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254 Cards in this Set

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how many strains?

CA-MRSA-

HA-MRSA-
CA- USA-300 strains

HA- USA 100 strains
CA-MRSA

risk factors?
location?
mortality?
growth rate?
mec gene?
RF- close quarters, poor, poor hygiene

locat- skin + soft tissue mainly

mortality-low
fast grower

mec IV
HA-MRSA

RF?
LOCATION?
MORTALITY?
GROWTH RATE?
MEC GENE?
RF- hosp, old, chronic disease, surgery, medical device w/i 1 yr

location-heterogenous- can be tissues, pulm, blood
high mortality
slower growing
mec I-III
CA-MRSA

resistance patterns?

susceptibility
resistance to B-lactams

suscept- clinda, bactrim, tetra
HA-MRSA

resistant to?
susceptible?
multi-drug resistance

susceptible to vanco
examples of primary infection
erysipelas
impetigo
lymphangitis
cellulitis
necrotizing fascitis
examples of secondary infection
previously damaged sking-polymicrobial

diabetic foot, pressure sores, bit wounds, burn wounds
define a complicated SSTI
deep skin infxn
or require surgery
or occur in immuno comped pt's
class 1 SSTI
afebrile, NOT cellulitis

outpt; tx with topical or roal abx
class 2 SSTI
febrile w.o co-morbidities

IV therapy, short obs. or hosp-->then OPAT
class 3 SSTI
toxic appearing or nontoxic + 1 or > comorbidity

hosp + IV abx therapy--->OPAT may need vascluar remediation
class 4 SSTI
sepsis syndrome or life threatening
NECROTIZING FASCITIS

hosp-> may need surgery
what accounts for majority of SSTIs
stap areus + streptococcus pyogenes
alpha strep are which 2 organisms

beta strep are
viridans, and pneumonia

beta-GroupA-strep pyogenes
3 types of follicular infxn

mainly caused by what?
folliculitis
furuncle
carbuncle

staph aureus
whats the presentation of folliculitis
superficial w/ pus at epidermis

pruritic erythematous papules

evolve into pustule
tx of folliculitis
wrm saline compress

ropical clindamycin, erythrom, mupirocin, benzoyl peroxide

for 2-4 x a day for 7 days
another name for furuncle

presentation of furuncle
boil

walled off mass of purulent stuff

extends into subq tissue
discrete lesions, singular or multiple
tx of furuncle
drugs
durations
small- moist heat

large-incision and drainage

extensive surrounding celllitis or fever- use abx:
dicloxacillin or cephalexin

PCN allergy-clindamycin
tx for 5-10days
a stye is what type of infection
its a folliculitis of the eye
presentation of carbuncle
deep and painful follicular masses

seen on back of neck
seen with fecer, chills, malaise
tx of carbuncle
moist heat
all require IND
use systemic abx: cephalexin or diclox
5-10days
cutaneous abscesses
what organisms?

presentation?
polymicrobial or staph aureus

pus in dermis + deeper
-surrounded by rim of erythematous swelling

contain bacteria of normal skin flora
tx of cutaneous abscess
drainage!!!-break up loculations
-may pack with gauze to close

gram-stain, abx are RARELY used
using abx in abscesses are rarely used..except...
multiple lesions
extensive surrounding cellulitis
cutaneous gangrene
high fever
common organism in erysipelas
strep pyogenes
erysipelas
aka
europeans interchange with what?
aka St. Anthony's fire-red color and burning pain

like cellulitis-but ery is more superfical-has demarcated raised margins
presenttion of erysipelas
lower extremeties
fever, malaise BEFORE lesion

streaking is common

early diagnosis=excellent prognosis
tx of erysipelas
mild to mod-pen G IM or Pen VK oral

severe-aqueous Pen G IV

if staph- use diclox or cephalexin
PCN allergy-clinda/erythromycin
tx for 7-10 days
organisms in cellulitis

presentation
strep pygoenes and stap aureus

acute, diffuse-does not have underlying foci
skin looks like orange peel
presentation of cellulitis
fever, tachycardia, leukocytosis- can appear before infxn

non elevated margins

predisposing factors-obesity, edema, previous damage, IVDU->staph aureus
tx of cellulitis

mild to mod
mild to mod w/o symptoms- step- oral PCN VK or IM
oral diclox or ceph
tx for 5 days
cellulitis
severe illness tx
tx for 10-14 days

