Open Wide:

Big Bolus of ID
2014 Internal Medicine
Board Review
Friday, July 18th
Jason Parham, MD, MPH
 Board AIDS and HIV infection 24
Lower respiratory tract infections 15
Question
Enteric infections 14
Breakdown CNS infections 13
Infectious Infectious arthritis 12
Disease (9%) Procedure- and device-associated infections 12
1921 Q Specific causative organisms 05
Skin and soft tissue infections 03
STD, genital tract infections 02
Endocarditis and other cardiovascular infections 02
Upper respiratory tract infections 02
Hepatic infections 02
Bacteremia/sepsis syndrome 02
Urinary tract infections 01
Osteomyelitis 01
Rheumatic fever 01
Nosocomial infections 01
Immunization 01
Prevention of infectious disease 01
Miscellaneous infectious disease disorders 01
 Antibiotic Questions
Options for treating Pseudomonas infection in a patient with a
serious PCN allergy: name 3 classes of antibiotics.
Antibiotic which can precipitate with calcium and form biliary
stones?
Class of antibiotics that can precipitate tendinitis and tendon
rupture in adults?
Name 3 antibiotics used to treat Listeria infections.
What lab do you need to monitor in patients on daptomycin?
 More Antibiotic Questions
Main side effect of metronidazole?
Most common side effect of rifampin?
What two antibiotics (in different classes) that can prolong
the QT interval?
Adverse events with linezolid?
Long-term use of this antibiotic can result in peripheral
neuropathy, hepatotoxicity and pulmonary toxicity, most
often seen in the elderly?
 Respiratory Infections
Bacterial Sinusitis
Acute Bacterial Sinusitis (ABS)
Often preceded by viral URTI
Suggests ABS
Symptoms past 7-10 d
Unilateral sinus pain/tenderness
Maxillary tooth or face pain
Purulent nasal discharge
Diagnosis: ultimately clinical and unsatisfying
Gold: culture of sinus aspirate (not often done)
Imaging for uncomplicated ABS not recommended
 Respiratory Infections
Bacterial Sinusitis
Acute Bacterial Sinusitis (ABS)
Micro: S.pneumonia, H. influenzae, M. catarrhalis
Treatment
Most will get better without abx
If treating, prefer amox-clav
Complications are rare but include meningitis, brain abscess,
osteomyelitis

HY: 1. Sounds viral/allergic/recent/stable dont give abx

2. In acute sinusitis, give abx or dont imaging isnt the answer
 Respiratory Infections
Bacterial Sinusitis
Chronic Sinusitis
Its all about obstruction use nasal
saline, topical corticosteroids,
antihistamines, decongestants
Micro
S.aureus, S. epidermidis, anaerobes
Targeting them probably doesnt help
If acute flare, treat same organisms as
ABS
CT sinuses may be helpful (polyps),
ENT should evaluate if present
 Respiratory Infections
Otitis Media
Starts with URI or allergies
Uncommon in adults
Most common symptoms: otalgia, fever
Bulging red TM (insufflation)
S. pneumonia, H. influenzae common
Amoxicillin/clavulanate, cefuroxime, azithromycin
(w/ questionable utility)
Meningitis, mastoiditis, osteomyelitis - rare
 Respiratory Infections
Pharyngitis
Usually viral (80%) in adults;
group A streptococci in kids
GABHS or Streptococcus
pyogenes (5-10%)
Sore throat, exudate, adenopathy,
fever+/-
No cough or hoarseness
Rapid antigen detection test
Most accurate: culture
Always susceptible to penicillin
(goal is to prevent rheumatic fever)

HY: 1. In adults, if rapid negative, pass on culture

2. Gram stain of throat is worthless
 Acute Rheumatic Fever
Noninfectious sequelae 2-4 weeks after
GAS infection (usually pharyngitis, not SSTI)
Most common in kids 5-15
Clinical diagnosis
80-85% have elevated ASO titers
Treatment: aspirin, eradicate GAS (pcn), treat heart
failure if present
Strong tendency to recur after reinfection with GAS,
so secondary prophylaxis to prevent (usually 10
years, or until 21, whichever is longer)
 Acute rheumatic fever: Jones criteria
GAS & 2 major or 1 major/2 minor
Major
J : Joints (migratory arthritis, usually
large joints)
: Pancarditis (50-60%) {aschoff bodies}
N: Nodules, subcutaneous (<4%)
E : Erythema marginatum (<10%)
S : Sydenham chorea (20-30%)
Minor
Fever, arthralgias, elevated
CRP/ESR, prolonged PR
 Infectious mononucleosis
Pharyngitis in adults -> consider
other possibilities
IM: primary infection with EBV
Fever, sore throat, LAD
Splenomegaly (no contact sports until
resolved)
Look for increased lymphocytes on
differential and elevated ALT, AST or LDH
If given amoxicillin diffuse, pruritic, MP
rash (not allergic rxn)
Heterophile Ab against EBV (90% +)
 Back to Respiratory Infections
Acute Bronchitis
Most common cause of acute cough in outpatients
In healthy, nonsmokers: 90% viral
Purulent sputum doesnt mean bacteria
In 50%, cough resolves by 2 weeks; 90% by 3 weeks
If cough is severe, >3 weeks: consider pertussis
No need for cultures if VS normal, chest exam normal
No chest x-ray
No antibiotics needed in healthy patients; self-limited
Symptomatic support
 Acute Exacerbation of Chronic Bronchitis

