1
Q
Name 3 gram negative cocci
A
- Neisseria meningitidis
- Neisseria gonorrheae
- Moraxella spp,
2
Q
Name 2 spore forming gram positive rods
A
- Bacillus sp.
- Clostridium sp.
3
Q
Name 2 non-spore forming gram positive rods
A
- Corynebacterium sp.
- Listeria sp.
4
Q
Name 2 anaerobic gram positive bacilli
A
- Cutibacterium
- Actinomyces
5
Q
Name 4 lactose fermenting gram negative bacilli
A
- E. Coli
- Klebsiella sp.
- Enterobacter sp.
- Proteus sp.
*“gut bugs”
6
Q
Name 2 non-lactose fermenting gram negative bacilli
A
- Pseudomonas
- Stenophotomonas
7
Q
Name 2 anaerobic gram negative bacilli
A
- Bacteroides
- Fusobacterium
8
Q
Name 3 spirochetes
A
- Treponema sp.
- Leptospirosis
- Borrelia
9
Q
Name 2 yeasts
A
- Candida
- Cryptococcus
10
Q
Name a mould
A
Aspergillus
11
Q
Name 3 dimorphic fungi
A
- Blastomycosis
- Histoplasmosis
- Coccidiomycosis
12
Q
List the HECK-Yes (SPICE-HAM) Organisms
What is special with these organisms and what antibiotics should be used in infections involving them
A
- Hafnia
- Enterobacter
- Citrobacter
- Klebsiella aerogenes
- Yersinia enterocolitica
- Seratia
- Providencia
- Indole postitive proteus
- Acinetobacter
- Morganella
Inducible amp-c resistance, must be treated with a carbapenem, TMP-SMX, FQ, AG
13
Q
List 2 ESBL producing organisms. What antibiotics can be used to target them
A
- E. Coli
- Klebsiella
- Carbapenems
- TMP-SMX
- FQ
- AG
14
Q
What antimicrobials can be considered in CPE producing organisms
A
- Colistin
- AG
- Tigecycline
- Possibly FQ or TMP-SMX if lucky
15
Q
What antimicrobials can be considered to treat MRSA
A
- Vancomycin
- Doxycycline
- TMOP-SMX
- Clindamycin
- Linezolid
- Daptomycin
- Ceftobiprole
16
Q
What antimicrobials can be considered to treat pseudomonas
A
- Pip-tazo
- Ceftazidime
- Cefepime
- Carbapenems (not ertapenem)
- Ciprofloxacin
- AG
- Azetronam
- Colistin
- Tigecycline
- Ceftazidime-avibactam
- ceftolozame-tazobactam
17
Q
What antimicrobials can be considered to treat enterococcus
A
- Ampicillin (if S)
- Vanco (not VRE)
- Linezolid
- Daptomycin
18
Q
Name symptoms associated with meningitis
A
- Predminantly headache, neck stiffness and fever
- altered LOC late in the course
19
Q
Name symptoms associated with encephalitis
A
- Predominantly altered LOC and fevers
- Can get seizures and focal neurological signs
20
Q
Name 3 signs that, if all absent, rule out meningitis (99%)
A
- Fever
- Neck stiffness
- Altered mental status
21
Q
What physical exam sign has the highest sensitivity for meningitis
A
Jolt accentuation
22
Q
What 2 physical exam signs are the most specific for meningitis
A
Kernig’s and Brudzinski’s
23
Q
What are symptoms of basal skull meningitis
A
- Regular meningitis symptoms plus:
- CN palsies
- long tract signs
24
Q
What organisms are known to cause basal skull meningitis?
A
- Tb
- Listeria
- Cryptococcus
- Syphilis
- Lyme
25
What are the most common pathogens in meningitis and what antibiotics should be used empirically
26
What should be the empiric coverage for meningitis in the case of a penicillin allergy?
Vancomycin + Moxifloxacin +/- TMP-SMX(if need to cover listeria)
27
Describe an approach to investigating suspected meningitis
28
Other than a positive culture, what would you expect to find on an LP in the case of bacterial meningitis, viral meningitis, TB meningitis and fungal meningitis?
29
When looking at glucose, protein, WBC, PMN on an LP ad well as the ratio of CSF:blood glucose, which thresholds are 99% specific for _bacterial_ meningitis?
* Glucose \<1.9
* Protein \>2.2
* WBC\>2000
* PMNs\>1180
* CSF:blood glucose \<0.23
30
If an LP is performed 2 days after the start of antibiotics, what values can you still rely on and what values may have already corrected on your LP results
* Biochemistry and cell count minimally affected
* Culture yield decreased
31
For how long should bacterial meningitis be treated
* Depends on the bacteria
* S. Pneumoniae: 10-14 days
* N. Meningitidis: 7 days
* L. Monocytogenes: 21 days
* No pathogen found:
* Depends on clinical context
* Consult ID
32
When should Dexamethasone be given for meningitis
* Before or with first dose of antibiotics
* Usually give 10mg IV q6h x 4 days
* Stop if CSF non-turbid, low cell count, non-pneumococcal by culture
\* DO NOT START IF ANTIBIOTICS HAVE ALREADY BEEN GIVEN
33
Who should get N. Meningitidis chemoprophylaxis
* Close contacts of N. Meningitidis meningitis cases as defined:
1. **Household contacts**
2. Persons **Sharing sleeping arangements**
3. Persons who have direct nose/mouth contamination with oral/nasal secretions
4. **Healthcare workers who have had intense unprotected (no mask) contact**
1. ******Intubating**
2. **resuscitating**
3. **closely examining nasopharynx**
5. Airline passengers sitting immediately on either side of the case when total time on aircraft \>8hours
34
Within how many days should you give N. Meningitidois chemoprophylaxis
10 days
35
What agents can be used for N. Meningitidis chemoprophylaxis?
* Ciprofloxacin 500mg po x1 (increasing resistance!)
* Ceftriaxone 250 mg IM x1
* Rifampin 600mg PO BID x 2 days
36
Who should get N. Meningitidis immunoprophylaxis?
1. **Household contacts** of a case of invasive menigococcal disease (IMD)
2. Persons **sharing sleeping arrangements** with a case of IMD
3. Persons who have direct nose/mouth contamination with oral/nasal secretions of a case with IMD
4. Children and staff in contact with a case of IMD in childcare or nursery school facilities
37
What agents can be used for N. Meningitidis immunoprophylaxis
* Depends on serotype of index case and age/underlying conditions of contact
* Men-C-ACYW
* 4CMenB
38
What is the diagnostic workup for suspected endocarditis?
1. 2 sets of blood cultures prior to antibiotics
2. Initial TTE for everyone
1. TEE if indicated (class 1):
1. non-diagnostic TTE
2. suspected IE complications
3. intracardiac leads
39
Who can be considered for a stepdown to oral antibiotics after initial IV antibiotics in IE?
* Patients with left-sided endocarditis caused by streptococcus, E. Faecalis, S. Aureus or CNST:
* Deemed stable by multidisciplinary team
* TEE MUST be done prior to switch and show no paravalvular infection
* Frequent and appropriate follow-up can be assured by the care team
* A follow-up TEE can be preformed 1-3 days before the completion of the antibiotic course
40
List the Duke criteria for diagnosis of IE
* **Major**
* Microbiological evidence
* Typical organisms: S. Aureus, Viridans group strep, S. gallolyticus (prev. bovis), Enterococcus, HACEK group
* 2 cultures \>12hrs apart or 3 cultures \> 1hr appart
* OR 1 blood culture demonstrating Coxiella brunetii OR Coxiella anti-phase 1 IgG \> 1:800
* Endocardial involvement
* Oscillating valvular/prosthetic mass
* Valvular abscess
* Dehiscence of prosthetic valve
* New valvular regurgitation
* **Minor**
* ****Predisposition
* Heart defect
* Prosthetic valve
* IVDU
* Fever
* Temp \>38
* Vascular phenomenon
* Arterial emboli
* septic pulmonary infarcts
* Mycotic aneurysms
* IC hemorrhage
* Conjunctival hemorrhage
* Janeway lesions
* Immunological phenomenon
* GN
* Osler nodes
* Roth spots
* Positive RF
* Microbiological evidence
* + blood culture not meeting major criterion
41
What is necessary for a diagnosis of IE
* **Definite IE**
* ****Positive vegetations on culture or histiopathology
* 2 major criteria
* 1 major + 3 minor criteria
* 5 minor criterria
* **Possible IE**
* ****1 major + 1 minor criteria
* 3 minor criteria
42
What antibiotics should be used to treat native valve IE caused by MSSA
Cloxacillin or cefazolin
43
What antibiotics should be used to treat native valve IE caused by MRSA or CNST
Vancomycin
\*Most CNST are beta lactam resistant. If susceptible can treat like MSSA
44
What antibiotics should be used to treat native valve IE caused by Viridans group strep or S. Gallolyticus
Pen G or ceftriaxone
\*If higher MIC to PNC levels, consider adding an aminoglycoside
45
What antibiotics should be used to treat native valve IE caused by E. Faecalis
Ampicillin + gentamycin
OR
Ampicillin + ceftriaxone
46
What antibiotics should be used to treat native valve IE caused by E. Faecium
Vancomycin + gentamycin
47
What antibiotics should be used to treat native valve IE caused by HACEK group bacteria
Ceftriaxone
48
What antibiotics should be used to treat _prosthetic_ valve IE caused by MSSA
Cloxacillin OR cefazolin
AND
Rifampin
AND
Gentamicin
49
What antibiotics should be used to treat _prosthetic_ valve IE caused by MRSA or CNST
Vancomycin
AND
Rifampin
AND
gentamicin
\*Most CNST are beta lactam resistant. If susceptible can treat like MSSA
50
What antibiotics should be used to treat _prosthetic_ valve IE caused by viridans group streop or S. Gallolyticus?
