Review for Infec-

Quick review Comments

TOPICS Answers.
Important to know the CX - Like meni
tious D. but also w
AMS , en-
cephalitis
Brain Inflammation toms

Treatment is always -? - Empiric fo

Initial workup for cx of Headache and Fever,
(acyclovir
LP if safe.-Need to rule out high ICP using (FAILS) and
then CT.
Start ATB (Vanc. Piptazo. Asap.) after blood cultures and
LP (if you get them)

Meningitis
Cx; photo phono phobia .
Dx: WBC PMN 1000s , GLu low. Proteins high.
fungal- glu low. Prot. High. Wbc. lymp.
TB-
If Bacterial - neisseria . H. Flu. s. Pneumo -> PMN high.
Treat EMP. Standard.
If PMN not that high. -> something else.
1. RMSF - camper. Maculopapular rash centrifugal
spread. Dx. With serology and tx with doxy or ceftriaxone.
2. Lyme - if disseminated or late . With heart block.
Neural cx. Arthralgias - > dx. Serology tx: ceftriaxone.
3. TB- homeless. Tb risk factors. -> get cxr- AFB.
Dx. With CSF (tb?)
tx: RIPE.
4. Cryptococc.- HIV . Opening pressure is high..
CSF- ag. Tx. Ampho _flucytosine . Later (8weeks of flucona-
zole)

Encephalitis
Dx: lp. Lymphocytes. GLu nl. Protein higher.
PCR - HSV -
TXl acyclorive iv.

Abscess or mass
Mass r/o cancer . If toxo signs . Periventricular calci. And
HIV.. serology TOxo.
Tx. Pyramethamine + sulfadiazine. \

Cryptococcal meningitis
Patients with HIV who have cryptococcal meningitis re-
quire treatment in 3 stages as follows:
1. Induction - amphotericin B and flucytosine for >2
weeks (until symptoms abate and CSF is steril-
ized)
2. Consolidation - high-dose oral fluconazole for 8
weeks
3. Maintenance - lower-dose oral fluconazole for >1
year to prevent recurrence

Quick review Comments or

TOPICS Answers.
Meningoenhalitis Causes are HSV, West nile,
Adenovirus(coxsakie)
 HIV
Acute retroviral Illness -
Cx Mono like. But it differs from mono. -
mucocutaneous painful. Ulcers. Rash-palm and
soles.
Dx: p23 + elisa ( hiv ab.)
do PCR for virus.
Tx: start ART * NNRT 2 + 1 (protease. Integrase . Fusion . )
things to consider before starting therapy.
1. Viral load. CD count .
2. Genotype.
3. Comorbidities.
HepB. Hep C. TB.
other STD.
chronic dz. - cuz hiv ppl are inflammatory
have risk for CAD.
Opportunistic infections
CD 200 -> PCP ppx with Bactrim. -> Dapsone ->
atorvaqone + levocarine.
CD 100 > TOXO. - Bactrim. -> pentamidine.
CD 50 > CMV .. MAI -azithromycin.
Other problems?
* HIV lipodystrophy. -
consider statin for this.

Diagnoses
tell pt after confirmation and also contact partner .
Report to CDC.

screening . Screening for post-ex-

posure
May be negative in 4-8week repeat test. But start ppx (2+1)
asap within hours of exposure.

pregnancy and HIV

Vertical transcmission is highest risk. =- mom on
2+1 and give AZT during birth.
 Sepsis
SIRS criteria.
2/4 - fever, WBC, RR, HR.

Sepsis
when there is infectious source.

Severe sepsis vs septic shock?

Bothe have organ dysfunction (lab values rise) . MAP <65,.
severe sepsis is responsive to fluid .
shock . Don’t respond.

Goals?- 6hr .
MAP - >65

U output >0.5ml / kg / hr.

CVP - 10-12

Sat Ven O2. >70%

Management?
ATB - empiric and IVF. Bolus.

pressors - norepi. Vasopressin - steroids.

Remove any source - lines. Plastic. Etc.

when to remove IV lines?

oxygen .

Follow ?
Lactate trending.
 Pediatrics
Neonatal Sepsis

Antibiotics in pediatric sepsis

Age Most common or- Empiric an-

ganisms tibiotics
‣Group B Strepto-
coccus
≤28 ‣Escherichia coli ‣Ampicillin +
days ‣Listeria monocy- gentamicin*
togenes (age <7
days)

‣Ceftriaxone
‣Streptococcus ‣± Van-
>28 pneumoniae comycin (if
days ‣Neisseria meningitis or
meningitidis MRSA is
suspected)

*Cefotaxime or ceftazidime can be used in place of

gentamicin for suspected meningitis due to superior
cerebrospinal fluid penetration.
MRSA = methicillin-resistant Staphylococcus au-
reus.