COPD associated
Can be viral or bacterial
Bacterial
Haemophilus influenzae (22%), especially smokers
Moraxella catarrhalis (9-15%)
Streptococcus pneumoniae (10-12%)
Pseudomonas and other GNR (up to 15%), prior abx use,
hospitalization, frequent flares
Bronchodilators, corticosteroids helpful
Antibiotics commonly used, not great data
 Question
An 18 year old male presents to your office with mild fever
and cough of several days duration. Negative PMH.
No h/o recent antibiotic use.
PE: O2 sat 99%, crackles left mid-lung.
CXR: infiltrate in the mid-left lung.
What is the most appropriate treatment?
a. Amoxicillin
b. Bactrim
c. Ceftriaxone
d. Doxycycline
e. Levofloxacin
 CAP Microbes/Associations
Pneumococcus: most common cause among all ages (urine Ag)
MRSA: cavitary infiltrates (w/o aspiration), sepsis, IVDU, recent
SSTI or influenza
Legionella can be epidemics, recent travel (hotel/cruise),
summer; severe CAP, GI sx, CNS sx, hyponatremia (urine Ag)
Klebsiella: alcoholics
H. flu and Moraxella more common in patients with chronic
lung disease
Pseudomonas: CF, bronchiectasis, severe COPD, chronic steroids
Adolescents and outpatients who are not that ill consider
Mycoplasma (serology, cold agglutinins) or Chlamydia
pneumoniae (serology) {resp. PCR best for both}
Anaerobic bacteria aspiration pneumonia
 CAP Microbes/Associations
Coxiella burnetti (Q fever) farm animals, parturient cats
(serology)
Viral (uncommon in adults): adenovirus, parainfluenza,
respiratory syncytial virus, and human metapneumovirus
Histoplasma bat or bird droppings
Francisella tularensis rabbits
Hantavirus - rodent poop/piss
Coccidioides, hantavirus Southwest US
Burkholderia pseudomallei Southeast Asia and China
 CAP Diagnosis in Hospitalized Patients:
2007 IDSA/ATS Guidelines
Sputum gram stain and culture (expectorated or endotracheal
aspirates) recommended for the following groups of patients:
Intensive care unit admission
Failure of outpatient antibiotic therapy
Cavitary lesions
Active alcohol abuse
Severe obstructive or structural lung disease
Positive urine antigen test for pneumococcus
Positive urine antigen test for legionella (special culture needed)
Pleural effusion

Blood cultures: low yield (5-14%) but when positive,

establishes the diagnosis
Urinary legionella and pneumococcal antigen tests
CXR
 CAP Treatment: 2007 IDSA/ATS Guidelines
Outpatient General Medical Ward ICU/Severe

If no significant risks for Beta-lactam (ceftriaxone, Beta-lactam (ceftriaxone,

DRSP*: cefotaxime, cefotaxime,
Macrolide or doxycycline ampicillin/sulbactam, ampicillin/sulbactam) plus IV
If risks for DRSP*: ertapenem) plus macrolide azithromycin or IV
Antipneumococcal (can use doxycycline if fluoroquinolone
fluoroquinolone macrolide not tolerated) If concern for Pseudomonas
OR OR (eg, presence of structural
High-dose amoxicillin (3 Antipneumococcal lung disease such as
gm/day) or high dose fluoroquinolone alone bronchiectasis):
amoxicillin/clavulanate (4 antipseudomonal agent
gm/day) plus macrolide (if (piperacillin/tazobactam,
amoxicillin is used and there is imipenem, meropenem, or
a concern for H. influenzae, cefepime) plus
use macrolide active for - antipseudomonal
lactamase producing strains) fluoroquinolone (ciprofloxacin
or high dose levofloxacin);
If concern for MRSA: add
vancomycin or linezolid

