≠Alya M.

Al-busaidi PGY4

ID Summary:
Vaginal discharge
Symptoms Treatment (non-pregnant) Treatment for pregnant patient Comment
Bacterial fishy odor metronidazole 500 mg prefer oral therapy in possible disulfiram-like
vaginosis clue cell bid for 7 days pregnant patients reaction with alcohol
consumption or
gastrointestinal
OR metronidazole 500 mg orally
metronidazole gel 0.75% symptoms in persons
BID for 7 days (preferred) taking oral
one full applicator (5 g)
metronidazole, or
intravaginally BID for 5 OR possible weakening of
days metronidazole 250 mg orally latex condoms with the
TID for 7 days use of topical therapies
OR or containing oil-based
Clindamycin cream 2% one Clindamycin 300 mg orally preparations
full applicator (5 g) BID for 7 days Treat sex partner not
intravaginally at bedtime indicated
for 7 days
** clue cell

vulvovaginal yeast hyphae *several topical azole * Topical clotrimazole or * topical azole creams
yeast cheesy, lack of odor, preparations miconazole for 7 days and suppositories may
vaginal redness * oral fluconazole (Diflucan) in be oil-based and can
a single 150-mg dose. weaken latex condoms
*for Nonalbicans
Candida vaginitis, used non–
fluconazole azole drug. Like
Intravaginal boric acid*
600 mg daily for 14 days
or Topical imidazoles (i.e.,
econazole, clotrimazole,
miconazole, and
ketoconazole)
Trichomoniasis STD, motile, * metronidazole 2 g orally metronidazole 2 g orally testing for reinfection
flagellated protozoa, given as a single dose given as a single dose three months after
Green or yellow, treatment, treat sex
* Tinidazole 2 g orally
frothy discharge; partner
foul odor, given as a single dose
*test for other STI
strawberry cervix
Alternative regimen
In men it can cause
Persistent, Metronidazole, 500 mg
recurrent urethritis orally twice per day for
symptoms seven days

Urethritis in men , chlamydia and gonorrhea

Unknown Dysuria , Inguinal Ceftriaxone, 500 mg
(empiric lymphadenopathy, intramuscularly
treatment) Erythema of the
penile, Urethral
plus
discharge
 Doxycycline, 100 mg orally
BID for 7 days

Chlamydia Most cases are One dose of azithromycin Recommended regimen Treat sex partner in the
trachomatis asymptomatic (Zithromax), 1 g orally last 2 months, advised
Azithromycin 1 g orally in a for sex absences for 7
single dose days after starting the
or
Tx
Alternative regimens
Doxycycline, 100 mg orally Amoxicillin 500 mg orally Best sensitive test:
BID for 7 days three times a day for 7 days NAAT

Alternative regimen

Erythromycin, 500 mg orally

QID for 7 days

or

Erythromycin ethylsuccinate
(Eryped), 800 mg orally QID
for 7 days

or

Levofloxacin (Levaquin),
500 mg orally per day for
seven days

or

Ofloxacin, 300 mg orally BID

for 7 days

Neisseria One dose of ceftriaxone, 500 One dose of ceftriaxone, 500 Best sensitive test:
gonorrhoeae mg IM for those < 150 kg or mg IM for those < 150 kg or NAAT
1,000 mg intramuscu- larly 1,000 mg intramuscu- larly for
for those > 150 kg those > 150 kg

Alternative regimen

One dose of:

Cefixime (Suprax), 800 mg
orally

or

Gentamicin, 240 mg IM, plus

azithromycin, 2 g orally as a
single dose
Mycoplasma Moxifloxacin (Avelox), 400 Difficult to culture it,
genitalium mg orally OD for 7- 14 days more common in men
who are younger, who
or smoke, and who have
multiple sex partners