PCN-ase resistant PCN OR 1st gen Ceph (nafcil, oxacillin or cefazolin)
PCN allergy-clinda or vanco

CA-MRSA- BACTRIM!!, clinda, doxy

HA-MRSA-vanco
VRE-linezo, dapto, tigecyclin, quinu/dalfopristin
impetigo
common organisms
staph aureus + step pyogenes
impetigo
common in? during?

spreads how?
usually on face, extremeties

in kids 2-5, during hot, humid weather
minor trauma gives it entry-cuts

spreads thru close contact
presentation of impetigo
pruritis common

nonbollus-papules--> vesicles->pustules-> THICK crusts

bollus- vesicles->yellow fluid filled bullae->can rupture leaving THIN brown crust like a lacquer
tx of impetigo
symptomatic relief-soap and warm water to get crust off

PCN IM benzathing
PCN-resistant PCN or 1st gen ceph
augmentin
topical-mupirocin oint TID x 7days
tx of MRSA in impetigo
becoming more common
clinda, doxy, bactrim, mino, vano, linezo, dapto

ran resolve by self
tx 7-10 days
lymphangitis
common organism?
what is it?
strep pyogenes

inflam of lympathic channels-acute or chronic

2nd to puncture wounds, bisters
presentation of lymphangitis
fever and chills before infxn
-leukocytosis common

lesion with red linear streaks toward lymp nodes = acute infxn
tx of lymphangitis
non drug tx-immobilization + elevation, warm water soaks q 2, 4 H

drug tx-PCN G IV x 72H, then PCN VK PO X 10 D

PCN allergy-use clindamycin
Necrotizing Fasciitis
type1
after surgery or trauma
mix of anerobes and faculative bacteria
ex-fournier gangrene
80% of necrotizing SSTIs
Necrotizing Fasciitis
type2
usually after minor trauma, called strep gangrene

90%-S pyogenes, 10% staph
flesh eating bacteria
-cause organ failure/shock
presentation of necrotizing fasciitis
can be anywhere-mainly abdomen
predisposing factors-DM, trauma, infxn, surgery

progresses to cutaneous gangrene w/o intervention
Necrotzing Fasciitis
type 3 aka
clostridial myonecrosis
caused by clost. perfingens-gas gangrene

advances over hours(quick)
bronze skin->then purple->reddish blue
C. Myonecrosis
occur when?
tx?
after earthquake, surgery, trauma, IVDU

tx-supportive care (pressers), remove debris, give clinda + penicillin
hyperberic 02
tx of necrotizing infxn
immediate and aggressive surgical debridement of ALL necrotic tissude

type2-give clinda + PCN
1st line abx for
mixed infxn-necrotizing infxn
amp/sulb OR pip/tazo
+ clinda + cipro

carbapenem

cefotax + (metro or clinda)
1st line STREP necrotizing infxn

1st line STAPH necrotizing
pencillin + clinda

nfacill, oxacill, vanco, or Clinda
Clostridium infxn tx
clinda AND/OR PEN
etiology of osteomyelitis
its uncommon
acute-several days
chronic-months

3 classifcations- contiguous spread, hematogenous spread, peripheral vascular disease
hematogenous osteomyelitis
age
site
<1 yo in long bone
1-20 long bone
>50 vertabrae involved
contiguous osteo
age
site
>50 yo mainly, seen in femur, tibia, mandible

RF- DM, trauma to spine, tattoos
vascular induffiencey
age
site
>50 yo in feet n toes

RF-DM, peripheral vascular disease
hematogenous osteomyelitis
what is sequestra?
bloodstream infxn->bone infxn

disease of children

sequestra=dead bone seperates from healthy bone cuz impaired blood flow
hematogenous osteomyelitis
organisms seen in:
children?

non-vaccinated immuno kids?

