Tag: ID

Meningitis/Encephalitis

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Differences between bacterial & viral meningitis
Viral
Bacterial
Common microbes
• Enteroviruses
(most common)
• Arboviruses
•Herpes simplex
virus type 2
• Adults: Streptococcus pneumoniae
& Neisseria meningitidis
• Neonates: Group B Streptococcus
& gram-negative bacilli.
CSF cell differential
• WBC # <500
• Lymphocytic predominance
·       WBC # often >1000
·       Neutrophilic predominance
CSF glucose & protein
• Glucose levels are
normal or slightly reduced
• Protein generally
<150 mg/dL
·       Glucose levels <45 mg/dL
·       Protein is often >250 mg/dL
CSF Gram stain & culture
• No organisms identified
·       Often positive for a specific organism

 Bacterial Meningitis
S/S
If FND → Abscess
Dx
Answer head CT first when any of the following is present:
· Papilledema
· SZ
· FND
· Confusion interfering with the neurological examination
When is a bacterial antigen test indicated? When the patient has received antibiotics prior to the LP and the culture may be falsely negative.
·       LP + Cultx
·       if ⤴️ ICP: Initiate Abx → CT –> LP
·       If ⓝ ICP: LP → ABx
Tx
Adults:
·       For regular adults (up to 50): Vanco + ceftriaxone +steroids
·       For elderly: Add ampicillin (go full hard-on baby, fuck all that bacteria the son of bitches who kill people).
Peds:
·       < 1 month: cefotaxime + ampicillin
·       1-3 months: cefotaxime + ampicillin + vancomycin
·       > 3 months: ceftriaxone + vancomycin
For Nisseria:
·       Respiratory isolation for 24 h
·       Rifampin, ciprofloxacin, or ceftriaxone to the close contacts to decrease nasopharyngeal carriage
Meningitis to Risk Factors
Rocky Mountain Spotted Fever
Fever, Rash that moves from arms to trunk. Tick bites, camping (not necessarily to Rocky Mountains)
Lyme Disease
Travel to Connecticut. Targetoid rash with arthralgias, arrhythmias (tic usually not seen)
Cryptococcal Meningitis
AIDS patient with fever and a headache. >20cmH20 opening pressure Cryptococcal Antigen India Ink
TB
Night Sweats, Weight Loss, Hemoptysis and meningitis. 
Homeless, Prison, Endemic Areas (Urban)
Syphilis
primary Chancre, Secondary Erythema Multiforme, Tertiary Any Neuro Sx Get CSF RPR Or CSF Antibodies
Meningiococcal Meningitis
Clx
·       Sx: Headache, nausea/vomiting, severe myalgias
·       Signs: Neck stiffness, AMS, petechial/purpuric rash, meningeal (Kernig & Brudzinski) signs
·       Complications: Multiorgan failure, DIC, adrenal hemorrhage, shock
Tx
·       3rd-gen cephalosporin + vancomycin
·       Glucocorticoids not helpful
·       Chemoprophylaxis (eg, rifampin, ciprofloxacin, ceftriaxone) for all respiratory contacts
C.Neoformans Meningitis
S/S
·       N/V
·       Confusion
·       CN6 Palsy
·       Scattered Skin Papules
·       It blocks arachnoid Villi —+ inc ICP –> (CN6 palsy / enlarged ventricles)
Dx
·       Lumbar puncture
Tx
·       Anti-fungal (may require daily LP)
C.Neoformans Meningitis
S/S
·       N/V
·       Confusion
·       CN6 Palsy
·       Scattered Skin Papules
·       It blocks arachnoid Villi —+ inc ICP –> (CN6 palsy / enlarged ventricles)
Dx
·       Lumbar puncture
Tx
·       Anti-fungal (may require daily LP)
Cryptococcal meningoencephalitis
Clx
• Headache, fever & malaise
• Develops over 2 weeks (subacute)
• Can be more acute & severe in HIV
Dx
CSF:
• High opening pressure
• Low glucose, high protein
• White blood cells <50/uL with mononuclear predominance
• Transparent capsule seen with India ink stain
• Cryptococcal antigen positive
• Culture on Sabouraud agar
Tx
Initial: Amphotericin B with flucytosine
Maintenance: Fluconazole  
Viral (herpes simplex virus) encephalitis
Sx
• Fever
• Altered mental status with confusion & agitation
• Risk of seizures & coma
Clx
• Hemiparesis, cranial nerve palsies (signs of focal neurologic deficits)
• Hyperreflexia
Inv
• Cerebrospinal fluid analysis: ↑ white blood cells (lymphocyte predominant), normal glucose, ↑ protein
• Brain magnetic resonance imaging: Temporal lobe abnormalities
• Diagnosis: CSF analysis shows presence of viral DNA on PCR
Tx
• Intravenous acyclovir: Start immediately after obtaining CSF fluid
 HSV Encephalitis
?
MCC
Sx
Fever + AMS
Dx
CT (⊕ Temporal lobe)
Tx
·       Acyclovir is the best initial therapy for herpes encephalitis.
·       Foscarnet is used for acyclovir-resistant herpes.

