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132 Cards in this Set

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UTI: common bug? DOC?

1. E. coli
2. TMP/SMX, nitrofurantoin, amoxicillin, quinolones
bronchitis: common bug? DOC?
1. virus, H. influenzae, Moraxella spp.
2. amoxicillin, erythromycin
pneumonia (classic): common bug? DOC?
1. Streptococcus pneumonia, H. influenzae

2. 3rd gen cephalosorin, azithromycin
pneumonia (atypical): common bug? DOC?
1. Mycoplasma, Chlamydia spp.

2. Macrolide antibiotic, doxycycline
osteomyelitis: common bug? DOC?
1. Staphylococcus aureus, Salmonella spp.

2. anti-Staph penicillin (dicloxacillin, methicillin), vancomycin
cellulitis: common bug? DOC?
1. Streptococci, staphylococci

2. anti-Staph penicillin covers both (dicloxacillin, methicillin)
meningitis (neonate): common bug? DOC?
1. Streptococci B, E. coli, Listeria spp.

2. ampicillin + aminoglycoside, 3rd generation cephalosporin
meningitis (child/adult): common bug? DOC?
1. S. pneumoniae, Neisseria meningitidis

2. 3rd gen cephalosporin, meropenem + vancomycin + dexamethasone
is H. influenzae a common cause of meningitis in children?
No, due to widespread vaccination
in a child who hasn't been vaccinated, what is most likely cause of meningitis?
H. influenzae
sepsis: common bug? DOC?
1. gram negative bugs, streptococci

2. 3rd gen penicillin/cephalosporin staphylococci + aminoglycoside, imipenem
septic arthritis (monogamous or not sexually active pts): common bug? DOC?
1. S. aureus

2. anti-staphylococcal penicillin, vancomycin
common cause of septic arthritis in young adults who are sexually active?
gonorrhea
endocarditis: common bug? DOC?
1. Gonococci, staphylococci, streptococci

2. Gonococci -> Ceftriaxone, penicillin, spectinomycin; streptococci -> Antistaphylococcal penicillin (or vancomycin) + aminoglycoside
Strep A or B: empiric abx?
first: penicillin, cephazolin

second: erythromycin
S. pneumoniae: empiric abx?
first: 3rd gen cephalosporin

second: fluoroquinolone (eg. levofloxacin)
Enterococcus: empiric abx?
first: penicillin or ampicillin + aminoglycoside

second: vancomycin + aminoglycoside
Staphylococcus aureus: empiric abx?
first: Anti-Staph Penicillin (eg. methicillin)

second: Vancomycin (MRSA)
Gonococcus: empiric abx?
first: ceftriaxone or fluoroquinolone

second: spectinomycin
Meningococcus: empiric abx?
first: penicillin/ampicillin

second: cefotaxime, chloramphenicol
Haemophilus: empiric abx?
first: 2nd or 3rd gen cephalosporin

second: ampicillin
Pseudomonas: empiric abx?
first: antipseudomonal penicillin + aminoglycoside

second: aztreonam, imipenem
Bacteroides: empiric abx?
first: metronidazole

second: clindamycin
Mycoplasma: empiric abx?
first: erythromycin, azithromycin

second: doxycycline
Treponema pallidum: empiric abx?
first: penicillin

second: doxycycline
Chlamydia: empiric abx?
first: doxycycline, azithromycin

second: erythromycin, fluoroquinolone
Lyme disease: empiric abx?
first: ceftriaxone, doxycycline

second: erythromycin, amoxicillin
with genital infections, always treat for a presumed co-infection with what bug? what do you treat with?
1. Chlamydia

2. azithromycin or doxycycline
gram stain: blue/purple color. bug?
Gram-positive
gram stain: red color. bug?
Gram-negative
gram stain: gram + cocci in chains. bug?
Streptococci
gram stain: gram + cocci in clusters. bug?
Staphylococci
gram stain: gram + cocci in pairs (diplococci). bug?
Streptococcus pneumoniae
gram stain: gram neg. coccobacilli (small rods). bug?
Haemophilus sp.
gram stain: gram neg. diplococci. bug?
STD, septic arthritis, meningitis: Neisseria sp.