IVDU-

sickle cell anemia
children-step aureus

immnocomped- H. flu type b

IVDU-psuedomonas aeuroginosa, gram -

sickle- salmonella
contiguous osteo
how does it enter?
common in
from outside body or spread of adjacent tissue

seen in >50 yo
organisms in osteomyelitis
staph aureus most COMMON
epidermidis, streptococci

gram - from puncture foot wounds + psudeomonas

anaerobes
vascular insufficency osteo
hard to manage
50-70 yo
comorbidities-DM

usually in toes, fingers

multiple organisms
tx of osteomy
get deep tissue cultures

drain, hardware removal-rifampin
tx of osteomyl
duration?
what dose of abx?
tx for 4-6 wks

high dose-infected bone hard to penetrate
diabetic foot infection
organisms seen?
polymicrobial + staph or strep common
3 types of foot infections
deep abscess
minor trauma, infxn from nail or web space of toes
3 types of foot infections
-cellulitis of dorsum
routine care related
3 types of foot infections
Mal perforans ulcers
chronic ulcer on sole of foot
on thickend, hardened calluses
diabetic foot infections
cost?
$200 to 350 million

check bottoms of foot-to avoid amputations
presenetation of diabetic foot infxn
neuropathy, angiopathy, ischemia, immunoogic defects

pt seeks swelling relief >pain cause neuropathy-can't feel pain

foul smelling=prescene of anerobes (culture anerobes + aerobes)
organisms of diabetic foot infxn
gram neg-pseudomans

anerobes-peptostrep, bacteroides, clostridium

gram + staph ,strep
tx of diabetic foot infxn
IND
FQ + clinda or (metro + augmentin)

MRSA-vanco, linezo, dapto, tigec
duration of tx for diabetic foot infxn
7 to14 days -mild to mod
2 to 4 wks- mod to severe
6 to 12 wks-osteomyelitis

if 6 wks of vanco-monitor for thrombocytopenia + CBC
pressure sores
AKA
decubitus ulcer or bed sore

seen in bony areas-ass, heel

not always infectious
4 stages of pressure sores
1- reversible, only epidermis
2-maybe revers. gets into subq fat
3-extends further into subq
4-deep fascia, both muscle and bone
tx of pressure sores
prevention-rotate on bed

goal-clean + decontaminate
animal bite wounds
polymicrobial
-pasteurella multocida

dog bites most common (80%)
organism in cat bite

cats associated with what infxn type

dogs>
capnocytophaga

cats-osteomy, abscess
dogs-crush injury
presentation of bite wounds
2 groups
1-w/i 12H of injury-wound care + repair tear wounds

2->12H, local cellulitis, fever is uncommon
tx of animal bite wounds
outpt 1st line
-augmentin
-doxy
-PCN VK +Diclox
mainly need irrigation

if allergy: bactrim, FQ, Macrolide(kids and preg)
tx of animal bite wounds
inpt 1st line
blctam/b-lactamase combo
2nd gen ceph w/ anerobe
carbapenem

mainly need irrigation
post exposure rabies tx
irrigate with soap
vaccine 5 1ml inj on days 0, 3,7,14,28

hyperimmune globulin 40 IU/kg
how do you give the hyperimmune flobulin in rabies tx
u infiltrate into and around wound!!*** rest give IM
human bite wounds
like organism?
eikenella, prevotella + shit tons of others
tx of human bite wounds
irrigate
augmentin commonly used for 3-5 days
if allergy-bactrim or (FQ + CLINDA) or metro
what is NOT recc for human bite wound
1st gen ceph, macrolide, clinda, or aminoglycoside
if serious infxn for human bite wound use what
cefoxitin, amp/sulfbactam or ertapenem

for 7 to 14 days
surgical site infx (SSI)
3 categories
usually w/i 30 days of surgery

1superficial incision- subq
2deep incision-fascia + muscle
3organ/space-any part of anatamoy
presentation of SSI
fever after surgery NOT ssi related

may take 2 weeks to appear

if within 48H-pyogenes or Clostridium
tx of SSI
prophylaxis- right drug, dose, dur, route

can resolve byself

clean infxn + no intest or genital involvement-staph aureus and strept. common
normal CD4 count