HIV/AIDS

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 HIV
Path
·       Env gene
·       Gp120: attach HIV to cells
·       Gp40: Fusion + entry into cells
·       gag gene
·       p24: capsid
·       p17: viral matrix protein
·       pol gene:
·       Reverse transcriptase
Dx
·       Fourth-generation combination HIV-1/2 immunoassay 
·       best initial test
·       detects both
o   HIV-1 and HIV-2 antibodies
o   HIV p24 antigen
·       interpretation
o   if negative → ø
o   if positive: perform an HIV-1/HIV-2 antibody differentiation immunoassay → Confirm Dx
o   if the differentiation immunoassay is negative or indeterminate → perform a viral load
·       CD4+ T-cell count and percentage
·       HIV genotyping
Tx
·       2 NRTI + 1 other (integrase inhibitor)
·       The MCC of tx failure is nonadherence
·       Pregnancy and HIV:
·       Tx the same except ⤵️
·       Avoid: dolutegravir – elvitegravir – tenofovir alafenamide
·       If viral load >1000 → C-Section + IV Zidovudine
·       AVOID BREASTFEEDING ❌
·       For the baby:
·       If viral load <1000 → Zidovudine for 4-6 weeks
·       If viral load >1000 → zidovudine, lamivudine, and nevirapine in the infant for 6 weeks
Opportunistic
Indication for ppx
First-line
Alternative
PCP pneumonia
CD4 <200
TMP-SMX
Dapsone (second line) or aerosolized
pentamidine or
atovaquone
Toxoplasmosis
CD4<100 cells/mm3
TMP-SMX
Dapsone AND
pentamidine or
atovaquone
MAC infection
CD4<50 cells/mm3
Azitlromycin or
Clarithromycin
Rifabutin
PPx
·       Post-exposure prophylaxis
·       first-line treatment given immediately after HIV exposure (such as in health care personnel)
·       initiate within 72 hours
·       drug regimen: tenofovir, emtricitabine, and raltegravir
·       Pre-exposure prophylaxis
·       to prevent HIV infection in high-risk patients
·       tenofovir and emtricitabine
·       HIV is an indication for obtaining the following vaccines:
·       pneumococcal 
·       hepatitis B (if not already immune)
·       meningococcal