One dose of azithromycin, 1

g orally

Alternative regimen

Doxycycline, 100 mg orally

BID for 7 days

Genital ulcer
HSV Multiple vesicles, 1st episode: 1st episode: Dx: PCR testing for HSV
painful DNA
-Acyclovir, 400 mg TID daily Acyclovir, 400 mg TID daily for
First-time for 7 to 10 days 7 to 10 days If not available:
infections may
cause constitutional recurrent episode
or -hx and PE
symptoms and
lymphadenopathy
Acyclovir, 200 mg 5 times Acyclovir, 800 mg BID for 5 Previous h/o HSV
daily for 7 to 10 days days, or
R/O other causes of
or Acyclovir, 800 mg TID daily for ulcer
2 days
Valacyclovir (Valtrex), 1 g
bid for 7 to 10 days Antiviral prophylaxis with
acyclovir is recommended from
36 weeks’ gestation until
or delivery in women with a history
of genital herpes to minimize
Famciclovir (Famvir), 250 active recurrence at the time of
mg TID daily for 7 to 10 delivery
days
use acyclovir 400 mg three times
Severe acute disease: daily as suppressive therapy.

Admit the patient, begin =Elective cesarean delivery

intravenous acyclovir, 5 to should be performed in laboring
10 mg per kg every 8 hours patients with active lesions to
for 10 days; intravenous decrease the risk of HSV
transmission
therapy for 2 to 7 days until
improvement, then switch to
oral therapy to complete 10
days of treatment

Recurrent:
 Acyclovir, 400 mg TID daily
for 5 days, or

Acyclovir, 800 mg BID for 5

days, or

Acyclovir, 800 mg TID daily

for 2 days, or

Acyclovir, 200 mg 5 times

daily for 5 days, or

Valacyclovir, 500 mg BID for

3 days, or

Valacyclovir, 1 g daily for 5

days, or

Famciclovir, 125 mg BID for

5 days, or

Famciclovir, 1 g BID daily for

1 day, or

Famciclovir, 500 mg once,

then 250 mg BID daily for 2
days

Suppressive therapy:

Acyclovir, 400 mg BID

,or Acyclovir, 200 mg 3 to 5

times daily, or

Valacyclovir, 500 mg daily,

or

Valacyclovir, 1 g daily, or
Famciclovir, 250 mg BID
daily

Syphilis A single, painless, A single dose of From omani guidline: Sex partners exposed
well-demarcated intramuscular penicillin G within 90 days before
ulcer with a clean benzathine, 2.4 million units, diagnosis should
base and is the preferred treatment undergo treatment
indurated borders for primary, secondary, and If early syphilis: Benzathine
syphiLIS is (chancre) early latent syphilis penicillin 2.4 MU i/m x 1 dose if
painLESS ulcer <28w gestation; or
Mild or minimally The recommended regimen
tender inguinal for late latent syphilis, latent Benzathine penicillin 2.4 MU i/m
lymphadenopathy syphilis of unknown x 2 doses one week apart if
duration, or tertiary >28w gestation
nonneurologic syphilis
 caused by active consists of three weekly If ndeterminate stage syphilis
infection with T. doses of intramuscular
pallidum. penicillin G benzathine, 2.4
Benzathine penicillin 2.4 MU i/m
million units each
weekly x 3 doses

The treatment of
neurosyphilis requires
intravenous aqueous
crystalline penicillin G

Any patient allergic to

penicillin should undergo
desensi- tization and then
treatment with penicillin

chancroid Nonindurated, Azithromycin (Zithromax), 1 Both azithromycin and ceftriax Definitive: H. ducreyi
painful with g orally in a single dose one identified on culture
serpiginous border can be used for the treatment
and friable base; of pregnant women with
Ceftriaxone (Rocephin), 250 What is a bubo?
covered with a chancroid
mg intramuscularly in a
necrotic, often
single dose
purulent exudate A large, unilateral
fluctuant lymph node
Ciprofloxacin (Cipro), 500 which can develop in
Multiple
mg orally BID for 3 days† chancroid.

