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83 Cards in this Set

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Endocarditis

Suspect in any pt with fever & murmur (particulurily new or changed murmur)




IV drug user is also suspcious for infectious endocardititis

Management for suspected endocarditis

Send 2-3 blood cx from different sites (sterile cx) prior to starting Abx




start empiric treatment with vanc for 4-6 weeks + gentamicin for 1st week




transthoracic echo (TTE), if normal, then transesophageal echo (TEE)




Surgical replacement if:


acute decompensation (CHF exacerbation)


myocardial abscess


repeated emboli


very large vegetations (>10cm)


fungal endocarditis


prosthetic valve endocarditis




If you are considering surgery, have to do TEE

Septic emboli from endocarditis

For IV drug users --> septic emboli from heart can go to lungs leading to nodular lesions on CXR causing pulmonary sxs (tricuspid 50%, aortic 25%, mitral 20%)




For left sided endocarditisis --> can cause emboli to brain leading to stroke

Signs of endocarditis embolus

Mostly seen in L sided endocarditis:




conjuctival petechiae




splinter hemorrhages




roth spots- retinal hemorrhages with white or pale centers




janeway lesions- non-tender, small erythematous or hemorrhagic macular or nodular lesions on the palms or soles




osler nodes- painful, raised, red lesions found on hands and feet (immune complex deposition)

Allergic nafcillin nephritis triad

Fever


Rash


Nephritis (ARF)



dx with eosinophiluria (eosinophils in urine)

Rx for methicillin sensitive staph

1st gen cepholosporin --> cefazolin 4-6 weeks




OR




oxacillin or nafcillin (4-6 weeks)




+ gentamicin for 1st week (contraindicated in pts with renal failure)

TTE then TEE

If TTE is negative, can consider doing TEE if high prob of looking for thrombus




Even if TTE is positive, still need to do TEE if:


considering surgical replacement of valve


new conduction delay on EKG


aortic valve endocarditis


persistent bacteremia or fever with proper coverage

Bugs in endocarditits in IV drug abusers

S aureus --> 60-90%




large portion are due to healthcare-associated bacteremia




vanc and gentamicin good empiric coverage until the results of blood cx




rx for 4-6 weeks

Bugs in subacute endocarditis

Streptococci --> 50-60%


S viridans acct for 75% of this (found in mouth flora) --> rx with Penicillin G or ceftriaxone (2 wks)


S bovis --> 20% assoc with colon cancer




Staphylococci --> 30%


S aureus acct 90% of this




Enterococci --> 5-10% --> rx with b-lactam + aminoglycoside (4-6 wks)

Culture negative endocarditits

HACEK --> < 2% of cases




Haemophilus --> H parainfluenzae, H aprophilus, H paraprophilus




Actinobacillus




Cardiobacterium hominis




Eikenella corrodens (human bites) --> amox+clavulanic acid




Kingella




rx with ceftriaxone, ampicillin-sulbactam, or cipro (4 wks)

Prosthetic valve endocarditis

Staph epidermidis is most common in first 2 months after replacement




Strep viridans becomes more common after that

Uses for Pencillin

Strep viridians --> endocarditis




Syphilis




Group A strep --> strep throat




Actinomyces




Clostridium species

Rx of MRSA

Vancomycin (but is bacteriostatic)




If allergic to vanc or resistant to vanc--> daptomycin




DO NOT USE DAPTOMYCIN FOR PNEUMONIA (surfactant inactivates daptomycin) --> use either vanc or linezolid

Side effect of daptomycin

myositis --> monitor CK




daptomycin inserts into cell membrane of bug & causes ion leak (particularily Ca)

Endocarditis prophx

Give amox 30-60 mins prior to procedure (if allergic, give clindamycin, cephalexin, or macrolide)




previous episode of endocarditis




prosthetic cardiac valve




CHD




cardiac transplant with cardiac valvulopathy




Prophx for:


dental procedures


respiratory tract procedures involving incision or bx


procedures on infected skin, skin structures, & musculoskeletal tissue

Libman-Sacks endocarditis

Young F with rash, joint pain, and MR w/o fever




Sterile vegetation assoc with SLE --> no fever




vegetations present on and under surface of mitral valve --> mitral valve regurg

Chronic rheumatic dz

caused by group A strep infection during childhood




bacterial M protein resemble proteins in valve leading to autoimmune destruction




fibrosis and scarring of valve leaflets leads to abnormalities causing stenosis or regurg