*RF for DRSP: >65, exposure to children in day care, alcoholism or other severe underlying disease, or recent antibiotics
 Community Acquired Pneumonia
A few last thoughts
Elderly
Present atypically (tachypnea best marker)
Account for 60% of pneumonia admissions
F/u CXR unnecessary except in >40, or in smokers
Smoking cessation, flu and pneumococcal vaccines are
always good answers
Will likely still have respiratory symptoms 14d out, 1/3 for
as long as 28d
 Healthcare-Associated Pneumonia
Risk Factors:
IV therapy, wound care, or IV chemo within 30 days
NH, LTAC
Recent hospitalization (last 90d) for 2+ days
Hospital or hemodialysis clinic last 30 days
Antibiotic choice depends on RF for multi-drug resistant
organisms (MDR):
No known risk factors for MDR: ceftriaxone 2 g IV daily, ampicillin-
sulbactam 3 g IV q6h or piperacillin-tazobactam 4.5 g IV q6h,
levofloxacin 750 mg IV daily, moxifloxacin 400 mg IV daily, or
ertapenem 1 g IV qd
Risk factors for MDR: cefipime 2 g IV q8h or ceftazidime 2 g IV q8h,
imipenem 500 g IV q6h, meropenem/doripenem, piperacillin-
tazobactam 4.5 g IV q6hr, or aztreonam 2 g IV q6-8hr
PLUS levofloxacin 750 mg IV qd or gentamicin 7 mg/kg IV daily
PLUS linezolid or vancomycin (if MRSA suspected)
 HAP & VAP
Pneumonia that occurs 48 hours or more after admission
and did not appear to be incubating at the time of
admission
Ventilator is the number one RF
Treatment regimens similar to health-care associated
pneumonia
Treat early and broadly, then de-escalate based on
clinical improvement and culture results
A short duration of therapy (eg, 7-8 days) is sufficient for
most patients with uncomplicated infection who have a
good clinical response
 Hospital acquired infections
Not present on admission, develop after 48h
Hand hygiene is the most important preventative measure
CAUTI (UTI in patient w/ catheter)
Pyuria not reliable
Local or systemic symptoms
D/c foley if possible, or if not possible, change if in place 2+ weeks, then get culture
Usually treat for 7 d, no more than 10-14d
Antiseptic-coated catheters, screening cultures unnecessary
CLABSI (bloodstream infection w/central line, w/o other source)
Removal of line most important (Staph aureus, Pseudomonas, Candida)
For prevention: site selection, HH, full barrier precautions, chlorhexidine
SSI (within 30d of surgery in local manipulated)
Staph aureus most common
Prevent: follow abx prophylaxis guidelines, clipping, chlorhexidine, glucose control
 Hospital acquired infections:
Multidrug-resistant organisms
Risk factors: ICU, transfer from OSH, HD, surgery,
indwelling devices, malignancy, multiple prior abx
MRSA: vancomycin (unless MIC>=2 and failing therapy)
Pneumonia : linezolid, clindamycin
Bloodstream: daptomycin
VRE: if ampicillin sensitive, use it (alt:linezolid, dapto)
ESBL: carbapenem; once susceptibilities back, may have
other options (but never pcn or cephalosporins)
 Urinary Tract Infections
Predisposing factors: stricture, stone, obstruction, tumor, foreign
body, DM
Presentation: all can have dysuria, frequency, urgency
Cystitis: SP pain, mild/absent fever
Pyelonephritis: CVA/flank tenderness, fever
Perinephric abscess: Same as pyelo but persisting despite appropriate
treatment
Diagnosis
Urinalysis
10+ WBC or +leukocyte esterase on dipstick
if above present w/ symptoms, then UTI
Urine culture
Not needed in uncomplicated cystitis
>100,000 cfu
Only image pyleo if cont. fever or flank pain after 72h of abx treatment
If perinephric abscess, aspirate to guide therapy
 Urinary Tract Infections
Treatment
Uncomplicated cystitis: empiric, 3 days (TMP-SMX, nitrofurantoin,
fosfomycin); 7 days if complicated
Pyelonephritis
14 days (TMP-SMX, AG or cephalosporin)
7 days cipro 500mg po bid
5 days levo 750mg po daily
Perinephric abscess: need culture, antibiotic pressure usually selects
for uncovered gram positive cocci
Asymptomatic bacteriuria:
Only screen and treat pregnant women and those undergoing
urologic procedures expected to cause mucosal bleeding
In all other cases, treatment increases resistance and does not
improve the outcome, including those with indwelling bladder
catheters and no signs systemic disease change catheter only
 Endocarditis Prophylaxis
2007 AHA guideline for the prevention of endocarditis made
major revisions, decreasing indications for prophylaxis.
Cardiac conditions associated with the highest risk of bad
outcome if IE (and thus worthy of prophylaxis):
Prosthetic cardiac valve or prosthetic material used for cardiac valve
repair
Previous IE
Congenital heart disease (CHD):
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first
6 months after the procedure
Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplants who develop cardiac valvulopathy
 Endocarditis Prophylaxis
Dental Procedures
Prophylaxis is reasonable for patients with high risk cardiac
conditions AND undergoing dental procedures involving
manipulation of gingival tissues/periapical region of teeth or
perforation of oral mucosa
Antibiotic regimens:
Oral:
Amoxicillin 2 grams
Clindamycin 600 mg
Cephalexin 2 grams
Clarithromycin 500 mg or azithromycin 500 mg
IV/IM (cannot take po):
Ampicillin 2 grams IM or IV
Cefazolin 1 gram IM or IV
Clindamycin 600 mg IV
 Endocarditis Prophylaxis
Respiratory Tract Procedures
Antibiotic prophylaxis is reasonable only for patients with high
risk cardiac conditions who undergo an invasive procedure of
the respiratory tract that involves incision and biopsy of the
respiratory mucosa
ABX prophylaxis is NOT recommended for bronchoscopy
unless the procedure involves incision of the respiratory tract
mucosa
ABX Regimens:
Amoxicillin 2 g PO
Ampicillin 2 g IV
Vancomycin 1 g IV (PCN allergic)
 Endocarditis Prophylaxis
GI, Biliary, and GU Procedures
Antibiotic prophylaxis is reasonable only for patients
with high risk cardiac conditions AND ongoing active
infections in the procedure area
If they meet that criteria, and arent on appropriate
coverage for their existing infection then,
ABX regimens:
Amoxicillin 2 g PO
Ampicillin 2 g IV
Vancomycin 1 g IV (PCN allergic)
 Endocarditis Prophylaxis Q&A
Patient with h/o IE undergoing root canal:
Prophylaxis or no?
What if hes allergic to penicillin?
Patient with prosthetic AV
Undergoing screening colonoscopy with expected biopsy of polyp?
Getting transbronchial biopsy of mediastinal node?
Patient with mitral valve prolapse with regurgitation getting
cystoscopy?
Given the dramatic reduction in indications for prophylaxis,
if you have to guess, no prophylaxis indicated
 Endocarditis
Presentation:
Fever & new/changed murmur
Hands/feet
Janeway lesions: flat & painless
Osler nodes: raised & painful
Splinter hemorrhages in nail beds
Retina: Roth spots
Hematuria
Emboli to kidneys
Post-infectious glomerulonephritis with immune complexes in glomeruli
Mycotic aneurysms
 Endocarditis
Diagnostic tests:
Blood cultures
Best initial test: 95-99% sensitive
If positive, then transthoracic echo
If both positive, youve got endocarditis
(but organism needs to be a typical microbe for endocarditis)

