- alternative diagnosis is established - if symptoms resolve and do not recur with ≤4 days of antibiotic therapy - if surgery or autopsy after ≤4 days of antimicrobial therapy yields no histologic evidence of IE

Community Acquired Flashcards by Internal Medicine Ciudad

prototypic lesion of infective endocarditis (IE)

the vegetation- is a mass of platelets, fibrin, microorganisms, and scant inflammatory cells

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analogous process involving arteriovenous shunts, arterio-arterial shunts (patent ductus arteriosus), or a coarctation of the aorta is called

infective endarteritis

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hectically febrile illness that rapidly damages cardiac structures, seeds extracardiac sites, and, if untreated, progresses to death within weeks.

Acute IE

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indolent course; causes structural cardiac dam-
age only slowly, if at all; rarely metastasizes; and is gradually progressive unless complicated by a major embolic event or a ruptured mycotic aneurysm.

Subacute IE

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the most common bacterial species causing IE

Staphylococcus aureus

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IE bacteria originates from the gastrointestinal tract and is associated with colonic polyps and tumors.

Streptococcus gallolyticus subspecies gallolyticus (formerly S. bovis biotype 1)

Enterococci enter the bloodstream primarily from the genitourinary tract.

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Microbial source of PVE arising within 2 months of valve surgery—i.e., early PVE

generally nosocomial: S. aureus, CoNS, facultative gram-negative bacilli, diphtheroids, and fungi.

PVE beginning >12 months after surgery—i.e., late PVE—are similar to those in community-acquired NVE

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Commonly causes IE in people who inject drugs (PWID), especially that involving the tricuspid valve

S aureus

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A. causes an indolent, culture-negative, afebrile form of IE.
B. has a predilection for prosthetic valves.
C. may involve intracardiac devices and be slow to grow in blood cultures.
D. difficult to recover from blood cultures unless special media is used, has caused a global outbreak of PVE and disseminated infection as a result of aerosols from contaminated heater-cooler machines used during cardiopulmonary bypass

A. Tropheryma whipplei
B. Coxiella burnetii
C. Corynebacterium species and Propionibacterium acnes
D. Mycobacterium chimaera,

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organisms that commonly cause IE have surface adhesin molecules, collectively called ____ that mediate adherence to NBTE sites or injured endothelium

microbial surface com-
ponents recognizing adhesin matrix molecules (MSCRAMMs)

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Fever in IE
A. Subacute
B. Acute

A. Low grade <39.4
B. 39.4 - 40

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Definite IE

2-1-3-5

two major criteria, of one major and three minor criteria, or of five minor criteria

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Possible IE criteria

one major and one minor criteria or three minor criteria are fulfilled

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IE is rejected if

alternative diagnosis is established
if symptoms resolve and do not recur with ≤4 days of antibiotic therapy
if surgery or autopsy after ≤4 days of antimicrobial therapy yields no histologic evidence of IE

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A negative TEE, when IE is likely, does not exclude the diagnosis but rather warrants repeating the study in how many days?

7–10 days

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What is the first imaging test for a patient with low clinical suspicion of IE?

Initial TTE

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What is the treatment for penicillin-susceptible streptococci (MIC ≤0.12 µg/mL) in IE?

Penicillin G 2–3 mU IV q4h × 4 weeks
OR Ceftriaxone 2 g daily × 4 weeks
OR Vancomycin (if severe penicillin allergy) × 4 weeks
OR Pen G or Ceftriaxone x 2 weeks PLUS Gentamicin x 2 weeks

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What is the treatment for moderately penicillin-resistant streptococci (MIC ≥0.5 µg/mL) or nutritionally variant streptococci (Granulicatella, Abiotrophia, Gemella)?

• Penicillin G (high dose) or Ceftriaxone × 6 weeks
PLUS Gentamicin × 6 weeks
• OR Vancomycin × 6 weeks (if allergy)
👉 Mnemonic: “Moderate = Max out (6+6)”

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What is the treatment for relatively penicillin-resistant streptococci (MIC >0.12–<0.5 µg/mL)?

• Penicillin G (4 mU IV q4) or Ceftriaxone × 4 weeks
PLUS Gentamicin × 2 weeks
• OR Vancomycin × 6 weeks (if allergy)

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What is the treatment for MSSA infecting native valves?

• Nafcillin, oxacillin, or flucloxacillin × 6 weeks
• OR Cefazolin × 6 weeks (if non-immediate penicillin allergy)
• OR Vancomycin × 6 weeks (if severe/immediate penicillin allergy)

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What is the treatment for MRSA infecting native valves?

