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Dr. Noto ID Handout
Dr. Noto ID Handout
Dr. Noto ID Handout
Frank P. Noto, MD
Assistant Professor
Mount Sinai School of Medicine
Internal Medicine Clerkship Site Director
HI All
Notice that I keep referring to the same themes over and over again:
MRSA: Vancomycin,
daptomycin, if resistant or allergic to vanco (NOT for pneumonia, check CPK)
→bacteremia, endocarditis, cellulitis
linezolid, (do NOT give SSRIs, watch platelets) →cellulitis, PNA
telavancin,
tigecycline (use for ESBL E coli that is resistant to imipenem, does NOT cover
pseudomonas)
Quinupristin/dapfopristin
Ceftaroline (5th generation) → community acquired MRSA pneumonia and cellulitis
Psuedomonas:
Cover in 1)neutropenic fever
2)nosocomial and ventilator associated pneumonia
3)burns
4)cystic fibrosis
5)ONLY serious diabetic foot infections or when the patient is soaking the foot in a hot
tube!!
Not need to cover in mild diabetic foot infections!!
Give prophylaxis with norfloxin, cipro or TMP/SMX for life after one episode
Gram-Positive Cocci
Penicillin G, VK, ampicillin, amoxicillin
Effective against group A streptococcus, most anaerobes (not Bacteroides),
actinomycosis, clostridium (not C. difficile), Listeria, syphilis
Not staph: need beta-lactamase inhibiters (sulbactam, clavulinic acid)!
Ampicillin is effective against E coli (resistance is rising)
Ampicillin and amoxicillin effective for enterococci and Listeria
Gram-Positive Cocci
Semisynthetic penicillinase-resistant penicillins (oxacillin, cloxacillin, dicloxacillin,
nafcillin)
Exclusive Gram-positive coverage, staph and strep
Drug of choice for MSSA, more effective than vancomycin
If you see viridans, must be endocarditis
Bone, heart, joint, skin
*
Gram-Positive Cocci
Cephalosporins Do not cover LAME
Listeria
Atypicals
MRSA -→ except ceftraoline
Enteroccus
Gram-Positive Cocci
Cephalosporins
If treating purely gram positive infection, use 1st generation, 2nd is too broad.
Always narrow your coverage!
Gram-Positive Cocci
.
Clindamycin
Excellent strep, staph and anaerobe coverage
Use in penicillin allergy
Use for anaerobic infections above diaphragm
Metronidazole
Use for below diaphragm infections
Use for C. difficile(use Metronidazole for the FIRST recurrence PO vancomycin taper
for 2nd Fidaxomicin after the 3rd recurrence) PPIs can lead to c diff
Gram-Positive Cocci
Cephalosporins
Allergic cross-reactivity
Only < 5% risk
Ok if rash
Never if anaphylaxis
If minor infection - use macrolide or new fluoroqinlones
Serious infections - aztreonam for gram negative, plus vancomycin, linezolid,
daptomycin for gram-positive
Very resistant gram negatives : First line is imipenem: but now have some resistance
Macrolides
Mild gram-positive infections
Atypical infections
Invasive Aspergillus
In patients with neutropenic fevers after 5 DAYS on antibiotics with new pneumonia
Treatment:
1st line Voriconazole
Caspofungin and Amphotericin B may also be used
Neutropenic Fever
ANC less than 500
Monotherapy with an antibiotic that covers pseudomonas only
If indwelling catheter, add vancomycin for MRSA
Gram-Negative Bacilli
Penicillins (piperacillin, ticarcillin, mezlocillin)
Full range of gram-negative Enterobacteriaceae (E coli, Enterobacter, Klebiella,
Citrobacter, Morganella, Proteus, Serratia), plus pseudomonas
Add beta-lactamase inhibitor, tazobactam or clavulanate) to add activity against staph
Gram-Negative Bacilli
Fluoroquinolones
Ciprofloxacin
GOOD: gram-negative coverage, including Pseudomonas
NO: gram-positive coverage
