Emergency Medicine Infectious Dz
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| Drug for MRSA | Vancomycin
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| Sepsis | Presence of infection plus systemic response (SIRS)
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| Severe sepsis | sepsis plus one or more sepsis related organ dysfunction
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| Septic shock | Sepsis plus hypotension (fluid unresponsive) plus tissue hypoperfusion
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| SIRS | Remote tissue inflammation, vasodilations (decreased SVR and CO), increased microvascular permeability, Leukocyte accumulation, Temp. >38 or <36, HR>90, RR>20, PaCO2>32, WBC>12,000 or <4,000 or >10% bands
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| Sepsis commonly involved bacteria | E.coli (25%), S. pneumoniae, S. aureus, multi-drug resistant gram negative bacteria (pseudomonas, acinetobacter, proteus), Group A streptococci, anaerobic bacteria, Fungi - mostly yeast, accounts for 4% of cases
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| Labs in Sepsis evaluation | CBC with differential, Chemistries: LFTs, bicarb, creatinine, PT/PTT (fibrinogen/D-dimer if coags abnl), Lactate (becoming increasingly important as marker of global tissue hypoxia)
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| Likley focus of Sepsis infections | GU, Pulmonary, intra-abdominal and skin sites, Get blood cultures, UA, Urine C &S, sputum, CXR, Pulurent discharge from skin lesions, sterile body fluids if suspected they may be site of infxn
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| Tx priorities in Sepsis | O2, Aggressive fluid replacement, vasopressors
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| How to treat infxn in Spesis | Empiric, broad spectrum abx (3rd generation ceph: ceftriaxone) possibly vancomycin. Recombinant human activated protein C (Xigris: antithrombotic, anti-inflammatory, given in ICU only, reduces M and M, $$$), Nutritional support, Euglycemia
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| Glucose goal in sepsis | between 80-110
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| Meningitis in the summer is more likely caused by | viral etiologies; b/c many are vector born and people are more likely to be outside. Bacterial associated with higher mortality
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| Most common bacterial cause of meningitis in people over age 5 | S. pneumoniae. (for people 0-2 and again in adolescents, N. meningitidis ranks high)
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| Clinical presentation of meningitis | fever, HA, photophobia, nuchal rigidity, altered mental status, seizures (25%). Classic triad: fever, stiff neck & AMS. All pts have at least one of these 3.
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| PE for meningitis | HEENT, fundoscopic exam:papilledema?(late finding), Neck ROM, Cardiopulmonary, Neurologic, Skin: purpura?
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| Pts with focal deficits in whom you suspect meningitis | increased risk of herniation with lumbar puncture
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| Lab workup in meningitis | Head CT (brain herniation risk), LP CSF, Blood cultures x2, CBC with diff. , PT/PTT, Chemistries (glu, Na, Creatinine), CRP
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| CSF findings in meningitis | Bacterial: WBC>1,000>80% Neutrophils, low glu. Viral: WBC<1,000 >50%Lymphocytes, norm glu, slightly increased protein
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| How many tubes of CSF are taken in evaluating Meningitis? | 4: Cell count, WBC with differential, gram stain and culture,Glu and protein.
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| Tx for bacterial meningitis | Begin abx stat, empiric tx: ceftriaxone or cefotaxime (2g IV) and vancomycin. Give dexamethasone (reduce swelling) before or w/ 1st dose and continue for 4 days
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| Supportive care for bacterial meningitis | hydration, pain meds, anticonvulsants, antiemetics. Treat contacts with ciprofloxacin (especially with N. meningitidis and H. influenza)
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| Cause of Meningococcemia | bacteremia secondary to meningeal infection with N. meningitidis. Usually epidemic outbreaks. Sx and signs: typical meningitis plus petechial rash (HALLMARK), hypotension, shock/sepsis.
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| Hallmark of Meningococcemia | Petechial rash. Fulminant Meningococcemia is "the most rapidly lethal form of septic shock" encountered in medicine
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| Tx of Meningococcemia | Ceftriaxone or cefotaxime; pen G and chloramphenicol as alternatives. Dexamethasone to decrease CNS swelling, admit to ICU,
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| Prevention of Meningococcemia | Prophylaxis: cipro, rifampin. Meningococcal vaccine (usually given between ages 11-17). Seen more in adolescents than peds
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| Risk factors for CAP | alcoholism, asthma, immunosuppression, age>70
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| Typical organisms causing CAP | S. pneumonia (90%), K. pneumonia, P. aeruginosa. Atypicals: M. pneumoniae, C. pneumoniae, Legionalla spp., respiratory viruses
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| Causes of Pneumonia | Aspiration (aerobic and anearobic flora) more in elderly, demented pts or intubated. ETOH abuse (Klebsiella, H. flu). Nosocomial (Pseudomonas, MRSA)
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| Clinical presentation of Pneumonia | fevers, rigors, malaise, cough, SOB, pleuritic pain, AMS, myalgias/arthralgias, GI sx (20%), increased RR, change in fremitus, rales, abnl percussion
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| Lab work up for Pneumonia | CBC, CXR, sputum gram stain and culture, Blood culutres, pulse ox, ABG, UA for Streptococcal and Legionella antigen, PCR assays, Serologies, Influenza rapid antigen
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| Worrisome signs and symptoms in Pneumonia | RR>30, Pulse>125, SBP<90, presence of comorbidities. Tx: within 6-8 hrs of arrival to ED. Oxygenation, Ventilation and Rehydration
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| PORT score used to | determine whether or not to admit a pneumonia patient. (age, nursing home status, coexisting illness, PE, Lab, radiographic findings). Note: road test before anyone goes home!