Common causes of diarrhea in AIDS
CD4 count
Sx
Cryptosporidium
< 180
·       Severe watery diarrhea
·       Low-grade fever
·       Weight loss
Mycobacterium avum complex
< 50
·       Watery diarrhea
·       High fever >39 
·       Weight loss
CMV
< 50
·       Frequent small diarrhea
·       Hematochezia
·       Abdominal pain
·       Low-grade fever
·       Weight loss
Opportunistic organisms in HIV
PCP
CD4+ < 200
Oral candidiasis
TMP-SMX
Toxo
CD4+ <100
+Toxoplasma IgG Ab
TMP-SMX
MAC
CD4+ < 50
Azithro
Histoplasma
CD4+ <150
Endemic area / Caves
Ohio+ Mississippi river
Itraconazole
Pneumocystis Jirovicii
Clx
·       Indolent (HIV) or acute respiratory failure (immunocompromised)
·       Fever, dry cough, ↓ oxygen levels (HYPOXIA)
Dx
·       ↑ LDH level
·       CXR: ⓑ Diffuse reticular infiltrates
·       Induced sputum or BAL (stain)
Tx
·       TMP-SMX
·       Prednisone if ⤵️ O2 levels
PPx
·       TMP-SMX (CD4 <200)
CMV Pneumonitis
CMV is a common opportunistic infection that may cause pneumonitis.
Marked by:
– dyspnea,
– nonproductive cough,
– low-grade fever,
– diffuse ground-glass opacities on CT scan.
Disseminated Mycobacterium avium complex (MAC)
Sx
Nonspecific sx (eg, fever, cough, abdominal pain, diarrhea, night sweats, weight loss)
+ splenomegaly
+ ALP
in pt w/ CD4 cell count <50/mm3.
Dx
Blood cultures (or lymph node or bone marrow biopsy)
PPx
CD4 cell count <50/mm3 should receive azithromycin prophylaxis against MAC.
Tx
1˚ clarithromycin or azithromycin.
DDx
CMV: check lgG/lgM
TB: check hx, cxr, skin test
HIV drug
SE
NRTI
·       BM suppression (can be reversed with G-CSF and EPO),
·       peripheral neuropathy,
·       lactic acidosis (nucleosides),
·       anemia (ZDV),
·       pancreatitis (didanosine).
·       Abacavir contraindicated if patient has HLA-B*5701 mutation due to risk of hypersensitivity.
NNRTI
·       Rash and hepatotoxicity are common to all NNRTIs.
·       Vivid dreams and CNS symptoms are common with efavirenz.
·       Delavirdine and efavirenz are contraindicated in pregnancy.
Protease inhibitor
·       Hyperglycemia,
·       GI intolerance (nausea, diarrhea),
·       lipodystrophy (Cushing-like syndrome).
·       Nephropathy, hematuria, thrombocytopenia (indinavir).
·       Rifampin (potent CYP/UGT inducer) reduces protease inhibitor concentrations; use rifabutin instead.
Integrase inhibitor
⤴️ CK

GI Infections

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Bloody Diarrhea
Blood
+ WBC
 in stool
·       Salmonella: poultry
·       Campylobacter: most common cause, associated with GBS
·       E. coli 0157:H7—hemolytic uremic syndrome (HUS)
·       Shigella: second most common association with HUS
·       Vibrio parahaemolyticus: shellfish and cruise ships
·       Vibrio vulnificus: shellfish, history of liver disease, skin lesions
·       Yersinia: high affinity for iron, hemochromatosis, blood transfusions
·       Clostridium difficile: white and red cells in stool
Dx
·       best initial test is blood and/or fecal leukocytes
·       Stool lactoferrin has greater sensitivity and specificity compared with stool leukocytes.
·       The most accurate test is stool culture.
Tx
depends on 👾
Giardiasis
RF
Exposure to contaminated food or water
Fecal incontinence & crowding (eg, daycare, nursing homes)
Clx
Acute
o Loose, foul-smelling, fatty stools
o Abdominal cramps
o Flatulence
o Weight loss
Chronic
o Malabsorption (eg, lactose intolerance)
o Profound weight loss
o Vitamin deficiencies
Tx
Metronidazole
Vibrio vulnificus
#
·       Gram-negative, free-living in marine environments
·       Ingestion (oysters) or wound infection
·       ↑ Risk in those with liver disease* (cirrhosis, hepatitis)
S/s
·       Rapidly progressive (often <12 hours)
·       Septicemia – septic shock, bullous lesions
·       Cellulitis – hemorrhagic bullae, necrotizing fasciitis
Dx
Blood & wound cultures
Tx
IV ceftriaxone + doxycycline
*Hereditary hemochromatosis is particularly high risk as iron acts as a growth catalyst.
Typhoid fever
Usually presents in a progressive manner
S/S
1st week: Fever.
2nd week: Abd pain + salmon-colored rash.
3rd week: HSM + Abd complications (bleeding – perforation).
Clostridium difficile colitis
RF
Recent antibiotics / Hospitalization
Path
·       Disruption of intestinal flora  → C difficile overgrowth
·       Exotoxins cause mucosal inflammation/injury
Clx
Watery diarrhea (most common)
Fulminant colitis/toxic megacolon (emergency 🚨)
Dx
Stool PCR
Tx
Oral metronidazole or vancomycin
Viral Hepatitis
👾
·       Hep A: Feco-oral
·       Hep B + C: Blood / sex
Path
Viral infection of liver parynchma
Clx
·       Jaundice + Fever
·       Dark urine
·       HSM
·       weight loss, and fatigue
Dx
·       LFT: ⤴️ direct bilirubin / ALP / AST&ALT
·       Serology (for all except hep B):
·       IgM antibody for the acute infection
·       IgG antibody to detect resolution of infection.
·       Disease activity of hepatitis C is assessed with PCR for RNA level
·       Hep B: u know it
Tx
·       Hepatitis A and E resolve spontaneously
·       Tx only Hep C:
·       Genotype 1: ledipasvir and sofosbuvir
·       Other genotype: sofosbuvir and velpatasvir
·       Tx of Chronic Hep B:
·       positive for e-antigen with an elevated level of DNA polymerase, treatment is any one of the following: entecavir, adefovir, lamivudine, telbivudine, interferon, or tenofovir.
Extra
·       If pt has fibrosis on Bx (Hep b / c): start tx
·       In Hep C: If the PCR-RNA viral load is elevated, patients should be treated.
Hepatitis C
Dx
·       IgG + IgM
·       PCR RNA
·       Everyone born between 1945 and 1965 is tested for hepatitis C regardless of risk factors.
·       Viral load testing has nearly eliminated the need for liver biopsy.
Tx
·       If the PCR-RNA viral load is elevated, patients should be treated.
·       If there is fibrosis on liver biopsy, initiating treatment becomes more urgent
·       Genotype 1 is treated with sofosbuvir + ledipasvir orally for 12 weeks.
·       The other genotypes are treated with sofosbuvir and velpatasvir orally.
·       Interferon is only used in treatment failure. 