Pen G OR ceftriaxone
51
What antibiotics should be used to treat _prosthetic_ valve IE caused by E. Faecalis
Ampicillin + Gentamicin
OR
Ampicillin + Ceftriaxone
52
What antibiotics should be used to treat _prosthetic_ valve IE caused by E. Faecium
Vancomycin + Gentamicin
53
What antibiotics should be used to treat prosthetic valve IE caused by HACEK bacteria
Ceftriaxone
54
for how long should IE be treated?
4-6 weeks
Longer for increasing beta-lactam resistance, S. Aureus, prosthetic valve
55
List the HACEK organisms
* Haemophilus
* Aggregatibacter
* Cardiobacterium
* Eikenella
* Kingella
56
List the class 1 indications for early surgery in IE
Early surgery: during initial hospitalisation before full treatment course of antibiotics
1. **Decisions about surgery should be made by a "multidisciplinary heart valve team" of cardiologists, CV surgeons, and ID specialists**
2. Valve dysfunction with signs or symptoms of heart failure
3. Left sided IE caused by S. Aureus, fungi or highly resistant organisms
4. Heart block, annular/aortic root abscess, destructive penetrating lesions
5. Persistant bacteremia or fever \> 5d after starting appropriate ABx
6. Complete removal of implantable electronic cardiac device systems in patients with definite IE
57
List the class 1 indications for delayed surgery in IE?
1. prosthetic valves: relapsing infection
1. Defined as new fever/bacteremia after a complete course of appropriate antibiotics and interval sterile blood cultures. No other source or portal of infection
\*In patients with recurrent endocarditis in the setting of continued IVDU, consultation with addiction medicine before repeat surgical intervention is considered
58
List the class II surgical indications in endocarditis
* **Early surgery** is reasonable in those with recurrent emboli and persistent vegetation despite appropriate antimicrobial therapy
* **Early surgery** may be considered in patients with native left-sided endocarditis with mobile vegetation \>10mm _with or without_ embolic phenomenon. Especially if it's on the anterior MV leaflet
* Early (as opposed to late) surgery in patients who have had a minor (no extensive neuro deficits) embolic stroke without ICH, in patients with an indication for IE surgery
* Consider delay surgery \>4 weeks in HD stable patients after a major ischemic or hemorrhagic stroke
59
When should IE prophylaxis be considered?
60
What ABx regimen should be given for endocarditis prophylaxis when such intervention is indicated?
* Amoxicillin 2g PO x1
* If NPO give 2g IV or IM or cefazolin/ceftriaxone 1g IV/IM
* If PNC allergy: Cephalexin 2g PO OR azithromycin 500mg PO OR doxycycline 100mg PO
* NPO + PNC allergy: Cefazolin/Ceftriaxone 1g IM/IV
61
How is pneumonia diagnosed?
Clinical (Fever, productive cough, SOB, consolidation) + Radiographic findings (CXR infiltrate)
62
What criterias can be used to decide who should be hospitalised in pneumonia?
* PSI/PORT (prefered by IDSA/ATS 2019)
* CRB-65
63
List the CRB 65 criteria
1. Confusion
2. RR\>30
3. SBP\<90 or DBP\<60
4. Age ≥ 65
if 0-1 treat as outpatient
if ≥2 admit to hospital
64
Give the IDSA/ATS criteria to define severe CAP
1. Minor criteria
1. RR\>30
2. PaO2/FiO2 ≤250
3. Multilobar infiltrates
4. Confusion/disorientation
5. Uremia (BUN\>20)
6. Leukopenia (WBC\<4)
7. Thrombocytopenia (plt\<100)
8. Hypothermia (T\<36)
9. Hypotension requiring aggressive fluid resuscitation
2. Major criteria
1. Septic shock with need for vasopressors
2. Respiratory failure requiring mechanical ventilation
65
What are common pathogens in CAP
1. **S. Pneumoniae**
2. H. Influenzae
3. M. Pneumoniae
4. C. Pneumoniae
5. Respiratory viruses
1. Influeza
2. Parainfluenza
3. RSV
4. rhinovirus
5. adenovirus
6. coronaviruses
6. Legionella pneumophila (severe disease)
66
What pathogens should also be considered in patients with pneumonia who have multiple comorbidities, antibiotic exposure or hospital exposures?
1. Gram negatives
1. Klebsiella pneumoniae
2. Pseudomonas
3. S. Aureus inc. MRSA
67
In which patients should sputum cultures be obtained in the context of CAP?
1. inpatients with severe CAP
2. intubated patients
3. Patients being treated empirically for MRSA or pseudomonas
68
What other investigations (other than CXR, basic blood work, sputum cultures, and blood cultures) should be considered in patients with CAP and in what setting should they be considered?
1. Pneumococcal + Legionella Ag +/- lower tract legionella NAAT
1. In severe CAP or when indicated by epidemiological factors such as an outbreak
2. Rapid influenza NAAT + COVID test when these viruses are circulating
\*Do not send procalcitonin
69
What are the outpatient treatment options for CAP?
* Healthy outpatients
* **Amoxicillin 1g TID (preferred)**
* Doxycycline 100mg BID
* Azithromycin 500mg PO x1 then 250mg PO BID only in areas with low pneumococcal resistance
* Not in most of Canada
* Patients with comorbidities (chronic heart, lung, liver, renal, DM, alcoholism, malignancy, asplenia)
* Amox-clav _or_ cephalosporin (cefpodoxime, cefuroxime) _plus_ macrolide _or_ doxycycline
* Respiratory fluoroquinolone (moxi, levo)
* adds additional coverage for H. Flu and moraxella catarrhalis as well as coverage for S. aureus and gram negatives
70
What are the inpatient treatment options for CAP?
* Non-ICU with no risk factors for MRSA or pseudomonas
* Beta lactam (CTx, amp-sulbactam, cefotaxime, ceftaroline) _plus_ macrolide
* Doxy is a _third line_ option if unable to give other options
* Respiratory fluoroquinolones (levo, moxi)
* \* Insufficient evidence for omadacycline
* ICU without risk factors for MRSA or pseudomonas
* Beta-lactam _plus_ macrolide
* Beta lactam _plu__s_ respiratory fluoroquinolone
* Some evidence for decreased death with beta-lactam + macrolide
* Aspiration pneumonia
* Don't add empiric anaerobe coverage unless empyema or abscess present
71
When should MRSA be covered in CAP and what agents can be used
* Based on local risk factors
* Use Vancomycin or Linezolid
* Daptomycin can't be used in respiratory infections as it is _inactivated by surfactans_
72
When should pseudomonas be covered in CAP and with what agents?
* Based on locally validated risk factors
* Use:
* Piptazo
* Cefepime
* ceftazidime
* azetronam
* meropenem
73
In admitted patients with CAP, when can a transition to PO antibiotics be considered
When the patient is hemodynamically stable, improving, tolerating PO intake and absorbing from GI tract
74
For how long should CAP be treated
* 5 days in well selected patients
* Afebrile x48hrs
* ≤1 sign of CAP clinical instability (HR\>100, RR\>24, SBP\<90, PaO2\<90%, can tolerate PO, normal mental status)
* Otherwise 10 days
75
When should steroids be considered in CAP
Only in refractory shock
76
How should influenza pneumonia be treated
* Oseltamivir if Sx \<48hrs and hospitalized
* COnsider treating bacterial superinfection
77
What are the pathogens involved in HAP/VAP
* S. Pneumoniae
* **MSSA**
* H. Influenzae
* **GNB including pseudomonas**
78
How is HAP/VAP diagnosed
Based on clinical gestalt + sputum/ETT/blood cultures
\*CPIS score NOT recommended by IDSA
79
List the risk factors for MDR VAP and HAP
* RF for MDR VAP
1. Prior IV ABx use within 90 days
2. septic shock at time of VAP
3. ARDS preceding VAP
4. ≥ 5 days hospitalization prior to VAP
5. Acute renal replacement therapy prior to VAP onset
* RF for MDR HAP
1. Priorr IV ABx use within 90 days
* RF for MRSA HAP/VAP
1. Prior IV ABx use within 90 days
* RF for MDR Pseudomonas VAP/HAP
1. Prior IV ABx use within 90 days
80
How should HAP/VAP be treated empirically?
81
In which patients should stool cultures be sent for Salmonella, Shigella, Campylobacter, yersinia and STEC
* Diarrhea and:
* Fever
* Bloody or mucoid stools
* Severe abdo pain
* Sepsis
82
In which patients presenting with diarrhea should you send C. Difficile testing
* Recent antibiotics
* Persons who work in healthcare, LTC, prison
* Compatible syndrome
* **IBD flare**
83
In what patients with diarrhea should blood cultures be sent?
* Immunocompromise
* Sepsis
* Suspicion of enteric fever
84
In what patients with diarrhea should stool samples be sent for Ova and parasites?
* Diarrhea ≥ 14 days
* Immunocompromise
* Travel
85
How can you increase the yield of stool Ovo and parasite testing?
Order daily x 3 days
86
Which patients with bloody diarrhea should get empiric antibiotic treatment?
1. Sick immunocompetent patients with bacillary dysentery (frequent scant bloody stools, abdo pain, tenesmus, fevers), suggestive of shigella
2. Recent travel with high fevers (\>38.5) and/or sepsis
3. Sick immunocompromised patients
87
What empiric antibiotic should be used when treating patients with bloody diarrhea? (empiric)
88
What is the first choice and alternative choice antibiotic to treat campylobacter diarrhea
First choice: Azithromycin
Alternative choice: Ciprofloxacin
89
What is the first choice and alternative choice antibiotic to treat S. enterica typhi and paratyphi diarrhea?