Tender,
Erythromycin, 500 mg orally Management of
suppurative,
QID daily for 7 days
unilateral inguinal Sex Partners :
lymphadenopathy Regardless of
or adenitis
whether symptoms
of the disease are

present, sex
partners should be
examined and
treated

Lymphogranulo Small, shallow, Doxycycline, 100 mg orally erythromycin, 500 mg orally Diagnosis:
ma venereum painless, genital BID for 21 days QID daily for 21 days
or rectal papule or
Definitive:
ulcer; no induration
Erythromycin base, 500 mg
orally QID daily for 21 days
Chlamydia trachomatis
Unilateral, tender
serotype L1, L2, or L3
inguinal or femoral
culture, identified from
lymphadenopathy
clinical specimen

Rectal bleeding,
or
pain, or discharge;
ulcerative proctitis;
constipation or Immunofluorescence
tenesmu demonstrating
inclusion bodies in
leukocytes of an
 Patient will be a inguinal lymph node
homosexual man (bubo) aspirate

With a history of or
recent travel to
tropical and
subtropical areas of Microimmunofluoresce
the world nce positive for
lymphogranuloma
venereum strain of C.
trachomatis

Sexual contact within

the 60 days

Granuloma Persistent, Treatment should continue Pregnant persons should be Definitive:

inguinale painless, beefy-red until lesions have healed treated
(donovanosis) (highly vascular) with erythromycin or azithrom
Intracytoplasmic
papules or ulcers ycin.
Doxycycline, 100 mg orally Donovan bodies on
twice daily for at least 21 Wright stain
May be days
hypertrophic,
or
necrotic, or
Azithromycin, 1 g orally
sclerotic
once weekly for at least 21
Positive result with
days
Giemsa stain or biopsy
No
of granulation tissue
lymphadenopathy
Ciprofloxacin, 750 mg orally
twice daily for at least 21
May have days
subcutaneous
granulomas
Erythromycin base, 500 mg
orally four times daily for 21
days

Trimethoprim/sulfamethoxa
zole (Bactrim, Septra)
double strength, 160/800
mg orally twice daily for at
least 21 days

HZV
Chikenpox prodrome of fever, For healthy children ≤12 Tx: Acyclovir 800mg five Great benefit if
(primary malaise, or years, varicella is typically times/day for 7 days (within antiviral therapy given
varicella) pharyngitis, loss of self-limited and we 24 hours) in the first 24 hours
appetite suggest not administering
antiviral therapy
* Transmission can occur in
followed by the utero, perinatally, or
development of a Use anti-viral: in postnatally
generalized unvaccinated, pregnant lady, incubation period: 10
vesicular rash, immunocompromised pt to 21 days after
Post exposure prophylaxis:
usually within 24 exposure.
rapid screening is necessary
hours
For Adult: since prophylaxis should be
offered within ten days of
exposure.
Oral valacyclovir(1 g three
times (7-10 days)
complication: If results of serologic testing
are not available within this
 • Pneumo Acyclovir 800mg five time frame, then postexposure
nia times/day (5-7 days) prophylaxis should be offered.
• Hepatitis
• Encephal
For children: Postexposure prophylaxis is
itis
not needed among women who
• Rarely, it
were immunized
may Oral valacyclovir
with varicella vaccine in the
result in 20mg/kg/dose TID
past.
death.
Or oral acyclovir
gave varicella-zoster immune
20mg/kg/dose QID for 5-7
globulin preparation, in all
days
nonimmune pregnant women
who have been exposed to
persons with VZV

avoid pregnancy for 4 weeks

after completing the two-dose
vaccine

Neonates born to mothers

who have clinical disease
within five days before to two
days after delivery are at the
greatest risk for severe
disease and poor outcome…
SO give immunoglobulin to
the neonate

Non-immune pregnant=
potentially infectious from 8–
28 days after exposure if they
receive VZIG and from 8–21
days after exposure if they do
not receive VZIG.

