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251 Cards in this Set

  • Front
  • Back
IV treatment of MSSA

Oxacillin/nafcillin, or cefazolin
Oral treatment of MSSA

Dicloxacillin or cephalexin
Treatment of severe MRSA infection

Vancomycin, linezolid, daptomycin, ceftaroline, tigecycline, telavancin

Major side effect of linezolid

Thrombocytopenia

Major side effects of daptomycin

Myopathy, rising CPK

Telavancin origin and mechanism


Vancomycin derivative with similar efficacy


Acts as bactericidal LPS - binds peptidoglycan

Alternative antibiotics to penicillin if anaphylaxis in history

Macrolides or clindamycin

Linezolid mechanism

Inhibits protein synthesis

Antibiotics specific for Streptococcus

Penicillin, ampicillin, amoxicillin

Piperacillin/ticarcillin coverage

Gram negative rods, streptococci, anaerobes

Aminoglycoside coverage and use

Works synergistically with other agents for Staph, enterococcus

Tigecycline coverage


MRSA, Gram negative rods


Is weaker than other anti-MRSA agents


Imipenem adverse effect

Seizures
Best antibiotic for abdominal anaerobes


Metronidazole


Carbapenems, piperacillin, ticarcillin with equal efficacy

Only cephalosporins that cover anaerobes

Cefoxitin and cefotetan (in cephamycin class)
Best antibiotic for anaerobic Strep
Clindamycin
Best long term therapy for CMV retinitis

Valgancyclovir
Gancyclovir/valgancyclovir adverse effects

Neutropenia, bone marrow suppression
Foscarnet adverse effect

Renal toxicity

Oral agents for hep C


Telaprevir


Boceprevir


Simeprevir


Sofosbuvir

Hep C treatment that doesn't have to be combined with interferon

Sofosbuvir

Oseltamavir and zanamivir mechanism

Neuraminidase inhibitor

Ribavirin uses


Hep C (with interferon)


RSV


Ribavirin adverse effects

Anemia

Chronic hep B meds


Lamivudine


Interferon


Adefovir


Tenofovir


Entecavir


Telbivudine


Echinodcandin mechanism

1,3 glucose inhibition in fungi only

Sofosbuvir mechanism

RNA polymerase inhibitor

Simeprevir, boceprevir, telaprevir mechanism


Protease inhibitor


(Hep C treatment)


Which species of Candida is NOT vulnerable to fluconazole?

Candida krusei, Candida glabrata

Fluconazole uses


Candida


Cryptococcus


Oral/vaginal candidiasis


Itraconazole indications


Rarely best initial therapy for anything


Equal to fluconazole


Best agent against Aspergillus

Voriconazole

Posaconazole coverage

Mucormycosis or Mucorales

What fungal infection do echinocandins NOT cover?

Cryptococcus

Examples of echinocandins


Caspofungin


Micafungin


Anidulafungin


Best antifungal for neutropenic fever

Caspofungin (echinocandins)

Echinocandin adverse effects

None - inhibits 1,3 glucan synthesis step in fungi

Azole antifungal mechanism

Inhibits conversion of lanosterol to ergosterol

Amphotericin coverage


All Candida


Cryptococcus


Aspergillus


2 main indications for Amphotericin


Cryptococcus


Mucormycosis


Amphotericin adverse effects


Renal toxicity


Hypokalemia


Metabolic acidosis


Fever/chills


Mechanism of renal toxicity in amphotericin


Toxic to distal tubules (RTA)




What should you do if patient develops renal toxicity to amphotericin?
Switch to liposomal amphotericin
Most accurate test for osteomyelitis

Bone biopsy and culture
Earliest finding of osteomyelitis on X-ray

Periosteal elevation - takes two weeks
How useful is a bone scan for osteomyelitis?

Not very - it is poor at distinguishing bone vs. soft tissue infection

Best way to follow therapy effectiveness for osteomyelitis

ESR

When should you culture a draining sinus tract or ulcer?