First line: ceftriaxone OR ciprofloxacin
Alternatives: Ampicillin OR TMP-SMX OR azithromycin
90
What is the first choice and alternative choice antibiotic to treat Shigella diarrhea
First line: Azithromycin OR ciprofloxacin OR ceftriaxone
Alternative: TMP-SMX OR ampicillin
91
What is the first choice and alternative choice antibiotic to treat Vibrio cholerae diarrhea
First line: Doxycycline
Alternative: Ciprofloxacin, Azithromycin, ceftriaxone
92
What is the first choice and alternative choice antibiotic to treat Yersinia enterocolitica diarrhea
First line: TMP-SMX
Alternative: cefotaxime, ciprofloxacin
93
What is the first choice and alternative choice antibiotic to treat STEC diarrhea
No ABx, risk of HUS
94
How is testing performed for C. Diff
* Stool toxin testing:
* EIA for GDH, toxin
* NAAT PCR for toxin
* Pseudomembranes on colonoscopy
95
Describe the clinical findings of CDiff
Unexplained new-onset ≥3 unformed stools in 24 hours
96
List the criteria for severe C. Diff
1. WBC ≥ 15 **OR** Serum creatinine 1.5 x pre-morbid levels
2. Age \> 65, immunosuppression, T\>38, albumin \<30
97
List the findings in fulminant C. diff
* Sepsis
* Shock
* Illeus
* perforation
* toxic megacolon (colon dilation \> 6cm)
98
How is the first episode of C. Diff treated
* STOP unnessessary antibiotics
* Stop PPI if not needed
99
Why is fidaxomicin superior to Vancomycin?
Less recurrence!
They have similar efficacy at treating the initial C.Diff infection
100
What are the risk factors for C. Diff recurrence?
1. Recurrent CDI in the last 6 months
2. Age \>65
3. immunocompromised
4. Severe CDI on presentation
101
How is recurrent C. Diff treated?
102
How are intra-abdominal infections managed?
1. Source control!
1. Percutaneous\>laparoscopic
2. If \<3cm, can forgo source control initially
2. Empiric antibiotics
1. CA-no previous hospitalisations
1. Ceftriaxone + Flagyl OR Cipro + flagyl
2. Healthcare associated or critically ill
1. Pseudomonas coverage: Pip-tazo, meropenem, ceftazidime or cipro AND metronidazole
2. Add enterococcal coverage (vanco) if immunocompromised. post-op or recurrent or if valvular heart disease/intravascular prosthesis
3. Consider targetted antifungal coverage in severe or nosocolilal IAI if candida isolated from intraabdomional or blood cultures
1. In other cases no mortality benefit
103
How long should antibiotics be continued for intraabdominal infections?
If source control is achieved: 3-5 days (STOP-it trial)
104
What are the criteria for a complicated UTI?
* Hemodynamically unstable
* Male
* Pregnancy
* Indwelling Foley catheter, instrumentation
* Functional or anatomic anomalies
* Urinary tract obstruction
105
How is a UTI diagnosed?
CLinically, supported by UA and culture
106
What are the first line empiric treatment options for cystitis?
1. Nitrofurantoin 100 BID x5 days
1. Avoid if concerns for pyelo
2. Septra DS 1 tab BID x 3 days
1. Avoid if recently used or in pregnancy
3. Fosfomycin 3g x1
1. Avoid if concerns for pyelo
2. Covers ESBLs
JAMA 2018: Nitrofurantoin superior to fosfomycin
107
What are the second-line empiric treatment options for cystitis?
* Fluoroquinolones (Levo or cipro)
* Beta lactams
108
What are the first line empiric treatment options for pyelonaphritis?
1. IV beta lactam (prefered in pregnancy) x7-14 days
2. Fluoroquinolones (if resistance rates are low) x 5-7 days
109
What organisms usually cause prostatitis
* E. Coli
* Pseudomonas
* Enterococcus
110
When should proatatitis be treated
* If symptomatic
* Do not treat if asymptomatic unless
* elevated PSA
* planning for Bx
* infertility
111
What are the symptoms of acute prostatitis?
* Fever
* intense local pain
* sepsis
112
What should be obtained before giving empiric antibiotics if there is suspicion for _acute_ proatatits?
UA+culture
113
What is the empiric antimicrobial treatment for acute prostatitis?
* If well
* Fluoroquinolone
* If unwell
* Fluoroquinolone
* 3rd gen cephalosporin
* Pip-tazo
114
How long should acute prostatitis be treated for?
2-4 weeks
115
What are the symptoms of chronic prostatitis
* May or may not be symptomatic
* If they are symptomatic, the symptoms are the same as acute prostatitis
* Fever
* Local pain
* Sepsis
116
What antibiotics should be used to treat _chronic_ prostatitis?
Fluoroquinolones or pathogen directed therapy
117
For how long should chronic prostatitis be treated?
* If using a fluoroquinolone: 4-6 weeks
* If using any other ABx: 8-12 weeks
118
What are the bacteria that tend to cause post-partum endometritis?
* Group B strep
* enterococci
* S. Aureus
* anaerobic GPC
* E. Coli
* Gardnerella
* Bacteroides
(polymicrobial)
119
What are the symptoms of post-partum endometritis?
* Fever
* Uterine tenderness
* Bleeding
* Foul-smelling lochia
120
Why do we worry about post-partum endometritis
It can progress to sepsis
121
What should you assess for once you diagnose post-partum endometritis?
* Retained products of conception
* abscesses
122
What empiric antibiotics can be used to treat post-partum endometritits?
* Clindamycin + Aminoglycoside(Add ampicillin or vancomycin if suspected enterococcus)
* Stepdown to oral once deferveses
* No good evidence on duration
123
What are the indications to treat asymptomatic bacteriuria?
For how many days should you treat for each indication
1. Pregnancy
1. Treat for 4-7 days
2. Invasive urological procedures
1. Treat for 1-2 days
3. Areas of limited evidence
1. First month after renal transplant
2. High risk neutropenia (ANC\<0.1 for ≥ 7 days)
124
What is the incubation period for gonorrhea?
2-7 days
125
What symptoms can be associated with gonorrhea?
* Can be asymptomatic
* Rectal and pharyngial infections more likely to ba asymptomatic
* Purulent discharge
* pelvic pain
* proctitis
* pyuria
* dysuria
* epididymitis
126
What symptoms can be associated with Chlamydia?
* Can be asymptomatic
* Rectal and pharyngial infections more likely to ba asymptomatic
* Purulent discharge
* pelvic pain
* proctitis
* pyuria
* dysuria
* epididymitis
127
How is gonorrhea diagnosed?
* NAAT /culture as indicated
* Urine
* Cervical
* rectal
* Pharyngeal
* Add blood, joint pustule swab for disseminated
\*cultures are generally preferred for sensitivity testing
128
How is gonorrhea treated
* Ceftriaxone 500mg IM x1
* Alternatives:
* Gentamycin 240mg IM x1 AND Azithromycin 2g PO x1 OR cefixime 800mg PO x1
* Doxy x 7 days if chlamydia not excluded
129
Name possible complications of gonorrhea and chlamydia
* In males
* Urethral strictures with fistula
* epididymitis (chlamydia\>gonorrhea)
* Infertility (rare)
* In females
* PID
* infertility
* ectopic pregnancy
* Fitz-Hugh-Curtis syndrome
* In both
* Re-infection
* reactive arthritis
* DGI: arthritis
* dermatitis
* endocarditis
* meningitis (more common in pregnant women, or MSM)
* Increased risk of HIV
130
What is the incubation period of chlamydia?
2-6 weeks
131
What percentage of chlamydia and gonorrhea infected patients are asymptomatic
50% Gono
70% chlam
132
How is chlamydia diagnosed?
Urine, cervical, vaginal, rectal, pharyngeal NAAT
133
How is chlamydia treated?
Doxycycline 100mg PO x 7 days
Azithro 1g PO x1 is an alternative
134
How should patients be counciled regarding sexual activity after a diagnosis of chlamydia or gonorrhea?
Abstinence x7days and until partner is treated
135
How is chlamydia treated differently in pregnancy?
Doxy is contraindicated 2nd and 3rd trimester of pregnancy
136
What criterias define treatment failure in chlamydia or gonorrhea?
1. Positive gram stain \>72hrs after treatment
2. Positive culture \>72hrs after treatment
3. Posiitve NAAT 2-3 weeks after treatment
\*\*\*Reinfection is more common that Tx failure
137
Which are the indications to perform a test of cure after treatment of chlamydia or gonorrhea?
1. All gonococcal infections, especially if suspected Tx failure/drug resistance, alternative Rx, pregnancy, pre-puberty or pharyngeal infection
2. Chlamydia in pregnancy (4 weeks post Tx)
3. Chlamydia Tx with ongoing symptoms, alternative regimen, suboptimal adherence
138
What are the indications for repeat testing (3 months later) after chlamydia or gonorrhea infection?
All individuals
139
What are the clinical manifestations of primary syphilis
Painless chancre and regional LN
140
How long after initial syphilis infection can primary syphilis last?
1st 3 weeks after infection
141
What are the manifestations of secondary syphilis?
1. Fever
2. Malaise
3. Rash
4. Alopecia
5. uveitis
6. meningitis
7. LN
8. herpatitis
9. arthralgias
10. condyloma lata
142
How long after initial syphilis infection can secondary syphilis last?
6 months
143
What timeframe differentiates early latent syphilis from late latent syphilis?
Early (\<1 year since infection)
Late (\>1 year or unknown duration)
144
What are the manifestations of latent syphilis
None
simply have positive serology
145
What are the manifestations of tertiary syphilis?
* Cardiovascular
* Aortitis
* Gummatous
* Late neurosyphilis
* Tabes dorsalis
* General paresis
146
What is the treatment for primary, secondary and early latent syphilis?