Fungal Infections

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Blastomycosis
Location
South/south-central states, Mississippi & Ohio River valleys,
(Wisconsin has the highest infection rate).
Clx
Lung: Acute & chronic pneumonia 
Skin: Wart like lesions/violaceous nodules
Bone: Osteomyelitis
CNS: Meningitis, epidural or brain abscesses
Dx
Culture (blood, sputum, tissue specimens)
Microscopy (body fluids. sputum, tissue specimens)
Antigen testing (urine, blood)
**The pulmonary symptoms and chest x-ray findings of Blastomycosis may resemble tuberculosis and histoplasmosis.
Tx
Mild + Immunocompetent →  ø
Mild-to-moderate/mild disseminated disease → Oral itraconazole
Severe/moderately severe to severe disseminated disease/immunocompromised patients → IV amphotericin B

Disseminated Histoplasmosis
Found in
Soil contaminated by bird or bat droppings 🦇🦜 
Location
Midwest & central 🇺🇸 (Ohio & Mississippi River Valleys)
Sx
Systemic (fevers, chills, malaise)
Weight loss & cachexia
Pulmonary (cough, dyspnea)
Skin (papules, nodules)
Hematologic (HSM, LAD)
Dx
CBC: Pancytopenia
LFTs: ⤴️
↑LDH & ferritin
Urine/serum Histoplasma Antigen (high sensitivity/rapid)
Cx (takes 4-6 weeks)
Tx
Amphotericin B (moderate-severe disease)
ltraconazole (mild disease/maintenance)
Aspergillosis
Invasive aspergillosis
Chronic pulmonary aspergillosis
RF
Immunocompromise (neutropenia, glucocorticoids, HIV)
Lung disease/damage (cavitary tuberculosis)
Findings
Triad Of fever, chest pain, hemoptysis
Pulmonary nodules with halo sign
Positive cultures
Positive cell wall biomarkers (galactomannan, beta-D-glucan)
>3 months: Weight loss (>90%), cough, hemoptysis, fatigue.
Cavitary lesion +/ – fungus ball
Positive Aspergillus lgG serology
Tx
Voriconazole +/- caspofungin
Resect aspergilloma (if possible)
Azole medication (voriconazole)
Embolization (if severe hemoptysis)
Pulmonary aspergillosis
#
Seen primarily in immunocompromised pts.
S&S
Classic triad of:
Fever, Pleuritic pain, Hemoptysis.
Imaging
Reveals nodules with surrounding  ground-glass infiltrate (halo sign).

