1
Q
Antimicrobial rx empiric for meningitis ?
A
Vanco + ceftriaxone + ampicillin
2
Q
ATB and duration of tx for meningitis if N meningitidis or H influenzae ?
A
CTX 2 g IV q 12h x 4-7 days
3
Q
ATB and duration of tx if meningitis with listeria monocytogenes ?
A
Ampicillin 2g IV q4h x 21 days
4
Q
ATB and duration of tx if meningitidis with S pneumonia ?
A
Pen G 4MU IV q 4h or CTX 2g IV q 12h for 10-14 days
+ add DEX x 4 days
5
Q
Bacterial meningitis : CT or no CT before LP ?
A
If focal neurological deficit / altered mental status, immunocomp, hx of CNS mass, new seizures, papilledema
6
Q
Best LR to know if ulcer infected in chronic wound management ?
A
1) Pain in chronic wound
2) Foul odour
Purulence, exudate, erythema, warmth and edema not helpful
7
Q
Can you give doxycycline in pregnancy ?
A
No but azithro is OK
8
Q
Can you use oral therapy for bone and joint infections ?
A
YES with highly bioavailable oral therapy
9
Q
Chlamydia trachomatis : sx or asx ?
A
50% men asx and 70% women asx
10
Q
CSF gram stains and gram negative bacilli or coccibacilli ?
A
H influenzae
11
Q
CSF gram stains with gram positive or negative diplococci ?
A
Gram positive diplococci : s pneumoniae
Gram negative diplococci : n meningitidis
12
Q
CSF predictors for bacterial meningitis each with > 99% certainty ?
- glucose
- CSF:blood glucose
- protein
- WBC
- PMNc
A
- GLucose < 1.9
- CSF:blood glucose < 0,23
- Protein > 2.2
- WBC > 2000
- PMNs > 1180
13
Q
Does this patient with diabetes have OM of the lower extremity : best LR ?
Name 4.
A
- ESR > 70 LR 11
- Bone exposure LR 9 LR-0,7
- Ulcer area > 2 cm2 LR 7
- Positive probe to bone LR 6.4
Presence or absence of ulcer inflammation does not modify probability of dx
Gold standard is bone bx and culture
14
Q
Empiric ATB for meningitis if PCN allergy ?
A
Vancomycin + moxifloxacin +/- TMP-SMX if listeria coverage needed
15
Q
Empiric therapy for non vertebral osteomyelitis ?
A
Ceftri +/- vanco if MRSA risk factors +/- metronidazole if sacral
16
Q
Empiric tx for vertebral osteomyelitis ?
A
Ceftriaxone + vancomycine
Duration 6 weeks
17
Q
Germ associated with black eschar in nasal mucosa or palate of diabetic ?
A
Mucormycosis (rhizopus spp)
18
Q
Germ associated with hot tub folliculitis, green nail syndrome, ecthyma gangrenosum ?
A
Pseudomonas aeruginosa
19
Q
Germ associated with meat, butchers, veterinarians ?
A
Erysipelothrix rhusiopathiae
20
Q
Germ associated with rose gardens ?
A
Sporothrix schenckii
21
Q
Germ associated with salt water ? fresh water ? Context of necrotizing fasciitis.
A
Vibrio vulnificus with salt water
Aeromonas spp with fresh water
Tx is doxy + cefta
22
Q
Germs associated with hot tub exposure ?
A
M fortuitum
23
Q
Gonorrhea : sx or asx usually ?
A
Men usually sx
Women often asx
Rectal/pharynx more likely to be asx
24
Q
Gram : pink ?
A
Gram negative
25
Gram : purple ?
Gram positive
26
Gram negative diplococci ?
Neisseria meningitidis / gonorrhea
27
Gram positive cocci clusters ?
Staph aureus or coag neg staph
28
Gram positive cocci pairs/chains ?
Streptococcus spp or enterococcus
29
H influenzae on gram stain ?
Gram negative bacilli or coccibacilli
30
Health care associated ventriculitis and meningitis : which ATB?
- Vanco + ceftazidime or meropenem
+/- rifampin if staph isolate
+/- intraventricular Abx if no response to systemic tx
31
How can you rule out meningitis ?
Ruled out by 99% if fever, neck stiffness and altered MS all absent
32
How do you test for syphilis ?
