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103 Cards in this Set

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Primary Prophylaxis
provided to pt w/ no history of OI but risk
Secondary Prophylaxis
pt w/ at least 1 OI
want to start ART..early disadv
-one disadv- IRIS- immune reconstitution inflam syndrome
if have acute IO on ART
-if w/i 12 weeks starting ART continue ART and tx OI

-if result of virologic failure- start tx OI, resisetance testing for ARV
Pneumocystis jiroveci pneumonia
-formerly PCP, protozoa like fungus
Pneumocystis jiroveci pneumonia

risks
-CD4 <200,

prior PCP,

oral trush,

high viral load
Pneumocystis jiroveci pneumonia

sx
hypoxemia,

weightloss,

cough,

fever
Pneumocystis jiroveci pneumonia

Dx
BAL-bronchoalvelar lavage

, CXR-bilateral infultrates

, biopsy worst case

Labs-PO2 down, CD4<200
Pneumocystis jiroveci pneumonia

Primary Prophlyaxis when
CD4<200 or oropharyngeal candidiasis

can D/C if CD4 above 200 for 3 months
Pneumocystis jiroveci pneumonia

Primary Prophylaxis what
TMP/SMX 1DS daily or 1SS daily (watch for SE, SJS, etc)

alternatives- dapsone, aerosolized pentamideine, atovaquone
Pneumocystis jiroveci pneumonia

Acute tx
DOC TMP/SMX-bactrim DOT 21 days

IV severe, PO mild-mod

Alt S-Pentamidine, or Primaquine + clindaymycin

M/M- Primaquine+ clindamycin , Atovaquone

if PO2 <70- add prednisone w/i 72h
Pneumocystis jiroveci pneumonia

Secondary Prophylaxis
basically depends on CD4 200 again

if get PCP when above 200 lifelong
Toxoplasma gondii Encephalitis
toxoplasmosis

-caused by protozoan in uncooked meat or cat feces oocytes
Toxoplasma gondii Encephalitis

sx
-focal encephalitis- headache, confusion, motor weakness

-if untreated- seizures, stupor, coma
Toxoplasma gondii Encephalitis

Dx
immune assays for IgG,

CT or MRI(one or more lesions identified),

worse case brain biopsy
Toxoplasma gondii Encephalitis

Primary P
+ve for IgG and CD4 under 100

stop when CD4 above 200 3 months

DOC TMP/SMX 1DS daily

Alt TMP/SMX-1DS 3x/w, Dapsone + pyrimethamine + leucovorin
Toxoplasma gondii Encephalitis

Acute tx
Pyrimethamine + sulfadiazine + leucovorin

at least 6 weeks!!!

if allergy to sulfadiazine put clinda
Toxoplasma gondii Encephalitis

secondary P
- usually lifelong unless CD4 >200 >6 months

same combo as acute tx
Disseminated Mycobacterium avium complex (MAC)
-found in environment, transmission via resp or GI tract
Disseminated Mycobacterium avium complex (MAC)

when risks
-CD4<50,
VL >100000,
previous OI, previous MAC

-if not on ARV- multiorgan infection

-on ARV localized
Disseminated Mycobacterium avium complex (MAC)

Labs, Dx
L-anemia, neutropenia, alk phos, hepatomegaly, spenomegaly, lymphadenopathy

S/Sx, blood cultures, acid fast baciili
MAC

Primary P
when CD4 <50

stop when above 100 >3 months

restart under 50

DOC Azithromycin 1200mg/wk or azithromycin 600mg 2x/wk or Clarithromycin 500 bid

Alt Rifabutin 300 mg/d adjust...
MAC

Acute tx
DOC clarithromycin 500 BID + ehtambutol 15/kg qd

Alt azithro

add Rifabutin if needed

at least 12 months!!!!

repeat blood cultures 4-8 wks after start
MAC

Secondary P
life long recommended unless IRIS

but...>12 months tx, cd4>100 >6months

same as acute
TB
-caused mycobacterium tuberculosis

transmission aerosolized

latent vs active tb

manifestation dependant on CD4 count 200-350 or <200 and any (intense and extrapulmonary)
TB

Dx
Tuberculin skin test- 48-72 h

interferon gamma release assay- IGRA or enzyme linked immunospot assay

in advanced immunosuppression get false negatives
TB

LTBI (no i dont know what it means)
all pts should be tested

if +ve (>5mm) rule out TB w CXR and clinical eval
TB

Active TB Dx
CXR, sputum sample
TB

Latent tx
when u have it and ur not tx it....