Neonates are at increased risk for serious bacterial in-

fection (eg, bacteremia, urinary tract infection [UTI],
meningitis) due to their immature immune systems,
and group B Streptococcus (GBS) and Escherichia
coli are the most common organisms found in the first
month of life.
 Zoonosis
Lyme
cx. Early. Rash. .
early dissed - arthralgia. Cn 7 palsy . Hear block .
late. 0meningitis. Encephalitis.
???

DX. Clinical in early phase. . serology for early dissed and

late
Tx. DOxy . Ceftriaxone for diss. Or late.
 GIT infections
C. Diff.
- watery diarrhea in ATB use pt.
cx; 3-4 times in 24hr. Pain. Fever. Wbc high.
dx. _ PCR. Stool .
tx. PO fidix. Po Vance.
f/u recurrence common cuz these re spores.
And diagnosis would be clinical with typical c diff. Cx.

Tx by severity.
- fido. Vanco.
- fulminant -> IV - metronidazole and Vance
enemas can be considered.
- if severe. Surgery . For mega colon.
Aspiration Pneumonia Concerning • Historical: smoke exposure
Old patient with massive parapneumonic effusion on chest x-ray. features • Physical: singed hair, facial

Strong indicators • Oropharyngeal blistering or

of airway injury • Retractions, respiratory distr

Management • 100% oxygen to displace CO

• Stable patients with concern
fiberoptic laryngoscopy
Respiratory infections •
tion
Unstable patients or patients

Pneumonia
Aspiration Pneumonia / Pneu-
CO = carbon monoxide.
monitis

Inhalation injury
CO and cyanide poisoning most common
Assess for airway edema or burn using bedside
fiberoptic bronchoscope and consider intubation
if burn present
If pt is unstable or unconscious just intubate.
And 100% O2.

Inhalation injury

Pathophysiology • Upper airway thermal injury ± lower airway chemical injury

• Concomitant CO & cyanide poisoning common
 ENT

Otitis Media and Externa

Path ‣ Complication of URI ear in-
fection or tympasnoplasty

Otitis Media Cx ‣ Acute Otitis Media + Poste-

rior bulging mastoid
‣ Ant. Rotated. Ear.
Dx ‣ Clinical
‣ CTscan (not needed)
‣ Respiratory bugs
Path ‣ H.flu (non-tapeable)
‣ St. Pneumo Tx ‣ Surgical drainage +
‣ Moraxella ‣ ATB same (amici. )

Cx ‣ Pulling of pinna (relieve F/U

pain)
‣ Hx of recent URI

Dx Otoscope -> bulging

tympanic membrane
- insufflation test - rigid.
- Amoxicillin Mastoiditis
Tx - Amoxi-clav Pen allergy ->
- Tympanoplasty - if cefdinir or
(>3/6mo or 4/yr) macrolide.
F/U
Path ‣ URI bugs
‣ Mostly viral - no treat-
ment needed.
Otitis Externa Cx ‣ Congestion sym >10d
‣ Purulent d/c
‣ Painful facial tap.
‣ Worsening.
Path ‣ Swimmer’s ear - pseudomonas Dx ‣ 2/4 criteria -> clinical dx.
‣ Digital trauma - Staph. ‣ Transillumination test is
also possible if unsure.
Cx ‣ Unilateral ear pain
‣ No relief with pulling ear.
‣ Red canal. Tx ‣ Amoxi-clav.
Dx ‣ Clinical ‣ Supportive if viral.

F/U ‣ CT scan for recurrence or

Tx ‣ Spontaneously resolves foreign body. For young
kids.