New fluoroquinolones (levofloxacin, gemifloxacin, moxifloxacin)
Very good gram-positive coverage, gram-negative, and atypical (mycoplasma,
chlamydia, Legionella)
Gram-Negative Bacilli
3rd/4th generation Cephalosporins
Full coverage of gram-negative bacilli, such as Enterobacteriaceae (E. coli, Proteus
mirabilis, indole-positive Proteus, Klebsiella, Enterobacter, Serratia, Citrobacter),
Neisseria, and H. influenzae
Only ceftazidime and cefepime (4th gen) will cover pseudomonas
Ceftazidime is not reliable for staph/strep
PO: cifixime = gonorrhea
PO: cefpodoxime
Gram-Negative Bacilli
Aminoglycosides
Good Gram-negative coverage, including pseudomonas
Synergistic with penicillin in treatment of staph
Use for endocarditis
Nephrotoxic and ototoxic
Aztreonam
Only Gram-negative coverage, use in serious infections with severe penicillin allergy
Gram-Negative Bacilli
Carbapenems
(imipenem, meropenem, doripenem, ertapenem)
Full coverage of Enterobacteriaceae, plus Pseudomonas
Plus excellent gram-positive and anaerobic coverage
Not MRSA, Enterococcus faecium, or Stenotrophomonas maltophila
Gram-Negative Bacilli
Ertapenem
Does not cover pseudomonas
Approved for intra-abdominal and soft tissue infections
Lower seizure threshold, especially imipenem
Gram-Negative Bacilli
Doxycycline
Early lyme - rash, joint problems, facial palsy
Rikettsiea
Chlamydia
Ehrlichiosis
Trimethoprim-sulfamethoxazole
PCP
Uncomplicated cystitis
Meningitis
Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes: HIV, steroids, lymphoma, leukemia, chemo, neonates and
elderly (> 50)
Cryptococcus
Rocky Mountain Spotted fever mid-Atlantic
Tb, Lyme disease, syphilis
Viruses: entero, HIV, HSV, West Nile, St. Louis
Meningitis:
Meningitis
Normal cell count is < 5
Bacterial: cell count in thousands all neutrophils
High protein and low glucose
Gram stain is positive only 50 to 70%
Cell count of several dozen to hundreds with lymphocytes: viral, Lyme, Tb, syphilis,
fungal, Rikettsia
Meningitis
Treatment
Ceftriaxone and vancomycin
Ampicillin if over 50 or 3 months old, HIV, steroids, hematologic malignancies,
pregnancy
Meningitis
Cryptococcus: amphotericin B, followed by fluconazole in HIV for life or until increase
in CD4 count to > 100 for 3 to 6 months on HAART
Cryptococcus neoformans: India ink and crypto antigen titer
Meningitis
Steroids in Tb and streptococcus meningitis
Dexamethasone 15-20 minutes before or with antibiotics
Neurocysticercosis
Ingestion of Taenia solium, also called the pork tapeworm
China, Southeast Asia, India, sub-Saharan Africa, and Latin America
Prevalence of cysticercosis in Mexico is between 3.1 and 3.9 percent
CT scan: calcified and uncalcified cysts, as well as distinguishing active and inactive
cysts. Cystic lesions can show ring enhancing and focal enhancing lesions.
Albendazole
Brain Abscess
Spread from mastoiditis, dental infections, sinusitis, otitis media, bloodstream
Streptococcus: 60 to 70% (viridans streptococci, Streptococcus milleri, microaerophilic
streptococci)
Bacteriodes fragilis: 20 to 30% (high resistance to clindamycin)
Enterobacteriaceae: 25 to 35 %,
Staphylococcus 10%
Brain Abscess
In HIV, 90% are toxoplamosis vs. lymphoma
Treat with pyrimethamine and sulfadiazine for 10 to 14 days
Encephalitis
Viral: HSV-1, varicella-zoster, CMV, enteroviruses, Eastern and Western equine, St.
Louis, West Nile
Headache and fever with AMS
Lethargy or coma, focal deficits, seizures.
Need LP: PCR for HSV has 98 % sensitivity and 95 % specificity
CT may show temporal lobe involvement.
