Infectious Disease Tst5 Set2

Front 1

Gonorrhea s/sx
a)male (3)
b)rectal (2)
c)female (5)

Back 1

a1)urethral discharge- 80%
a2)dysruia- 50%
a3)asymptomatic- 10%

b1)rectal discharge- 12%
b2)rectal discomfort/pain- 7%

c1)asymptomatic (50% or less)
c2)incr or altered vaginal discharge (50% or less)
c3)lower ab pain (less than 25%)
c4)dysuria (12%)
c5)metorrhagia or menorrhagia (rare)

Front 2

Disseminated Gonorrhea (5)

Back 2

1)more common in men
2)petechial or pustular skin lesions
3)arthritis
4)tenosynovitis
5)asymmetrical arthralgia (SWOLLEN/HURTING JOINT)******

Front 3

Gonorrhea tx
a)uncomplicated (3)
b)disseminated (3)
c)partners

Back 3

a1)cefixmie 400mg po (1st)
a2)ceftriaxone 125mg IM (2nd)
a3)spectinomycin 2g IM (pregnancy)
SINGLE DOSE

b1)ADMISSION
b2)ceftriaxone 1g IV/IM qd x7d
b3)change to po after 48h of improvement

c)evaluate and tx

Front 4

Gonorrhea FQ resistance is seen where? (4)

Back 4

1)cali
2)MSM
3)hawaii/pacific islands
4)asia

Front 5

Tx of Gonorrhea
a)conjunctivits
b)neonatal prophylaxis (2)

Back 5

a1)ceftriaxone 1g IM (SINGLE DOSE)

b)ceftriaxone (SINGLE DOSE)
b)topical erythromycin or silver nitrate (swab of eyes/all babies get it)

Front 6

Gonorrhea and concomitant tx (3)

Back 6

ALL PATIENTS ARE TX FOR CHLAMYDIA TOO (C. trachomatis) w/
a)azithromycin
b)doxycycline

Front 7

Chlamydia Trachomatis
a)s/sx (3)
b)complications (3)

Back 7

a1)onset of 1-3wks BUT VAST MAJORITY ARE ASYMPTOMATIC
a2)MEN- dysuria/discharge and pharyngitis
a3)WOMEN- dysuria/discharge/bleed and pharyngitis

b1)PID
b2)infertility/ectopic pregnancy
b3)epididymitis

Front 8

Chlamydia Trachomatis tx
a)uncomplicated (2)
b)pregnancy (2)
c)neonate

Back 8

a1)azithromycin 1g po x1 dose
a2)doxycycline 100mg bid x7d (use w/ azith allergy)

b1)amox 500mg tid x7d
b2)azithromycin 1g po x1dose

c)ADMIT and give erythromycin 50mg/kg/day for 14d

Front 9

Chlamydia
a)monitoring/follow-up (3)
b)what to consider w/ tx failure (2)

Back 9

a1)high cure rates
a2)follow-up appointment
a3)pregnancy (3wks post therapy)

b1)non-compliance
b2)untreated partners/new exposure

Front 10

Conclusions for:
a)Gonorrhea (4)
b)Chlamydia (3)

Back 10

a1)most common sx is urethral/vaginal discharge
a2)disseminated
a3)resistance to FQ's
a4)often coninfected w/ chlamydia (so tx concomitantly)

b1)most common STD in US
b2)often asymptomatic
b3)responsible for long-term complications

Front 11

Vaginal Dischange STDs?? (3)

Back 11

1)bacterial vaginosis
2)trichomoniasis
3)candidiasis

Front 12

Bacterial Vaginosis
a)s/sx (5)
b)diagnosis (2)

Back 12

a1)polymicrobial
a2)normal vaginal flora replaced w/ anaerobic bacteria
a3)often asymptomatic
a4)THIN,WHITE vaginal discharge
a5)can be an STD, not always one

b1)see clue cells
b2)(+) whiff test

Front 13

Bacterial Vaginosis tx (5)