Never

Time frame and route for treatment of Staph osteomyelitis

IV only, 4-6 weeks
Most common causes of Gram negative osteomyelitis


Salmonella


Pseudomonas


Strategy for treatment of Gram negative osteomyelitis


PO antibiotics


Must do bone biopsy and culture with sensitivites

Diagnosis if pain with manipulation of tragus

Otitis externa

Historical causes of otitis externa


Swimming


Foreign objects (cotton swabs, hearing aids)

Diagnostic testing for otitis externa


Based on exam


Do NOT culture

Treatment of otitis externa


Topical antibiotics - ofloxacin, cipro, polymixin/neomycin


Topical hydrocortisone


Acetic acid solution to reacidify ear


Pathology of malignant otitis externa

Osteomyelitis of skull from Pseudomonas in diabetic

Serious complications of malignant otitis externa


Brain abscess


Destruction of skull


Diagnosis of malignant otitis externa

MRI, bone biopsy

Best initial test for malignant otitis externa

CT/MRI

Most accurate test for malignant otitis externa

Bone biopsy

Treatment of malignant otitis externa


Surgical debridement


Antibiotics against Pseudomonas


Most sensitive finding in otitis media

Immobility of tympanic membrane

Most accurate test for otitis media


Tympanocentesis and aspirate for culture


Only for recurrent or persistent cases


What antibiotics to use for otitis media if failed therapy?


Augmentin, cefdinir, ceftibutan, cefuroxime, cefprozil, cefpodoxime


If no improvement at 3 days


Best initial test for sinusitis

X-ray

Most accurate test for sinusitis

Sinus aspirate for culture

Treatment of sinusitis

Amoxicillin, inhaled steroids

When to use Augementin for sinusitis


Fever/pain


Persistent despite one week of decongestants


Purulent nasal discharge


Most accurate test for Strep pharyngitis

Culture

Treatment of Strep pharyngitis if allergic to penicillin


Azithromycin or clarithromycin


Cephalexin if allergy is rash


Strongest indications for influenza vaccine


COPD


CHF


Dialysis


Steroid use


Health care workers


Age >50


When is it ok to use live flu vaccine?

Age <50, no medical problems

Best initial treatment of impetigo

Topical mupirocin or retapamulin

Treatment of severe impetigo
PO dicloxacillin or cephalexin

Treatment of impetigo if allergic to penicillin


Clindamycin


Doxycycline


Linezolid


Treatment of erysipelas


Initial - PO dicloxacillin or cephalexin


Penicillin VK if confirmed group A Strep


Retapamulin use

Topical antibiotic only for impetigo

Treatment of minor cellulitis

PO dicloxacillin or cephalexin

Treatment of severe cellulitis

Oxacillin, nafcillin, or cefazolin IV

Treatment of cellulitis if rash to penicillin

Cefazolin, ceftaroline

Size and classication of infected follicle

Folliculitis --> furuncle --> carbuncle --> boil --> abscess

Treatment of follicle infections

Same as cellulitis; drains boils and abscesses

Route for treatment of fungal skin infections


Topical if no hair/nail involvement


Oral if scalp or nail

Topical antifungals for skin infection

Clotrimazole, miconazole, ketoconazole, econazole, terconazole, nystatin, ciclopirex
PO antifungals for scalp/nail infection


Terbinafine


Itraconazole


Griseofulvin (less efficacy)


Defining characteristic of urethritis

Urethral discharge - even without dysuria
Signs of disseminated gonorrhea


Polyarticular disease


Petechial rash


Tenosynovitis

Best test for gonorrhea and chlamydia
Nucleic acid amplification test (NAAT)
Best measure of severity of pelvic imflammatory disease

Leukocytosis
Best initial test for pelvic inflammatory disease

Pregnancy test, then cervical culture and NAAT
Most accurate test for pelvic inflammatory disease

Laparoscopy

Inpatient treatment of pelvic inflammatory disease

Cefoxitin (or cefotetan) IV, doxycycline, with or without metronidazole

Treatment of pelvic inflammatory disease if penicillin allergy

Clindamycin and gentamicin
How to collect sample for NAAT in gonorrhea/chlamydia


Men - voided urine


Women - Self-administered blind vaginal swab

What antibiotics are safe to use in pregnancy?


Penicillins


Cephalosporins


Aztreonam


Erythromycin


Azithromycin

How can you differentiate epididymo-orchitis from testicular torsion
Abnormal testicular position (elevated, transverse) in torsion

Treatment of epididymo-orchitis


If under 35 - ceftriaxone and doxycycline


If over 35 - fluoroquinolone


Best initial test for chancroid

Swab for Gram stain (Gram neg coccobacilli) and culture

Culture medium for chancroid

Nairobi medium or Mueller-Hinton agar

Treatment of chancroid

Single dose or IM ceftriaxone or oral azithromycin

Cause of lymphogranuloma venereum

Chlamydia trachomatis

Diagnostic test for lymphogranuloma venereum

Serology for Chlamydia trachomatis
Treatment of lymphogranuloma venereum

Aspirate bubo, doxycycline or azithromycin
Next best step if genital vesicles present

Treat - acyclovir 7-10 days

Most accurate test for herpes

Viral culture

Treatment of acyclovir resistant herpes

Foscarnet
Patient with fever, headache, and myalgia 24 hours after treatment for early syphilis. What is the diagnosis?