- Start with treponemal test
- Then confirmatory NTT and confirmatory TT
33
Incubation for chlamydia ?
2-6 weeks
34
Incubation for gonorrhea ?
2-7 days
35
Is cloudy smelling urine a symptom of UTI ?
No
36
Listeria monocytogenes on gram stain ?
Gram positive bacilli
37
LP criteria : normal glucose ?
2.5-3.5
38
LP in bacterial meningitis ?
Opening pressure > 30
WBC > 1000 NEUTROPHILS
Glucose < 2.2
Protein > 1
39
Meningitis : which physical test has high sensitivity ?
Jolt accentuation has 97% sensitivity
Exacerbation of baseline headache with horizontal rotation of the head
40
Meningitis : which test has high specificity ?
Kernig’s and Brudzinski’s : high specificity but POOR sensitivity
41
Meningitis common pathogens ?
S pneumoniae, N meningitis, H influenzae
42
Most common pathogen in vertebral osteomyelitis
S aureus
43
Neisseria meningitis : who needs chemoprophylaxis ? Name 6.
- Household contacts
- Sleeping arrangements
- Contact oral/nasal secretions
- Children / staff in childcare
- HCWs who have had intensive unprotected contact
- Airline passengers sitting next to case for ≥ 8 hours
44
Prosthetic joint infection : empiric tx ?
Ceftri + vanco
45
Prosthetic joint infection : when should you start ATB ?
Withhold ATB if stable pending arthrocentesis OR to ensure pathogen determined
46
Recommendations in case of recurrent cellulitis ?
- Trial of oral penicillin if > 3 / year despite controlling other risk factors
- Compression therapy for pts with chronic leg edema and recurrent cellulitis as part of first line prevention measures
47
Should you do a test of cure after tx for gonorrhea/chlamydia ?
Gonorrhea : TOC of cure 2w after tx for all
Chlamydia : TOC 3-4w after tx only if LGV, unclear compliance, alternative regimen, pregnancy
48
Name of spirochetes (spirals) ?
Treponema spp, leptospirosis, borrelia (lyme)
49
Toxic shock syndrome management ?
Surgical source control
ATB : B lactam PLUS clindamycin
Contact and droplet precautions
IvIg limited evidence but consider if severe
Hyperbaric O2 : efficacy unknown
50
Tx for chlaymdia ?
Anogenital or pharyngeal
- PHAC : azithro 1g PO x 1 or Doxy 100mg PO BID x 7d
51
Tx for disseminated gonorrhea infection ?
Ceftri 1-2g IM/IV q 24h x 7d
52
Tx for gonorrhea ?
Anogenital or pharyngeal
- PHAC : ceftri 250 IM x 1 + azithro 1g PO x 1
- CDC : ceftri 500 IM x 1
53
Tx for lymphogranulomatose venerienne ?
Doxycycline 100 PO BID x 21d
54
Typical pathogens in prostatitis ?
E Coli, other enterobacteriaceae, pseudomonas
55
UTI empiric tx : acute simle cystitis ?
- Nitrofurantoine 100 BID x 5 d
- TMP SMX x 3 days
- Fosfo x 1 dose
56
UTI empiric tx : complicated UTI or PNA ? Oral vs IV?
Oral
- Cipro x 7 days
- TMP SMX x 7-14 days
IV
- Ceftri q24h
- Cipro
- Genta +/- ampi
57
Vertebral osteomyelitis : when should you start tx ?
Hold ABx until bx result if no sepsis / neuro compromise
Dx 50-60% of time with 1st bx
58
WBC criteria for bacterial meningitis ?
WBC > 1000 NEUTROPHILS
59
WBC criteria for viral meninigitis ?
< 1000 LYMPHOCYTES
60
WBC criteria on LP for TB and fungal meningitis ?
Variable but differential is lymphocytes
61
What are the benefits of steroids in meningitis ?
- 50% ↓ mortality / morbidity for pneumococcal meningitis
- ↓ hearing loss and short term neurological sequelae in high income countries for all pathogens
HOWEVER increased mortality in neurolisteriosis
62
What are the dx criterias of toxic shock syndrome ?