when ur -ve but in contact w/ those who do

hx ofuntreated or inadequate txed tb

Primary Isoniazid (INH) 9 months

`if resist Rifampin (RIF)4 months

if not on ART, INH and rifapentine 12 weeks
TB

Active tx
DOT recommended, 2 phase

phase 1, 2 months
INH + RIF or rifabutin (RFB) + pyrazinamide (PZA) + ethambutol (EMB) (EMB possibly early D/C)

continued phase (4 (pul) or 7 (extrapul) months)
INH + RIF or RFB daily or 3x/wk or 2/wk but not 2x if CD4<100

if drug resistant:
to INH then just keep others on for 6 months then d/c PZA

to rifamycin then put in FQ but prolly not work
TB

ARV interactions
no interaction w/ NRTIs

NNRTI and PI interaction (hepatic metab)

PI based regimen-- NOT WITH RIF....use RFB

RIF- adjust EFV, rest dont coadmin

CCR5- RIF not recomm.
Mucocutaneos Candidiasis
-candida albicans

-most common oropharyngeal, esophageal - CD4<200

-resistance- C. glabrata

Primary p not recommended
Mucocutaneos Candidiasis

sx
-white plaques, painless that can be scrapped off

-with esophageal can have discomfort

-Vulvovaginitis (VVC)- discharge from well u know, creamy yellow, burns and itches...
Mucocutaneos Candidiasis

Dx for each
oro- clincal manifistation, lesions

eso-clincal and endoscopy

vulvo- KOH preperation, clinical
Mucocutaneos Candidiasis

oro tx
7-14 days
fluconazole 100 mg daily

clotrimaole troches
nystatin susp

Alt itraconazole
Posaconazole
Mucocutaneos Candidiasis

tx Eso
14-21 days

Pre Fluconazole 100mg up to 400 PO/IV daily

Alt- who fuck cares
Mucocutaneos Candidiasis

tx Vag


and secondary P overall
uncompl- fluconazole x1, topical azoles 4-7 days

compl- same but more doses (>7 days... 2-3 doses flu)



secondary- for eso only flu 100 daily D/C >200 CD4
Cryptococcal Meningitis

Sx and Primary P
-no primary

Sx-neck stiffness and photophobia, mental disturbances
Cryptococcal Meningitis

Dx
check CSF- lumbar puncture,

elevated serum protein,

decreased lymphocytes,

culture
Cryptococcal Meningitis

Tx
DOC

phase 1- amphotericin B + flucytosine > 2 wks

phase 2- fluconazole x8 wks

Alt:

1- amphotericin + fluconazole 4-6 wks
OR- fluconazole + flucytosine

2- itraconazole
Cryptococcal Meningitis

second preve
once 10 wks complete, D/C >200 + on ARV >6 months

use flu
Cytomegalovirus (CMV) retinitis

what, risk, leads to, proph
double stranded DNA herpes

risk-CD4 <50

can lead blindness

no P prophylax
Cytomegalovirus (CMV) retinitis

Sx and Dx
retinitis- floaters,
decreased retinal acuity,
fluffy yellow white
retinal lesions

dx- clincal present, ophtalmoscopic examination
Cytomegalovirus (CMV) retinitis

Tx
for sight threatening:

IO ganciclovir implant + valganciclovir 900 mg pO ...14-21 days

for small lesions:
valganciclovir 14-21

Alt- fuck em
Cytomegalovirus (CMV) retinitis

secondary P
prolly lifelong

Cd4>100 3-6 months, ask the eye man
Two types of STDs
Dischargers...

Genital Ulcer Diseases
Dischargers are
HIV

Chlamydia

Gonorrhea

Trichomoniasis
Genital Ulcer Diseases
Herpes

Syphilis

Chancroid

HPV
Chlamydia

cause

who, transmission
C. trachomatis bacteria

lack PG wall

likes women and black ppl

trans- infected fluids, also mother to newborn
Chlamydia

Sx s
females- endocerical canal, urethra, rectum

60% asymptomatic, screening useful

abnormal discharge...

complication in pelvic infalm disease
men or wmoen also reiter syndrome
Chlamydia

Dx
hx

culture

NAAT (amplification test)

EIA (enzyme immunoassay)

DNA hybrid

DFA
Chlamydia

Tx
uncomp:

rec- azithromycin once
or doxycycline 7 days

alt ofloxacin 7 days
levofloxacin 7
erythromycin 7

prego: -- follow up fur sur

rec- azithromycin once
amoxicillin 7 days

alt erythromycin 7 days
Chlamydia
other considerations
dont forget about parnter managment 60 days from symptoms
Gonorrhea

what, trans
N. gonorrhoeae

trans- body fluids like chlamy and prego to baby
Gonorrhea

where
sx
most common in male- urethra

female-endocervical canal

watch eye for blind

general asymptomatic

discharge...
Gonorrhea

complications
f- pelvic inflammatory dx

b- disseminated gonorrhea
Gonorrhea

dx
gram stain smears great for sym males

NAAT

hybrid tests

dont have sex 7 days after single dose therapy
Gonorrhea

tx
uncomp ceftriaxone IM

cefixime

cefoxitin IM once w/ probenecid once

cefotaxime IM plus chlamydia if not ruled out

alt cefpodoxime once plus chlam

disseminated ceftriaxone IM, iV q 24h

alt cefotaxime IV or ceftizoxime IV q 8 hs

prego- ceftriaxone IM once plus chlam

alt azithromycin
Syphilis

what
trans
Treponema pallidum- spirochete

strong HIV association

trans- direct contact with infected membranes or lesions
prego to child after 12 wks gestation
Syphilis

different types
Primary

Secondary

Latent- early and late latency...