VL count does what?
500-1500 cells/m3
-determines when to start regimen

VL measures HIV RNA in blood, + effectiveness of ART
cycle of HIV
attaches to door
enters room
reverses transcrip (undoes zipper)
intergrates into host DNA(puts it in)
viral transcript + transla (busts)
assembly of virion + budding (pregers)
HIV diagnosis
1 Elisa-screens for antibodies
-may be (- )so confirm with Western blot
takes days

2western blot- confirm test
done for all + elisa tests
takes weeks
AIDS diagnosis
posistive test for HIV (elisa +wb)
+ 1 or more: CD4<200 or <14%
or + kaposi, candidas in espogeal, cryptococcus, TB, PCP, wasting, MAC
IF CD4 count is 1000 and post elisa + wb, and pt has TB- whats diagnosis?
AIDS, EVERYONE HAS AIDS, AIDS, AIDS, AIDS, AIDS!
4 STAGES of HIV infxn
exposure + initial infxn
exposure to infxn- no symptoms, - ELISA
4 STAGES of HIV infxn
acute retoviral sndrome
1-4 wks after exp, flu like symptoms
high VL, low CD4
4 STAGES of HIV infxn
clinical latency (steady state)
6 wks after exposure
HIV has resrovoirs set up
sero-con happened- +ELISA
4 STAGES of HIV infxn
clinically apparent
AIDS symptoms may no occur for a decade later
goals of ART
extend life
reduce transmiss
VL of <50 copies or undectable
increase CD4 -no limit

tx=prevention
when to start ART
when CD4 <500 cells
or regardless of CD4: pregnant, HIV caused nephrotox, have hepB
risks vs benefirts of starting ART early
risks-adverse effects, pill fatigue(burnout), develop resistance

benefit-increase survival, decrease transmiss, dec HIV secondary illnesses
ART should consist of how many drugs
3+....no monotherapy
common HIV therapies
2NRTIs + 1 NNRTI
2NRTIs + 1 PI (boosted)
2NRTIs + integrase inhib.
what is preferred Non nuke regimen for tx Naive pt
Atripla
EFV + TDF + FTC
PI based reigmen for tx niave pt
reyataz+norvir+truvada
or
prezista+norvir+truvada
3 tests to determine info about HIV virus
VL
genotype + phenotype
impt lab test for HIV pt
liver, kidney, lipid panel and glucose
tests to determine best regimen for each pt
tropism for maraviroc

HLA-B for abacavir
CD4 + VL monitoring
at diagnosis,
q 3 to 6 months for untreated pt
-start of tx or switching, + 2-8 wks after starting

then q 3 months
spontaneous resistance mutation
HIV copies lots, n can have errors- offspring can be diff from parent- ART no longer as effective
transmitted resistantance mutation
is about 3-27% in N America
resistance testing
genotype
when is it indicated
compares genest to wild types of HIV
results in 1-2 wks
indicated at baseline + if tx failiing
resistance testing
phenotype
when is it indicated
measures ability of virus to grow in prescence of ARV
2-4 wks
more exp
indicated to do with genotype if resistance suspected
when is resistance testings reccommended?
note reccomended
rec- if virologic failure during ART

not rec-after discont. drug >4wks -resistant virus can't be seen cause its not being provoked by the drug

not rec-if VL <500
types of ART failure
virologic failure-unable to suppress viral repl.

immuno failure- failed to have enough CD4 response

clinical progress- recurrence of HIV related events after 3 months of ART
when should u do resistance test
while on failing regimen or at least within 4 wks of D/C
tips for changing ART if regiemn is failing
don't change just 1 drug or add 1 drug-change whole damn thing