ENT Infections

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All pictures in this blog are (c) to UWorld (hope they don’t catch me 🤭)
Otitis Externa
RF
·       Water exposure
·       Trauma (Cotton swabs, ear candling)
·       Foreign material (Hearing aid. headphones)
·       Dermatology (Eczema. contact dermatitis)
👾
1st: Pseudomonas aeruginosa → Staphylococcus aureus
Clx
·       Otalgia, pruritis, discharge, hearing loss
·       Pain with auricle manipulation
·       Ear canal erythema edema, debris
·       ⓝ TM (clear, not inflamed, no middle ear fluid)
Tx
Topical Abx (Fq) topical GCS
Systemic (oral) for immunocompromised pts (DM/HIV)
OE
·       An infection of the external ear canal caused by excessive moisture
·       Sub category of otitis externa known as necrotizing (or malignant) otitis externa
o   DM
o   Pseudomonas aeruginosa is MCC
o   EMERGENCY: Can cause osteomyelitis
o   Tx is IV ciprofloxacin
·       Dx: Clx
o   In DM –> CT to r/o osteomyelitis
·       Tx: ABx drops, If DM (Admission + IV ABx)
Necrotizing (malignant) OE
RF
Elderly (age >60) / Diabetes mellitus
👾
Pseudomonas aeruginosa
Clx
·       Severe, unremitting ear pain (worse at night & with chewing)
·       Granulation tissue in the external auditory canal
·       ↑ ESR
Tx
·       IV antipseudomonal Abx (ciprofloxacin)
·       May consider surgical debridement

 
Otitis Media
features
RF:
·       Down syn

·       2nd-hand smoking

·       previous ear infxn
·       precipitated by URTI
S/S
Sx
·       ear tugging
·       fever
·       hearing loss
·       irritability
·       feeding difficulties
·       vomiting
PEx
·       bulging or fullness of the tympanic membrane (TM)
·       erythema of the TM
·       possible perforation with otorrhea
·       possibe absence of light reflex
Dx
Pneumatic otoscopy
·       for visualization of the TM and also important in assessing mobility of the TM
Tx
Medical
·       1˚: Amoxicillin/Claculanic acid – 10 days.
·       if penicillin allergy? cephalosporin
·       if both penicillin & cephalosporin allergy? Macrolides
Surgical
·        myringotomy with t-tube insertion for recurrent cases

Acute OM
👾
·       S.pneumoniae
·       H. influenzae
·       Moraxe/la catarrhalis
Clx
Middle ear effusion + Bulging TM
Tx
1˚ Amoxicillin
2˚ Amoxicillin-clavulanic acid
–
<6 months: Oral Amoxicillin
>6 months + ⓑ AMO + High fever: Oral Amoxicillin
>6 w/ mild features: Supportive.
Comp
Conductive hearing loss
Mastoiditis-Meningitis

Complications of AOM
Bollous Maryngitis
bulla on TM
Cholesteatoma
pearly white mass
Conductive Hearing loss
ⓝ TM
Chronic supporative OM
>6 weeks
Pus (otorreha)
Hearing loss
OM w/ effusion
no fever
Can lead to hearing loss
TM effusion
PEx

 
OM w/ Effusion
features
Rx OM
S/S
Asx
Tx
Otitis media with effusion
if the child does not have risk for speech and language development or other learning disabilities, observation may be appropriate
Steroids, decongestants and antihistamines do not completely resolve effusion
Mastoiditis
features
A complication of OM
S/S
Persistant fever + pain
Painful mastoid process
>3 weeks dischare
Dx
CT + Otoscope
Tx
IV Abx + Maryngotomy
·       What Abx?
o   Vanco –> if no hx of recurrent AOM
o   Vanco + either ceftazidime / pip-tazo –> if they have recieved abx or have hx of AOM
·       Maryngotomy + T-Tube insertion
If SEVERE & DO NOT IMPROVE ON THE ABOVE CHOICES –> Mastoidectomy
Mastoiditis
Path
·       Complication of acute otitis media
·       Most commonly due to Streptococcus pneumoniae
Clx
·       Fever & otalgia
·       Inflammation of mastoid
·       Deviation of ear
·       1˚ Opacification of mastoid air cells on CT scan or MRI
Tx
·       Intravenous antibiotics
·       Drainage of purulent material

