Ids Trans and Samplex

INFECTIOUS DISEASES
Topic: Urinary Tract Infections

Lecturer: Dr. Iturralde
DEFINITIONS ETIOLOGY
 Cystitis – infection of the urinary bladder  Pathogens vary by clinical syndrome but are USUALLY ENTERIC GRAM-
 Pyelonephritis – infection of the kidneys NEGATIVE RODS that have migrated to the urinary tract
 Escherichia coli: uncomplicated cystitis, uncomplicated pyelonephritis,
 Uncomplicated – cystitis or pyelonephritis in non-pregnant outpatient
CAUTI
women without anatomic abnormalities or instrumentation
 *worldwide increase in resistance to TMP-SMX and Ciprofloxacin
 Complicated – symptoms of cystitis or pyelonephritis with an anatomic
o This happens primarily because of the left and right use of
predisposition to infection with a foreign body in the urinary tract, or
these antibiotics even if they are not indicated
with factors predisposing to delayed response to therapy
 Uncomplicated Cystitis and Pyelonephritis:
 Recurrent UTI - >2 UTIs in 6 months or >3 UTIs in 1 year
o Staphylococcus saprophyticus, Klebsiella, Proteus,
 Catheter-associated UTI (CAUTI)
Enterococcus, Citrobacter species
 Complicated UTI:
EPIDEMIOLOGY AND RISK FACTORS
o Pseudomonas aeruginosa, Klebsiella, Proteus, Citrobacter,
 Males > Females (neonatal period)
Acinetobacter, Morganella species; Enterococci,
o In <1 year old, UTI is more common among males because
Staphylococcus aureus; yeasts
newborn males usually have a congenital anatomic
abnormality in the urinary tract
NOTE: All the aforementioned organisms enter the urinary tract
 Females > Males (>1 year old to ~50 years old)
when they gain access to the urethra via the anus. Many of them are
o >1 year old to 50 years old, female are more common to have part of the normal flora of the GI tract
UTI due to risk factors (will be discussed later)
Yeasts can also cause UTI. They gain access to the urinary tract via
 Males = Females (after 50 years of age)
hematogenous route
o After 50 years of age, male equals with females to have UTI
because BPH (benign prostatic hyperplasia) is common at this
PATHOGENESIS
age group
 Bacteria establish infection by ascending from the urethra to the
bladder
Uncomplicated cystitis risk factors:
 Interplay of host, pathogen, and environmental factors
 Recent use of diaphragm with spermicide
o This is a form of contraception wherein a device is placed up to  Continuing ascent up the ureter to the kidney is the pathway for most
renal parenchymal infections
the inferior of the cervix in order to prevent the sperm from
entering the cervix
 Frequent sexual intercourse (1.4x-4.8x)
o The relative risk increases on a dose related manner  the
more frequent the sexual intercourse in the previous week =
increased risk of developing UTI
o 1.4x increased risk of having UTI if one sexual intercourse in
the preceding 1 week prior to the infection  it increases to
4.8x or even 5x if there is five episodes of sexual intercourse in
the preceding week prior to the onset of UTI
 History of UTI
 *DM, incontinence, and sexual activity in postmenopausal
o Not urinary incontinence per se but rather the incontinence
brought about by a surgical procedure
 Infection, colonization, and elimination of the organisms depends on
NOTE: These factors are also the risk factors for developing the interplay of the 3 factors: host, organism, environment
pyelonephritis because of the pathogenesis of UTI  the infection from  Host Factors:
the bladder (cystitis) just ascended to the kidneys (pyelonephritis) o Genetics  they have seen a genetic backgrounds, especially
in females, wherein they develop UTI at an early age (<15 yrs.
The first 3 bullets are risk factors during the premenopausal age old) because of the structure in their uroepithelium and it
The last bullet are risk factors during the postmenopausal age provides receptor for the E. coli
o Behavior  use of spermicides
Recurrent UTI o Comorbidities  DM will predispose a person to UTI because
 Premenopausal: frequent sexual intercourse, use of spermicide, new if there will be uncontrolled blood sugar, there will be
sexual partner, maternal history of UTI, first UTI before 15 years of age glucosuria and the presence of glucose on the urine will
o Those in red are those consistent behavioral risk factor for facilitate growth of bacteria in the GUT
recurrent UTI o Tissue-specific receptors  related with the gene expression
o 1st UTI before 15 years of age  there is a genetic background for the receptors which facilitate attachment of the E. coli
that will predispose an individual to UTI before age 15. It has  Organism Factors:
something to do with epithelial lining that will facilitate the o Species  some strains of E. coli will not cause UTI while
attachment of the bacteria others can due to presence of virulence factors
 Postmenopausal: history of premenopausal UTI, cystocoeles, urinary o Virulence Factors  fimbriae and pilus which facilitates
incontinence, residual urine attachment to the uroepithelium of human can cause infection
and colonization of the urinary tract
#GrindNation Page 1 of 5
Strength in knowledge
INFECTIOUS DISEASES
Pathogenesis continued….. DIAGNOSTIC APPROACH

 Environmental Factors: Acute Onset of Dysuria, Frequency and Urgency
o Vaginal ecology  the vagina has normal flora, Lactobacillus,  Healthy, nonpregnant female; low risk for multidrug resistance:
which maintains the acidic pH. Disruption of the normal flora Uncomplicated cystitis; no urine culture needed
such as use of antibiotics or feminine wash will predispose the o If with history or risk factors for STI: uncomplicated cystitis vs
woman to pathogenic E. coli STI
o Anatomy  females has increased incidence of UTI than male  Male with perineal, pelvic, prostatic pain: Acute prostatitis; do
because of the proximity of the female urethra to the anus urinalysis and culture; possible urology consult
and NOT because of females having a shorter urethra than  Patient with IFC: CAUTI; change/remove IFC, blood cultures
males (According to Dr. Iturralde) o IFC for >2 weeks  probably a case of CAUTI
o Urinary retention  the more frequent you urinate = less o CAUTI is a complicated UTI
chance of UTI = less time for bacteria to grow. It is like flushing  All other patients: complicated UTI; urinalysis and culture and address
out the bacteria from the GUT modifiable anatomic/functional abnormalities
o Medical devices  the use of foley catheters (CAUTI) o If patient has BPH  address the BPH (e,g, giving Finasteride)
CLINICAL SYNDROMES Acute Onset of Back pain, Nausea/Vomiting or Fever

Asymptomatic Bacteriuria (ASB/ABU)  Otherwise healthy, nonpregnant female: uncomplicated
 Bacteriuria in screening urine culture detected incidentally in a patient pyelonephritis; urinalysis and culture
without local or systemic symptoms referable to the urinary tract  All other patients: pyelonephritis vs acute prostatitis; urine and blood
cultures
Cystitis
 Dysuria, frequency, urgency; nocturia, hesitancy, suprapubic Fever, Altered Mental Status, Leukocytosis
discomfort, gross hematuria  Elderly, spinal cord injury, immunocompromised, and no alternate
 Dysuria, frequency & urgency  commonly termed as lower urinary diagnosis: complicated UTI; urine and blood cultures; other etiologies?
tract symptoms
No Urinary Symptoms: + Urine culture
Pyelonephritis  In pregnant patient, renal transplant recipient, or patient undergoing
 Fever + lower back pain / CV angle tenderness; rigors, nausea, vomiting, invasive urological procedure: ASB (Asymptomatic bacteriuria);
flank and/or loin pain screening and treatment warranted
 Fever is the most distinguishing feature of pyelonephritis o Treatment is given for the aforementioned patients (pregnant,
o There is no fever in cystitis (whether complicated or renal transplant, invasive urological procedures) with ASB
uncomplicated) o If pregnant patient is not treated for their ASB  increased risk
o Fever happens because there is tissue invasion of preterm delivery or low birth weight baby
 In all other patients: ASB; no additional workup/treatment needed
Prostatitis o No treatment needed because studies have shown that there
 Infection is almost always bacterial; dysuria, frequency, pelvic/perineal is very low risk of developing complication or morbidity even if
pain; fever and chills, symptoms of bladder outlet obstruction ASB is not treated  advantage of this is no unnecessary use
o Chronic pelvic pain syndrome or chronic prostatitis of antibiotics
o Treatment of prostatitis is usually longer than UTI (can take up  In patients with IFC: CA-ASB (Catheter associated-ASB); no additional
to 4 weeks treatment with antibiotics) workup/treatment; remove/change IFC
Complicated UTI Recurrent Urinary Symptoms

 Symptoms of cystitis or pyelonephritis with an anatomic predisposition  Otherwise healthy, non-pregnant female: recurrent cystitis; urine
to infection, with a foreign body in the urinary tract, or with factors culture; prophylaxis or patient-initiated management
predisposing to delayed response to therapy  Male patient: chronic bacterial prostatitis; urology consult
o Examples: presence of stones in the bladder, problem with
function of the bladder, DM, immunocompromised state, renal **Next page is the whole diagram for diagnostic approach to UTI for better
transplantation understanding**
INFECTIOUS DISEASES
INFECTIOUS DISEASES
TREATMENT
Acute Uncomplicated Cystitis
NOTES:
 Nitrofurantoin 100 mg in the Philippines has a different formulation
o The dosing is not BID (2 times a day) but rather QID (4 times a day), every 6 hours for 5 days
o Nitrofurantoin is very effective for uncomplicated cystitis. It also has poor tissue deposition which is why it is not very effective in cases of pyelonephritis
 TMP-SMX
o Before, it was the 1st line agent in the late 1990’s
o Due to inappropriate use of this drug, antibiotic resistance of bacteria (especially E. coli) to this drug increased
o There has been a decrease on its use due to occurrence of Stevens Johnson Syndrome (manifested as rashes)
 Fluoroquinolones
o Also effective for acute uncomplicated cystitis but as much as possible, if culture reveals that the bacteria that a patient has is susceptible to a specific
drug (e.g. TMP-SMX)  then use it as treatment
o Collateral damage  common in fluoroquinolones wherein it also kills the normal flora
 Beta-lactams
o Its use will be dependent on a country’s local data  check if it is effective or not
 In the Philippines, cephalosporins are still effective
Pyelonephritis Complicated UTI

 Ciprofloxacin  Individualized; culture-guided
 Ceftriaxone o Depending on the result of culture  to know what antibiotic
 *Extended spectrum cephalosporin, carbapenems, B-lactam + B- you will use
lactamase inhibitor o Manage also what makes the condition complicated:
o *Use of these drugs are guided by urine culture  E.g. anatomic abnormality, presence of DM
UTI in Pregnant Women ASB

 Nitrofurantoin, ampicillin, cephalosporin (Asymptomatic or  Treatment is discouraged EXCEPT in pregnant women, persons
Symptomatic UTI) undergoing urologic surgery, neutropenic, or renal transplant patients
o It is safe to use Cefuroxime (cephalosporin) or Nitrofurantion o Pregnant women  not treating ASB leads to low-birth weight
or Ampicillin in pregnant patients infants and preterm delivery
 Parenteral B-lactam with or without aminoglycosides
o Although this is a second line drug  avoid using CAUTI
aminoglycosides in pregnant females because it has effects on  Urine cultures are essential to guide treatment
the fetus  Prevent!
o Also, fluoroquinolones is avoided in pregnant patients o Done by minimizing (prolonged) use of IFC
UTI in Men Candiduria

 Fluoroquinolone (Ciprofloxacin/Levofloxacin) or TMP-SMX; 7-14 days  Fluconazole 200-400mg/day for 7-14 days
o Almost always, UTI in men is complicated  Other drugs that can be used: Amphotericin B IV if they do not respond
o Uncircumcised men has increased incidence of UTI because to fluconazole
the E. coli attaches to the prepuce and glans efficiently if the
foreskin is there
o BPH also predisposes men to UTI (Age >50 years old)
o Moxifloxacin may be used but it is given longer because its
levels in the blood is not as high as that of cipro- and
levofloxacin
o Chronic prostatitis: Levofloxacin for 4 weeks
INFECTIOUS DISEASES
PREVENTION OF RECURRENT UTI IN WOMEN

Three strategies:
1. Continuous
2. Post-coital
3. Patient-initiated
Continuous and Post-coital

 Low-dose TMP-SMX, fluoroquinolone, nitrofurantoin
Patient-Initiated
 Supply patient with materials for urine culture and with a course of
antibiotics for self-medication at the first symptoms of infection
 When a patient feels that she has the episode of UTI again, since she is
already familiar with the symptoms, she well send a urine culture and
the physician will prescribe the medication
 Or the physician will already prescribe the antibiotic to the patient so
that anytime that the patient will experience the first symptoms of UTI,
even without doing culture, she may self-medicate
 Note that this is done for Recurrent UTI
PROGNOSIS
 UTI is treatable in general and they do not cause significant morbidity if
they are treated adequately
 Cystitis is a risk factor for recurrent cystitis and pyelonephritis
 ASB does not increase risk of death in elderly and catheterized patients
 Long-term IFC is a well-documented risk factor for bladder cancer in
patients with spinal cord injury
o This happens due to chronic irritation of the uroepithelium 
there will be mutation  become malignant and become
cancer
INFECTIOUS DISEASES
Topic: Rational and Effective Use of PPEs
PERSONAL PROTECTIVE EQUIPMENT (PPE) List of Aerosol Generating Procedures:

 Includes any gear to protect against infection  Intubation, extubation and related procedures
 It is a specialized clothing or equipment worn by healthcare workers for  Tracheotomy/tracheostomy
protection against infectious materials  Cardiopulmonary resuscitation
 Bronchoscopy
DEFINITION OF TERMS  Dental procedures
COVID-19 SUSPECT CASE:  Surgical procedures
 Unexplained SARI (Severe Acute Respiratory Illness)  Non-invasive ventilation
o Fever, cough, occurring within 7-10 days and it requires  CPAP ventilation
hospitalization  High-frequency oscillatory ventilation
 ILI (Influenza-like Illness  almost the same with SARI but does NOT  High-flow nasal oxygen provision
require hospitalization) cases with any one of the following:  Induction of sputum
o Fever, cough, occurring within 7-10 days but it does NOT  GI endoscopy
require hospitalization, OR  Evacuation of pneumoperitoneum during laparoscopic procedures
o Unexplained AND a history of travel to or residence in an area
that reported local transmission of COVID-19 disease during Extended Use:
the 14 days prior to symptom onset, OR  Use of PPE without removing for up to 6 hours, when caring for a group
o With contact to a confirmed or probable case of COVID- 19 of COVID-19 patients
disease during the 14 days prior to the onset of symptoms
 It implies that the use of any PPE item for a longer period of time than
o Individuals with fever or cough or shortness of breath or other
normal according to standards for conventional use and manufacturer
respiratory signs or symptoms fulfilling any one of the
recommendations
following conditions:
 >/= 60 years old
Decontamination:
 With a comorbidity
 Refers to a process of decreasing antimicrobial presence in an area or
 High-risk pregnancy
on a surface
 Healthcare worker
 Removes pathogenic organisms from objects so that they are safe to
handle, use, or discard
COVID-19 PROBABLE CASE:
 Suspect case whom testing for COVID-19 is inconclusive
Disinfection:
 Suspect who underwent testing for COVID-19 not conducted in a
 Refers to the elimination of virtually all pathogenic organisms on
national or subnational reference laboratory or officially accredited
inanimate objects and surfaces thereby reducing the level of microbial
laboratory for COVID-19 confirmatory testing
contamination to acceptably safe levels
 Suspect case for whom testing could not be performed for any reason
 Elimination of all pathogenic microorganisms EXCEPT bacterial spores
o E.g. place is very far from any laboratory, problems with
on inanimate objects
transportation such those in far flung areas
 Some patients who tested negative for 2 to 3 consecutive times BUT the
Sterilization:
course of the illness is very compatible with COVID-19  you label them
 Destruction of all forms of living microorganisms from a surface or
as COVID-19 Probable Case
substance
 Process that destroys all forms of microbial life and is carried out in
COVID-19 CONFIRMED CASE:
healthcare facilities by physical or chemical methods
 Any individual, irrespective of the presence or absence of clinical signs
and symptoms, who is laboratory confirmed (using RT-PCR) for COVID-
PRACTICAL STRATEGIES TO CONSERVE PPE
19 in a test conducted at the national reference laboratory, a
 Teleconsultation/telemedicine
subnational reference laboratory, and/or officially accredited
 Use of physical barriers
laboratory testing facility
 Zoning based on risk levels of transmission
o Green: low-risk
COVID-19 Area:
o Orange/Yellow: moderate-risk
 A space or place in the hospital where probable, suspected, confirmed
o Red: high-risk
cases of COVID-19 stay for > 6 hours or where potentially aerosol
 Monitoring, audits; safety officers
generating procedures (AGP) are performed
 Earn commitment of healthcare workers
Aerosol Generating Procedures:  Extended use/reprocessing
o This is a last resort/temporary measure
 Any medical or patient care procedure that result in the production of
aerosols o This should be adopted when there is anticipated PPE shortage
that will adversely affect healthcare workers’ safety and care
 You must be familiar what these procedures are because this
delivery OR in areas where access to the global supply chain of
determines what type of PPE should be worn in the area where this is
PPE remains limited despite attempts to use exceptional
done
procurement processes
INFECTIOUS DISEASES
ZONING High Risk Areas
Low Risk Areas  COVID-19 suspects/COVID-19 ward, ICCU, operating room (OR)
complex, labor room and delivery room complex, ER isolation
area/endoscopy procedure area
 High-risk activities: all aerosol-generating procedures (nebulization,
intubation, manual ventilation, non-invasive ventilation, resuscitation,
tracheostomy, and gastroenteral endoscopy), handling of other
respiratory specimen for microbiologic studies
 Require Level 4 Protection PPEs (N95 mask, face shields, surgical caps,
 Outpatient department, reception areas, non- COVID-19 wards double globes, disposable or impermeable coveralls, scrub suit,
 Require Level 1 or 2 Protection PPEs dedicated shoes, shoe cover)
o Level 1 PPE  surgical mask, hand hygiene + alcohol o Although there is no benefit in doubling gloves, since we are
o Level 2 PPE  surgical mask, hand hygiene + alcohol, face dealing with a relatively new disease and it is highly
shields/goggles transmissible, doctors wear double gloves
Moderate Risk Areas RECOMMENDED PPE IN EMERGENCY ROOM
 ER pre-triage area, ER triage area, hemodialysis unit, ICCU set-up, eye

center examination area, ENT examination area
RECOMMENDED PPE IN THE OPD
 Moderate-risk activities: non-respiratory specimen examination of
suspected patients, imaging examination of suspected patients
(including use of portable x-rays), cleaning of surgical instruments used
with suspected patients
 Require Level 3 Protection PPEs (N95 mask, face shields or googles,
surgical caps, gloves, disposable or impermeable, coveralls)
INFECTIOUS DISEASES
RECOMMENDED PPE IN PRIVATE PATIENT ROOMS

In the Orange or Red Zone: Wear Level 3
If you are:
 Staying <4 hours
 Brief patient interaction
 Performing NPS or OPS
 Assigned as safety officer on the doffing area
In the Orange or Red Zone: Wear Level 4

If you are:
 Staying > 4 hours
RECOMMENDED PPE IN THE OPERATING ROOM  Performing close contact procedures
 Performing AGP
 In doubt!
 If you are high-risk to develop Covid-19, example you have
comorbidities like hypertension or diabetes
DESCRIPTION OF EACH PPE

PPE Description
 Specifications: disposable, non-woven, pleated, hypoallergenic, high filtration capacity, with adaptable nose bar, very low resistance
to breathing
 If you are not directly handling COVID-19 patients
Surgical Mask
 If there is no risk of splashing or spraying bodily fluids
 Extended use of up to 6 hours is FEASIBLE but it increases risk of contamination
When you use a face shield over a face mask (wherein the face shield covers
the chin and the sides of the face)  it may extend the use of face mask
 Reprocessing is NOT RECOMMENDED

 Cloth masks not considered as an alternative to surgical masks for healthcare workers
Cloth masks are allowed when used in public places (e.g. malls) but not inside the
hospitals
 Specifications: anti-fog with side shield, polycarbonate, lightweight, adjustable head strap, must cover side of face and below the chin
 If you are directly handling COVID-19 patients and/or performing AGP
 If there is a risk of splashing or spraying bodily fluids
 Extended use and limited reuse is ACCEPTED
o Discard face shields or goggles if there is damage already, it doesn’t fasten securely to the face and head, or if visibility is obscured
Eye Protection
when used
 Reprocessing is ACCEPTED
o Wash with soap/detergent and water
o Disinfect
How do you disinfect?
 0.1% sodium hypochlorite (e.g. Zonrox)
for 5 mins.
 Wipe with 70% ethyl alcohol minimum
contact time of 5 minutes
 Soak with 3% hydrogen peroxide for 30
minutes
o Rinse with water
o Airdry
o Clean and decontaminate, expose to UV radiation in a UV sterilizing cabinet for 15 mins.
NOTE: The reuse, reprocessing of goggles or face shields without decontamination or sterilization is strongly discouraged because it is
one of the principal sources of transmission to healthcare workers
INFECTIOUS DISEASES
PPE Description
 Specifications: at least 95% filtration efficiency, fluid resistance, with nose clip, 2-strap design with welded strap attachment, with nose
foam; FIT TESTING
Fit Testing is a critical component to a respiratory protection program whenever workers use tight fitting respirators. Use a test
agent either qualitatively detected by the wearer’s sense of taste, smell or involuntary cough of irritant smoke OR quantitative
measure by an instrument to verify the respirator’s fit
 If you are directly handling COVID-19 patients and/or performing AGP

 If there is risk of splashing or spraying bodily fluids
 Can be used for up to 8 hours
 Extended use is SAFE and ACCEPTED provided that the respirator must maintain its fit and function
Respirators (N95, N99,  Conditions that prevent extended use: soiled with blood/bodily fluids, discarded after AGP, close contact with suspect/confirmed cases,
N100) damaged, hard to breathe through
 Extended use is favored over reuse
 Reuse after extended use is NOT ACCEPTED
Reuse is permitted provided that you do or observe the following steps:
 Reduce contact transmission
 You can rotate 5-7 pieces of N95 respirators for each healthcare workers (this is very expensive to do!)  you use 1 N95 in a
particular day, take off and store it by hanging in a storage area or use a breathable container such as paper bag in between
uses
 Avoid respirators touching each other in storage areas to minimize potential cross-contamination
 Minimize cross-contamination by labeling the respirator of each healthcare worker
 Use a face shield over an N95 respirator
A limited reuse for not more than 5 times per device to ensure adequate safety margin
Contact transmission caused by touching a contaminated mask is identified as a primary hazard for use and reuse of respirator
 Reprocessing:
o Vapor of hydrogen peroxide for 55 minutes  allow reuse for up to 3 times
o UV radiation lamp for 15 minutes  allow reuse for up to 3 times
o Moist heat incubation at 70oC for 30 minutes  allow reuse for up to 2 times
 Decontamination methods are NOT RECOMMENDED by current evidences such as:

o Use of ethylene oxide, ionizing radiation, microwave, high temperature (autoclaving)
 Expired N95 masks can still be used as long as there is no signs of damage (e.g. no discoloration, residue, no loss of elasticity of the ear
loops)  better get in touch with the manufacturer prior to use
 Damage to the shape of the respirators due to reprocessing may affect fit and protection properties
 Components: headgear or hood, face shield, head harness, nose cup assembly, spectacles, visor covers, inhalation and exhalation
valves, port adapter, cartridge filter, PAPR system, belt, air hose, battery chargers, etc.
 PAPR is a battery powered blower that forces air through filter cartridges or canister into the breathing zone of the wearer. An airflow
is created inside, either a tight-fitting face piece or loose-fitting hood/helmet providing a higher assigned protection factor (APF)
 It uses High Efficiency Particulate Air or HEPA filter which implies that they have a greater level of respiratory protection than N95
masks
Personal Air-Purifying  Loose-fitting PAPR is better than Tight-fitting non-powered purifying respirator
Respirators (PAPR)
Advantages:
 No fit testing
 It can be worn with a limited amount of facial hair
 Significant splash protection for the face and the eyes
 Full face of HCW can be seen because there is no need to wear a mask
 Better interpersonal communication
 Can be cleaned, disinfected, reused, shared
 Less taxing (easier to breath)
Disadvantages:
 Limited downward vertical view
 Batteries need to be recharged and replaced
 Required storage space
 Limited ability to use stethoscope
 Reduced ability to hear
 Access may be even more limited due to cost and need for routine maintenance
INFECTIOUS DISEASES
PPE Description
 Material non-woven polypropylene (disposable single use), or non-woven cloth, polyester-cotton (washable, reusable)
 Long-sleeved, tie back, covers down to mid-calf, lightweight, durable, breathable, water, and blood-resistant
 Worn over scrub suit
In conventional capacity situations, use of surgical or isolation gowns are recommended
In contingency capacity strategies, you shift gown toward the use of cloth gowns  just like in this pandemic because
it can be REUSED
 Cotton-made gown over polypropylene made gown

Use a clean isolation gown when entering suspected or confirmed COVID-19 patients
Gowns
If having close contact with COVID-19 patients  use 2 layers of gowns (cotton-made + polypropylene made gown)
 Inner layer – polypropylene
 Outer layer – cotton
Dispose the cotton gown once stained or soiled  replace immediately if necessary
 In the operating room, you don a sterile gown as 1st layer then proceed at the operating cubicle for another layer of sterile gowning
process
 Remove or dispose the gown if it is wet, soiled or damaged, exposed to chemicals or infectious substances/ fluids from the body, or
used it in providing care outside designated COVID-19 areas
 Extended use is ACCEPTABLE

 Reuse/reprocessing of cloth gown ACCEPTED
 Reprocessing of cotton gowns:
o Machine wash  with warm water + laundry detergent
o Manual wash  soak and stir with hot water and then soak in .05% chlorine for 30 mins. then rinse with water and dry fully
Alternatives:
 Disposable lab coats  less durable
 Disposable impermeable plastic aprons  cannot protect arms and back of torso
 Reusable patient gowns/lab coats  design and thickness are not comparable
Combinations of the ff. may be considered for activities that may involve body fluids and there are NO GOWNS AVAILABLE:
 Long sleeve apron + Long sleeve patient gowns/Laboratory coat
 Open back gowns + Long sleeve patient gowns/Laboratory coat
 Sleeve covers + Aprons/Long sleeve patient gowns/Laboratory coats
 Made of high-density polyethylene formed into non-woven fabric; other materials are polypropylene fiber with polyethylene coating,
breathable, lightweight, water-based liquids and aerosol repellant, low linting, tunneled elastic bands for the wrists, ankles and face,
and thumb loops
 Ideal color is white or light blue, ideally single-use, biohazard protective cover all clothing
 If you are directly handling COVID-19 patients (whether suspected, confirmed or probable) and/or performing AGP (aerosol generating
procedures)
Coverall (HAZMAT Suit)  If there is risk of splashing or spraying bodily fluids
 Provide 360o protection (including back, lower legs, head and feet)
 Reuse/reprocessing is ACCEPTABLE in times of severe shortage
o Ideally they are for single use only BUT reuse/reprocessing is ACCEPTABLE especially if supply is an issue  just clean, disinfect,
or sanitize it
 Disinfection:
o Wash with soap/detergent and water
o Disinfection (Soak with .1% sodium hypochlorite, 3% hydrogen peroxide for 30 minutes)
o Rinse with water
o Air and sun drying
Alternatives to Commercially available Coveralls:

 Non-woven polypropylene  same material used to make reusable shopping bags
 Thermoplastic polymers  it is recyclable and reusable
 Coveralls can be washed if they are used in low-risk areas (green areas)
 Infectious Disease experts do not recommend non-woven polypropylene coveralls as these are not meant for healthcare workers who
come into direct contact with infected patients
 Advise on locally-manufactured coveralls:
o License to operate (national standards, technical requirements, safety testing)
INFECTIOUS DISEASES
PPE Description
Surgical Cap
 Specifications: disposable, non-woven surgical bouffant cap, shower-type

 Worn if you are part of the Level 3 or 4 PPE
Shoe Cover
 Specifications: disposable, non-woven

 Fabric does not tear/break easily
 Non-skid, does not slip on wet floor
 No recommendation for use of shoe covers vs. no shoe covers for healthcare personnel caring for patients with COVID-19
 It is used for extra protection
 Specifications: hypoallergenic, nitrile, powder-free, latex-free (some are too thin), standard thickness, beaded cuff, smooth with
micro-textured finish, safe grip easy downing and comfort, excellent hand fitting
 Superb tensile strength
 With left and right hand marking on gloves
Gloves  Extended use is NOT RECOMMENDED
 Double gloving is not recommended, EXCEPT in surgical procedures where there is increased risk of glove perforation
o But in settings where there is limited healthcare workers  double gloving is done
o There is no study or RCT or meta-analysis showing its benefit
o Why is double gloving utilized even if it is not recommended?
 Using a single pair of gloves put one at a theoretical risk that the organism may be transferred from the
contaminated PPE to the hands after removal of the contaminated gloves/clothing which may contribute to
infections
 Recommendations:
o When providing direct care for a COVID-19 patient and then removed followed by hand hygiene
o When doing PE
o Do not use the same pair for multiple patients  this is also the reason for double gloving in the COVID-19 areas
 The inner gloves remains while the outer gloves is used only ONCE for each patient
o Change gloves between dirty and clean tasks in the delivery of care to the patient (accompanied by hand hygiene)
KEYPOINTS
 Most personal protective equipment are designed for single use; the following PPEs may be reprocessed then reused:
o N95 mask
o Goggles
o Face shields
o Scrubs
o Coveralls
o Covered shoes
o Cotton gowns
 Reprocessing should follow the principles of cleaning and decontamination before disinfection and sterilization
 Disinfection and reuse of disposable PPE may be possible, but always be aware that the processes used may compromise the integrity of the product and impact
its effectiveness
 PPE not only protects you from acquiring infection, it is also a way for you to protect other people
INFECTIOUS DISEASES
Topic: Tuberculosis (Adults, Childhood and Infancy)
Lecturer: Dr. Sy, Celia
If a person has a positive skin test (TST) and had no symptoms, his chest CXR
is normal, he is classified as:
A. Latent Tuberculosis Infection (LTBI)
B. TB disease
DEFINITIONS
 Asymptomatic or Latent Tuberculosis Infection (LTBI)
o Infection associated with tuberculin hypersensitivity as shown
by a POSITIVE TUBERCULIN SKIN TEST(TST) with no striking
clinical or roentgenographic manifestations
Example: If the doctor has done a PPD test or TST and the
patient became positive but with no symptoms  then it is Lecture Discussion: Primary Complex
a case of latent TB infection
The first thing the TB bacilli will do is to lodge into the adjacent lymph nodes
 creates lymphadenopathy. So in the CXR, you will see enlarged LNs. Now,
o Mycobacterium tuberculosis complex infection in a person
the TB bacilli may travel through lymphatic spread to the adjacent lung (this
who has POSITIVE TUBERCULIN SKIN TEST (or IGRA) results,
is what we called as a primary focus). The 3 elements: primary focus,
with no clinical manifestations of disease and chest lymphangitis, and regional adenitis  all of these consists the Ghon’s
radiographic findings that are normal complex (Primary complex)
INCUBATION PERIOD In children, we usually request for PA or AP and Lateral CXR. On the lateral
 Time interval from the exposure to mycobacterium to the development CXR  we would like to look for any enlarged LNs
of delayed hypersensitivity reaction as manifested by a POSITIVE TST (or
IGRA) DIAGNOSTIC TESTS
o This is approximately around 3-4 weeks. By the time you inhale
CASE: P.T. 16 y/o male, cough >2 weeks, blood streak sputum
or ingest an M. TB bacilli  it goes to the lungs, lymph nodes
or other organs  body creates a reaction to the bacteria as You want to test if he has tuberculosis?
manifested by a (+) TST
 For TB infection
o TST (Tuberculin Skin Test)
o IGRA (gamma interferon release assay)
 For TB disease
o DSSM (direct sputum smear microscopy)
o Gene Xpert
o Culture and sensitivity
Mantoux Test
 Current standard for TST
 A skin test for tuberculosis infection
 0.1 ml of solution containing:
o 0.1 ug of 5 tuberculin units (5”TU”) of PPD-S
o or 2 TU of PPD-RT 23 with Tween 80
 IGRA  also a test to check for TB infection but instead of using a What is the difference between the 2 solutions?
tuberculin test, they use blood 5”TU” PPD-S  is readily available; this is the one that we are using
 Incubation period depends on the bacilli load and it usually ranges from in the clinical practice
7 days to 3 months 2 TU of PPD-RT 23  usually used by large organizations (e.g. WHO,
 So if you inhaled a M. tuberculosis, it can get into your lungs and it is DOH) for clinical or epidemiologic surveillance
where it will lodge into the adjacent lung tissues or lymph node (this is
what we called the primary complex). Later on, these TB bacilli may  Intradermal/intracutaneous
travel through hematogenous spread into the different organs or if the  Positive result read as INDURATION between 48 to 72 hours of
patient has a ↓ immune system (e.g. HIV patient), the TB bacilli may go injection
directly to the lungs as a progressive cavitary TB Remember that it is an INDURATION! It is NOT a wheal or redness
 In some individuals who are immunocompromised, 5-10% of infected Induration  raised portion (“Tambok”)
persons upon lodging of TB bacilli on the lungs directly goes into the
lung parenchyma
PRIMARY COMPLEX (GHON)

 The first “landing” or “encounter’ of TB bacilli on the lungs is what we
called Primary Complex (Ghon’s Complex). Common in children
 Initial lung lesion of primary TB (ghon focus)
 Composed of :
o Primary focus
o Lymphangitis Image Above: A positive tuberculin skin test (TST) =/> 10 mm induration
Site: Volar surface of the forearm
o Localized pleural effusion
o Regional lymphadenitis
INFECTIOUS DISEASES
 10 mm induration is considered as positive generally Gene Xpert MTB/RIF Assay