GROUP A STREP
- Hypotension AND isolation of GAS from normally sterile site
and at least two of :
- Renal impairment Cr > 177
- Coag (PLT < 100 or DIC)
- Liver fx abN
- ARDS
- Generalized erythematous macular rash that may desquamate
63
What are the empiric ATB for necrotizing fasciitis ?
Piptazo + vanco + clindamycin
Consider IVIG if shock or pre op
64
What are the germs in erysipelas ?
Group A streptococcal
65
What are the SPICE HAM (Amp C) bacterias ?
(SPICE HAM)
Serratia
Providencia
Indole positive Proteus
Citrobacter
Enterobacter
Hafnia
Acinetobacter
Morganella
66
What are the two types of necrotizing fasciitis ?
- Type 2 is S pyogenes/GAS
Young pts, after minor trauma or bruise
- Type 1 is polymicrobial
Older, DM, pelvic wounds
BUT CANNOT clinically distinguish types
67
What are two germs in toxic shock syndrme?
Group A strep usually
Sometimes S aureus with tampons/nasal packing
68
What ATB for chemoprophylaxis for neisseria meningitis ?
Cipro 500 PO x 1 dose (but increasing resistnace)
Ceftri 250 IM x 1 dose
Rifampin 600 PO BID x 2d
69
What is a non tremponemal test ?
Non specific antibody released during infection
70
What is a treponemal test ?
Specific antibody against T pallidum, persist over lifetime
71
What is the chemoprophylaxis for toxic shoc syndrome ?
Cephalexin x 10 days
Clinda if PNC allergy
72
What is the clinical presentation of basal skull menigitis ?
+ CN palsies
+ long tract signs
73
What is the clinical presentation of latent syphilis ?
Early if < 1year or late if > 1 year
Positive serology but no clinical manifestations
74
What is the clinical presentation of primary syphilis ? Timing?
Painless chancre, regional LN
Timing 3 weeks up to 90 days
75
What is the clinical presentation of secondary syphilis ? Timing ?
Fever, malaise, rash, alopecia, uveitis, meningitis, LN, hepatitis, arthlagias
Timing 12w-6 months
76
What is the clinical presentation of tertiary syphilis ?
Cardiovascular : aortitis
Gummatous
Late neurosyphilis (tabes dorsalis, general paresis)
77
What is the defined tx for furuncle/carbuncle/abscess ?
Moderate severity :
- MRSA : TMP SMX
- MSSA : cephalexin
Severe :
- MRSA : vanco
- MSSA : cefzolin
78
What is the dose of steroids in meningitidis ?
Dexamethasone 10mg IV q6h for 4 days
79
What is the empiric tx for furuncle/carbuncle/abcess ?
I&D
Empiric : cephalexin or TMP SMX or doxy and if severe : vanco
80
What is the germ in impetigo usually ?
S aureus
81
What is the normal LP opening pressure ?
5-20
82
What is the serology of a previoulsy treated syphilis ?
- Screening TT positive
- Confirmatory NTT negative or positive
- Confirmatory TT positive
83
What is the tx for acute and chronic prostatitis ?
Acute : tazo, 3rd gen ceph, FQ x 2-4 w
Chronic : FQ x 4-6w or TMP SMX x 8-12w
84
What is the tx for impetigo/erysipelas/cellulitis ?
- Oral cephalo like cephalin or IV like cefazolin
Generally 5 days ad 14 days
85
What is the tx for late latent or unknown duration and tertiary syphilis ?
Benzathine penicillin G 2.4 mU IM weekly x 3
86
What is the tx for neurosyphilis ?
Aqueous penicilin 4mU q4h IV x 14 days
87
What is the tx for primary, secondary and early latent syphilis ?
Benzathine penicillin G 2.4mU IM x 1
88
What is the tx of type 1 and type 2 necrotizing fasciitis ?
- Type 1 : piptazo + vanco or carbapenem
- Type 2 : PCN + clindamycin
89
What is the typical presentation of arterial chronic wound ?
Lateral malleolus, dry and punctate, decreased pulses, cold and dry foot
90
What is the typical presentation of venous chronic wounds ?
Medial malleola, irregular margins, mildly painfuls, venous stasis dermatitis
91
What recommendations for sexual practice should you give to patients while on tx for chlam/gono ?