try new class -Integ Inhib, entry inhib-less resistance

never stop all ART-increase mortality
NRTIs class effex
few drug interactions
they r renally eliminated-nephrotox
N/V/D-short term
mitochondrial tox-long term
Nuke drugs
stavudine
zidovudine
lamivudine
emtricitabine
abacavir
didasonine
tenofovir
whats analog of stavudine
zidovudine
whats along of lamivudine
emtricitabine
along of didanosine
tenofovir-but is nucleoTIDE
stavudine
whats brand name?
abbrev
Zerit
d4T
zidovudine
brand name?
abbrev?
Retrovir
AZT, ZDV
lamivudine
brand name?
abbrev?
Epivir
3TC
emtricitabine
brand name?
abbrev?
Emtriva
FTC
abacavir
brand name?
abbrev?
Ziagen
ABC
DIDANOSINE
brand name?
abbrev?
videx
ddl
tenofovir
brand name?
abbrev?
Viread
TDF
Epzicom
whats in it?
ABC/3TC
Truvada
whats in it
TDF/FTC
Combivir
whats in it
AZT/3TC
Trizivir
whats in it
AZT/3TC/ABC
Atripla
whats in it
TDF/FTC/EFV
Complera
whats in it
TDF/FTC/RPV
ALL NRTIs have this BBW
lactic acidosis and steatosis(hepatotox)
if taking combo med with nukes and CrCL of <50 do what?
cant take combo...give individual drugs and adjust dose
what 2 nukes have overlapping toxicities
stavudine + didanosine
Tenofovir
pros, cons, + counseling
1st line ART
covers HepB
causes renal insuff-monito SCr CrCl

must stay hydrated
lamivudine
pros, cons, + counseling
coverss HepB
minimal toxicity
need to renally dose
emtricitabine
pros, cons, + counseling
its Epivir(3TC) + Florine
covers HepB
causes hyperpigmentation of palms + soles
renally dose
abacavir
pros, cons, + counseling
alternative ART
BBW-hypersensitivity react.-use HLA B to make sure pt is negative before starting
increases risk of MI
HLA-B screening
should be done before starting abacavir
if + must be documented as true allergy
DO NOT RECHALLENGE
mainly in whites (FML)
zidovudine
pros, cons, + counseling
used in pregnancy, + peds
not preferred as alt
BBW-liver tox
causes anemia, monitor CBC
36%Nausea
didanosine
pros, cons, + counseling
used in peds
TK ON EMPTY STOMACH
S.E.-pancreatisis, peripheral neuropathy
stavudine
pros, cons, + counseling
NO food restrictions
BBW-pancreatitis + peripheral neuropathy (mito tox)
NNRTIs class effex
adv-less metabolic tox than PI
no renal adjustments needed
causes rash, hepato-tox, and high resistance
which NRTIs cover hepB
tenofovir, lamivudine, emtricitabine
nonnuke drugs
efavirenz
rilpivirine
nevirapine
etravirine
efavirenz
brand name?
abbrev?
comment?
Sustiva
EFV
teratogen, CNS SE
Rilpivirine
brand name?
abbrev?
comment?
Edurant
RPV
needs acidic environment-PPI C/I
Nevirapine
brand name?
abbrev?
comment bout it?
Viramune
NVP
dose esclation to avoid rash + hepta tox
Etravirine
brand name?
abbrev?
comment?
Intelence
ETR
2nd gen nonnuke-active against resistant virus
Efavirenz
pros,cons, pt counseling
preferred ART-QD regimen
neuropschiatric-wierd dreams, drowisness
teratogenic Cat D(1st trimester)
tk at BEDTIME, w/o FOOD
use contraception
Rilpivirine
pros,cons, pt counseling
QD regimen
alt. therapy
tk WITH food(high calorie)
don't give to pt's with VL >100,000
avoid PPI's..seperate H2 and antacids
Nevirapine
pros,cons, pt counseling
has XR form
BBW-SJS, hepato tox
don't give to women w/ >250CD4
or men w/ >400 CD4 cuz rash

tk 1 qd x 2 wks, then BID
-if rash in 1st 2 weeks, don't increase
Etravirine
pros,cons, pt counseling
2nd gen NNRTIs
for tx experienced only
tk WITH food
drug interactions with PI
PI Class Effex
highly resistant to resistance ha
no renal adjustment
lots of DIARRHEA!!!
metabolic prob-CV/MI
Ritonavir
pros,cons, pt counseling
brand name, abbrev?
Norvir, RTV
only to boost PI conc.
many interactions
tabs-heat stable, caps-need fridge
Ritonovir does what
inhibits metab
eases pill burden of PIs
increase AUC, decreases variablity in through
Ritonovir
don't boost this med with ritonovir?
already comes boosted?
nelfinavir
kaletra alrady boosted
ritonovir boosting helps?