 If your patient is immunocompromised (e.g. HIV patient or patient  Real time PCR based molecular test
taking corticosteroid for a long time)  5 mm induration is already  It can detect TB bacteria and rifampicin resistance in less than 2 hours
positive  More sensitive and specific than smear microscopy for detecting MTB
 If a patient is living in an endemic area to TB (e.g. Neighborhood or
Barangay has many cases of TB)  5 mm induration is already positive Recommended by WHO as replacement for conventional microscopy
(DSSM), culture and drug susceptibility testing as initial diagnostic test in
Interferon Gamma Release Assays (IGRA) both Adults and children with PTB and suspected at risk for drug
 Whole blood specimen resistance TB or have HIV-associated TB
 Measure person’s immune system reactivity to MTB
 Cellular immune response  In Gene Xpert, you also have a bonus exam which is RIF Assay  checks
 QuantiFERON TB Gold if the patient is resistant to Rifampicin. It has been shown in many
studies that if they are resistant to Rifampicin, the chances of him/her
 Recommended by WHO either IGRA or TST can be used to test for latent
TB infection (LTBI) being resistant to other anti-TB drugs is high
 It detects TB infection, NOT TB disease
TST IGRAs
 2 visits required (minimum)  1 visit required
 Method: injection into skin  Method: blood draw
 Results affected by BCG  Results not affected by BCG
 Results in 48-72 hours  Next-day results
 Subjective results  Objective results
 Can cause booster  Does not cause booster
phenomenon phenomenon
 This test are sometimes free in  Drawbacks: Not available in
some institutions; Price for this most institutions; Price is higher
test is cheaper compared to compared with TST (5k-6k pesos)
IGRA
 MTB detected, RIF Resistance not detected (T)  treat with drug
sensitive or DS-TB regimen
Diagnostic Tests  MTB detected, RIF Resistance detected (RR)  can be high DR-TB risk
 If the patient is already coughing out blood and has positive exposure or low DR-TB risk
to TB, aside from doing TST or IGRA you can also do diagnostic tests o High DR-TB risk  do further testing and revise regimen
o Low DR-TB risk  repeat test and treat accordingly based on
Sputum (DSSM) the second result
 2 sputum specimens in 2 different days  MTB detected, RR Indeterminate (TI)  Collect new specimen and
o Get 1 specimen once the patient wakes up in the morning repeat test; treat accordingly based on the second result
 Minimum volume — 3 ml  Error/Invalid (I)  Collect new specimen and repeat test; treat
 Transport asap, if delayed more than 1 hr, must be stored and accordingly based on the second result
refrigerated
NOTE: If you see a letter “I”  automatic that you have to repeat the
If the patient is a child  since they do not know how to cough out testing
sputum (“dahak”) then you can do gastric aspiration
 MTB not detected (N)  if patient is coughing and is highly suspicious
Gastric Aspirate
of TB, reassess the patient
 Done in children who are usually admitted in the hospital
 5 ml to 10 ml
WHAT IS THE BEST DIAGNOSTIC TEST/PROCEDURE FOR TB?
 Collect it on 2 consecutive days  Chest x ray
 Patient should be on NPO first before doing the gastric aspirate  TST Answer: No single laboratory test should
 Ask the patient to lie down on the bed upon waking up and put an NGT  IGRA be used in diagnosing TB, it depends on
or OGT then get the aspirate of about 5-10 mL (for 2 consecutive days) the age of the patient, immunologic
 DSSM
 Gene Xpert status, and financial status
 Community that has only CXR machine  then use it as a test for TB
 Hospital has all the lab tests needed but patient has no money  use
TST because it is the least expensive
 2 important test to use: DSSM and Gene Xpert
INFECTIOUS DISEASES
Lecture Discussion:
If you have a patient suspected of TB, Do a Gene Xpert and DSSM
 Gene Xpert – for diagnosis
 DSSM – for screening
 If these are (+)  patient is bacteriologically confirmed TB
If patient clinically has fever >2 weeks, coughed blood-streak sputum, weight
loss, (+) contact from household member with TB. CXR shows cavitary lesion
 If you did not do any of the tests but has the signs and symptoms of
TB  Clinically-diagnosed TB
TB Disease based on History of Previous Treatment

 A patient who has NEVER had treatment for TB or who
has taken anti-TB drugs for less than one (<1) month
New Case
 INH preventive therapy (IPT) is not considered as previous
TB treatment
 A patient who has been previously treated with anti-TB
Retreatment Case
drugs for at least one (1) month in the past
 If a patient presents at least one of the signs and symptoms for >2
weeks  it is a Presumptive TB case TB Disease based on HIV Status
o You collect a sputum sample for Gene Xpert (Smear or TB  HIV-negative
LAMP  alternative if Xpert not available) o Bacteriologically-confirmed or clinically-diagnosed case of TB
 If a patient has presents the symptoms but <2 weeks (e.g. 5 days cough) who has a negative results from HIV testing at the time of TB
 request for CXR if CXR is suggestive of TB  Presumptive TB case diagnosis
o If CXR is not suggestive of TB  check for other diseases  HIV-positive
CLASSIFICATION AND PRESUMPTIVE DIAGNOSIS OF TUBERCULOSIS TB Disease based on Drug Susceptibility Testing
 Anatomic Site
Mono-resistant TB  Resistance to one first-line anti-TB drug only
 Bacteriologic Status
 Resistance to more than one first-line anti-TB drug
 History of Previous Medication Polydrug-resistant TB
(other than Isoniazid and Rifampicin)
 Drug susceptibility testing Multidrug-resistant TB
 Resistance to at least both Isoniazid and Rifampicin
(MDRTB)
TB Disease based on Anatomic Site and Bacteriologic Status  Resistance to any fluoroquinolones and to at least one of
Extensively drug- three second-line injectable drugs (Capreomycin,
ANATOMIC SITE BACTERIOLOGIC STATUS DEFINITION OF TERMS resistant TB (XDR-TB) Kanamycin, and Amikacin), in addition to multidrug
 Smear-positive resistance
Bacteriologically-confirmed  Culture-positive  Resistance to Rifampicin detected using phenotypic or
Rifampicin-resistant
 Rapid diagnostic test-positive genotypic methods, with or without resistance to other
TB (RR-TB)
 Patient with 2 DSSM (-) with anti-TB drugs
CXR consistent with active TB
 Child with 2 DSSM (-) but  Studies have shown that if a person is RR-TB  most likely they are also
PTB fulfills 3 out of 5 criteria for
resistant to other anti-TB drugs
TB disease
Clinically-diagnosed  HIV/AIDS patient with 2
DSSM (-) regardless of CXR is TB CASE CLASSIFICATION/DEFINITION
decided by MD (attending
physician) or TBDC (TB
Disease Control Committee)
to have TB disease
 Patient with smear / culture/
rapid diagnostic test from a
Bacteriologically-confirmed biological specimen in an
extra-pulmonary site positive
for AFB or MTB complex
EPTB  Patient with histological
and/or clinical or radiological
evidence consistent with
Clinically-diagnosed
active EPTB and there is
decision by MD to treat
patient with anti-TB drugs
 Histologically-diagnosed EPTB through biopsy of appropriate site will be

considered clinically-diagnosed TB. Laryngeal TB, though likely to be
sputum smear (+), is considered an EPTB in the absence of lung infiltrate
on CXR
INFECTIOUS DISEASES
CLINICAL DIAGNOSIS OF TB TREATMENT

 Presumptive diagnosis based on signs and symptoms Treatment Regimen for Tuberculosis
 Laboratory diagnosis  Standard Therapy – 6 months treatment
 Radiologic diagnosis o Intensive Phase
 Special considerations  To rapidly eliminate the majority of organisms and
 Diagnostic algorithm prevent emergence of drug resistance (hence the
greater number of drugs)
IDENTIFICATION OF PRESUMPTIVE TB  2 months
 HRZE
Patient 15 years old and above:
o Continuation Phase
 Cough of at LEAST 2 WEEKS duration with or without the ff:  To eradicate dormant organisms (fewer drugs used as
o Significant and unintentional weight loss risk of acquiring drug resistance is low as most have
o Fever been eradicated)
o Bloody sputum (hemoptysis)  4 months
o Chest/back pains not referable to any musculoskeletal  HR
disorders
o Easy fatigability or malaise
Basis for Treatment Regimen
o Shortness of breath or difficulty of breathing
1. Anti-TB treatment regimen shall be based from:
o Night sweats
o a. Anatomical site
 Unexplained cough of any duration in: o b. Bacteriologic status
o Close contact of a known active TB case o c. Drug resistance
o High risk clinical groups (HIV/AIDS, diabetes, ESRD, cancer, CT o d. History or prior treatment
disease, autoimmune disease, silicosis, postgastrectomy or 2. Treatment may be modified in special circumstances
solid organ transplantation, and on prolonged systemic
steroids)
Goals of Treatment
o High risk populations (e.g. elderly, urban poor, inmates and
 To cure the patient (by rapidly eliminating most bacteria)
other congregate settings)
 To prevent death from active TB
 To prevent relapse (by eliminating dormant bacteria)
Patient below 15 years old:
 To prevent drug resistance (by using a combination of drugs)
 At least 3 of the following clinical criteria:
 To decrease TB transmission
o Coughing/wheezing of 2 weeks or more, esp. unexplained
 To achieve minimal toxicity
o Unexplained fever of 2 weeks or more after causes such as
malaria or pneumonia is excluded
o Loss of weight/ failure to gain weight/ weight faltering/ loss of
appetite
o Failure to respond to 2 weeks of appropriate antibiotics for
LRTI
o Failure to regain previous state of health 2 weeks after a viral
infection (measles)
o Fatigue, reduced playfulness, or lethargy
 Any one of the above signs and symptoms (Clinical criteria) in a child
who is a close contact of a known active TB case
Chest X-ray suggestive of PTB
 Dosage for children are higher since there are more metabolizing
enzymes among children than adults leading to faster metabolism
Key Points
 The primary goal in the treatment of TB is to cure the patient
 Different drugs are used to treat a child with TB to effect cure and
prevent resistance
 Anti-TB treatment regimen shall be based on:
o Anatomic site, bacteriologic status, drug resistance, history of
prior treatment
 HRZE remain to be the mainstay in the treatment of a child with TB
INFECTIOUS DISEASES
SPECIAL CONDITIONS C. Breastfeeding

A. Pregnancy  A breastfeeding woman afflicted with TB should receive a full course of
 When a woman is pregnant, she can be given anti-TB drugs TB treatment
 Ascertain whether or not a woman is pregnant before she starts TB  Timely and properly applied chemotherapy is the best way to prevent
treatment transmission of tubercle bacilli to the baby.
 Most anti-tuberculosis drugs are safe for pregnant women, except  In lactating mothers on treatment, effects of such exposure on infants
Streptomycin, which is ototoxic to the fetus. have not been established.
 Recommended standardized treatment regimen 2HRZE/4HR  Most anti-tuberculosis drugs will be found in the breastmilk in
 Pregnant women taking isoniazid should be given pyridoxine (Vitamin concentrations equal to only a small fraction of the therapeutic dose in
B6) at 25 mg/day infants.
o Some obstetricians say that it is better to give anti-TB drugs at  It is recommended that lactating mothers feed their infants before
the 2nd trimester of pregnancy taking medications
 The risk of the baby being infected with TB is highest if a mother was  Supplemental Pyridoxine should be given at 5-10mg/day to the infant
diagnosed of TB at the time of delivery or shortly thereafter who is taking INH or whose breastfeeding mother is taking INH
 Separation from mother not advised for resource-limited settings
 Mother should wear mask during infectious stage for 2 weeks WHEN TO INTERRUPT TREATMENT IN PATIENT WITH LIVER DISEASE?
 In this case, it is very important that health workers should assess the  SGPT/ALT level >3x the upper limit of normal + symptoms (nausea,
newborn at once vomiting and abdominal pain) and or
 SGPT/ALT >5x the upper limit WITHOUT symptoms
B. Baby born to a mother with PTB  If it is not possible to perform liver function tests, it is advisable to wait
 Isoniazid can be given to a newborn infant born to a mother with active an extra 2 weeks after resolution of jaundice and upper abdominal
TB tenderness before restarting TB treatment
ADDITIONAL INFORMATION
If you have a patient on TB treatment, at what month do you have to check for
the progress of treatment? What is the diagnostic test will you request?
 After 2 months by the end of the patient’s treatment
 Request for DSSM only
o No Gene Xpert because it may still be positive for M.
tuberculosis due to presence of the dead bacteria
 If the patient is still (+) for TB (DS-TB case)  continue treatment
o At what month are you going to repeat the test? 5th month of
treatment
o If still it is (+) at the 5th month of treatment  treatment failed
It is hard to get sputum on pediatric patients and the parents do not allow
gastric aspiration. What will you do?
 Just go by clinical diagnosis
INFECTIOUS DISEASES
Topic: Salmonella Infections
ETIOLOGY Lecture Discussion: Pathophysiology of Typhoid Fever

 Gram-negative bacilli First, there will be accidental ingestion of the S. Typhi  it reaches then the
 Resistance to heat: terminal ileum where it will invade the enterocytes lining, with the help of
o Can be destroyed at 54.4 C (130 F) for 1 hour the “M” cells  there will be formation of salmonella-vacuoles at the
60 C (140 F) for 15 minutes Peyer’s Patches (vacuole formation will help the bacteria to evade the host’s
o So if you suspect that a food may contain salmonella  you immune response)  at the Peyer’s patches, since there are a lot of lymph
heat the food to destroy it (at 60oC for 15 mins.) node around, it will hide inside the mesenteric lymph nodes  patient will
 Family of Enterobacteriaceae present with intestinal manifestations such as abdominal pain, nausea and
vomiting which may be due to the inflammation of lymph nodes  the
 2500 Salmonella serovars
bacteria can then go into the blood stream  primary bacteremia  patient
o Salmonella serotype Typhi is classified in O serogroup D
will go into have high grade fever, chills, diarrhea, etc.  later on, the
 Example of complete name bacteria will be disseminated into various organs (e.g. bone, kidney, liver,
o S. enterica subspecies enterica serovars Typhi gallbladder, meninges)  secondary bacteremia  patient will have
o S. enterica subspecies enterica serovars Typhimurium overwhelming infection which may lead to DIC (disseminated
o S. enterica subspecies enterica serovars Paratyphi A intravascularcoagulopathy)
WHAT ARE THE 2 TYPES OF SALMONELLA? Clinical Manifestations

1. Typhoidal  Fever, headaches, malaise, anorexia, lethargy, abdominal pain
 Salmonella enterica serovars Typhi (salmonella typhi)  Hepatosplenomegaly
 Salmonella enterica serovars Paratyphi  Dactylitis
 Restricted to human host  Rose spots
 Protracted bacteremia
2. Nontyphoidal Salmonella (NTS)  Changes in mental status/meningitis
 1000 species  Bradycardia more common in adults
 Broad host range: birds, amphibians, turtle, lizards
 Foods of animal origin: eggs, poultry, beef, dairy products Rose Spots
 Fruits  A distinguishing skin manifestation of
typhoid fever
Lecture Discussion: Types of Salmonella  Macular patches/rashes
Clinically, there are 2 types of salmonella. As a clinician, one should be able  Visible on the 7th-10th days of illness
to recognize which is a typhoidal salmonella from a nontyphoidal  Appears in crops of 10-15 on the lower
salmonella. Why? chest and abdomen
 Because the tyhpoidal salmonella  more toxic and most cases are  Last for 2-3 days
due to salmonella typhi. It’s mode of transmission is feco-oral
route
Lecture Discussion: Macular Patches vs. Maculopapular Rashes
 The nontyphoidal salmonella  most hosts are animals. Foods of
animal origin such eggs, poultry, beef, dairy products may be its Macular patches  flat red dots on the skin
cause. Others are fruits Maculopapular rash  common among viral infections; raised surface may
be rough when palpated
ENTERIC FEVER (TYPHOID FEVER)
 Salmonella enterica serovars typhi  Take note that Rose Spots are different from the type of rash in dengue
o Paratyphi A  Herman’s Sign
o Paratyphi B  Herman’s rash  when you try to press it, there is blanching
o Paratyphi C (“namumuti”) of the surrounding
 Caused by ingestions of foods or water contaminated with S. Typhi from o Dermatologic finding usually appears on the afebrile state 
human feces the time when there is “no fever”
o So it is important to ask “when did the rashes appear? Was it
Pathogenesis of Typhoid Fever during fever? Or after fever?”
Sample Case Typhoid Fever of Dr. Sy:

 A patient came to your clinic with 7 days of fever with anorexia,
vomiting, abdominal pain and with rashes that does not blanch
upon pressure
INFECTIOUS DISEASES
Lecture Discussion: Typhidot Test

The test has a very low sensitivity and specificity because it detects IgM and
IgG antibodies  a positive test will depend on how the immune system of
the patient will generate the antibodies (for it to be detected). Therefore its
use should be discouraged BUT it can be used in institutions where blood
culture is not available (e.g. hospitals in far flung areas)
How to interpret a Typhidot Test?
 In children, most common presentation is high grade fever. It is very

rare to see them having intestinal perforation
 In adults, presentation are more of GI manifestations: abdominal pain,
constipation, and intestinal perforation
Complications of Typhoid Fever

 Hepatitis
 Jaundice C – control lines  automatically there will be a line there, once used
 Cholecystitis T – test lines  the one we look at to see if it is (+)
 Intestinal hemorrhage and perforation
This is a dangerous sign. If a patient has severe abdominal pain and
fever  think of possible causes. Common are:
 Appendicitis
 Typhoid fever – consider this if the abdomen is still soft
 Osteomyelitis
Diagnosis of Typhoid Fever

 Blood culture
o Gold standard
o Results can be received as early as 3rd day of illness ~ but
although results will be delayed, treatment should be given
immediately If you see a line at the T of IgM (no line at IgG)  early infection
If you see a line at the T of IgG (no line at IgM)  previous infection
o Positive in 40-60%
If both have lines  patient currently is infected AND had a previous
 Stool and urine cultures - positive after the 1st week infection of salmonella
 CBC: Leukocytosis (young children)
Leukopenia (usually adults) - depends on the severity of the disease Take note that this interpretation also applies to the rapid testing of dengue
 Thrombocytopenia - marker of severe illness or DIC and even COVID-19
 Widal Test
o Measures the O and H antigens of S. typhi Treatment of Typhoid Fever
o Lacks specificity and sensitivity Classify whether mild or severe:
o Prone to error of interpretation  Mild cases: home with oral antibiotics and hydration
o Not used anymore due to a lot of cross-reactions. Positive  Severe cases: persistent vomiting, severe diarrhea, abdominal
results depends on the bacterial load of the patient, therefore distention needs to admit to the hospital and give IV antibiotics
if the patient still has low bacterial load = may turn out
negative Drugs for Treatment:
 Typhidot Test  Chloramphenicol, Amoxicillin have a high relapse rate
o A medical test consisting of a dot ELISA kit that detects IgM o Chloramphenicol  has a lot of side effects like gray baby
and IgG antibodies against the outer membrane protein syndrome, ↓ bone marrow production, ↑ rates of resistance
(OMP) of the Salmonella typhi o Here in the Philippines, according to a national survey, typhoid
o Positive within 2-3 days of infection and separately identifies fever cases are still very sensitive to chloramphenicol  which
IgM and IgG antibodies is why public health centers still use it as treatment
o Low sensitivity 26.7% o Oral or IV Chloramphenicol = has the same
o Low specificity 61.5% efficacy/effectiveness
o Positive predictive value (PPV) 7.4%  Azithromycin, Quinolones, and 3rd generation cephalosporin
o Negative predictive value (NPV) 87.9% associated with higher cure rates
o Even though Typhidot is rapid, easy, and affordable, its use  Ceftriaxone or fluoroquinolones as empiric treatment
should be discouraged due to low sensitivity and specificity o Ceftriaxone or fluoroquinolone are drugs of choice if one
and insignificant (p=0.067) association to the disease decides to admit the patient
o If the patient had typhoid fever for the 1st time – Ceftriaxone
INFECTIOUS DISEASES
o If the patient is already a carrier – Chloramphenicol Typhoid Vaccines

o If the patient is a child - Ceftriaxone  Typhoid vaccines live TY21a (Vivotif)
 For severely ill patients with shock, obtunded, stupor, or coma: o Live attenuated vaccine
o Additional meds: Dexamethasone 3 mg/kg (initial dose) then 1 o For children 6 years and older and adults
mg/kg every 6 hours for 48 hours o Enteric-coated capsule (given orally) every other day for a total
of 4 capsules
 E.g. of schedule of intake  MWFSu
o Should be taken with cold water at 1 hour before meal
 Since it is a live vaccine, it is taken before meals so that
it will not be destroyed
 Typhoid Vi polysaccharide vaccine (Typhim Vi) (conjugated)

o For 2 years and older
o 0.5 ml (25-ug) dose administered intramuscularly
o Given at least 2 weeks before possible exposure
o Given every 2 years (cannot provide lifelong immunity)
NONTYPHOIDAL SALMONELLA (NTS)

 Caused by:
o Salmonella enteritidis Animals-to-humans
o Salmonella typhimurium
 Clinical Manifestations:
o Gastroenteritis: most common manifestation
 Uncomplicated typhoid fever case: o Others (happens to immunocompromised patients):
o Determine first the sensitivity pattern in your locality  Bacteremia
o If fully sensitive  give Chloramphenicol given for 14-21 days  Meningitis
o If multidrug resistant  Fluoroquinolone (5-7 days) or  Osteomyelitis
Cefexime (7-14 days)  Antimicrobial therapy is not recommended for asymptomatic
 For Dr. Sy, she gives Cefexime for 10 days nontyphoidal
o If quinolone resistant  Azithromycin (7 days) or Ceftriaxone  Salmonella-infected people, or uncomplicated diarrhea, EXCEPT for
(10-14 days) young infants and immunocompromised patients
 If you want to admit an uncomplicated typhoid fever
patient  IV Ceftriaxone
Antimicrobial therapy is not recommended for asymptomatic nontyphoidal
 Since IV Ceftriaxone is costly, what you can Salmonella-infected people, or uncomplicated diarrhea, EXCEPT for:
do as clinician is give IV Ceftriaxone for the  Young infants
first 7 days and then shift to Oral Cefexime  and immunocompromised patients
for the next 7 days (since both drugs are 3rd
generation cephalosporins)
 Management of NTS is usually by rehydration and giving of probiotics
 Severe typhoid fever
(supportive treatment)
o Ceftriaxone and Cefotaxime are still the drug of choice – give
for 10-14 days
SUMMARY
 Typhoid fever (salmonella serovars typhi) causes more severe diseases
Prevention of Typhoid Fever
such as bacteremia
 Proper foods and water handling and hygiene practices
 Nontyphoidal salmonella causes less severe disease such as
 Avoid contact with acutely infected individual or with chronic carriers
gastroenteritis
o Individuals who are chronic carriers can excrete S. typhi > 3
 Ceftriaxone is the empiric antimicrobial recommended
months after infection
 The best way to prevent Typhoid infection is through:
o So if you live with someone who had typhoid fever, be careful
o Proper foods handling
because he/she can still excrete typhoid bacilli for > 3 months
o Avoid contact person infected with typhoid
(even up to 1 year)~ meaning that even after the patient
o Immunization
recovered, their stools can still possibly have salmonella typhi
 Immunization
INFECTIOUS DISEASES
Topic: Snake Bite
Lecturer: Dr. San Diego
SNAKE BITE
 Well-known occupational hazard
o Farmers
o Plantation workers
o Other outdoor workers
 Results in much morbidity and mortality throughout the world
 This occupational hazard is no more an issue restricted to a particular
part of the world
 It has become a global issue
 Accounts 30,000-40,000 deaths annually
 It is certain to be higher than what is reported
o Because even today, most of the victims initially approach
traditional healers for treatment and many are not even
registered in the hospital
 Philippines – there are no reliable estimates of mortality among the
many islands of the archipelago
Picture Above: Identification Features of Poisonous vs Non-poisonous Snakes
 Figures of 200-300 deaths each year have been suggested
 Only Cobras cause fatal envenoming, their usual victims being Rice Poisonous (Venomous) snakes – their head are usually triangular; their eyes
Farmers (pupil) are elliptical; It HAS fangs
Non-poisonous (Nonvenomous) snakes – their head are usually rounded;
These cobras are usually found on the Northern part of Luzon or
their eyes (pupil) are rounded; It does NOT have any fangs
Central Luzon where rice farming is common
VENOM
 Not all snakes are fatal
Composition:
o Majority of snakes are not poisonous
 More than 90% of snake venom is protein
List of Poisonous Snakes:  Each venom contains more than a hundred different proteins
 Cobra A. Enzymes
 Copperhead B. Non-enzymatic polypeptide toxins
 Coral snake – usually found in South Philippines (Palawan; Mindanao) C. Non-toxic proteins such as nerve growth factor
 Cottonmouth (water moccasin)
 Rattlesnake Venom Enzymes:
 Various snakes found in zoos  Zinc Metalloproteinase (Hemorrhagins):
o Damage vascular endothelium, causing bleeding
Classification of Poisonous Snake:
This enzyme damages the endothelium (arteries, veins)
 There are 2 important groups (families) that causes spontaneous bleeding which is a common
o Elapidae manifestation of snake bites
 Have short permanent erect fangs
 This family includes the cobras, kraits, coral snakes,  Procoagulant Enzymes:
and the sea snakes o These enzymes stimulate blood clotting with formation of
o Viperidae fibrin in the blood stream
 Have long fangs which are normally folded up against Since this enzymes stimulate blood clotting, there
the upper jaw but, when the snake strikes, are erected shouldn’t be any bleeding right? But the problem here is
 King Cobras and Vipers that it overconsumes the fibrin  leads to a very low fibrin
count therefore enhances the bleeding
 Phospholipase A2 (Lecithinase):
o Damages mitochondria, red blood cells, leucocytes, platelets,
peripheral nerve endings, skeletal muscle, vascular
endothelium
Important thing why snakes wants to increase its venom to
its prey is to paralyze its prey (through damaging the
abovementioned cells)
o Produces:
 Presynaptic neurotoxic activity – causes paralysis
 Opiate-like sedative effects
This contributes to the weakness, paralysis or
prostration
Prostration – the victim feels that they are totally
Picture Above: Poisonous vs. Non-Poisonous Snake Bite exhausted to the point that they cannot move
Poisonous snakes – have fang marks; it is like a bite of a “vampire” where
there are 2 punctured wounds in close proximity (distance usually 1 and a  Leads to release of histamine and anti-coagulation
half inch apart) ↑ histamine causes hypotension/↓ BP  one
Non-poisonous snakes – have multiple punctured wounds; Common bites reason why we immediately need to give
usually come from Pythons antihistamine because if not = SHOCK
INFECTIOUS DISEASES
Topic: Snake Bite
Venom Enzymes continued….. EARLY SYMPTOMS AND SIGNS

 Acetylcholinesterase  Increasing local pain (burning, bursting, throbbing) at the site of the
o Found in most elapid venoms bite
o It does not contribute to their neurotoxicity  Local swelling that gradually extends proximally up to the bitten limb
and tender
 Hyaluronidase  Painful enlargement of the regional lymph nodes draining the site of
o Promotes the spread of the venom through tissues the bite
 Other Proteolytic Enzymes (Metalloproteinases, Endopeptidases,

Bites by Kraits, Sea Snakes and Philippine Cobras may be virtually painless
Hydrolases) / Polypeptide Cytotoxins (also known as Cardiotoxins) and may cause negligible local swelling
o Increase vascular permeability causing edema, blistering,
bruising and necrosis at the site of the bite
Further increase vascular permeability  which is why LOCAL SYMPTOMS AND SIGNS
another manifestation of snake bites are edema, blistering,  Fang marks
bruising and leading to the point of necrosis  Local bleeding
 Bruising
CATEGORY OF SNAKES (WHO)  Blistering
Categorization of snakes by WHO is more focused on the epidemiology (unlike  Lymph node enlargement
in rabies, categories is based on the classification of bites)  Inflammation
 Blistering
Category 1: Highest medical Importance  Local infection
 Highly venomous snakes which are common or widespread and cause  Necrosis
numerous snake-bites, resulting in high levels of morbidity, disability or Necrosis usually happens if first aid was done wrongly  leads to
mortality amputation
 Here in the Philippines, we are in Category 1 because the only species of
snake that causes common bites and snake bites resulting to mortality GENERALIZED (SYSTEMIC) SYMPTOMS AND SIGNS
and morbidity are the Philippine Cobras  Nausea
 Categorization is important in terms of securing or procuring your anti-  Vomiting
venom  Malaise
 Category 1  we only use the monovalent anti-venom  Abdominal pain
 Weakness
Category 2: Secondary medical importance  Drowsiness
 Highly venomous snakes capable of causing morbidity, disability, or  Prostration
death, but: Prostration  feeling of being totally exhausted that they usually
a) For which exact epidemiological or clinical data are lacking or want to lay in bed. They may look like sleeping but they are actually
b) Are less frequently implicated because of their behavior, awake. They usually answer only in phrases with their eyes closed
habitat preferences or occurrence in areas remote to large
human population CARDIOVASCULAR (VIPERIDAE)
 Countries included are Thailand, India and Indonesia  Visual disturbances
 Category 2  since they have several snakes that causes envenoming,  Dizziness
they use the polyvalent anti-venom  Faintness
 Collapse
HOW DO SNAKE BITES HAPPEN?  Shock/Hypotension
 Snake bite is an occupational hazard of rice farmers  Cardiac Arrhythmias
 Most snake bites happen when the snake is trodden on (stepped on) o Commonly are Bradycardia
 The snake may be picked up:  Pulmonary Edema
o Unintentionally in a handful of foliage  Conjunctival Edema (Chemosis)
o or Intentionally by someone who is trying to show off
 Some bites occur at home during the night in search of its prey BLEEDING AND CLOTTING DISORDERS
Traumatic and Spontaneous Systemic
Picture On Left:  Intracranial hemorrhage
Snake Whisperer (Abu Zarin Hussin)  Epistaxis
 Hemoptysis
The 33-year-old Malaysian firefighter  Hematemesis
who had earned the name the “snake  Melena
whisperer” died Friday, a few days  Hematuria
after he was bitten by a cobra. Hussin  Vaginal bleeding
was rushed to a hospital Monday  Skin (Petechiae, Purpura, Ecchymoses)
after he was bitten in Bentong in the
state of Pahang, the Malaysian news
outlet the Star Online reported
INFECTIOUS DISEASES
Topic: Snake Bite
NEUROLOGICAL MANIFESTATIONS MANAGEMENT

 Drowsiness  The first aid being currently recommended is based around the
 Paresthesia mnemonic:
 Abnormalities of taste and smell “Do it R.I.G.H.T.”
 Ptosis  R = Reassure the patient. 70% of all snakebites are from non-venomous
 External ophthalmoplegia species. Only 50% of bites by venomous species actually envenomate
 Paralysis of facial muscles and other muscles innervated by the cranial the patient
nerves  I = Immobilise in the same way as a fractured limb. Use bandages or
 Aphonia cloth to hold the splints, not to block the blood supply or apply pressure.
 Difficulty in swallowing Do not apply any compression in the form of tight ligatures, they can be
 Respiratory and generalized flaccid paralysis dangerous!
 G. H. = Get to Hospital Immediately. Traditional remedies have NO
Lecture Discussion: PROVEN benefit in treating snakebite.
What we have to remember here is that what is evident in neurological  T = Tell the doctor of any systemic symptoms such as ptosis that
manifestations are ABNORMALITIES OF THE CRANIAL NERVES manifest on the way to hospital.
SKELETAL MUSCLE FIRST AID TREATMENT

 Generalized pain  Aims of first-aid attempt to retard systemic absorption of venom
 Stiffness  Preserve life and prevent complications before the patient can receive
 Tenderness of muscles Very common in patients who are medical care
bitten by Kraits or Sea Snakes
 Trismus  Control distressing or dangerous early symptoms of envenoming
 Myoglobinuria  Arrange the transport of the patient to a place where they can receive
 Hyperkalemia medical care
 Cardiac Arrest  ABOVE ALL, AIM TO DO NO HARM!
 Acute Renal Failure
 Reassure the victim who may be very anxious
RENAL  Immobilize the patient’s body by laying down in a comfortable and safe
 Lower back pain position
 Hematuria  Immobilize the bitten limb with a splint or sling
 Hemoglobinuria o Any movement or muscular contraction increases absorption of
 Myoglobinuria venom into the blood stream and lymphatics
 Oliguria/Anuria  Avoid any interference with the bite wound such as:
 Symptoms of Signs and Uremia o Incisions, rubbing, vigorous cleaning, massage, application of
herbs or chemicals
 As this may introduce infection, increase absorption of
venom and increase local bleeding
Snake bites are unlike rabies bites wherein we
need to clean the bite wound. It is recommended
that we do not do any interference at the site of
the snake bite
 Tight (arterial) tourniquets are NOT RECOMMENDED (level of

evidence E):
o Traditional tight (arterial) tourniquets are not recommended.
To be effective, these had to be applied around the upper part
of the limb so tightly that the peripheral pulse gets occluded.
This method can be extremely painful and very dangerous if
the tourniquet was left on for too long (more than above 40
minutes), as the limb might be damaged by ischemia.
Tourniquets have caused many gangrenous limbs
**This was skipped during the Lecture**
Transport to Hospital
 Treatment in the Hospital
o Rapid primary clinical assessment and resuscitation: ABCDE
approach
 Airway
 Breathing (respiratory movements)
 Circulation
 Disability of the nervous system (level of
consciousness)
 Exposure and environmental control (protect from
cold, risk of drowning etc.)
INFECTIOUS DISEASES
Topic: Snake Bite
Lecture Discussion: ABCDE Approach LABORATORY TESTS

How do we know if the patient is breathing? We can know if the person is  20-minute whole blood clotting test (20WBCT)
breathing on his own by looking at the rise and fall of chest o Place 2 ml of freshly sampled venous blood in a small, new
or heat cleaned, dry, glass vessel
Consciousness of the patient can be assessed using the Glasgow Coma Scale o Leave undisturbed for 20 minutes at ambient
temperature
Treatment in the Hospital continued….. o Tip the vessel once
 Clinical Situations requiring Urgent Resuscitation: o If the blood is still liquid (unclotted) and runs out, the
o Profound hypotension patient has hypofibrinogenaemia (incoagulable blood) as
 Release of inflammatory vasoactive mediators a result of venom induced consumption coagulopathy
 Anaphylaxis induced by the venom itself o In the South-East Asia region, incoagulable blood is
o Terminal Respiratory Failure diagnostic of a viper bite and rules out an elapid bite
 Paralysis of the respiratory muscles o Warning! If the vessel used for the test is not made of
 There will be a need to intubate the patient ordinary glass, or if it has been cleaned with detergent,
o Cardiac Arrest its wall may not stimulate clotting ofthe blood sample
 Precipitated by hyperkalemia (surface activation of factor XI – Hageman factor) and
 If patient is pulseless = do rescue maneuvers test will be invalid
(ACLS/BLS) o If there is any doubt, repeat the test in duplicate, including
 Giving of vasopressors (epinephrine) a “control” (blood from a healthy person)
 Hemoglobin concentration/Hematocrit
o Vasculotoxic patients  Platelet count
 Bleeding from multiple orifices with hypotension,  White blood cell count
reduced urine output, obtunded mentation (drowsy,  Blood film
confused), cold extremities  Plasma/Serum
1. Need urgent attention  Biochemical abnormalities:
2. ICU care o Aminotransferases and muscle enzymes
3. Volume replacement  Arterial blood gases and pH
4. Pressor support  Urine examination
5. Dialysis
6. Infusion of blood and blood products WHAT IS ANTIVENOM?
o Neuroparalytic patients
 Respiratory paralysis, tachypnea or bradypnea or
paradoxical respiration, obtunded mentation, and
peripheral skeletal muscle paralysis
1. Need urgent ventilator management
2. Endotracheal intubation
3. Ventilation bag or Ventilator assistance
DETAILED CLINICAL ASSESSMENT AND SPECIES DIAGNOSIS