Teriary
Syphilis

presentations of types
1- appearance single sore or multiple sores

2-skin rash and mucous membrane lesions

L-nothin

3-gummatous lesions, CV, neuro (meningitis)
syphilis

more about times
Primary- single painless, lesion, highly infectious...persist up 2 8 weeks

Secondary- 2-8 after initial if untreated, multisystem involvement, rash, disappears 4-10 wks

latent- positive serological testing, early and late latency before or after year

Tertiary-10-30 yrs after initial, CNS, heart, eyes, bones, joints
Syphilis

dx
s/ Sx

screening - non-treponemal test- VDRL or RPR

confirmatory- FTA-ABS, measure IgG
Syphilis

tx
1, 2, early latent:
benzathine PCN G 2.4 MU IM once

alt:
doxy x 14days, tetra x 14days, ceftriaxone 10-14day IM/IV, azithromycin once

tertiary, late latent or unknown:
benz PCN G, 2.4 MU IM once weekly x3

alt:
doxy x 28 days, tetra 28days
Syphilis

prego and followup
prego- PCN additional dose recommended, ADR-jarisch herxheimer

followup- 1 and 2 at 6 and 12 months

latent- 6, 12, 24 months

sexual partners w/i 3 months
Bacterial Vaginosis

risks

sx
risk- multiple partner, new partner, douching, lack lactobacilli

sx- thin white discharge, fishy odor.... vulvar itching
Bacterial Vaginosis

Dx
gram stain or clinical criteria,

at least 3-
thin white discharge,
fishy odor,
presence clue cells microscoped,
pH vag >4.5
Bacterial Vaginosis

Tx
sex partners no need tx

Non preg Metro PO 7 days or gel for 5 days
or clindamycin cream 7 days

Alt clindamycin 7
clinda ovules intravag 3 days

tinidazole 3 days or 5days depend on dose

Prego:
metro PO 7 days
or clindamycin 7 days
Trichomoniasis

who
what
how
Protozoal

-both men and women

-direct exposure contaminated surfaces or sexual contact, mother to newborn
Trichomoniasis

where
Sx
-M-urethra, usually asymp,
F- endocervical canal

-Sx-yellow, green foamy discharge....
vulvar irritation,
strawberry spots (surface errosions 90%)
Trichomoniasis

Dx
elevated vaginal pH
, strawberry spots
, wet mounts microscoper
, culture,
EIA
Trichomoniasis

Tx
Metro 1x
or Tinidazole x1

Alt Metro 7 days lower dose

Prego metro x1

Failure use alternate

avoid sex until asymp, treat partners
Herpes

what
types
who
trans
virus

HSV-1 oral infections
HSV2 genital lesions

more women

trans- direct contact, symptomatic lesions,
asymptomatic lesion shedding, mother to newborn
Herpes

stages
Primary mucocutaneous infxn->infxn ganglia->
latency-->reavtivation-->recurrent infxn
Herpes

primary
recurrent

DX
P-painful multiple vescular lesions on external genitalia, also systemic flu like
shedding lasts 11-12 days

R:
worse in HSV2, less systemic, more severe women, prodromal symptoms, viral shedding 4 days


Dx- physical exam, virologic test-culture, PCR assays, type specific testing
Herpes

Tx
first 7-10 acyclovir 5x/day, famciclovir, valacyclovir

recurrent x5 or 2x 5x or 1x or 2x 3x or 5x (in order of above)

daily supress- more than 6 episodes / year (can use for up to 6 years..?)

prego- acyclovir- risk trans to neonate still
HPV

what...
risks
Condylomata Acuminata

-HPV types 6 and 11

-warts on genital/perianal areas...