Jarisch-Herxheimer reaction - due to release of pyrogens
Treatment of Jarisch-Herxheimer reaction


Is a self limiting condition


Use aspirin


Do not stop antibiotics


Symptoms of secondary syphilis


Rash


Mucous patch


Alopecia areata


Condyloma lata

Initial diagnostic test for secondary syphilis


RPR


FTA (more sensitive than VDRL for neurosyphilis)

Treatment of secondary syphilis


Single dose of IM penicillin


(Doxycycline if allergic)

Symptoms of tertiary syphilis


Neurosyphilis - tabes dorsalis, Argyle-Robinson pupil, general paresis


Gummas


Aortitis

Initial diagnostic test for tertiary syphilis

RPR/FTA, lumbar puncture (VDRL and FTA)

Treatment of tertiary syphilis

IV penicillin

Treatment of tertiary syphilis if penicillin allergy

IV penicillin - must desensitize

Presentation of granuloma inguinale

Beefy red lesion that ulcerates

What organism causes granuloma inguinale?

Klebsiella granulomatis

Diagnosis of granuloma inguinale

Biopsy or touch prep - look for Donovan bodies

Treatment of granuloma inguinale


Doxycycline, Bactrim, or azithromycin




What part of the body is pediculosis most common on?

Hair bearing areas - pubic and axilla

Most common place on body to find scabies

Web spaces
Treatment of pediculosis


Permethrin


Pyrethrins


Lindane


Treatment of scabies


Permethrin


Lindane


Ivermectin

Indications for imiquimod


Basal cell carcinoma


Actinic keratosis


Minor squamos cell carcinoma


Venereal warts


First line treatment for cystitis

Bactrim for 3 days


Levaquin/Cipro if >20% resistance


Fosfomycin, Macrobid


Definition of complicated cystitis

Anatomic abnormality present - stone, stricture, tumor, etc.

Treatment of complicated cystitis

7 days Bactrim or Cipro

Outpatient treatment of pyelonephritis

Cipro
Inpatient treatment of pyelonephritis


Ceftriaxone


Ertapenem


Fluoroquinolone


Ampicillin/gentamicin


Patient with pyelonephritis and no treatment response at 5-7 days. What is diagnosis and confirmation?

Perinephric abscess - sonogram or CT to confirm
What is best next step after diagnosis of perinephric abscess?

Biopsy - to guide therapy
Empiric treatment of perinephric abscess


Fluoroquinolone


Add Staph coverage


Best initial test for prostatitis

UA

Most accurate test for prostatitis
Urine WBCs after prostate massage
Treatment for prostatitis

Cipro or Bactrim - 2 weeks for acute, 6 weeks for chronic

Diagnostic criteria for infective endocarditis


Duke's criteria


Must have either 2 major, 1 major + 3 minor, or 5 minor


Duke's major criteria


1. 2 positive blood cultures


2. Abnormal echo


Duke's minor criteria


1. Fever


2. Risk factors


3. Vascular findings


4. Immune findings


5. Positive blood culture that doesn't meet major criterion


Most common bugs in infective endocarditis


Staph aureus


Strep viridans


Strep bovis/epidermis


Enterococci


Gram negative rods


Candida


HACEK organisms


HACEK organisms in endocarditis


Culture negative endocarditis


Haemophilus aphrophilus/parainfluenzae


Actinobacillus actinomycetemcomitans


Cardiobacterium hominis


Eikenellla corrodens


Kingella kingae



Echo findings in endocarditis


Intracardiac mass/valvular vegetation, OR


Abscess, OR


New partial dehiscence of prosthetic valve

Risk factors for endocarditis


IVDA


Structural heart disease


Prosthetic valve


Dental procedure with bleeding


History of endocarditis


Next best step if fever + new murmur


Blood cultures


If positive, do echo

What are Janeway lesions?


Vascular findings in endocarditis


Flat, painless lesions

What are Osler nodes?


Immunogical findings in endocarditis


Raised and painful

Diagnostic testing for infective endocarditis


TTE


If negative, then TEE


Most common cause of culture negative endocarditis

Coxiella and Bartonella

What endocarditis bug is most closely associated with colonic pathology?