Abstain from sex x 7d AND partner treated
92
What timing for neisseria meningitis chemoprophylaxis ?
Within 10 days usually
93
When can you reimplante new shunt in case of healthcare associated ventriculitis and meningitis ?
Once repeat CSF culture have been negative for 7-10 days
94
When is immunoprophylaxis necessary for N meningitis ?
In case of invasive meningococcal disease
95
When should you give steroids in meningitis ?
Dexamethasone 10mg IV q6h for 4 days PRIOR TO ro WITH first dose of ATB
Do not start if ATB have already been given to patient
Stop if CSF is non turbid or low cell count or non pneumococcal by culture
96
When should you not treat prostatitis ?
Do not treat if asx unless elevated PSA, planning bx or infertility
97
When should you remove prosthesis in prostehtic joint infection ?
If duration of sx > 3 weeks or joint age > 30 days
Or if not well fixed prosthesis, presence of sinus tract
98
When should you repeat MRI for native vertebral osteomyelitis ?
ONLY if poor clinical response after ABx
99
When should you suspect Listeria monocytogenes in meningitis ?
> 50 years or immunocompromised
100
When should you treat asx bacteruria ?
- Pregnant
- Urologic procedure with mucosal transection
101
Which ATB for enterococcus ?
Ampicillin if S or vanco (not VRE), linezolid, daptomycin
102
Which ATB for ESBL bacterias ?
Carbapenem, TMP SMX, FQ, AG (if sensitive)
103
Which ATB for MRSA ?
Vancomycin, Doxycycline, TMP-SMX, Clindamycin, Linezolid, Daptomycin, Ceftobiprole
104
Which germs in basal skull meningitis ?
TB, Listeria, Cryptococcus, Syphilis, Lyme
105
When should you do TEE in contexte of infectious endocarditis ?
- Initial TTE for everyone
- Before switching to oral and repeat TEE 1-3 days before completing ATB regimen
106
What are the major criterias for IE dx per Duke criterias ?
A) Microbiologic criteria (at least 1 of):
- ≥ 2 BC with typical organisms
- ≥ 3 BC with occasional/rare oragnisms
- Blood PCR for coxiella, bartonella, T whipplei
- Coxiella burnetii in 1 BCx or IgG ≥ 1:800
- Bartonella henselae or quintana IgG ≥ 1:800
B) Imaging criteria
- Echo or cardiac CT: vegetation, valve/leaflet perforation or aneurysm, abscess, pseudoanevrysm, fistula, prosthetic valve dehiscence or NEW significant valve regurg
- PET with abnormal activity
C) Surgical criteria: IE by direct inspection
107
What are the typical organisms in IE per Duke criterias ?
S aureus/lugdunensis, Streptococci (except GAS or pneumo), E faecalis, HACEK, granulicatella, abiotrophia, gemella
108
What is the definition of a DEFINITE IE per Duke criterias ?
- Microorganism identified on vegetation / valve
- 2M or 1M + 3m or 5m criteria
109
What is the definition of POSSIBLE IE per Duke criterias ?
1M+1m or 3m criteria
110
What are the minor criteria in the Duke criterias ?
- Predisposition : prior IE, prosthetic valve, prior valve repair, congenital HD, regurg/stenosis, PMP/ICD, HOCM, IDU
- Fever
- Vascular phenomena
- Immunologic phenomena
- Microbiologic evidence
- Imaging criteria (abN activity on PET within 3 months of implant of prostehtic valve, aortic graft...)
- Physical exam criteria (NEW valve regurg on auscultation)
111
Janeway lesions : vascular or immunologic phenoma ?
Vascular
112
What are the immunologic phenomenas in IE ? Name 4.
Rheumatoid Factor
Osler Nodes
Roth spots
Immune complex GN
113
IE ATB tx if MSSA ?
Native valve : cloxa or cefazolin
Prosthetic valve : cloxa or cefazolin PLUS rifampin PLUS gentamicinI
114
IE ATB tx if MRSA or CNST (coag neg staph) ?
Native valve : vanco
Prosthetic valve : vanco PLUS rifampin PLUS gentamicin
115
IE ATB tx if viridans group strep or S gallolyticus / bovis ?
PenG or Ceftriaxone for native and prosthetic valve
116
IE ATB tx if enterococcus faecalis ? enterococcus faecium ?
