatment: bactrim, clindamycin, vancomycin, linezolid, ceftaroline, or doxycycline Skin Infections Cat bites and dog bites Pasteurella multocida Resistant to dicloxacillin and nafcillin Dog and human bites Fusobacterium, Bacteroides, Eikenella corrodens DOGS capnocytaphia (life threatening in aspenic patients) Augmentin (amoxicillin/clavulanate) Oral clindamycin + fluoroquinolone Oral clindamycin + tetracycline Oral clindamycin + trimethoprim/sulfamethoxazole (pediatric)
Skin Infections Necrotizing Fasciitis Immediate Surgical debridement is most important!!
Group A strep Penicillin G (or 1st or 2nd generation cephalosporin) plus clindamycin Mixed aerobes and anaerobes Vancomycin PLUS 1) piperacillin-tazobactam or 2) cefepime and metronidazole or 3) meropenem or imipenem PLUS clindamycin (to stop group A strep toxin production)
Skin Infections Gas Gangrene Fever, severe pain and swelling, crepitus Deep cuts and black tar heroine X-ray → feathery gas pattern Clostridium perfringens Penicillin plus clindamycin Surgical debridement and hyperbaric oxygen
Vibrio vulnificus
Fisherman, Gulf of Mexico Cirrhosis (HEMOCHROMOTOSIS) and poorly controlled DM
Dark bullous lesions Wound infections leading to septicemia 3rd generation cephalosporin (ceftazidime, cefotaxine, ceftriaxone) AND
doxycycline or ciprofloxacin LIFE THREATENING!!!!
Bone and Skin Infections Osteomyelitis
Presentation Pain, erythema, edema, tenderness X-ray (1st test) Periosteal elevation, 50-75% of bone loss before abnormal, takes 2 weeks ESR Normal value strongly against OM, used to follow up treatment Bone and Skin Infections Osteomyelitis Diagnosis Bone biopsy and culture is the best test (not swabs of sinus tract or ulcer) Never culture the draining sinus tract!!!!
CT, indium, gallium Not as sensitive or specific CT scan MRI Bone scan is crapy!!
MRI allows for better differentiation between bone and soft tissue Always get MRI if you can Cannot get MRI if patient has metal get CT scan
Bone and Skin Infections
Osteomyelitis Treatment Wound drainage and debridement IV Antibiotics for 6 weeks, get sensitivities Chronic OM → treat for 12 weeks DM - 30% gram negative → cipro (only oral abx can be used for OM)
Bone and Skin Infections Osteomyelitis Treatment Empiric therapy (low yield)
1) piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid 2) Third or fourth generation cephalosporin with metronidazole 3) Clindamycin plus cipro or levofloxacin If concern or proof of MRSA Vancomycin, linezolid or daptomycin Bone and Skin infections Septic Arthritis Nongonococcal Gram positive (>85%) S. aureus (60%) Streptococcus (15%) Pneumococcus (5%) Gram negative (10-15%)
Septic Arthritis
Monoarticular, swollen, hot, tender, erythematous, decreased ROM Joint aspirate Cell count >50,000-PMN, low glucose
2000-20,000 = inflammatory Culture positive in 90-95% Gonococcal - Polyarticular in 50% Tenosynovitis, effusions less common Migratory, petechiae
Septic Arthritis Diagnosis Culture cervix, rectum, urethra, pharynx Only 50% positive cultures Therapy Joint aspiration and antibiotics Empiric VANCOMYCIN and CEFTRIAXONE!!!!