• Vancomycin × 6 weeks
• OR Daptomycin × 6 weeks

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What is the treatment for MSSA infecting prosthetic valves (PVE)?

Nafcillin, oxacillin, or flucloxacillin × 6–8 weeks
PLUS Gentamicin × 2 weeks
PLUS Rifampin × 6–8 weeks

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What is the treatment for MRSA infecting prosthetic valves (PVE)?

Vancomycin × 6–8 weeks
PLUS Gentamicin × 2 weeks
PLUS Rifampin × 6–8 weeks

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What is generally considered an alternative β-lactam agent for the treatment of methicillin- susceptible staphylococcal (MSSA)

Cefazolin

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What is the empirical treatment of NVE with a subacute presentation and late PVE?

vancomycin plus ceftriaxone

What is the empirical therapy for blood culture–pending PVE, if the prosthetic valve has been in place for ≤1 year?

vancomycin, gentamicin, and cefepime should be used

What are the emergent (same day) surgical indications in IE?

• Valve dysfunction with pulmonary edema or cardiogenic shock • Acute aortic regurgitation + preclosure of mitral valve • Sinus of Valsalva abscess rupturing into right heart • Rupture into pericardial sac

Paravalvular infection is most ommon in infection of which valve?

Aortic valve

Prophylaxis of endocarditis for high risk cardiac lesions

A. Standard oral regimen Amoxicillin: 2 g PO 1 h before procedure B. Inability to take oral medication: Ampicillin: 2 g IV or IM within 1 h before procedure C. Penicillin allergy 1. Clarithromycin or azithromycin: 500 mg PO 1 h before procedure 2. Cephalexinc: 2 g PO 1 h before procedure 3. Doxycycline: 100 mg PO 1 h before procedure D. Penicillin allergy, inability to take oral medication Cefazoline or ceftriaxonec: 1 g IV or IM 30 min before procedure

What soft tissue infection due to S. pyogenes and is characterized by an abrupt onset of fiery-red swelling of the face or extremities. The distinctive features are well-defined indurated margins, particularly along the nasolabial fold; rapid progression; and intense pain

erysipelas Tx Penicillin

Cellulitis caused by MSSA or MRSA is usually associated with a focal infection, such as a furuncle, a carbuncle, a surgical wound, or an abscess; the U.S. Food and Drug Administration preferentially refers to these types of infection as

Purulent cellulitis

cellulitis due to S. pyogenes is a more rapidly spreading, diffuse process that is frequently associated with lymphangitis and fever and should be referred to as

Nonpurulent cellulitis

causes aggressive cellulitis and occasionally necrotizing fasciitis in tissues surround- ing lacerations sustained in freshwater (lakes, rivers, and streams).

Aeromonas hydrophila

most often associated with fish and domestic swine and causes cellulitis primarily in bone renderers and fishmongers

Erysipelothrix rhusiopathiae

Organism causing: A. Pyomyositis, bullous impetigo B. Primary myositis, impetigo contangiosum

A. S aureus B. S pyogenes

Gas gangrene of the uterus is caused by

Clostridium sordellii

Most commonly implicated organism in bacterial arthritis

N gonorrhoeae

In septic arthritis, it accounts for most nongonococcal isolates in adults of all ages

S aureus

In nongonococcal septic arthritis, 90% of patients present with involvement of what joint

Knee IV drug users- infections of the spine, sacroiliac joints, and sternoclavicular joints Rheumatoid arthritis- polyarticular

Empiric therapy for nongonococcal arthritis A. GS gram + B. MRSA unlikely C. GS gram - D. IV drug users/ P aeruginosa

A. IV vancomycin (15−20 mg/kg/dose) every 8–12 h B. cefazolin (2 g every 8 h), oxacillin (2 g every 4 h), or nafcillin (2 g every 4 h) C. IV third- generation cephalosporin such as cefotaxime (1 g every 8 h) or ceftriaxone (1–2 g every 24 h) D. cefepime (2 g every 8−12 h) or ceftazidime (2 g every 8 h)

Characteristic synovial counts in acute bacterial arthritis

100,000/μL (range, 25,000–250,000/μL), with >90% neutrophils Normal <180 cells

Patients with _____ have the highest incidence of infective arthritis (most often secondary to S. aureus)

rheumatoid arthritis

Gonococcal arthritis treatment

Ceftriaxone 1g IV or IM q24 Add Azithromycin 1g tab single dose for chlamydial co-infection

In early congenital syphilis, periarticular swelling and immobilization of the involved limbs complicate osteochondritis of long bones