Clostridium septicum, then Strep bovis

Best empiric therapy for infective endocarditis

Vancomycin + genamicin

Length of treatment for endocarditis

4-6 weeks
Indications for surgery in infective endocarditis


Valve rupture


Abscess


Prosthetic valves


Fungal endocarditis


Embolic events once antibiotics have already been started


Cardiac defects that require endocarditis prophylaxis


Prosthetic valves


Unrepaired cyanotic heart disease


Previous endocarditis


Transplant recipients who develop valvular disease




Procedures that require endocarditis prophylaxis


Dental procedures that cause bleeding


Respiratory tract surgery


Surgery of infected skin


Procedures that do not need endocarditis prophylaxis

Dental fillings


Flexible scopes


OB/GYN procedures


Urinary procedures

Cardiac defects that do not require endocarditis prophylaxis


Aortic stenosis/regurge


Mitral stenosis/regurge


ASD/VSD


Pacemaker/ICD


MVP


HOCM

What antibiotics to use for endocarditis prophylaxis in dental procedures?


Amoxicillin


If allergic and rash - cephalexin


If anaphylaxis - clindamycin or macrolide


What antibiotics to use for endocarditis prophylaxis in skin procedures?


Cephalexin


If allergic, use vancomycin

When to start therapy for HIV


CD4 <500


If symptomatic with any CD4 count or viral load


All pregnant women


Needle stick scenario


Optional at CD4 >500

Typical drug combo used in HAART

Tenofavir + emtricitabine + efavirenz/atazanavir/darunavir

When to use ritonavir in HIV

When using protease inhibitor (atazanavir, darunavir) in combination with tenofavir and emtricitabine - boosts protease inhibitor levels
Raltegravir mechanism and use

Integrase inhibitor - use with two nucleosides

Adverse effects or NRTIs as a class

Lactic acidosis

Adverse effects of protease inhibitors as a class

Hyperglycemia, hyperlipidemia
Name the NRTIs


Zidovudine


Didanosine


Stavudine


Lamivudine


Abacavir


Emtricitabine


Tenofavir


Name the protease inhibitors for HIV


Indinavir


Ritonavir


Lopinavir


Nelfinavir


Saquinavir


Darunavir


Tipranavir


Amprenavir


Atazanavir

Name the NNRTIs


Efavirenz


Nevirapine


Etravirine


Rilpivirine

Zidovudine adverse effect


Anemia



Didanosine adverse effect


Pancreatitis


Peripheral neuropathy

Stavudine adverse effects

Pancreatitis, neuropathy

Abacavir adverse effects

Rash

Tenofavir adverse effects


Renal toxicity


Indinavir adverse effects

Kidney stones

Efavirenz adverse effects

Drowsiness

Maraviroc mechanism

Blocks CCR5 - prevents HIV entry into cell
Management of exposure to HIV+ blood

HAART for 1 month
Ritonavir mechanism

Inhibits hepatic p450 - blocks metabolism of other protease inhibitors
Antiretroviral to avoid in pregnancy

Efavirenz
Prophylaxis of PCP if bactrim allergy

Atovaquone or dapsone (not in G6PD deficiency)
When to prophylax against Mycobacterium avium-intracellulare in HIV

CD4 <50
Antiobiotics for Mycobacterium avium-intracellulare prophylaxis in HIV

Azithromycin weekly
Lab findings in PCP pneumonia


Hypoxia


Increased LDH


Most accurate test for PCP pneumonia

Bronchoalveolar lavage

Treatment of PCP pneumonia and alternate is allergic


IV Bactrim


Allergy - IV pentamidine OR clinda + primaquine

When to use steroids in PCP pneumonia


pO2 <70


A-a gradient >35

Ganciclovir adverse effect

Low WBC

Foscarnet adverse effect

Elevated creatinine

Best initial test for toxoplasmosis

Head CT with contrast

Management of toxoplasmosis

Pyrimethamine and sulfadiazine for two weeks, then repeat CT

Differentiation of toxoplasmosis from lymphoma in AIDS

Treat toxo for 2 weeks then repeat head CT; if lesions shrink, is toxo; if not, biopsy for lymphoma
Presentation of CMV in HIV

CD4 <50 and blurry vision

Evaluation of CMV retinitis in HIV

Dilated ophthalmologic exam - appearance of lesions
Treatment of CMV retinitis

Ganciclovir or foscarnet

Maintenance therapy for CMV in HIV

Oral valganciclovir lifelong, unless CD4 rises with HAART

Presentation of Cryptococcus in HIV

CD4 <50, fever, headache

LP findings in Cryptococcal meningitis

Increased lymphocytes
Most accurate test for Cryptococcal meningitis

Cryptococcal antigen test

Treatment of cryptococcal meningitis

Amphotericin + 5-FC, followed by fluconazole
Maintenance therapy for Cryptococcus in HIV