If negative transthoracic echo, then TEE

TTE and TEE equally specific (95%)
Sensitivity: TTE (60%); TEE (90-95%)
 Endocarditis
Diagnostic tests (cont.)
Normocytic anemia in 90%
Elevated ESR (& CRP)
UA with proteinuria, hematuria, red cell casts
Culture negative endocarditis
In the 1-5% with negative blood cultures, vegetation on
ECHO also needs any 3 minor criteria
Fever
Risk factor (PV, IV drug use)
Vascular phenomena (infarcts, hemorrhages, Janeway)
Immunologic phenomena (GN, Osler, Roth)
Atypical organisms
 Endocarditis Treatment
Best initial empiric if acutely ill: vancomycin
Strep Viridans group
Penicillin or ampicillin or ceftriaxone x 4 weeks
If partial resistance, pen or amp x 4 weeks,
with gentamicin added for first 2 weeks
Enterococcus
Ampicillin and gentamicin x 6 weeks
MSSA
Oxacillin or Nafcillin x 6 weeks (+/- gent for 3-5 days)
MRSA
Vancomycin x 6 weeks
HACEK (Haemophilus,Aggregatibacter/Actinobacillus,Cardiobacterium,Eikenella,Kingella)
Ceftriaxone or ampicillin/sulbactam x 4 weeks
 Endocarditis: Micro Pearls
Streptococcus gallolyticus (formerly bovis): colonoscopy, r/o CA
Q fever: parturient cats, livestock, chronic fibrosis on histopath; if
positive culture and serology for Coxiella burnetii = major criteria
Staphylococcus lugdunensis coag negative staph, NVE, bad
infection
Gram negative rods: healthcare associated >> IVDU
Bartonella: homeless, alcoholic, body lice, cats
Whipples: histopath: foamy macrophages; indolent infection
with arthralgias, CHF, murmur, emboli; no fever; diarrhea and GI
symptoms may be mild/absent
Culture negative:
prior antibiotics #1 cause (usually masking a typical strep)
also think about HACEK, Bartonella sp., Coxiella burnetii, Brucella, and
Tropheryma whipplei
 Endocarditis
Indications for surgery
Acute rupture of valve or chordae tendinae
Acute congestive heart failure
Abscess
Fungal endocarditis
AV block
Recurrent major embolic events on antimicrobials
 Endocarditis Treatment Questions
Right-sided due to MSSA (IVDU)?
Nafcillin/Oxacillin (x4w) + Gent (x2w)
Prosthetic valve due to MSSA?
Nafcillin/Oxacillin + Rifampin (x6w), + Gent (x2w)
Prosthetic valve due to MRSA?
Vanco + Rifampin (x6w), + Gent (x2w)
Central Nervous System Infections
Most likely diagnosis
All present with fever and headache
Also could see N/V, seizures
Some overlap sx, but if alone
Focal neurologic findings (abscess)
Altered mental status and confusion (encephalitis)
Neck stiffness (meningitis)
If multiple overlap sx, then you need CT or LP for
diagnosis
 Meningitis
Most commonly present with mix of fever, HA, stiff
neck, photophobia
Diagnostics
Best initial test: CSF cell count (sens: 95-98%)
Most accurate test: CSF culture (spec: ~100%)
GS: if positive, specific (sens: 60-70%);
narrow Rx accordingly
Protein: normal protein excludes meningitis
Glucose: poor sens/spec
Cell count: if very high neutrophil count, fairly specific
Bacterial antigen (latex agglutination) doesnt usually add
to treatment, so ACP advising not to order
 CSF in Meningitis
Bacterial Viral TB Cryptococcus
20-50 cm H20 < 25 18-30 >20
1000-5000 wbc 50-1000 wbc 50-300 wbc 20-500 wbc
Neutrophils Lymphocytes Lymphocytes Lymphocytes
Glu < 40 mg/dl >45 (nl-50% of < 45 < 40
(less than 18 strongly serum glu)
predictive)

Protein 100-500 < 200 (slightly 50-300 >45

mg/dl (nl 20-40 elevated)
1mg/1000 rbcs)
Gram stain (+60- Stains (add fungal, AFB (25%+) (add India ink + > 60%)
90%) VDRL, AFB, India fungal studies,VDRL, (obtain crypto Ag
Ink, HSV PCR) India Ink, etc.) CSF)
(repeat at 3 days if
suspicion remains)
 Meningitis
CT head before LP if
Papilledema
Focal neurologic deficits
Seizure or severe confusion
Immunocompromised
H/o CNS disease
If a CT is needed, answer antibiotics prior to CT
Regardless, there is always time for STAT blood
cultures before antibiotics and/or LP
 Meningitis
Etiology
Pneumococcus (GPC): common (60-70%), OM/sinusitis/pna,
immunocompromised, csf leak
Neisseria meningitidis (GN diplococcus): young, healthy,
military, college (young adult w/ petechial rash, 1000s neutrophils on CSF)
Haemophilus influenzae (GN coccobacilli): rare since vaccine
Listeria monocytogenes (GP rod): immunocompromised, >50
Staphylococcus aureus (GPC): NSG, penetrating trauma
 Meningitis Associations
Cranial nerve involvement
TB, sarcoid, Lyme disease (especially 7th: Bells palsy - also may
have foot drop), carcinomatosis
Exposures
TB prisoner, immigrant, abnormal CXR
Cryptococcus- HIV, alcoholics, chronic steroids, AIDS, ALL,
Hodgkins lymphoma
Listeria elderly, alcoholics, pregnant, immunosuppressed
Coccidioides Southwest US
Meningococcal crowded living conditions
Recurrent meningitis
Aseptic NSAIDs, Mollarets (herpes simplex), tumor
Pneumococcal CSF leak, asplenia
Meningococcal properdin & C5-9 deficiency, asplenia
 Empiric Therapy for Meningitis
Based on Age or Underlying Condition

Age 2-50 S. pneumo/N.meningitidis Vanc + third generation ceph

(cefotaxime, ceftriaxone)
Age > 50 S. pneumo/N.meningitidis/ Vanc + 3rd ceph + Amp
Listeria
Basilar skull FX S. pneumo/H. flu/ gr A strep Vanc + 3rd ceph