Back 13

1)flagyl 500mg bid x7d
2)flagyl gel qd x 5d
3)clindamycin cream qd x7d
4)partners no tx on initial episodes

start topically and NO alcohol even w/ topical flagyl

Front 14

Trichomoniasis
a)MO
b)s/sx
c)diagnosis
d)tx (4)

Back 14

a)T. vaginalis
b)yellow-green vaginal discharge that is diffuse/malodorous
c)wet prep or point-of-care

d)flagyl 2g x1dose (1st)
d)tinidazole 2g x1dose (2nd)
d)flagyl for 7-14d (3rd)
d)eval/tx partners

Front 15

Candidiasis (NOT STD)
a)MO
b)s/sx (3)
c)tx (3)
d)counsel

Back 15

a)C. albicans

b)pruritis
b)vaginal discomfort
b)abnormal vaginal discharge

c)oral fluconazole 150mg po x1dose
c)partners NO tx
c)recurrent eps require longer tx

d)W/ RECURRENT EPS GET HIV TEST****

Front 16

HPV vaccine targets (2)

Back 16

types 16/18- cervical cancer

types 6/11- genital warts

Front 17

HPV
a)prevention (2)
b)other tx (3)

Back 17

a)Gardasil IM @ 0,2,6 months
a)indicated for girls 9-26yo

b)cryotherapy
b)podophyllin
b)surgery
BUT WILL COME BACK EVEN AFTER THESE

Front 18

Gardasil ADR's (4)

Back 18

1)94% non-serious
2)GBS
3)blood clots
4)death (only 27)

Front 19

In tx of STDs pts must....******

Back 19

abstain from sex during tx (usually a week)

Front 20

CDC criteria for HIV infexn (2)

Back 20

1)repeatedly reactive ELISA
2)positive western blot or immunofluorescence assay

Front 21

CDC lab categories (3)

Back 21

Cat1- CD4 count over 500
Cat2- CD4 count 200-499
Cat3- CD4 count under 200 (AIDS)

Front 22

CDC clinical characteristics (3 w/ 3,1,2)

Back 22

CatA
a)asymptomatic
b)PGL
c)acute/primary HIV infexn

CatB
a)nonthreatening diseases/infexns

CatC
a)life threatening disease/infexns
b)NO aspegillus infexns thou

Front 23

HIV Viral "Set Point" (2)

Back 23

1)equilibrium established b/w viral replication rate (viral load) and host immunity
2)predictive of individual's rate of subsequent disease progression to AIDS

Front 24

HIV Resistance Development (3)

Back 24

1)Reverse transcriptase is highly error prone = source of resistance
2)numerous variants of original HIV strain exist within a pt
3)never go back to drugs pt has resistance to!!

Front 25

2 types of HAART for HIV and adv/disadv of each (2 w/ 3,1)

Back 25

Combo therapy of:

NNRTI + NRTI1 + NRTI2
a)simpler to use (qd)
b)decr ADRs
c)quicker to resistance

PI(s) + NRTI1 + NRTI2
a)v.v. of above

Front 26

PI to know (4)

Back 26

1)Lopinavir/Ritonavir
2)Atazanavir
3)Fosamprenavir
4)Darunavir

Front 27

Ritonavir speciality (3)

Back 27

1)inhibits P450s to maintain good levels of other PIs
2)is a PI booster (incr t1/2 of other PIs at therapeutic doses)
3)not used at therapeutic dose

Front 28

Nucleoside/tide RT inhibitors to (NRTIs) to know (2)

Back 28

1)Emtricitabine
2)Tenofovir

Front 29

NNRTI to know (2)
Entry inhibitors (2)

Back 29

Efavirenz
Etravirine (use if efavirenz fails)

Enfuvirtide (T20)
Maraviroc (CCR5 antagonist)

Front 30

NRTI considerations (4)