. A planned delivery should

normally be avoided for at
least 7 days after the onset of
the maternal rash to allow for
the passive transfer of
antibodies from mother to
child

If less than 28 weeks of

gestation: referred after 5
weeks of infection or at 16-20
weeks of gestation of fetal US

Herpes zoster nonspecific Antiviral: Maternal herpes zoster Diagnosed clinically

prodrome with infection is not associated with
malaise, headache, a significant risk of congenital
Acyclovir 800mg 5 Other: PCR of testing
fever, or abnormal varicella syndrome
times/day for 7 days of vesicle or other body
skin sensations
fluids
(e.g., itching,
burning, pain). Or famiclovir 500mg TID for
7 days
Acyclovir 800mg 5 times/day
Rash: Usually
for 7 days
affecting a single, Or valacyclovir 1g TID for 7 Acyclovir is the only
unilateral days antiviral medication
dermatome, approved for the
maculopapular
 lesions appear With pain management, -/+ treatment of herpes
proximally to steroid zoster in children
distally,
progressing to clear
Great benefit if given within When herpes zoster
vesicles that
72 houres vaccination is indicated
become cloudy and
(eg, immunocompetent
eventually crust
individuals ≥50 years
over in seven to 10
of age,
days.
immunocompromised
patients ≥19 years of
age at increased risk of
herpes zoster), it
should be given
regardless of a history
of prior herpes zoster
infection.

However, the timing of

vaccination in a patient
with a recent episode
of zoster is uncertain.
We typically delay
vaccination for
approximately one
year since herpes
zoster.

Malaria
Malaria: can develop within Artemether/ lumefantrine Artemether/ lumefantrine The primary means of
six to seven days of ((24 total tablets): (in2nd and 3rd trimester) human infec- tion is
exposure, but the through the bite of a
P. falciparum, P.
presentation may female Anopheles
vivax, P. ovale, P. 4-4-4-4 Tablets Chloroquine,
be delayed for mosquito.
malariae, P. (0,8,24,36,48,60 hours) hydroxychloroquine, and qui-
several months
knowlesi. nine with clindamycin or
after leaving an
mefloquine may be used Microscopic
endemic region Take it with high-fat foods
through- out pregnancy. examination of Giemsa-
for best absorption
stained blood smears is
There are no typical the refer- ence
features of malaria CI in 1st trimester standard for laboratory
diagnosis.
Primaquine should not be used
P. falciparum If artemisinin resistance :
during pregnancy. Tafenoquine
malaria is a medical Thick and thin blood
should not be used in patients
emergency. smear
Atovaquone/ proguanil who are pregnant or
(Malarone) : Four tablets breastfeeding.
once per day for three days Three negative results,
(one adult tablet is 250 12 hours apart, are
mg/100 mg) CI: eGFR<30, needed to rule out
not in pregnant or in malaria
breastfeeding infants
Congenital transmission is rare

If artemisinin not available:

nonsevere infections from
regions with chloroquine
sensitivity

Chloroquine (4 tablets):
1000,500,500,500 mg
(0,6,24,48 hours)
 Hydroxy- chloroquine : 4
tablest 800,400,400,400
(0,6,24,48 hours)

Do not use if chloroquine or

hydroxychloroquine was
used for prophylaxis

May be used in all trimesters

of pregnancy

quinine (Qualaquin) plus

tetracy- cline, doxycycline,
or clindamycin

Quinine 648 mg salt TID (3-

7)days

Doxycycline: 100 mg bid (7

days )

Tetracycline: 250 mg QID for

7 days

Clindamycin: 20 mg per kg
per day in three divided
doses for seven days;

Mefloquine : Use only if no

other treatment options are
available

In P. ovale or P. vivax : add

primaquine and tafenoquine
(if no G6PD) in case of G6PD
used chloroquine
prophylaxis for 1 year