Or vancomycin and anything that covers gram negatives like gentamycin
Endocarditis Infective endocarditis
Acute S. aureus, normal valves Large bulky vegetations Rapid onset with fever Abscess and rapid valve destruction Endocarditis Embolic, especially lung Subacute Viridans most common Abnormal valves Risk factors:
Endocarditis Native valves: Streptococcus viridans 50-60 % Endocarditis: Treatment ID organism Empiric: Vancomycin (or daptomycin ) and gentamicin Strep viridans: Penicillin 4 weeks OR penicillin or ceftriaxone PLUS gentamicin for 2 weeks Vancomycin or ceftriaxone for pen-allergic
MSSA: Nafcillin PLUS (5 days of) gentamicin for 4-6 weeks Cefazolin or vancomycin PLUS gentamicin for pen-allergic MRSA: Vancomycin for 4-6 weeks Enterococcal Penicillin or ampicillin AND gentamicin for 4-6 weeks Vancomycin AND genatmicin for 4-6 weeks for pen-allergic Endocarditis: Treatment Surgery (high yield) CHF, recurrent septic emboli, regurgitation that affects hemodynamic functions, vegetation larger that 10 mm Fungal, extravalvular infection (AVB, purulent pericarditis), prosthetic valve obstruction, recurrent infection or persistent bacteremia, abscess or fistula
Endocarditis Prophylactics high yield
-prosthetic valves, history of IE, most congenital malformations, especially cyanotic lesions if not repaired. -dental procedures NO prophylaxis: -Urinary, GI,
-corrected pulmonary shunts, rheumatic valves, HOCM, -MVP with regurgitation, repaired intra-cardiac defects Endocarditis Amoxicillin, if allergic, clindamycin, macrolide or cephalexin
Acute Pericarditis Chest pain is sharp. Improved with sitting forward Pericardial friction rub. Low grade fever Tamponode: pulsus paradoxus: 10 mm Hg drop in BP with inspiration. Distended neck veins, tachycardia, hypotension EKG: diffuse ST elevations PR depressions Echo to look for effusions Acute Pericarditis NSIADS Colchicine for recurrence Pericardiocentesis and pericardial window if large effusions causing tamponade
Lyme Disease
Borrelia budorferi Ixodes scapularis 3 -30 days: erythema migrans, fever, chills, myalgias 7th cranial nerve, facial paralysis (Bell’s palsy)
Meningitis, encephalitis, memory loss AV heart block, myocarditis, pericarditis Joint involvement months to years later- 60 %, migratory polyarthritis Lyme disease
Serologic testing-ELISA with western blot. May be negative early in disease and can not distinguish between old and new disease. Minor disease treat with doxycyline or amoxicillin Cardiac (high degree AVB and PR > 3 s) and serious neurological manifestations (meningitis) treat with IV ceftriaxone, cefotaxime,
Ehrlichiosis
. Vector: American dog tick Deer tick Lone Star tick Ehrlichiosis Fevers (90 %) Headaches (>85%) Rigors (60%) Nausea (40%) Vomiting (40%), Anorexia (40%) Fatigue. A rash is uncommon lymphopenia, and/or thrombocytopenia Abnormal liver enzymes are found in 86% of patients.
Ehrlichiosis Doxycycline Babesiosis
Babesia microti, a parasite of small rodents Northeastern United States Babesia divergens Ixodes scapularis is the carrier Fever, fatigue, headache, arthralgia, and myalgia Nausea, vomiting Abdominal pain Anemia Thrombocytopenia, splenomegaly
Babesiosis Diagnosis Parasite on Giemsa-stained blood smears An indirect immunofluorescent antibody test for B microti antibody is detectable within
2–4 weeks after the onset of symptoms and persists for months
Diagnosis can also be made by polymerase chain reaction
Babesiosis
Treatment Mild illness: oral atovaquone plus azithromycin for 7–10 days