Faecalis : ampi PLUS genta or ampicillin PLUS ceftri
Faecium : vanco PLUS gentamicin
Same for native and prosthetic valve
117
IE ATB tx for HACEK group ?
Ceftriaxone
118
Duration of ATB tx in IE ?
4-6 weeks
119
When is a switch to oral therapy acceptable in IE ?
- If left sided IE caused by streptococcus, E faecalis, S aureus or CNST that is STABLE
- TEE before switch to oral with no paravalvular infection
- Frequent and appropriate follow up
- Follow up TEE performed 1-3days before completion of ATB course
120
IE class I recommendations for early surgical indications ?
Name 5.
- Valve dysfunction with signs or sx of heart failure, persistent despite OMM
- Left sided IE caused by s aureus, fungi, highly resistant organisms
- Heart block, annular/aortic root abscess, destructive penetrating lesions
- Persistent bacteremia or fever >5 d after appropriate ATB
- Complete removal of PPM/CRT/ICD in pts with definite endocarditis
121
IE class I for surgery indications for relapsing infection ?
- Prosthetic valve : relapsing infection (new fevers/bacteremia after a complete course of ATB and interval steril blood cultures)
- Recurrent endocarditis in setting of addictions and injection drug use : addiction medicine before repeat surgical intervention
122
IE class II surgical indications ?
Name 4.
- Early surgery reasonable if recurrent embolia and persistant veggetations despite appropriate tx
- Early surgery to consider if native left sided valvule endocarditis with mobile vegetation > 10mm
- Early surgery for pts who have had a minor embolic stroke without ICH, in pts with an indication for IE surgery (no extensive neuro deficits)
- Consider delay IE surgery > 4 weeks in stable pts after a major ischemic or hemorrhagic stroke
123
IE treatment if major stroke ?
Delay IE surgery > 4 weeks if stable, after a major ischemic or hemorrhagic stroke
124
IE prophylaxis : what are the 4 patient population ?
- Prosthetic cardiac valve (TAVI, annuloplasty rings, clips...)
- Previous IE
- Congenital heart disease (cyanotic unrepaired, if repair with patch/prosthetic within 6 m, if residual defect near patch/prosthetic)
- Cardiac transplantation recipients who develop cardiac valvulopathy
125
IE prophylaxis indicated for which procedures ?
Dental procedures (gingival manipulation...)
Respiratory tract procedures (WITH transection of respiratory mucosa like tonsillectomy or adenoidectomy)
Any piercing of infected skin (bx of rash)
126
What is the IE prophylaxis regimen ?
Give 30-60min before dental or respiratory procedures
- Amox 2g PO x 1
- if NPO : ampi g IV/IM OR cefazolin/ceftri 1g IV/IM
- PCN allergy : cephalexin 2g or azithro 500 or doxy 100
- NPO + PCN allergy : cefazolin /cetriaxone 1g IV/IM
127
IE prophylaxis if PCN allergy ?
Cephalexin 2g or azithro 500 or doxy 100
If NPO : cefazolin/cetri 1g IV/IM
128
IE prophylaxis if NPO ?
Ampicillin 2g IV/IM or cefazolin/ceftri 1g IV/IM
129
What is the most common pathogen in community acquired pneumonia ?
S pneumoniae
130
What are the most frequent pathogens in CAP ?
- S pneumoniae
- M pneumoniae
- C pneumoniae
- H influenzae
131
CAP outpatient tx for healthy patients without comorbidities or risk factors ? Name 3.
- Amox 1g TID
- Doxy 100 BID
- Azithro 500 then 250 (or clarithro) only in areas with pneumococcal resistance < 25%
132
CAP outpatient tx for pts with comorbidities ?
- Amox clav OR cephalo (cefpodoxime, cefuroxime) PLUS macrolide Or doxy
- Resp FQ (levo/moxi)
Adds coverage for H flu and M catarrhalis (both produce beta lactase frequently) and provides coverage for S aureus and gram negatives
133
CAP inpatient tx for non severe without risk factors for MRSA or PsA ?
- Beta lactam PLUS macrolide
- Resp FQ
134
CAP inpatient tx for severe CAP without risk factors for MRSA or PsA ?