 A precise history of circumstances of the bite and the progression of
local and systemic symptoms and signs is very important
o “IN WHAT PART OF THE BODY HAVE YOU BEEN BITTEN?”
o “WHEN AND UNDER WHAT CIRCUMSTANCES WERE YOU
BITTEN?”
o “Where is the snake that bit you?”
o “How are you feeling now?”
 Physical examination: General examination

o Measure the blood pressure and heart rate
o Examine the skin and mucous membranes
o The conjunctivae
o Thoroughly examine the gingival sulci
o Abdominal tenderness
o Loin (low back) pain Lecture Discussion: Antivenom
o Intracranial hemorrhage From the picture itself, we can see that initially it is coming from a horse (an
o Convulsions or impaired consciousness animal that is already immunized to the venom toxoid). Initially we get a
venom from the snake and then introduced to an animal and then later blood
will be taken from the animal to be purified for us to get the antibody,
concentrate it  we now get a Purified Cobra Antivenom (PCAV)
RITM is the only cobra snake antivenom producer and distributor in the
Philippines
INFECTIOUS DISEASES
Topic: Snake Bite
Antivenom Treatment: Administration of Antivenom:

 First introduced by Albert Calmette at the Institut Pasteur in Saigon  Freeze-dried (lyophilised) antivenoms are reconstituted, usually with 10
1890s ml of sterile water for injection per ampoule
 Immunoglobulin purified from the plasma of:  Two methods of administration are recommended:
o Horse 1. Intravenous “push” injection:
o Mule o Reconstituted freeze-dried antivenom or neat liquid
o Donkey (Equine) antivenom is given by slow intravenous injection (not
o Sheep (Ovine) more than 2 ml/minute)
o This method has the advantage that the
that has been immunized with the venoms of one or more species of doctor/nurse/dispenser giving the antivenom must
snakes remain with the patient during the time when some
early reactions may develop. It is also economical,
“Specific” Antivenom: saving the use of intravenous fluids, giving sets,
 Contain specific antibody that will neutralize that particular venom and cannulae etc.
perhaps the venoms of closely related species (Paraspecific 2. Intravenous infusion:
Neutralization) o Reconstituted freeze-dried or neat liquid antivenom is
diluted in approximately 5-10 ml of isotonic fluid per
1. Monovalent (Monospecific) Antivenom kg body weight
o Neutralizes the venom of only one species of snake o Example: 250-500 ml of isotonic saline or 5% dextrose
in the case of an adult patient) and is infused at a
2. Polyvalent (Polyspecific) Antivenom constant rate over a period of about one hour.
o Neutralizes the venom of several different species of snakes,
usually the most important species, from a medical point of Patient must be closely observed for at least 1 hour after starting
view, in a particular geographical area intravenous antivenom administration, so that early anaphylactic antivenom
reactions can be detected and treated early with epinephrine (adrenaline)
Indications for Antivenom Treatment:
 Antivenom should be given only to patients in whom benefits are
HOW LONG AFTER THE BITE CAN ANTIVENOM BE EXPECTED TO BE
considered likely to exceed its risks. Since antivenom is relatively costly
EFFECTIVE?
and often in limited supply, it should not be used indiscriminately. The
 It may reverse systemic envenoming even when this has persisted for
risk of reactions should always be taken into consideration (level of
several days or, in the case of haemostatic abnormalities, for two or
evidence E)
more weeks.
 Antivenom treatment is recommended if and when a patient with
proven or suspected snake-bite develops one or more of the following
CAN WE DO LOCAL ADMINISTRATION OF THE ANTIVENOM?
signs:
 Local administration of antivenom at the site of the bite is not
o Systemic Envenoming
recommended:
 Haemostatic abnormalities: spontaneous systemic
o It should not be used as it is extremely painful
bleeding (clinical), coagulopathy (20WBCT or other
o May increase intracompartmental pressure
laboratory such as prothrombin time) or
o Not been shown to be effective
thrombocytopenia (<100 x 109/liter) (laboratory)
 Neurotoxic signs: ptosis, external ophthalmoplegia,  Intramuscular injection of antivenom:
paralysis etc (clinical) o Antivenoms are large molecules
 Cardiovascular abnormalities: hypotension, shock, o Are absorbed slowly via lymphatics
cardiac arrhythmia (clinical), abnormal ECG o Bioavailability is poor
 Acute renal failure: oliguria/anuria (clinical), rising o Pain of injection of large volumes of antivenom
blood creatinine/ urea (laboratory)
 (Hemoglobin-/myoglobin-uria:) dark brown urine DOSE OF ANTIVENOM
(clinical), urine dipsticks, other evidence of  No image available
intravascular hemolysis or generalized  Basically, the table shown during the lecture only gives us an idea that
rhabdomyolysis (muscle aches and pains, if the country is Category 2  there will be different manufacturers of
hyperkaliemia) (clinical, laboratory) the antivenom. Category 1 (like the Philippines)  RITM is the sole
 Supporting laboratory evidence of systemic producer and distributor of antivenom
envenoming
o Local Envenoming Picture on Left:
 Local swelling involving more than half of the bitten This is a study that shows that the
limb (in the absence of a tourniquet) Philippines should also buy the
 Swelling after bites on the digits (toes and especially polyvalent antivenom because
fingers) there is another species of
 Rapid extension of swelling (for example beyond the venomous snake that is increasing
wrist or ankle within a few hours of bites on the hands (it is the Samar Cobra). Since there
is no polyvalent antivenom
or feet)
available here, there is a need to
 Development of an enlarged tender lymph node
double the dose of monovalent
draining the bitten limb
antivenom = too expensive for
patients bitten by the Samar Cobra
INFECTIOUS DISEASES
Topic: Snake Bite
RESPONSE TO ANTIVENOM  Dark Brown Urine (Myoglobinuria or Hemoglobinuria):

General Patients: o Correct hypovolemia with intravenous fluid
 The patient feels better o Correct acidosis with a slow IV infusion of 5-100 mmoL of
o Nausea, headache and generalized aches and pains may sodium
disappear very quickly o Consider a single infusion of mannitol- 200 mL of 20% mannitol
 Spontaneous systemic bleeding (e.g. from the gums): may be infused IV over 20 minutes
o This usually stops within 15-30 minutes
 Blood coagulability (as measured by 20WBCT)
o This is usually restored in 3-9 hours
 Bleeding from new and partly healed wounds
o Stops much sooner than this
In Shocked Patients:
 Blood pressure may increase
o Within the first 30-60 minutes
o Arrhythmias and sinus bradycardia may resolve
 Neurotoxic envenoming of the post-synaptic type (Cobra bites)
o Begin to improve as early as 30 minutes after antivenom, but
usually takes several hours
 Active hemolysis and rhabdomyolysis
o Cease within a few hours and the urine return to its normal  Severe Local Envenoming: Local Necrosis/Intracompartmental
color Syndromes
o Surgical intervention may be needed
ANTIVENOM REACTION o Prophylactic broad spectrum antimicrobial treatment is
 Epinephrine (Adrenaline) should always be drawn up in readiness justified
before antivenom is administered
At the earliest sign of a reaction:

 Antivenom administration must be temporarily suspended
 Epinephrine (adrenaline) (0.1% solution, 1 in 1,000, 1 mg/mL) is the
effective treatment for early anaphylactic and pyrogenic antivenom
reactions
WHAT IF?
 What if there is no antivenom? What will you do?
o What we should do is conservative management (alleviate
the patient’s symptoms)
Conservative Treatment when No Antivenom is Available

 Neurotoxic envenoming with respiratory paralysis
o Assisted ventilation. This has proved effective, and has been
followed by complete recovery, even after being maintained
for periods of more than one month.
o Manual ventilation (anesthetic bag) by relays of doctors,
medical students, relatives and nurses has been effective
where no mechanical ventilator was available.
o Anticholinesterases should always be tried
 Hemostatic Abnormalities
o Strict bed rest to avoid even minor trauma
o Transfusion of clotting factors and platelets
o Ideally, fresh frozen plasma and cryoprecipitate with platelet
concentrates
 If these are not available, fresh whole blood
o Intramuscular injections should be avoided
 Shock/Myocardial Damage
o Hypovolemia should be corrected with colloid/ crystalloids
o Controlled by observation of the central venous pressure
o Ancillary pressor drugs (dopamine or epinephrine-adrenaline)
may also be needed
o Patients with hypotension associated with bradycardia should
be treated with atropine
INFECTIOUS DISEASES
Topic: Rabies
ANIMAL BITES: RABIES
Regions 3, 4-A, 5 and 12

reported the most number
of cases from 2008 to 2018
 95% Rabies death occurs in Asia and Africa

 Rabies is a major public health problem
o Fatal once symptoms appear
o One death every 15 mins. worldwide News report cases of
o 99% human cases result from dog bites rabies every now and
o 4 out of 10 deaths are in children then to keep us aware
 Rabies is 100% vaccine preventable that there a lot of lives
o Vaccinate to save lives taken away by this
o Vaccinate to stop transmission infection
o No bites = No rabies
 Zero by 2030
 September 28 – World Rabies Day SPECIES AFFECTED BY RABIES
 Factors for rabies incidence (WHO, 2013):
o Poverty  Canine (Dog samples):
o Poor sanitation common
o Crowding  Category 2: Predominates
in all cases
 Male patients are common
to be bitten
 Age >15 years old
predominates
 Most are domestically
owned
R.A. No. 9482: ANTI RABIES ACT OF 2007

 Goals:
o Adequate funding for Vaccine production
o Eliminate Rabies and Declare Philippines as Rabies Free
Country by 2030
Lecture Discussion: Rabies, Countries or Areas at Risk  This law penalizes irresponsible dog owners
2 Countries are shaded light green  means there is no risk of rabies

infection at all Fine for Irresponsible Owners:
 Japan  500 – dog became stray
 New Zealand because it was not caged or
leashed
Africa and Asia in general are shaded red  high risk of rabies infection  2,000 – owner refuses to get
 Travelers who want to visit some countries here  WHO their dog vaccinated
recommends that they get pre-exposure immunization (PrEP)  10,000 – unvaccinated dog bit
 Other people whom contact with domestic animals is very likely someone
(e.g. dogs and other vectors of rabies)  get also PrEP  25,000 – unvaccinated dog bit
someone and the owner
refuses to give help/
assistance to the victim
 Although we have this law in the Philippines, the problem right now is
implementation
INFECTIOUS DISEASES
Topic: Rabies
RABIES Non-bite exposures are less important and are infrequent modes of
 An infectious Viral disease caused by Lyssa Virus transmission:
 Envelope, ssRNA virus under the family Rhabdoviridae  Contamination of intact mucosa (eyes, nose, mouth, genitalia) with the
 This viral infection is mainly spread by infected animals saliva of infected animal
 Mode of transmission: Close contact with infected saliva from rabid  Licks on broken skin
animals  Inhalation of aerosolized virus in closed areas (e.g. caves with rabid
bats, laboratories for rabies diagnosis)
Rhabdovirus:
1. Rabies – meningoencephalitis Lecture Discussion: Non-bite exposures in the Clinical Setting
2. Ebola – hemorrhagic fever Non-bite exposures can happen in the clinical setting  intubating of a
3. Marburg – hemorrhagic fever rabies infected patient
 When this happens, the team involved in intubating will need to be
CASE: given vaccination
Pathology of Rabies Infection
 Case above is a rat bite

 However, bites from rats, rabbits, other rodents, reptiles and birds
do not pose a risk for rabies infection
What if the patient is asking you “Do I need to receive an anti-rabies

vaccination?”
 No, it is not necessary to take PEP in bite cases by house rats
(domesticated rats)
 If the patient is bitten by wild rats/rodents  prudent to take PEP
from an infectious disease physician  Entry of infection  virus is introduced from a rabid dog bite (the virus
is present in saliva)
 Initially, virus will replicate on the muscle where the patient was bitten
 Main objective of the virus is to ascend to the brain, so it will utilize the
nervous system, starting from the peripheral nervous system to the CNS
 Virus ascends spinal cord
 Virus reaches the brain and causes fatal encephalitis
 Once it reaches the brain, it will spread to different organs, one of which
is the salivary glands
 Although rat rabies is extremely rare  if the patient is willing to

JEANNA GIESE:
pay then you can give the vaccine. The difference is that the
regimen you will give is the pre-exposure prophylaxis (PrEP)
wherein you just give 3 doses
How to treat a Rat Bite:
 While she was trekking on a park, she saw a bat lying on the ground.
Due to her curiosity, not knowing it was rabid, she picked it up and
was bitten
 When her symptoms appeared she was rushed to the hospital and
the Milwaukee protocol wherein she was induced to a comatose
state and antiviral medication was given
 She was able to survive the rabies infection  In 2011, she was able
to graduate from college
Trivia about Jeanna Giese:
 Jeanna Giese was only 15 yrs. old when she became the world’s first
known survivor of Rabies without receiving any vaccination
 New method of Rabies treatment was formulated, known as
 Control bleeding Milwaukee protocol developed by Rodney Willoughby Jr. and is a
 Clean the wound with soap and warm water treatment used in rabies-infected human beings
 Apply antibiotic ointment  It involves chemically inducing the patient into a coma, followed by
 Cover with a clean, dry dressing the administration of antiviral drugs combined with ketamine and
 Watch for signs of infection amantadine
INFECTIOUS DISEASES
Topic: Rabies
INCUBATION PERIOD STAGES OF HUMAN RABIES INFECTION
 Once the virus enters the body, it will initially in an incubation period
 Incubation period  it is the phase where there is presence of the virus
but no signs and symptoms develops
o Length of incubation period depends on:
 Infecting strain
 Size of inoculum
 Prodrome  stage where you develop the classic manifestations
 Degree of innervation
o Typical constitutional signs like fever, headache, malaise,
 Proximity to CNS
irritability, nausea and vomiting
o It can happen within months or even years
o The virus has already arrived at the CNS
 Incubation period  best time to give the 2 types of vaccines
o Duration 2-10 days
o Active vaccine – takes care of the virus that has a slow phase
 Acute neurologic phase  stage where you see the encephalitic or
of ascending infection
paralytic rabies
o Passive vaccine – introducing antibodies to immediately kill
o Symptoms are hyperexcitability, hyperactivity, hallucinations,
any virus (creates an immediate response)
excessive salivation, hydrophobia, and aerophobia
o Duration 1 week
Incubation Period
 Coma  stage where patient becomes calm
 Average: 1-3 months (90-95% of cases)
o Results from the damage to brain stem and hypothalamus
 >1 year (5-10% of cases)
o Virus is spread to other organs  multiorgan failure and
 Duration of incubation period depends on certain factors:
autonomic instability
o The amount of the virus inoculated into the wound or mucosa
o Duration 5-14 days
o Severity of exposure
 Death
 Patients with multiple and/or deep penetrating bite
o Cumulative impact of cardiac, respiratory, and organ failure
wounds may have shorter incubation period
from other stages  increased risk cardiac arrhythmias and
o Location of exposure
respiratory depression
 Patients with bite wounds in highly innervated areas
o Duration is variable
and/or close to the CNS may have shorter incubation
period
Acute Neurologic Stage
 Is the stage when the virus reaches the CNS and replicates most
 In vitro studies show that velocity of axonal transport of the virus exclusively within the gray matter
ranges from 25 to 50 mm per day  Has 2 types: Neurologic or Paralytic
 The spread of the rabies virus in the coulometer and optic nerves
could be as fast as 12 mm/day
 This happens in patients who are bitten on the head or
near the vicinity of the CNS
 Neurologic/Furious Type – accounts for 80-90%

o Classic manifestations are seen here: hydrophobia and
aerophobia
 Paralytic/Dumb Type – accounts for 10-20%
o Silent type
 Incubation period is the 1st stage of human rabies infection o Manifestation: paralysis, muscle fasciculation, and sensory
disturbance
INFECTIOUS DISEASES
Topic: Rabies
Coma
 Begins within 5-10 days after symptoms start
 Cardiac arrhythmias is common
 Hyperventilation which leads to periodic and ataxic respiration to apnea
 Hematemesis is experienced by 30-60% of patients before death
 Pituitary dysfunction is also present as part of disordered water balance
LABORATORY DIAGNOSIS
 Category 3 examples:
o For letter c)  intubation of rabies infected patients
o For letter e)  Kinilaw/Kilawin na aso, a type of dish wherein
dog meat is prepared raw (uncooked) and is cured in vinegar
 NOTE: If meat is properly cooked (through heat) 
rabies virus will die because they are sensitive to heat
Case What Category Is It?
CATEGORY OF EXPOSURE
Category 3  because although it is a minor or
superficial scratch, since it is located on the face,
Dog owners fall on this category it is automatically elevated to Category 3
Category 3  it is also a minor or superficial

scratch but since it is bleeding spontaneously
then it is Category 3
Category 3  because it is a bite with punctured

wounds
ACTIVE VS. PASSIVE IMMUNITY
Remember this! Even if it is a Category 2 exposure,

if it is in the head and neck  automatically
elevated to Category 3
INFECTIOUS DISEASES
Topic: Rabies
 Most patients are initially okay to receive the vaccine BUT if they will be
given the idea that they are to receive 2 types of rabies vaccine, they
will now become hesitant. Why is this so?
o Due to the payment
o Another is injecting it on the site of bite (very painful)
 As physicians, we need to be able to explain the importance of them
receiving the 2 types of vaccine to prevent the rabies infection
o Explain to the patient that once symptoms already manifest 
it is already late and nothing can be done to reverse the
condition
ACTIVE RABIES VACCINE  Intramuscular  uses 1.0 mL dose and the syringe is angulated at a 90o
angle for it to hit the muscle
How to Perform the ID and IM PEP regimen
 3 Types of Active Vaccines:

o Verorab
o Rabipur
o Speeda
 Vials are usually prepared as 1.0 mL and route of administration is

either ID or IM Lecture Discussion:
o In private practice, we usually give the whole 1.0 mL vial When doing the intradermal method, this is the dosing  2-2-2-0-2
o An alternative practice is that we can use just 0.1 mL of it so it  Schedule: 0, 3, 7 and 28
can be divided into 10  more will be shared with the vaccine  Initially, the patient will have 1 dose (0.1 mL) given ID at 2 sites (right
 This practice was initially introduced by WHO and left deltoid)
 Each time the patient goes back to you (starting day 0), you give it
at the 2 sites
 Based on the latest guidelines  day 28 can be omitted. This means
that the patient can just receive until day 7 (2-2-2-0)
Lecture Discussion:
When doing the intramuscular method, this is the dosing  1-1-1-1-1
 5 dose IM regimen
 Schedule: 0, 3, 7, 14 and 28
 Give the vaccine on the deltoid region
 If the patient cannot comply with this schedule, then a different
schedule may be utilized  2-1-1 regimen
 Intradermal  uses 0.1 mL dose and you angulate the syringe in a 15o
angle so that it will not penetrate the subcutaneous and muscle.
Vaccine is introduced in between the epidermis and dermis
INFECTIOUS DISEASES
Topic: Rabies
How to give the Passive Vaccine:

 It is directly injected on the site of bite
o So if a patient is bitten on the face, then you inoculate the
passive vaccine on the face
Lecture Discussion:
Alternative schedule for IM method  2-1-1
 No anesthesia is given because it will just intervene with the vaccine
 2-0-1-0-1
 2 doses are given on day 0 on the right and left deltoid  If the patient has multiple bite sites, then distribute the vaccine to the
 If the patient is a child, inject it on the right and left thigh different areas using the computed dose
 Patient must go back for an additional dose on day 7 and 21  If the computed dose is lesser than what is needed by the patient, you
can dilute the vaccine with sterile water to at least 2x
PASSIVE RABIES VACCINE
 When a patient receives the full vaccination at day 7, at day 14, 90 or

 HRIG  immune globulins are from humans. It is more expensive
after 1 year  there is seroconversion
because you will be needing more vials (as it is only prepared at 2
o Seroconversion is the transition from the point of viral
mL/vial)
infection to when antibodies of the virus become present in
 ERIG  immune globulins are from horses (equine). It is more
the blood
affordable than HRIG (prepared at 5 mL/vial)
 What if the patient did not comeback at day 7?
o Then the seroconversion will be lesser (less production of
antibodies against the rabies virus)
MANAGEMENT OF REACTION
Anaphylaxis
 Give 0.1% adrenaline or epinephrine (1:1,000 or 1 mg/mL) underneath
the skin (subcutaneous) or into the muscle (intramuscular)
o Adult – 0.5 mL
 Comparing the use of HRIG vs. ERIG on a 50 kg patient: o Children – 0.01 mL/kg, maximum of 0.5 mL
o For HRIG, you will be needing 1000 IU  Repeat epinephrine dose every 10-20 minutes for 3 doses
 1000 / 150 (since each vial has 150 IU/mL) = 6.6 mL  Give steroids after epinephrine
 6.6 / 2 (since each vial has 2 mL) = 3.3 vials needed
 You cannot buy a 3.3 vial in the market so you Hypersensitivity Reactions
will be needing a total of 4 vials  Give antihistamines, either as single drug or in combination
 If status quo for 48 hrs. despite combination of antihistamines, may give
o For ERIG, you will needing 2000 IU short course (5-7 days) of combined oral antihistamines plus steroids
 2000 / 200 (since each vial has 200 IU/mL) = 10 mL  If patient worsens and condition requires hospitalization or becomes
 10 / 5 (since each vial has 5 mL) = 2 vials needed life threatening, may give IV steroids in addition to antihistamines
 We can see from the computation that although HRIG requires a lower
IU, since its preparation contains less  it is much more expensive
INFECTIOUS DISEASES
Topic: Rabies
CRITERIA FOR HIGH AND LOW RISK EXPOSURES ADDITIONAL VACCINE
 If the patient does not know his vaccination history about anti-tetanus
 give tetanus toxoid (Td) and TIG/ATS
o Td  active immunization
o TIG/ATS  passive immunization
 Td is given on the deltoid
 TIG/ATS is directly inoculated on the site of bite
MEDICAL MANAGEMENT OF ANIMAL BITES
Key steps in medical management of bite wounds: CLINICAL MANAGEMENT
 Considering the fatal outcome and absence of cure for human rabies
 Wash with soap and water
once signs and symptoms begin, management should center on
 Liberal irrigation
ensuring comfort for the patient, using sedation, avoiding intubation
 Debridement of devitalized tissue
and life support measures
 If signs of infection are present:
o Swab for culture
o Antibiotic therapy
 Immediate suturing of the wound – not advisable
Antibiotic Use in Wound Management:

 In any classification of any animal bites, these are the medications you
can give
 Recommended antimicrobials for frankly infected wounds include:
o Amoxicillin/clavulanic
 Adults - 500 mg p.o. TID
 Children - 30-45 mg/kg/day in 3 divided doses SUPPORTIVE CARE
o Cloxacillin  Patients should be admitted in a quiet, draft-free, isolation room
 Adults - 500 mg p.o. QID  IV fluids may be given
 Children - 10-150-100 mg/kg/day in 4 divided doses  Invasive and Heroic procedures must be avoided. (Intubation,
o Cefuroximeaxetil Mechanical Ventilation, Cutdown)
 Adults - 500 mg p.o. BID  Provide suitable emotional and physical support
 Children - 10-15 mg/kg/day in 2 divided doses  Discuss and provide important information to relatives concerning
transmission of disease and indication for post-exposure prophylaxis of
contacts.
 Honest gentle communication concerning prognosis should be provided
to the relatives
ISOLATION ROOM
 Isolation rooms are advised to minimize harm on patients and care
givers
 Rooms should be draft-free; with grilled windows and doors that can be
locked from outside
INFECTIOUS DISEASES
Topic: Diarrhea
Lecturer: Dr. Fortuno
INCIDENCE NORMAL PHYSIOLOGY

 Rank second only to respiratory tract infections as the most common  Digestion starts from the mouth
illness worldwide Digestion starts when our mouth start to masticate whatever food
 The reason why it is only ranked 2nd is because diarrhea can range from we put into it. So the mere act of masticating food is already
mild annoyances, that we often do not seek any medical attention, or it digestion. We also have enzymes in our mouth which are salivary
can also lead to death (especially in the extremes of ages  the young enzymes (amylase). So the initial digestion starts in the mouth by
and the very old) the secretion of amylase and by the action of our teeth, tongue and
mouth
 Diarrhea is underreported because it is usually self-limited. In our
experience before when we have bouts of diarrhea, we really do not
seek medical attention. We just wait for it to resolve itself and not  Food goes down to the esophagus going into the stomach and small
intestines
taking any medicine or without consulting any healthcare practitioner
 Esophagus also has peristaltic movements  so the esophagus is NOT
involved in the digestion but rather movement of the food particles
CASE 1: from the mouth down to our stomach and then into the small intestines
A 29 year old female teacher trainee reports passage of loose stools over the  Primary function of the small intestine:
past 2 months. She notices this whenever her school principal sits in her class
o Digestion and assimilation of food nutrients
to observe and grade her. She also feels epigastric discomfort but is relieved
after defecating. The stools are scanty but semi watery
Functions at different anatomical levels:
 Stomach and small intestines
A. What other questions will you ask in her history? o Synchronized MMCs (migrating motor complexes) in fasting –
 We can ask if there are any other associated symptoms such as fever clears non-digestible residues from the small intestines
during the past 2 months that she is having these kind of symptoms MMCs are found in the stomach and small intestines. If you
 We can also assess the dehydration of the patient are not eating now and only sitting to listen on the lecture,
 Ask also how often does the school principal sits on her class then what is being innervated are the migrating motor
o This is important to know because we want to find out if the complexes (MMCs)
diarrhea is related to the number of times she is being Once food is staying in our stomach and small intestines 
observed by the school principal. The diarrhea might be the stomach and small intestines will then serve as
happening for the past 2 months but if the principal only comes reservoir
to her class once a month  we cannot say that the patient is If you think that you are not digesting the food the you ate
dehydrated yesterday or recently  in reality, you are already digesting
it BUT you just do not notice it due to the fine movements
o The number of times that the school principal sits in her class
of our MMCs
would equate to the number of times that she experiences the
epigastric discomfort and passage of scanty semi watery stools
o Ileal reservoir empties boluses
o It does not matter how long the patient has been having the
o Accommodation, mixing, transit
symptoms but what is more important is what is the frequency
 Stomach – 3 hours
of these symptoms in the duration of the past 2 months
 Small bowel – 3 hours
If you know that the food will stay in our stomach for 3
B. What are the possible causes of this condition?
hours, is it still advisable for you as future doctors to say
 The cause of the patient’s diarrhea is her nervousness (whenever that you need to space out taking tablets (drugs) ~ taking it
observed by the principal) every 30 minutes after eating?
 Nervousness  what is innervated is the parasympathetic (autonomic)  Example you are presented with a patient that is
nervous system prescribed to be taking 4 medicines (to be taken
 Defecation  parasympathetic nervous system is what is active after breakfast) and he asks you “Doctor, can I
(innervating our GI tract) take all of these 4 tablets at the same time? Or
o Remember that the sympathetic system is for the fight and must I put a certain space (interval) whenever I
flight response so you do not defecate where you are going take these tablets?”
into a fight! You do not defecate when you are running from a  As doctor, your answer would be you can take all
the 4 tablets in one sitting  because it will be
fight! You hold your bowels
staying there anyway in the next 3 hours SO there
o So any kind of increase innervation to the parasympathetic
is no need to space out giving the tablets to the
nervous system would cause us to have an ↑ GI motility  patients
there will be ↑ mucus secretion  The only thing that is important is WHEN THE
o ↑ firing of the parasympathetic (autonomic) nervous system = MEDICINE SHOULD BE GIVEN (e.g. before or after
↑ GI motility & mucus secretion and ↓ water, nutrient, & breakfast)
electrolyte absorption  You do not anymore have to tell that the patient
 Is this a case of Diarrhea? Yes, but not of the usual etiologies of should take the medicines 1 hour apart until you
diarrhea because its etiology is the nervousness that she feels finish all the medicines  If you do that, there is
a chance that he might forget taking the medicine
C. Manage the patient because of the spaced out interval of taking them
INFECTIOUS DISEASES
Topic: Diarrhea
SMALL AND LARGE INTESTINES  The number of resident bacteria in our GI tract not only protect us from
 Regulates secretion and absorption of water and electrolytes pathogenic bacteria but they also improve our nervous system, and
 Storage of intra-luminal contents protect our heart because we will have less pathogenic bacteria in the
The small and large intestines not only serve as reservoir for food GI tract
but also pathogenic bacteria or viruses that the patient may have o This is why many studies suggest the intake of pro-biotic
ingested supplements
o Diabetics  when given pro-biotics, there is an increased
 Transport of intra-luminal contents aborally (into the rectum) benefit in lowering the glucose level
 Salvage some nutrients from bacterial metabolism of carbohydrates
that are not absorbed in the small intestines COLON
Remember that our resident bacteria are there not only to protect  Irregular mixing, fermentation, absorption and transit
us from pathogenic bacteria, but also to digest carbohydrates. The  The colon has 3 parts: ascending, transverse and conduit (descending)
resident bacteria that we have NO ROLE in absorbing non- o Reservoir: ascending and transverse (15 hours)
carbohydrate food particles o Conduit: descending (3 hours)
Conduit is the descending part  due to its shape, it allows
ILEO-COLONIC STORAGE the food particles to move out into the sigmoid and rectum
 This is a very important part of the GI tract because that is when the
small caliber intestines suddenly becomes the large caliber colon o Sigmoid and rectum: volitional reservoir
 This is where most obstructions and diseases will take place Any abnormalities of the sigmoid or rectum will cause any
 Distal ileum empties intermittently by bolus movements patient to be incontinent
 Facilitates mixing, retention of residues and formation of solid stool
Stools will now become solid when it enters the colon Colonic Motility and Tone
 MMC rarely reach the colon
 HAPC
o High amplitude propagating complexes
o Associated with mass movements throughout the colon
o Up to 5 times per day in the AM and post-prandially
 It will depend on the individual how many times the
HAPC will fire in a day
 Occurs usually in the morning or after eating
o Increased frequency results in diarrhea or urgency
DEFECATION
 It is a complex process because it is elicited by the presence of fecal
material in the rectum, and the fecal material is there due to the
peristaltic movement of the colon. Once it is there, our sensory stimuli
in the anal canal will provoke a sudden drop of tone of the internal anal
Picture Above: Crypts of Liberkuhn sphincter. Once there is now less control of the sphincter (there is also
The Crypts of Liberkuhn are structures within the lamina propria of the relaxation of the puborectalis muscle & levator muscle)  will lead to
colon. It is where the stem cells of the GI epithelial cells reside in. So any defecation
destruction of crypts of liberkuhn will already slow down the production of  Defecation is complex because it involves not only the rectum but also
the epithelial cells of the GI tract the brain as well
RESIDENT BACTERIA PSEUDODIARRHEA

 Resident Bacteria  Not diarrhea in the strictest sense
o Necessary in digestion of unabsorbed carbohydrates from the  Pseudodiarrhea – frequent passage of small volumes of stool  with
small intestine rectal urgency  IBS and proctitis
o Also protect the colon from pathogenic bacteria  This should be ruled out in any case of diarrhea
 Our GI tract has its own microbiota. This microbiota are predominantly  Pseudodiarrhea is what our 1st Case had  a cytogenic diarrhea and not
due to our resident bacteria a true diarrhea
 The resident bacteria can be given nutrients by giving pre-biotics Examples of Pseudodiarrhea
o Pre-biotics provide food to the resident bacteria which can be Fecal Incontinence
in the form of fiber, fruits, vegetables or whole grains. These  Involves discharge of fecal contents
are all rich in pre-biotic substances  Usually secondary to neuromuscular disorders and structural anorectal
 Pro-biotics is different from pre-biotics. Pro-biotic supplements on the problems
other hand is when you add good/resident bacteria to the GI tract. o Examples: post-hemorrhoidectomy, CVA, neuromuscular
These can be found in fermented foods such as kimchi, yogurt, & miso disorders
soup
Pre-biotics  increasing the nutrition to the resident bacteria Overflow Diarrhea
Pro-biotics  increasing the number of resident bacteria  Due to fecal impaction – usually occurs on the ascending colon
o If our brain senses an obstruction on the distal colon  there
 So when a person gets diarrhea, it may be because our resident bacteria will be ↑ peristaltic movement which causes overflow
has already decreased its population making it less protective for us diarrhea
from the pathogenic bacteria  Not true diarrhea
INFECTIOUS DISEASES
Topic: Diarrhea
DIARRHEA  Ingested agent overwhelms the host’s immune and non-immune