lungs, sinusitis: Moraxella
gram stain: plump gram neg. rod with thick capsule (mucoid appearance). bug?
Klebsiella sp.
gram stain: gram + rods that form spores. bug?
Clostridium sp., Bacillus sp.
gram stain: pseudohyphae. bug?
Candida sp.
gram stain: acid fast organisms. bug?
Mycobacterium (usually M. tuberculosis), Nocardia sp.
gram stain: gram + with sulfur granules. bug?
Actinomyces sp. (pelvic inflammatory disease in intra-uterine device users; rare cause of neck mass/cervical adenitis)
gram stain: silver staining. bug?
Pneumocystis carinii and cat-scratch disease
gram stain: positive Indian ink preparation (thick capsule). bug?
Cryptococcus neoformans
gram stain: spirochete. bug?
Treponema sp., Leptospira sp. (both seen only on darkfield microscopy); Borrelia sp. (seen on regular light microscope)
gold standard for pneumonia diagnosis? what do you think about?
sputum culture; get it before starting abx; get blood cx too because of possible bacteremia in pneumonia
most common cause of pneumonia?
Streptococcus pneumoniae
classic presentation of S. pneumoniae pneumonia?
rapid onset, shaking chills after 1-2d of URI sx (sore throat, runny nose, dry cough), followed by fever, pleurisy, productive cough (yellowish green or rust-colored from blood), especially in older adults.
what is shown on CXR and CBC in S. pneumoniae pneumonia?
lobar concentration

WBC count is high c large % of neutrophils
how do you treat S. pneumoniae pneumonia?
1. 3rd gen cephalosporin (ceftriaxone)
2. macrolide (azithromycin)
3. broad spectrum floroquinolone (levofloxacin)
best prevention against S. pneumoniae?
vaccination
who should get the S. pneumoniae vaccine?
1. children and adults>65yrs
2. splenectomized pts
3. sickle-cell disease pts (autosplenectomy)
4. pts with splenic dysfunction
5. immunocompromised pts (HIV, malignancy, organ transplant)
6. pts with chronic disease (DM, cardiac, pulm, renal, liver)
how do you recognize Haemophilus influenze pneumonia?
2nd most common cause

this is more common in kids than adults

presents clinically like S. pneumoniae pneumonia; but it's a gram negative coccobacilus on sputum Gram stain
what are 3 different ways you could treat H. influenza pneumonia?
1. ampicillin/amoxicillin
2. cephalosporin
3. TMP/SMX
empyema and lung abscesses are more common in what type of pneumonia?
Staph aureus pneumonia
what are hallmarks of Staph aureus pneumonia?
1. tend to be nosocomial pneumonia
2. CF pts often get it (that, or Pseudomonas)
3. IV drug useres
4. pts c chronic granulomatous disease (recurrent lung abscess)
how do you treat gram neg. pneuonias?
3rd gen penicillin/cephalosporin plus an aminoglycoside
in what clinical situations do you get gram-negative pneumonias?
pseudomonas -> CF

Klebsiella -> 'skid-row' alcoholics and homeless people (currant jelly sputum)

enteric gram neg. organisms (E. coli) -> aspiration, neutropenia, nosocomial pneumonia
pneumonia common in adolescents, young adults; classically a college student or soldier in dormitory. what is the bug?
Mycoplasma pneumonia
how is atypical pneumonia different than typical in presentation?
long prodrome with gradual worsening of malaise, headaches, dry, non-productive cough and sore throat; low grade fever
CXR in atypical pneumonia?
patchy, diffuse bronchopneumonia, classically looks terrible, but pt doesn't feel that bad
what in atypical pneumonia can cause hemolysis or anemia?
cold-agglutinin antibody titers
DOC in atypical pneumonia?
macrolid abx (azithromycin) or broad spectrum fluoroquinolone (levofloxacin)
2 common bugs that cause atypical pneumonia in adolescents and young adults?
1. Mycoplasma sp.
2. Chlamydia sp.
in what setting do you see Pneumocystis carinii (PCP) and cytomegalovirus (CMV) pneumonia
HIV positive pts with CD4 counts <200/mm3 (AIDS); other severely immunocompromised pts (organ transplant pts, CA pts)
how do you diagnose and treat Pneumocystis carinii pneumonia?
dx: bronchoalveolar lavage; silver stain and bilateral interstitial lung infiltrates

rx: TMP/SMX or pentamidine
what is particular about the diagnosis of CMV pneumonia? how do you treat?
intracellular inclusion bodies

ganciclovir; foscarnet is an alternative
when do you think about PCP prophylaxis in an HIV pt? what do you give?
when CD4 < 200/mm3

TMP/SMX or pentamidine
buzz: stuck with thorn or gardening. bug? rx?
Sporothrix schenckii

oral potassium iodide or ketoconazole
buzz: aplastic crisis in sickle cell disease. bug?
parvovirus B19
buzz: sepsis after splenectomy. bugs?
S. pneumoniae, H. influenzae, N. meningitidis (encapsulated bugs)
buzz: pneumonia in the southwest. bug? rx?
Coccidioides immitis