Post S. aureus, Coag-neg Vanc + Ceftazidime or

neurosurg/trauma staph/gram negative bacilli Cefepime or meropenem
(including pseudomonas)
CSF Shunt S. Aureus, coag-neg staph/ Vanc + Ceftazidime or
gram negative bacilli Cefepime or meropenem
(including
pseudomonas)/diptheroids
 Meningitis
Treatment
If positive gram stain (or culture) should narrow Rx
Meningococcus, Haemophilus 3rd gen cephalosporin
Pneumococcus vanco, 3rd gen cephalosporin,
dexamethasone
Listeria ampicillin or PCN G
If meningococcus
Suspected - needs droplet isolation (for 24 hours after abx)
Confirmed: close contacts
Get cipro, rifampin or ceftriaxone within 24h of ID
CC are day care, household contacts, salivary contacts, or HCW in
direct contact with oral or respiratory secretions
If random HCW, classroom/office contact, reassurance only
CSF lymphocytosis (aseptic meningitis)
Tuberculosis
Immigrant, lung lesions, very high Enteroviral
protein PCR for diagnosis
Treatment is supportive
high volume serial lp for AFB; also PCR
4 drug rx + steroids
Drug-induced
NSAIDs, IVIG, trim-sulfa
RMSF Stop the offender
Camper/hiker w/ rash moving to trunk Cryptococcus
Serology, biopsy AIDS, cd4 <50
Doxycycline India ink, Ag
Ampho, then fluconazole
Lyme
Tick bite, rash, joint pain, carditis
Serology
IV ceftriaxone/cefotaxime
 Encephalitis Associations
West Nile: flu-like symptoms followed by flaccid paralysis,
seizures
Rabies presume exposure if bat in room and patient not at
100% awareness (Sx: hydrophobia, pharyngeal spasms,
hyperactivity)
Mumps parotitis present
VZV - Grouped vesicles - (but can have without vesicles)
HSV - Temporal lobe changes on imaging studies - *clinically
most important to r/o since treatment changes mortality*
 HSV & CNS
Type I traditionally non-genital
Type II predominantly genital (see STD section)
Common infection in the general population
(Type I 80%, Type II 20% adults positive)
Acute treatment reduces duration of symptoms
Chronic treatment reduces symptomatic episodes,
asymptomatic shedding and transmission
Two neurological syndromes:
Aseptic meningitis Type II, benign but may be recurrent
Encephalitis Type I, needs IV acyclovir, high
morbidity/mortality if untreated
 HSV Infections Ophthalmologic &
Neurologic Syndromes
Dendritic keratitis usually caused by Type I, reactivation of the virus in
the trigeminal ganglion, ulcers seen on fluorescein staining, most
frequent cause of corneal blindness in US
Encephalitis usually caused by Type I
CSF with lymphocytic pleocytosis, increased number of erythrocytes, and
elevated protein
Unilateral temporal lobe lesions on imaging with associated mass effect
Diagnose with HSV PCR CSF (98% sensitive, 94-100% specific)
Treat with IV acyclovir 10 mg/kg q8h; give early if clinical picture is suspicious
for this infection; early therapy prevents mortality and limits the severity of
chronic post-encephalitic behavioral and cognitive impairments
70% mortality if untreated
Duration of therapy 14-21 days
Aseptic meningitis Type II, benign but may be recurrent (Mollarets)
VZV Infection (shingles)
Characteristic clinical presentation: rash in a
dermatomal distribution with acute neuritis
Complications in immunocompetent patients:
Post herpetic neuralgia
Bacterial skin infections
Ocular complications, including uveitis and
keratitis
Motor neuropathy
Meningitis
Ramsay Hunt Syndrome
(Bell's palsy, deafness, vertigo, and pain)
Cause of herpes zoster ophthalmicus:
Linked to VZV reactivation in the trigeminal
ganglion; sight-threatening disease
Vesicular lesions on the nose: Hutchinsons
sign: involvement of nasociliary branch of CN V:
conveys high risk of zoster opthalmicus
Cause of acute retinal necrosis (ARN)
 Varicella Zoster Virus
Treatment:
Acyclovir, valacyclovir, famciclovir (high dose)
Analgesia for acute neuritis
Prednisone role uncertain may be useful in acute
neuritis that is not controlled by opioid analgesics
Immunocompromised IV acyclovir
Varicella zoster immune globulin for high risk patients
(exposed immunocompromised or seronegative pregnant)
Herpes zoster vaccine for prevention of shingles if >60;
reduces incidence, decreases postherpetic neuralgia
 Influenza
Influenza A
Subtypes based on surface proteins (hemagglutinin, neuraminidase)
Drifts: minor mutations, local outbreaks
Shifts: major mutations, epidemics/pandemics (if human illness, efficient human
to human transfer, and little preexisting immunity)
Influenza B
Less severe outbreaks, cant differentiate clinically
Illness in winter months, most serious <2, >65, comorbidities
1-4d incubation
Symptoms: fever, HA, myalgia, nonproductive cough, sore throat, nasal d/c
Rapid test helpful if positive, doesnt exclude if negative
If influenza in community, diagnose w/ signs/symptoms only
Treat (oseltamivir, zanamivir) hospitalized, severely infected, severely at
risk; try to start in first 2 days of illness
Vaccinate all above 6 months of age
 Malignant Otitis Externa
Invasive infection of the external auditory canal and temporal bone
Elderly patients with diabetes mellitus
Pseudomonas always the responsible organism
Patients present with exquisite otalgia and otorrhea, which are not
responsive to topical measures used to treat simple external otitis;
also can have a cranial neuropathy (usually CN 7) and intracranial
complications (meningitis, brain abscess, dural sinus thrombosis)
Diagnosis: culture and sensitivity of drainage from ear, imaging
studies (CT, MRI, bone scan)
Treatment: anti-pseudomonal antimicrobial; duration 6 weeks due to
associated osteomyelitis
Surgery reserved for local debridement, removal of bony sequestrum,
or abscess drainage
Soft Tissue Infections from Cat or Dog Bites
Microbes
Pasteurella species: 50% dog wounds, 75% cat wounds
Capnocytophaga canimorsus: fastidious GNR, bacteremia and fatal sepsis,
especially in asplenic, hepatic disease
Anaerobes
Staph and strep from human skin
Wound care, antibiotics, and tetanus vaccination
Amoxicillin/clavulanate, or if severe ampicillin-sulbactam IV
Antibiotic prophylaxis X 3-5 days w/ amox-clav if :
Deep puncture wounds (especially due to cat bites)
Moderate to severe wounds with associated crush injury
Wounds in areas of underlying venous and/or lymphatic compromise
Wounds on the hand(s) or in close proximity to a bone or joint
Wounds requiring surgical repair
Wounds in immunocompromised hosts
 Human Bites
Human mouths are nasty
Microbes
Oral flora, polymicrobial
Staph, strep, Haemophilus, Eikenella,
anaerobes
Consider evaluation other potential pathogens
HIV, Hep B, Hep C, HSV
Prophylaxis for all wounds w/ amoxicillin-clavulanate
for 3-5 days
Closed-fist injuries deserve radiography, hand consult,
possibly admission
 MRSA Infections
Altered penicillin binding proteins resistant to all
beta-lactam antibiotics
Causes skin/soft tissue infections, bacteremia, and pneumonia
Hospital and community strains differ:
CA-MRSA associated with Panton-Valentine leukocidin (PVL) virulence factor
HA-MRSA strains more resistant to other antibiotics
CA-MRSA associated with crowding (prisons), athletes, hot tubs,
body shaving, etc.
CA-MRSA now dominant clone of community isolates, and
increasingly in hospital
 MRSA Outpatient Treatment
Local Drainage Most Important for Skin/Soft Tissue Infections