Intravenous artesunate is
the treatment of choice for
severe disease and should be
initiated as soon as possible

Brucellosis
Brucellosis usually presents as Doxycycline 100 mg BID rifampicin 15 mg/kg body a gram-negative, non-
an acute febrile daily for 6 weeks + weight (maximum daily dose of motile, non-sporing
Streptomycin 1 g daily for 2- 900 mg) and (TMP 80 mg+SMZ intracellular
3 weeks 400 mg) for 45 days depending coccobacilli.
- History of animal
on clinical outcome
exposure or
occupational or There is no evidence of
exposure or transmission from
drinking person-to-person
Doxycycline 100 mg BID a
unpasteurized milk
day + rifampicin 15 mg/kg
or travel to an
body weight (maximum Transmission: direct
endemic area.
daily dose of 900 mg) daily contact, food,
for 6 weeks inhalation of infected
dust or aerosols

Definitive diagnosis:
culture, PCR DNA,
 Brucella agglutination
titre

Yellow fever
Yellow fever (history of travel to Supportive tx: Supportive Dx:
endemic countries
within 1 week)
mosquito-borne fuid resuscitation, ventilator * it is important to note that YF -4-fold or greater rise
viral disease management, and treatment has been reported to be in YF antibody titer
acute onset and of disseminated transmitted to infants if YF
constitutional intravascular coagulopathy develops in a breastfeeding
tropical regions -PCR (Should not be
symptoms followed (DIC), haemorrhage, mother.
(Sub-Saharan used to r/o YF)
by a brief remission secondary infections, and
Africa and because it will be
and a recurrence of renal and hepatic
tropical South negative over the time
fever, hepatitis and dysfunction.
America when symptoms
albuminuria. In
became severe
some cases, leading
one of acute to renal failure,
haemorrhagic shock and LFT: AST>ALT
fevers generalized
syndromes haemorrhages
Low albumin, high
direct bilirubin

A single subcutaneous
injection of live
attenuated 17D YF
vaccine confers near
lifelong immunity in
95% of recipients (>9
years)

Typhoid and paratyphoid

Typhoid and Insidious onset of First-line drugs, namely - by gram-negative
paratyphoid sustained fever, chloramphenicol, ampicillin, bacilli, namely
headache, malaise, amoxicillin and Salmonella typhi and
anorexia, relative trimethoprim- paratyphi (A,B,C)
systemic
bradycardia, rose sulfamethoxazole
bacterial
spots on the trunk,
diseases Fecal oral rute
splenomegaly and
Fluoroquinolones (ofloxacin,
constipation more
ciprofloxacin, fleroxacin,
developing common than The incubation period
perfloxacin) are highly
countries diarrhoea in depends on the
active and equivalent in
adults infecting dose.
efficacy

=History of travel Chronic carriers shed

to endemic the organisms from
countries or areas their gall bladder and
biliary tract

Dx: Positive culture of

salmonella from
stool/urine/blood.