itraconazole, fluconazole, or amphotericin B for severe disease
buzz: pneumonia after cave exploring or exposure to bird droppings in Ohio and Mississippi River valleys. bug?
Histoplasma capsulatum
pneumonia after exposure to parrot or exotic bird. bug?
Chlamydia psittaci
fungus ball/hemoptysis after TB or cavitary lung disease. bug?
Aspergillus sp.
pneumonia in pt with silicosis. bug?
TB
diarrhea after hiking/drinking from a stream. bug? findings and rx?
Giardia lamblia

stool cysts; tx with metronidazole
pregnant woman with cats gets infection. bug?
Toxoplasma gondii
B12 deficiency with abdominal sx. bug?
Diphyllobothrium latum
seizures with ring-enhancing lesion on CT. bug?
Taenia solium (cysticercosis) or toxoplasmosis
squamous cell bladder CA in Middle East or Africa. bug?
Schistosoma haematobium
worm infection in children. bug? findings?
Enterobius sp.

positive tape test, perianal itching
fever, muscle pain, eosinophilia, and periorbital edema after eating raw meat. bug?
Trichinella spiralis (trichinosis)
gastroenteritis in young kids. bugs?
rotavirus, Norwalk virus
food poisoning after eating reheated rice. bug?
Bacillus cereus
food poisoning after eating raw seafood. bug?
Vibrio parahemolyticus
diarrhea after travel to Mexico. bug?
E. coli (Montezuma's revenge)
baby paralyzed after eating honey. bug? mxn?
Clostridium botulinum

toxin blocks Ach release
genital lesions in children in absence of sexual abuse or activity. bug?
Molluscum contagiosum
cellulitis after cat/dog bites. bug? rx?
Pasteurella multocida

prophylactic ampicillin
slaughterhouse worker with fever. bug?
Brucellosis
pneumonia after being in hotel or near air conditioner or water tower. bug? rx?
Legionella pneumophila

azithromycin or levofloxacin
burn wound infx with blue/green color. bug?
Pseudomonas sp.

S. aureus is also a common burn infx, but lacks blue/green color
ring enchancing brain lesion as a complication of AML and immune compromise. bug?
Asperigillus spp.
how do you screen for syphilis?

how do you confirm a positive screen?
1. RPR (rapid plasma reagin) or VDRL (Venereal Disease Research Laboratory) test

2. confirm with FTA-ABS (fluorescent treponemal antibody absorbed) or microhemagglutination (MHA-TP)
2 tests remain positive for life in syphilis patients after a cure. which are they?
FTA-ABS and MHA-TP
if you scrape the base of a genital chancre or conyloma lata, what do you see under dark-field microscopy?
spirochetes
what group of pts should always be screened for syphilis?
pregnant women; prevent birth defects
how do you treat syphilis?
penicillin

use doxycycline for penicillin allergic pts
describe the 3 stages of syphilis.
1*) painless chancre resolves spontaneously w/in 8 wks

2*) 6 to 18wks after infection, look for condyloma lata, maculopapular rash (palms and soles of feet), lymphadenopathy

-- latent phase --

3*) gummas (granulomas in many different organs), neurologic sx and signs (neurosyphilis, Argyll-Robertson pupil, dementia, paresis, tabes dorsalis, Charcot joints), and/or thoracic aortic aneurysms
how do you recognize measles (rubeola) infx in a child?
- lack of immunization
- Koplik's spots (tiny white spots on buccal mucosa) seen 3 days after high fever, cough runny nose, and conjuctivitis with or without photophobia
- on the next day, a maculopapular rash begins on head and neck, spreading down to cover trunk
what are the complications of measles?
- giant cell pneumonia in very young or immunocomprimised pts
- otitis media
- encephalitis (either acute or late - subacute sclerosing panencephalitis can occur years later)
why is rubella infx (German measles) an important disease?
- infx in pregnant moms can cause severe birth defects in the fetus
- must screen and immunize all women of reproductive age w/o evidence of rubella antibodies before pregnancy

* the vaccine is contraindicated in pregnant women *
how do you recognize rubella infection in kids? complications?
1. rubella is milder than measles; sx include low-grade fever, malaise, tender swelling of suboccipital and postauricular nodes, arthralgias

after 2 to 3 day prodrome, faint maculopapular rash appears on face and neck and then spreads down to trunk (like measles)

complications include encephalitis and otitis media
how do you recognize roseola infantum (exanthum subitum)? what causes it?
- distintive progression: high fever with no apparent cause for 4d (possible febrile sz's), abrupt return to normal temp as diffuse macular/maculopapular rash appears on chest and abdomen

disease is rare in kids older than 3yrs

caused by human herpesvirus type 6 (DNA herpes family virus)
what disease is caused by the human herpesvirus type 6 (DNA herpes virus)?
roseola infantum (exanthum subitum)
how do you recognize erythema infectiosum (fifth disease) in kids? cause?
- classic 'slapped cheek' appearance
- mild constitutional sx (low fever, malaise)
- one day later, maculopapular rash appears on arms, legs and trunk