Drug Issues

Doxycycline 15% resistance

Trimethoprim/sulfa Not good for group A strep

Fluoroquinolone Resistance frequent HA-

MRSA
Clindamycin 15% resistance, inducible
resistance, positive D test
Linezolid High cost, marrow
suppression
 MRSA Treatment for
Pneumonia/Bacteremia
Drug Issues

Vancomycin Time tested, slow clearance of

bacteremia, MIC creep (2+)
Daptomycin Poor pulmonary activity, high
cost
Linezolid IV/PO, BMT, high cost

Tigecycline Low blood levels / not for BSI,

high cost
 Necrotizing fasciitis
Severe infection of SC soft tissues;
erythema, swelling bullae,
cutaneous gangrene (rapid).
Often LE, abdomen, perineum
Type I: polymicrobial
(anaerobes/strept/enterobacter)
Type II: group A strep
Also can see w/ CA-MRSA
RF: DM, PVD, surgery, trauma
Surgical exploration stat
Empiric antibiotics (vancomycin plus
clindamycin plus beta-lactam/bl-inhibitor
or carbapenem)
 Gas Gangrene
Clostridial myonecrosis: life-
threatening muscle infection that
develops from contiguous area of
superficial trauma
Diagnosis: severe pain at site of injury,
systemic toxicity,
swelling/crepitance/gas in the soft
tissues, large gram variable rods in
tissue
Treat with surgical debridement, PCN +
clindamycin
 Streptococcal Toxic Shock Syndrome
Group A streptococcal infection (usually SSTI), fever,
hypotension MOF
Mediated by toxins, cause release of inflammatory cytokines
capillary leak and tissue damage
Risk factors: minor trauma, liposuction, vaginal delivery or c-
section, minor and major surgeries, viral infections, NSAIDs
Complications include bacteremia (usually), ARDS, DIC, MSOF
Usually no rash or desquamation
Treat with IV fluids, penicillin, clindamycin
 Staphylococcal Toxic Shock Syndrome
Fever, sunburn rash, hypotension MOF
Associated with colonization of wound or vagina with toxin-
producing S. aureus w/o invasive disease
Not usually bacteremic
Desquamation occurs late
Most commonly associated with menstruation
Support with IV fluids, removal of source (tampon, sponge) are
most important treatments
ABX may help; vanco and clinda empiric; if cultured + for MSSA
can do naf/ox and clinda
 Vibrio vulnificus
Present w/ sepsis, hemorrhagic bullae,
necrotizing fasciitis
H/o exposure
Warm brackish/salt water, Gulf of Mexico, summer
Inoculation through skin trauma
(Can also see as septicemia after ingestion of raw
or undercooked shellfish)
RF: hemachromatosis, liver disease
Rx: Doxycycline + ceftriaxone
 Infectious Arthritis
Nongonococcal arthritis
Acute onset, monoarticular joint pain, swelling
Knee most common, then hip
Staph aureus, Strept most common
Ecoli, Pseudomonas less common
RF: age >80, DM, IVDU, endocarditis, recent joint surgery,
joint prosthesis, skin infection, RA
Fever, chills, NWB, pain w/ motion, large effusion, hot and
tender joint
Diagnosis:
Blood cultures + in <50%
Typical arthrocentesis: >50k wbc, >90% neutrophils
 Infectious Arthritis
Gonococcal arthritis
Most common < 40 yo
Women > men
Migratory polyarthralgias, tenosynovitis,
papulopustular rash, fever
Arthrocentesis
Can see >50k wbc
10% w/ positive gram stain
<50% are culture positive
Treat with ceftriaxone, include doxy or azithro to
cover chlamydia
Osteomyelitis
 Osteomyelitis
Contiguous or hematogenous
Predisposing conditions: PAD, DM, Skin ulcer with local
infection
Presents with
pain, tenderness, erythema, warmth
severe osteomyelitis can lead to sinus tract
fever and systemic signs rare (10%)
Staphylococcus aureus most common, but many others
 Osteomyelitis
Diagnostic tests
X-ray best initial
If positive no need for further imaging
2-3 weeks to see changes (periosteal elevation, destroyed bone)
MRI if X-ray negative; dont f/u MRI for resolution
Nuclear bone scan: only if MRI contraindicated (PM)
To guide therapy you need:
Most accurate: bone biopsy with culture
Positive blood cultures (10%)
Sterile metal probe to bone gives diagnosis, but biopsy for culture
needed to get organism
Treatment
Empiric therapy shouldnt be an answer
MSSA: ox/naf/cefaz
MRSA: vanco
GNR: oral FQ
Anyone out there still awake?
 Sexually Transmitted Diseases
Gonorrhea
Chlamydia
PID
Trichomonas
Genital Ulcerative Disease
Syphilis
Herpes
Chancroid
LGV
Genital Warts /HPV
 Gonorrhea
Urethritis in males; cervicitis and PID in females