- B lactam PLUS macrolide
- B lactam PLUS resp FQ
135
CAP inpatient tx for aspiration pneumonia ?
Recommend against adding empiric anaerobic coverage unless empyema or abscess present
136
CAP : when should you consider MRSA coverage ?
If severe post influenza pneumonia, mechanical ventilation/ICU, significant recent ATB
137
CAP : how do you cover for MRSA ?
Vanco 15mg/kg q12h or linezolid 600 q12h
138
CAP : risk factors for pseudomonas ?
Recent mechanical ventilation or prior isolation of organism
139
CAP duration of tx ?
5 days if afebrile x 48h and < 1 sign of CAP clinical instability
140
What are the risk factors for multi drug resistant pathogens in HAP/VAP ?
If IV antibiotic use within 90 days
141
Duration of antibiotics for HAP/VAP usually ?
7 days
142
Empiric treatment for HAP/VAP ?
Column A +/- column B +/- column C
Column A should cover pseudo + MSSA : pip tazo, cefepime, meropenem, levofloxacin
Column B for MRSA coverage : vanco / linezolid
Column C 2nd antipseudo agent
143
Can flu and covid be differentiated clinically ?
No
144
Influenza : who should you treat ?
Name 3.
- Any pt hospitalized with influenza
- Any outpatient with severe/progressive illness or risk factors (>65, pregnant or 2w post partm, immunocompromise, comorbidities)
- Consider in other outpatients < 2d onset or with high risk household members
145
Influenza : how do you treat ?
Neuraminidase inhibitor as soon as possible : oseltamivir 75 BID x 5 days as resolution of sx 1 day sooner
But causes No/Vo
Can treat for longer PRN
No steroids or immunomodulators
146
Influenza : when to consider bacterial co infection ?
- Initial severe disease
- Deterioration after initial improvement with antivirals
- If not improving with 3-5d of antivirals
147
Avian influenza H5N1 risk factor ?
Primary risk factor is exposure to deal or ill poultry
148
How do you treat avian influenza H5N1?
Oseltamivir or zanamivir
Notify lab / IPAC / public health
149
COVID 19 : what's the benefit in treating mild illness?
Reduce risk of hospitalization
No evidence of reducing sx burden or duration
150
COVID 19: tx for mild lilness ?
- Nirmatrelvir/ritonavir x 5 days for outpatients
*start within 5 days
- Remdesivir IV for inpatient
*start within 7 days
Can be offered regardless of vaccine status (although benefit not totally clear) if over 70 with > 3 high risk comorbidities
151
What are the precautions when using nirmatrelvir/ritonavir in covid 19?
- Dose adjustement for CKD
- Cannot be used in severe liver disease
- Many drug interactions
Amiodarone CI
Many statins and antihypertensives need to be held
Rivaroxaban CI
152
What is the tx for COVID 19 moderate and severe illness ?
- Dexamethasone x 10 days
- Remdesivir for moderate illness
- Immunomodulators if moderate not improving or severe
153
What are the side effects of COVID 19 vaccines ?
- Janssen : VTE, capillary leak syndrome, GBS
- Pfizer: myocarditis, pericarditis, Bell`s palsy
154
When should you order C difficile testing ?
- Recent ATB
- Work in healthcare/LTC or prison
- Compatible syndrome
- IBD falre
155
When should you order stool culture for ova and parasites?
- Diarrhea over 14 days
- Immunocompromise
- Travel
Increased yield if ordered daily x 3 days / repeat up to 3x
156
When is empiric therapy in adults with bloody diarrhea indicated? Name the 3 indications.
Not recommended UNLESS :
- Sick immunocompetent patients with bacillary dystentery suggestive of Shigella
(frequent scant bloody stools, abdo pain, tenesmus, fevers)
- Recent travel with high fever ≥ 38.5 and/or sepsis
- Sick immunocompromised patient
157
What is the empiric antibiotic choice for diarrhea ?
Cipro or azithro
Cipro left to russia and azithro right to russia / africa
158
Diarrhea treatment for campylobacter ?
Azithromycin (ciprofloxacine as alternative)
159
S enterica typhi or parayphi diarrhea tx ?
Ceftriaxone or ciprofloxacine
160
Shigella diarrhea tx ?