Clindamycin plus quinine is the second choice HIV HIV infects subset of T lymphocytes called CD4 cells, causing a decrease in the CD4 count, increasing the risk for opportunistic infections and certain malignancies. MSM, IV drug users, heterosexual intercourse 10 year lag between contracting HIV and the first symptoms CD4 count drops 50-100 uL/year Normal CD4 count is 700/mm3 HIV: Opportunistic Infections Pneumocystis jiovecii Trimethoprim-sulfamethoxazole (first line) Dapsone and trimethoprim Primaquine and clindamycin Atovaquone Pentamidine IV Steroids if PaO2 < 70 or A-a gradient of > 35 mm Hg
HIV: Opportunistic Infections Pneumocystis jiovecii Prophylaxis (< 200) TMP/SMZ PO Dapsone Atovaquone
Aerosolized pentamadine Discontinue if CD4 over 200 for 6 months HIV: Opportunistic Infections
Cytomegalovirus (HHV-5) (CD4 < 50) Retinitis: blurry vision, double vision, any disturbances Colitis: diarrhea Esophagitis: odynophagia, fever, CP, ulcers Encephalitis: AMS, cranial nerve defects Fundoscopy: retinitis: yellowish-whitish granules with perivascular hemorrhages and exudates Biopsy-intra-nuclear inclusion bodies (owl’s eyes) HIV: Opportunistic Infections Cytomegalovirus (HHV-5) (CD4 < 50) Valganciclovir oral and intravitreal ganciclovir IV ganciclovir CNS infections Cidofovir Foscarnet HIV: Opportunistic Infections Cytomegalovirus (HHV-5) (CD4 < 50) Ganciclovir - neutropenia Cidofovir - renal toxicity Foscarnet - renal failure
HIV: Opportunistic Infections Mycobacterium avium complex (CD4 < 50) Inhaled or ingested Fevers, night sweats, wasting, anemia, diarrhea Blood cultures Bone marrow, liver, other body tissue cultures Therapy: clarithromycin and ethambutol +/- rifabutin Prophylaxis (CD4< 50): azithromycin PO weekly or clarithromycin 2 X a day HIV: Opportunistic Infections Toxoplasmosis (CD4 < 100) Headache, confusion, seizures, focal deficits CT or MRI show ring enhancing lesion with edema and mass effect Diagnosis is the shrinkage with treatment! Toxo serology and CSF polymerase chain reaction to T. gondii, IgG will be positive Brain biopsy if no shrinkage in 2 weeks HIV: Opportunistic Infections Toxoplasmosis (CD4 < 100) Pyrimethamine and sulfadiazine
Clindamycin and Pyrimethamine in sulfa allergies Give with leucoveorin to prevent bone marrow suppression Prophylaxis: TMP/SMZ or Dapsone/ Pyrimethamine HIV: Opportunistic Infections Crypotococcosis ( CD4 < 100) Meningitis: fever, headache, malaise LP with India ink and cryptococcus antigen Serum cryptococcus antigen High titer and high opening pressure: worse prognosis Amphotericin B IV and flucytosine for 10–14 days, then fluconazole PO for maintenance until CD4 is above 100 for 3 to 6 months
HIV: Vaccines Pneumococcus, influenza and hepatitis B If CD4 is over 200 → give varicella vaccine
HIV: CD4 cell count 700 or above: normal 200 to 500: oral thrush, Kaposi, Tb, Zoster, lymphoma 100 to 200: PCP, dementia, progressive multifocal leukoencephalopathy, histoplasmosis and coccidiomycosis < 100: toxoplasmosis, Cryptopoccus, cryptosporidiosis, disseminated herpes simplex < 50: CMV, MAC, CNS lymphoma HIV: Viral load Best method to monitor adequate response the therapy on HAART: goal is undetectable viremia High viral load indicates that the CD4 count will drop more rapidly Viral sensitivity testing should be done if patient is failing HAART or pregnant patient who has not been fully suppressed on meds HIV: Antiretroviral Therapy Nucleoside Reverse Transcriptase Inhibitors Zidovudine (AZT) - leukopenia, anemia, GI Didanosine DDI - pancreatitis, peripheral neuropathy, lactic acidosis Stavudine (D4T) - periperhal neuropathy Lamivudine
Emtricitabine Tenofovir - nucleotide analog HIV: Antiretroviral Therapy Nucleoside Reverse Transcriptase Inhibitors Abacavir (NOT A PI, A is for AIDS) - hypersensitivity-rash, fever, N/V, sob, muscle aches Zalcitabine - pancreatitis, peripheral neuropathy, lactic acidosis HIV: Antiretroviral Therapy the A is for AIDS before the vir!!! Protease Inhibitors Hyperlipidemia, hyperglycemia, elevated LFT’s