IV acyclovir
Sinusitis
Maxillary is most common
Facial pain, headache postnasal drainage, purulent drainage, fever, tooth pain
Pharyngitis
Strep pyogenes, group A beta-hemolytic strep 15 to 20%
Majority are viral
Influenza
Fever, myalgias, headache, fatigue, coryza, nonproductive cough, sore throat
Rapid antigen detection, swab of nasopharyngeal secretions
Symptomatic therapy
Neuraminidase inhibitors: oseltamivir and zanamivir (48 hours)
Amantadine and rimantadine effective against Influenza A NOT used much
Vaccinate Everyone!
Bronchitis
Acute bronchitis NO antbiotics!!!!
Lung Abscess
90% have anaerobes involved
Peptostreptococus, Prevotella, Fusobacterium are most common
85 to 90% have periodontal disease or aspiration
Fever, cough, sputum, chest pain
Putrid, foul-smelling sputum and a more chronic cough
Several weeks of weight loss, anemia, fatigue
Lung Abscess
CXR will show thick-wall cavity
Need aspiration of abscess for diagnosis
Clindamycin is first line
Penicillin
Most respond to antibiotics and do not need drainage
Pneumonia
Sixth leading cause of death
Risk factors: DM, ETOH, smoking, malnutrition, immunosuppression
Most common: Community-acquired pneumonia
Strep pneumonia (15-35%)
Haemophilus (2-10%)
Atypical Legionella (15%)
Mycoplasma (10%)
Chlamydia (5-10%)
Viral
Pneumonia
Haemophilus influenzae - smokers, COPD
Mycoplasma -healthy
Legionella - air conditioning
Pneumocystis jiroveci - HIV
Coxiella burnetti (Q-fever) - exposure to animals
Klebsiella - alcoholics
Staphylococcus aureus - post influenza
Coccidioidomycosis - southwest (Arizona)
Pneumonia
Chlamydia psittaci - birds
Histoplasma capsulatum - bird droppings, spelunking, bats
Bordetella pertussis - cough with whoop and post-tussive vomiting
Francisella tularensis - hunters, rabbits
Avian infuenza - Southeast Asia
Bacllus anthracis, Yersina pestis Francisella tularensis - bioterrorism
Pneumonia
Cough, fever, sputum production, dyspnea
Klebsiella - current jelly
Rales, rhonchi, dullness to percussion, egophony
RR, hypoxia leads to hyperventilation
CXR-lobar PNA S. pneumonia
Interstitial infiltrates - PCP, viral, atypical
Sputum for Gram stain and culture
Pneumonia
Treatment
Severity:
Hypoxia, PO2 < 60 (< 94%),
RR > 30
Confusion, uremia, hypotension
High fever, leukopenia, tachycardia, hyponatremia
Outpatient →
empiric therapy
Macrolide or new fluoroquinolone
Pneumonia
Treatment:
Inpatient
New fluorquinolones, or
2nd or 3rd generation cephalosporins (ceftriaxone, cefuroxime) with macrolide or doxy,
or
Beta-lactam/beta-lactamase combination, with macrolide or doxy
MUST give 2 for pseudomonas and one for MRSA 3 antibiotics total!!
Ceftazidime OR
Cefepime OR
Pipercillin/tazobactam OR
Ticarcillin/clavulinate OR
Imipenem, meropenem, doripenem OR
Aztreonam →the answer when serious gram negative infection with anaphylactic
reaction to penicillin
PLUS
Cipro (or levofloxacin)
Or
Gentamycin (or any aminoglycoside) → not in renal failure
PLUS
Vancomycin OR
Linezolid
Pneumonia
Pneumonia Vaccine
> 65, serious underlying lung, cardiac, liver, renal disease, steroids, HIV,
splenectomized, diabetics, hematological malignancies.