 2 Components of Diarrhea: mechanism
1. Passage of abnormally liquid or unformed stools o The diarrhea occurs because of the acute infection when the
2. at an increased frequency gut microbiota of the patient is overwhelmed by whatever
What does increased frequency mean? ingested agent he took in  destroying the immune
This is very relative depending on the patient because one mechanism
patient can move her bowels 5x a day while another can
move her bowels only once a day. The one that moves her WHAT ARE THE COMMON CAUSES OF DIARRHEA?
bowels 5x a day is not considered diarrheic because it is her We can group it into 3:
usual routine. So always ask the patient what is her normal  Viral infections – Adenovirus Rotavirus, Norwalk virus
frequency (the times) that she usually passes her stools in
 Bacteria – ETEC, EAEC, EPEC, Vibrio cholera, Campylobacter, Shigella,
a day when she was not yet sick
Salmonella
 Parasites – Cryptosporidium, Giardia, Isospora
 Stool weight increased
 Fungus – an additional cause of diarrhea
Etiologies of Diarrhea
Lecture Discussion:
 Secretory
o Mechanism is an ↑ in electrolyte secretion into the bowel Diarrhea is usually self-limited  no need to give medications
lumen leading to an ↑ water (into lumen) via osmotic pressure
and ↓ nutrient, electrolyte and water absorption Patients that we see in the clinics or hospital, there are usually 3 etiology of
o No destruction of the GI tract diarrhea:
1. Viral infections account most cases of diarrhea:
o Examples: Coffee, Endocrine Disorders (Hyperthyroidism),
 Rotavirus – common among children
Laxative Use, Bacterial enterotoxins
 Adenovirus, Norwalk virus – common among adults
 Osmotic/Malabsorptive States
o Seen in all patients with diarrhea (always present no matter 2. Diarrhea that present with blood in a sample stool or if the patient
what the cause is) notices bleeding in their stool  think of bacteria because they can
o There is always a problem of osmosis destroy the GI epithelial lining
o There is ↓ in water, nutrient, and electrolyte absorption
because of the ↑ osmotic pressure  causing malabsorption 3. You can also think of parasites such as cryptosporidium, giardia and
of intestinal nutrients isospora
o Examples: Antibiotics (acts directly on the intestinal flora), 4. There is another one that can cause diarrhea which are fungus
Decreased digestion, Decreased or Defects in mucosal  But take note that you only see these kind of infection in
transport (intestinal lymphoma, Celiac’s Disease, Whipple’s immunocompromised patients
Disease)
 Inflammatory MODES OF TRANSMISSION
o Expect that there is destruction of the GI tract  Fecal oral route
o There is ↑ mucus production leading to bleeding and ↑ GI o Happens when a person with diarrhea prepares food without
motility washing his hands  now is able to transmit whatever
o ↑ GI motility will cause ↓ water, nutrient, and electrolyte organism he had in his GI tract to the person who will be eating
absorption the prepared food
o Examples: Collagen vascular diseases, Hypersensitivity  Ingestion of contaminated food or water
reactions (to Food), Infectious (due to production of cytotoxins  Sexual activity
of an organism), Inflammatory bowel diseases (e.g. Crohn’s  Less common causes:
disease, Ulcerative Colitis, Intestinal Ischemia) o Leakage around a fecal impaction, narcotic withdrawal,
 Pseudodiarrhea diverticulitis, medications
o Fourth type of diarrhea When you become doctors, you will be prescribing
narcotics to certain groups of patient who have difficulty in
sleeping. Patients who have been taking narcotics for a long
Classification of Diarrhea
time  side effect is CONSTIPATION. Since narcotics wants
When you have a patient with diarrhea, always ask: “When did it start?”  we
to make us sleep, the sympathetic system will be the one
can then classify their diarrhea according to duration
innervated. BUT suddenly withdrawing narcotics will cause
DIARRHEA. So be careful in prescribing narcotics:
 Acute - <2 weeks  Always advise the patient that taking narcotics for
 Persistent – 2-4 weeks a long time will cause Constipation
 Chronic - >1 month  Stopping the intake of narcotics will then cause
the reverse  Diarrhea
ACUTE DIARRHEA
 90% infectious etiology This is important to know because we might be treating a
patient with antibiotics, when in reality, the patient had
 Fecal oral transmission
only narcotic withdrawal which causes his diarrhea. So
 Ingestion of contaminated food and water with pathogens from human
always have a good history of narcotic use
or animal waste
 In elderly patients ~ 10% - medications (laxatives & antibiotics), toxin
ingestions, ischemia (mesenteric ischemia) and other conditions
o Elderly patient may not present with the usual symptoms of a
patient belonging to the general adult population n
INFECTIOUS DISEASES
Topic: Diarrhea
2. Consumers of Certain Foods

CASE 2:
A 46 year old female has abdominal pain in the Right Lower Quadrant and Organism Possible Food Source
weight loss for the past four months. She also notes of low grade intermittent Salmonella, Campylobacter Picnic, Banquet, Restaurants
fever and bouts of bloody diarrhea, sometimes 4-6 times a day. She informs Shigella Chicken
you that she is also being treated for PTB and is currently in the maintenance EHEC Undercooked hamburgers
phase Bacillus cereus Fried rice
Staphylococcus aureus, Salmonella Mayonnaise and Creams
Her vital signs are normal and there is minimal RLQ tenderness but no Salmonella Eggs
palpable masses. Palpebral conjunctiva were pale Vibrio, Salmonella, Hepatitis A Seafood (especially if uncooked)
Take note first of the salient features:  It is important to ask the patients with diarrhea “What is the last food
 Middle aged patient you have taken?”
 Female  If you think that the organism is not in the last meal that was taken,
 RLQ pain then ask the patient the PREVIOUS (PRIOR) MEAL before the last meal
RLQ is an important area because it is where the small intestines because some organisms have longer incubation period
suddenly becomes the large intestines because of the ileocolonic  Think of Shigella when patients eat undercooked chicken and they have
junction. That area will make us think of appendicitis, peritonitis, or bloody diarrhea
obstruction. RLQ is more important than the LLQ because it contains  Food containing eggs such as mayonnaise and creams may harbor the
more important structures (e.g. ileocolonic junction, appendix) toxins of S. aureus or Salmonella
 Always educate your patients that eggs should not be eaten raw. Eating
 Weight loss raw eggs  there is increased risk of acquiring Salmonella infection
 Fever o Best way to prepare eggs? Soft-boiled preparation
 Bloody diarrhea  What is the difference in manifestation Hepatitis A from Vibrio &
It is important to ask patients with blood in their stool the Salmonella?
“description of the blood” because remember, it can be in 2 forms: o Hepatitis A  may have liver involvement (hepatomegaly) and
Oxidized and Non-oxidized yellowing of sclera (icterisiae)
 Oxidized bloody stools – looks black
o So you have to do liver palpation and sclera inspection
 Non-oxidized bloody stools – looks red
How do we have to differentiate melena from blackish stools? CASE 3:

 Melena usually are described as tarry (“sticky”) A 22 year old female patient presents in the ER because of diarrhea. This
 Blackish stools (e.g. due to intake of iron supplements) will started 4 hours ago after eating food served in an office party
not be tarry but only colored black
 So it is important to note the consistency of the stool ~ The food consisted of steamed rice, hard boiled eggs sandwiches with
melena is described as “sticky” mayonnaise and cream puffs
Black stools  usually may come from a source that is far from the While in the ER, the patient felt dizzy and vomited seven times
rectum. It can involve the small intestines or initial part of the colon
 Heat will destroy salmonella so it would not been coming from the hard
A. What is your Impression?
boiled eggs BUT salmonella can be found in mayonnaise and cream
 It is important to note the side effects of drugs (for us to know if it
puffs. Also aside from salmonella, it can also be due to Staph. Aureus
causes something to a patient’s condition). TB drugs have no capacity
to produce diarrhea. So we can think here that the TB infection itself
A. What will you ask about the history?
can be the one causing the diarrhea  this can be a possible case of TB
 Assess the dehydration of the patient
of the colon
o To assess the dehydration of the patient, we can ask “When
B. What is the mechanism involved for this to occur?
was the last time you have urinated?”
 This probably happened because she swallowed a sputum that is filled
 Assess electrolyte imbalance
with M. tuberculosis bacilli. This was able to enter the GI tract ~ the
o Since the patient is vomiting, she is at risk of hyponatremia
large inoculum was able to infect the colon
 If the patient defecates too much (diarrhea), she is at
C. How will you manage the patient?
risk of hypokalemia
 TB of the colon is an extrapulmonary TB so you treat it similarly like
o How do we assess hyponatremia?
PTB. The difference is the duration of giving the medication
 Check for muscle cramps, generalized body weakness
o Extrapulmonary TB  give the drugs for a longer duration
 Check for seizures
 Reassure the patient that her medicine for her PTB is the same medicine
If the patient is an elderly, hyponatremia is life-
that can treat her extrapulmonary TB threatening because they are prone to have
seizures, generalized body weakness and more
FIVE HIGH RISK GROUPS anorexia
1. Travelers – Latin America, Asia, Africa
 ETEC, EAEC, Campylobacter, Shigella, Norvovirus, Coronavirus, o If the patient cannot ambulate but can move the upper
Salmonella extremities = hypokalemia
 Mountaineers, backpackers, backwoods – Giardia o If the patient has generalized body weakness and wants to stay
 Cyclospora in bed most of the time = hyponatremia
 People coming from DEVELOPED countries going to DEVELOPING
countries  think more of bacteria and parasites as etiology Continued next page…..
INFECTIOUS DISEASES
Topic: Diarrhea
B. Is this an admissible case? 4. Day Care Patients and their Caregivers

 Yes because the patient is already vomiting 7x already. She has not been  These are patients living in day care or long-term care facilities
taking anything but she vomits. If we let the patient go home with o Long-term care facilities have ambulatory and non-
prescribed medications, the patient will just come back to you ambulatory patients
complaining that she keeps on vomiting all the medicines she is taking o Non-ambulatory patients are being taken care of by a
 In patients who are vomiting several times (they are at risk of caregiver, nanny, midwife or nurse. Sometimes, the ratio of
aspiration)  always admit them. If they are able to eat orally already, elderly to caregiver is 1:5 or even 1:10
they can then be sent home o If you have 1 infected elderly being taken care of 1 caregiver
 Take note that you should not give oral medicines because they will just and he/she missed washing his/her hands or any sanitary
vomit it measures  the diarrheic elderly can indirectly transmit the
bacteria through the caregiver  will cause an epidemic of
C. What is your management? diarrhea in the long-term care facility
 Management is assess the dehydration status, make her vomit less,  Shigella, Giardia, Cryptosporidium, Rotavirus
more nutrition to the patient through IV o Think of these organisms when there are cases in day care or
long-term care facilities
Bacteria responsible for Food Poisoning o Patients living in long-term care facilities already have weak
 Bacillus cereus immune system  we have to be astute in trying to find out
 Clostridium perfringens type A the cause of the diarrhea
 Staphylococcus aureus
5. Institutionalized Patients
Lecture Discussion: Bacteria responsible for food poisoning  C. difficile
 This is a nosocomial diarrhea  this is when a patient entered a
You must always distinguish between food poisoning and acute
gastroenteritis. They are not the same! hospital NOT because of any GI symptoms but after 72 hrs., now
 Acute gastroenteritis  involves more the GI tract which may be complains of diarrhea
due to a bacteria, virus, parasite or medicines; there is more o So the patient never had diarrhea but after 72 hours,
diarrhea developed diarrhea  so the patient acquired the organism
 Food poisoning  there is no involvement of the pathogenic while staying in the hospital
bacteria; what is involved is the toxin that caused the patient to  30-40% of the time, C. difficile is the organism that is responsible for
vomit; there is more vomiting (less of diarrhea) nosocomial diarrhea BUT we have to remember also other causes of
diarrhea such as:
So always associate the bacteria (pathogen) with the food the patient had o Staphylococcus aureus
taken o Pseudomonas aeruginosa
CASE 4: PATHOGENIC MECHANISMS

A 41 year old male, diagnosed with HIV for 6 years, seeks consult because of  Enteric pathogens  tactics to overcome host’s defense systems
crampy abdominal pain and diarrhea. He claims that he is not taking his ART  Understand the virulence employed to better understand the diagnosis
for several months because he does not feel like taking it and treatment
3. Immunodeficient persons INOCULUM SIZE

 Primary immunodeficiency (born to be immunodeficient), Secondary  Number to be ingested to cause the disease
immunodeficiency (AIDS, senescence, pharmacologic suppression)  Varies from species to species
 Common enteric pathogens can cause a more severe and protracted  Shigella, EHEC, Giardia, Entamoeba  10-100 bacteria or cysts
diarrheal illness  Vibrio cholera  100,000 to 100,000,000
o We do not think of Shigella or Salmonella as the common
organism causing diarrhea in these patients. We think more PATHOGENESIS
now of the opportunistic infections  Organisms must adhere to the mucosa as their first step
 Agents through venereal (sexual) transmission: o Without any adherence = no defect in the GI tract
o Neisseria, Treponema, Chlamydia may contribute also to  Can compete with the normal bowel flora, and colonize the mucosa
proctocolitis  Specific cell surface proteins: attachment of the bacteria to intestinal
 Check for CMV walls  important virulence determinants
o Think of CMV for those who are not sexually active
Examples:
o CMV  most of us harbors this virus in our GI tract (either
 Vibrio cholera: adheres to the brush borders of small intestinal
through food intake or soil contamination). But since we are
enterocytes
immunocompetent, CMV is only an opportunistic infection 
You do not expect any bleeding or hemorrhage in this kind of
it will not bother us. Any change in our immune mechanism
infection. What you will see is “rice watery stools.”
will make CMV an opportunistic infection and more pathogenic
 ETEC: adherence proteins called colonization factor  colonizes the

upper small intestine prior to enterotoxin production
 EPEC (young children) and EHEC (hemorrhagic colitis and hemolytic-
uremic syndrome): produce virulence determinants that attach to the
brush borders of the intestinal epithelium
o EPEC is the only strain that can also affect the urinary system
INFECTIOUS DISEASES
Topic: Diarrhea
TOXIN PRODUCTION Intestinal Motility

 Enterotoxin  Peristalsis: major form of clearance from the proximal small intestines
o Causes watery diarrhea by directly acting on the secretory  Impaired motility (opiates, anti-motility drugs, anatomic abnormalities,
mechanisms hypomotility states)  increased frequency of bacterial overgrowth
 Cytotoxin and infection with enteric pathogens is increased
o Cause destruction of mucosal cells and also inflammatory o Allows more time for the bacteria to grow; So do not prescribe
diarrhea anti-peristaltic medicines
 Neurotoxins
o Acts directly on the central and peripheral NS Immunity
 Cellular and antibody or humoral immunity play a role
Enterotoxin  IgG, IgM, IgA
 Cholera toxin: causes persistent activation of the adenylate cyclase   Mucosal immune mechanism is the first line of defense
increased cyclic AMP  increased chloride secretion and decreases
sodium reabsorption  diarrhea Genetic Determinants
 It does not destroy the GI epithelium but only increases the cAMP   Poorly understood
more peristalsis and more Cl secretion  Blood type O: increased susceptibility to cholera, shigella, and
norovirus
ETEC  Polymorphism in Interleukin 8: increased risk of diarrhea from EAEC
 Produce a protein called LT: similar to cholera toxin and causes
secretory diarrhea using the same mechanism DIAGNOSTICS
 Most cases are self-limited and physicians may treat these cases
Cytotoxins empirically
 Destroy intestinal mucosal cells  Do stool culture: fever and evidence of inflammatory disease: shigella,
 Produce dysentery (bloody stools with inflammatory cells) salmonella, campylobacter
 Shigella, Clostridium, Shiga-producing strains of E.coli Do stool culture if you suspect for bacterial or parasitic involvement
 Produce outbreaks of hemorrhagic colitis BUT if it is food poisoning  no need to do fecalysis
If the cause is Norovirus  no need to do fecalysis (findings will be
Neurotoxin normal)
 Produced by bacteria outside the host]
 They cause food poisoning (symptoms are more of vomiting, light-  Nosocomial diarrhea: focus on C. difficile
headedness, headache) o Stool culture useless
 Symptoms immediately upon ingestion o Do latex agglutination tests and rapid enzyme detection of
 Bacillus and Staphylococcus  vomiting the toxins produced (Toxin A, Toxin B)
 Amoeba:
HOST DEFENSES o Examine fresh stools  cysts and trophozoites
 Must combat a number of microorganisms most of the time o Amoeba does NOT reside in the lumen. It is intraluminal  it
resides on the walls of the GI tract. Since they are in the walls
Normal Flora of the GI tract, patients usually presents as asymptomatic
o The only time that we see amoeba in the stools is when we
 Normally inhabiting bacteria in the intestinal mucosa act as host
defense have increased peristaltic movement secondary to another
organism
 Less normal flora: infants, people taking antibiotics  greater risk of
 The peristaltic movement shook the amoebas from
developing infections
the walls of the GI tract going into the lumen  that’s
 Majority of the normal bacteria are anaerobic organisms  acidic pH,
the time when we see cysts or trophozoites in
volatile fatty acids are good resistors to enteric pathogens
fecalysis
o Trophozoites  invasive form
Gastric Acid
o Cysts  infective form
 Acidic pH is an important barrier
Example: 56 year old male, complaining of diarrhea. You
o The more acidic pH = more effective in destroying pathogens
requested for stool exam and found Entamoeba coli. There
 Increased frequency in patients who underwent gastric surgery are cysts and trophozoites. You know that amoebas are
o Partial gastrectomy  there is a change in the acidic milieu of treated with metronidazole so you prescribed it.
the GI tract
 Neutralization of gastric acid (H2 blockers, PPI) After 5 days, the patient comes back to you telling you that
o Tell the patient not to take PPIs or H2 blockers not to take it he still has diarrhea. How come he still has diarrhea? This
for a long time because they are good in decreasing the acidity happened because you (as the doctor) did not prescribe for
in the stomach  bacteria will find it more conducive to the primary cause of the diarrhea. Remember, amoebiasis
colonize and replicate in usually is incidental. It is usually found in a person who is
o As much as possible give it only for 2 weeks having diarrhea NOT because of amoeba BUT because of
o If patient has PUD  you can give the drug for up to 1 month another organism (e.g. bacterial). It was that organism that
increased the peristaltic movement of the colon making the
 Longer than that, you have to consider the side effect
amoeba fall from the mucosa into the lumen of the GI tract.
of PPI
 Rotavirus can withstand acidic environment and is highly stable in acid In cases like that, give metronidazole and an antibiotic
(depending on the etiology)
INFECTIOUS DISEASES
Topic: Diarrhea
INFECTIOUS DIARRHEA OR BACTERIAL FOOD POISONING? moist), check the lips (see if there are fissures or ulcers)  signs of
 Adequate hydration dehydration
o WHO: 3.5 g sodium chloride, 2.5 g sodium bicarbonate, 1.5 g  Some patients will deny their symptoms (some do not tell the truth) 
potassium chloride, 20 g glucose or 40 g sucrose + 1 L water do not accept anything that the patient tells you. How will you go
o Severe dehydration: IV fluids – lactated ringers solution around that? Do a good P.E. and history taking
 Give ORS every time the patient defecates  After a good P.E. and history taking  that is the time you ask for
 Advise the patient to drink water when the patient is not defecating laboratory examinations
o Example:
 Patient defecates in the toilet now  tell the patient
to take ORS
 Patient feel thirsty but is not defecating (happening in
between defecations)  tell the patient to drink
water
 Why is the patient advised not to keep on drinking water? Because there
can be a possibility of the cells becoming hypotonic (bursting) since
water is hypotonic  only give ORS (which is an isotonic solution) every
time the patient defecates
ADDITIONAL NOTES FROM DR. FORTUNO

 When you have a patient with diarrhea, ask the ff.:
o When did you last urinate?
o Are you having trouble ambulating?
o Do you feel weak all over?
o Are you vomiting?
o What was your last food intake?
o What was the prior food intake before the last food intake?
We ask the last 2 meals of the patient because certain
organisms have a longer incubation period
 For patients who are vomiting more and having less diarrhea  think
of food poisoning
o Since food poisoning is very fast (usually 4-6 hours upon
ingestion of toxin)  you may not anymore ask the previous
food intake
o Why is it very fast? Because the bacteria is not the one that
was ingested but rather the toxin  this explains the swiftness
of the symptoms to occur
o For food poisoning, also ask “How many people are
experiencing the same symptoms?”  because if it is a shared
food source, you will expect other people (aside from the
patient) to have the symptoms
o Food poisoning is usually of the outbreak type  meaning, not
only one experiences the symptoms but several people
o Knowing the people who have the same symptoms will help
you track the food that caused the development of symptoms
 Gastroenteritis  more diarrhea, less vomiting
Sample Case:
A patient developed vomiting along with his father and mother. They all ate
sardines and fried rice. They heated the sardines before heating
 Possible source is fried rice  B. cereus may be the culprit
 You will not request for fecalysis because it is the TOXIN that caused
the symptoms (not the bacteria)
 Management: Hydrate the patient  insert an IV line (since the
patient is vomiting)
 You do not prescribe any medicine. You have to admit the patient
 In diarrhea, medicine is not of importance but rather the correction
of dehydration. Not all cases of diarrhea need medicines
 All cases of diarrhea have to be rehydrated
 In assessing the dehydration of elderly, you do not do the “skin fold

test”  they have already loose skin (have less elasticity already) so it
will just be (+). Better do is check the mucosa, check the lips, ask the
patient to stick out the tongue, look at the conjunctiva (check if it is
INFECTIOUS DISEASES
Topic: Pneumonia
INTRODUCTION PHASES OF PNEUMONIA

Pneumonia
Phase Description
 Is an infection of the pulmonary parenchyma
 Initial phase
o The demarcation of the anatomic involvement would be the 1. Edema  Characterized by the presence of exudates and
pulmonary parenchyma bacteria in the alveoli
o If an infection involves the upper respiratory tract  then it  Characterized by erythrocytes in the
cannot be pneumonia BUT it may be the same organism that intraalveolar exudate
had infected the upper respiratory tract 2. Red hepatization  Neutrophil influx is an important standpoint of
 Generally caused by bacteria, fungi, viruses, and protozoa host defense
o Other pathogens include metapneumoviruses, the  Bacteria may occasionally be in the exudates
coronaviruses responsible for Covid-19, severe acute  Cessation of erythrocyte extravasation
respiratory syndrome (SARS) and Middle east respiratory  Degradation of remaining erythrocytes
syndrome, and community-acquired strains of methicillin- 3. Gray hepatization  Neutrophils predominate
resistant Staphylococcus aureus (MRSA)  Abundant fibrin deposition
 Bacteria have disappeared
BASIC PATHOPHYSIOLOGY  Macrophages predominate
 Lower respiratory tract involving the parenchyma  Inflammatory response stops – gives at least 2
4. Resolution
o Pneumonia is an infection of the lower respiratory tract. It has weeks of immunity from another pathogen that
to involve the lung parenchyma could enter the respiratory system
o Sometimes contiguous structure, such as the pleura, may be
affected  leads to pleural effusion Causes of Atypical Pneumonia?
 Due to the invasion and proliferation of the pathogens at the alveolar  Klebsiella pneumoniae – typical
level and subsequent host’s mounted immunologic response Implicated among alcoholics who have high risk
o All the symptoms of pneumonia cannot be explained merely of developing aspiration
by the bacterial infection because most of the time, patients
 Pseudomonas aeruginosa – typical
will be manifesting symptoms secondary to our mounted
Can cause severe pneumonia of the typical type
immunologic response  this is another reason why our
patients expire NOT due to the pathogen BUT due to the host’s
 Staphylococcus aureus – typical
exaggerated immunologic response It is usually spread through hematogenous route
 Aspiration is the most common access of the microbial pathogens coming from a primary focus
o There are different ways for the pathogens to access the
pulmonary parenchyma:  Chlamydophyla pneumonia
 Hematogenous  Legionella species
 Inhalation  Mycoplasma pneumonia atypical
 Aspiration  the most common access  Respiratory syncytial viruses (RSV)
 Adenoviruses
CLINICAL MANIFESTATIONS  Influenza
Typical Pneumonia Manifestations:
 Acute cough or productive cough Risk Factors for CAP in general?
o Cough should be present within the last week  Asthma
Cough that is present for >2 weeks, the possibility of it  Institutionalization
being pneumonia is less. Chronic cough is usually secondary  Alcoholism
to conditions like: TB, Reflux, Allergy  Age > 70 years
 Immunosuppresion
o Always distinguish 1st “when did the cough start?”
 Acute onset – think of pneumonia Community acquired pneumonia  does not necessarily involves
 Present for months or years – think more of allergic streptococcus pneumonia (most common cause of typical pneumonia). In
reactions general means that all of the organisms that causes typical pneumonia could
be a risk factor for CAP
 Abnormal vital signs or tachypnea
All of the listed items are risk factors for CAP
 Tachycardia  Asthma – causes chronic inflammation of the airways
o This may be a “reflex” of the fever because fever can also  Institutionalization – due to proximity to other index patients with
increase out heart rate pneumonia
 Fever  Alcoholism – at the height of their stupor, they may be already
 At least one abnormal chest and lungs PE finding: vomiting and possibility of aspirating their vomitus
o Ronchi  Age > 70 year – due to the theory of wear and tear already becomes
o Crackles weaker in terms of immune mechanisms
o Wheezes  Immunosuppression – like HIV patients, those who chronically use
o Decreased breath sounds steroids, asplenic patients
 Seen in pleural effusion and consolidation
INFECTIOUS DISEASES
Topic: Pneumonia
COMMUNITY ACQUIRED PNEUMONIA (2016 PSMID GUIDELINES) What are the additional questions we have to ask our patient?
 What?
Clinical Scenario: o What are the associated symptoms of the pneumonia?
 A 72 years male with controlled hypertension and T2DM smoker  E.g. anorexia, body malaise, urination
presents in the ER because of dyspnea
 Where?
 Condition started 5 days PTA with productive cough, remittent
o Where is it more painful/tender?
fever with a highest temperature of 38.5oC
Remittent fever  the patient’s temperature does not go back  When?
to normal. It may go down a little but it does not reach normal o When did it start?
levels  Why?
o Look for other people within his family or workplace that have
 There is note of right sided lower chest pain, more pronounced the same symptoms of your patient
during coughing and deep inspiration  Bacterial pneumonia  attack rate is slower
 RT-PCR and RAT for Covid-19 is (-)  Viral pneumonia  attack rate is faster
 He tells you that he is asthmatic with his last exacerbation a year  How?
ago controlled by bronchodilator MDI o How probably did you acquire this symptoms?
 If a patient tells you that he was exposed to another
Physical Examination:
person manifesting with the same symptoms:
 BP – 140/90 mmHg
 5-7 days ago  probably bacterial in origin
 HR – 106/min
 RR – 25/min  If only one day ago  more of viral in origin
 T – 38.9oC  What else?
o Ask about the control of hypertension and control of diabetes
 Diabetes  already puts a patient in an
What are your expected PE findings based on the case?
immunocompromised state whether or not the blood
 Inspection
sugar is controlled
o Retractions of accessory muscles
 Evident on the trapezius muscles You informed the patient’s private physician and you were ordered to assess
o Retractions of intercostal muscles the patient and admit if needed in accordance with the guidelines of
 This happens when you ask the patient to inhale Community Acquired Pneumonia (CAP) 2016
deeply
 During the course of inhaling deeply, normally we
Risk Factors for Pneumococcal Pneumonia?
expect the intercostal spaces to expand together with  Bronchial asthma
the deep inhalation  Smoking
 In retractions, the intercostal spaces retract inward Smoking initially causes discoordinated movement of the cilia
with the chest wall expanding outward and later on damage to the cilia
 Retractions may signify a pulmonary infection Normally, the cilia move in a coordinated manner to push out
occurring in the patient any pathogens out of the airways
o Asymmetry of chest expansion
 Asymmetric side is usually located at the more painful  HIV infection
side  COPD
 In the case of the patient, since there is pain on the COPD is worse than bronchial asthma because bronchial asthma
right side, asymmetry or “lagging” would be seen on is only episodic, therefore their steroid use is not all the time
the right side  the patient will not want to inhale COPD patients most of the time use their steroids  steroids
deeply because there would be pain are good in decreasing inflammation but one of its side effects
 Palpation is to decrease the immunity
o Fremitus Steroids is like a double-edged sword  makes patients feel
 May be appreciated when there is consolidation very well BUT taking it constantly decreases the immunity
 In the case, it may be appreciated on the right side
o Check for asymmetry  Seizure disorders
o Check for tenderness Patients with epilepsy are more prone to develop
 Percussion pneumococcal pneumonia most probably because of aspiration
o Dullness Case: 54 yr. old male developed right-sided body weakness and
 Confirms the fremitus appreciated on palpation was found in his bed and could not move. MRI and CT scan
 Heard usually on areas of the lung with consolidation showed he has stroke (infarct on the brain). The patient did not
 Auscultation present any respiratory manifestations but when you did a CXR
o When using the stethoscope, we primarily use the diaphragm  there was infiltrates on the right lung. Why did this happen?
because the lungs are more deeply situated  The patient probably aspirated when he had right-
sided weakness. It will go to the right side of the lungs
o Pattern of auscultation should be from bottom to top
because of the position of the bronchus
 Because if we do top to bottom  with the number of
 CXR showing right-sided lung involvement more than
deep inhalation that the patient will be doing, by the the left  think of aspiration pneumonia
time you are already at the lower lung areas, crackles  CXR showing a balance of right and left lung
might already have been cleared up involvement  think of CAP
 Remember also in cases of pneumonia, crackles are
usually found in the lower or more dependent areas. Streptococcus pneumonia is the most common organism to cause
It is not usually found in the apical areas pneumonia in all age groups
INFECTIOUS DISEASES
Topic: Pneumonia
MANAGEMENT OF CAP Low-risk CAP:

Low-risk CAP  Risk here means the risk of dying
 Low-risk CAP  at less risk of dying compared to those in a higher
stratification
 They can be sent home already
 Patient can be seen as outpatient basis and treated accordingly
 Patients who are vomiting  need to be admitted
o Medicine prescribed may be vomited or coughed out
In which subsets of patients should sputum culture be done?

 All patients hospitalized for cough – sputum culture is not done
For cough, they might just be sent home. Remember also that
the most common cause is streptococcus pneumonia for
productive cough so there would be no need for sputum culture
 Presence of neutropenia
 Setting of asplenia or complement deficiency
 Concurrent chronic liver disease
 Severe CAP
Moderate-risk CAP
Case Management
Patient WITHOUT CO-MORBID
ILLNESS presenting with
productive cough  you know
that it is a typical pneumonia Amoxicillin 1 gm TID (or two 500 mg capsules
(commonly caused by TID)
Streptococcus pneumonia)
Azithromycin 500 mg OD or
Clarithromycin 500 mg BID
NOTES:
 Azithromycin is more advantageous because
it is taken only once a day (better for patient
compliance)
Patient WITHOUT CO-MORBID  Clarithromycin maybe given if patient is
ILLNESS presenting with atypical allergic to azithromycin
symptoms  possible organisms  GI upset is a common side effect of
are chalmydophila and azithromycin. So in patients with dyspepsia,
mycoplasma better give clarithromycin
Salt Compositions of Azithromycin:

 Azithromycin Monohydrate
 Given for 5-7 days
 Azithromycin Dihydrate
 Given for 3-5 days
Moderate-risk CAP:
 Risk stratification is the reverse of those of low-risk CAP
Co-amoxiclav 1 gm BID or  BP <90/60  not good because it means that there is more nitric oxide
Sultamicillin 750 mg BID or due to the increase in bacteria
Cefuroxime axetil 500 mg BID
 Included here are those with:
+ o
o
Uncontrolled DM
Active malignancies
Azithromycin 500 mg OD or
Clarithromycin 500 mg BID o Neurologic disease
Patient WITH STABLE CO- NOTES: o CHF (Class 2-4)
MORBID ILLNESS  If patient is allergic to penicillins  do not o Unstable coronary artery disease
give co-amoxiclav or sultamicillin
 Usually complains of easy fatigability and paroxysmal
 If patient is allergic to sulfa-drugs  do not
give sultamicillin nocturnal dyspnea
 Use Cefuroxime as alternative o Renal failure on dialysis
 Since patients have co-morbid illness, we o Uncompensated COPD
need to cover for the atypical organisms  o Decompensated liver disease
reason why we add macrolides
 Azithromycin or clarithromycin  Pathogens:
o Includes those organism in low-risk CAP
o Legionella and anaerobes are added
INFECTIOUS DISEASES
Topic: Pneumonia
Management: High-risk CAP

 Ampicillin-Sulbactam 1.5 gm q6h IV or
If allergic to penicillin then give 2nd generation cephalosporin
(Cefuroxime) or 3rd generation cephalosporin (Ceftriaxone)
 Cefuroxime 1.5 g q8h IV or

 Ceftriaxone 2 g OD
+
 Azithromycin 500 mg OD PO or We always add Macrolides in order
 Clarithromycin 500 mg BID PO or to cover for the atypical organism
 Levofloxacin 500 mg OD PO or Quinolones are option to those who

 Moxifloxacin 400 mg OD PO cannot afford the IV form
Difference of Moderate-risk to Low-risk CAP management:

 Same antibiotics are given BUT the route of administration is
different (Intravenous)
What if the patient does not have any money to afford IV antibiotics?
 We can give a more superior antibiotics which are the quinolones
 Levofloxacin & Moxifloxacin  used for infections that are above
the diaphragm
 Ciprofloxacin  used for infections below the diaphragm
Risk Factor for Legionella Infection?

 Diabetes
 Leukemia
 Breast cancer
 Female gender – not a risk factor
 Alcoholism – not a risk factor
Smoking is a risk factor for legionella BUT NOT alcoholism
Other risk factors for Legionella:

 Smoking
 Ask the patient if he came from a cruise trip (ship)
 Ask the patient if he checked in a hotel
 Does he has HIV
 Male patient
 Moderate-risk patients should be admitted to the ward and treated

accordingly
 If aspiration pneumonia is suspected and, a regimen containing:
o Ampicillin-sulbactam and/or Moxifloxacin
o There is no need to add another antibiotic for additional
anaerobic coverage. If another combination is used may add
Clindamycin to the regimen to cover microaerophilic
streptococci High-risk CAP:
 Patient manifests all the symptoms of moderate-risk CAP together with:
o Sever sepsis
o Septic shock or
o Need for mechanical ventilation
 Pathogens:
o Includes those organisms in both low-risk and moderate-risk
CAP
o Staphylococcus aureus and Pseudomonas aeruginosa is
added
INFECTIOUS DISEASES
Topic: Pneumonia
Management:
Which oral antibiotic are recommended for de-escalation or switch
 If patient has no risk for Pseudomonas:
therapy from parental therapy?
o 3rd generation cephalosporin + IV macrolides or IV quinolones
 If patient is at risk for Pseudomonas:
o 4th generation cephalosporin or Carbapenems + IV macrolides
+ aminoglycosides
 If patient is at risk for MRSA:
o Patients at risk are those with HIV, men having sex with men,
prison inmates, those in long-term care facilities
o Antibiotics listed above + Vancomycin or Clindamycin or
Linezolid
When should Empiric treatment for CAP be initiated?