-risk cervical cancer... men too oral cancer

risks- sex partners, <25yo, sex younger, uncircumcised males
HPV

trans

Sx

complications
T- intercourse, genital/gential,
manual genital, oral genital

Sx- cauliflower like....painful, weeks or months after intercourse

-complications malignacies
HPV

Dx
physical,

pap smear,

PCR detect HPV-DNA
HPV Tx

provider
- remove visible warts..
pregors not use Imiquimod, podophyllin, podofilox- remove warts

Provider:

cryotherapy- freeze them bitches

podophyllin resin

trichloroactetic acid

surgical removal when large affected area
HPV Tx

Pt applied
podofilox 3x 4 cycles

imiquimod 3 times 16 weeks

sinecatechins 16 weeks
Pharmacist intervention
prevention:
abstinence
preexposure vaccine
condoms
other contraceptives

abstince during tx

compliance

theres a herpes hotline....and dating site.....James why is that ur number
Different types of UTI
Uncomplicated- lower tract - women, health, no abnormalities

-Bladder - cystitis
-Prostate - prostatitis
-epididymis (epididmytitis)

Complicated- lower and upper, men and women, possible abnormality

-kidneys - pyelonephritis
-ureters (comp) vs urethra (uncomp)
UTI Organisms
E Coli - 85%

Staph saprophyticus

Kleb pneumo

Enterobacter

Proteus

Pseudomonas aeruginosa
UTI

Virulence factors

Host defenses
V- adherence to tissues,
production hemolysin (breaks down cells)
and aerobactin (binds iron)

HD-low pH,
osmolar extremes,
urea [ ],
anti adhereance mechs,
inflam response,
lactobacillus
UTI

risks

complicated risks
gender,
obstruction,
incomplete emptying
, prego,
spermicide,
menopause,
immunosupressed

Comp-environment
UTI presentation

comp vs uncomp
Lower- dysuria, freq/urgency, some blood (hematuria), suprapubic discomfort

Upper- flank pain, fever, chills, N/V, more generallized seemingly
UTI

labs
bacteriuria,
nitrate in urine,
leukocyte esterse urine
, antibody covered bacteria (in upper)
UTI

Dx
-midstream clean catch method (use gloves!!) gold standard

-urinalysis by dipstick, nitrate, leukocyte esterase

-cloudy, alkaline, positive for other shit >10WBC...

- do bacterial susceptibility testing
UTI

adjunct therapy
fluids,
cranberry juice,
topical estrogen (post menopause),
UT analgesics
UTI

Tx
TMP/SMX, FQ, nitrofurantoin, beta lactams

do susceptbility test, consider allergies

duration- usually 7-14 women, at least 10 men, can do short term or one dose

if STD associated azithro or tetra
UTI

Acute complicated cystitis
E coli.....Kleb, Proteus, saphrophytucis

Nitrofurantoin- 5 days

TMP/SMX- 3 days DS
UTI

Acute Pyelonephrisitis
complicated- can have temp and severe flank pain

E coli, Kleb, proteus,, +ves- faecalis saphro and others

IV antiobiotics for severe

FQ, AG and Amp, broad ceph.....betalactamases, bactrim

mild- bactrim, FQ OP

DOT 14 days!!! can stop IV 3 days then PO for 14 total
UTI

Symptomatic Abacteriuria
acute urethral syndrome
sex..?

E coli, Staph spp, Chlam

-tx bactrim 1 DS 3 days or azithromycin/ doxy for 7 days
UTI

Asymptomatic bacteriuria
elderly, children, pregos

relapse

E Coli, do cultures

TX THEM IF CHILD OR PREGO

amoxicillin/ clav 7 days or ceph 7 days, bactrim 7 days (not thrid)
UTI in males
complicated

BPH risk, instrumentation, catheter, stones

uncomplicated rare

obtain culture!!! prior therapy

usually BACTRIM or FQ - high renal tissue [ ]

DOT 10 -14 days!!!! not short or single course!!!!
UTI in pregos
risk dilation pelvis, less tone bladder, less bacteria defence....

E Coli

tx or prematurity, low birth weight, still birth

Tx try to use

Amox/ clav or amox, cephalexin, nitrofurantion, not bactrim in thrird)
UTI in catheterized
risk- 30 days, open system, poor aseptic technique

complications- pyelonephritis, bacteremia

remove catheter... durrr

symptomatic- start tx copmlicated
Recurrent UTI
women...again

class ify 2, 3, more 3

risks- sex, spermicides

greater than 3 eventually start long term low dose tx
Prostatitis

categories
what
increased inflam cell in prostate gland - infectious or inflammatory

Category I- Acute Bacterial Prostatitis

Category II- Chronic Bacterial Prostatitis

2 others but who cares they werent bolded!!
Prostatitis

bacteria
-E coli, pseudomonas, serratia, kleb, proteaus +ve- entercoccus, saphro,.....
Prostatitis acute
more generalized systems and severe, tender and swollen- urine culture!!

complications- bacterimia, sepsis, epidiymitis, abscess, chronic

tx- initial IV maybe proxy 3-5 days, febrile 48 hours

bactrim,, FQ, Amp w/ gent

DOT 4-6 wks!!!!
Prostatitis

chronic
Chronic- difficult and less intense, enlarged- pre/ post massage test!!!

tx- FQ need to reach [ ] also bactrim (TMP)

tx 6-12 wks!!!!