**Pen G 2.4 mU IM x1**
Alternatives (really use penG if you can!):
Doxycycline 100 mg PO x 14 days
Tetracycline 500mg po QID x 14 days
Ceftriaxone 1g IV /IM x 10 days
147
What is the treatment for late latent, unknown duration or tertiary syphilis?
**Pen G 2.4 mU IM Weekly x 3**
Alternative (Use pen G when possible)
Doxycycline 100 mg PO BID x 14 days
Tetracycline 500 mg QID PO x 14 days
148
What is the treatment for neurosyphils?
* Aqueous penicliiin 4mU q4h IV x 14 days
No alternatives, desensitize if allergy to PNC
149
What are the treponemal tests
* Immunoassay
* TPPA
* FTA-ABS
150
What are the non-treponemal tests?
* VDRL
* RPR
151
What is the difference between treponemal and non-treponemal tests?
* Treponemal
* Specific antibody against Treponema Pallidum
* Persists for life
* Non-treponemal
* non-specific antibody released during infection
152
Interpret the various combinations of negative and positive Screening CIMA, confirmatory RPR and confirmatory TPPA tests
153
What are the indications for PNC desensitization in syphilis patients
1. Neurosyphilis
2. Pregnancy
3. Late latent or latent of unknown duration syphilis
4. Tertiary syphilis
154
What are the indications to get an LP in syphilis?
1. Neuro, occular or auditory symptoms or signs
2. HIV and neuro symptoms or signs
1. HIV and RPR ≥ 1:32
2. HIV and CD4 \< 350
3. Previously treated syphilis and failed to achieve adequate serological response to treatment (i.e. four fold drop in RPR)
155
What should be considered in persistant PID, urethritis or cervicitis
Especially if initial gono-chlam comes back negative after empiric Tx
* Retreat once for usual pathogens
* Remember, risk of reinfection\>risk of Tx failure)
* Consider mycoplasma genitalium or T. Vaginalis
* Test available for mycoplasma henitalium at national microbiology lab in Winnipeg
* Treat with moxifloxacin x7-14 days depending on extent of infection
156
What is the organism responsible for chancroid?
H. Ducreyi
157
What are the symptoms and signs of chancroid
* Painfull ulcer with granulomatous base that bleeds
* Painfull inguinal LN
158
What is the treatment for chancroid?
Azithromycin 1g PO x1
CTx 250 mg IM x1
Cipro 500 mg PO BID x3days
159
What is the organism causing LGV
Chlamydia. Serovars L1-L3 more invasive
160
What are the symptoms of LGV
* Painfull LN
* Hemorrhagic proctitis
161
How is LGV treated
Doxycycline 100 mg PO BID x21 days and treat partners
162
What are the symptoms of genital HSV?
Painfull vesicles/ulcers with prodrome
163
What can be used to treat genital HSV
1. Acyclovir
2. Valacyclovir
3. Famcyclovir
164
What can be used to treat anogenital warts
* HPV vaccine for prevention
* For treatment
* Spontaneous resolution
* consider imiquimod or cryotherapy
165
What are the symptoms of trichomonas vaginalis
* Vaginal pH \>4.5
* Neg Whiff
* yellow frothy discharge
* strawberry cervix
166
How is trichomonas vaginalis treated?
* Metronidazole
* 2g PO x1
* OR 500 mg po x 7 days
* Treat partners
167
What are the symptoms and diagnostic tests for vulvovaginal candidiasis?
* Vagina pH \< 4.5
* Neg whiff
* wet mount with 10% KOH budding yeast
168
How is vulvovaginal candidiasis treated?
* clotrimazole or miconazole cream
* fluconazole 150mg PO x1
169
What are the symptoms and diagnostic tests for bacterial vaginosis?
* Vaginal pH \>4.5
* pos whiff
* clue cells on gram stain
* fishy odor
170
How is bacterial vaginosis treated?
* Metrronidazole 500mg PO BID x 7 days or 5g application PV x 5 days
171
Name 4 purulent skin and soft tissue infections
* Folliculitis
* Infection of hair follicle
* Furuncle
* Infection of hair follicle extending into the dermis and sc tissue
* Carbuncle
* coalescence of several infected follicles
* Abscess
* collection of pus within the dermis + sc tissue
172
Name 4 non-purulent skin and soft tissue infections and their most common infectious etiologies
* Impetigo
* S. Aureus
* Erysipela
* GAS
* Cellulitis
* GAS
* Necrotizing fasciitis
* Depends on type
173
How should purulent SSTIs be managed
I&D and C&S should be performed
174
How should non-purulent SSTIs be managed?
Treat predisposing trauma, tinea pedis, xerosis, lymphedema, etc...
Consider MRSA coverage if cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonisation with MRSA or IVDU
If severely immunosuppressed, consider pip-taz vanco or mero-vanco
175
When should prophylactic antibiotics be considered to _prevent_ recurrent cellulitis and which agent should be used?
* Consider if ≥3 episodes of cellulitis a year _despite controlling other risk factors_
* Use penicillin or an equivalent beta lactam (amoxicillin, cephalexin)
176
What should be done in patients with lymphedema and recurrent cellulitis?
COmpression
177
What symptoms suggest nec. fasc.
* Erythema with
* systemic toxicity
* gangrene/anesthesia
* hard induration
* hemorrhagic bullae
* pain out of proportion
* Pain extending beyond erythema
178
How is necrotizing fasciitis treated emipically?
* Emergent surgical inspection/debridement
* Consult surgery urgently
* Empiric antibiotics
* Piptazo + Vanco + Clindamycin
* Consider IVIG if shock or pre-operative
179
What are the organisms associated with each type of nec. fasc and how are they treated
180
Who gets type 1 nec. fasc.
* Usually younger patients
* following minor trauma
* they can have DM/PAD/IVDU
181
Who gets type 2 nec. fasc.?
* Older patients
* DM
* pelvic wounds
182
What is associated with clostridium induced nec. fasc.
* Trauma
* **colon Ca**
183
What is associated with vibrio vulnificus nec. fasc.
* **Saltwater exposure**
* Underlying liver disease
* seafood ingestion
184
What is associated with Aeromonas hydrophila induced Nec. Fasc.
Freshwater exposure, injury
185
What bacteria cause toxic shock syndrome?
* GAS
* S. aureus
186
What are the diagnostic criteria for toxic shock syndrome?
1. Hypotension (SBP\<90) AND
2. Isolation of GAS for normally sterile site AND
3. At least 2 of:
1. Renal impairment (Cr \>177)
2. Coagulopathy (plt\<100 or DIC)
3. Liver function abnormalities (ALT/AST/bili 2x ULN)
4. ARDS
5. Generalized erythematous macular rash that can desquamate
187
How is toxic shock syndrome managed?
* Contact + droplet precautions
* Volume resuscitation
* Surgery (esp. if necrotizing SSTI suspected)
* ABx
* Beta lactams + clindamycin
* IVIG -- Limited evidence, can be considered if severe infection
* Hyperbaric O2 -- efficacy unknown
* Chemoprophylaxis -- cephalexin x 10 days (clinda if allergy)
188
What microbiology is classically associated with diabetes
* Polymicrobial infections
* Often pseudomonas and anaerobes
189
What SSTI microbiology is classically associated with water exposure?
* Vibrio vulnificus (salt water)
* Aeromonas spp (fresh water)
* M. Marinum (fish tank exposures)
* M. Fortuitum (hot tub exposure)
190
What SSTI microbiology is classically associated with rose gardens?
sporothrix schenckii
191
What SSTI microbiology is classically associated with meat, butchers and veterinarians?
Erysipelothrix rhusiopathiae
192
What SSTI microbiology is classically associated with ecthyma gangrenous, malignant/invasive otitis external, hot tub folliculitis, and green nail syndrome?
Pseudomonas
193
What SSTI microbiology is classically associated with herpetic whitlow and eczema herpeticum?
HSV-1 and HSV-2
194
What SSTI microbiology is classically associated with umbilicated lesions, HIV, subacute meningitis and increased LP opening pressure?
Cryptococcus neoformans
195
What SSTI microbiology is classically associated with burrows, pruritus and visible tracts in web spaces?
Scabies
196
What SSTI microbiology is classically associated with HIV+ patients with white plaques on lateral aspects of the tongue that don't scrape off?
Oral hairy leukoplakia (EBV)
197
What SSTI microbiology is classically associated with black eschar in nasal mucosa or palate of diabetic patients?
Mucormycosis (Rhizopus spp.)
198
How does osteomyelitis develop (pathophysiology). Which pathophysiological mechanism is more likely to cause monomicrobial infections and which is most likely to cause polymicrobial infections?
* Hematogenous spread
* More common in children
* In adults, commonly causes vertebral OM
* Monomicrobial
* Contiguous spread
* From SSTI, trauma, surgery
* Polymicrobial
199
Differentiate neuropathic, arterial and venous foot ulcers
* Neuropathic
* Pressure points
* punched-out appearance
* deep ulcer
* minimal pain
* warm dry foot
* Arterial
* Lateral malleolous
* Dry and punctate
* Decreased pulses
* Cold-dry foot
* Venous
* Medial malleolous
* Irregular margins
* Shallow depth
* mildly painfull
* venous stasis dermatitis/lipodermatosclerosis
200
What are signs that a foot ulcer is infected
* Pain in a chronic wound (LR 11-20)
* Foul odor (LR 1-3)
* Purulence, exudate, erythema, warmth edema (LR\<1)
201
What is the most likely microbiological etiology of osteomyelitis in patients with the following risk factors:
* All patients
* Foreign body, prosthetic infections
* Nosocomia
* DM
* immunocompromise
202
What clinical findings have the highest +LR and -LR for OM of the lower extremities in patients with diabetes?