mitral valve almost always involved




causes mitral stenosis with "fish mouth" appearance

Acute rheumatic heart dz

JONES criteria




elevated ASO and a-DNase B titers




migratory polyarthritis




pancarditis (endocarditis, myocarditis, pericarditis)




subcutaneous nodules




erythema marginatum (involving trunk and limbs)




sydenham chorea --> rapid involuntray muscle movements

Lower extremity edema w/u

Duplex u/s --> look for DVT




pt with warm, tender, unilateral swollen leg with neg u/s has cellulitis until proven otherwise

Rx for cellulitis

most likely gram + --> either Staph or group A strep (S pyogenes)




elevation of leg and warm soaks




For mild cases:


oral dicloxacillin --> mild penicillin allergy then use cephalexin


if severe penicillin allergy --> clinda, macrolides, fluoroquinolones




For moderate cases resistant to oral rx:


IV cefazolin




For severe cases:


IV antibiotics with oxacillin or nafcillin or cefazolin q4 hr for MSSA

High risk community assoc MRSA groups

Household contacts of pt with MRSA




children




MSM




IV drug users




athletes engaged in contact sports




native american and pacific islanders

Rx of MRSA cellulitis

Treat when there is an abcess or purulent cellulitis




Vancomycin drug of choice




Daptomycin




Ceftaroline




Tigecycline (doesnt cover pseudomonas and actinomyces)




Telavancin




Linezolid (common side effect is thrombocytopenia & dont give with SSRIs)




For mild infections:


Clinda


Doxycycline


Trimethoprim/sulfamethoxazole

Cellulitis abscess

Surgical drainage




small abcess with no surrounding erythema does not need Abx




ALWAYS DRAIN AN ABCESS

Necrotizing fasciitis

Extreme pain and tense edema with dark bullae




fever




systemic toxicity




maybe septic

Initial w/u of necrotizing fasciitis

CBC




Chemistry




Lactic acid level (if low --> sepsis)




Broad spectrum IV Abx




SURGERY CONSULT IMMEDIATELY




If PE is uncertain, then can think of CT to look for gas formation

Rx of necrotizing fasciitis

Immediate surgical debridement




Send to OR w/o imaging!




Clindamycin + Penicillin for group A strep




for mixed flora:


cover MRSA (vanc or daptomycin or tigacycline or ceftaroline or linezolid)




PLUS




cover gram - and anaerobes (imipenem/meropenem or pipercillin/tazobactam or ticarcillin/clavulinate or cefepime + metronidozole)




PLUS




toxin production inhibition --> clinda

Bugs of necrotizing fasciitis

destruction of fascia and muscle through the release of toxins, which include S pyogenic exotoxins




most cases are polymicrobial with anaerobes and aerobes




Group A strep (any serious skin infection gets 2 drugs with one being clinda)




S aureus




C perfringens




Bacteroides fragilis




Pseudomonas

Clostridium perfringens

rare cause from deep stab wounds




black tar heroin abuse




Rx with surgical debridement along with penicillin + clinda

w/u of suspected menigitis

blood cxs




dexamethasone (specifcally in case of pneumococcal or Tb meningitis)




empiric Abx (ceftriaxone + vanc)




head CT (if required)




LP

Menigitis vs encephalitis

encephalitis HAS to have AMS --> coma, lethargic, altered, confused

CT before LP

papilledema




confusion




focal neurologic findings




seizures




immunocompromised

Bugs of bacterial meningitis

Most common cause --> Strep pneumonia




Neisseria meningitis




In neonates --> gram - bacilli & group B strep is most common




Consider Listeria in:


neonates


> 50 yr


DM


immunocompromised


liver or kidney dz




If Listeria --> add ampicillin to empiric ceftriaxone

Viral meningitis

neutrophilic predominance in first 24 hrs but then lymphs




WBC in 100s vs bacterial in 1000s

Brain abcess

surgical drainage




PLUS




metronidazole




PLUS




ceftriaxone w/ or w/o vanc

Coverage for post neurosurgy

Need to cover MRSA and pseudomonas




vanc + cefepime or meropenem or ceftazidime




If immunocompromised add ampicillin

Unusual causes of meningitis

Spontaneous peritonitis

thought to occur from hematologic seeding in absence of perforation




first step in managment is to get u/s to confirm pt has true asciites




then need to perform paracentesis --> PMN >250 or WBC >500




If low glucose (< 50), very high LDH, PMN >10,000, or polymicrobial --> secondary peritonitis from bowel perforation