GS of urethral discharge showing PMNs
with intracellular gram-negative diplococci,
but not sensitive enough to exclude, so NAAT
Treatment options:
Ceftriaxone 250 mg IM X 1
Cefixime 400 mg po X 1
Alternatives:
Spectinomycin 2 g IM X 1 (not readily available)
Azithromycin 2 g po X 1 (GI tract symptoms in 35% patients, expensive)
Pregnant:
Either of the above cephalosporins or spectinomycin or azithromycin
Note: Fluoroquinolones not recommended anymore
Always treat for Chlamydia infection as well as co-infection rates are high
Always treat partners
Disseminated Gonococcal Infection
Fever, migratory polyarthralgias, tenosynovitis, and skin lesions
(maculopapular, vesicular, or necrotic)
Asymmetric joint involvement common
If untreated, patient can later present with a monoarticular septic arthritis
Diagnosis: send specimen to be plated on Thayer-Martin media:
Arthrocentesis diagnostic procedure of choice:
Synovial fluid cultures positive in only 25-30% patients
80% patients have a positive test for gonorrhea from cervix, urethra,
rectum, blood, or pharynx
Treatment options:
Ceftriaxone 1 g IV qd
Cefotaxime 1 g IV q8
After improvement, can do Cefixime 400 mg po bid
for at least a week
 Chlamydia
Non-gonococcal urethritis (NGU)
in males; cervicitis and PID in
females
Intracellular organism
Diagnosed with NAAT
Treatment options:
Azithromycin 1 gram po X 1
Doxycycline 100 mg po bid X 7 days
Pregnant women:
Amoxicillin 500 mg po tid X 7 days
Zithromax 1 gram po X 1
Need test for cure in 3-4 weeks
Treat all partners of infected
patients
 Pelvic Inflammatory Disease
PID is considered polymicrobial, GC and CT cause most of it
Highest risk in young, sexually active females
Can be mild, have to have high index of suspicion due to
complications (FT scarring, TOA, infertility)
Consider if sexually active woman w/ low abd or pelvic pain,
plus cervical motion, uterine or adnexal tenderness
Mucopurulent cervicitis increases likelihood
Can also see fever, +GC/CT on NAAT
Rx
Parenteral: cefotetan/cefoxitin + doxycycline
Outpatient (PO + IM) ceftriaxone + doxy, +/-metronidazole
 Trichomoniasis
Intense pruritis with a malodorous, frothy, yellow
discharge
Pelvic exam demonstrates diffuse erythema of vaginal
walls and cervical inflammation (strawberry cervix)
Typically asymptomatic in men
Diagnosis made by observing motile trichomonads on wet
prep; vaginal pH > 4.5
Treatment options:
Metronidazole 2 grams po X 1
Tinidazole 2 grams po X 1
Failure: Metronidazole 500 mg po bid X 7 days
Pregnant: Clotrimazole 100 mg vaginal suppository or
cream qd for 7 days: may relieve symptoms
Treat all partners of infected patients
 Genital Ulcer Diseases
Syphilis painless ulcer
Genital herpes painful ulcer
Chancroid painful ulcer, tender nodes
Lymphogranuloma venereum painless ulcer,
tender nodes
 STD Question 1
A 26 year old sexually active male comes to the STD clinic
for routine screening. He has no complaints and physical
exam is normal. Review of the chart shows that he had a
nonreactive RPR at his last visit 8 months ago. A repeat RPR
today is reactive at 1:1024. What is your diagnosis?
A) Early latent syphilis
B) Late latent syphilis
C) Tertiary syphilis
D) False positive reaction
 STD Question 2
What is the treatment of choice for this
patient?
A) Benzathine penicillin G 2.4 million units IM in
a single dose
B) Benzathine penicillin G 2.4 million units IM in
three consecutive doses once a week for three
weeks
C) Aqueous crystalline penicillin G 4 million
units IV q4hrs for 14 days
D) Doxycycline 100 mg po bid X 14 days
 Syphilis
Primary syphilis
Painless chancre; resolves in 3-6 weeks
Regional LAD
Secondary syphilis
MP rash, condylomata lata, alopecia, mucous patch
LG fever, malaise, pharyngitis, laryngitis, LAD, anorexia,
weight loss, arthralgias, HA, meningismus
Usually 2-8 weeks after chancre
Latent syphilis
Positive serology, no symptoms
Early latent: less than a year
Late latent: > 1 year or unknown
 Syphilis
Tertiary syphilis
Can have aortitis, gummas
Neurosyphilis
CSF: wbc>5, increased protein,
low glucose, positive VDRL
Usually asymptomatic
Some signs
Tabes dorsalis wide-base gait, foot slap
Argyll Robertson pupil (small, does not react to light,
contracts normally to accommodation)