Presence or absence of ulceration does not modify probability of disease
203
What is the gold standard for diagnosis of lower extremity OM in diabetic patients?
* **Bone biopsy and culture**
* Superficial swab cultures do not reliably predict bone microorganisms or diagnose infection
204
What are the most commonly involved organisms in native vertebral OM?
* **S. Aureus (most common)**
* Beta hemolytic strep
* GNB
* Less common
* Tb
* Brucella
* Fungi
205
List risk factors for native vertebral OM
* Elderly
* immunocompromised
* IVDU
* Patients with PICCs/Ports
206
What are the signs and symptoms of native vertebral OM?
* New/worstening back pain in the context of suggestive blood work
* Fever in 45% of patients
207
How can a diagnosis of native vertebral OM be posed? What is the workup
* **Biopsy**
* Blood cultures (50% pos. if S. Aureus)
* ESR, CRP (sens 94-100%)
* MRI (sens. 97%, spec. 93%)
208
When might a biopsy not be required when diagnosing native vertebral OM
* If S.Aureus bacteremia in last 3 months
209
How is native vertebral OM treated?
* If no sepsis/neuro compromise, hold ABX until Bx results
* If empiric ABx must be used : Ceftriaxone + vanco
* Treat for 6 weeks
* Surgery if
* Neuro deficits
* spinal cord compression
* progression/recurrence despite appropriate ABx
210
How should native vertebral OM be followed after ABx started?
* Monitor clinically and repeat inflamatory markers
* repeat MRI _only if_ poor clinical response after ABx
211
How should a possible prosthetic joint infection be worked up in patients with suggestive symptoms
1. Make a microbiological diagnosis
1. Withhold ABx if stable clinically
2. perform arthrocentesis
212
What is the surgical management of prosthetic joint infections (i.e when do you change the prosthesis and when do you debride)?
213
What are the empiric antibiotics of choice in prosthetic joint infections and for how long should a patient be treated
IV or high dose oral ABx for 4-6 weeks
Empirically: Vanco + CTx
214
Name 7 steps in the management of a new diagnosis of HIV
1. Stage the HIV infection
* Confirm the positive test
* CD4 count
* Viral load
* Genotype (assess for resistance)
* Tropism testing (CCRS)
2. Assess for opportunistic infections
* Treat if present
* Prophylaxis based on CD4 count
3. Assess for co infections
* TB: TST/IGRA, CXR
* Serologies
* CMV
* toxoplasma
* Hepatitis B/C
* STIs and sexual health
* Syphilis
* Gono/chlam
* pap-test (cervical +/- anal)
4. Immunizations
* Hepatitis A if at risk
* Hepatitis B
* Annual influenza
* COVID
* HPV
* PCV-13 then PPV-23 eight weeks later
* Hib, meningiococcus
* caution with live vaccines if CD4\<200
5. Assess general health
* CBC, lytes, Cr, PO4
* Non-fasting lipids, glucs
* UA, beta-HCG
6. Initiate ARV
* Drug safety screening
* HLA-B5701 (ABC hypersensitivity)
* G6PD
* Start ASAP and council on side effects
7. Follow-up and councilling
* Prognosis
* Safe sex
* HIV in pregnancy
* Duty to disclose
215
What are the symptoms and signs of early HIV infection. Which ones have the highest +LR and -LR
* Fever
* Nausea
* emesis
* weight loss
* arthralgias/myalgias
* pharyngitis
* oral ulcers
* rash
* LADP
216
Which patients with HIV should be getting ARV?
1. All individuals with HIV who are ready for treatment. No waiting period
217
What are the recommended initial treatments for HIV
* 2 NRTIs PLUS INSTI OR NNRTI OR PI
* bictegravir/tenofovir alafenamide/emtricitabine
* Dolutegravir plus:
* Tenofovir alafenamide/emtricitabine
* Tenofovir disoproxil fumarate/emtricitabine
* Tenofovir disoproxil fumarate/lamivutide
* Dolutegravir/lamivudine with cavieats
\*Tenofovir alafenamide has fewer bone and renal side effects wheras tenofovir disoprooxil fumarate is associated with lower lipid levels and lower costs
218
Against what agents should prophylaxis be provided in HIV and at what CD4 count thresholds?
* CD4 \<200
* PJP prophylaxis
* CD4 \<100
* Toxoplasmosis
* CD4 \<50
* MAC (no longer recomended unless patients are noot on ART or not on fully suppressive ART
219
What is the preferred agent for PJP prophylaxis? What are the alternatives?
* Prefered
* TMP-SMX 1 DS tab daily
* Alternatives
* TMP-SMX 1 ss tab daily or 1 DS tab M/W/F
* Dapsone
* Atovaquone
* aerosolized pentamidine monthly
220
What is the preferred agent for Toxoplasmosis prophylaxis? What are the alternatives?
* Preferred
* TMP/SMX 1 DS tab daily
* Alternatives
* TMP/SMX 1 SS tab daily or 1 DS tab M/W/F
* Dapsone + pyrimethamine
* Atovaquone
221
What is the preferred agent for MAC prophylaxis? What are the alternatives?
* Prefered
* Azithromycin 1200mg weekly
* Clarythromycin 500mg BID
* Alternative
* Rifabutin
222
What is the preferred and alternative _treatment_ for PJP in HIV patients
* Preferred
* IV TMP SMX
* If PaO2 \<70 or A-a gradient \>35 (severe PJP)
* Prednisone 40mg PO BID x 5 days then
* Prednisone 20 mg PO BID x 5 days then
* Prednisone 20 mg PO daily x 11 days
* Alternative
* Moderate to severe
* Primaquine + clindamycin IV
* Pentamidine IV
* Mild-moderatge
* Dapsone + TMP
* Primaquine + clindamycin PO
* Atovaquone 750mg PO BID
223
What is the preferred and alternative treatment for toxoplasmosis in HIV patients
* Preferred
* Sulfadiazine + primethamine(AI) x 6 weeks +/- chronic maintenance if ongoing clinical or radiographic disease
* Not available in Canada
* Alternative
* Primethamine + Clindamycin (AI)
* TMP-SMX (b1)
* Atovaquone +sulfadiazine
* atovaquone + pirymethamine
* Atovaquone
224
What is the preferred and alternative treatment for MAC in HIV patients
* Preferred
* Clarithromycin + ethambutol OR Azithromycin + ethambutol x 12 months
* Alternative
* COnsider ADDING rifabutin, amikacin, FQ if advanced HIV or severe disease
225
What antimicrobials should not be used in G6PD deficiency
* Dapone
* Primaquine
226
What should be added to pyrimethamine to prevent toxicity
Leucovorin
227
What HIV complications can arise with CD4 counts above 500
* Fever
* Night sweats
* LADP
* headache
* Malaise
* Weight loss
228
What additional complications can arise in HIV when the CD4 count drops to between 200-500
* Non-invasive candidiasis
* Recurrent mucocutaneous HSV-1, HSV-2, VZV
* Oral hairy leukoplakia (EBV)
* Cutaneous KS (HHV-8)
* Sinusitis, bacterial pneumonia (esp. invasive pneumococcus)
* TB
* Cervical dysplasia, cervical carcinoma in situ
* CVD, stroke, CKD
* Psoriasis, seborrheic dermatitis, bacillary angiomatosis, molluscum contagiosum
* ITP
229
What additional complications can arise in HIV when the CD4 count drops \<200
* HIV associated myelopathy
* Visceral KS
* Endemic fungi
* Coccidiosis
* Histoplasmosis
* Blastomycosis
* Non-endemic fungi
* Aspergillosis
* cryptococcus
* PJP (subacute presentation over 2 weeks)
* NHL\>HL, MM, leukemia, anal cancer, liver cancer, cervical cancer, vulvar/vaginal cancer
230
What additional complications can arise in HIV when the CD4 count drops to between \<100
* Toxoplasmosis
* PML (JC virus)
231
What additional complications can arise in HIV when the CD4 count drops \<50
* CMV retinitis, colitis
* **MAC**
* CNS lymphoma, HAND
232
When is it safe to get pregnant if you have HIV?
* When on ARV and undetectable viral load\
233
How should HIV be managed through pregnancy?
* Always continue ARV
* If VL \>1000 copies (or unknown) near delivery, give IV Zidovudine and recommend schedules C/S
* If VL is suppressed, no increased risk with vaginal delivery
234
How should HIV patients be managed in the post partum period?
* If maternal viral load not suppressed at birth, give zidovudine to baby x 6 weeks and nevirapine x 3 doses
* **Breastfeeding NOT recommended**
235
Describe the natural history of Tb
236
How is latent Tb diagnosed
TST or IGRA
237
What are the particularities of the TST and IGRA?
238
Who should be tested for latent Tb?
* As a general rule: Patients with a high probability of infection or significant risk factors for reactivation and low risk of treatment toxicity and high probability of treatment completion:
* Contacts of an active case of pulmonary Tb
* Immigrants from countries with a high Tb incidence
* Travelers to countries with high Tb incidence
* Indigenous communities
* People who inject drugs
* Homeless
* Health care workers
* Residents of LTC facilities or correctional facilities
239
How is a TST interpreted
* 0-4mm
* Negative
* 5-10 mm
* Positive if:
* **HIV**
* **Contact with positive case within past 2 years**
* **Presence of fibronodular disease on CXR**
* **Organ transplant**
* TNF alpha inhibitor user
* Patients on immunosuppressive drugs
* **ESRD**
* \>10 mm
* Positive in all situations
240
How is latent Tb managed?