 Answer: All patients whenever they are diagnosed, should be
started the treatment as soon as possible  Cefuroxime (2nd gen. cephalosporin) has both ORAL and IV form
 Ceftriaxone (3rd gen. cephalosporin) is only given IV (it has NO ORAL
What initial antibiotics should be started for the treatment of CAP? form)
 Answer: All treatment depends upon the risk of the patients and co-  So when you shift ceftriaxone IV to oral form, you give oral
morbidities cefixime instead (also a 3rd gen. cephalosporin)  since
 For Low-risk = Amoxicillin remains the drug of choice. Extended there is no ceftriaxone oral form
macrolides can also be used
 For Moderate-risk = a combination of IV non-antipseudomonal B- How long is the duration of treatment for CAP recommended?
lactam with either of Extended Macrolides and Respiratory
fluoroquinolones
 For High-risk = if without risk of Pseudomonas aeruginosa  a
combination of IV non-antipseudomonal B-lactam (BLIC,
Cephalosporin or Carbapenem) with either of Extended Macrolides
and Respiratory fluoroquinolones
= if with risk of Pseudomonas aeruginosa  a
combination of an IV antipneumococcal, antipseudomonal B-
lactam (BLIC, Cephalosporin or Carbapenem) with an Extended
Macrolides and Aminoglycosides
OR
Combination of an IV antipneumococcal, antipseudomonal B-
lactam and IV Ciprofloxacin or high dose IV Levofloxacin
How can response to initial therapy be assessed?  For Moderate-risk  count the number of days that the patient
 Temperature, respiratory rate, heart rate, blood pressure, was given the antibiotic in the hospital together with the days that
sensorium, oxygen saturation and inspired oxygen concentration you will be prescribing to the patient, once the patient is sent home
should be monitored to assess response to therapy  Patients with Legionalla pneumonia  give for 2-3 weeks (14-21
 Response to therapy is expected within 24-72 hours of initiating days)
treatment. Failure to improve after 72 hours of treatment is an  Patients with Mycoplasma or Chlamydophila pneumonia  give
indication to repeat the chest radiography for 2 weeks (10-14 days)
 Failure to improve after 72 hrs.  need to change empiric
treatment, unless you have the result of the culture (either
When can the Hospitalized patient be Discharged?
sputum or blood)
 In the absence of any unstable coexisting illness or other life
 Primary sample for culture for pneumonia is sputum
threatening complication, clinically stable and once oral therapy is
 If blood culture is requested, inform the laboratory that
started
you are trying to isolate a gram-negative bacteria (for them
 A repeat chest radiography is not needed if the patient is clinically
to use culture medium for gram-negative bacteria)
improving
 Blood culture will be done in patients in a severe state. If
 A repeat chest radiography is recommended after 4-6 weeks (1 and
the patient is only a moderate case, opt for sputum culture
a half month) after discharge during follow up to exclude any
only
Malignancies associated CAP specially in Smoker patient
 Follow-up cultures of blood and sputum are not indicated for
patients who are responding to treatment
What is Updated in 2016 Guidelines?
 Better to start the antibiotic at the same time when diagnosed as
When should de-escalation of empiric antibiotic therapy be done?
CAP
 When we say shift  it is not a shift from one antibiotic to another
 For low risk without co-morbidities, macrolides were
(e.g. from co-amoxiclav to sulbactam). When we say shift, it means
recommended
change in the route of administration (e.g. from IV to Oral)
 For low risk with stable co-morbidities, in case of failure with the 1st
 De-escalation of initial empiric broad-spectrum antibiotic or
line drugs it is recommended 3rd generation oral cephalosphorin
combination parenteral therapy to a single narrow spectrum
 In 2010, Carbapenem was recommended even in the Moderate-risk
parenteral or oral agent based on available lab data is
CAP but now only for High risk
recommended once the patient is clinically improving, is
 Dose of Amoxicillin is increased to 1g TID, previously it was 500mg
hemodynamically stable and has a functioning GI tract
TID
 No need for repeat CXR if patient is clinically improving
INFECTIOUS DISEASES
Topic: Pneumonia
Regarding Clinical Scenario:

 A 46 years Diabetic, Smoker male has presented in the ER with
productive cough for 4 days, fever on/off but febrile since 4 hours with
T=39oC and Right sided lower chest pain and now with Difficulty of
Breathing
 May be Low Risk, Moderate Risk or High Risk
o Prescribing the wrong antibiotics = patient is at risk of dying
o So it is important for future doctors to know the antibiotics and
organism involved for you to know what to correctly prescribe
WHAT ABOUT IMMUNIZATION AGAINST PNEUMONIA?

 IPD
 2 types: PPSV 23 or PCV 13
 Route is intramuscularly (IM)
 Patient population
o High risk population (healthcare workers)
o Elderly (60 yrs. old above)
Give PCV 13 now then PPSV 23 the year after. It is more
prudent for us doctors to give the 2 types of vaccines =
better immunity
Other vaccine you can give: tetanus, flu (quadrivalent),
VZV, pneumococcal, COVID-19
When you tell your patient that he will be immunized for pneumonia, it is not
for CAP but for invasive pneumococcal disease (streptococcus pneumoniae)
 PPSV 23
o Lay people call this the every 5 years vaccine
 PCV 13
o Lifetime vaccine
When do you give your vaccines?

 2 weeks after the patient gets discharged and improved
o 2 weeks  remember that the stage of resolution usually lasts
for 2 weeks. Once the 2 weeks is over, immunity will then wane
Sample Case:
You were administered today with PPSV 23. Will you be required for another
PPSV 23? If yes, when? Or can we give PCV 13, since he was already given the
PPSV 23?
 Either vaccines can be given
 If you are to give another PPSV 23, then you give it after 5 years
 Since PPSV 23 was given today (2021), the next vaccine
would be at 2026
 If you are to give the PCV 13, then you give it after 1 year
 Since PPSV 23 was given today (2021), the next vaccine
would be at 2022
NOTES:
 PCV 13 is only given once. PPSV 23 can be given twice if it purely
PPSV 23 that was given to the patient
 HIV patients are not given with live-attenuated vaccines
INFECTIOUS DISEASES
Topic: Adult and Pediatric Immunization
Lecturer: Dr. Herrera
THE IMMUNE/DEFENSE SYSTEM TYPES OF IMMUNIZATION

 Active Immunization
o Other terminology used for active immunization is vaccination
o Antigen, protection produced by the person’s own immune
system
 You introduce an antigen and then the body will
produce an antibody against to that antigen
o Protection not immediate (wait for 2 weeks for the body to
produce antibodies), but long acting (protection usually lasts
for a year e.g. flu vaccine)
 Passive Immunization
o Antibody, protection transferred from another person or
animal
 You introduce a pre-formed antibody that is coming
from either a person or animal
 Animal sources are usually equine (horses)
Lecture Discussion: The Immune/Defense System o Protection is immediate but short-acting (protection usually
We have 2 lines of defense: Innate and Acquired lasts only for 3-6 months)
Innate  it is something inherent to us. The moment an infant is born, they
already have it WHAT ARE VACCINES?
 It is non-specific  Vaccines are substance containing the INACTIVATED or WEAKENED
 No memory
micro-organism introduced into the body to TRAIN the immune system
 Aside from the cells that is innate to us, we have other 1st line of
to defend itself QUICKLY when the organism invades through natural
defense that is innate to us human which is our intact skin &
mucous membranes means
Acquired  we get it from somebody WHO SHOULD BE VACCINATED?

 It is specific  Everybody needs to be vaccinated, healthy or otherwise
 Has memory o Elderly/ at risk
o Young adults
o Adolescents
o Infants
Vaccines prevents:
 Lethal hospital and community acquired infections
 Miscarriages, fatalities among newborns
 Cancer, meningitis
 Meningitis, blood and soft tissue infections
High Risks/Special Groups

 Healthcare workers
 Travelers
For people who love to travel, they should be receive vaccination
Lecture Discussion: Acquired Immunity
against hepatitis A because traveling in other countries  we eat
Acquired immunity can be divided into: Natural and Artificial foreign food in order to taste different cuisines. It will prevent
Both natural and artificial are further subdivided into Passive or Active hepatitis A infection since it’s mode of transmission is feco-oral
Acquired Natural Passive  Pregnant women

 The best example here is maternal antibodies that the infant 2 mandatory vaccines for pregnant women: Tdap and Influenza
acquires from the mother in-utero (in the form of IgG)
 Other example is IgA that is acquired by the infant through
 Premature infants
breastfeeding
 Patients with cancer or chronic diseases
Acquired Natural Active
 We get it from infection WHAT VACCINES SHOULD BE GIVEN?
 Examples are community acquired infections such as chickenpox,  Vaccines used in NIPs are considered safe and effective when used
measles, mumps and rubella correctly. Vaccines are, however, not risk-free and adverse events will
occasionally occur following vaccination (WHO)
Acquired Artificial Passive
 Antibody transfer
 Examples are whole blood transfusion, injection of
immunoglobulins (IM/IV), convalescent plasma therapy
Acquired Artificial Active

 Immunization/Vaccination
 We talk here about vaccinations
INFECTIOUS DISEASES
LEGAL BASIS FOR IMMUNIZATION IN THE PHILIPPINES WHEN SHOULD ONE BE VACCINATED?
 Presidential Decree No. 996, Sept. 16, 1976
o Providing for compulsory basic immunization for infants and
children below eight years of age, signed by President
Ferdinand E. Marcos
 EO 663
o Bakuna and Una sa Sanggol at Ina, signed by President Gloria
Macapagal-Arroyo
 Republic Act No. 10152
o Mandatory Infants and Children Health Immunization Act of
2011, signed by President Benigno Aquino III in July 26, 2010
o Providing mandatory basic immunization services for infants
and children, repealing for the purpose of Presidential Decree
No. 996, as amended
WHAT ARE THE VACCINES THAT ARE GIVEN FOR FREE BY THE PHILIPPINE
GOVERNMENT?
Lecture Discussion: Schedule of Vaccination for Children <1 yr. old

Memorize the table above!
At birth – BCG and Hepa B are given
6 weeks of age – 1st dose of pentavalent, OPV and PCV13
10 weeks of age – 2nd dose of pentavalent, OPV and PCV13
14 weeks of age – 3rd dose of pentavalent, OPV and PCV13. Single dose of
IPV is also given
 OPV is given orally
 Pentavalent, PCV and IPV is given intramuscularly
 In infants, we inject it on the thigh (vastus lateralis)
 We can give the pentavalent on the right thigh
 The IPV and PCV on the left thigh but take note that there
should be a spacing of about 2.5 cm apart from the
 1979 previous injection site
o Infants are given: OPV, BCG, DPT
o Pregnant patient: TT (tetanus toxoid) 9 months of age – give the MMR
 1982  MMR is given subcutaneously
o Anti-measles vaccine was introduced  If MMR is unavailable, measles vaccine may be given as substitute
 1992
1 year old – another dose of MMR
o Hepatitis B vaccine was introduced
 If again there is no available MMR, give measles vaccine as
 2010
substitute
o MMR was introduced
o Pentavalent vaccine – a 5 in 1 vaccine containing: Why is there a need to give MMR or Measles vaccine at 9 months? Why not
 DPT – diphtheria, pertussis, tetanus give the MMR after 1 month (after giving the 3rd dose of pentavalent, OPV &
 Hep B – hepatitis B PCV and IPV)?
 HiB – haemophilus influenza B  We give the MMR or Measles vaccines at 9 months because we
 2012 have to wait for the maternal antibodies in the baby to decline
o Rotavirus vaccine was introduced for infants  If MMR/Measles vaccine is given early in life  it will just get killed
o Flu & PPV (pneumococcal) for senior citizens by the maternal antibodies
 2013  Earliest case of measles for infants is 6 months of age because in
some infants, maternal antibodies gets depleted/consumed early.
o PCV (pneumococcal) for infants was introduced
So between 6-9 months maternal antibodies  that is the time
o MR (measles, rubella) & Td for adolescents was introduced
when these antibodies may decline
 2014  9 months  we are sure that at this time, the infant already has no
o IPV (inactivated polio vaccine) for infants was introduced maternal antibody for protection
 After the 3rd dose of OPV, IPV should be then given as
single dose Why are there vaccines given early in life of the infant? (e.g. BCG, Hepa B,
 2015 pentavalent, OPV, PCV)
o HPV was introduced for adolescent females  Vaccines that are given early in life are actually diseases that are not
 2016 & beyond covered/affected by the maternal antibodies. Therefore, the
o Dengue infant is not protected from those diseases which is why, there is a
o JE (Japanese encephalitis) & Cholera vaccines were introduced need for them to get vaccinated early in life
to selected areas
 2021
o Covid-19 vaccines
INFECTIOUS DISEASES
Lecture Discussion: Adult Immunization Recommendation 2017

TdaP
 This is given to pregnant patients  best time to give it at 27-36
Lecture Discussion: Adult Immunization Recommendation 2017 weeks AOG
 For every pregnancy, you give one dose of TdaP
Vaccines for Adults are NOT given for free by the Philippine government
 Those who receive TdaP late in life (19-64 yrs. old)  every 10
Hepatitis A years, Td maybe given as booster dose (take note, it is Td only and NOT
 Given for 2 doses (booster dose after 6-12 months) TdaP)
Hepatitis B Varicella
 Given for 3 doses (Schedule is 0,1,6 months)  2 doses given with 1-2 months interval
 If under accelerated schedule it is given at 0,2,6 weeks  It can be given as PEP (post-exposure prophylaxis): single dose
 Booster may be given 1 year after the 1st dose if the anti- within 72 hrs. of exposure
HbS titer is <10 U/L  This is done to lessen the chickenpox marks
Influenza Cholera
 Given every year  For suspension (Shancol): 1.5 ml given 2 doses at 2 weeks interval
 Best time to receive this vaccine is during March or April  Booster dose after 3 years
 Receiving this vaccine late (e.g. around August)  no need to wait  For capsule (Orovacs): 1 capsule on Days 0, 7, 28
for 1 year for another dose. Just give it at March or April of the  If booster is indicated, restart primary immunization
following year. Why? Dengue
 March and April are the months when NEW influenza  Earliest age you can give this is at age 9 (table should be 9-45 y/o)
vaccines are released for a particular year  You can now only get this abroad because the FDA suspended
MMR dengue vaccines in the Philippines
 1-2 doses given to adolescents/adults, given at least 1 month apart Herpes Zoster
Pneumococcal  Given to >60 yrs. old as single dose
 Given to elderly or immunocompetent adults
 For elderly and immunocompetent
VACCINES FOR PEOPLE WITH HIV
 PCV 13 then PPSV 23 after 1 year
 For immunocompromised  Hepatitis B
 PCV 13 then PPSV 23 after 8 weeks  HPV for those up to age 26
All of these INACTIVATED VACCINES can be
 For those with previous PPSV 23  Influenza (flu) given to HIV (+) patients, as long as their CD4
 Give PCV 13 at least 1 year after the most recent dose  Meningococcal count is >200. If CD4 count is <200  then
 PPSV 23 may be given 5 years after initial dose  you can  Pneumococcal (pneumonia) ALL VACCINES WILL BE CONTRAINDICATED
receive it as a booster dose. After this, no more need for  Tdap
another dose
 In a lifetime, you only receive 2 pneumococcal vaccines
Additional vaccines may be recommended for a person with HIV based on
the person’s age, previous vaccinations, risk factors for a particular disease,
or certain HIV-related factors
NOTE: All live attenuated vaccines are CONTRAINDICATED in people with
HIV (you can only give inactivated vaccines)
INFECTIOUS DISEASES
Examples of Live Attenuated Vaccines: WHY DOES EVERYBODY NEED TO BE VACCINATED?

 BCG  Every 60 seconds, 5 lives are saved by vaccines worldwide
 OPV  Immunization saves up to 3 million lives annually
 Measles  Vaccines are available to protect against the following 26 infectious
 MMR diseases, with many more in development
 Varicella ● Cholera ● Dengue ● Diphtheria ● Hepatitis A ● Hepatitis B ●
 Yellow virus Hepatitis E ● Haemophilus influenza type B (Hib) ● HPV ● Influenza
 Rotavirus ● Japanese Encephalitis ● Malaria ● Measles ● Meningococcal
meningitis ● Mumps ● Pertussis (whooping cough) ● Pneumococcal
disease ● Poliomyelitis ● Rabies ● Rotavirus ● Rubella ● Tetanus ●
Just take note of the live-attenuated vaccines because they are Tick-borne encephalitis ● Tuberculosis ● Typhoid ● Varicella
contraindicated to HIV (+) patients (chickenpox) ● Yellow fever ●
VACCINATION OF PREGNANT WOMEN  Malaria vaccine is included there BUT it is still not yet approved by the
 Live vaccines should not be administered to women known to be FDA
pregnant
 In general inactivated vaccines may be administered to pregnant Vaccines Protect the Community
women for whom they are indicated  Community Immunity
 Mandatory: o When a sufficient proportion of a population is immune to an
o Flu infectious disease to make its spread from person to person
o Tdap unlikely
 Additional vaccines upon Doctor’s recommendation:  Coverage Threshold
o Meningococcal o The minimum percentage of individuals immune to a disease
o Hep B vaccine needed to prevent an outbreak
o Hep A vaccine o An outbreak  is a sudden appearance of a particular disease
that does not usually occur in a particular place
Lecture Discussion: HPV vaccine in Pregnant women  Best definition of it is  “from 0 to 1,” so if there is
no disease existing in a particular place and then one
What about HPV vaccines? Are they recommended for pregnant women?
individual had it (e.g. Covid-19)  it is an outbreak
 Even though it is an inactivated vaccine, they are NOT
recommended to be given on pregnant women
What if one dose of HPV vaccine was accidentally given during pregnancy
(the patient not knowing she was pregnant)?
 You just wait for the pregnant woman to deliver the baby and then
you can give the 2nd dose of HPV vaccine
ACTIVE IMMUNIZATION FOR ADULT FEMALES

 Rubella vaccine (or MMR) is given in adolescence, before or after
marriage, but not during pregnancy and has to be before 3 months of
conception
o If the woman has plans of getting pregnant, MMR vaccine
should be given at least 2 months before conception
WHERE CAN ONE BE VACCINATED?

 Barangay health centers
 Clinics
 Public hospitals
 Private hospitals
 Workplace
 Animal Bite treatment centers (if bitten by animals)
 Bureau of Quarantine (if going to countries endemic for certain disease
like yellow fever)
 Mass immunizations and Door to Door visits
“Iligtas sa Tigdas and Pinas”  a door to door Measles-Rubella (MR)
immunization campaign vaccinating all children, 9 months to below
8 years old
 School-based immunizations
o MMR
o TdaP
o HPV
INFECTIOUS DISEASES
Explanation of Picture on Lower Right (Page 4): Immunization

The image highlights the importance of immunization/vaccination
If no one is immunized
 Contagious disease will spread though the population
If some of the population gets immunized

 Contagious disease will spread through SOME of the population
 Only those who are immunized are protected
If most of the population gets immunized

 Spread of contagious disease is contained
 There has been a decrease in the value of vaccination in the Philippines

 In the year 2018  there was a dramatic drop in vaccine confidence
o From 93% in 2015, it dropped to 32% in 2018
o Due to this  there had been a polio outbreak
 The Philippines has been polio free since October
2000 but a polio virus case was confirmed on
September 16, 2019
o Also, there had been a measles outbreak
 R0  it means R-naught
 The coverage rate necessary to stop transmission depends on the basic
reproduction number (R0), defined as the number of transmissions
expected from a single primary case introduced into a totally
susceptible population
 Diseases with high R0 (e.g. measles) require higher coverage to attain
herd protection than a disease with lower R0 (e.g. rubella, polio and
Hib)
The R0 of Measles is 12-18

 This means to say that 1 infant can infect 12-18 other infants or
children
 Since it has a high R0, herd immunity can be achieved if 83-94% of
children are vaccinated
 This survey results shows that there has been a dramatic drop on
vaccine confidence
What do R0 Values Mean?
Three possibilities exist for the potential transmission or decline of a disease,
depending on its R0 value:
 If R0 < 1
o Each existing infection causes less than one new infection, thus
the disease will decline and eventually die out
 If R0 = 1
o Each existing infection causes one new infection. The disease
will stay alive and stable, but there won’t be an outbreak or an
epidemic
o This means that the infection is constantly present. This is bad
because there may be mutations of the disease
 If R0 > 1
o Each existing infection causes more than one new infection.
The disease will be transmitted between people, and there
may be an outbreak or epidemic  Dengvaxia is top reason for vaccine hesitancy in NCR (metro manila)
o Covid-19 in the Philippines has an R0 of 2  so for example we  Due to the fake news and sensationalization of the media in cases filed
have 10 infected people, each infected people can infect 2 by the PAO (public attorney’s office)  dramatic drop in vaccination
other people (totaling to 20 new infections)  As clinical clerks/interns  we need your help to spread the correct
o 70 million Filipinos need to be vaccinated since the Philippines information, and champion vaccination
has an R0 of 2
INFECTIOUS DISEASES
TYPES OF VACCINES VACCINE DEVELOPMENT

 Live attenuated: contain weakened pathogen; require 1-2 doses.
o Ex. Measles, MMR, rotavirus, varicella (chickenpox), yellow
fever, BCG, OPV
 Inactivated: contain killed pathogen; require several doses (booster
shots). Ex. Hep A, rabies, inactivated poliovirus, flu
o Subunit (recombinant, polysaccharide, conjugate): contain
killed, antigenic component of pathogen; require several doses
(booster shots). Ex. Hib, HPV, Hep B, pneumococcal, pertussis,
meningococcal, shingles
 Recombinant – Hep B
 Polysaccharide – Pneumococcal
 Conjugate - HiB
o Toxoid: contain toxin made by pathogen; may require booster
shots. Ex. Diphtheria, tetanus
o Other new types of inactivated vaccines:
 mRNA
 Viral vector Lecture Discussion: Events in Vaccine Development
Identification of Candidate Disease  Laboratory isolation of antigens (which
Vaccine Dosing Through the Lifespan
are usually coming from bacteria or viruses)  Vaccine development 
 Some vaccines provide life-long immunity from a single dose
Animal testing  Human testing  If vaccine is under Phase 4 Clinical trial
 Others provide greater protection after multiple doses  can now apply to FDA
 New vaccines are needed frequently for pathogens that mutate often
(best example is influenza & Covid-19 possibly) There are 4 Phases of Clinical Trials:
Phase Researchers try to answer these questions:
Vaccines aren’t just for children! Older populations need targeted Phase 1:
20-100 Healthy Volunteers  Is the vaccine safe?
protection from certain diseases
 Are there any serious side effects?
 How does the vaccine dose relate to side
VACCINE COMPONENTS: SAFE AND EFFECTIVE effects?
 Provide immunity  Is the vaccine causing an immune
o Antigens (e.g. live attenuated, killed bacteria/virus, toxoids) response?
o Adjuvants
 What are the most common short-term
 Adjuvants are substances that help the immune side effects?
system respond more strongly to a vaccine Phase 2:  What’s the body’s immune response?
 Example is aluminum Several Hundred Volunteers  Are there signs that the vaccine is
 Keep vaccines safe and long-lasting protective?
o Preservatives (thimerosal, formaldehyde, phenols)  They also want to know here how many
shots are needed to trigger an immune
o Stabilizers (sugar/gelatin)
response
 From the word itself, it stabilizes the vaccine against
 They also want to know here how many
adverse conditions like freeze drying or exposure to percentage of protection is provided by
heat the vaccine
 Used during the production of vaccines  How do disease rates compare between
o Cell culture materials people who get the vaccine and those
 Eggs are used to help grow the vaccine antigens who do not?
o Inactivating ingredients Phase 3:  Comparison studies are done (Placebo
1000+ Volunteers vs. Vaccine) and we want to get the
 Formaldehyde  weakens or kills the viruses,
efficacy rates or risk reduction of the
bacteria, or toxins present in the vaccine
vaccine on a particular disease
o Antibiotics  How well can the vaccine protect people
 Neomycin helps keep the outside germs/bacteria from disease?
from growing in the vaccine  They confirm here the effective dosing
levels (how many shots should be given),
 Take note that not all of the aforementioned components are included checking of side effects (if it is tolerable or
in every vaccines worse), and weighing of the benefits vs.
o Example: Aluminum is not present for live attenuated vaccines, risks vs. treatment
it is only used in inactivated vaccines Phase 4:  FDA approves a vaccine only if it’s safe,
Vaccine is Approved effective, and benefits outweigh the risks
 Vaccine can now be used commercially or
for general consumption
 Researchers continue to collect data on
the vaccine’s long-term benefits and side
effects
INFECTIOUS DISEASES
 NOTE: Covid-19 vaccines at present are all under Phase 3 Clinical Trial.  Immunization anxiety: anxiety about the immunization
We are only using those vaccines because we are in a pandemic so it o E.g. fainting before or after vaccination  vasovagal syncope ;
was authorized for emergency use Increased BP prior to vaccination; Palpitations prior to
o We cannot buy Covid-19 vaccines commercially. The vaccination
procurement of the vaccines are only through government to  Coincidental event: event that happens after immunization but not
government transactions caused by the vaccine
o Currently, Pfizer, Moderna and AstraZeneca are all applying o A chance association
for Phase 4 o E.g. after receiving the Covid-19 vaccine, within 10-12 hours’
time, the person experienced cough, nasal symptoms, loss of
WHAT ARE THE COMMON SIDE EFFECTS OF VACCINES? taste or smell  patient presented with Covid-19 symptoms
Local side effects: NOT because of the vaccine but rather due to the long
 Pain, swelling, or redness on the site of injection incubation period of the virus (he/she was exposed to Covid,
For this side effects, we advise the patient to apply cold weeks prior to his/her vaccination)
compressions for the first 24 hours. After the first 24 hours, they o Another example is after receiving the Covid-19 vaccine, the
can now apply warm compress but they still have to alternate it with person had fever, chills, rashes but in reality, it was already
cold compress dengue
Systemic Side effects: VACCINES COVERED BY NIP (NATIONAL IMMUNIZATION PROGRAM)

 Mild fever 1.) BCG Vaccination
 Chills  Bacille Calmette-Guerin is a live attenuated derived from
 Feeling tired Just give paracetamol for these side Mycobacterium bovis
effects
 Headache  Given ID (intradermal) at birth in right deltoid
 Muscle and joint aches  Second dose given at 6 years of age in left deltoid
 Not recommended to children with known primary immunodeficiency
(e.g. congenital) and symptomatic HIV
INVALID CONTRAINDICATIONS TO VACCINATION  BCG efficacy in published studies to date (0-80%)
 Mild illness (low grade fever,  Premature birth o Generally accepted that provides protection against more
URTI, mild diarrhea)  Allergies to products not in the severe types of TB
 Antibiotic therapy vaccine o BCG will not prevent the infant from acquiring a primary
 Mild/Moderate local reaction  Family history unrelated to complex (pulmonary TB) but is protective against the severe
or fever after prior dose immunosuppression types of TB (e.g. extrapulmonary TB like military TB, GI, Pott’s
 Disease exposure or  Need for TB skin testing disease, GI tract)
convalescence  Need for multiple vaccines
 Pregnancy in the household
2.) DTaP/DPT
 Breastfeeding
Routine DTaP/DPT Schedule for Children Younger Than 7 Years of Age
PERMANENT CONTRAINDICATIONS TO VACCINATION  1st Primary Dose – 6 weeks
 Severe allergic reaction to a vaccine component or following a prior  2nd Primary Dose – after 4 weeks Given for free
dose (all vaccines)  3rd Primary Dose – after 4 weeks
 Encephalopathy not due to another identifiable cause occurring within  4th Primary Dose – after 1 year
7 days of pertussis vaccination
 History of intussusception and immunodeficiency for rotavirus Booster Dose
vaccines  5th Dose – 4 to 6 years of age
 6th Dose (Tdap) – 11 or 12 years of age or after 5 years since last dose
ADVERSE EVENT FOLLOWING IMMUNIZATION (AEFI) CLASSIFICATION  Once they have received Tdap, Every 10 years thereafter (Td)
 Vaccine reaction: event caused or precipitated by the vaccine when
given correctly; caused by inherent properties of the vaccine Lecture Discussion: DTaP/DPT vaccination
o This is what we call the local and systemic reactions – this is Remember that DTaP or DPT is only given up to <7 years of age. For children
common that are already 7 years old  what they should receive is the Tdap
o E.g. After receiving Covid-19 vaccine you experienced
sleepiness, pain on injection site, fever and chills, muscle ache Routine Td Schedule for Unvaccinated Persons
 Vaccine quality defect: caused or precipitated by a vaccine due to one
7-18 years old
or more quality defects of the vaccine product, including the
Dose* Interval
administration device, as provided by the manufacturer
Primary 1 -- (Tdap)
o E.g. Manufacturer failed to completely inactivate the
Primary 2 4 weeks (Td)
inactivated polio vaccine leading to vaccine acquired paralytic
Primary 3 6 to 12 months (Td)
poliomyelitis
Booster dose Every 10 years (Td)
 Immunization errors: result from human errors in vaccine preparation,
handling, storage, or administration
19 years old and above – 1 dose Tdap, Td every 10 years
o E.g. Failure of cold chain during transport of vaccine;
administration (improper aspiration) or failure to push the
NOTE: For pregnant patients, they should receive Tdap for EVERY pregnancy and
plunger; The nurse did not perform aseptic technique
it is best given at 27-36 weeks AOG because the antibodies can also be passed
onto the baby
INFECTIOUS DISEASES
3.) Hepatitis B Vaccine 6.) Polio Vaccines

 Infants: several options that depends on the status of the mother  Two types of vaccine:
o If mother is HBsAg (-): birth, 6 weeks, after 8 weeks, booster o Oral Polio Vaccines (OPV)
dose after 1-5 years o Inactivated Polio Vaccines (IM)
o If mother is HBsAg (+): vaccine and Hep B immunoglobulin  Polio Vaccine Schedule:
within 12 hours of birth, 6 weeks, after 8 weeks, booster dose Age Schedule
after 1-5 years Primary Dose 6 weeks
Those in red are the additional immunizations given to Primary Dose 10 weeks
HBsAG (+) mothers (as compared to HBsAg (-) mothers) Primary Dose 14 weeks
Booster Dose 15-18 mos.
 Adults Booster Dose 5 yrs.
o 0, 1, 6 months
 Vaccine recommended in all, especially people who are at risk o If 4 or more doses have been given prior to age 4 years an
 Routine booster doses are NOT routinely recommended for any group additional dose should be administered at age 5 years
o Before giving any booster doses to adults, do first an HBsAg
titer Oral Polio Vaccine
 Contains 3 serotypes
4.) Haemophilus Influenzae Type B Conjugates Vaccine o Most paralytic: Type 1
 Haemophilus is also part of the pentavalent, however it can also be o Least paralytic: Type 3
given as a monovalent vaccine  Grown on monkey kidney (Vero) cells
 Given intramuscularly (IM)  Contains neomycin and streptomycin
 Schedule:  50% immune after 1 dose
3 doses (0,1,2) with 1 booster dose  >95% immune after 3 doses
6 wks. old or <6 mos. old at 15-18 mos. of age with interval of  Shed in stool for up to 6 weeks following immunization (herd immunity)
at least 6 mos. to the 3rd dose o It has a superior mucosal immunity and can cause her
2 doses (0,1) with 1 booster dose at immunity
6 mos. to <12 mos. of age 15-18 mos. of age with interval of at o Downside of OPV: if there is an HIV (+) in the household, this
least 6 mos. to the last dose person can get the infection (due to the shedding in the stool
1 primary dose and 1 booster dose  some of the virus can be inhaled from the air). So OPV is
12 to 15 mos. of age at 15-18 mos. of age with interval of contraindicated in infants if a household member is
at least 3 mos. to the last dose
immunocompromised or HIV (+)  instead of giving OPV, give
>15 mos. of age but <5 yrs.
1 dose only the infant inactivated polio vaccine
old
Inactivated Polio Vaccine
 One dose of Hib vaccine should be considered for unimmunized
 Contains 3 serotypes of vaccine virus
children age 5 years or older who have sickle cell disease, leukemia,
 Grown on monkey kidney (Vero) cells
HIV infection, or who had splenectomy
 Inactivated with formaldehyde
 >90% immune after 2 doses
5.) Pentavalent Vaccine
 Composition: Each dose of 0.5 mL contains:  >99% immune after 3 doses – shows that it is more superior than OPV
o Diphtheria Toxoid  Highly effective in producing immunity to poliovirus
o Tetanus Toxoid  Intended to reduce the risk of vaccine-associated paralytic polio (VAPP)
o B. pertussis (whole cell) o Aside from the pentavalent, there is also a 6-in-one vaccine.
o HBsAg (rDNA) The one being added is the inactivated polio vaccine (IPV)
o Purified capsular Hib polysaccharide (PRP)
 NID schedule: 6, 10, 14 weeks 7.) Measles Vaccine
 No booster dose for pentavalent vaccine, however the boosters for:  Given subcutaneously (SC)
o DPT are recommended one year after the P3 (3rd dose of  If MMR is unavailable, measles vaccine may be a substitute
pentavalent) and at 4-6 years of age  Given at 9 mos of age, second dose at 12 mos of age and third dose at
 Recall that the 4th Primary dose is given after 1 year 15 mos of age (preferably MMR), at least with interval of one month for
 5th dose (booster) is given at 4-6 years of age 2nd to 3rd dose
o Hep B vaccine booster at one year also after P3 (3rd dose of  Measles vaccine may be given as early as 6 months of age in cases of
pentavalent) outbreaks as declared by public health officials
o Reason for this is because the maternal antibodies are
individualized for every infants (some consumes it as early as 6
months)
o If we give it at 6 months of age, we still need to give it at 9
months because there is a possibility that the infant still has
maternal antibodies against the measles vaccine (the vaccine
will only get killed by it). At 9 months of age, we are sure that
the maternal antibodies are consumed  so we always count
the vaccine at 9 months as first dose, regardless if we have
given it at 6 months
INFECTIOUS DISEASES
Measles Vaccine continued….. Pneumococcal Conjugate Vaccine (PCV 13)