Re-dose in 5 years if severely immunocompromised
Tuberculosis
Mycobacterium tuberculosis
Tuberculosis
Tuberculosis
Latent Tb → positive PPD or positive quantiferon gold or the interferon-gamma release
assays (IGRAs) (check this instead of PPD in patients who received the BCG)
With a negative chest X-ray
> 5 mm: close contacts, HIV, abnormal CXR consistent with old Tb, steroid use or
organ transplant recipients
> 10 mm: healthcare workers, prisoners, NH residents, immigrants (5 years), homeless,
immunocopromised (hematologic malignancies, DM, dialysis, IV drug users)
> 15 mm: low risk
Positive PPD and negative CXR: 9 months of INH
If positive CXR, collect sputum for AFB
*
Viral Hepatitis#
Hepatitis A and E
Oral/fecal route
Incubation 2-6 weeks, Acute infection for days to weeks
Hepatitis B, C, D
Parental route
B and C can be chronic
Viral Hepatitis
Presentation
Acute - jaundice, dark urine, light stools, fatigue, malaise, tender enlarged liver
Hep C can cause cryoglobulinemia
Hep B associated with PAN
Hep D can only be co-infected with B
Viral Hepatitis
Diagnosis
ALT higher than AST
High bilirubin
Alkaline phosphatase and GGT less elevated
High PT in severe disease
Check pcr-RNA viral load for hep C to access activity
Hepatitis B
Surface Ag = infected
Surface Ag + IgM Core Ab = acute infection
Surface Ag + IgG Core Ab= chronic infection
Core Ab:
IgM = acute infection
IgG = 1) chronic infection (if Hep Bs Ag), or
2) recovery (if Hep Bs Ab)
Hepatitis B
Surface Ab = vaccinated
Resolution of infection = Hep Bs Ab, IgG Hep Bc Ab (exposed, recovered, and immune
- 95%)
Window period = Hep Bc IgG antibody and Hep Be antibody (2-6 weeks between the
loss of surface antigen and development of surface antibody)
Viral Hepatitis
Treatment
Acute hepatitis - supportive care.
Chronic hep B - interferon, entecavir, adofovir, lamivudine, telbivudin
Cirrhosis - liver transplant
Needle stick hep B - hep B Immunoglobulin and vaccine if not immune
Chronic Hepatitis C
Antibody to hepatitis C with elevated viral load for hepatitis C by PCR → treat
Pegylated interferon and ribavirin
Genotype 2 and 3: 80% response
Genotype 1 and 4: 40 to 50% response
Telaprevir or BOCEPREVIR for genotype 1
With the addition of these protease inhibitors, the rate has increased to 70-80%
Urethritis
Purulent discharge, dysuria, urgency, frequency
Neisseria gonorrhea
Nongonococcal
Chlamydia trahcomatis (50%)
Ureaplasma urealyticum (20%)
Mycoplasma hominis (5%)
Trichomonas (1%)
HSV (rare)
*
*
STIs: Gonorrhea
Disseminated Gonorrhea
Classic triad of dermatitis, migratory polyarthritis, and tenosynovitis
Skin findings
Small macules or hemorrhagic pustules on an erythematous base located on palms
and soles or on the trunk AND elsewhere on the extremities
STIs: Gonorrhea
Diagnosis
Blood smear shows gram-negative, coffee bean-shaped intracellular diplococci
Culture for gonorrhea
Serology for Chlamydia by swabbing urethra, or
Ligase chain reaction test of urine
STIs: Gonorrhea
Treatment
One dose of ceftriaxone IM or cefixime PO and azithromycin PO
Alternative is doxycycline for 7 days
(NOT FQ)
Diagnosis
Culture on Thayer-Martin for gonococcus and Gram stain of discharge
STIs: PID
Treatment
Single dose IM ceftriaxone and oral doxycycline for 2 weeks
OR
Ofloxacin and metronidazole (both oral) for 2 weeks
Syphillus
Spirochetes are Gram-negative bacteria that are long, thin, helical and motile via axial
filaments (a form of flagella)
Primary infection
Chancre in 3rd week and disappears in 10-90 days, painless lymphadenopathy
Secondary infection
Cutaneous rash during 6-12 weeks - symmetric, more on flexor and volar surfaces,
condylomata lata, papaules at mucocutaneous junctions
Tertiary or late
3-20 years later - gumma in any tissue
Neurological and CV manifestations (aortitis)
STIs: Syphilis
Other long-term sequelae
Argyll Robertson pupil
Small, irregular, reacts to accommodation, but not to light
Tabes dorsalis
3 to 20 years after infection
Pain, ataxia, sensory changes, loss of tendon reflex
STIs: Syphilis
Diagnosis
Screening = VDRL, RPR
More specific
FTA-ABS (Fluorescent Treponemal Antibody absorption)
MHA-TP
Darkfield of chancre
Neurosyphilis
FTA of CSF is more sensitive than a VDRL
Treatment
Primary/secondary/early latent (less than one year)
Penicillin G, IM times one
STIs: Syphilis
Treatment (cont’d)
Neurosyphilis (includes ocular syphilis)
Penicillin IV for 10 to 14 days
Doxycycline for penicillin G-allergy in primary and secondary
STIs
HSV
Vesicles become eroded and painful
Itching and soreness precede
PCR (NOT tzanck culture)
Acyclovir, valacyclovir, famciclovir
UTIs
Cystitis
Dysuria, frequency, urgency, suprapubic pain
Urinalysis for WBC, RBC, nitrites, Gram-neg infxn
Urine culture with >100,000 is confirmation, but not necessary
Trimethoprim/sulfamethoxazole, nitrofurantoin, or quinolone for 3 days
7 days if DM or complicated-stones, strictures, obstruction, pregnant, men
No quinolones in pregancy
UTIs
Pyelonephritis
Obstruction due to tumor, stricture, calculi, PBH, neurogenic bladder, or vesicoureteral