F/U ‣ If Toxic, malignant otitis externa ->

use Cipro and Steroid ear drops.
Sinusitis

Path

Cx

Dx

Croup
 Tx

F/U

Cold - Rhinitis

Pharyngitis

Path

Cx

Dx ‣ Centor (4)-> treat

‣ 3-> Rapid strep

Tx

F/U
 Infective endocarditis Major Criteria
1. Bacteremia
Minor
1. Risk factors
2. Echo -> new (IVDU, Hx, pros-
murmur thetic valve)
Major Criteria 3. Echo- confirm 2. Fever
vegetation 3. Vascular ( Septic
2 major emboli, Splinter
1 major + 3 minor hemorrhages,
Jane-lesions)
- Bacteremia 4. Rheum*immuno
- Murmur (rothspots, osler
- Echo shows vegetation nodes.GN.)
Signs: FROM JANE ACUTE Subacute
Fever, Roth spots, Oslers, Murmur. ‣ - immunologic
Janeway lesions , Anemia, Nailbed signs
hemorrhages, emboli
Dx ‣ 2 blood cultures - Blood cultures 3 until
‣ Follow until neg. you get positive don’t
Minor criteria: ‣ TEE.
start ATB
- TEE
4. Risk factor
- IVDU
- Hx of endocarditis. Tx ‣ Vanco No Vanc but Genta +
- Prosthetic Valve
2. Fever Ceft.
3. Vascular signs:
- Septic emboli
- Splinter , nailed hemorrhages F/U
- Janeway lesions.
4. Immune signs
- Roth spots
- Osler nodes,
- GN.

Treatment
4-6weeks Vanco
Native - Vanco + Gent
Prosthetic - Vanc + gent
- <60days + Cefipime
- 1yr + Ceftriaxone
Subacute - no Vanco. - Gent + Ceft.
Major Criteria Minor
1. Bacteremia 1. Risk factors
2. Echo -> new (IVDU, Hx, pros-
murmur thetic valve)
3. Echo- confirm 2. Fever
vegetation 3. Vascular ( Septic
emboli, Splinter
hemorrhages,
Jane-lesions)
4. Rheum*immuno
(rothspots, osler
nodes.GN.)

ACUTE Subacute

Path ‣ Staph • HACEK

‣ Strep
Cx ‣ CHF, - Fever - on and off.
‣ Bacteremia
‣ TOxic - Non-toxic
Acute
 SKIn and Soft Tissue Infec-
tions Path Strep Infection into Lymph.

Cx Red, defined, (tracks or lines)

5. Cellulitis +/- fever

Dx ‣ Clinical

Tx Amoxicillin (beta lactase) cuz its strep.

F/U

Erysipelas

Path P. Acnes

Cx Zit

Dx

Path: Tx ‣ Comedones - Top retinoids

St. Aureus or S. Progenies ‣ Inflamed - Top _ Benz peroxide.
Cx ‣ Severe- pustular - + doxy .
‣ Resistant - Isoret.
Dx
Tx
Treatment is either
Cef (2/1 gen) or amoxicilin -> pip/tazo or amoxiclav. F/U UPT - before isotret.
TMX-SMX or Clinda -> Vanco.
F/U
- DM-> Pip/tazo and Vanco. Acne Vulgaris

Path Strep Pyogenes

Staph Aureus (bulbous)
Cx Child
Honey-crusted lesion on face

Dx Clinical

Tx Local - Mupirocin
Lots of dz -> Amoxi (strep)
Refractory - clindamycin
(staph)

F/U Can cause PSGN .

Impetigo
6. Osteomyelitis
Path: recurrent or non-resolving
Cx
Dx: probe
Xray, MRI.
BEST : biopsy.
Tx :
Debridement + ATB(targeted based on biopsy)
for 4-6 weeks.
F/U- ESR and CRP (to follow resolution of in-
flammation)
7. Gas Gangrene
Path:
Cx
Dx
Tx : PCN + clindamycin.
F/U

8. Necrotizing Fasciitis

Path: mcc is S. Pyogenes in healthy

DM- polymicrobial (due to poor peripheral cir-
culation (PAD)
Cx: look toxic. In shock.

Dx

Tx - Debride
Ceftriaxone + Clinda + Ampl-sulbac.
F/U

9.
10. Key concepts and HY points
Vibrio
MCC osteo is staph (for all pt groups)
DM - polymicrob
Perforated wounds - pseudomonas.
Sickle cell - salmonella

vulnificus
Bite wounds - amoxi-clav.for all.
Human bites-> eikinella species. (Gram neg)
Pastuerella -> cellulitis + osteomyelitis 1-2 days after a
dog/cat bite

Cat-scratch Disease
Vs. papule -> LAD
 Urinary Tract Infections
Urethritis
Path: STD - Gono or chlam
Cx: discharge +
Dx: NAAT for Gono and Chlam
Tx: Ceftri - Gono
Doxy or Azithro - Chlam
Treat for both if present !
F/U- HIV. And partner treatment .