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| Which drug should not be used as a first line in pneumonia? | Levofloxacin (levaquin)
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| TB precuations: High risk patients | Elderly, nursing home, immigrants, HIV+positive patients, ETOH/drug users, Residents/staff of prisons or shelters
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| Screening Questions for TB Precautions | Hx of night sweats, weight loss, hemoptysis. Protocol for suspected TB: separate waiting area, respiratory isolation, admit for work up, followup PPDs for all contacts
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| Consider _____ when you have fever of unknown origin. | Endocarditis. Most commonly associated with heart valves.
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| ____ is the causative agent associated with acute endocarditis | S. aureus. Other causes of endocarditis: S. epidermidis, S. viridians. Negative cultures in up to 1/3 of cases
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| Cutaneous findings of endocarditis (due to circulating immune complexes) | petechiae, splinter hemorrhages, Osler nodes, Janeway lesions, Roth spots
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| Major criteria at Duke for endocarditis | positive blood cultures (x2), vegetation on echocardiogram, new valvular regurgitation. Minor criteria: fever, IVDU, vascular, immunologic
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| If you have prosthetic valves, which Echo type should you get when working up Endocarditis? | Transesophageal (TEE)
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| Endocarditis Tx | Stabilization of cardiopulmonary sx, evaluate for surgical intervention, Abx tx, admit
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| In treating Endocarditis in IVDU and pts w/ prosthetic valves, include ___ in their abx regimen | vancomycin
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| Etiologic agents of UTIs | E.coli (80% of all pts), Proteus, Klebsiella, Pseudomonas, S. saprophyticus (young women)
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| Lab evaluation for Cystitis | UA (squamous epithelial cells, Heme, LE, Nitrite, WBC, RBC, casts, bacteria, yeast, Trichomonas. Urine C&S in select pts, blood cultures is suspect urosepsis, imaging rarely indicated
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| When to culture a patient for suspected Cystitis | Children, elderly, men, pregnant women, post-menopausal women, tx failures, recurrent infxn, prior resistant organisms, NOT NECESSARY IN YOUNG HEALTHY FEMALES (E. COLI 99% OF THE TIME)
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| Duration of treatment of uncomplicated cystitis | 3-5 days. Uncomplicated infxns in children, pregnant women and complicated infxns in all pt populations 7-10 days. Abx: TMP/SMZ, Nitrofurantoin, Quinolones, Cephalexin
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| Cystitis Adjunctive Tx | Urinary Anesthetics: Pyridium, Azo. Prophylaxis for yeast vaginitis: OTC creams, fluconazole
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| Ascending infection post-UTI | Pyelonephritis
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| Pyelonephritis Tx | Cipro 500 bid x7-10 days; same drugs as UTI tx, just longer
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| When to admit a pt being treated for pyelonephritis | vomiting/uncontrolled fever, elderly (at risk for sepsis), DM, renal failure, stone, immunocompromised, pregnant, failed OP therapy
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| Mucocutaneous STDs | HSV, HPV
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| painful chancre | Chancroid (may look like syphilis, but syphilis is generally painless)
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| Etiology of Impetigo | GABHS or S. aureus (MSSA or MRSA)
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| Etiology of Pyodermas | S. aureus
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| Etiology of Erysipelas | GABS
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| Reasons to admit someone with Cellulitis | failing PO tx, rapid progression of sx, unreliable for f/u, face or hand involvement (hand has lots of tendon sheaths that cannot accomodate swelling), systemic sx
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| Etiologic agents of SSTIs | GAS, perfringens, MRSA. REMEMBER: PAIN OUT OF PROPORTION, and PAIN MOVING PAST WHERE YOU CAN SEE INFXN
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| Crepitus is a finding of | Necrotizing soft tissue infection. (from gas filling the tissue)
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| Order of severity for animal bites (worst to least) | cats, humans, dogs
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| When should bites be closed? | Fresh bites less than 24 hours old post exploration and irrigation. (close if on face, head, neck)
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| Rabies causes | fatal encephalitis
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| Joint fluid analysis in septic arthritis | WBC>50,000-60,000 (<200 nl), >50% neutrophils: infectious/inflammatory. Possible gram stain and culture positive, possible presence of crystals
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| Most common agent of Osteomyelitis | S. aureus, group A/B strep next.
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| Treatment time for Osteomyelitis | 4-6 weeks IV abx
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| ANC < ___ is a medical emergency | <500cells/mL. >100 a single agent for tx is acceptable. <100, two agents necessary
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| >6 months post transplant, etiologic agent of infection is | cryptococcus neoformans
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| Add Vancomycin in Immunocompromised Pts if | MRSA risk or line sepsis
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| Add Clindamycin in Immunocompromised pts if | anerobes suspected
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| Returning travelers are at risk of infection up to ___ after they return | 1 year
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| Most common post-travel infxn | Malaria.
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| If meningitis is suspected and an LP must be delayed to get a CT (to rule out mass lesion), what should be administered? | Immediately, you can give corticosteroids (if>1yr) and THEN abx. If the time between initiation of abx and LP is less than 2 hours, culture of CSF will not be adversely affected.
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| Prophylactic abx should be given to household contacts if the patient has which type of meningitis? | bacterial due to Neisseria meningitidis
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