Lipoatrophy, redistribution to neck and abdomen Nelfinavir - GI Indi navir - nephrolithiasis, hyperbilirubinemia Rito navir – GI Darunavir navir Nelfi navir Fosamprenavir HIV: Antiretroviral Therapy Protease Inhibitors Saqui navir - GI Amprenavir Lopi navir /Ritonavir - diarrhea Ataza navir - diarrhea, hyperbilirubinemia Tipranavir
HIV: HAART Only statins safe with HAART are Rouvastatin Pravastatin HIV: Antiretroviral Therapy Non-Nucleoside Reverse Transcriptase Inhibitors Efavirenz - neurological, somnolence, confusion, psychiatric Nevirapine - rash, hepatotoxicity
Delavirdine - rash Rilpivirine HIV: Antiretroviral Therapy When to start? CD4 < 500 What to start? 2 nucleosides and one protease inhibitor or 2 nucleosides with efavirenz or 2 nucleosides with 2 protease inhibitors Emtricitabine, Tenofovir, and Efavirenz HIV: Antiretroviral Therapy Guidelines 2 NRTIs with NNRTI or PI Boosted PI: PI with ritonavir: alone: modest efficacy and significant drug interactions Low dose in combination with other PIs gives the other PI a � boosted� PI: last longer and increases the chances of success. Never pick Ritonavir as the answer if it is the only PI
Raltegravir A for AIDS before vir Integrase inhibitor Used for resistance to reverse transcriptase inhibitors or protease inhibitors HIV: Antiretroviral Therapy Goal of therapy Drop of at least 50% of viral load in the first month!
HIV: Antiretroviral Therapy Pregnant patients: Start triple therapy IMEDDIATLEY regardless of CD4 count 25–30% will be positive without treatment
Women with low CD4 and high viral load should get triple therapy C-section if not controlled (viral load over 1000) Start therapy as soon as you know the patient is pregnant Efavirenz is teratogenic HIV
Post exposure prophylaxis AZT, lamivudine, nelfinavir or another 3 drug regiment for 4 weeks Neutropenic fever = pseudomonas!!!!!! Psuedomonas: Cover in 1)neutropenic fever 2)nosocomial and ventilator associated pneumonia 3)burns 4)cystic fibrosis 5)ONLY serious diabetic foot infections or when the patient is soaking the foot in a hot tube!! Not need to cover in mild diabetic foot infections!! Ceftazidime 3rd generation Cefepime 4th generation Pipercillin/tazobactam Ticarcillin/clavulinate Imipenem, meropenem, doripenem Aztreonam the answer when serious gram negative infection with anaphylactic reaction to penicillin Cipro and gentamycin DO cover pseudomonas but we prefer a Beta-lactam if we do not have sensitive’s (Beta-lactams are Best )
Ceftriaxone is a 3 rd generation cephalosporin (NOT COVER pseudomonas!!) it is the answer for: 1) Community acquired pneumonia that needs be admitted WITH a macrolide or doxycycline 2) Meningitis WITH vancomycin and maybe add ampicillin for listeria 3) Pyelonephritis 4) Septic arthritis WITH vancomycin 5) Lyme disease with AV block or meningitis 6) Spontaneous bacterial peritoneal treatment or prophylaxis in a cirrhotic with bleeding varices 7) Gonorrhea (with azithro or doxy for chlamydia ) 8) Vibrio vulnificus with doxy or cipro
9) GI infections with metro
Intraadominal infections: 1)ascending cholantitis 2)diverticlulitis 3)cholecystitis Must cover gram negative and anaerobes (especially B fragilis) Can use ANY of the following: 1) Cipro and metronidazole 2) Ceftriaxone or cefotaxime and metronidazole (avoid ceftriaxone in biliary disease causes biliary sludge) 3) Amp/sulbactam 4) Ertepenem 5) Pipercillin/tazobactam 6) Moxifloxicin B fragilis is resistant to clindamycin !! Spontaneous bacterial peritonitis cover E coli and pneumococcus cefotaxime or ceftriaxone Give prophylaxis with norfloxin, cipro or TMP/SMX for life after one episode
Lower yield :
Q-fever Coxiella burnetti Inhalation of placenta of cattle, sheep and goats Atypical pneumonia, hepatitis, endocarditis, hepatomegaly Doxycycline Rocky Mountain Spotted Fever Rickettsia rickettsi