caused by parvovirus B19, the same virus that causes aplastic crisis in sickle cell
how do you recognize chicken pox? what virus causes it?
progression of the disease: discrete macules (usually on trunk) turn to papules, which turn to vesicles that crust over; happens in crops, so different patches with different stages of progression

all this happens within 1 day

varicella virus
how do you make the definitive dx of chicken pox? when is a pt no longer infectious
Tzanck smear of tissue from base of a vesicle shows multinucleated giant cells

when last lesion crusts over
complications of chickenpox?
infection of lesions with streptococci or staphylococci which cause erysipelas, cellulitis and/or sepsis
can a child get chickenpox from someone with shingles?
yes
what is tx and ppx for chickenpox?
tx: supportive care c acetominophen, fluids, don't infect others; acyclovir in severe cases

routine vaccination for all kids in U.S.
what do you give pts with debilitating illness within 4 days of exposure to someone with chickenpox?
Varicella-zoster immunoglobulin
what is scarlet fever?
febrile illness with rash caused by certain Streptococcus spp.
describe the hx of someone with scarlet fever.
- hx of untreated streptococcal pharyngitis
- only streptococcal spp. that produce erythrogenic toxin can cause scarlet fever
- pharyngitis followed by sandpaper-like rash on abdomen and trunk with classic circumoral pallor and strawberry tongue
- rash desquamates once fever subsides
how do you treat streptococcal pharyngitis? what do you want to prevent?
- penicillin
- rheumatic fever
what is another name for Kawasaki's syndrome?
mucocutaneous lymph node syndrome
what are the diagnostic criteria for Kawasaki's syndrome?
- seen in pts under 5yrs old
- fever for more than 5 days
- bilateral conjunctival injection
- changes in lips, tongue, oral mucosa (strawberry tongue, fissuring, injection)
- changes in extremities (eg. skin desquamation, edema, erythema)
- polymorphous truncal rash, beginning one day after the fever starts
- cervical lymphadenopathy
what disease must you include in the ddx of a child with MI?
Kawasaki's syndrome
what is the most feared complication of Kawasaki's disease?
heart problems:
- coronary artery aneurysms
- CHF
- arrhythmias
- myocarditis
- MI
what do you give to kids with Kawasaki's syndrome to reduce risk of cardiac lesions?
aspirin and IV immunoglobulins

Kawasaki's syndrome is one of the FEW indications for aspirin in children
what is an important ddx of EBV infection?
acute HIV infection; it can cause a mononucleosis-type syndrome
what is the link between EBV and CA?
- nasopharyngeal CA
- African Burkitt's lymphoma
- posttransplant lymphoproliferative d/o
what are the classic findings of EBV infection (infectious mononucleosis)?
Fatigue
Fever
Pharyngitis
Cervical lymphadenopathy

all in a young adult
what do you see in EBV infx that don't appear in streptococcal pharyngitis?
- splenomegaly (could lead to splenic rupture)
- hepatomegaly
- atypical lymphocytes with lymphocytosis, anemia, or thrombocytopenia
- positive serology (heterophile antibodies [Monospot test], specific EBV antibodies)
vignette:
- hx of tick bite in pt on East Coast
- severe HA, malaise about a week before high fever and chills
- rash appears 4d later on palms/wrists and soles/ankles and spreads rapidly to trunk and face

diagnosis?
Rocky Mountain spotted fever
what bug causes Rocky Mountain spotted fever? treatment?
Rickettsia rickettsii

tetracycline; chloramphenicol is 2nd choice
describe typical lesions of impetigo caused by Streptococcus and Staphylococcus spp. where do they typically present on the body?
- look for hx of break in the skin (eg. prior chickenpox, insect bite, scabies, cut)
- rash starts as thin-walled vesicles that rupture and form yellowish crusts
- classically described as 'weeping' skin

- typically present on face and tend to be localized; rash is infectious
how do you treat impetigo caused by Streptococcal and Staphylococcal spp?
tx with oral antistaphylococcal penicillin (eg. methicillin) to cover both Streptococcus and Staphylococcus spp.
what are the 2 types of endocarditis? how do they present?
1. acute or fulminant: affects normal heart valves

2. subacute: insidious onset and typically affects previously damaged or mechanical valves
what do you think about if Streptococcus bovis shows up on culture in someone with endocarditis?
suspect colon CA
what bug is most common cause of acute endocarditis? subacute?
acute: Staphylococcus aureus

subacute: Streptococcus viridans (and others: S. bovis, S. epidermis, S. faecalis)
what is another term for S. faecalis?
enterococci
how is endocarditis diagnosed? what is empiric treatment?
1. diagnose with blood cultures

2. third generation penicillin or cephalosporin plus and aminoglycoside