reflux
E. coli most common. Also Proteus, Klebsiella, Enterococcus.
Candida in immunocompromised or with Foley cath
Symptoms: Fever, chills, flank pain, n/v, CVA tenderness, urinary complaints
Diagnosis: urinalysis and urine cultures
Always get cultures before starting antibiotics!
UTIs
Treatment
3rd generation cephalosporin, fluoroquinolone, amp and gent
10-14 days of antibiotics
Do not use TMP/SMZ for empiric therapy due to up to 20% resistance
Skin Infections
Cellulitis
Infection involving subcutanous tissue
Localized pain, erythema, edema, warmth
Most commonly: Staph and group A Strep (GAS), Strep pyogenes
Dicloxacillin or cephalexin
If life-threatening diabetic foot infection: must cover gram negatives and anaerobes:
Use imipenem and vanco!!
Skin Infections
Cat bites and dog bites
Pasteurella multocida
Resistant to dicloxacillin and nafcillin
Augmentin (amoxicillin/clavulanate)
Vancomycin PLUS
1) piperacillin-tazobactam or
3) meropenem or imipenem
Skin Infections
Gas Gangrene
Fever, severe pain and swelling, crepitus
Deep cuts and black tar heroine
X-ray → feathery gas pattern
Clostridium perfringens
Penicillin plus clindamycin
Surgical debridement and hyperbaric oxygen
Vibrio vulnificus
Osteomyelitis
Presentation
Pain, erythema, edema, tenderness
Septic Arthritis
Nongonococcal
Gram positive (>85%)
S. aureus (60%)
Streptococcus (15%)
Pneumococcus (5%)
Gram negative (10-15%)
Septic Arthritis
Diagnosis
Culture cervix, rectum, urethra, pharynx
Only 50% positive cultures
Therapy
Joint aspiration and antibiotics
Empiric
VANCOMYCIN and CEFTRIAXONE!!!!
Or vancomycin and anything that covers gram negatives like gentamycin
Endocarditis
Infective endocarditis
Acute
S. aureus, normal valves
Large bulky vegetations
Rapid onset with fever
Abscess and rapid valve destruction
Endocarditis
Embolic, especially lung
Subacute
Viridans most common
Abnormal valves
Risk factors:
Endocarditis
Native valves:
Streptococcus viridans 50-60 %
Endocarditis: Treatment
ID organism
Enterococcal
Penicillin or ampicillin AND gentamicin for 4-6 weeks
Vancomycin AND genatmicin for 4-6 weeks for pen-allergic
Endocarditis: Treatment
Surgery (high yield)
CHF, recurrent septic emboli, regurgitation that affects hemodynamic functions,
vegetation larger that 10 mm
Fungal, extravalvular infection (AVB, purulent pericarditis), prosthetic valve
obstruction, recurrent infection or persistent bacteremia, abscess or fistula
Endocarditis
Prophylactics high yield
-prosthetic valves, history of IE, most congenital malformations, especially cyanotic
lesions if not repaired.