 CASE: You are a private practitioner and the mother requests you to  The EPI schedule has three doses which are given at the ages 6 weeks,
vaccinate her child at 8 months of age, will you give the vaccine or not? 10 weeks and 14 weeks
o Answer is yes, you can yield to the mother’s request but you  Booster dose at 12-15 months
have to advise or educate the mother that there might be the
presence of maternal antibodies and that you need to repeat 11.) Vaccine Released by DOH (2015)
giving the vaccine at 9 months of age Human Papilloma Virus Vaccine
o Any vaccines given below 9 months of age (at 6,7 or 8 months  Quadrivalent (Type 6, 11, 16, 18) [Gardasil]:
of age)  we do not count it as 1st dose o 10-14 yrs. old up to 26 yrs. old (this was increased to 45 y/o)
o 1st dose is always counted at 9 months of age o Schedule: 0, 2, 6 mos.
 HPV 9 (Type 6, 11, 16, 18, 31, 33, 45, 52 and 58) [Gardasil 9]:
8.) Measles, Mumps, Rubella (MMR)
o Age: 9-45 yrs. old
 Given subcutaneously (SC)
o Schedule: 0, 2, 6 mos.
 Schedule:
o As discussed earlier, this is given as early as 9 months
 Bivalent (Type 16, 18) [Cervarix]:
o 12 months – one dose and booster dose at age 4-6 years
o Age: 10-55 yrs. old
o Schedule: 0, 1, 6 mos.
9.) Tetanus Toxoid
 Before the advent of Tdap, what we gave was tetanus toxoid
Lecture Discussion: HPV Vaccine
Minimum Percent Can we give HPV vaccine to Male patients?
Vaccine Duration of Protection  Yes, but we have to give the quadrivalent or HPV 9 because it covers
Age/Interval Protected
Given 20 for HPV 6 and 11 that can cause anogenital warts (these can cause
TT1 -- --
weeks AOG anal and genital cancer)
 Infants born to mothers will be  Bivalent will not work because its coverage is for HPV 16 and 18
At least 4
TT2 80% protected from neonatal tetanus which causes cervical warts (that can later lead to cervical cancer).
weeks later
 Gives 3 years protection for the mother They are specific for female (obviously, males do not have cervix)
 Infants born to mother will be
At least 6
TT3 95% protected from neonatal tetanus
months later OTHER VACCINES OUTSIDE OF EPI
 Gives 5 years protection for the mother
 Infants born to the mother will be Hepatitis A
TT4
At least 1
99%
protected from neonatal tetanus  Given intramuscularly (IM)
year later  Gives 10 years protection for the  Hepatitis A vaccine is recommended for all children age >12 months. A
mother
second dose of the vaccine is given 6 to 12 months after the first dose
 Gives lifetime protection for the
At least 1 mother  This is given usually to people who love to travel
TT5 99%
year later  All infants born to the mother will be
protected Varicella Vaccine
 Given subcutaneously (SC)
 As much as possible, for pregnant patients  in practice, any vaccines  Schedule:
should be given at 20 weeks AOG and beyond o First dose: 12-15 mos. of age
 NOTE: if TdaP or Td is not available, that is the time that we give TT o Second dose: 4-6 yrs. of old
(tetanus toxoid)  All individuals age >13 years and without previous evidence of immunity
o First choice: Tdap should receive 2 doses of varicella vaccine given at least 4 weeks apart
o Second choice: Td – give this if TdaP is unavailable  The good thing if you receive varicella vaccine is that:
o Third choice: TT – give this if TdaP or Td is unavailable o 1 dose  chickenpox marks will be around 100-200
o 2 doses  chickenpox marks will be 50 and below. Also during
10.) Other Vaccines released by DOH (July 2012) recovery, there will be no crusting of lesions  lesions are
 Rotavirus Vaccine – against diarrheal diseases dried up within 7 days
o Schedule:  NOTE: If you are unprotected by the varicella vaccine, naturally the
 1st dose – 6 to less than 15 weeks old chickenpox marks will be around 400 (minimum). Among adults,
 2nd dose – 15 to less than 32 weeks old chickenpox marks are around 500 to 4000 and infection may last for 2-
 PPV23 – single dose for adults 65 yrs. and older 3 weeks
 Influenza vaccine – yearly for senior citizens
KEY POINTS
Influenza Vaccine  Vaccination is one of the greatest public health achievements
 Protection in 2 weeks after vaccination  Vaccines used in National Immunization Programs (NIPs) are considered
 Given yearly safe and effective when used correctly
Age Dose  However, not risk free and adverse events will occur occasionally
3 years old above Full dose (0.5 mL)  Vaccine safety is key to success of vaccination programs
6 months - 35 months Half dose
 NOTE: Children 8 yrs. old and below who are receiving influenza
vaccine for the first time should receive two doses separated by at least
4 weeks
INFECTIOUS DISEASES
Topic: COVID-19 Vaccination
4 PHASES OF CLINICAL TRIALS
 Pfizer-BioNtech and Moderna has the same vaccine platform  mRNA

 Gamaleya (Sputnik V) has a vaccine platform that is a viral vector
o It is unique because the 1st dose is different from the 2nd dose
 At present, COVID-19 vaccines are at the Phase 3 clinical trial  1st dose: viral vector is Ad26 (adenovirus 26)
 But because of the emergency use authorization (EUA) we are able to  2nd dose: viral vector is Ad5 (adenovirus 5)
use it o You cannot interchange the 1st dose from the 2nd dose
 3 vaccines are applying for Phase 4 clinical trial for commercial use:  AstraZeneca, CanSino, Johnson & Johnson  the vaccine platform
o Pfizer used is a viral vector
o AstraZeneca o AstraZeneca: the adenovirus used is ChAdOx1
o Moderna o CanSino: the adenovirus is Ad5
o Johnson & Johnson: the adenovirus is Ad26
 Janssen (Johnson & Johnson) vaccine is the only
COVID-19 vaccine that is given as single dose
 Vector Institute & Novavax  vaccine platform is protein subunit
 Sinopharm, Sinovac, Sinopharm-Wuham, & Bharat Biotech  vaccine
platform is inactivated virus
VACCINE PLATFORM
 Traditional vaccine development timeline  will take around 10 years

before a vaccine to be under Phase 4 (for distribution)
 Accelerated vaccine development timeline  due to the pandemic,
the COVID-19 vaccine development was accelerated
o COVID-19  they diagnosed this disease December 2019. By  DNA-based vaccines – at present, there is no EUA approval for these
January 2020, vaccines development were started kinds of vaccine
o Vaccine rollout was started by December 2020 o Manufacturers: Sanofi and Inovio
 Vaccine rollout started 1st week of March 2021 o These are currently at Phase 2 and 3
o As shown above, you can see that steps for the COVID-19  RNA vaccines
vaccine are done in parallel in order to accelerate its o Manufacturers: Pfizer, Moderna, Curevac
development  Inactivated vaccines
o Even though it was accelerated, all usual safety and efficacy o Manufacturers: Sinopharm, Sinovac, Bhat Biotech
monitoring mechanisms remain in place; such as adverse event  Viral vector vaccines
surveillance, safety monitoring & long-term follow-up o Manufacturers: AstraZeneca, Johnson & Johnson, MERCK,
CanSino, Gamaleya (Sputnik V)
VACCINE DEVELOPMENT  Subunit vaccines
 There is no direct correlation between the trial phase of vaccine and its o Manufacturers: Novavax, Clover
superiority or future success  Live-attenuated vaccines
 A vaccine reaching Phase 3 would not necessarily indicate that it is o At present, no manufacturer is using this vaccine platform
better than a vaccine in Phase 1 or Phase 2
INFECTIOUS DISEASES
VACCINE STATISTICS
 As of August 8, 2021  11,391,969 Filipinos that are fully vaccinated
 If we want to vaccinate around 107 million Filipinos, the 11 million fully
vaccinated is just around 10.6% of the total population Dr. Herrera Question: What does 95% efficacy of Pfizer means?
 DOH aims to vaccinate around 70 million Filipinos by on/before  95% Efficacy of Pfizer  means that there is 95% risk reduction
December 2021 o People vaccinated with Pfizer have 95% lower risk of
COVID-19 VACCINE EFFICACY getting COVID-19 compared with a control group of
participants who were not vaccinated
Measured thru:
 Prevent Severe Disease Current data shows that Covid-19 vaccines
 Prevent Clinical Disease prevents severe disease and clinical disease  As to efficacy for >60/65 years old
 Prevent Transmission o Pfizer 92% (>65)
o Currently, not enough data or evidence that Covid-19 vaccine o Sputnik 91.8% (>60)
can prevent transmission o Moderna 84.4% (>65)
 As to efficacy in preventing severe covid
VACCINE EFFICACY o Pfizer, Moderna, AstraZeneca, Sputnik, Janssen, Sinovac (Brazil
trial) all claimed 100%
OVERALL EFFICACY (prevent symptoms)
 As to efficacy vs. S. African and UK variant
Pfizer 95%
o Pfizer and Moderna claimed they are effective
Moderna 94%
o AstraZeneca 74.6% vs. UK variant and effective also against
Sputnik 91%
Brazilian variant
Novavax 89.3%
o Janssen 66% vs. S. African variant
AstraZeneca 70%
50.4% (Brazil trial) o Novavax 49.3% vs. S. African variant
Sinovac 91.25% (Turkey trial)
65.3% (Indonesia trial)
Janssen 66%
INFECTIOUS DISEASES
VACCINE EFFICACY VS. EFFECTIVENESS

Why you can’t compare Covid-19 vaccines?
https://www.youtube.com/watch?v=K3odScka55A  Efficacy
o % reduction in disease incidence in a vaccinated group
Key Points of the Video: compared to an unvaccinated group under optimal conditions
 We cannot compare the efficacy rates of each vaccines
 Vaccine’s efficacy rate is calculated in large clinical trials (testing it  Effectiveness
on thousands of people)  divided into 2 group: Placebo group and o Ability of vaccine to prevent outcomes of interest in the “real
Vaccine group world”
 After they get vaccinated  they are sent out and see whether or o Primary care settings
not they get Covid-19 over several months o Clinically relevant treatment selection and follow up duration
 Pfizer BioNtech – out of 43,000 participants only 170 people were o Adequate sample size to detect clinically relevant differences
infected with Covid-19
 How those 170 people fall in the 2 groups, would
determine the vaccine’s efficacy rate
 If the 170 people were evenly split into the 2 groups:
 85 on Placebo and 85 on Vaccine  Efficacy is 0%
 If the 170 people were all on the Placebo group and 0 were
on the Vaccine group  Efficacy is 100% March 11, 2021 – a year after WHO pandemic declared
 In the Pfizer trial, there were 162 in the Placebo group and  Real-world roll-out data from Ministry of Health Israel, Pfizer
8 in the Vaccine group  This means that the 8 vaccinated vaccine
people were 95% less likely to get Covid-19  94% of asymptomatic infection prevented
 97% effective against symptomatic COVID-19 cases,
hospitalizations, severe and critical hospitalizations, and deaths
 Unvaccinated individuals 44 times more likely to develop
symptomatic COVID-19 and 29 times more likely to die from
COVID-19
 80% of circulating virus during roll-out was B117 variant

REAL WORLD STUDY (Coronavac)

Chile: (10.5 M)
 67 % in preventing symptomatic infection
 Misconception: it does not mean that if 100 people were  85% in preventing hospitalization
vaccinated, 5 of them will get sick  80% in preventing deaths
 The 95% applies to the individual  the person is 95% less likely to
get sick compared to the unvaccinated each time they are exposed Indonesia (25,374 HCWs)
to Covid-19  96% preventing hospitalization
 All vaccines’ efficacy rate is calculated in the same way BUT the  100% protection from death
circumstances when the trial was done may be different from each
other
 Moderna and Pfizer did their clinical trial at a time when
Covid-19 exposure was less
 Johnson & Johnson did their clinical trial at a time when
Covid-19 exposure was high, was done on countries with
high number of cases, and there were different variants 
this affected the efficacy of the vaccine
 Efficacy numbers  just tells us what happened on their clinical
trials NOT EXACTLY what will happen in the real world
 Goal of vaccines: not to get zero Covid cases but rather to tame the
virus and reduce its ability to cause severe hospitalization and death  Mutations – means change in sequence and is a natural byproduct of
viral replication. RNA have higher mutation rates than DNA viruses
 All viruses mutate at a particular rate, SARS CoV-2 appears to mutate
every week
o The more that the pandemic lingers, the more that there
would be mutations
o That is why we have to stop it early because if it lingers, some
mutations can get deadly  will be a problem for us humans
 Real purpose of Covid-19 vaccine  give the body enough

protection to cover against severe symptoms, hospitalization, and
death
 So if ever you were vaccinated and you get the Covid infection  it U.K
will feel more like a common cold than something you will be .
hospitalized for
 All Covid-19 vaccines prevented hospitalization and death
 Efficacy matters, but it does not matter the most
 The best vaccine right now is the one that you are offered 
INFECTIOUS DISEASES
COVID-19 VACCINE EFFICACY AGAINST VARIANTS
U.K. variant S. Africa variant Brazil variant
Why so many Covid-19 variants are showing up now?

https://www.youtube.com/watch?v=Ha6yUxze1vk
Key Points of the Video:

 Viruses are a shell of protein surrounding a genetic material (DNA
or RNA)
 The genetic code that it has instructs on how to make specific
proteins that allow the virus to function
 All vaccines for both the South African and Delta variant have reduced
 Goal of viruses is to make more of itself  but in order to do that,
efficacy (reduced antibody levels)
it has to use human cells
 At some point, as the viruses replicates itself in a human cell, it  All vaccines have the same efficacy for the original virus (U.K. variant)
makes a mistake  mutation happens wherein it slightly changes  Pfizer and AstraZeneca have the same efficacy against the Brazil
the instruction for making the virus  the mutated virus is now a variant
different variant of the original virus
 Since viruses are constantly going through the copying process, it is COVID-19 VACCINE ADVERSE REACTIONS
normal for them to change over time. Most of the time, mutations Reactogenic vs. Allergic Reactions
are harmless but other times, mutations get a slight edge over  A reactogenic reaction is an inflammatory response that occurs after
humans  making them bind to human receptors better and enter vaccination
human cells better o Local reactions which include pain, swelling and tenderness
 Coronaviruses are covered with spike proteins that they use to bind
on the injection site
with and infect human cells
 To relieve this, we give cold compress within the first
 The thing is, that binding is not a perfect fit  so it does
not always get past the human cell’s defenses 24 hours
 But a mutated variant (B.1.1.7 a.k.a. “Alpha” variant) has o Systemic postvaccination reactions are mild to moderate in
multiple spike proteins making it easier for the virus to severity, such as headache, fatigue, malaise, muscle pain,
bind with cells  therefore it is more transmissible chills, fever and vomiting
 Mutations of viruses are random errors  the longer the virus is  To relieve this, we give paracetamol
around, and the more people it infects, the more it will change   An allergy or hypersensitivity reaction is an exaggerated immune
the more those changes accumulate, the more chances the virus response to a usually harmless substance that is present in the vaccine
has to evolve into something more dangerous
 The variants of concern (Alpha, Beta, Gamma, Delta), all has What to do with Side Effects of vaccine while onsite?
mutation on the spike proteins. Delta variant  a “double mutant”
 Reactogenic reactions are managed with supportive care
because it has 2 significant mutations we have seen before:
 Mild allergic reactions can be treated with antihistamines
 L452R – makes the virus more transmissible (found in
Epsilon)  Anaphylaxis, although rare, should be recognized and managed
 E484Q – makes it easier for the virus to reinfect people promptly with EPINEPHRINE. 0.3-0.5 mL IM. May increase the risk of
who have already Covid-19 (original version is E484K found mortality if not treated promptly
in Gamma and Beta)  Every patient should be observed for at least 30 minutes post-
 The 2 mutations may have evolved to dodge our natural vaccination
immune response  Note: cough, SOB, sore throat, runny nose, loss of taste and smell are
 The immune response that we get from vaccines is much stronger not side effects of the vaccines. Get tested for Covid-19
than our body’s natural immune response o This is just a coincidental event
 While we may see variants that make our vaccines somewhat less
 Do not take prophylaxis such as antihistamines or paracetamol, may
effective, most experts think it’s unlikely one will emerge that
mask the reactogenic reactions
completely evades our vaccines. But it does not mean it cannot
happen  if we give the virus enough time and replicative cycles, it
will sample a very large evolutionary space, and find a solution to Will COVID-19 vaccines sensitize us and cause ADE?
the vaccination we are doing  Antibody-dependent enhancement (ADE) has not been identified as a
 If we want to stop the variants  we need to stop the virus through concern related to SARS-CoV 2 infection or following COVID-19
widespread vaccination vaccination
 The vaccines we have still protect against all the variants o ADE seen in Dengue viruses is NOT a concern with COVID-19
 The trouble is that we are not getting those vaccines around the vaccines
world fast enough  which is giving the virus more time to change o Many coronaviruses has already infected us in our lifetime and
 We need to stop the virus because we do not want a variant that ADE has not been observed
affects immunity and the only way to do that is stopping its o No report of ADE in human studies
replication everywhere
INFECTIOUS DISEASES
Lecture Discussion: ADE on Dengue vaccines PEOPLE WHO SHOULD FOLLOW SPECIAL PROCEDURES
After receiving 3 doses of dengue vaccine (Dengvaxia) and the patient  With known Covid-19 exposure should finish the quarantine period first
experienced dengue  dengue infection can be more severe due to the before getting vaccinated
antibody-dependent enhancement (ADE)  People who currently have Covid-19 disease should wait until they have
 But take note that this is not necessarily true to all individuals recovered
 ADE happens when you have not experienced dengue yet and you o Mild to moderate: wait for 14 days
received 3 doses of the vaccine o Severe to critical: wait for 21 days
 This is why, the recommendation for the Dengvaxia is you have to o Received monoclonal antibodies or plasma convalescent: wait
receive the vaccine if you already experienced dengue for 90 days
Can COVID-19 vaccines be given at the same time as other recommended ACHIEVING HERD IMMUNITY WITH A COVID-19 VACCINE
vaccines?
 Population proportion that must be
 Yes. According to the Centers for Disease Control and Prevention (CDC),
vaccinated to achieve herd immunity
COVID-19 vaccines and other vaccines may be given on the same day
depends on:
o Before, we do not have sufficient data regarding this one but
o Basic reproduction number, R0;
at present we can receive any other vaccines simultaneously
for SARS-CoV-2, R0 estimated
with COVID-19 vaccine
at 2
o Example: You received COVID-19 vaccine today, you can also
o Efficacy of the vaccine
receive a flu vaccine today OR…. receive the flu vaccine on the
 For COVID-19, estimated vaccinated
following days (not necessarily at the same day)
population should be around 70%
o 70% is around 70 million Filipinos
Contraindication to COVID-19 vaccine
 Ending the pandemic through achieving herd immunity
 The only absolute contraindication is ALLERGY to a previous dose of
COVID-19 vaccine and any of its components
COMMON MYTHS AND FACTS ON VACCINATION
 Patients who have experienced moderate to severe (anaphylaxis)
allergic reaction to COVID-19 vaccine after the first dose should not MYTH: Vaccines cause Autism
receive the second dose FACT: No links exists between Vaccines and Autism
 Ex. of vaccine excipients:
o Polyethylene glycol (PEG) ingredient of mRNA vaccines  Myth incited by flawed and frustrated study
o Polysorbate ingredient in vector vaccines and protein subunit  Study retracted and lead author had his medical license revoked
vaccines  Subsequent studies have found no connections between vaccines and
o Aluminum ingredient of Sinovac their ingredients and autism
SPECIAL GROUPS WHO CAN RECEIVE THE VACCINE

MYTH: It is better to space out childhood vaccines using
 Patients with allergic reactions to food, medications, environmental an alternative schedule
allergens, as long as it is not related to vaccines and their components FACT: Spreading out vaccines leaves children unprotected
can receive COVID-19 vaccines
 Patient’s with immunodeficiency and autoimmune diseases (GBS, Bell’s  From birth, a baby’s immune system is well equipped to respond to
palsy) may get vaccinated, however they should be informed that there vaccines
is not enough data available to establish safety and efficacy in these  There is no evidence that spreading out the schedule improves health
conditions outcomes
 Patient’s with well-controlled asthma and on inhaled corticosteroids  Delaying vaccines increases the time children will be susceptible to
can receive the vaccine diseases
o The only relative contraindication is when a person had an
attack of asthma in the vaccine site  better to delay the MYTH: Vaccines cause the diseases they are designed to
vaccination on another day prevent
o Make sure that there are not attacks of asthma on the day of FACT: Vaccines undergo extensive monitoring and
vaccination testing before approval
 Breastfeeding mothers
 Cancer patients/chemotherapy? Vaccine response is not as good as  Inactivated vaccines cannot cause disease
desired  It is nearly unheard of for live attenuated vaccines to cause disease
o The recommendation is that they should receive the vaccine in  Mild symptoms are rare, but can indicate immune response (not
remission  this is the time when they are not taking infection)
chemotherapy
 HIV patients (CD4 >200)
MYTH: My child is at greater risk of harm from a vaccine
 Patients on anti-coagulation therapy but with precaution. Latest INR than from the disease itself
should be below the upper level of the therapeutic range FACT: The Benefit of immunization far outweighs the Risk
o Advise the vaccinator to use Gauge 25 and to put firm pressure
on the site of injection  The risk of natural infection are greater than the risks of immunization
 Person who had COVID-19 or tested positive may still benefit from for every recommended vaccine
vaccination  Severe side effects from immunization are incredibly rare
 Pregnant? Benefit outweigh the Risk, Limited data available… consult  Immunization is the best protection against deadly diseases
the health care provider, not contraindicated to give  Immunization prevents individual illness and large-scale outbreaks
o At present, pregnant patients can also receive the vaccine
INFECTIOUS DISEASES
VACCINATION CASE DISCUSSION True/False Questions about Vaccine Facts

CASE 1: OLIVIA  Aluminum is the component of thimerosal that some parent are
 AGE: 7 months concerned is toxic
o False, because it is Mercury that is the component of
Well Child Visit thimerosal and NOT Aluminum
 No known complains, healthy since o Aluminum is NOT toxic because vaccines contain only low dose
birth, product of term pregnancy, of it
weighs 3200 grams via NSVD. She went  Aluminum is added to vaccines as inert chemical filler
home on day 2 of life o False, is added as adjuvant and not as an inert chemical filler
 Hospitalizations: None o Adjuvant  aluminum is added in order to boost the immune
 Medications: Multivitamins response to the vaccine
 Allergies: None  Babies are exposed to more aluminum through breastfeeding and
 Growth and development: normal to formula than through routine vaccination
age and no developmental concerns o True, because as mentioned earlier, only low dose are found in
 FH: No siblings. Mother had severe asthma as a child, still on inhalers. vaccines
Breast cancer in maternal grandmother  All vaccines contain aluminum
 PE: Wt. 8.2 kg, T = 36.8oC, PR = 90, RR =24. Well nourished, well o False, because generally it is only inactivated vaccines that
developed contain aluminum
 Fontanel 1 cm, rest of the PE essentially normal o Aluminum is NOT used in live-attenuated vaccines
Dr. Herrera Question: What is your understanding of Fontanel 1 cm?
 Fontal 1 cm means that it is still open  this is normal What possible vaccines will you give to Olivia today to complete her
 Upon palpation of the head the fontanel is still soft vaccination schedule based on NIP
 Infants has 2 fontanels: Posterior and Anterior fontanel  Birth: BCG, Hep B vaccine
 Posterior fontanel: shape is triangular and it closes at 2-3  2 months old: PentaV d1, RV d1, OPV d1
months  3 months old: PCV 13 d1, OPV d2
 Anterior fontanel: shape is diamond and it closes at 12-18  4 months old: PentaV d2, RV d2, OPV d3
months
 5.5 months old: PentaV d3, PCV 13 d2
 During the P.E. of pediatric patients, do not write anymore
if the fontanel is closed (especially if the patient is beyond  7 months old: PCV 13 d3, IPV
18 months of age)  because at 18 months, we expect that
the fontanels are closed Since the patient is already 7 months old, the vaccines that can be
 We only write if the fontanel is open beyond 18 months of given are:
age  PCV 13 - 3rd dose
 IPV – single dose
Immunization History
 Birth: BCG, Hep B vaccine When would you bring Olivia back for additional vaccine and what vaccine will
 2 months old: PentaV d1, RV d1, OPV d1 you give?
 3 months old: PCV 13 d1, OPV d2  Answer: After 2 months and MMR vaccine
 4 months old: PentaV d2, RV d2, OPV d3 o Based on the NIP, MMR vaccines are given at 9 months old 
And since the child is currently 7 months old therefore she
 5.5 months old: PentaV d3, PCV 13 d2
should be back after 2 months
Dr. Herrera Question: What can you say regarding the immunization
history of the patient?
 There is a possibility that the mother spaced out the giving of
vaccines
Olivia’s mother is concerned that her young immune system is too fragile to
receive so many vaccines so close together. Won’t the number and frequency of
immunization overwhelm Olivia’s immune system? What will be your response
to the Mother?
 Answer: Many of the life threatening diseases that vaccines prevent
occur in very young infants. The only way to protect them is to give the
vaccines according to the schedule. Vaccination will build immunity
against these diseases
INFECTIOUS DISEASES
CASE 2: MARY What vaccine/s will you give to Mary today for her prenatal check-up?
 AGE: 23 yrs. old  Received BCG, 3 doses of DPT, OPV and Hep B and 1 dose of Measles
 24 weeks AOG vaccine before reaching 1 year of age
 Received 1 dose of MMR and 1 dose of Hib vaccine at 15 months of age
Pre-natal Checkup  Received 4th dose of DPT and OPV at age 5
 Current complaints: Mary complains of  Tdap and flu vaccines
congestion and cough for 5 days. Nasal
discharge is clear. She is 24 weeks Current recommendations is that pregnant women should receive
pregnant flu vaccine first and when she reaches 27 weeks AOG  that is the
 PMH: She has a history of mild anxiety. time that she should receive the Tdap vaccine
Varicella at age 2 Tdap vaccination is best given at 27-36 weeks AOG
 FH: Father is alive with a history of CHF
and diabetes. Mother is alive with a NOTE: Note that >20 weeks AOG, any time you can give the Tdap
vaccine, it’s just that current recommendations says that it is best
history of mastectomy
given at 26-36 weeks AOG  this is to protect also the baby with
 Social History: Stay at home Mother the maternal antibodies
 OB History: G2P1 (1001)
o 1st Pregnancy: NSVD at age 20, delivered at hospital, male (40
weeks)
 PE: essentially normal, uterus palpable at level appropriate for
gestational age
Immunization History
 Received BCG, 3 doses of DPT, OPV and Hep B and 1 dose of Measles
vaccine before reaching 1 year of age
 Received 1 dose of MMR and 1 dose of Hib vaccine at 15 months of age
 Received 4th dose of DPT and OPV at age 5
What can you say regarding the immunization history of the patient?
 Mary basically received all the childhood immunization.
However, during her 1st pregnancy  there was no history of
vaccination
True/False Questions about Vaccine Safety

 All vaccines, including live-virus vaccines can be given to breastfeeding
mothers
o True, because generally speaking, there is no contraindication
for a breastfeeding mother to receive any type of vaccination
o If the statement was changed from breastfeeding mothers to
pregnant women  answer would now be False because live-
attenuated vaccines are contraindicated to pregnant patients
o Remember: All live-attenuated vaccines are contraindicated
to give to HIV (+), immunocompromised, people receiving large
doses of steroids and pregnant patients. But generally, they are
allowed to be given inactivated vaccines
 Mild illness is a reason to withhold vaccination
o False
 A pregnancy test should be performed routinely for adolescent females
before giving them MMR vaccines
o False, because pregnancy test is NOT ROUTINELY done
 If there is an immunosuppressed child in the household, the pregnant
mother should not receive any kinds of vaccines
o False, even if there is an immunosuppressed child in the
household, pregnant mothers can still receive vaccines
o If the question is changed to: If there is an immunosuppressed
adult in the household, the infant should not receive what kind
of vaccine? Answer: OPV  oral polio vaccine is not given
because virus will be shed on the stools which may cause
infection to the immunosuppressed adult. Better give IPV as
alternative vaccine
INFECTIOUS DISEASES
Topic: COVID-19 and Fever or Unknown Origin
TIMELINE OF THE COVID-19 PANDEMIC VIROLOGY & TRANSMISSION

4 Genera of Coronaviruses:
 Do not confuse Genera with Variants!

o Initially, the variants were named after the place where it was
1st discovered BUT this was changed by the WHO to also
naming it as alpha, beta, delta, gamma etc.
 Genera is the genus name
 The 4 genera of coronaviruses are:
o Alpha
o Beta
As of August 4, 2021
o Gamma
 Death rate for Covid-19 worldwide = 2.13%
o Delta
 Death rate for Covid-19 in the Philippines = 1.45% (1,612,541/111,025,935)
 Many of the coronaviruses that infect humans belong to the beta
= 1.75% (28,141/1,1612,541)
coronaviruses
 Death rate for Covid-19 in the Philippines is somewhat lower compared
o SARS-CoV 2  the one causing the pandemic now (Covid-19)
from the death rate worldwide
o SARS-CoV 1  the one causing the 2001 epidemic; Fatality rate
is around 10%
o MERS-CoV  caused the 2011-2012 epidemic in the Middle
East with a fatality rate of 30%
 SARS-CoV 2 is genetically similar to the 1st SARS
 The first coronavirus discovered in the 1960s which was causing upper
respiratory illness to humans also belong to the beta coronaviruses
 Other coronaviruses causes infection in other animals (e.g. mammals &
birds)
 The journal article above just shows that there are other diseases that
are more fatal than Covid-19 which are Non-Communicable Diseases
o Hypertension
o Diabetes
o Cancer/Malignancies  Coronaviruses was discovered as early as 1930s and it was noted to be
o Effects of Smoking causing bronchitis in chickens but at that time, they couldn’t identify
 Death rate among ages 30-70 from the main 4 NCDs was 28%  this is what specific virus it was
way higher than the death rate for Covid-19  1950s  hepatitis in mice
 Covid-19 infection  one can still recover  1960s  human upper respiratory infection
 NCDs  no treatment = no cure  Later 1960s, when microscope was available  they
studied the 3 viruses and they all looked the same 
they named it coronavirus (due to its appearance)
INFECTIOUS DISEASES
SARS-CoV 2 Structure  Delta variant is of concern as of the moment because it is said to be

more transmissible (similar to chickenpox) and causes a more severe
disease
SARS-CoV 2 Variants of Interest
 Variants of Interest differs from Variants of Concern because there is a

proven mutation in the receptor binding domain of the virus
 There is a potential (meaning there has been NO established proof yet)
for it to be easily transmissible, evade antibodies (whether previous
infection, from vaccinations, or treatment like monoclonal antibodies),
or cause a more severe disease (fatal)
 Theta Variant (P3)  Philippine variant
 Structures of SARS-CoV 2
 Epsilon Variant  U.S/California variant
o Spike protein
 Eta and Iota Variant  New York variant
o Nucleocapsid  where the RNA is wound
o Membrane  Lambda Variant  Peru variant
o Envelope  is within the membrane protein
o ssRNA  + sense, 30k bases Pathogenesis of SARS-CoV 2
 For a virus to infect a cell, it should have a receptor. The identified
receptor for SARS-CoV 2 is the Angiotensin Converting Enzyme-2
Receptor (ACE-2)
o ACE 2 receptor is found in many types of cell in the body but
mainly it is found in the respiratory tract
 The variants of SARS-CoV 2 are caused by the mutation in the gene that
code for the spike proteins
 Variants of SARS-CoV 2 can be divided into 2:
o Variants of Concern
o Variants of Interest
SARS-CoV 2 Variants of Concern
 Once the virus is inside the cells, its S1 subunit will attach to the ACE 2
receptors  S1 will be cleaved from the S2  the transmembrane
serine protease 2 (TMPRSS2) will cause changes in the membrane to
facilitate the fusion of the membrane of virus with the cell membrane
 Initially, the variants were named after the place where they have been of human  it will be endocytosed  once inside, cathepsin will
discovered (e.g. Indian variant for Delta)  WHO renamed the variants degrade the endosome to release the virus and its RNA  RNA is
into Alpha, Beta, Gamma, Delta etc. translated to different proteins  RNA will also be replicated into its
 There are spike protein substitutions found in the receptor binding daughter RNAs  the proteins and RNAs replicated will be assembled
domain of the different variants of SARS-CoV 2 to form new virions  when mature, it will be released to other cells
o Example: for Alpha variant  E484K, S494P, N501Y…
o In biochemistry, amino acids have their 1 letter names. E is SARS CoV 2 Transmission
glutamic acid and K is lysine. So in the alpha variant, there is a  Droplets from close contact – primary mode of transmission
substitution on the 484th amino acid from glutamic acid into  Airborne
lysine o Viruses transmitted by this route are SARS-CoV, measles virus,
o S is serine and P is proline. There is substitution on the 494th and VZV (From Harrison’s 20th Ed. p. 1382)
amino acid from serine to proline o If proven that SARS-CoV 2 is transmitted airborne  virus
o N is asparagine and Y is tyrosine. There is substitution on the remains suspended in the air (social distancing will not work).
501st amino acid from asparagine to tyrosine As long the air does not dissipate to a larger or open space,
 Variants of Concern  it already has been proven to be easily virus will remain circulating in an enclosed room
transmitted, can cause evasion of immunity, or can cause a more severe  Fomite
disease  Others (?): fecal-oral, ocular, semen, vertical – still no strong evidence
INFECTIOUS DISEASES
SARS CoV 2 Transmission continued…..  Rapid antigen test more appropriately done during the first 10
 Fomite transmission  possible but usually, the virus will not be viable days/first week of the illness
if it remains there for a long period of time (especially when exposed to  Patients who have already recovered, no more symptoms but have a (+)
UV light) RT-PCR after the illness  may be due to ↑ sensitivity to virus in the
o Handwashing is an effective way to prevent transmission body that are already dead
 Face mask  helps prevent virus transmission via droplets or airborne o For those who have mild-moderate illness but still (+) RT-PCR
 Face shield  questionable use in preventing Covid-19 transmission after 10-14 days from the 1st day of symptoms  low likely that
they are infectious
CLINICAL MANIFESTATIONS
 Incubation period: 14 days (4-5 days)
 Asymptomatic
 Mild: 80-85% In the Philippines: Most present with Mild Symptoms
 Moderate (95%). The other 5% are Moderate or Severe/Critical
 Severe/Critical
 Case Fatality Rate: 2-3%
o SARS CoV 1 fatality rate: 10%
o MERS CoV: 30%
 Fever, cough, dyspnea  most common complaint of those with
COVID-19 pneumonia
 Headache, rhinorrhea, diarrhea, nausea, vomiting, anorexia, sore
throat, fatigue, ocular reaction, skin rash
 Others: anosmia (loss of smell), ageusia (loss of taste)
COURSE OF THE DISEASE  The reason why Covid-19 infection is self-limiting most of the time is
because the immune response is also self-limiting (80%)
o It is severe in 15-20% due to the severe immune response
o It is a fatal in 1-2%
 Stage 1 – Asymptomatic
o Have a high viral load but low immune response  no
symptoms
 Stage 2 – Nonsevere symptomatic
o There is intermediate immune response  causes fever,
elevation in inflammatory markers that dissipates/resolve
later on
 Stage 3 – Sever respiratory-inflammatory
o There is hyperimmune response (“Cytokine storm”)  since
there is a hyperinflammatory response, it will cause severe
 Once the patient is infected with the virus, he will first undergo symptoms
presymptomatic phase  no symptoms
o 4-7 days up to 14 days RISK FACTORS FOR SEVERE ILLNESS
 When viral load is already high  patient will now have symptoms  Increasing age
 Before the end of the 1st week of illness, the body will start to synthesize  Comorbidities
the antibodies against the virus  Laboratory abnormalities
o By the end of the 1st week or after 10 days (starting from onset o Elevated: D-dimer, CRP, LDH, Troponin, Ferritin, CPK
of symptoms)  there will be resolution of symptoms o Decreased Absolute Lymphocyte count
o Covid-19 is self-limiting most of the time  Viral Load
 Severe/Critical Covid-19 is not due to the virus anymore but rather due  Genetics?
to the hyperimmune response or hyper inflammation (“Cytokine
Storm”)  leading to some organ damage and more severe
manifestations
When is the right time to do the RT-PCR testing and Rapid antigen, antibody test?
 1st week of illness  best time to do the RT-PCR because there is high
viral load
 2nd-3rd week of illness  virus may negative on RT-PCR due to declining
viral load
 Antibodies formed during the 2nd week; rapid antibody test will have a
positive result
o Positive result on rapid antibody test is good  it is not a sign
of active infection but rather, they have already recovered
(possibly they were infected but did not know)
INFECTIOUS DISEASES
 Comparing an 18-29 year old to the younger ones (0-4 & 5-17)  The “Long COVID”:
younger ones have a lower chance of being hospitalized and dying from  Post-COVID conditions, post-COVID syndrome, post-acute sequelae of
Covid-19 SARS-CoV 2 infections (PASC)
 Comparing an 18-29 year old to the older one’s (30’s and above)  You  Symptoms that develop during or after acute Covid-19 illness, continue
will see that the risk for hospitalization and chance of dying from Covid- for > 4 weeks, and are not explained by alternative diagnosis
19 increases  This happens because after the cytokine storm, the body’s desire to
heal leads to extensive fibrosis and scarring (especially in the lungs) 
symptoms persists even after the illness
CLINICAL/LABORATORY EVALUATION
Diagnostic Evaluation
 CBC, SGPT, SGOT, LDH, Ferritin, CPR, ESR, Prothrombin time and Partial
Thromboplastin time, Procalcitonin, D-dimer; ABGs
 CXR, Chest CT scan
 SARS-CoV 2 RT-PCR
 Home management vs. In-person clinical evaluation
NOTE: You are not limited to the aforementioned tests. You can request for
other tests if your history and P.E. tells you that you need to do so. Example,
diabetic patient with Covid-19  you can request for HbA1c to check his control
of blood sugar for the past 3 months
 If a patient has Covid-19 and they have the above-mentioned conditions
 chance of hospitalization is increased
Chest X-ray CT scan
 Chest x-ray finding of bilateral and peripheral infiltrates  common