(Parrot’s pseudoparalysis)

a late manifestation of congenital syphilis that typically develops between ages 8 and 15 years, is caused by chronic painless synovitis with effusions of large joints, particularly the knees and elbows

Clutton’s joint

In tertiary syphilis, ______ results from sensory loss due to tabes dorsalis

Charcot joint

reactive symmetric form of polyarthritis that affects persons with visceral or disseminated tuberculosis

Poncet’s disease

Reactive arthritis is most common among young men (except after Yersinia infection) and has been linked to what potential genetic predisposing factor

HLA-B27

Causes reactive polyarthritis

Yersinia enterocolitica, Shigella flexneri, Campylobacter jejuni, Clostridioides difficile, and Salmonella species

Most ommon manifestation of Primary Bacterial Peritonitis

Fever

Microbiology in primary bacterial peritonitis

Gram - bacilli and gram + cocci

Empiric treatment PBP

Third-generation cephalosporins such as cefotaxime (2 g q8h, administered IV) Broad-spectrum antibiotics, such as β-lactam/β- lactamase inhibitor combinations (e.g., piperacillin/tazobactam, 3.375 g q6h IV for adults with normal renal function) or ceftriaxone (2 g q24h IV)

mortality benefit from ____ in PBP has been demonstrated for patients who present with serum creatinine levels ≥1 mg/dL, blood urea nitrogen levels ≥30 mg/dL, or total bilirubin levels ≥4 mg/dL

Albumin (1.5 g/kg of body weight within 6 h of detection and 1.0 g/kg on day 3)

In which patients is chronic antibiotic prophylaxis recommended for patients who are at highest risk for PBP

ascitic-fluid total protein level <1.5 g/dL impaired renal function (creatinine, ≥1.2 mg/dL; blood urea nitrogen, ≥25 mg/dL; or serum sodium, ≤130 mg/dL) and/or liver failure (Child-Pugh score, ≥9; and bilirubin, ≥3 mg/dL)

Empiric therapy secondary peritonitis

ticarcillin/clavulanate, 3.1 g q4–6h IV; or piperacillin/tazobactam, 3.375 g q6h IV) or a combination of either a fluoroquinolone (e.g., levofloxacin, 750 mg q24h IV) or a third-generation cephalosporin (e.g., ceftriaxone, 2 g q24h IV) plus metronidazole (500 mg q8h IV)

newer antibiotic in the tetracycline class that has been approved by the U.S. Food and Drug Administration for treat- ment of complicated intraabdominal infections

Eravacycline

added to these regimens for enterococcal coverage in very ill patients until culture results are available

Vancomycin or ampicillin

For patients known to be colonized with ampicillin-resistant vancomycin- resistant enterococci (VRE)

a VRE-active agent, such as linezolid or daptomycin, should be included

Empirical therapy for CAPD peritonitis

first-generation cephalosporin such as cefazolin (for gram-positive bacteria) and a fluoroquinolone or a third-generation cephalosporin such as cef- tazidime (for gram-negative bacteria)

CAPD peritonitis findings

The dialysate is usually cloudy and contains >100 WBCs/μL, >50% of which are neutrophils

anaerobe most frequently isolated from intraabdominal infections, is especially prominent in abscesses, and is the most common anaerobic bloodstream isolate.

B fragilis

The single most reliable laboratory finding in liver abscess

elevated serum concentration of alkaline phosphatase

most common bacterial isolates from splenic abscesses

Streptococcal species

Prophylaxis of traveler’s diarrhea

Bismuth subsalicylate w tabs (525mg) 4x a day (up to 3 weeks)

First antibiotics associated with CDI

Clindamycin, ampicillin, and cephalosporins Fluoroquinolones

superior to vancomycin in reducing further recurrences in patients who have had one CDI

Fidaxomicin

First line treatment for CDI

Oral vancomycin or Fidaxomicin x 10 days

adjuvant therapy (in addition to and during antibiotic treatment) for patients at high risk for recurrent CDI

Bezlotoxumab

associated with the production of gas in renal and perinephric tissues and occurs almost exclusively in diabetic patients

Emphysematous pyelonephritis

First line treatment for CDI

Oral vancomycin or Fidaxomicin x 10 days

chronic urinary obstruction (often by staghorn calculi), together with chronic infection