is required in which drugs?
helps indinavir(TID to BID)
atazanavir, fosamprenavir

required: STD-saquinavir, tipranavir, darunavir
atazanavir
pros,cons, pt counseling
brand name, abbrev
most lipid friendly PI
Qd dosing
causes hyperbilirubinemia + scleral icterus
tk with food, avoid antacids,PPIs, H2RA

Reyataz, ATV
Darunavir
pros,cons, pt counseling
brand, abrrev
good for resistant virus
pt naive or exp QD
liver toxic
must give with Ritonovir
Sulfa allergy

DRV, Prezista
Fosamprenavir
pros,cons, pt counseling
brand? abbrev?
skin rash
sulfa allergy

Lexiva, FPV
Kaletra
pros,cons, pt counseling
gen name, abrev
QD or its BID if resistance
Diarrhea(50%)
GI problems

Lopinavir/ ritonavir (LPV/r)
Saquinavir
pros,cons, pt counseling
brand name, abbrev?
use with caution
PR + QT interval prolong.
TK WITH food(w/i 2 H of food)

Invirase, SQV
Indinavir
pros,cons, pt counseling
brand name? abrev?
NO PROS
nephrolithiasis(kid stones)
hyperbillirubinemia
drink > 2L fluid/day
cuases metalic taste

Crixivan IDV
Nelfinavir
pros,cons, pt counseling
BRAND? abbrev?
only PI never boosted
use in preg, kids
mad Diarrhea!!
give with loperamide
tk with fat ml to incr. absp.

Viracept, NFV
Tipranavir
pros,cons, pt counseling
brand? abbrev?
only for exp pt-active for resistant virus
BBW-intracranial hemm. hepatotox!!
sulfa allergy
refig caps prior to opening

Aptivus, TPV
WHICH drugs have sulfa allergy
darunavir
fosamprenavir
tipranavir
2 Entry inhibitor drugs
selzentry- maraviroc

Fuzeon-enfuvirtide
Maraviroc
pros,cons, pt counseling
brand
CCR5 antag
must do tropism test to see if virus is R5
BBW-hepato tox, rash

MVC, Selzentry
when should you obtain topism test
prio to MVC to confirm r5
and when virologic failure on MVC

tropism assasy determines isolate-r5, x4, or mixed
enfuvirtide
abbrev, brand name?
MOA
SE
inhibits gp41 fusion
no renal/hep adjustments
SQ injection
salvage therapy
causes painful nodules
ENF, Fuzeon T20 or ENF
Raltegravir
pros,cons, pt counseling
Brand, abbrev?
preferred inital tx-integrase inhib.
no p450 interaction
no BBW
easily cause resistance
rhabdo reported

Isentress RAL
entery inhibitor interaction potentials
enfuvirtide
maraviroc
enfuvirtide-green- no interactions

maraviroc-yellow-med interaction-metab by 3A4
integrase inhib interaction
raltegravir-yellow
metab by UGT1A1
Interactions
Nukes-

Nonnukes-
Nukes-yellow

nonnukes-red- mainly induce
nonnukes: most induce except-
efavirenz-inducer/inhibitor
rilpivirine- 450 substrate
etravirine-inducer/inhibitor
Interactions
PI
mainly inhibit metab
RTV is worst
SQV is least
Antiretrovirals interact with
antacids
statins
rifamycin
macrolides
PIs and ARVs
which drug is contraindicated with PPIs
Rilpivirine
if taking atazanavir with PPI what are directions
ataz must be boosted with ritonavir
only for tx niave pt's
if pt is exper. this combo is CONTRAINDICATED
PI + statin interaction
PI increases stating levels
-avoid simva, lova, pitavastatin

atorvastatin, prava are safest
NNRTI + statin interaction
NNRTI can decrease statin levels
PI + Rifampin interaction
Rifampin will dec PI by 75%
AVOID!!
NNRTI + Ridampin interaction
decreases EFV AUC by 25%
maravirox + Rifampin interaction
avoid, combo not reccommended
rifabutin + NNRTIs
its a weaker inducer-prolly safer