Azithro or cipro or ceftri
161
Vibrio cholerae diarrhea tx ?
Doxycycline
162
Yersina enterocolitica diarrhea tx ?
TMP-SMX
163
Criteria for severe C difficile ?
- WBC ≥ 15 OR Cr 1.5 x premorbid level
- Risk factors : age > 65, immunosuppression, T > 38, albumin < 30
164
C difficile and PPI ?
Stop PPI if not needed
165
C difficile tx : benefit of fidaxomicin ?
Similar response but less recurrence after 1st episode, but expensive and not often covered
166
C difficile : tx for 1st episode non fulminant disease?
- Fidaxo 200 BID x 10 days
- Vanco 125 QID x 10d
- Metronidazole 500 TID x 10-14 d only for low risk patients
167
What is fulminant C diff ?
Sepsis, shock, ileus, perforation, toxic megacolon
168
C difficile : tx for 1st episode fulminant disease ?
Vanco 500 PO QID (vs 125 in non fulminant) + IV metronidazole 500 q8h
+/- PR vanco
+/- total colectomy
169
C difficile tx if first relapse (within 3 months of previous infection) ?
- Fidaxo 200 BID x 10d or BID x 5d then q2d x 20d
- Vanco taper + pulse
- Vanco 125 QID x 10-14d
- Metronidazole 500 TID x 10-14d
- Bezlotoxumab
170
When is fecal transplantation indicated in c difficile infection ?
If over 3 episodes
171
What are risk factors for recurrence in c difficile infection ? Name 4.
- Recurrent CDI in last 6m
- age > 65
- immunocompromised
- severe CDI on presentation
172
Which intra-abdominal collections can be managed with ATB alone ?
If 3cm or smaller, other percutaneous drainage
173
Intra abdominal infection community acquired and no previous hspitalization : initial tx ?
Ceftri or cipro PLUS metronidazole (OR amox-clav)
174
Intra abdominal infection healthcare associated or critically ill : initial tx ?
Need pseudo coverage
Piptazo, meropenem, ceftazidime OR cipro + metronidazole
175
Does empiric antifungal coverage for intra abdominal infection improve mortality ?
No
176
40 year old male with S. mitis endocarditis on a bicuspid aortic valve. Echo shows mild AI and small vegetations on both cusps. Treated with ceftriaxone. 10 days after initiating therapy he develops a cold, ischaemic pale leg. Symptoms last 6 hours then
A. Change antibiotics to vancomycin
B. CT head
C. Consult CV surgery for surgical assessment
D. IV heparin followed by warfarin
E. Continue present management
C -This is one of the indications for consideration of surgical approach (emboli despite antibiotic therapy). Know these for your exam. No indication to change antibiotics (strep universally susceptible).
177
What stage is neurosyphilis ?
Neurosyphilis can occur at any stage
Think of it if dementia !
Can be ASX !
Tx is different than late syphilis
178
When should you consider PCN allergy desensitization in syphilis ?
IF pregnancy or neurosyphilis
For other scenarios : alternative would be doxy x 14-28days or ceftri x 10 days
179
Neisseria meningitis isolation precautions ?
Droplet precautions as still febrile
180
Enterobacter cloacae for a patient intubated : how do you treat ?
- Enterobacter is a high risk SPICE/AmpC organism that may induce resistance to penicillins and cephalosporins that isn’t present at the time of initial culture results. Preferred treatment is Carbapenem or non-beta lactam (however Vancomycin does not cover gram negative organisms)
181
Which BLSE bacteries have a moderate to high risk of developping resistance ?
Enterobacter cloacae
Klebsiella Aerogenes
Citrobacter Freundii
= may be sensitive at time of culture but resistance may develop after a few days on tx
Rx : carba, TMP SMX, FQ, AG
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What is the difference between ESBL and AMPc ?
ESBL : B lactamases a spectre etendu : gène qui produit B lactamase et detruit C3G
Résistance transmissible entre bactéries
AMPc : gène qui est dormant mais si exposé s’exprime et induit une résistance
183
Reasonable IE empiric treatment ?
If unstable/septic or show high risk signs like concern for embolization : empiric after initial blood cultures taking with vanco + ceftri
184
Definition of C diff relapse ?
Within 3 months of previous infection
Infectio trololo
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