* Rule out active disease
* Balance the risks of reactivation and the risk of treatment adverse events
* If treating, then
* Prefered
* Isoniazid daily x 9 months
* Alternative
* Isoniazid daily x 6 months
* isoniazid + rifampin daily x 3 months
* \* new evidence for rifampin x 4 months, not in guidelines
241
What is the treatment for active Tb
* Caveats
* EMB can be stopped early if fully susceptible isolate
* Supplement INH with vitamin B6 to prevent peripheral neuropathy
* Steroids in Tb Meningitis or *pericardial disease (not in newer guidelines)*
* Consider prolonged treatment if persistent cavity, culture positive at 2 months CNS or bone disease
242
What are the side effects of isoniazid?
* Common
* Rash
* hepatitis
* neuropathy
* Unusual but important
* CNS toxicity
* Anemia
243
What are the side effects of rifampin?
* Common
* Drug interactions
* rash
* hepatitis
* Uncommon but impoortant
* Hepatitis
* Flu-like illness
* Neutropenia
* thrombocytopenia
244
What are the side effects of pyrazinamide?
* Common
* Hepatitis
* Rash
* arthralgias
* Rare but important
* Gout
245
What are the side effects of ethambutol?
* Common
* Eye toxicity
* Rare but important
* rash
246
Rash and hepatitis are side effects of most anti Tb drugs. List Tb drugs in RIPE in the order of most to least likely to cause both of these side effects
247
How should active Tb be managed in pregnancy?
* In pregnancy risk to the foetus from active Tb\>risk from Rx
* In pregnancy INH, RIF, EMB are safe
* WHO recommends the use of PZA in pregnancy
* Some uncertanties about safety but no reports of teratogenic effects
* Give in women with extensive disease or in patients who cannot tolerate other first line drugs
248
When should Latent TB be treated in pregnancy?
* Close contact of TB case
* Otherwise, wait until after delivery
249
Who should get an HIV test after a diagnosis of Tb
Everyone
250
Which HIV patients with latent Tb should be treated for latent Tb
Everyone, high risk of reactivation!
251
When should ART be started in patients with HIV and Tb
* CD4\<50: within 2 weeks
* CD4 \>50: Within 8 weeks
* Pregnancy: ASAP regardless of CD4
* In the presence of Tb meningitis: defer 8 weeks given increased risk of IRIS, especially if low CD4 count
252
What should be given to patients at high risk of Tb-IRIS
Preemptive predisone
253
What is the new prefered treatment for latent Tb in HIV+ patients?
* Isoniazid + Pyridoxine x 6-9 months
254
What are the diagnostic criteria non-tuberculous mycobacteria lung disease
* Clinical AND
* pulmonary or systemic symptoms
* Radiological PLUS
* Nodular or cavitary lesion on CXR
* Bronchiectasis on CT
* one of:
* 2 or more sputum positive for same species NTM
* 1 BAL/bronch culture positive for NTM
* Biopsy with mycobacterial histology (AFB/Granuloma) and positive culture
255
How are NTM pulmonary infections treated
* Discussion around clinical factors, infecting species and patient priorities
* Ideally treat based on succeptibilities
* Minimum 3 drug regimen
* Macrolide
* ethambutol
* +/-rifampicin
* +/-aminoglycoside
No empiric treatment
256
Name 4 species of NTM
1. Mycobacterium avium ocmplex
2. mycobacterium Kansaii
3. Mycobacterim Xenopi
4. Mycobacterium abscessus
257
what questions should you ask a patient with fever after travel
* pre travel
* PMHx, meds
* pre-travel consultation?
* Vaccines?
* malaria prophylaxis?
* travel
* purpose (greatest risk = VFR)
* travel itinerary
* Type of accommodation (urban or rural)
* Insect precautions
* Individual exposures
* raw meat, seafood, street food, unclean water, unpasteurized dairy products
* Freshwater exposure
* Visits on farms, slaughterhouses, funerals, hospitals
* Animal bites or scratches, insect or arthropod bites, hiking/caving
* Body fluid exposure (tattoo, sexual activity)
* Medical care overseas
* Post-travel
* Timing of fevers/clinical symptoms
* Short incubation period:
* Malaria, dengue, chikungunya, travelers diarrhea, viral URTI, influenza
* Long incubation period
* Malaria, TB, hepatitis, HIV, enteric fever, due to salmonella spp.
* Pattern of fever
* Daily: malaria, traveller's diarrhea, viral RTI, enteric fever
* Biphasic: Malaria, Dengue
* Relapsing: Malaria, enteric fever
258
What is the main DDx for fever in returned travelers?
* Infectious -- Travel-related
* **MALARIA**
* Typhoid/enteric fever
* Dengue, Chikungunya, Zika
* Viral hepatitis
* Rickettsiae, Brucellosis, Leptospirosis, Q-Fever, Ebola
* STIs, acute HIV
* Infectious -- Non travel related
* UTI
* CAP
* mono
* Meningitis
* C. Diff.
* influenza
* COVID-19
* Non-infectious
* VTE
* Drug fevers
* illicit drugs
259
What are the initial investigations that should and can be sent in patients with fevers returning from travel?
* CBC+diff, peripheral smear
* Electrolytes, Cr, urea, glucose
* ALT, ALP, AST, bili, INR/PTT
* Blood cultures x2, urine culture
* CXR
* Malaria x3 (over 24hrs)
* RDT
Consider
* Stool C&S, stool O&P, C. difficile
* Dengue, chikungunya, zika, PCR or serology
* hepatitis serology
* HIV, STI screen
* NP swab for viral PCR
260
How is malaria diagnosed?
* Thick and thin blood smear x3 over 24hrs separated by at least 6hrs
* Thick smear: Looks for parasites
* Thin smear: Identifies parasitemia (%) and speciation
* Rapid detection test
* Seperate tests for P. falciparum and others
* Highest sensitivity for falciparum
261
Name the 6 species of malaria
* P. Falciparum
* P. Ovale
* P. vivax
* P. Malariae
* P. Knowlesi
* P. Simiun
262
What is unique to P. Vivax and Ovale
Can present years later due to hypnozoites in the liver
263
Name the severity criteria for malaria
* Essentially any end-organ damage:
* Neurological: Confusion, prostration (severe weakness), seizures
* Respiratory: ARDS, pulmonary edema
* Hematological: DIC, Jaundice, hemoglobinuria. Black water fever
* Severe anemia (Hb\<50)
* Hypoglycemia (glucose\<2.2)
* Acidosis (pH\<7.25, HCO3 \<15)
* Renal impairment (Cr \>265)
* Lactic acidosis
* Hyperparasitemia
* ≥ 5% for non-immune adults
* ≥ 10% for semi-immune adults
264
How is falciparum malaria managed
* Uncomplicated
* From chloroquine sensitive area: Chloroquine
* From chloroquine resistant area:
* Atovaquone-proguanil
* Quinine+doxycycline
* Quinine + clindamycin
* Complicated
* IV artesunate x 48hrs then:
* PO atovaquone proguanil
* Doxycycline
* Clindamycin
265
How is non-falciparum malaria managed?
* Uncomplicated
* Chloroquine sensitive area (most): Chloroquine
* Chloroquine resistant area
* Atovaquone-proguanil
* Quinine + doxycycline
* Complicated (unusual for non-falciparum)
* IV artesunate x 48hrs then:
* PO atovaquone proguanil
* Doxycycline
* Clindamycin
266
Describe the areas of the world with chloroquine sensitive/resistant malaria
Sensitive=grey areas on map
267
What agents can be used for malaria chemoprophylaxis?
1. Chloroquine in sensitive areas
2. Atovaquone proguanil
3. Doxycycline
4. Mefoquine
5. primaquine
268
Which forms of malaria chemoprophylaxis are safe in pregnancy?
* Chloroquine
* Mefloquine
* Atovaquone proguanil has insuficient data regarding use in pregnancy
269
What clinical findings have the highest +LR and -LR for malaria
270
What is the incubation period of dengue?
\<2 weeks
271
What are the clinical features of Dengue
* Fever
* Maculopapular rash
* retro-orbital pain
* myalgias ("break bone fevers")
* Cytopenias
272
What is the treatment for Dengue?
* Supportive care
* avoid NSAIDS
273
What is the incubation period of Zika?
* \<2 weeks
274
What are the clinical features of Zika virus?
* 75% are asymptomatic
* Fever
* Rash
* arthralgias
* myalgias
* conjunctivitis
* HA
* retro-orbital pain
* Association with GBS
* If caught in the first trimester, association with congenital Zika:
* Microcephaly
* intracranial calcifications
* renal and hearing abnormalities
* Arthrigryposis
275
How is Zika virus treated?
Supportive care
276
What is the incubation period for chikungunya
\< 2 weeks
277
What are the clinical findings in chikungunya?
* Fever
* Polyarthralgias (usually arthritis)
* Lymphopenia
* Maculopapular rash
278
What is the treatment for chikungunya
Supportive care
279
What is the etiological agent for typhoid?
Salmonella Typhi/paratyphi
280
What is the incubation period for typhoid?
5-21 days
281
What are the clinical features in Typhoid?
* Fever
* Flu-like illness
* salmon colored spots
* constipation
* abdo pain
* relative bradycardia
282
How is typhoid treated?
* IV ceftriaxone
* IV cipro
* Azithromycin
\* increasing FQ resistance in SE asia
283
From what type of exposure can a person get Leptospirosis?
* Animal waste
* Soil, water exposure
284
What is the incubation period for Leptospirosis
2-26 days (average 10 days)`
285
What are the clincal features of Leptospirosis?
* Fever
* Myalgias
* HA
* Conjunctivitis
* Hypokalemia
* Cytopenias
* sterile pyuria
* Rarely in severe disease
* Jaundice + Renal failure (weil's disease)
* ARDS
* Pulmonary hemorrhage
286
How is leptospirosis treated?