Preseptal vs Orbital cellulitis
Preseptal
Orbital
Clx
·       Eyelid erythema & swelling
·       Chemosis
·       Symptoms of preseptal cellulitis
PLUS
·       Pain with EOM, proptosis &/or
·       ophthalmoplegia with diplopia
Tx
Oral Abx
IV antibiotics
Orbital cellulitis
RF
·       Local infection (eg, sinusitis, dental
·       infection, skin infection)
·       Orbital trauma
Clx
·       Painful eye movements
·       Ophthalmoplegia
·       Proptosis
·       Visual changes
Dx
·       Can be a clinical
·       CT scan if diagnosis is uncertain
Tx
·       IV antibiotics
·       Surgical drainage for abscess
Acute Bacterial Rhinosinusitis
Clx
·       S.pneumonia / H.influenza / Maroxilla catarrahlis
·       Cough,
·       Nasal discharge
·       Fever
·       Face pain/headache
Dx
·       ∆ l of 3:
·       ≥10 days without improvement
·       Fever ≥39 C [102.2 F] + drainage ≥ 3 days
·       Worsening sx following initial improvement
Tx
·       Abx (Amoxicillin ± clavulanate)
Rhino-orbital-cerebral mucormycosis*
RF
·       Diabetes mellitus (ketoacidosis)
·       Hematologic malignancy
·       Solid organ or stem cell transplant
S/S
·       Acute/aggressive
·       Fever, nasal congestion, purulent nasal
·       discharge, headache, sinus pain
·       Necrotic invasion of palate, orbit, brain
Dx
Sinus endoscopy with biopsy & culture
Tx
·       Surgical debridement
·       Liposomal amphotericin B
·       Elimination of risk factors (eg, inc glucose, acidosis)
  
Bell palsy
Involve
CN7: facial nerve
Clx
·       ⓤ mouth drooping, disappearance of the nasolabial fold, and, importantly, involvement of the upper face weakness in closing the eye or raising the eyebrow).
·       hyperacusis / lacrimation / taste sensation
Path
Reactivation of a neurotrophic virus → HSV
Tx
Glucocorticoids

Common Infections and Tx

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Tx
Traveller’s diarrhea
·       Rehydration & Flouroquinolones
·       If ped (< 8yo): azithromycin 
Cholera
·       Adult: Doxycycline
·       Peds/Pregnants: Erythromycin –> since doxycycline is contraindicated.
Enteric fever
·       Ciprofloxacillin
Salmonella
·       Peds: ceftri → Ciprofloxacillin
Shigella
·       Peds: Ceftriaxone
·       Adults: Ciprofloxacillin
Giardia
Metronidazole, tinidazole
Cryptosporidia
·       Treat underlying AIDS,
·       nitazoxanide
Meningitis
·       < 1 month: cefotaxime + ampicillin
·       1-3 months: cefotaxime + ampicillin + vancomycin
·       > 3 months: ceftriaxone + vancomycin
Whipple’s
·       Dx: Bx (Ē small bowel Bx showing periodic acid shiff foamy MØ)
·       Tx: TMP-SMX for 12 months
Acute Sinusitis
Amoxicillin (Azithromycin if PCN allergic)
Best initial? Face X-ray
Complications? CNS / Eyes / Osteo
AOM
Amoxicillin or Azithromycin
Pharyngitis (GAS)
·       No cough
·       ⊕ Tender LN
·       Dx: Rapid streptococcal Ag + Cx
·       Amoxicillin / Azithromycin
Influenza
If dx w/i 48 hs → Osetalamivir
Epiglottitis
IV Ceftrixone + Vancomycin
👶🏼 septic arthritis
·       ❤ months: Vanco + Gentamicin
·       >3 months: nafcillin / vanco
Human bite infxn?
Amoxicillin-clavunate
Young pt acute epidydimitis?
Chlamydia (Azithro + ceftriaxone)
old pt acute epidydimitis?
E.col (Fq)
coccidiomycosis?
·       itraconazole or fluconazole if mild
·       Amphotericin B if severe or immunocompromised;
blastomycosis?
·       Observe if mild
·       Oral itraconazole
Histoplasmosis
·       dissiminated:  amphotericin B
Mucormycosis
·       Surgical debridement and amphotericin B
Sporotrichosis
·       Oral itraconazole
Bacillary angiomatosis
·       Erythromycin
Toxo
·       PPx: TMP-SMX
·       Tx: Sulfadiazine and pyrimethamine, 2wk duration
C.neoformans
·       Next best step in management Head computed tomography (CT) scan then lumbar puncture
·       Best initial treatment Amphotericin B with flucytosine
·       Most specific test Cryptococcal antigen in CSF
·       imaging finding  ventricular enlargement
Mycobacterium avium
complex (MAC)
·       Azithromycin
PCP
·       Most specific dx test: Silver stain of sputum or bronchoalveolar lavage showing cysts and organisms
·       TMP-SMX + Corticosteroids if hypoxic
Progressive multifocal
leukoencephalopathy
Brain MRI showing multiple demyelinating lesions without enhancement
Actinomyces
·       Best initial treatment Penicillin
·       Most common risk factor Dental trauma + immunosuppression
·       complication Local invasion with necrosis
Nocardiasis
TMP-SMX
Elderly (>64) w/ meningitis
Vancomycin, cefepime, and ampicillin
Human bite
·       Best initial treatment Amoxicillin-clavulanate
·       Best initial treatment Surgical debridement
Febrile neutropenia
·       Next best step in management Blood cultures x2, prior to starting abx
·       Best initial treatment 
·       high-risk patients (requires hospitalization)
o   IV
o   cefepime 
o   piperacillin-tazobactam
o   imipenem-cilastatin
·       low-risk patients (OP)
o   oral ciprofloxacin and amoxicillin-clavulanate
stepped on a rusty nail
which pierced pt shoe
·       Best initial treatment IV ciprofloxacin and surgical debridement
·       Most likely etiology (organism) Pseudomonas aeruginosa
DM w/ Osteo
IV piperacillin-tazobactam + vancomycin + surgical debridement
pneumococcus pna
azithro
atypical pna
azithro
legionella pna
Fq
aspiration pna
Clindamycin
2˚ bacterial pna
Vancomycin + Piperacillin/Tazobactam
Acute necrotizing pna
·       Post-URTI w/ s.aureus leading to cavitary lesions
·       Vancomycin + Piperacillin/Tazobactam