In Oman, Vi
polysaccharide typhoid
vaccine (Typhim Vi®)
is offered to food
handlers every 2 years
*Hepatitis C:
RF:
Injection drug use accounts for
approximately 60% of acute HCV
infections
Men who have sex with men
(particularly people with HIV or those
who have unprotected anal
intercourse), perinatal transmission,
and exposure to blood products before
1992 are other sources.
Nosocomial exposure (e.g.,
hemodialysis, needlestick) and
cosmetic exposure (e.g., tattooing,
piercing) are less likely routes of
transmission if standard infection-
control practices are followed
By Anti-HCV antibody testing follow-up
reflex HCV RNA polymerase chain
reaction testing for positive results to
confirm the active disease.
*acute HCV infection
-Most patients with acute HCV
infection are asymptomatic. 80%
-Anorexia, malaise, jaundice, and
abdominal pain occur in 10% to 20% of
patients two to 12 weeks after
exposure.
-HCV RNA indicates acute infection and
can be present as early as one to two
weeks after exposure
-HCV antibody becomes detectable
four to 10 weeks after exposure and is
present in 97% of patients by six
months.
-Alanine transaminase levels peak at 10
to 20 times the upper limit of normal,
typically rising eight to 10 weeks after
infection
-15% to 45% of patients spontaneously
clear the virus
-Factors associated with increase
clearance:
*Younger age, female sex
*Jaundice, elevated alanine
transaminase level, hepatitis B surface
antigen (HBsAg) positivity
*HCV genotype 1, and host genetic
polymorphisms (i.e., IL28B gene).
- Clearance rates are lower in patients
with HIV infection
-tx for acute HCV : The American
Association for the Study of Liver
Diseases recommends
 Either delaying treatment
for a minimum of six months
to monitor for spontaneous
clearance of HCV RNA and
then following treatment
recommendations for
chronic HCV infection,
 or treating the acute
infection after monitoring
HCV RNA for a minimum of
*chronic HBV: 55%-85% from acute
HCV
symptom clusters (i.e.,
neuropsychiatric, gastrointestinal,
algesic, and dyseshetic
- Fulminant hepatitis usually does not
occur
- Approximately 20% to 30% of
patients with chronic HCV develop
cirrhosis over 25 to 30 years
- Risk factors for cirrhosis include
*male sex, being older than 50 years,
*hepatitis B virus infection, HIV
infection
*immuno-suppressive therapy, alcohol
use, hepatotoxic drugs
* obesity, NASH
= 74% of patients develop an
extrahepatic manifestation
 ** All patients with chronic
HCV infection should be
considered for treatment.
Tx:
-Hx, basic lab inx, radiology
(noninvasive to look for fibrosis)
- Vaccinations (hepatitis A, B, and
pneumococcal (19 to 64 years) (to all
chronic liver disease, cirrhosis, or HCV )
- Confirm active HCV infection
(positive quantitative HCV RNA)
before treatment
- Select appropriate direct-acting
antiviral regimen (referral)
- Repeat HCV RNA + AST 3 months
after completeting the therapy
-Patients without cirrhosis do not
need liver-specific follow-up
-For patients with cirrhosis,
 12 to 16 weeks to allow for
spontaneous clearance
- Do not repeat hepatitis C virus
antibody testing in patients with a
previous positive hepatitis C virus
test result. Instead, order hepatitis C
viral load testing for assessment of
active vs. resolved infection.
abdominal US(with or without alpha-
fetoprotein) every 6 months
indefinitely to monitor for HCC and
esophagogastro- duodenoscopy
every 2 to 3 years for esophageal
varices
NOTE: direct-acting antiviral
medications carry risk of hepatitis B
reactivation
Tx: Direct-acting antiviral therapy
(New) VS interferon and ribavirin-
based regimens.
Direct-acting antiviral therapy:((
greater than 95% cure rate)) more
effective, better tolerated, short course,
pretreatment genotyping and on-
treatment monitoring is decreased
sustained virologic response:
Undetectable HCV RNA 12 weeks after
completion of treatment/ Once a
patient achieves sustained virologic
response after 12 weeks of treatment,
any detectable amount of HCV RNA
indicates reinfection or relapse (relapse:
within 12 weeks)
- Glecaprevir/pibrentasvir : 8 weeks
,in pt without cirrhosis and for those
with compensated cirrhosis,
effective against all HCV genotypes
- Sofosbuvir/velpatasvir : 12 weeks
(patients without cirrhosis and
patients with compensated
cirrhosis)
**both unclear safety during
pregnancy
Advise:
 Herbal and dietary
supplements should be
discontinued.
 Acetaminophen is generally
safe if less than 2 g per day is
used
 avoid alcohol, tobacco, and
illicit drugs
 Breastfeeding is safe when
nipples are not damaged,
cracked, or bleeding (should
 abstain from breastfeeding
when their nipples are
cracked or bleeding)
 Maternal HCV antibody
passively transfers and can
be present for up to 18
months after delivery
 Mode of delivery does not
matter for preventing
transmission
 Transmission occurs in
5.8% of pregnancies
 Heterosexual transmission
is low