* Mild disease
* Doxycycline
* Azithromycin
* Severe disease
* CTx
* Penicillin
* doxycycline
287
What finding on a CBC increases suspicion for nematodes in returned travelers?
* Eosinophilia
288
How is the diagnosis of nematode diseases posed?
* Stool/urine/sputum(strogyloides) microscopy (Ova and parasites)
* +/- serology (positive for life)
289
Where can one get Strongyloides stercoralis?
Soils in Africa, South America, Asia
290
How does strongyloides stercorales manifest in _immunocompromised patients_
* Disseminated disease
* Polymicrobial GNB bacteremia
* GNB meningitis
291
How is strongyloides stercoralis treated?
Ivermectin
292
How can one get schistosomia?
Contact with water (water/snail host) in troopical/sub-tropical areas
293
What are the manifestations of Schistosoma
1. Chronic infection
2. Can predispose to liver and bladder Ca
294
How is Schistosoma treated?
Praziquantel
295
How is taenia solium treated?
Neurocysticercosis: albendazole +/- praziquantel +/- steroids
296
How can one get Taenia Solium
By eating infected/uncooked meat (taeniasis) or eggs (neurocysticercosis)
297
How might one get trichinella spiralis?
From eating undercooked wild animal meat (bear/pork)
298
List symptoms of trichinella spiralis
* GI symptoms
* Muscle pains (cysts)
299
How is Trichinella spiralis treated?
Albendazole/mebendazole
300
How is COVID 19 transmitted?
Droplets
Aerosols in AGMP
301
What is the incubation period of COVID 19?
2-14 days (average 5-6 days)
302
What are the clinical features of COVID 19?
* Fever
* Cough
* SOB
* fatigue
* anosmia
* GI Sx
* anorexia
303
How is COVID 19 diagnosed?
RT-PCR
Highest sensitivity with LRT specimen
Rapid antigen available
304
Listt risk factors for severe COVID 19 infections
305
What are the side effects of viral vector-based COVID vaccines?
* Common vaccine side effects
* VTE (VITT)
* capillary leak syndrome
* GBS
* anaphylaxis
306
What are the side-effects of COVID 19 mRNA vaccines?
* Myocarditis/pericarditis
* Bell's palsy
* Anaphylaxis
307
Who should get a booster shot of the COVID-19 vaccine?
* Should be offered at least 6 months after primary series
* Adults \> 50
* Adults living in LTC or other settings that provide congregate care for seniors
* Recipients of a viral vector vaccine only series
* Adults from or in first nation communities
* Frontline healthcare workers regardless of interval from initial series
* Can be considered in other adults 18-49
* Adults with moderate to severe immunocompromise
* Active cancer treatment
* Transplant recipients
* CAR-T or HSCT in last 2 years
* Advanced untreated HIV
* immunosuppressive meidications
308
List therapies that can be used in COVID 19 and when they should be used
* Dexamethasone 6mg PO/IV x 10 days
* If requiring O2, hospitalized, intubated
* Remdesevir 200mg IV x1 then 100mg IV x4 days
* If needing O2 but _not intubated_
* Tocilizumab
* If requiring O2/intubation with systemic inflammation (CRP\>75) and worstening despite 24-48hrs of steroids
* Casirivimab+imdevimab and sotrovimab
* Consider in certain population
* Mild-moderate COVID 19 in adults and adolescents at high risk for progression to hospitalisation and death
* Within 10 days of positive test
* VTE prophylaxis
* More in heme deck
* Antibiotics
* Do not start empirically
* Not recomended
* Colchicine, IFN, Vit D
* Recomended against
* Hydroxychloroquine, Ivermectin, lopinavir/ritonavir
309
Where is Zika virus endemic?
* **Most of carribean and south america**
* Africa
* South east asia
310
How is Zika transmitted?
* Primarily through mosquito bites "day biters"
* Reports of transmission via sexual intercourse or blood donations
311
How is zika virus diagnosed
* Molecular testing
* Within 2 weeks of symptom onset
* Confirmatory plaque reduction neutralization test
* Acute and convalescent serologies
* Carefull: cross reactions, lack of specificity
* Order \>10 days after symptom onset
312
Who should get tested for Zika?
* Relevant exposure and:
* Symptomatic patient within 3 days of arriving or 14 days of departing a high risk area
* _Symptomatic_ pregnant women
313
What is the incubation period of Ebola?
8-12 days usually (2-21 day range theoretically)
314
What are the symptoms of Ebola?
* Fevers
* Myalgias
* GI Sx
* Anorexia
* Bleeding \<20%
315
What should be the isolation protocol for patients with Ebola?
Droplet/contact and call IPAC vs impermeable neck to toe with N95 and face shield
316
How is Ebola diagnosed?
* Viral cultures
* NAAT
* viral antigen testing
* Serology from appropriate sites
317
How is Ebola treated?
* Supportive care, essential procedures only
* Don't forget to rule out malaria
318
What is the case fatality rate of Ebola?
60%
319
What is the incubation period of Measles
14 days
320
What are the symptoms of measles
1. Fever
2. Cough
3. Coryza
4. conjunctivitis
5. Koplik spots
6. rash (centrifugal)
321
How should patients with measles be isolated?
1. Airborne precautions
322
Who should be contact traced after a diagnosis of measles?
1. Contacts 4 days before and after onset of rash
323
How is measles diagnosed
PCR of pharynx, NP, urine
Serology possible but can be false negative early
324
List possible complications of measles
1. Pneumonia
2. Encephalitis
3. subacute sclerosing pancreatitis
325
What should be used for post-exposure prooophylaxis in measles
* MMR vaccine
* Immunoglobulins
\*based on time from exposure
326
Describe the testing for lyme disease
327
In what condition can you diagnose Lyme disease without serology?
In the presence of erythema migrans = clinical diagnosis
328
What are the manifestations of CNS lyme disease
1. meningitis
2. radiculoneuritis
3. mononeuritis multiplex
4. CN palsy
5. Spinal cord inflamation
329
How is CNS lyme disease diagnosed
Serum antibody testing (not with PCR or culture of CSF!)
330
What should be considered in Lyme patients with persistent fevers on antibiotics
COnsider co-onfections (Babesia, anaplasma)
331
How should Lyme disease be treated?
332
What is the definition of Fever of Unknown origin?
To \>38.3 over 3 weeks with 1 week investigations
333
What is the DDx of FUO?
* Infection
* Intra-abdominal abscess (30%)
* IE
* Sinusitis
* TB
* CMV
* EBV
* HIV
* Inflammatory (25%)
* GCA
* Still's disease
* IBD
* Malignancy (15%)
* Lymphoma
* RCC
* CRC
* leukemia
* Drugs/misc (10%)
* VTE
* Antimicrobials
* NSAIDs
* Allopurinol
* Anti-epileptics
* Idiopathic (25%)
334
What are the first line investigations that should be sent in the context of FUO?
1. Hx & PE. Comprehensive fever diary
2. CBC + Differential + blood film
3. Lytes Cr,
4. LDH, TSH, CK, LFTs, SPEP
5. Blood cultures, urine C&S
6. HIV, CMV IgM, Hepatitis serologies
7. CXR, Abdo U/S
8. ANA, ANCA, RF
9. Consider EBV, monospot, q-fever serologies in right setting
335
What second line investigations/steps should be undertaken if the first line investigations don't lead to any diagnosis?
* in this order
1. Discontinue non-essential medications, institute fever diary
2. CT abdomen
3. Nuclear imaging
4. TTE and duke criteria
5. Doppler U/S bilaterally -- lower extremities (R/O DVT)
6. Temporal artery biopsy (IF ESR\>50, patient\>50)
7. Liver biopsy
\*Empiric trials of ABx or steroids rarely establish a diagnosis. Discouraged
336
What workup should be sent before starting long-term corticosteroids?
* TST/IGRA:
* If planning Prednisone\>15mg for \>4 weeks AND \> 1 other Tb risk factor
* RF: close contact, recent immigration, high risk work/life exposure
* Hepatitis B
* If prednisone \>7.5 mg
* PJP
* Consider prophylaxis if pred \>20mg for \>4-8 weeks
* Strongyloides
* Screen with serology +/- stool O&P if any immunosuppression and lived (or extended travel) to endemic areas
337
Which cancer patients on chemotherapy should get antimicrobial prophylaxis?
* Prophylaxis with **ciprofloxacin** in those at high risk for FN or prolonged profound neutropenia (ANC\<0.1 for \>7 days)
* **Antifungal** (oral triazole or echinocandin) if prolonged and profound neutropenia such as in AML/MDS, HSCT. _Not in solid tumors_
* **TMP-SMX** in chemo with PJP risk \>3.5% (e.g. prednisone ≥20mg for \>1 month)
* Patients who are _HSV +_ undergoing allo-HSCT or leukemia induction should get prophylactic **acyclovir**
* **NRTI** if high risk of hep B reactivation
* Yearly flu vaccine
* Avoid environments with high concentrations of fungal spores
338
How should Healthcare-associated ventriculitis and meningitis be managed?
1. Complete removal of infected CSF shunt/hardware and replacement with external drain
2. Empiric ABx:
1. Vanco + (ceftazidime OR Meropenem)
1. Add rifampin if staph isolate
2. Intraventricular ABx if no response to systemic ABx
3. Repeat CSF cultures to confirm negative growth
1. After the end of treatment:
1. 10-14 days post last + culture for gram positives
2. 21 days post last + culture for gram negatives
4. Reimplantation of new shunt once repeat CSF culture negative for 7-10 days
339
When should a line infection be suspected?
* Fever + line: Dx should be considered
* Get peripheral + line cultures
340
How are line infections treated?