Lifelong fluconazole, unless CD4 rises
Presentation of progressive multifocal leukoencephalopathy

CD4 <50, focal neurological deficits
Best initial test for progressive multifocal leukoencephalopathy

Head CT or MRI (no findings)

Most accurate test for progressive multifocal leukoencephalopathy

PCR of CSF for JC virus
Treatment of progressive multifocal leukoencephalopathy

HAART - resolves when CD4 rises

Presentation of Mycobacterium avium-intracellulare


CD4 <50, weight loss, fever, fatigue


Anemia from bone marrow invasion

Lab findings for hepatic involvement of Mycobacterium avium intracellulare

Increased alk phos and GGTP with normal bilirubin
Relative sensitivities of tests for Mycobacterium avium intracellulare

Blood Cx < bone marrow < liver biopsy (most sensitive)
Treatment of Mycobacterium avium intracellulare


Clarithromycin + ethambutol


Rifampin may be added


Animal exposure + jaundice + renal involvement; what is diagnosis?

Leptospirosis
Treatment of leptospirosis

Ceftriaxone or penicillin

Presentation of tularemia


Ulcer at site of contact and enlarged lymph nodes


Conjunctivitis


Diagnosis of tularemia

Serology

When to culture for tularemia

Never - spores can cause severe pneumonia

Treatment of tularemia

Gentamicin or streptomycin

CT findings in cysticercosis
Thin-walled cysts in head, most often calcified
Treatment of cysticercosis

Albendazole, unless no active lesions - then anti-seizure meds if needed

Treatment of CNS or cardiac Lyme disease

Ceftriaxone IV
Most common late manifestation of Lyme disease

Joint involvement

Treatment of Lyme disease

Doxycycline, amoxicillin, or cefuroxime

Presentation of babesiosis

Hemolytic anemia, severe in asplenic patients
Diagnosis of Babesiosis


Peripheral smear - tetrads in RBCs


Or do PCR


Treatment of babesiosis

Azithromycin or atovaquone

Presentation of Ehrlichia/Anaplasma

Elevated LFTs, thrombocytopenia, leukopenia; NO rash
Diagnosis of Ehrlichia


Peripheral smear - morulas in RBCs


Or PCR


Treatment of Ehrlichia

Doxycycline

Presentation of malaria


Traveler with hemolysis


GI complaints always present


Treatment of acute malaria


Mefloquine; atovaquone/proguanil


Quinine/doxycycline if severe

Prophylaxis of malaria


Mefloquine (weekly), or atovaquone/proguanil (daily)
Mefloquine side effects


Neuropsych side effects


Sinus bradycardia


QT prolongation

Branching, Gram positive filaments, weakly acid fast; what bug?

Nocardia
Most common sites of Nocardia infection


Respiratory


Most commonly disseminates to skin and brain

Best initial test for Nocardia



CXR
Most accurate test for Nocardia

Culture

Treatment of Nocardia

Bactrim
What history is typically present in Actinomyces infection?
Facial or dental trauma
Treatment of Actinomyces infection

Penicillin

Difference in history between Nocardia and Actinomyces infection


Nocardia - immunocompromised


Actinomyces - normal immune system

Diagnosis of Actinomyces

Gram stain, confirm with anaerobic culture
Geographic location for Histoplasmosis infection

Wet areas - Ohio and Mississippi River Valleys
Bat dropping association

Histoplasmosis

Physical exam findings in histoplasmosis

Palate/oral ulcers and splenomegaly
Finding in disseminated histoplasmosis

Pancytopenia - invasion of bone marrow
Best initial test for histoplasmosis
Histoplasmosis urine antigen
Most accurate test for histoplasmosis

Biopsy with culture
Treatment of acute pulmonary histoplasmosis
Transient, requires no therapy
Treatment for disseminated histoplasmosis

Amphotericin

Geographic location for coccidioidomycosis infection

Very dry areas - Arizona
Presentation of coccidioidomycosis

Joint pain, erythema nodosum
Treatment of coccidioidomycosis

Itraconazole

Geographic location of blastomycosis infection

Rural southeast
Histology of blastomycosis

Broad budding yeast
Common site of extrapulmonary lesions in blastomycosis

Bone

Treatment of blastomycosis

Amphotericin or itraconazole