Summary of Abx

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Drug
Uses
SE
Linozolid
MRSA
  • ⤵️ PLT
  • Interaction w/ MAOI
Daptomycin
MRSA
  • ⤴️ CPK
Penicillin
  • viridans group streptococci, 
  • Streptococcus pyogenes,
  • oral anaerobes,
  • syphilis,
  • Leptospira
  • Actinomyces
Amoxicillin
Ampicillin
  • =
  • H. influenzae, E. coli, Listeria, Proteus, and Salmonella.

    1˚ Line in:
  • AOM
  • Listeria
  • UTI in pregnany
Oxacillin
Nafcillin
  • Skin infections
  • Osteo
  • Meningitis by MSSA
Pipertacillin,
Ticarcillin
  • Pseudomonas
    Use in:
  • Cholecystitis and ascending cholangitis
  • Pyelonephritis
  • Bacteremia
  • Hospital-acquired and ventilator-associated pneumonia
  • Neutropenia and fever
Cefotetan or cefoxitin
Best initial therapy for pelvic inflammatory dease (PID) combined with doxycycline.
a disulfiramlike reaction with alcohol
Ceftriaxone
  • Pneumococcus infections
  • Gonorrhea infections
  • CAP
  • Lyme w/ CNS
Avoid ceftriaxone in neonates because of impaired biliary metabolism
Cefotaxime
  • SBP
Ceftazidime
  • Ciftaz for pseudomonaz
Cefepime
  • w/ neutropenia
Ceftaroline
  • covers MRSA
Carbapenem
  • Gram ⊖
Aztreonam
  • Gram ⊖ including peudomonas
FQ
  • Best therapy for CAP, including penicillin-resistant pneumococcus
  • Gram-negative bacilli including most pseudomonads
  • Ciprofloxacin for cystitis and pyelonephritis.
  • Diverticulitis and GI infections, but ciprofloxacin, gemifloxacin, and levofloxacin must be combined with metronidazole because they don’t cover anaerobes.
  • Moxifloxacin can be used as a single agent for diverticulitis and does not need metronidazole.
Bone &
Tendons
Rupture
Aminoglycosides
  • Drug + gentamycin = pyelonephritis, cystitis, children sepsis, endocarditits
  • gram ⊖
Ototoxic
Renal failure
Doxycycline
Animal related infxn
tooth discoloration (children), Fanconi syndrome (Type II RTA proximal), photosensitivity, esophagitis/ulcer
TMP-SMX
PCP
Nocardia
Toxo ppx
  • BM suppression
  • G6PD
  • Rash (SJS)
  • RTA 4
Abx in pregnancy
Contraindicated
  • Aminoglycosudes: ototoxic
  • Tetracyclines: teeth & bones
  • Sulfonamides neonatal jaundice
  • Chloramphinicol
  • Fq
Safe
  • PNC
  • Cephalosporins
  • Erythromycin + Azithromycin