Xanthogranulomatous pyelonephritis

Drugs used for UTI that have a minimal effect on fecal flora

pivmecillinam, fosfomycin, and nitrofurantoin

Treatment for Acute Uncomplicated Cystitis

TMP SMX Nitrofurantion (5 days) Fosfomycin ! Do not use fluoroquinolones

first-line therapy for acute uncomplicated pyelonephritis

Fluoroquinolones

4 C’s of prevention and control in STD

Contact tracing Compliance Counseling on risks Condom promotion

Diagnosis of STD a. GS urethral swab b. Centrifuged Urine (1st void 20-30ml)

a. GS urethral swab- 2 or more neutrophils/1000x field b. Centrifuged Urine (1st void 20-30ml)- 10 or more leukocytes/hpf

Diagnosis for absence of typical gram-negative diplococci on Gram’s-stained smear of urethral exudate containing inflammatory cells

NGU (non gonococcal urethritis)

finding of a single urinary pathogen, such as E. coli or Staphylococcus saprophyticus, at a concentration of ≥102/mL in a properly collected specimen of midstream urine from a dysuric woman with pyuria indicates probable

Bacterial UTI

men under age 35, acute epididymitis is caused most frequently by

C. trachomatis Tx: Ceftriaxone (500 mg as a single dose IM) followed by doxycycline (100 mg by mouth twice daily for 10 days)

pyuria with <102 conventional uropathogens per milliliter of urine (“sterile” pyuria) suggests

Urethral syndrome due to C trachomatis or N gonorrhea

Treatment urethritis a. Gonorrhea b. NGU (Chlamydia) c. T vaginalis

a. Ceftriaxone 500mg IM b. Azithromycin or Doxycycline c. Metronidazole/Tinidazole

Antibiotics for PID

Patient with recent antibiotic use develops diarrhea with hypotension and toxic megacolon. What is the treatment?

Fulminant CDI - Oral Vancomycin plus Metronidazole IV and consider rectal instillation of Vancomycin

Lung abscess in which an infection begins in the pharynx (classically involving Fusobacterium necrophorum) and then spreads to the neck and the carotid sheath (which contains the jugular vein) to cause septic thrombophlebitis

Lemierre’s syndrome

SSS vs TEN Punch biopsy with frozen section is useful in making this distinction since the cleavage plane is For SSS? For TEN?

the stratum corneum in SSSS and the stratum germinativum in TEN

cause recurrent cellulitis among patients with chronic lymphedema resulting from elephantiasis, lymph node dissection, or Milroy disease

Streptococci

Cause recurrent cutaneous infections among individuals who have eosinophilia and elevated serum levels of IgE (Job syndrome) and among nasal carriers

staphylococci

Etiology of skin infection A. Cat bite B. Dog bite C. Necrotizing fasciitis from freshwater D. ecthyma gangrenosum in neutropenic patients, hot-tub folliculitis, and cellulitis following penetrating injury E. Fish and domestic swine in fishmongers F. Cellulitis/granulomas exposedto water in aquarium/swimming pools

A. Pasteurella multocida B. Staphylococcus intermedius and Capnocytophaga canimorsus C. Aeromonas hydrophila D. P aeruginosa E. Erysipelothrix rhusiopathiae F. M marinarum ** Amoxicillin-clavulanate, ampicillinsulbactam, and cefoxitin are good choices for the treatment of animal or human bite infections E rhusiopathiae susceptible to B lactams, clinda, erythro and cephalosporins BUT resistant to Vanco For M marinarum, rifampin + ethambutol, co tri or tetracycline

Prophylactic regimens for adults with normal renal function include

fluoroquinolones (ciprofloxacin, 500 mg weekly; or norfloxacin 400 mg/d) or trimethoprim-sulfamethoxazole (one double-strength tablet daily; Rifaximin 1200mg daily

What is the most common associated infection in splenic abscess?

Bacterial endocarditis

55/M European with no co-morbidities who travelled to South East Asia developed 5-day history of non-inflammatory, watery diarrhea upon arrival. Which of the following antibiotics can significantly reduce the duration and severity of his disease? A. Ciprofloxacin 750 mg PO as a single dose B. Levofloxacin 500 mg PO as a single dose C. Azithromycin 1000mg PO as a single dose D. Rifaximin 400 mg PO BID for three days

C. Azithromycin 1000mg PO single dose

Which is a correct monitoring diagnostic protocol for acute rheumatic fever? (HPIM21 C359 P2770) A. Inflammatory markers should be repeated every one to two weeks until normalization B. 2D Echocardiography should be repeated after one week C. Throat swab culture for Group A streptococcus should be repeated after antibiotics D. If initial ECG shows PR prolongation, 12-lead ECG should be repeated weekly

A. Inflammatory markers should be repeated every one to two weeks until normalization Repeat 2D echo after 1 month

Community Acquired Flashcards

(92 cards)