decreases Rilprivine AUC by 45%- AVOID
macrolide interactions
inhibitors
eryth>clarith>azith

if maraviroc+clarith- dec mara dose to 150

azithromycin is preferred, no interactions with ART
ETR can be safely given with which PIs
only*
Lopinavir/Ritonovir
Saquinavir/R
Darunavir/R
Maraviroc has how many doses?
3
half dose-if given with inhib (PI)
standard-if with nukes
double dose-if with inducers(nonnukes)
MVC should be halved with PIs except which one
tipranavir/ritonavir
whats first sign of advanced AIDS
define it
wasting- involuntary weight loss of 10%
correlates with death
what metabolic disorders are associated with ART
insulin resistance, high fasting glucose

increase in triglycerides, Tchol, LDL
what morphological probs are seen with ART
lipodystrophy-fat loss(lipoatrophy) in face, ass, arms

lipohypertophy-buffalo hump, breast enlargement, fat stomach
glucose metabolism probs seen in what drugs

monitor glucose how often
PIs, d4T, AZT

at baseline, then 3-6 months, tx like DM2
what to monitor if pt is wasting
CD4, VL
Testosterone level annually
depression assessment
check food intake
non-pharmacy tx for wasting
manage concurrent diseases
-diarrhea, depression(anorexia)
nutritonal counseling
interventions for wasting
ARV
tx underlying HIV
doesn't lead to wt gain, but minimizes wasting
interventions for wasting
appetite stimulants-megace
FDA approved HIV tx for wasting
suspension
weight gain is fat, $$$
interventions for wasting
appetite stimulants-periactin
cyproheptadine
stimulates appetite, cheaper
FDA approved antihistamin- not appeptite stim
not recc of HIV wasting
interventions for wasting
appetite stim- marinol
dornabinol
approved in AIDS app stim.
wt doesn't incr consistently
interventions for wasting
protein anabolic agents
serostim HGH- approved for HIV, increases wt + decr. fat

SQ inj. $$$ once D/Ced lose wt
interventions for wasting
anabolic steroids
testosterone
not FDA approved
may increase CV risk
risk of lipid probs seen in which drugs
LPV, EFV, D4T

monitor fasting, 2-8 wks, then q 6 months

use ATP3 guidelines- avoid simva, lova, pitavstatin with PIs
lipohypertophy
which drugs have higher risk
PI or NNRTI with d4T or AZT
dorsocervical fat pad-buffalo hump
lipoartrophy
seen in what drugs
NRTI...d4T
thinning of extremeties-with venous guttering
switching ARV will it help progression of morphologic changes?
it will slow/halt progession but NOT fully reverse

sculptra-fillers for facial atrophy
NNRTI class SE
Rash AND hepato tox
but efavirenz has this + CNS
if mild to mod rash-tx through with antihistamine
whats the mech of NRTI mitochondrial tox
inhibit DNA polymerase gamma- enzyme required for synt of mitochondrial DNA

TDF is least risky
which NRTI has BMD effects
TDF + d4T
which NRTI has GI problems
AZT, ddl
how to tx
GI effects with NRTIs
self limiting
if N-tk with small snacks
use ginger or anitemetics

D-use antimotility
Abacavir and MI consensus
there is none
use in caution in those with strong CV factors
avoid if pt has high risk
TDF SE
osteopenia + osteoporosis
screen with DEXA

nephrotoxic- presents as fanconi syndrome
hydrate, if proteinura usually reversible
abacavir hypersenstivity reaction
must have how many symptoms
2
rash
fever
or N/V, D
cough, weak
which PI has high risk of diarrhea
nelfinavir- give with loperamide

also lopinavir
which 2 PIs increase billirubin levels
atazanavir
indinavir
how long do PIs GI intol effects last
transient..usually 1st few doses
enfuvirtide
injection directins
do at room temp, in fatty sq area, massage after to decrease nodule formation
if OI within 12 wks of starting ART do what?
start OI tx
continue ART
if OI occurs when virlogic failure, do what?
start OI
but do ARV resistance testing
whats most common OI in AIDS pts
PJP (jiroveci)...used to be called PCP
occurs in 70-80% of AIDS pt
symptoms of PJP
NONPRODUCTIVE cough
SOB
hypoxemia
gold standard for diagnosising PJP
bronchoalveolar lavage (BAL)
LABS- cd4<200
what to start primary prophylaxis for PJP