Infective Endocarditis

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Infective Endocarditis
Tx
Empiric –(waiting for sensitivity)–> Specific
·       Best 1˚: Vanco + Gentamicin
·       If pt doesnt respond? add aminoglycosides 
·       If pt has prosthetic valve and staph? add rifampin
When Is Surgery the Answer?
·       CHF or ruptured valve or chordae tendineae
·       Prosthetic valves
·       Fungal endocarditis
·       Abscess – AV block
👾
Tx
Viridans
Ceftriaxone for 4 weeks
S.aureus (MSSA)
Oxacillin, nafcillin, or cefazolin
Fungal
Amphotericin and valve replacement
S.epidermidis/MRSA
Vancomycin
Enterococci
Ampicillin and gentamicin
HACEK
Ampicillin-Sulbactam
PPx
Who need PPx?
1. Significant cardiac defect: Prosthetic valve / Previous endocarditis / Unrepaired cyanotic heart disease
2. Risk of bacteremia: Dental work with blood / Respiratory tract surgery that produces bacteremia
What to give them? Amoxicillin prior to the procedure. (If allergic: clindamycin, azithromycin)
–––––––––
Procedures that do not need prophylaxis are: ✳️
·       Flexible endoscopies, even with biopsy
·       Obstetrical and gynecologic procedures
·       Urology procedures (including prostate biopsy)
·       GI procedures including ERCP
·       Valvular heart disease including MVP, even with a murmur ·
·       MR/MS, AR/AS, HOCM, ASD

Vascular & immunologic features of infective endocarditis
Vascular phenomena
·       Systemic emboli (cerebral, pulmonary, or splenic infarcts)
·       Mycotic aneurysm
·       Janeway lesions – Macular, erythematous, nontender lesions on the palms & soles
Immunologic phenomena
·       Osler nodes – Tender, violaceous nodules seen on the fingertips & toes
·       Roth spots – Edematous & hemorrhagic lacerations of the retina

Bacteria in infective endocarditis
S.Aureus
Prosthetic valves
IV catheters
Pacemaker/defibrillator
IVDU
S.Viridans
Gingival manipulation
S. epidermidis
Prosthetic valves
IV line
Enterococci
Nosocomial UTI
Streptococcus gallolyticus (S bovis)
Colon carcinoma
IBD
Fungi – Candida
Immunocompromised
IV catheters
Prolonged Abx use
Infective endocarditis in IV drug users
·       HIV infection increases IE risk in intravenous drug users
·       Staphylococcus aureus the most common organism
·       Tricuspid valve involvement (right-sided) more common than aortic valve
·       Holosystolic murmur increases with inspiration indicating tricuspid involvement
·       Septic pulmonary emboli common
·       Fewer peripheral IE manifestations (eg, splinter hemorrhages, Janeway lesions)
·       Heart failure more common in aortic valve involvement but rare with tricuspid valve disease

IE- Modified Duke criteria
Dx
Major criteria
• Culture +ve for typical organism (S.aureus, Enterococcus, viridans)
• Echocardiogram showing valvular vegetation
Minor criteria
• Predisposing cardiac lesion
• IVID
• FEVER >38
• Embolic phenomena
• Immunologic phenomena (GN)
• Culture +ve  for atypical organisms
Definite IE: 2 major OR (1 major + 3 minor)
Possible IE: (I major + I minor) / (3 minor)

Infective Endocarditis Complications
Cardiac
•      Valvular insufficiency – common cause of death
•      Perivalvular abscess
•      Conduction anomalies
•      Mycotic aneurysm
Neurologic
•      Embolic stroke
•      Cerebral hemorrhage
•      Brain abscess
•      Acute encephalopathy or meningoencephalitis
Renal
•      Renal infarction
•      Glomerulonephritis
•      Drug induced acute interstitial nephritis from therapy
MSK
•      Vertebral osteomyelitis
•      Septic arthritis
•      MSK abscess