* Remove line if possible
* ALWAYS for S. aureus and candida or with complicated infection (IE, OM, thrombophlebitis)
* Directed therapy x 7 days
* Minimum 14 days if S. Aureus or candida
341
How are surgical infections managed
* Superficial
* Treat as cellulitis
* deep or organ space
* Drainage +/- ABx
342
How are catheter associated UTIs managed?
* Only get culture if patient symptomatic
* If Sx and + culture, treat for 7 days
* Remove/change catheter if possible
343
List prevention strategies for VAP
1. Avoid intubation if possible (lol)
1. Use NIPPV if possible
2. Keep head of bed at 30-45 degrees
3. Daily oral care with chlorhexidine
4. Daily sedation vacation and assessment of readiness to extubate
5. Facilitate early mobilisation
344
List prevention strategies for central line associated infections
1. Subclavian ≥ Jugular \> femoral
2. Use maximal sterile barrier precautions and sterile full body drapes when inserting CVCs
3. Clean skin with chlorhexidine before inserting line
4. chlorhexidine bathing
5. Use sterile gauze or transparent, semi-permeable dressing to cover catheter site
6. Daily assessment of wether CVC is needed
345
List prevention strategies for catheter-associated UTIs
1. Hand hygiene; insert catheter using aseptic technique and sterile equipment
2. Use smallest possible catheter
3. Maintain sterile, continuously closed drainage system
4. keep collection bag below the level of the bladder
5. Empty collection bag regularly
6. Daily discussion of indication for catheter
7. Avoid unnecessary re-insertion
346
List the sensitivity profiles of the various species of Candia
347
List risk factors for Candidemia
1. Use of broad spectrum antibiotics
2. ICU admission
3. CVC
4. TPN
5. Neutropenia
6. Immunosupressive agents
7. Intra-abdominal surgical procedures
8. Necrotizing pancreatitis
9. Candida colonization in 3 sites
348
How is Candidemia treated?
* IF stable, no recent azole exposure: Fluconazole
* IF unstable, neutropenic or recent azole exposure: Echinocandin
* **Pregnancy: Amphotericin B**
* **CNS infections: Amphotericin B +/- flucytosine**
**\***Consult ophthalmology to R/O endophtalmitis
\*remove CVC
\*Treat for 2 weeks after 1st negative BC
\*Consider TTE if persistent candidemia. R/O IE
349
What are 4 syndromes associated with aspergillus infections?
* ABPA/Allergic rhinosinusitis
* Aspergiloma
* Chronic cavitary pulmonary aspergilosis
* Invasive aspergilosis
350
What is ABPA and what are its clinical/lab findings
* Hyper-sensitivity response to Aspergillus antigens/precipitants
* Presents with Asthma-like Sx, brown sputum, eosinophilia, bronchiectasis, elevated IgE
351
What is an aspergilloma
* Mycetoma that forms within a pre-existant cavity
* "Fungus ball"
352
What is Chronic cavitary pulmonary aspergillosis and what are its clinical/lab findings
* Progression of aspergilloma in pre-existing structural lung disease (most commonly COPD)
* Weight loss, Worsening cough +/- hemoptysis
353
What is invasive aspergillosis and how is it diagnosed
* Opportunistic infection seen in neutropenia/cellular immunocompromise
* Diagnosis using:
* CT chest
* indirect tests (Serum/sputum galactomannan)
* Direct tests (fungal culture or pathology)
354
How is ABPA treated?
* Steroids/anti-IgE +/- itraconazole (anti-fungal controversial)
355
How are aspergillomas treated
* Single lesion: surgical resection +/- antifungals
* Multiple lesions: Antifungals x6 months
356
How is chronic cavitary pulmonary aspergillosis treated?
Antifungals x 6 months
357
How is invasive aspergillosis treated
Voriconazole ≥ 6 weeks or longer
358
Where is blastomycosis endemic?
Border of the great lakes (incl. northern Ontario)
Southeastern/central USA
St. Lawrence river valley
359
What are the symptoms of Blastomycosis?
Pneumonia
Skin/joint infections
360
How is blastomycosis diagnosed?
* Fungal cultures
* PCR
* Pathology
* Serum/urine antigen
361
How is blastomycosis treated?
* Mild to moderate: Itrraconazole
* Severe: Amphotericin B
* Treat for 6-12 months or 3 months after complete resolution
362
Where is Histoplasma endemic?
St. Lawrence and Ohio rivers
363
What are the clinical manifestations of Histoplasmosis?
* Self limited PNA
* TB mimicker
364
How is Histoplasmosis diagnosed?
* Fungal culture
* PCR
* Pathology
* Urine antigen
365
How is histoplasmosis treated?
* Mild: no Tx
* Moderate: Itraconazole
* Severe: Amphotericin B
Treat for 12 weeks
366
Where is Coccidioides endemic
* Valley fever
* New mexico
* Arizona
* Mexico
* Central America
367
In which patients should we suspect Coccidiodomycosis?
* Returned travelers with PNA, meningitis
368
How is coccidiodomycosis diagnosed?
* Fungal culture
* Path
* antigen test
* LP if meningitis symptoms
369
How is coccidiodomycosis treated?
Only treat if symptomatic
Itraconazole
370
List aerosol generating medical procedures
1. Intubation/extubation, manual ventilation
2. Open endotracheal/deep succison
3. CPR (\*not chest compressions but airway manipulations)
4. Bronchoscopy and BAL
5. Tracheostomy/laryngoscopy
6. Sputum induction
7. Nebulized therapy (not MDI)
8. HFNC
9. NIPPV
10. Some dental procedures
1. Drilling
2. U/S scaling
371
What isolation precautions need to be taken in the following diseases, for how long:
* Tb
* Disseminated VZV
* Primary or disseminated, extensive varicella
* Measles
* COVID-19
* Mumps
* Meningococcus
* VHF inc. ebola
372
What isolation precautions need to be taken in the following diseases, for how long:
* Invasive GAS (TSS/NF/PNA/meningitis)
* C. Difficile
* Disseminated/primary extensive HSV
* Diphteria (pharyngeal)
* Influenza
* Norovirus
* Scabies
* Antibiotic resistant organisms
373
Which patients should get prophylactic or pre-emptive antibiotics antibiotics after a bite?
* Immunocompromised
* Asplenic
* Advanced liver disease
* Pre-existing or resultant edema of affected area
* Moderate to severe injury (especially to hand or face)
* Penetrating injuries to periosteum or joint capsule
374
What is the microbioology of animal bites
* Pasteurella multocida
* Capnocytophagia Canimorsus
* Staph
* strep
* anaerobes
375
What empiric antibiotic regimens can be considered following an animal bite?
* Clavulin
* 2nd or 3rd generation cephalosporin + metronidazole
* Moxifloxacin
* Doxy + clinda
376
What empiric antibiotic regimens can be considered following a human bite?
* Clavulin
* 2nd or 3rd generation cephalosporin + metronidazole
* Moxifloxacin
* Doxy + clinda
377
What is the microbiology of human bites?
* Eikenella corrodens
* Strep
* S. Aureus
* Anaerobes
378
Who should get a tetanos shot and/or immunoglobulins after wound management
379
In which patients with bite wounds should you give rabies post-exposure prophylaxis?
* If exposure to rabies is considered likely
* Ask about animal species, type of exposure, circumstance, behavior and vaccination status of the animal, domestic vs stray animal, provoked vs unprovoked attack, location and severity of the bite
* Make sure to immediately clean and flush the bite for 15 min
* Call public health for assistance in risk management
380
What should be given for rabies post-exposure prophylaxis
RabIg + vaccination
If prior vaccination, no need to give RabIg
381
What tests should be sent following a bloodborne pathogen exposure?
382
How much time does it take before an HIV, HCV and HBV test become positive after an exposure?
383
What is the risk of transmission from percutaneous exposure to HIV, HCV and HBV
* HIV: 0.23-1.3%
* HBV: 6-30%
* HCV: 3-10%
384
What post-exposure prophylaxis should be offered after HIV exposure?
Truvada + Dolutegavir (or raltegravir) x 28 days within 72 hrs of exposure
385
What post-exposure prophylaxis should be offered after HBV exposure
* Immune Anti HBs\>10: No further management
* Non-immune (non-vaccinated or Anti HBs\<10) or unknown: Vaccine series +/- HBIG
386
What post-exposure prophylaxis should be offered to patients following hep-c exposure
None. Repeat testing in 4-6 months
387
Which vaccines should be given to adults, and at what age
388
Which adult patients should get a Hib vaccine
* Asplenia/hyposplenism
* HIV
* Malignant hematological disorders
* PID
* Solid organ transplant
* Cochlear implants
389
Which adult patients should get a meningococcal vaccine?
* Asplenia/hyposplenism
* HIV
* Complement deficiency
* Travelers to "meningitis belt" (subsaharan africa)
* Pilgrims to hajj
* military personnel
* lab workers
* close contacts to a case
390
Which adult patients should get the pneu-c-13 followed by pneu-P-23 8 weeks later (pneumococcal vaccine). with single re-immunisation with pneu-p-23 5 years after?
* Asplenia/hyposplenism
* Sickle cell disease
* hemoglobinopathies
* HIV
* nephrotic syndrome
* solid organ transplant
* leukemia
* lymphoma
* immunisupressed
* complement deficiencies
391
Which adult patients should get 1 dose of pneu-p-23 then a second one 5 years later?
* Age \> 65
* Chronic CSF leak
* Chronic cardiac/pulmonary disease
* DM
* CKD
* CLD
* EtOH
* smokers
* homeless persons
* LTC
* IVDU
392
How should patients be managed when there is a suspicion for influenza? (who should be tested and treated empirically)
393
For how many days should Oseltamivir treatment be given
5 days, longer if immunocompromised, severe PNA, ARDS
394
When should patients with influenza be treated for bacterial coinfection?
* Initial severe disease
* Failure to improve
* Biphasic response
395