- Any evidence of hepatic

decompensation or HCC is a
contraindication for the simplified
treatment regimen and requires a
referral

HCV RNA testing is indicated

periodically for people with ongoing at-
risk behavior and anytime an increase
in transaminase levels occurs

Patient not eligible for simplified

regimen :

• Current or previous episode of

decompensated cirrhosis defined as
Child-Pugh (B or C) score of ≥ 7
(ascites, esophageal varices, hepatic
encephalopathy, total bilirubin > 2.0
mg per dL [34.21 mmol per L],
albumin ≤ 3.5 g per dL [35 g per L] or
international normalized ratio ≥ 1.7)

• Current pregnancy
• Known or suspected hepatocellular
carcinoma
• Patients ≤ 18 years
• Patients infected with HIV or
hepatitis B virus
• Previous liver transplantation
• Received HCV treatment previously
• Stage 4 or 5 chronic kidney disease
with compensated cirrhosis

**HBV:
- 25% of children and 15% of adults Acute hepatitis B: Chronic hepatitis B:
with chronic HBV die prematurely from - discrete onset of symptoms (e.g.,
(HCC) or cirrhosis fever, headache, malaise, anorexia,

- HBV has 10 genotypes (A through J)
and more than 30 subtypes
- Postvaccination testing is
recommended only in individuals who
may not elicit a complete response to
the vaccine based on risk factor
assessment
**persons on hemodialysis; persons
who are immunocompromised, such as
those with HIV infection; sex partners
of persons positive for HBsAg; and
health care personnel**
- = testing for anti-HBs should be
performed one to two months
following the completion of the vaccine
series
=A responder is defined as a person
with an anti-HBs level of 10 mIU per mL
or more after completion of the
vaccine series.
=If the anti-HBs level is less than 10
mIU per mL after the initial vaccine
series, revaccination is indicated
RF for developing chronic infection:
younger the age
nausea, vomiting, diarrhea, abdominal
pain)
-High ALT, test results showing HBsAg
and HBcAg
- antiviral treatment has no benefit
for acute hepatitis B based on low-
quality or very low-quality evidence.
-OUTCOME: complete immune
clearance yielding lifelong immunity or
develop chronic hepatitis B.
Anti-HBe usually remain detectable
for years after recovery.
- persistence of HBsAg for more than
six months
- five distinct phases
The resolution of chronic hepatitis B is
defined as the clearance of HBsAg
with the detection of anti-HBs.
- =Among adults with untreated
chronic hepatitis B, the cumulative
five-year incidence of cirrhosis is 8% to
20%, and the risk of HCC is 2% to 5%.
-lab inx and determine the level of
liver disease
-recommend screening for HCC every
six months with abdominal
ultrasonography and alpha fetoprotein
testing.
-If ultrasound findings are abnormal,
then computed tomography or
magnetic resonance imaging of the
liver is recommended.
-=Treatment does not eliminate the
risk of HCC; therefore, surveillance for
HCC should continue
=postexposure:
-When indicated, hepatitis B immune
globulin should be administered
IM(0.06 mL per kg) as soon as possible
after exposure. The effectiveness is
unknown when administered more
than seven days after percutaneous
mucosal or nonintact skin exposure.
=Tx: Immunologic cure: defined as the
loss of HBsAg with sustained HBV DNA
suppression
*Pegylated interferon alfa-2a is
administered for 48 weeks ((e.g., low
pretreatment HBV DNA and high ALT
levels, HBV genotypes A or B, young
women who wish to become pregnant
in the future, concomitant hepatitis C,
and younger age)
*nucleoside/ nucleotide analogues
(duration of their use is often indefinite
because of frequent relapses or