Back 30

Tenofovir/emtricitabine- avoid in renal insufficiency***

Abacavir/lamivudine- avoid in high CV risk and genetic screen for hypersensitivity

Zidovudine/lamivudine- avoid w/ anemia or neutropenia

Didanosine + lamivudine/emtricitabine- do not use w/ hx of pancreatitis or peripheral neuropathy

Front 31

NNRTI considerations (2)

Back 31

Efavirenz- avoid w/ unstable psychiatric disease or during pregnancy****

Nevirapine- NO in women w/ CD4 over 250 or men w/ CD4 over 400 (is back up to efavirenz)

Front 32

PI considerations (2)

Back 32

Atazanavir/ritonavir- no in pts w/ high dose PPIs (over 20mg/d omeprazole)***

Lopinavir/ritonavir- use bid in pregnancy (not qd)***

Front 33

Antiretroviral agents NOT recommended (6)

Back 33

1)NO monotherapy w/ ANY agent
2)stavudine/zidovudine (antagonism)
3)lamivudine/emtricitabine (antagonism)
4)stavudine/didanosine (incr toxicity)
5)zalcitabine (toxicity/potency)
6)NNRTI + Tenofovir + Didanosine (poor response)

Front 34

PREFERRED INITIAL antiretroviral therapy (5)

Back 34

NNRTI
Efavirenz/Tenofovir/Emtricitabine (qd/1pill)

PI (all have tenofovir/emtricitabine + _____/ritonavir)
1)atazanavir (qd/3pills)
2)darunavir (qd/4pills)
3)fosamprenavir (bid/5pills)
4)lopinavir (qd/5pills)

Front 35

General Antiretroviral selection guidelines (8)

Back 35

1)sometimes optimal regimen is NOT preferred b/c of resistance or ADRs
2)"boosted" PIs preferred b/c of incr potency
3)NNRTI-based regimens are simpler but more prone to resistance than PI-based
4)Triple NRTI regimens are inferior to PI or NNRTI based regimens
5)Emtcitabine and lamivudine are interchangeable
6)PI(s) + NNRTI + NRTI may be used when NRTI options are limited (or 2PI + NRTI)
7)Enfuvirtide (T20) and integrase inhibitors are limited to pts w/ extensive drug resistance
8)maraviroc requires tropism assay to see if virus is binding CCR5 or CXCR4 (limited to pts w/ drug resistance)- will fail if binding CXCR4 or both

Front 36

Initiation of therapy in symptomatic
a)s/sx (5)
b)recommendation

Back 36

a1)chronic fever
a2)night sweats
a3)wt loss
a4)thrush
a5)AIDS

b)therapy recommended in ALL pts

Front 37

Initiation of therapy in
a)asymptomatic
b)CD4 over 350
c)HIV RNA over 100,000

Back 37

recommended but many clinicians defer therapy and monitor CD4 counts more closely

Front 38

Initiaion of therapy in
a)asymptomatic
b)CD4 200-350
c)any viral load

Back 38

consider therapy if pt is willing to adhere to complex regimen

Front 39

Initiation of therapy in
a)asymptomatic
b)CD4 under 200
c)at any viral load

Back 39

therapy recommended

Front 40

Evaluating Response to Antiretroviral therapy (3)

Back 40

2)1 or more log decline in viral load should occur within 8wks (10fold decr)
3)pts should be undetectable within 16-24wks (under 48copies/mL)
4)pts w/ higher virologic "set points" take longer to become undetectable (24-36wks)

Front 41

Virologic Failure (3)

Back 41

1)persistent rise in viral load in a pt who was previously undetectable
2)recent immunization or viral illness (within 4wks) may lead to temporary incr in viral load
3)pts w/ persistently falling CD4 count despite viral suppression (undetectable viral load) should be considered for tx change

Front 42

Alterations in Therapy (4)