when to stop
if CD4<200, OR oropharyngeal candidiasis

stop if cd4>200 for at least 3 months...restart if goes lower again
whats DOC and alt for prophylaxis tx of PJP
Bactrim (TMP/SMX) 1DS daily
or 1SS daily

alt- dapsone, aerosolized pentamidine, atovaquone
whats DOC for acute tx of PJP (PCP) and how long
21 days!
IV bactrim for severe
PO for mild-mod
whats alt drugs for acute tx of PCP
severe?
mild to mod?
still 21days!
severe- Pentamidine, primaquine+clindamycin

mild-primaquine+clindamycin, atovquone
whats an adjunct to PCP tx
prednisone or IV methylprednisone
give within 72H of starting PCP tx ONLY if severe
common ADR with bactrim
SJS
whats the tx for secondary prophylaxis of PCP
when do you disonctinue?
same as primary

can stop if: cd4>200 at least 3 months AND sustained VL AND on ART
IF CD4>200 and get PCP
do what?
fucker is taking meds LIFELONG
whats the clinical presentation of toxoplasmosis
yes we know-gandi cat tacos
focal encephalitits-confusion, motor weakness

if untx-seizure, coma, stupor
if pt has Toxoplasmosis whats the MRI gonna show
a ring enhanced lesion in brain-GIANT CIRCLES OF DEATH!
when to start primary prophylaxis for TE(toxoplasmosis)
+ anti-toxoplasma IgG
AND CD4 <100-need both to tx

stop if cd4>200 at least 3 months
whats DOC for primary prophylaxis of TE

alt?
TMP/DMS 1DS daily

alt- bactrim 3x/wk
-dapsone+pyrimeth+leuco
preferred tx of acute TE
for 6 weeks
pyrimeth+sulfadiazine+leuco
alt tx of acute TE
pyrimeth+leuco+clindamycin x 6 weeks
when to start secondary prophylaxis of TE
once pt completes intital tx

second. proph lifelong unless- CD4>200 for at least 6 month+ pt is asymptomatic w/ sustained Viral suppress.
what drugs to use for secondary prophylaxis of TE
same as primary
pyrimeth+leuco+sulfadiazine
presentation of MAC
not receiving ARV
multi-organ infxn
night sweats, abdominal pain
presentation of MAC
receiving ARV
localized

pneumonitis
abscess
ulcers
CNS infection
abnormal labs for MAC pts receiving ARV
anemia, neutropenia, increased alk phosphate

enlarged spleen, liver, + lymphadenopathy
when to start primary prophylaxis for MAC
when stop?
CD4<50
stop if cd4>100 for at least 3 months
DOC for primary prophylaxis for MAC

alt?
azithromycin 1200mg/wk
or azithromycin 600 2/wk
or clarithro

alt- rifabutin (adjust ART)
Acute tx of MAC
clarithromycin + ethambutol

alt- azithro + ethambutol
azithro + ethambutol + rifabutin
TX FOR AT LEAST 12 MONTHS!!
when to do secondary prophy for MAC

can D.C when
its lifelong maint. tx unless IRIS on ART

D/C- if >12 month tx completed +asymptomatic+ cd4>100 for 6months on ARV

tx-same as primary
latent TB shows as-

active TB shows as
latent-asymptomatic

active- varies on degree of immunosupp
pumlonary TB presentatins
cd4 >350 (200-350 also)
upper lobe-nodular,patchy infiltrates
frank hemolysis, night sweats
diagnostic tests for TB
TST- + if >5mm at 48-72H

false negatives-in adv. immunosupp. so look at clinical presentation also
who should be tested for TB

how to rule out active TB?
all HIV pts

if + TST test- use Chest radiography + evaluation to rule out active TB
Latent TB tx when?
if +LTB and no hx of tx for active or latent TB

-TB but close to ppl w TB
primarty tx for latent TB
isoniazid x 9 months DOT

IF resistant- rifampin x 4 months

INH+rifapentine x 12 wks