Asymptomatic Bacteruria
Path: not routine, only for pregnancy and urologic
procedures.
Cx:
Dx: UA
U-culture positive => 10^5
Tx: amoxiclav. Or Cephalexin.
Gyne UTI
Nitrofurantoin
Recurrent UTI is >2 in 6mo or >3 in yr.
Tx with postcoital ATB.
F/U

Pyelonephritis in pregnancy:
manage with IV ceft.
no tetracyclines, Bactrim. Floro-
quinolones
Cystitis
Path: complicated vs non-compl
Non-comp - non-pregs. (3daystx) Pyelonephritis
Comp - Penis, Plastic, Procedure, Pyelo. (5day
Path:
tx)
Same G-neg.
Gram neg. Ecoli.
Cx:
Cx: U/F/D. F/U/D + fever. Chills.
Dx: UA -> nitrites + Leuk esterase. Dx
UA + U-culture
U-culture not necessary here
Tx
Tx : Nitrofurantoin or Bactrim (3 or 5 days)
Ceftriaxone (target gram-negs) for 7days
Amoxicillin for pregs.
Cipro - also alternative .
F/U: f/u to check for resolution.
F/U - follow in 3 days to see improvement .
If not improving , ATB not working or abscess.
Pyelonephric Abscess
Path: - not improving in 3 days.

Cx :
Dx : US or CT- abd.
Tx: Drain + ATB 14 days.
F/U

Recurrent UTI
If associated with sex-> manage with postcoital ppx
bactrim or nitrofurnatoin
Not associated with sex can have daily low dose ATB.
 Syphillis in Pregnancy

Treat all Syphillis with Pen-IM (desensitize if allergic)

Lactational Mastitis
Most Common pathogen? And treatment?
- ant-staph. (Dicloxacilin or cephalexin)
What is a common complication that can occur and how
to solve this?
- breast abscess
- Do US, then drain it.

UTI in pregnancy
- All women are screened for asymp bacteriuria during
first prenatal visit (12-16weeks)
-

Pregnancy and obstetrics

Antenatal screening (36-38)

What are the exceptions to universal screening of GBS?
1. Hx of GBS bacteriuria,
2. Invasive early onset GBS in prior child.
You just treat with intrapartum ppx IV PCN.

STD
Genital Ulcers ‣ What is important to know?
syphillis ‣ Number
‣ Painful or not
Chancroid
 Fu

Syphillis

Path Spirochete,

Cx ‣ 1. Chancre- Painless, single ulcer or basically asymptomatic.

‣ 2. Fever, systemic signs + Targetoid rash on palm and soles,
‣ 3. Organs, bones, gammas, Neuro. //Tabes Dorsalis -, Arg. Rob. Pupil.

Chancroid

Path H. Ducreyi

Cx Painful single Ulcer

LAD is tender..
Dx 1. Primary - dark field micro
2. RPR -> confirm with FTA ABS
3. Neuro - CSF -> RPR -> FTA ABS
Dx Gram stain + culture
Tx 1. PCN IM ( 1/2/ early Latent <1yr)
PCM IM 3 times . ( Latent - late or unknown )
PCN IV - (14days ) for neurosyphilisTx Macrolide or Cipro.

F/U

Fu Follow treatment with RPR - titers.

HIV and other STD tests.

Lymphgranuloma Venorum LGV.

Path Clamydia. Trachoma (rare in US) ,

Cx Painless . Singles Ulcer

But LAD is painful and suppurative, ulcerate, drain.

Dx NAAT

Tx • Doxycycline
Herpes (HSV) Quic
k re-
Com-
ment
view s or
TOP- An-
ICS swers
Path HSV 1 or HSV 2 .

Cx Painful. Prodrme
Painful vesicles
Red base,
Coalesce and become ulcer.

Dx PCR

Tx Acyclovir or Valacyclovir

F/U -

Other STDs to note

Path
Quick re- Comments or Cx
view Answers.
TOPICS
Dx

Tx

F/U

Trichomonas
Quick review
TOPICS Comme
Funfact about treating during • Stop
Trichomonas breastfeeding? 24hrs
cause

P
a Why important to treat both part- - !! Risk
t ners regardless of symptoms? in high
h

C
x

D
x

T
x

F
/
U
 Template
Path

Cx

Dx

Tx

F/U

?? = Question to check cuz I’m unsure

!! - important HY stuff.