 The chance of dying from Covid-19 if they have pre-existing conditions
finding in Covid-19 BUT it is not pathognomic
is increased as compared to those with no pre-existing conditions
 Plain chest CT scan  you will see ground glass opacity that are also
 This is the reason why people who have comorbidities are highly
bilateral and peripheral in location
advised to get vaccinated
COMPLICATIONS & ASSOCIATED SYNDROMES

Cardiovascular Complications:
 Stress cardiomyopathy, hypoxic injury, myocarditis, right heart failure,
microvascular dysfunction, SIRS  elevated troponin
 Dysrhythmias
 Heart failure
Thrombotic Complications:
 Venous thromboembolism/VTE (DVT and PE)
 Arterial thrombosis (stroke, MI limb ischemia)
 Bleeding?
Dermatologic Syndromes:
 Most common: exanthematous (morbilliform) rash
 Pernio-like acral lesions
 Livedo-like lesions
 Retiform purpura
 Necrotic vascular lesions
 Urticaria
 Vesicular eruptions
 Erythema multiforme-like lesions
 Erythematous, polymorphic rash
INFECTIOUS DISEASES
 Sotrovimab  used for mild-to-moderate COVID-19 who are not

hospitalized but at risk of progression to severe COVID-19
o This means that patients usually have comorbidities (which
is why they are at risk to progressing to a more severe
disease)
o If a patient has mild-to-moderate symptoms BUT DOES
NOT have a risk for progression to severe COVID-19  not
authorized for emergency use
o It cannot be given to patients who already are in severe or
critical COVID-19
 Not authorized for use in patients:
o Who are hospitalized with COVID-19, OR
o Who require oxygen therapy for COVID-19, OR
o Who require an increase in baseline oxygen flow rate
because of COVID-19 (in those on long-term oxygen
therapy for underlying non-COVID-19-related comorbidity)
 Abu Dhabi  the first country to order Sotrovimab as treatment

for COVID-19
 Close Contact – a person who had interaction with a Covid-19 probably
o 97.3% of COVID-19 patients recovered from COVID-19
or confirmed case in <6 ft. (<2 meters) and he/she stayed there for >15 after treatment with Sotrovimab and they have also used
mins. not wearing any face mask or PPE it for severe cases of COVID-19
 For those with (+) SARS-CoV 2 Antigen-RDT and goes to the hospital   Singapore has already ordered Sotrovimab for use as treatment
still request for RT-PCR
In-Patient Management
TREATMENT
 Moderate: Supportive; manage comorbidities; *Fluids
Home Care/Isolation Facility
o CXR with pneumonia = moderate even without hypoxia
 Asymptomatic
o Fluids given are usually 1 L for 16 hrs.
 Mild
 With Hypoxia: (usually labeled as severe COVID-19)
 Antibody-based treatment*: Sotrovimab?
o Oxygenation (low-flow nasal cannulation)
 Isolation: duration (symptom- and time-based approach)
o Dexamethasone 6 mg OD
o Isolation should not be based on the RT-PCR result. It should
Patients who require oxygen supplementation are
be symptom- and time-based approach  meaning if you recommended to start on dexamethasone 6 mg OD for 5-7
have symptoms, you isolate and count up to 10 days. If you do days
not develop severe illness and many of your symptoms have
resolved (e.g. >24 hrs. afebrile) at the 10th day  low-risk for o Remdesivir 200 mg IV (D1) then 100 mg IV OD (D2-D5/D10)
infectivity and can now go back to work o Anticoagulation
 Supportive care: antipyretics/analgesics, hydration, monitor for clinical LMWH (e.g. enoxaparin) is given if they have elevated D-
worsening, manage comorbidities dimer
Sotrovimab
 Tocilizumab – an anti-IL 6
 Recombinant human IgG1-kappa monoclonal antibody
 Binds to a conserved epitope on the spike protein receptor binding This is given if there is impending or beginning a cytokine storm
domain of SARS-CoV 2 but does not compete with human ACE2 receptor
binding  Others: immunomodulators/anti-inflammatory (melatonin, Vitamin D,
 Inhibits an undefined step that occurs after virus attachment and before Fish oils, colchicine)
fusion of the viral and cell membranes o These other treatment have no strong evidence for its use but
 This is the first drug specifically made for SARS-CoV 2 created by at this time that we have nothing to give or cure for Covod-19,
GlaxoSmithKline we give these because theoretically they may be useful
 May 27, 2021: Emergency Use Authorization (EUA) issued by the FDA
for treatment of mild-to-moderate COVID-19 in adults and pediatric
patients aged >12 years who weigh >40 kg with positive results of SARS-
CoV 2 viral testing, and who are at high risk for progression to severe
Continued next page…..
COVID-19, including hospitalization or death
 500 mg as a single IV infusion
 Administer as soon as possible after positive results of direct SARS-CoV
2 viral testing and within 10 days of symptom onset in patients at high
risk for progressing to severe COVID-19 and/or hospitalization
INFECTIOUS DISEASES
 Severe/Critical Sample Case of COVID-19

 ARDS, Sepsis, Organ failure  B.J. 54/Male
o Proning is done if a patient has ARDS. Mild-to-moderate  Admitted: March 5, 2021
COVID-19 do not need to do proning because it does not give  Discharged: March 13, 2021
any benefit
 Manage comorbidities; Oxygenation (High-flow cannula/Mechanical
ventilation)
 Remdesivir, Dexamethasone, Tocilizumab
 Immunomodulators
o Helps calm down the immune system
 Convalescent Plasma Therapy, Hemoperfusion
o These are not strongly recommended by guidelines but
because of their theoretical benefit, we give it for the patient
to have a fighting chance
 A 54 male, known hypertensive on Losartan, 4 days prior he went to the

ER due to epigastric pain but during the P.E. the doctor noted there
were crackles. Work-up was done, CXR showed suspicious infiltrates on
the right base but since the patient has no dyspnea or any respiratory
manifestations  he was sent home with antibiotics and some PPI for
 Convalescence plasma therapy  patients who recovered are asked to the epigastric pain
have their blood tested for neutralizing antibodies. Those who have  After 1 day, the patient had productive cough, anorexia, and shortness
high neutralizing antibodies are then asked to donate their blood to get of breath. The patient became tachypneic and the tachypnea probably
it from the plasma. The plasma is then transfused to the severe/critical lead to respiratory alkalosis causing hypocalcemia  manifestation of
COVID-19 patient tingling sensations on the extremities
 P.E.: tachycardic, ↑ RR, O2 sat. is 97%, bibasal crackles
 Comparing the 2 CXR results, you will see that there is change on the
left and right lower lung field (↑ infiltrates)
 Principle of hemoperfusion: If the patient is having cytokine storm,

what we do is remove the cytokines. So we connect the patient to a
dialysis machine with a cartridge that is specific to absorb the pro-
inflammatory cytokines (e.g. IL-6) to somewhat stop the cytokine storm
INFECTIOUS DISEASES
 Above is the official result of the 2nd CXR  there is significant increase
in the degree of the bilateral lobe pneumonia
Date: 3/8/2021
 CBC of the patient: WBC is normal, neutrophils are ↑, slightly anemic,

platelets are normal
o Severe/Critical patients  if they have low platelets, they
usually have sepsis
 Above is the result of the CXR after several days of treatment. It showed
that there is now decrease in the opacities at the left middle and both
lower lung regions
 Since the patient was hypertensive, he is at risk of becoming a

severe/critical COVID-19 case. C-reactive protein was requested to
check signs of hyperimmune/hyperinflammatory response  he was
 Above is his Chest CT scan  there was ground glass opacity in both positive CRP in 4 concentrations
lungs, more in the lower lobes. This is very highly suspicious of Covid-
19
 This is the result of the patient after several days of treatment  he

 RT-PCR was done and it showed that he was positive for SARS-CoV 2 was now negative for CRP
INFECTIOUS DISEASES
 Ferritin is the stored iron. It is an acute phase reactant so it is elevated

in inflammatory states. The patient’s results showed that ferritin was
very elevated  This is just a medication report. It is where the nurses will write
whatever drug is given to the patient. They write the drug’s name, dose,
frequency, time they gave it
o We do not nebulize patients because it is an aerosol generating
procedure. Better give inhalers
o Melatonin  used as an immunomodulator (not for sleeping)
o Enoxaparin  for DVT prophylaxis. This was given because the
patient has elevated D-dimer
 Ferritin was requested again after three days treatment, result showed
that it was starting to go down (from 1396 to 1208)
 This is the temperature, PR, RR, BP report/graph. The nurses usually

plot what the clerks have determined during the vital signs monitoring
 D-dimer is slightly elevated
o Pre-covid, clerks usually monitor patients every 4 hours
 Fluid intake and output is also recorded because this guides us with the
IV fluid rate of the patient
Prevention of Covid-19 Infection

 Block portals of entry of the virus by wearing your face masks
 Wash hand frequently
 Wear face shields (as implemented by the government)
 Another is receive the vaccines
 Dr. Iturralde requests for antibodies on his patients when they are
about to get discharged in 1 to 2 days. This rapid antibody test will tell
you if the patient developed antibodies against the infection. Seeing it
positive, we are somewhat confident that the patient is already on the
recovery phase especially if the patient’s clinical presentation has
improved
INFECTIOUS DISEASES
VACCINES FOR COVID-19 FEVER OF UNKNOWN ORIGIN

Definition of Terms
 Fever: Temp > 37.3oC (99.1oF) (AM) or > 37.8oC (100oF) (PM); an elevation
of body temperature that exceeds the normal daily variation and occurs
in conjunction with an increase in the hypothalamic set point
o >41.6oC (106.8oF) is hyperpyrexia
o NOTE: In the exam, Celsius will be converted to Fahrenheit so
memorize the Fahrenheit reading
 All these vaccines will protect you from symptomatic Covid-19 but to a
certain extent only. What is good is that all of these vaccines will protect
patients from severe Covid-19
 If ever you get infected, you may be asymptomatic, mild-to-moderate
case only
 Hyperthermia: uncontrolled increase in body temperature > ability of

the body to lose heat; no change in hypothalamic set point
o Example of Hyperthermia: Heat stroke or heat exhaustion
 Almost all who are vaccinated will be spared from having severe Covid-
 Exercise-induced hyperthermia: elevated body temperature
19. That is why those who are elderly or have comorbidities are advised
associated with moderate to strenuous exercise lasting from half an
to get vaccinated
hour up to several hours without an increase in CRP or ESR levels
Factitious vs. Fraudulent Fever

 Factitious: fever that is artificially induced by the patient; THERE IS
FEVER!
o Example: Patient that injected contaminated water in her veins
and developed fever
 Fraudulent: patient is normothermic but manipulates the
thermometer; NO FEVER! (fake news)
o Example: Patient manipulated the thermometer and showed
you she has fever
Recurrent Fever
 Repeated episodes of fever interspersed with fever-free intervals of at
least 2 weeks and apparent remission of the underlying disease
o Example: Recurrent UTI  will have fever when patient has UTI
INFECTIOUS DISEASES
Fever of Unknown Origin (FUO) Etiology of Fever

 Classical/Original Definition: illness of > 3 weeks duration + fever  Infections – most common
>38.3oC on two occasions + uncertain diagnosis despite 1 week of  Noninfectious inflammatory diseases: vasculitis, granulomatous
inpatient evaluation disorders, autoinflammatory syndromes
o This old definition requires the patient to be on the hospital  Neoplasms
 Present Definition:
o Fever > 38.3 C on at least two occasions “It is important to remember that FUO is far more often caused by an atypical
o Illness > 3 weeks duration presentation of a rather common disease than by a very rare disease.”
o No known immunocompromised state (e.g. HIV)
o Diagnosis that remains uncertain AFTER a thorough history-  The most important step in the dx work-up is: the search for potentially
taking, physical examination, and doing the OBLIGATORY diagnostic clues (PDCs)
INVESTIGATIONS o You will know that something is a PDC if you have the
Obligatory Investigations: experience (but since clerkship is only online, you will have
 CBC with platelets, ESR, CRP, electrolytes, creatinine, total protein, limited experience)
alkaline phosphatase, ALT, AST, LDH, CPK, ferritin, ANA, rheumatoid  Potentially Diagnostic Clues (PDCs)
factor, protein electrophoresis, urinalysis, blood cultures (n=3), urine o All localizing signs and symptoms, and abnormalities,
culture, CXR, abdominal UTZ, and TST or IGRA (interferon gamma potentially pointing toward a diagnosis
release assay)
o This will come out in the exam!
o If you have done all of these tests and still there is no diagnosis,
then you now label the patient as FUO
STRUCTURED APPROACH TO PATIENTS WITH FUO
You need to stop any treatment or drugs

because it might affect the results of the
obligatory investigations
Exclude Fraudulent Fever
FDG-PET/CT Scan
 It is a whole body scan that will identify
which parts of the body is taking up
If there is still no diagnosis you may do other glucose a lot (more than the surrounding
test: cells)  therefore it will glow in the screen
 Cryoglobulin fundoscopy  Glowing area might give us a clue of the
 FDG/PET/CT scan etiology of the fever
Abnormal Scintigraphy  we can do

biopsy or culture of the glowing area
If there is still no diagnosis you may do other

test:
 Repeat history and P.E.
 Check again for PDCs
If there is still no diagnosis and patient is
rapidly deteriorating:
If there is still no diagnosis and patient is  Start with broad-spectrum
stable: antibiotics
 Continue looking for PDCs  Anti-TB treatment
 NSAID treatment  Steroids
INFECTIOUS DISEASES
Treatment
 Empirical therapeutic trials with antibiotics, glucocorticoids, or anti-TB
agents should be avoided EXCEPT when a patient’s condition is rapidly
deteriorating after the diagnostic tests have failed to provide a definite
diagnosis
Prognosis
 Our goal is to arrive at a diagnosis and name the patient’s illness 
Why? Because when if we know the diagnosis = we will know how to
prognosticate
 FUO-related mortality rates have continuously declined over recent
decades
 Majority of fevers are caused by treatable diseases and risk of death is
related to FUO is dependent on the underlying disease
o If the cause of FUO is due to infection and you know the cure
for that infection = patient will be saved from dying
o If FUO is caused by a malignancy  high chance of patient
dying
INFECTIOUS DISEASES
Topic: Dengue
DENGUE
 Mosquito-transmitted viral illness and the leading cause of arthropod-borne viral disease in the world
 Swahili “dinga”; Spanish “dengue” = careful gait of a person suffering from bone pains of the disease
o This is why in other translations it is called a “breakbone fever”
Epidemiology
 Affects >100M humans annually; ~25,000 deaths primarily children
 Epidemics occur annually in the Americas, Asia, Africa, and Australia
 Dengue is a perennial disease  meaning it occurs all year round

 Prior the pandemic, the Philippines had a surge of dengue cases in 2019. This is the reason why dengue is declared epidemic here in the Philippines
 Most affected age group were 5-9 year old
 Regions that is mostly affected:
o Region IV-A (CALABARZON)
o Region V (Bicol Region)
o Region VI (Western Visayas)
o Region IX (Zamboanga Peninsula)
o Region X (Northern Mindanao)
INFECTIOUS DISEASES
Topic: Dengue
Vector Viral Replication Cycle

 Aedes aegypti principal vector – an arthropod vector
 Characteristics of Aedes aegypti:
o Breed in or close to houses
o Laying eggs in both man-made and natural water containers
o Relatively short flight distance
o Daytime feeders
 Endemic in many countries; Present throughout SE Asia
Transmission Cycle
 E-protein: facilitates virus entry to the cell

 Once the virus is inside the body, it will attach to a cell
o The receptor up to this date is still not yet identified
o Candidate receptor is Heparan sulfate
 After attaching to the receptor  there will be endocytosis of the
dengue virus  once inside, it will be released and its content (RNA)
will be now free for translation and transcription  the RNA will be
replicated so that the new RNAs + the translated proteins will be
packaged and assembled to form a new virion  this is the immature
virus
 Immature dengue virus has PrM-Envelope protein complex  the PrM
protein will be cleaved from the Envelope protein  the virus will
 The mosquito takes its blood meal from a patient who has dengue. become mature and be smaller (50 nm)
Since the virus is in the patient’s blood, the virus will be taken along by o Importance of cleaving the PrM protein: it makes the virus
the mosquito more infectious
 As more mosquito bites a dengue infected patient, more mosquito will
be carrying the virus and is able to inoculate it to other healthy people CLINICAL MANIFESTATIONS
 Incubation period: 3-14 days
Dengue Virus (DENV) Virology o This are the days starting when the virus infects the body up to
 Flavivirus; 50 nm virion the time he manifests symptoms (if ever there will be
o 50 nm is the mature dengue virus symptoms) because there are some who have asymptomatic
o 60 nm is the immature dengue virus  this is because of the dengue
complex of PrM protein from the Envelope protein  Phases of infection: Febrile, Critical, Convalescence
 ssRNA, 10.7kb; 3 structural and 7 nonstructural proteins o Those people who become symptomatic undergo these 3
o The 10,700 bases code for the 3 structural and 7 nonstructural phases
proteins o Currently there is no drug available to kill the virus
o Structural proteins: C, prM and E o Dengue infection is self-limiting
o Nonstructural proteins: 1, 2A, 2B, 3, 4A, 4B, 5 o It is important for us to know each phase along with its
 DENV1, DENV2, DENV3, DENV4 management  so that patient and their relatives will not
o These are the current serotypes of dengue that we know think that you are doing nothing about their condition
o One serotype, if ever you get infected, is only protective to that
specific serotype Febrile Phase
 Time when the patient has symptoms
 Sudden fever (>38.5oC), headache, vomiting, myalgia, arthralgia,
transient macular rash, anorexia, abdominal pain, diarrhea,
hemorrhage; 3-7 days
o Bleeding is rare on the febrile phase
o Febrile phase may last for 1 week
 Leukopenia, thrombocytopenia, hemoconcentration; elevated ASTs
o CBC is usually the test requested  every day we monitor the
platelets
o AST (SGOT) is markedly more elevated than ALT (SGPT)
o In cases where the platelets are normal  probably not
dengue
o Hemoconcentration is due to many factors:
 Fever  increased insensible water loss
 Vomiting and diarrhea  also cause of water loss
 Anorexia and abdominal pain  makes patient to
take in less fluids
 Endothelial dysfunction  extravasation of
intravascular fluid
INFECTIOUS DISEASES
Topic: Dengue
Febrile phase continued…..  Others: liver failure, neurologic manifestation, cardiovascular

 It is important to hydrate the patient during the Febrile phase manifestation, AKI
 Since dengue patients are usually young  we give fluids at a rapid rate o Dengue hepatitis, dengue encephalitis, dengue myocarditis
o Crystalloids – Plain NSS or Plain LR o Dengue myocarditis
 Usually, Plain NSS 1 L for 8 hrs. or 6 hrs.  The patient is in shock but the heart rate is normal
 Giving of fluids would depend on the degree of  Normally, if someone has low BP  heart will increase
dehydration HR. But due to dengue myocarditis, the heart does not
 Elevated AST respond to the low BP (heart is not tachycardic  will
o Is due to the direct effect of the virus on the liver present as normal HR)
o Resolves spontaneously o AKI
 At this phase, the patient can eat whatever they want EXCEPT dark-  Due to prerenal injury caused by the antigen-antibody
colored foods: complex and complements that will be trapped in the
o Reason for the avoidance of dark-colored foods  we do not glomerulus
want to be confused if ever the patient will have dark stools (to  For Dr. Iturralde , he divides the critical phase into early and late critical
be able to tell if it is a sign of bleeding) phase
o But if patient insists on eating a dark-colored food (e.g. o Late critical phase  signs that we are at this phase are: No
chocolate cake)  just allow them to eat it (better for them to fever or anorexia, patient can eat and drink a lot. WBC is now
eat it than eat nothing due to restriction) increasing
o Melenic stools can be distinguished from the black stools that o We decrease the rate of IV fluid rate at the late critical phase
are not due to bleeding because we are anticipating the next phase (convalescence
 Melenic stools  are usually “sticky” or “tarry”. It will phase) wherein the endothelial dysfunction resolves  we
stick to the toilet bowl and usually cannot be flushed want to avoid the fluid overload because if not, it will lead to
readily pulmonary congestion and pleural effusion
 Fever here can be managed by paracetamol. If patient is vomiting,
paracetamol should be in IV form Convalescence Phase
o IV form of paracetamol  300 mg IV every 4 hrs. for fever  Resolution of plasma leakage and
 Bone pains that are not relieved by paracetamol  give combination of hemorrhage; resorption of accumulated
paracetamol + tramadol fluids
o Never give NSAIDs because they have antiplatelet effects   “Convalescent rash of dengue”, aka
will aggravate the thrombocytopenia of the patient and there “Herman’s rash” – islands of white in
will be increased risk for bleeding the sea of red
o This is only present in the
Critical Phase convalescence phase
 After 3-7 days, there will come a time that the patient will have No more o If patient complains itchiness due to the rashes  you may
fever give antihistamine (e.g. Cetirizine, Levocetirizine, Bilastine,
o Patients who asks if they can go home since they have no more Diphenhydramine)
fever  tell them that they cannot go home yet since most  By this time, the platelet will start to increase
probably they are on the 2nd phase of dengue o Even if the platelet is not in the normal range after 2-3 CBC’s
o Complications and some severe manifestations might occur at but the trend of the platelet level is increasing  you can send
this phase, especially those who are at risk for severe dengue the patient home
 Hemoconcentration; marked thrombocytopenia; narrow pulse COURSE OF DENGUE ILLNESS
pressure; hemorrhage; pleural effusion
o The lowest number of platelets is seen in the Critical phase
o Bleeding is likely at this phase
o Pulse pressure is the difference between the systolic vs.
diastolic BP
 Narrow pulse pressure  if the difference between
the systolic and diastolic BP is 20 or less
 Example: 6 am – 120/80 mmHg
10 am – 120/100 mmHg – narrow PP
 Narrow pulse pressure is an indication that the
intravascular volume that is circulating is low
 Not recognizing this narrow pulse pressure  may
lead to overt hypotension
 Management for this is usually boluses of fluids
 But before giving fluids, auscultate  check if there
are no signs of congestion, equal breath sounds
 Febrile Phase
 If after giving fluids and still the patient has narrow
o There is fever
pulse pressure  norepinephrine is usually given
o Problem is dehydration  manifests as hemoconcentration
o Pleural effusion is possible due to the third spacing of fluids
o To resolve the issue, we give fluids
o Decreasing platelet levels
o High levels of virus  inflammatory reaction against it which is
why many symptoms present in the febrile phase
INFECTIOUS DISEASES
Topic: Dengue
Course of Dengue illness continued….. WHO DENGUE CASE CLASSIFICATION

 Critical Phase
o No more fever
o Time when complications may occur (Shock, Bleeding, Organ
impairment)
o Monitor patient closely
o There is marked hemoconcentration and thrombocytopenia
 Recovery Phase
o Reabsorption of fluid that extravasted
o Fluid overload is a potential problem if you are not keen on
your management  this can be prevented by decreasing
fluids at the late critical phase
o Platelets start to increase
o Antibodies (IgG/IgM) against the virus is produced
 Antibodies produced are meant for the same
serotype; Patient can still be infected by other
serotypes
PATHOPHYSIOLOGY OF DISEASE MANIFESTATIONS

 Capillary leak syndrome  We label patients as:
o Due to endothelial dysfunction o Dengue without warning signs
 Direct viral effect on bone marrow o Dengue with warning signs
o Patient will have leukopenia, thrombocytopenia o Severe dengue
 Viral infection of hepatocytes and Kupffer cells  We also write this as diagnosis of the patient after we discharge them
o Elevated AST and ALT (patient is already well)
o Possible liver failure (in severe dengue cases)
Severe Dengue
DIAGNOSIS  Severe plasma leakage
 History, Physical Examination o There is Shock  may happen if you were not able to identify
o Before the pandemic, any patient presenting with fever, the narrow pulse pressure
headache, vomiting, abdominal pain, joint pains, etc.  the o Fluid accumulation with respiratory distress  pleural effusion
top differential is dengue since it is endemic here in the causes difficulty in breathing
Philippines  Severe bleeding as evaluated by the clinical
o Currently, COVID-19 is the top differential diagnosis o For Dr. Iturralde, severe bleeding is when the patient is:
 CBC with platelets, AST, ALT; Dengue NS1Ag, IgM, IgG  Hypotensive
o During the 1st day of illness , the 1st CBC result will look normal  Caused the clinician to do blood or platelet
(platelet is on the low normal) transfusion
 Normal platelet: 150,000-450,000  Caused the clinician to give inotropics (e.g. norepi.)
 Dengue patient platelet: around 150,000-200,000   Bleeding spontaneously (non-stop)
looks normal but the following days, platelet will  Severe organ involvement
decrease o Liver: AST or ALT >1000
o AST is markedly more elevated than ALT o CNS: impaired consciousness
o IgG  tells you that the patient had previous dengue infection o Heart and other organs
 It is important to ask in the history of any previous
dengue infection because it is a risk for severe dengue Dengue Without Warning Signs
(should the patient be infected again by dengue)  These are patients who went from febrile phase  jumping into
 Other laboratory tests may be requested if necessary recovery (convalescent) phase
o E.g. CXR – patient is complaining of cough or DOB
o Kidney function and Serum electrolytes – patient presented
with vomiting, diarrhea or severe dehydration
INFECTIOUS DISEASES
Topic: Dengue
FACTORS INFLUENCING DISEASE SEVERITY PREVENTION

 Viral factors In endemic areas:
o Dengue serotype 2 “most problematic”  Mosquito control
 Prior dengue exposure o Aedes aegypti breeds on clean water
o Antibody-dependent enhancement of infection  Personal protective measures
 If you had dengue before and you recovered  you o If you are going to areas that is infested by mosquitoes  use
will have antibodies mosquito killers (e.g. katol), repellant, mosquito net
 The antibodies are supposed to protect us from the  Vaccination: CYD-TDV (Dengvaxia): 2017 “...based on 6 years of clinical
subsequent viral infection of the same serotype data, the vaccine had a persistent beneficial effect in individuals who
 Studies have shown that the protective had been previously infected with DENV prior to vaccination; in
ability/neutralizing capability of the antibody individuals without prior episode of DENV infection, however,
depends on the level vaccination was associated with an increased risk of severe disease and
 Low levels  facilitates the entry of the virus hospitalization”
 High levels  it will neutralize the virus o Dengue vaccine in the Philippines has been banned because of
 So for those patients with previous dengue infection some people with political agendas  propagation of fake
 tell them that their subsequent dengue infection news against Dengvaxia
might be more severe than their previous dengue o Persistent beneficial effect of Dengvaxia  can be explained
infection by the antibody-dependent enhancement of infection. If a
 Age: between 6-12 months previously infected patient will be vaccinated there will be high
o Severe dengue commonly occurs in pediatric age group levels of antibodies against dengue  there will be
o Example: Female on her reproductive age had dengue but was neutralization the virus
able to recover. Later on she got pregnant  her antibodies  Those with no previous dengue infection and they will
can cross the placenta giving it to the baby. After the baby was be vaccinated  antibodies will be at the low levels at
born, a mosquito bites the baby. Since the baby has low first so if ever they get dengue infection  can lead to
antibodies for dengue coming from the mother  there will severe dengue
be an antibody-dependent enhancement of infection o Increased risk due to Dengvaxia  this is not absolute that all
 Malnutrition? patients with no previous dengue infection and they will be
o Undernourished  of course there may be problems with vaccinated will lead to a severe disease and hospitalization
recovery, especially if they have protein catabolism. Low
proteins = low antibody production
o Obese  obese patients with dengue are usually the ones who
will have problems on the critical phase of dengue. They are
prone to have pleural effusion, bleeding, hypotension, etc.
 Adipocytes is a reservoir for inflammatory molecules
(e.g. IL, cytokines)
 Fat post metabolism will produce more inflammatory
molecules = risk for severe dengue
 Genetic factors
TREATMENT
 Outpatient/inpatient
o Outpatient management  if the patient can eat and drink,
has no warning signs, & no vomiting
o Inpatient management  for patient with warning signs and
severe manifestations
 Supportive; symptomatic
 No NSAIDs
 Fluids - oral rehydration; intravenous fluids (i.e. crystalloids), with close
monitoring of volume status
o Know when to decrease the IV fluid rate
o Auscultation of the lungs is important before giving fluids
(correlate any findings with the patient’s condition)
 Blood transfusion
o Given to patient with severe bleeding and hypotension
 Platelet transfusion – only in severe thrombocytopenia AND active
bleeding
o Given to those patient with <20,000 to <10,000/uL and the
patient is bleeding  these 2 criteria need to be met for
platelet transfusion
o It is not cost-effective to give platelet transfusion if the 2
criteria above is not present. Many patients have <20,000 to
<10,000/uL but they feel nothing  so no need to transfuse
platelet
o 1 unit of platelet for every 10 kg for adults
INFECTIOUS DISEASES
Samplex: Exit Exam
S.Y.: 2020-2021
QUESTIONS
1) Snake bites are a well know occupational hazard that often results in 9) A patient weighing 50kg was bitten by a stray dog on the check and you
morbidity and mortality. Common victim of their fatal envenoming are are going to give ERIG. Which of the following is TRUE?
veterinarian (farmers)  EGIR dose is constant at 20IU/kg – HRIG! Should be 40 IU/kg
 If 1st statement is FALSE 2nd is TRUE  The computed total dose of ERIG to given is 10 ml
 If 1st statement is TRUE 2nd is FALSE  The patient will be needing 4 vials of EGIR based on
 If both statements are TRUE computation - HRIG
 If both statements are FALSE  ERIG preparation (available) 150 IU/ml at 2ml/via - HRIG
2) In the Philippines, there is an established statistics about cases of 10) The following is TRUE regarding wound management of animal bites?
snakebite. Making males aged 15 more prone to be inflicted with their  2 hours interval is given after RIG if suturing would be done
venom (these statements refer to DOG bites NOT snakebites)  Cloxacillin 500 mg can be prescribe BID for 7 days to avoid
 If 1st statement is FALSE 2nd is TRUE infection
 If 1st statement is TRUE 2nd is FALSE  Antibacterial creams are recommended at the bite site to
 If both statements are TRUE avoid the growth of bacteria
 If both statements are FALSE  Primary suturing of the wound should be the primary concern
3) It is always a constant public health reminder that all snakebites are 11) Case: A 65-year old male complains of hematochezia. He is not yet
considered fatal (not all snakebites are fatal, majority are not poisonous) . In dehydrated but is anxious about the appearance of his stool. Upon
our census bites, form cobras are the most common and given the examination, there are no hemorrhoids noted
highest medical importance.
 If 1st statement is FALSE 2nd is TRUE What could the etiologic agent be?
 If 1st statement is TRUE 2nd is FALSE  Norwalk virus
 If both statements are TRUE  Vibrio cholera
 If both statements are FALSE  Shigella
 Rotavirus
4) The following are generalized symptoms of snake bites EXCEPT
 Prostration Rationale: Based on the lecture, if the stool sample is bloody 
 Weakness etiologic agent is probably bacterial in origin.
 Blistering – local symptoms Vibrio cholera  stool is not bloody but “rice watery”
 Malaise
12) Case: You are presented in the emergency room with a 78-year-old
5) Difficulty in swallowing a manifestation of a snake bite that signifies that resident of a long-term care facility in Quezon City. The caregiver notes
the venom has already spread at ______________ that the patient has been having anorexia and episodes of hypothermia
 Skeletal muscle for the past eight days. CXR shows patchy infiltrates in the right lower
lung. Gram stain shows plump gram (positive) cocci in clumps.
 Neurological
 Renal
What is the most likely microbe?
 Cardiovascular
 Pseudomonas aeruginosa
6) Based on the World Health Organization which of the following factors  Anaerobes
affects the incidence of an animal bite.  Staphylococcus aureus
 Poverty  Streptococcus pneumonia
 Mental health issues
13) Case: You are presented in the emergency room with a 78-year-old
 Poor hygiene (sanitation)
resident of a long-term care facility in Quezon City. The caregiver notes
 Urbanization
that the patient has been having anorexia and episodes of hypothermia
for the past eight days. CXR shows patchy infiltrates in the right lower
7) Based on the demographic profile of animal bite what age
lung. Gram stain shows plump gram (positive) cocci in clumps.
predominates the incidence of an animal bite,
 5 years old
What is a possible complication of this organism?
 10 years old
 Meningitis
 15 years old
 Cavitations
 20 years old
 Endocarditis
 Pericarditis
8) Transmission of rabies can occur on which of the following routes
EXCEPT
 Inhalation
 Bites
 Direct contact of intact mucosa
 Licks of intact skin – broken skin
INFECTIOUS DISEASES
Samplex: Exit Exam
S.Y.: 2020-2021
QUESTION ANSWER
14) Case: You are presented in the emergency room with a 78-year-old Which vaccine is given soon after birth Hepatitis B
resident of a long-term care facility in Quezon City. The caregiver notes Antimicrobial is recommended to all
that the patient has been having anorexia and episodes of hypothermia patient infected with nontyphoidal False
for the past eight days. CXR shows patchy infiltrates in the right lower salmonella
lung. Gram stain shows plump gram (positive) cocci in clumps. MDR Tb refers to case of TB which is
Isoniazid and Rifampicin
resistant to
What is the antibiotic of choice if this is a methicillin-susceptible strain? What is the term for the process of
hepatic extraction of orally administered
 Penicillinase resistant penicillin - X First pass effect
drugs before they reach systemic
 Fluoroquinolone
circulation
 Imipenem – does not cover for MRSA This specific treatment under evaluation
 Amoxicillin - X has been shown by some preliminary
studies to reduce hospital mortality in Not sure but answer possibly here is
Tocilizumab  an anti IL-6 which is
15) Case: You are presented in the emergency room with a 78-year-old patients who are critically ill with given if patient has an impending
resident of a long-term care facility in Quezon City. The caregiver notes markedly elevated dimer ferritin. cytokine storm
that the patient has been having anorexia and episodes of hypothermia However , this may be associated with
for the past eight days. CXR shows patchy infiltrates in the right lower an increased risk secondary infections
lung. Gram stain shows plump gram (positive) cocci in clumps. The dengue patient assigned to you 5
days of admission on the morning you've He needs to stay because he
Aside from a sputum GS CS, what other test would you require? requested you to inform the attending needs to be aggressively given
that he is going home because he has no fluids because of
 CT scan of the chest with contrast – not
more fever neu 0.40 , 0.54,Hct0.52 hemoconcentration.
 Sputum TB culture and sensitivity – Tb usually involves upper lobes
platelet advise the patient ?
 Blood CS – check if there is sepsis? Cross placental transfer of
 Repeat sputum GS and CS Which of the following confers passive
maternal
immunity
antibody
16) Tuberculosis is an infectious disease transmitted by: Inactivated influenza vaccine
The following is true about vaccination
 Spitting are preferred to live attenuated
in pregnancy
 Sneezing vaccine in pregnancy
 Coughing Based on the World Health Organization
 All of the above which of the following factors affects the Poverty
incidence of animal bite
On managing victim of snakebite the
17) The primary diagnostic method adopted by the National TB Program Fecalysis
following should be requested EXCEPT
among children and adults who can expectorate is:
From the pooled plasma of
 Tuberculin test Immunoglobulins are made
blood stream
 TB culture and sensitivity A - year old traveler develops diarrhea
 TB-PCR and is brought to the hospital. He claims
 DSSM to have eaten raw oysters mixed with LR
vinegar and raw onions. He is seen
18) The ideal volume of sputum to be submitted for DSSM should be at severely dehydrated with scanty urine Based on the lecture, we give IV
least? output. A foley catheter is inserted and lactated ringer for severely
only 75 ml of urine is passed through the dehydrated patients
 3 ml
 10 ml urine bag.
What is the IV fluid of choice?
 2 ml
Among the antimicrobials used typhoid Chloramphenicol
 1 ml
fever which of the following is not Has many side effects  E.g. Gray baby
recommended for child syndrome
19) When monitoring response to treatment, follow up DSSM should be Possible Answers?
done at the end of the ___ month of treatment – end of intensive phase  Place 2 ml of freshly sampled venous
blood in a small, new or heat cleaned,
 Third dry, glass vessel
 Second  Leave undisturbed for 20 minutes at
ambient temperature
 Sixth  Tip the vessel once
 First  If the blood is still liquid (unclotted) and
runs out, the patient has
hypofibrinogenaemia (incoagulable
20) Which among these are the first-line drugs for tuberculosis? blood) as a result of venom induced
The following are TRUE regarding the 20 consumption coagulopathy
 Ethambutol  In the South-East Asia region,
minutes whole test?
 Kanamycin incoagulable blood is diagnostic of a
viper bite and rules out an elapid bite
 Levofloxacin  If the vessel used for the test is not made
 Co-amoxiclav of ordinary glass, or if it has been
cleaned with detergent, its wall may not
stimulate clotting ofthe blood sample
(surface activation of factor XI –
Hageman factor) and test will be invalid
 o If there is any doubt, repeat the test in
duplicate, including a “control” (blood
from a healthy person)
INFECTIOUS DISEASES
Samplex: Exit Exam
S.Y.: 2020-2021
QUESTION ANSWER QUESTION ANSWER