-dental procedures
NO prophylaxis:
-Urinary, GI,
-corrected pulmonary shunts, rheumatic valves, HOCM,
-MVP with regurgitation, repaired intra-cardiac defects
Endocarditis
Amoxicillin, if allergic, clindamycin, macrolide or cephalexin
Acute Pericarditis
Chest pain is sharp. Improved with sitting forward
Pericardial friction rub. Low grade fever
Tamponode: pulsus paradoxus: 10 mm Hg drop in BP with inspiration. Distended neck
veins, tachycardia, hypotension
EKG: diffuse ST elevations
PR depressions
Echo to look for effusions
Acute Pericarditis
NSIADS
Colchicine for recurrence
Pericardiocentesis and pericardial window if large effusions causing tamponade
Lyme Disease
Borrelia budorferi
Ixodes scapularis
3 -30 days: erythema migrans, fever, chills, myalgias
7th cranial nerve, facial paralysis (Bell’s palsy)
Meningitis, encephalitis, memory loss
AV heart block, myocarditis, pericarditis
Joint involvement months to years later- 60 %, migratory polyarthritis
Lyme disease
Serologic testing-ELISA with western blot. May be negative early in disease and can
not distinguish between old and new disease.
Minor disease treat with doxycyline or amoxicillin
Cardiac (high degree AVB and PR > 3 s) and serious neurological manifestations
(meningitis) treat with IV ceftriaxone, cefotaxime,
Ehrlichiosis
.
Vector:
American dog tick
Deer tick
Lone Star tick
Ehrlichiosis
Fevers (90 %)
Headaches (>85%)
Rigors (60%)
Nausea (40%) Vomiting (40%), Anorexia (40%)
Fatigue.
A rash is uncommon
lymphopenia, and/or thrombocytopenia
Abnormal liver enzymes are found in 86% of patients.
Ehrlichiosis
Doxycycline
Babesiosis
Babesia microti, a parasite of small rodents
Babesiosis
Diagnosis
Parasite on Giemsa-stained blood smears
An indirect immunofluorescent antibody test for B microti antibody is detectable within
2–4 weeks after the onset of symptoms and persists for months
Diagnosis can also be made by polymerase chain reaction
Babesiosis
Treatment
Mild illness: oral atovaquone plus azithromycin for 7–10 days
Clindamycin plus quinine is the second choice
HIV
HIV infects subset of T lymphocytes called CD4 cells, causing a decrease in the CD4
count, increasing the risk for opportunistic infections and certain malignancies.
MSM, IV drug users, heterosexual intercourse
10 year lag between contracting HIV and the first symptoms
CD4 count drops 50-100 uL/year
Normal CD4 count is 700/mm3
Pneumocystis jiovecii
Trimethoprim-sulfamethoxazole (first line)
Dapsone and trimethoprim
Primaquine and clindamycin
Atovaquone
Pentamidine IV
Steroids if PaO2 < 70 or A-a gradient of > 35 mm Hg
HIV: Vaccines
Pneumococcus, influenza and hepatitis B
If CD4 is over 200 → give varicella vaccine
HIV: HAART
Only statins safe with HAART are
Rouvastatin
Pravastatin
What to start?
2 nucleosides and one protease inhibitor or
2 nucleosides with efavirenz or
2 nucleosides with 2 protease inhibitors
Emtricitabine, Tenofovir, and Efavirenz
HIV
Post exposure prophylaxis
AZT, lamivudine, nelfinavir or another 3 drug regiment for 4 weeks
Lower yield :
Q-fever
Coxiella burnetti
Inhalation of placenta of cattle, sheep and goats
Atypical pneumonia, hepatitis, endocarditis, hepatomegaly
Doxycycline
Tetanus
Complication of wounds caused by Clostridium tetani, a Gram-positive rod
Tonic spasms of muscles, respiratory arrest, dysphagia, irritability, stiff neck and
extremities
Lock jaw
High mortality
Tetanus toxoid
Wound care, debridement
Antitoxin tetanus immunoglobulin
Rx: Penicillin 10-14 days
Blastomycosis
Rotting organic material
Southeast and central US
Inhalation of decaying wood
Immunocompetent
Pulmonary with fever, cough weight loss
Disseminates anywhere-skin most common
Blastomycosis
Isolation of fungus in sputum, pus, or biopsy
Amphotericin for severe disease
Itraconazole or ketoconazole for mild disease for 6-12 months