*HAV:
-Hepatitis A virus is a nonenveloped
positive-strand RNA virus classified as a
picornavirus, whose only natural host is
humans.
-widespread vaccination, food safety
practices, and improved sanitation
decreased the incidence of hepatitis A
-ingestion of infected stool particles
-Close interpersonal or sexual contact
with an infected person and
consumption of contaminated food or
water are the most common routes of
infection
-Less commonly, infection has resulted
from injection drug use or blood
transfusion
**Routine vaccination is recommended
for children 12 to 23 months of age and
for other high-risk populations
-Detectable virus in blood: 10 to 12
days after infection
-Viral shedding may begin weeks
before symptom onset, contributing to
the scope of outbreaks
-70% of children younger than six years
remain asymptomatic.
-Patients often initially experience
nonspecific flulike symptoms of fever,
malaise, nausea with vomiting, and
abdominal pain that may progress to
the classic findings of dark urine and
jaundice in 70% of adults and older
children
-Hepatomegaly and jaundice
-most likely to spread the disease in
the 14 days before jaundice develops
-Infectivity decreases after jaundice is
observed, and most individuals are
considered to be noninfectious one
week after the onset of jaundice
Dx:
High liver enzyme: which may take two
to three months to resolve
-; a creatinine level greater than 2 mg
per dL (176.8 μmol per L) is a positive
predictor of fulminant hepatitis and
death
-(IgM) anti–hepatitis A antibodies:
detectable five to 10 days before the
onset of symptoms, peak within one
month of illness, and can persist for
more than six months
reactivation of hepatitis B after
cessation of treatment.)
**^Pegylated interferon alfa-2a
(Pegasys), entecavir (Baraclude), and
tenofovir are recommended as first- line
treatment options for chronic hepatitis B.
**Tenofovir is the preferred antiviral in
pregnant women
-Most cases of acute hepatitis A are
self-limited
-approximately 10% to 15% of patients
may take up to six months to fully
recover or may have recurrent
symptoms during this time frame
-less than 1% of patients, acute liver
failure (older than 40 years at the time
of infection and in those with
underlying liver disease).
-Pregnant patients: preterm labor and
delivery
-Dx:
-rest, oral rehydration, and treatment
of symptoms such as nausea, vomiting,
and diarrhea are recommended
-fulminant hepatic failure: liver
transplantation
-Prevention:
*Vaccination with inactivated hepatitis
A antigen
*Long- term data following the
completion of a two-dose series of
both Havrix and Vaqta suggest lifelong
immunity with this immunization
schedule
*Hepatitis A vaccines can be
administered concurrently with other
vaccines.
*safe during pregnancy
*adverse effects of immune globulin
include hypersensitivity reactions and
an increased risk of thrombosis
*Unlike with the hepatitis A vaccine,
the protection provided by immune
globulin is limited to approximately
three months
*Pre-exposure prophylaxis: pre-travel,
unimmunized
*, all otherwise healthy children
younger than six months and persons
with an allergy to the hepatitis A
vaccine should receive immune
globulin instead
*Persons older than 40 years and those
older than six months who are
immunocompromised or have chronic
liver disease should receive both the
vaccine and immune globulin.
*All other individuals should receive
hepatitis A vaccine only

*Postexposure prophylaxis is
recommended for all unvaccinated
individuals with significant exposure in
the previous two weeks, including sex
partners, household contacts, or
known contaminated food sources

*Immune globulin should be given

only to children younger than 12
months and those in whom the
vaccine is contraindicated
*Both the vaccine and immune
globulin are recommended for adults
older than 40 years and children older
than 12 months who are
immunocompromised or have chronic
liver disease
*All other patients should receive a
single dose of hepatitis A vaccine