Back 42

1)replace one (or more) drug(s) in existing regimen when tx failure has occurred based on resistance testing results or resistance is suspected
2)replacement of only one drug in existing regimen can be performed when intolerance is clearly attributalbe to ONE agent
3)interruption of all agents should be performed if the basis for toxicity is unknown
4)Minimum of 3 active drugs ALWAYS

Front 43

NRTI ADRs
a)Tenofovir
b)Abacavir
c)Zidovudine
d)Didanosine (2)
e)Stavudine (2)
f)FOR THE CLASS

Back 43

a)nephrotoxicity

b)HYPERSENSITIVITY RXN

c)anemia/neutropenia

d)neuropathy
d)pancreatitis

e)neuropathy
e)lipoatrophy (loss of fat in extremeties)

f)LACTIC ACIDOSIS

Front 44

NNRTI ADRs
a)Efavirenz
b)Class
c)Nevirapine

Back 44

a)CNS (dreams, hallucinations)

b)ALL HAVE RASH

c)rash is the worst with this one

Front 45

PI ADRs
a)Atazanavir (3)
b)lopinavir/ritonavir (2)
c)CLASS (2)

Back 45

a)hyperbilirubinemia
a)EKG changes
a)NO hyperlipidemia

b)hypertriglyceridemia
b)DIARRHEA

c)impaired glc tolerance
c)lipodystrophy (fat redistribution, hyperlipiemia)

Front 46

Enfuvirtide ADR

Back 46

injexn site rxns

Front 47

____ is the best PI to use when all the others have failed

Back 47

Darunavir

Front 48

Abacavir Hypersensitivity Rxn (HSR) management (3)

Back 48

1)typically occurs within first 8wks of therapy
2)more common in whites (HLA5701)
3)NEVER rechallenge pt once HSR dx is established

Front 49

Pregnancy and Retroviral therapy (3)

Back 49

1)offer HAART to all pregnant women irrespective of CD4 count and viral load
2)tx may be deferred until after 1st trimester if mother wishes to avoid unknown teratogenicity
3)ALWAYS include Zidovudine or add it to any regimen used

Front 50

Zidovudine and Pregnancy (4)

Back 50

1)3 step Zidovudine monotherapy should be offered if mother refuses HAART
a)prepartum (mother > 14wks) give ZDV po until onset of labor
b)labor/delivery give ZDV IV via cont infusion til cord clamping
c)postpartum (for the infant) give ZDV syrup po x6wks

Front 51

Other retroviral drugs and delivery/pregnancy (non-ZDV) (2)

Back 51

1)nevirapine can be given as SINGLE dose to mother during labor and within 48-72h to the child but high resistance
2)C-section @ 38wks if viral load is over 1000copies/mL @ 36wks gestation

Front 52

Retroviral to NOT use in pregnancy (3)

Back 52

1)efavirenz (teratogenic)
2)stavudine + didanosine (incr lactic acidosis and fetal demise)
3)CHRONIC nevirapine b/c of hepatoxicity

Front 53

Pertinent Retroviral drug interaxns (and how to fix)
a)Atazanavir
b)Didanosine
c)lopinavir/ritonavir

Back 53

a)w/ Tenofovir (admin w/ 100mg ritonavir)

b)w/ Tenofovir (decr dose of didanosine)

c)w/ efavirenz/nevirapine (incr dose of lopinavir/ritonavir to 600/150 bid)

Front 54

Retrovirals to give w/o food (6)

Back 54

1)Atazanavir
2)Saquinavir
3)Ritonavir
4)Nelfinavir
5)Lopinavir/Ritonavir
6)Etravirine

Front 55

Mutations of _____ affect what drugs:
a)K103N (3)
b)M184V (2)

Back 55

a)Efavirenz
a)Nevirapine
a)Delaviridine

b1)Lamivudine
b2)Emtricitabine

Front 56

NNRTI effective w/ K103N mutation

Back 56

Etravirine

Front 57

K65R mutation effects

Back 57

Tenofovir