Bugs for spontaneous peritonitis

Most common --> E coli




S. pneumoniae




group A strep (S pyogenes)




Enterococci

Abx for spontaneous peritonitis

cover gram - bacilli and S pneumoniae




cefotaxime or ceftriaxone




Infuse IV albumin if albumin >1.5 in asciites fluid




Any pt with spontaneous peritonitis gets prophx abx for life --> oral norfloxacin+cipro OR trimethoprim-sulfamethoxazole




Cirrhotic pts with bleeding esophageal varices are at increased risk of developing spont peritonitis --> give ceftriaxone for 1 week during the bleeding episode

Next steps for recent dx of HIV

RPR or VDRL --> syphilis


Toxo serologies


CBC & chem


Pap smear


PPD


Hep A, B, C serology


T-cell subsets


Viral load & resistance testing (most important test to monitor rx)



Latent syphilis

Syphilis serologies convert to positive in:




< 1yr --> early latency


1 dose of IM penicillin




>1yr or unknown --> late latency


3 doses of IM penicillin



HIV with close contact with Tb

TREAT FOR LATENT Tb REGARDLESS OF PPD, g-INTERFERON RELEASING ASSAY, OR CXR RESULTS




Latent Tb --> 9 months INH + Vit B6

PPD Guidelines

15mm+ is positive for general population




10mm+ is positive for intermediate risk:


recent immigrants from endemic countries


health care personnel


IV drug users


<4 yrs old




5mm+ is positive for high risk pts:


HIV+


recent contact with Tb


Organ transplant receipients


Fibrotic changes on CXR c/w prior dz

CD4 <200 Prophx

Pneumocystis jiroveci --> Trimethoprim/Sulfamethoxazole --> if allergic, give dapsone or atovaquone




Mycobacterium avium complex --> Azithro weekly




HAART with 2 nucleosides + non-nucleoside RT inhibitors OR integrase inhibitor OR protease inhibitor




Pneumococcal pneumonia vaccine




Hep A & B vaccine




Influenza vaccine yearly

Rx of PCP infection

TMP/SFX but if allergic:




IV pentamidine




OR




Clinda + primaquine




OR




Atovaquone




Pentamidine is very toxic --> hypo/hyperglycemia, acute pancreatitis, ATN, hepatotoxicity




Give prednisone if P02 <70 or A-a gradient >35

Presentation of MAC

CD4 <50


Anemia


Low albumin


Cachectic looking


Fever


Diarrhea

Rx of MAC

Macrolide (eg azithro or clarithromycin)




PLUS




Ethambutol




+/-




Rifabutin

Rx of HIV

CD4 >500:


Nothing unless pregnant




CD4 <500:


antiretrovirals with 3+ drugs

HIV and vaccines

CD4 >200 --> any vaccine




CD4 <200 --> no live attenuated (eg varicella)

Drug induced hepatitis

Acetaminophen


Methotrexate


Amiodarone


Halothane


a-Methyldopa


Erythromycin


Valproic acid


Allopurinol

Rx for Hep C

First genotype strain --> type 2 & 3 are most easily treated but type 1 is most common




Everyone gets Peg interferon + Ribavarin




If type 1 also get:




Sofosbuvir




OR




Simeprevir

W/u of suspected osteomyelitis

CBC


ESR


XRay




If XRay normal --> CT or MRI (most accurate for osteomyelitis)




MRI maybe contraindicated in pts with hardware




If imaging is positive for osteo --> bone bx to identify organism prior to starting Abx




NO NEED FOR CX FOR OSTEO

Bugs causing osteomyelitis

most common --> S aureus




in diabetics:


gram - bacilli (eg E coli or Pseudomonas)

Bugs of atypical pneumonia

b/l lung infiltrates




Legionella


Mycoplasma


Chlamydia


PCP


Viral

Abx for pneumonia

Abx take up to 72 hrs to become effective




CXR takes longer to show improvement




IV Abx:


Ceftriaxone OR Ampicillin/Sulbactam



PLUS




Azithro OR Dox OR Moxifloxacin OR Levofloxacin




For outpatient:


fluoroquinolones or macrolide

CURB-65

Confusion


BUN >19.6


RR >30


BP <90/60


Age >65




1 point for each --> 2+ score should be hospitalized

Legionella Triad

Atypical pneumonia


SIADH --> hyponatremia


Diarrhea

Contraindication for macrolides and fluoroquinolones

pt with prolonged QT interval --> use dox

Community acquired MRSA pneumonia

IV drug users


Concurrent or recent influenza infection


Produces severe pneumonia req intubation


Necrotizing (cavitary) pneumonia

Rx MRSA pneumonia

Ceftriaxone + Azithro + Vanc OR linezolid OR Clinda




Ceftaroline + Azithro

Hospt acquired pneumonia

Pseudomonas or MRSA




Need 2 drugs for Pseudomonas and 1 drug for MRSA

Rx for cryptococcal meningitis

Amphotericin B + flucytosine




Casfofungin has widest coverage for fungal infections EXCEPT crypto

Immune Reconstitution Inflammatory Syndrome (IRIS)

Pt with AIDS begins rx with HAART after dx w/another infection




As CD4 rises, start to get worsening of underlying opportunistic infections




Stop HAART & treat underlying infection

Ddx for urethral d/c

Gonococcal urethritis


Chlamydia


Trichomoniasis


Reiter syndrome



First step --> urethral swab with gram stain and wet mount



Most accurate test --> urine PCR

Rx for gonorrhea

1 dose IM Ceftriaxone




1 dose Azithro or Dox for 1 week to cover Chlmydia

Disseminated Gonococcal Infection

1) Migratory polyarthralgia


2) Tenosynovitis


3) Skin lesions (hemorrhagic pustules on palms & soles)

Thayer-Martin agar

Used to grow Neisseria organisms




Blood agar plate that contains:




Vanc --> kills most gram +


Colistin --> kills most gram - except Neisseria


Nystatin --> kills most fungi


Trimethoprim --> inhibits Proteus

Recurrent Neisseria infections

test for C5 or C9 def

Consideration of lyme disease

young patient in northeast




camping/tick bite




bradycardia or heart block

Bradycardia with heart block DDx

Lyme dz




hypothyroid




b-blocker or Ca channel blocker




ischemic heart dz

Reversal of b-blocker overdose

glucagon

Tx of lyme dz with heart block

IV ceftriaxone




Testing:


ELISA for Borrelia burgdorferi initial test


Western for confirmation

Presentation of Lyme Dz

Early localized lyme dz occurs 1-2 wks following infection




Initial presentation is erythema migrans (erythematous skin lesion at site of tick bite)




Border of erythema expands over several days, and lesion develops centrally & referred to as target or bulls-eye appearance




If rash is present do not send serologies (too soon to be positive) just tx with dox OR amox

Neuro Sxs of lyme

Cranial nerve palsy (unilateral or b/l) --> Bell's palsy




aseptic meningitis




radiculopathy

Late stage lyme

migratory mono or oligoarticular inflammation, which improves and recurs in months or years later




85% has knee involvement

IV ceftriaxone for lyme with...

myocarditis




2nd or 3rd degree heart block




meningitis or encephalitis

Urinary tract infection

febrile with dysuria




high fever with flank pain --> upper urinary site




perinephric abcess arises from pre-existing pyelo that is present for several weeks, particularly in assoc with stones

Use of IV Abx for UTI

high fever




shaking chills




bacteremia

Uncomplicated UTI Abx

TMP/SMZ for 3 days




OR




Fosfomycin single dose




OR




Nitrofurantoin for 5 days

TMP/SMZ side effects

TMP:


type 4 renal tubular acidosis --> hyperkalemia




SMZ:


allergies


myelosuppression

IV Abx for pyelo

Ceftriaxone




Levofloxacin




Ciprofloxacin




Amp/sulbactam




Gentamicin




Aztreonam

Pyelo and unstable

Imipenem




OR




Meropenem




bc of suspicion of extended-spectrum beta-lactamases

Additional testing for pyelo

if Abx is not responsive, can do:



renal u/s



OR



IV pyelography (suspcion of stone, stricture, or tumor)



OR



CT of kidney to r/o abscess