Annual influenza vaccine In the combined DTP Immunization used
in the past, which one of the three
The adult immunization program Annual pneumococcal
Pertussis
components reportedly caused severe
includes polysaccharide vaccine for those reactions?
aged 65 and above  incorrect
By 14 months of age, all children should Three doses of dtap opv
because it is not given annually
have received the following vaccine - 14 weeks of age  the child
You are contemplating a possible
except receives the 3rd dose of OPV, DPT
envenomation with no idea what snake
What type of reaction commonly occurs
bit him. He is presenting abdominal pain, Swelling and tenderness at the
Cobra after diphtheria, tetanus and acellular
paresthesia but with no evidence of loss injection site
pertussis (DTP) vaccine?
of consciousness. What possible snake
had bitten the patient? A farmer was rushed to the Emergency
room due to a confirmed snakebite. As a
A year old traveler develops diarrhea Hyperkalemia – leads to Cardiac
physician, you are observing clinical
and is brought to hospital. He claims to Arrest
signs that warrant urgent resuscitation,
have eaten raw oysters mixed with
Vibrio cholera adheres to the brush which includes?
borders of small intestinal A pregnant woman passes antibodies to
severely dehydrated with scanty output. enterocytes and releases enterotoxin
A foley catheter is inserted and only 75 her unborn through the placenta to
 increased cAMP It usually lasts for 9 months. But it
ml of urine is passed through the urine protect against certain diseases About can be depleted as early as 6 months
bag. how long does this natural immunity last
What is the pathogenesis of diarrhea? after birth?
If your patient remains a sputum smear Most common manifestation of UTI Acute Cystitis
positive at what month of treatment, Fifth Typhoid vi
Which typhoid vaccine is the most
you will classify it as failure polysaccharide vaccine
appropriate for a 2 year old child
Hyaluronidase, a venom enzyme, is to (typhim)
the endothelium causing bleeding. In It is not safe to be at
Proteolytic Enzymes A dengue patient assigned to you finally home because he should be
addition, victims of snake bite present
with blistering due to had lysis (of fever) after 5 days closely monitored because he is
Based on the lecture, it is due to a entering the critical
congenital urinary tract anomaly Bacterial meningitis strikes infants more
Why is UTI predominantly an illness in often than any other age group
Harrisons 20th Ed.:
Hib
young or young men? Which vaccine will help prevent one
previously common type of meningitis?
This specific treatment under evaluation
A 32 year old traveler develops diarrhea has shown to cause a has reduction in
and is brought to the hospital. He claims time to recovery in patients with severe
Remdesivir
to have eaten raw oysters mixed with covid-19. The suggestive adult dose is
vinegar and raw onions. He is seen as 200 mg intravenously on day 1 then 100
severely dehydrated with scanty urine Vibrio Cholera mg iv od for 5-10 days.
output. A foley catheter is inserted and Based on the demographic profile of
only 75 ml of urine is passed through the animal bite what age predominate the 15 years old
urine bag incidence of an animal bite.
What is the etiologic agent? The ff. are risk factors for UTI:
 Recent use of diaphragm with
Infective endocarditis is
spermicide
Which is true about the etiology and most common  Frequent sexual intercourse
epidemiology of FUO?  History of UTI
Most common etiology of FUO is Not an established risk factor for UTI:  DM, Incontinence, and sexual
infections activity in postmenopausal
A year old traveler develops diarrhea  Cystoceles
and is brought to hospital. He claims to  New sexual partner
have eaten raw oysters mixed with  Urinary incontinence
 Residual urine
severely dehydrated with scanty output. Possibly this is secretory diarrhea This specific treatment under evaluation Possible Drugs for Severe Covid-19:
(caused by V. cholera)  increase in has shown to and is recommended for  Dexamethasone
A foley catheter is inserted and only 75 electrolyte secretion severe patients with COVID 19 who  Remdesivir
ml of urine is passed through the urine
hypoxemia and require ventilatory  Anticoagulation (Enoxaparin)
bag.
What is the underlying process in this support
Based on the lecture, flu vaccination
patient?
A flu vaccination must be given to a is given every year because a
A-year old traveler develops diarrhea different influenza formulation is
person every year because
and is brought the hospital. He claims to created annually
have eaten raw oysters mixed with Spike proteins of coronaviruses
vinegar and raw onions. He is seen as Which is true about the spike proteins of
attach to ACE-2 receptors and
severely dehydrated with urine output. variants of SARS-CoV 2 are cause by
IV fluid bolus coronaviruses? mutation in the gene that code for
A foley catheter is inserted and only 75
the spike proteins
ml of urine is passed through the urine
bag. A maculopapular rash that appears on
What is to be done with the decreased the abdomen of a patient typhoid fever Rose Spot
to absent urine output ? is known as
INFECTIOUS DISEASES
Samplex: Exit Exam
S.Y.: 2020-2021
QUESTION ANSWER QUESTION ANSWER

Not sure of the context of this Questions that should be asked are:
question BUT I am guessing that it is  In what part of the body have
Babies are born : related with vaccination  they are you been bitten?
Which of the following question must be
well equipped to respond to vaccines  When and under what
asked during your taking in patients circumstances were you bitten?
Enveloped positive single-
bitten by a snake. EXCEPT  Where is the snake that bit
Which is true about the coronaviruses stranded RNA
you?
virus
 How are you feeling now?
Blood Culture is the gold standard
for diagnosing typhoid fever 1st statement is TRUE
Snake bites early symptoms are Pain and 2nd statement is FALSE
Stool or Urine Culture  possible local swelling that gradually extends
also and will be positive after the 1st proximally up to the bitten limb and Bites by Kraits, Sea snakes &
A patient was diagnosed to have typhoid week tender. This is especially true to sea Philippine Cobras may be virtually
snake painless and may cause negligible
fever on his 2nd weeks of illness, which
BUS–123 local swelling
laboratory will you request to confirm Blood culture (+) on 1st week Which of the following applied the
the diagnosis? Urine culture (+) on 2nd week concept of first aid treatment of snake Tight tourniquet
Stool culture (+) on 3rd week bite except?
Widal Test and Typhidot Test – not
much used due to low specificity and
sensitivity
A 45/F with fever, nonproductive cough
and, and desaturations even with
inhalation via nasal negative in COVID -
19 nasopharyngeal swab three The patient is probable case of
consecutive times and serial Chest CT covid-19
scan revealed progression of bilateral
and peripheral ground - glass opacities .
What is the best to this case?
Urinary
After the age of 50, UTI incidence is as
obstruction brought about by
high among men as among because of
prostatic hypertrophy
Which among the clinical manifestations
of typhoid fever warrants a patient to be Severe Abdominal pain
admitted to the hospital?
SARS-COV-1 and SARS-COV-2 are
Betacoronovirus
members belong to
What should be done before doing the
Hold antibiotics and steroids
obligatory investigation for FUO?
Apply warm compress on the
After getting a vaccination: injection site or take paracetamol to
control the systemic symptoms
This is observed in dengue infection
wherein if the antibodies is below a
threshold level, the uptake of antibody Antibody dependent
bound by cells that express enhancement of infection.
immunoglobulin receptors is
paradoxically
The most common pathogen of
salmonella species that is considered Salmonella enterica serovars
only occurs through human -to -human typhi
transfer is
What is a proven drug/intervention/diet
to increase platelet count in dengue Platelet Transfusion
patients
Among the following complications of
Intestinal bleeding
typhoid fever which one most common?
When should an infant not be given a All
DTaP vaccine? (no choices to confirm this answer )
How many ml of sterile water should the
antivenom be reconstituted prior to its 10 ml
administration?
A minor side effect of anti-tb drugs is Arthralgia due to
due to hyperuricemia
1. Recurrent UTI is defined as:
a. 2 x UTI/ 3 months
b. 8 x UTI/ year
c. ≥ 3 x UTI/ year
d. ≤ 2 UTI/ 6 months
2. Which of the following is the most specific in the diagnosis of UTI?
a. clinical microscopy
b. dipstick for urinary nitrite
c. urine bacterial culture
d. detection of leukocyte esterase
3. The most common manifestation of UTI is…
a. acute cystitis
b. acute urethritis
c. acute pyelonephritis
d. asymptomatic bacteriuria
4. Which of the following situations associated with urinary tract infection is not considered
complicated?
a. 6 month pregnant
b. ultrasound with cortical cyst
c. spinal cord injury
d. athlete patient with renal failure
5. Which of the following in men does not decrease the risk of UTI?
a. longer urethra
b. prostatic antibacterial factor
c. circumcision
d. testosterone level
6. The annual mean decline in GFR with age from the peak GFR of 120cc/min/1.73m2 is…
a. 1 cc/min/kg/yr/1.73m2.
b. 2 cc/min/kg/yr/1.73m2.
c. 3 cc/min/kg/yr/1.73m2
d. 4 cc/min/kg/yr/1.73m2
7. Which of the following statements regarding GFR is true?
a. Mean GFR is lower in women than in men
b. Mean GFR is lower in men than in women
c. n GFR is equal in both sexes
d. Mean GFR is not affected by gender
8. Estimation of GFR using Cockcroft-Gault formula requires which of the following data?
a. Height
b. Urine creatinine
c. Weight
d. Urine protein
9. Renal ultrasound will not provide which of the following information?
a. Parenchymal changes
b. Functional capacity
c. Calyceal dilatation
d. Cortical thickness
10. Which of the following CKD conditions can still provide a bilateral normal size kidney?
a. Chronic glomerulonephritis ?
b. Amyloidosis related renal disease
c. Chronic pyelonephritis
d. Hypertensive nephrosclerosis
11. What is the key step in evaluating a patient with thrombocytopenia?
a. Bone marrow evaluation
b. Peripheral blood smear review
c. Platelet aggregation studies requesting for CBC and Actual platelet count
d. palpate for splenomegaly
12. An 80y/o female diagnosed with MDS was admitted for dyspnea on exertion, body weakness,
dizziness and easy fatigue. Her latest hemoglobin is 90g/dL. What will you recommend?
a. Start Erythropoietin alpha 4000 IU 3xa week SC ?
b. Give Folic Acid 5 mg OD Start FeSo4 325mg TID before meals
c. Transfuse 1 U PRBC
d. Start immediate chemotherapy
13. A 50 y/o male recently diagnosed with Acute leukemia was admitted for severe headache with
latest platelet count of 3,000/uL. Which of the following statement below is not an appropriate
approach in this case?
a. Transfuse Platelet concentrate 1u/10kgBW
b. Do immediate plain Cranial Ctscan
c. Start Thrombolytic if still in the golden period
d. Transfuse 1 unit of apheresed platelet none of the above
14. A 60 y/o male known CKD from DM Nephropathy for a year now developed decreasing
platelet count. He’s on regular dialysis 3x a week. Present medications include Ketoanalogue and
Insulin. No fever, cough, nor bleeding symptoms. PE was unremarkable. What is the most likely
cause of the thrombocytopenia in this patient?
a. Infection induced Thrombocytopenia
b. Drug-induced Thrombocytopenia
c. Heparin Induced Thrombocytopenia
d. Immune ThrombocytoPenia
e. Hemolytic Uremic Syndrome
15. A young adult female presents with pallor and easy fatigue. She was diagnosed with PUD a
year ago. She denies episodes of abdominal pain and melena.On PE there’s pallor of the palpebral
conjunctivae, the rest is unremarkable. CBC showed Hgb 81g/L Hct .27, RBC ct 3.5, WBC ct 7,
Seg 65, Lym 32, Mon 03, Platelets are adequate. Coombs test (-), Reticulocyte index is <1, LDH
is normal. Which of the following is the likely diagnosis?
a. Thalassemia
b. Autoimmune Hemolytic anemia ?
c. Iron deficiency Anemia
d. Megaloblastic Anemia
e. Aplastic Anemia
16. Which autoantibody is considered as the best screening test for lupus ?
a. Anti DS DNA
b. ANA
c. Anti Sm
d. Anti U1 RNP
17. The presence of which of these antibodies in lupus patients increases the risk for lupus nephritis
?
a. Anti DS DNA
b. ANA
c. Anti Sm
d. Anti U1 RNP
18. In patients diagnosed with lupus who also happens to have rheumatoid arthritis, which
autoantibody would you request to check for the presence of mixed connective tissue disease ?
a. Anti DS DNA
b. ANA
c. Anti Sm
d. Anti U1 RNP
19. A 55y/o female comes to you complaining of 2 days history of left knee joint pain with
swelling, warmth and erythema of the involved joint. Which of the following conditions would
you most likely consider ?
a. Crystal induced arthropathy
b. Rheumatoid arthritis
c. Osteoarthritis
d. Psoriatic arthritis
20. A 40y/o male patient comes to you presenting with 3 days history of swelling, tenderness,
warmth and redness of his right 1st MTP joint. Which of the following medications would be best
to give to your patient at this time ?
a. Allopurinol
b. Probenecid
c. Febuxostat
d. Colchicine
21. The ACC/AHA UA/NSTEMI guideline recommends that supplemental oxygen be given to all
patients with suspected ACS
a. patients who complain of fatigue
b. patients who complain of epigastric pain
c. patients at high risk for hyperoxia
d. patients who have an arterial oxygen saturation of less than 90% ?
22. Patients with cardiac disease resulting in slight physical activity belong to functional capacity:
a. Class I
b. Class II
c. Class III
d. Class IV
e. Class V
23. Characteristic/s of STEMI: Pain may radiate below the umbilicus Pain can simulate pain from
GI disorders
a. Commonly occurs with exertion
b. Most common presentation is sudden loss of consciousness
c. Chest pain is in decrescendo pattern
24. Class I recommendation for use for an early invasive strategy:
a. EF 50%
b. Normal BP
c. Sustained VT
d. Negative stress test
e. Sinus tachycardia
25. Which of the following drug/s prevent cardiac remodeling in heart failure patients?
a. ACE inhibitor
b. Beta blockers
c. Dihydropyridine calcium channel blockers
d. Nondyhydropyridine calcium channel blockers
e. Diuretics
26. Which of the following is compatible with Graves’hyperthyroidism
a. High FT4, FT3 and TSH with positive anti-TPO antibodies
b. High FT4, FT3 and TSH with negative anti-TPO antibodies
c. High FT4, FT3 and low TSH with positive anti-TPO antibodies
d. High FT4, FT3 and low TSH with negative anti-TPO antibodies
e. High FT4 and low FT3, TSH with negative antiTPO antibodies
27. A Patient underwent total thyroidectomy with radical neck dissection for Papillary thyroid
carcinoma. 6 hrs post operation she developed circumoral numbness with positive Chvostek’s
sign. This findings is suggestive with
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
e. Hypernatremia
28. A patient who previously diagnosed to have primary hypothyroidism probable Hashimoto’s
disease and already on replacement therapy of levothyroidism become pregnant. What will be
your advice to her
a. Stop levothyroxine and check her TSH Maintain levothyroxine and assure her that its
alright
b. Increase the dose of levothyroxine about 10-20 percent and check her TSH after a month
c. Stop levothyroxine and resume it after pregnancy
d. Reduce the levothyroxine and request for TSH after a month
29. In iodine sufficient area, which among the following is the most common cause of
hyperthyroidism
a. Plummer’s disease
b. Graves’ disease
c. Multinodular toxic Goiter
d. Hashimoto’s disease
e. Thyrotoxicosis factitia
30. Which regulatory mechanism describe as inhibition of iodine organification due to increase
level of extracellular Iodine concentration
a. Burck-Wartofsy phenomenon
b. Wolff-Chaikoff effect
c. Jod basedow phenomenon
d. Somogyi’s phenomenon
e. Dawn effect
31. This structure is commonly used by gram negative bacteria for attachment to host cells and
tissues:
a. Peritrichous flagella
b. Fimbriae
c. Lipopolysaccharide
d. Adhesins
32. The most common route for microbial pathogens to gain access to the lower respiratory tract:
a. Aspiration from the oropharynx
b. Droplet spray from an infected person
c. Airborne pathogens suspended in the air
d. Nosocomial
33. This is a biomarker for severe inflammation and is of use in the identification of worsening
disease or treatment failure:
a. Procalcitonin
b. Specific IgM antibody titer
c. C reactive peptide
d. Polymerase chain reaction
34. This is what consists of the viral genome of the dengue virus:
a. positive sense RNA
b. negative sense RNA
c. positive sense DNA
d. Option 4
35. This is the major exposed protein of dengue fever and antibodies to this provide immunity
during natural infection.
a. C protein
b. E protein
c. dengV protein
d. serovars
36. In the algorithm for the management of patients you suspect of having stroke, aside from
securing the ABCs, which of the following test would you initially request?
a. Glucose
b. Cranial CT scan ?
c. Cranial MRI
d. Any of the above
37. What is the most common site for hypertensive hemorrhage?
a. Putamen
b. Thalamus ?
c. Pons
d. Cerebellum
38. What is the first treatment proven to improve clinical outcomes in ischemic stroke and is cost-
effective and cost-saving?
a. IV tPA
b. ASA
c. Clopidogrel
d. Cilostazol
39. What seizure type is typically seen in patients suffering from metabolic derangements?
a. Generalized tonic clonic seizure
b. Absence Seizure
c. Atonic seizure
d. Complex
40. Which among the anticonvulsants modulate the release of synaptic vesicles?
a. Levetiracetam
b. Phenytoin
c. Valproic acid
d. Carbamazepine
INFECTIOUS EXIT
1. Which vaccine is given soon after birth- Hepatitis B
2. Antimicrobial is recommended to all patient infected with nontyphoidal salmonella -
False
3. MDR Tb refers to case of TB which is resistant to - Isoniazid and rifampicin
4. What is the term for the process of hepatic extraction of orally administered drugs before
they reach systemic circulation- first pass effect
5. This specific treatment under evaluation has been shown by some preliminary studies to
reduce hospital mortality in patients who are critically ill with markedly elevated dimer
ferritin . However , this may be associated with an increased risk secondary infections -
Zinc
6. The dengue patient assigned to you 5 days of admission on the morning you've
requested you to inform the attending that he is going home because he has no more
feve neu 0.40 , 0.54,Hct0.52 platelet advise the patient ? He needs to stay because he
needs to be aggressively fluids because of hemoconcentration.
7. Which of the following confers passive immunity cross placental transfer of maternal
antibody
8. The following is true about vaccination in pregnancy In activated influenza vaccine are
preferred to live attenuated vaccine in pregnancy
9. Based on the World Health Organization which of the following factors affects the
incidence of animal bite. Poverty
10. On managing victim of snakebite the following should be requested EXCEPT Fecalysis
11. Immunoglobulins are made From the pooled plasma of blood stream
12. A - year old traveler develops diarrhea and is brought to the hospital. He claims to have
eaten raw oysters mixed with vinegar and raw onions . He is seen severely dehydrated
with scanty urine output . A foley catheter is inserted and only 75 ml of urine is passed
through the urine bag. What is the IV fluid of choice ? D5LR
13. You are presented in the emergency room with a 78 resident of a long term care facility
in Quezon City who notes that the patient has been having hypothermia for the past
eight days. CXR shows in the right lower lung. Gram stains show plumo cocci in clumps .
What is the antibiotic of choice if this is a methicillin susceptible strain S. aureus
14. Among the antimicrobials used typhoid fever which of the following is not recommended
for child Chloramphenicol.
15. The following are TRUE regarding the 20 minutes whole test?
16. The following should be checked during follow-up
17. The adult immunization program includes Annual pneumococcal polysaccharide
vaccine for those aged 65 and above.
18. You are contemplating a possibile envenomation with no idea what snake bit him. He is
presenting abdominal pain , paresthesia but with no evidence of los What possible
snake had bitten the co * m ^ 2
19. A year old traveler develops diarrhea and is brought to hospital. He claims to have
eaten raw oysters mixed with vinegar and raw onions . He is seen severely dehydrated
with scanty output . A foley catheter is inserted and only 75 ml of urine is passed through
the urine bag . What is the pathogenesis of diarrhea
INFECTIOUS EXIT
20. If your patient remains a sputum smear positive month of treatment , you will classity
failure . Third
21. Hyaluronidase, a venom enzyme, is to the endothelium causing bleeding. In addition
victims of present with blistering due to Proteolytic enzymes
22. Why is UTI predominantly an illness in young or young men ? Men have longer urethra
and the microorganism has required lots of atp.
23. A 32 year old traveler develops diarrhea and is brought to the hospital. He claims to
have eaten raw oysters mixed with vinegar and raw onions . He is seen as severely
dehydrated with scanty urine output . A foley catheter is inserted and only 75 ml of urine
is passed through the urine bag What is the etiologic agent ? Vibrio cholera
24. Which is true about the etiology and epidemiology of FUO? Infective endocarditis is
most common
25. A year traveler develops diarrhea and is brou hospital. He to have eaten raw oysters
moed and aw onions. He is seen severely dehydrated with output A foley catheter is
inserted and only 75 of urines passed through the urine bag What is the underlying
process in this patient ?
26. You are presented in emergency room with resident of a long- term care facility in
Quezon City . The notes that the patient has been having anorexia and episodes of
hypothermia for the past eight days . CXR shows patchy in the right lower lung . Gram
stain shows plump ( cocci in clumps . What is the most likely microbe ?
27. A-year old traveler develops diarrhea and is brought the hospital. He claims to have
eaten raw oysters mixed with vinegar and raw onions. He is seen as severely
dehydrated with urine output . A foley catheter is inserted and only 75 ml of urine is
passed through the urine bag. What is to be done with the decreased to absent urine
output ? Iv fluid bolus
28. You are presented in the emergency room a 78 resident of a long term care facility in
Quezon . The notes that the patient has been having anorexia and hypothermia for the
past eight days . CXR shows in the right lower lung . Gram stain shows plump cocci in
clumps . Aside from a sputum GS CS what other test would you require -
Fluoroquinolone.
29. In the combined DTP Immunization used in the pastwhich one of the three components
reportedly caused severe reachons? Pertussis
30. By 14 months of age, all children should have received the following vaccine except
Three doses of dtap opv
31. What type of reaction commonly occurs after diphtheria, tetanus and acellular pertussis
(DTP) vaccine? Swelling and tenderness at the injection site.
32. A farmer was rushed to the Emergency com due to a confirmed snakebite. As a
physician, you are observing clinical signs that warrant urgent resuscitation , which
includes ? Hyperkalemia
33. A pregnant woman passes antibodies to her unbom through the placenta to protect
against certain diseases About how long does this natural immunity last after birth? 3, 6
months
34. Most common manifestation of UTI Acute Cystitis
INFECTIOUS EXIT
35. Which typhoid vaccine is the most appropriate for a 2 year old child - Typhoid vi
polysaccharide vaccine ( typhim )
36. A dengue patient assigned to you finally had lysis after 5 dayS It is not safe to be at
home because he should be closely monitored because he is entering the critical
37. Immunoglobulins are made
38. Bacterial meningitis strikes infants more often than any other ago groupWhich vaccine
will help prevent one previously common type of meningitis ? Hib
39. This specific treatment under evaluation has shown to cause a has reduction in time to
recovery in patients with severe covid-19. The suggestive adult dose is 200 mg
intravenously on day 1 then 100 mg iv od for 5-10 days. Remdesvir
40. Based on the demographic prohle of animal bite what age predomina the incidence of an
animal bite. 15 years old
41. Case: A 65 old male complains of hematocheza He is not yet dehydrated but is anxious
about the appearance of stood. Upon examination , there are no hemorrhoids noted .
What could the etiologic agent ?
42. Not an established risk factor for UTI:
43. This specific treatment under evaluation has shown to and is recommended for severely-
patients with COVID 19 who hypoxemia and require ventilatory support
44. A flu vaccination must be given to a person every year because
45. Which is true about the spike proteins of coronaviruses?
46. Babies are born :
47. A maculopapular rash that appears on the abdomen of a patient typhoid fever is known
as Rose Spot
48. The following are generalized symptoms of snake bites except Blistering
49. Which is true about the coronaviruses Enveloped positive single- stranded RNA
virus.
50. A patient weighing 50kg was bitten by a stray dog on the are going to give ERIG Which
of the following TRUE The computed total dose of ERIG to given is 10 ml.
51. Transmission of rabies can on of the following routes EXCEPT
52. How are diseases and illnesses often caused?
53. It is always a constant public health reminder that considered fatal. In our census bites,
form cobras are the most and given the highest medical importance .
54. A patient was diagnosed to have typhoid fever on his 2nd weeks of illness, which
laboratory will you request to confirm the diagnosis? Widal test
55. A45/F with fever, nonproductive cough and , and desaturations even with inhalation via
nasal negative in COVID - 19 nasopharyngeal swab three consecutive times and serial
Chest CT scan revealed progression of bilateral and peripheral ground - glass opacities .
What is the best to this case ? The patient is probable case of covid-19
56. The following is TRUE regarding wound management of animal bites? 2 hour intraval is
given after RIG if suturing would be done
57. After the age of 50, UTI incidence is as high among men as among because of Urinary
obstruction brought about by prostatic hypertrophy.
58. Which among the clinical manifestations of typhoid fever warrants a patient to be
admitted to the hospital? Severe Abdominal pain.
INFECTIOUS EXIT
59. Difficulty in swallowing a manifestation of a bite the venom has already spread at
Neurological
60. SARS-COV-1 and SARS-COV-2 are members belong to Betacoronovirus
61. What should be done before doing the obligatory investigation for FUO ? Hold
antibiotics and steroids.
62. After getting a vaccination :
63. This is observed in dengue infection wherein if the antibodies is below a threshold level ,
the uptake of antibody bound by cells that express immunoglobulin receptors is
paradoxically Antibody dependent enhancement of infection.
64. Snake bites are a well know occupational hazard that often results morbidity and
mortality. Common victim of their fatal enveroming veterinarian TF
65. The most common pathogen of salmonella species that is considered only occurs
through human -to -human transfer is Salmonella enterica serovars typhi
66. What is a proven drug/intervention/diet to increase platelet count in dengue patients
Platelet Transfusion
67. Among the following complications of typhoid fever which one most common ? intestinal
bleeding
68. When should an infant not be given a DTaP vaccine? All
69. How many ml of sterile water should the antivenom be reconstituted prior to its
administration ? 10 ml
70. A minor side effect of anti-tb drugs is due to Arthralgia due to hyperemia.
71. Which of the following question must be asked during your taking in patients bitten by a
snake . EXCEPT
72. In the Philippines, there is an established statistics about cases of snakebite . Making
males aged 15 more prone to be inflicted with venom
73. Pain and local swelling that gradually. This is especislly true to sea snake - TF
74. Which of the following applied the concept of first aid treatment of snake bite except ?
Tight tourniquette

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INFECTIOUS DISEASES

Topic: Urinary Tract Infections

Pathogenesis continued….. DIAGNOSTIC APPROACH

CLINICAL SYNDROMES Acute Onset of Back pain, Nausea/Vomiting or Fever

Complicated UTI Recurrent Urinary Symptoms

Pyelonephritis Complicated UTI

UTI in Pregnant Women ASB

UTI in Men Candiduria

PREVENTION OF RECURRENT UTI IN WOMEN

Continuous and Post-coital

PERSONAL PROTECTIVE EQUIPMENT (PPE) List of Aerosol Generating Procedures:

ZONING High Risk Areas

Moderate Risk Areas RECOMMENDED PPE IN EMERGENCY ROOM

 ER pre-triage area, ER triage area, hemodialysis unit, ICCU set-up, eye

RECOMMENDED PPE IN PRIVATE PATIENT ROOMS

In the Orange or Red Zone: Wear Level 4

DESCRIPTION OF EACH PPE

 Reprocessing is NOT RECOMMENDED

 If you are directly handling COVID-19 patients and/or performing AGP

 Decontamination methods are NOT RECOMMENDED by current evidences such as:

 Cotton-made gown over polypropylene made gown

 Extended use is ACCEPTABLE

Alternatives to Commercially available Coveralls:

 Specifications: disposable, non-woven surgical bouffant cap, shower-type

 Specifications: disposable, non-woven

PRIMARY COMPLEX (GHON)

 10 mm induration is considered as positive generally Gene Xpert MTB/RIF Assay

TB Disease based on History of Previous Treatment

 Histologically-diagnosed EPTB through biopsy of appropriate site will be

CLINICAL DIAGNOSIS OF TB TREATMENT

Chest X-ray suggestive of PTB

SPECIAL CONDITIONS C. Breastfeeding

ETIOLOGY Lecture Discussion: Pathophysiology of Typhoid Fever

WHAT ARE THE 2 TYPES OF SALMONELLA? Clinical Manifestations

Sample Case Typhoid Fever of Dr. Sy:

Lecture Discussion: Typhidot Test

How to interpret a Typhidot Test?

 In children, most common presentation is high grade fever. It is very

Complications of Typhoid Fever

Diagnosis of Typhoid Fever

o If the patient is already a carrier – Chloramphenicol Typhoid Vaccines

 Typhoid Vi polysaccharide vaccine (Typhim Vi) (conjugated)

NONTYPHOIDAL SALMONELLA (NTS)

Venom Enzymes continued….. EARLY SYMPTOMS AND SIGNS

 Other Proteolytic Enzymes (Metalloproteinases, Endopeptidases,

NEUROLOGICAL MANIFESTATIONS MANAGEMENT

SKELETAL MUSCLE FIRST AID TREATMENT

 Tight (arterial) tourniquets are NOT RECOMMENDED (level of

Lecture Discussion: ABCDE Approach LABORATORY TESTS

DETAILED CLINICAL ASSESSMENT AND SPECIES DIAGNOSIS

 Physical examination: General examination

Antivenom Treatment: Administration of Antivenom:

RESPONSE TO ANTIVENOM  Dark Brown Urine (Myoglobinuria or Hemoglobinuria):

At the earliest sign of a reaction:

Conservative Treatment when No Antivenom is Available

ANIMAL BITES: RABIES

Regions 3, 4-A, 5 and 12

 95% Rabies death occurs in Asia and Africa