Meningovascular disease
 Syphilis serology
Non-treponemal tests (Screening test)
Relies on reactivity of serum antibodies against a cardiolipin-lecithin-
cholesterol antigen (RPR, VDRL)
Not highly specific; can have false positives
Insensitive in primary and late syphilis: check a treponemal test
Titers of 1:8 or higher are unusual for false positives
4-fold decline in titer is considered an adequate response
Treponemal tests: antibody to T. pallidum (TPPA, FTA-Abs)
Confirmatory test
May remain positive for extended periods, possibly for life, even after
adequate treatment of syphilis
A persistently reactive treponemal test does NOT indicate inadequate
treatment, relapse, or re-infection
 Syphilis Treatment
Primary, secondary, early latent (test and treat contacts):
Benzathine penicillin G 2.4 million units IM X 1
Alternative:
Doxycycline 100 mg po bid X 14 days
Tertiary (not neurosyphilis) and late latent:
Benzathine penicillin G 2.4 million units IM q week X 3 weeks
Alternative:
Doxycycline 100 mg po bid X 28 days
Neurosyphilis:
Penicillin G IV x 10-14 days
Alternative:
Ceftriaxone 2 g IV qd x 10-14 days
If pregnant + penicillin allergic: desensitize to penicillin
If neurosyphilis + penicillin allergic: desensitize to penicillin
 Genital Herpes
Caused by HSV-1 or HSV-2 infection
45 million Americans with positive HSV-2 serology
Spread by direct contact abraded skin or mucous membranes are
more susceptible than intact skin
Characterized by small, painful, grouped vesicles in the anogenital
region that rapidly ulcerate and form shallow, tender lesions:
Initial episode most severe and may present with fever, myalgias,
inguinal adenopathy, headache, and aseptic meningitis
Recurrent episodes may be proceeded by a prodromal period
associated with pain
Diagnosis by viral culture or PCR (more sensitive)
Serologic studies useful for counseling couples
Serodiscordant considerations: avoid sex during prodrome/outbreak,
condoms, daily suppressive medication
Genital Herpes
Anogenital Herpes
 Treatment of Genital Herpes
Initial episode
Acyclovir 400 mg po tid x 7-10 days
Famciclovir 250 mg po tid x 7-10 days
Valacyclovir 1 g po bid x 7-10 days
Recurrent episode
Same meds, slight changes in dosing
Most effective if initiated during the prodrome or within
one day of recurrence of vesicles
Daily suppressive therapy
If the patient is having 6 or more episodes per year, or
serodiscordant couple
Asymptomatic viral shedding can still occur on treatment
 Chancroid
Common worldwide, uncommon in U.S., usually related to sex
for drugs
Caused by Haemophilus ducreyi
Painful genital ulcers with tender suppurative inguinal
lymphadenopathy
Consider only after syphilis and HSV excluded
Diagnosis made by inguinal LN biopsy
Re-examine in one week to evaluate for ulcer improvement
Treatment options:
Zithromax 1 g po X 1
Ceftriaxone 250 mg IM X 1
Ciprofloxacin 500 mg po bid X 3 days
Erythromycin base 500 mg po tid X 7 days
Chancroid
Lymphogranuloma Venereum (LGV)
Caused by Chlamydia trachomatis serovars L1-L3
Painless ulcer at inoculation, resolves, followed by unilateral
tender inguinal lymphadenopathy which may suppurate, drain
Diagnosis made by type-specific Chlamydia serology
Treatment of choice:
Doxycycline 100 mg po bid X 21 days
Alternative treatments:
Zithromax 1g po qweek X 3 weeks
Ciprofloxacin 750 mg po bid X 3 weeks
Erythromycin base 500 mg po qid X 3 weeks
Bactrim DS bid X 3 weeks
LGV
 Genital Warts
Usually due to HPV serotypes 6 and 11 (16 and 18 associated
with cervical CA)
Perianal warts common in MSM, associated w/ CA
Usually asymptomatic
Clinical diagnosis
Treatment only if symptomatic, or cosmetic concerns
HPV vaccine recommended for 11-12 yo males x 3 doses;
protects against HPV, related CA, and likely will protect
females by reducing transmission of cervical CA causing
serotypes
 Antifungal Questions
Antifungal known to cause electrolyte disturbances, especially
hypokalemia and hypomagnesemia?
Name 3 antifungals that are active against aspergillus infection.
Name 2 antifungals that needs an acidic environment for
absorption.
What is standard of care treatment for cryptococcal meningitis?
In pregnancy?
What species of Candida is intrinsically resistant to fluconazole?
 Invasive Fungal Infections
Dimorphic fungi Opportunistic Yeasts
Histoplasma capsulatum and Molds
Blastomyces dermatitidis Candida
Coccidioides immitis Cryptococcus
Penicillium marneffei Aspergillus
Sporothrix schenckii Pneumocystis
Zygomycetes
 Sporotrichosis
Soil fungus that causes a subacute to
chronic infections (Sporothrix schenckii)
Suppurating multiple subcutaneous
nodules that progress proximally along
lymphatic channels (lymphocutaneous
sporotrichosis)
Initial reddish, necrotic, nodular papule
of cutaneous sporotrichosis generally
appears 1-10 weeks after a penetrating
skin injury: usually from a splinter, thorn,
or woody fragments of plants
Associated with: gardening,
landscaping, farming, berry-picking,
horticulture, and carpentry
Definitive diagnosis requires isolation of
the organism in a specimen culture or
visualization (cigar-shaped yeast) in a
tissue biopsy
Itraconazole is the drug of choice for
treatment, continue until 2-4 weeks after
all lesions have resolved
 Candidemia
Candida in blood is not a contaminant, its an emergency
Start empiric antifungal therapy
Echinocandin
If previous exposure to fluconazole
If institution has high % of resistant species (C. glabrata & krusei)
If severe sepsis
After speciation, change to fluconazole if possible
Cheaper
Oral fine if stable
Remove lines
Dilated ophthalmologic exam to r/o candidal endophthalmitis
Treat at least 2 weeks after clearance of blood cultures
 Mucormycosis
Rare OI (rhino-orbital-cerebral
most common, rapidly fatal)
RF: diabetes, iron overload, burn
patients, immunocompromised
state
HA, fever, visual changes, sinusitis,
& eventually proptosis
Black necrotic tissue on nose or
palate is pathognomonic
Diagnose with imaging studies,
FNA of material in sinuses with
histopathology: non-septate
hyphae with broad right angle
branching
Treat with Amphotericin B,
aggressive, surgical excision
Fungal Question 1
A 26 year old man underwent
alloBMT for relapsed Hodgkins;
complicated by GVHD. He is on
prednisone and tacrolimus.
Admitted with fever, headache,
and ataxia
MRI shows cerebellar mass and
brain biopsy shows septate
hyphae with branching at acute
angles
What is your diagnosis?
A.) Mucormycosis
B.) Cryptococcus
C.) Aspergillus
D.) Blastomycosis
Fungal Question 2
48 year old man from Chicago
went on an archaeological dig in
the caves of Costa Rica. Three
weeks later he developed fever,
chills, sweats, diarrhea, and 10
pound weight loss
Exam: T 103, + cervical and
axillary LAD, and splenomegaly
WBC 2000, Hgb 8, Plts 75K
His peripheral smear is shown.
What is your diagnosis?
A) Blastomycosis
B) Histoplasmosis
C) Coccidioidomycosis
D) Disseminated tuberculosis
 Fungal Question 3
39 year old woman from Chicago
presents with 3 weeks of fever, dry
cough, and pleurisy
CXR shows LLL infiltrate, treated
with azithromycin without relief
Over the next month, she develops
raised, painless skin lesions on her
face and cough persists
A skin biopsy is performed
What is your diagnosis?
A) Cryptococcal infection
B) Histoplasmosis
C) Blastomycosis
D) Coccidioidomycosis
Fungal Question 4
A 48 year old man with no PMHx
presents with a non-pruritic rash on
his neck and finger. He denies fevers
or other symptoms
Camped in AZ one month ago
WBC 7000 with 12% eosinophils,
CXR is clear. HIV Ab is negative
A skin biopsy is performed
What is your diagnosis?
A) Histoplasmosis
B) Coccidioidomycosis
C) Blastomycosis
D) Paracoccidioidomycosis
 Tuberculosis Skin Testing (TST)
> 5 mm
HIV positive
Persons on steroids (15mg/day)/immunosuppressive drugs
Transplant patients
Close contact of an active case
Fibrotic CXR lesions c/w prior TB
> 10 mm
Healthcare workers
Recent immigrants
IVDU
Homeless, prisoners, longterm care facilities
Some chronic health conditions
> 15 mm
No increased risk
 TB screening: IGRA vs. TST
IGRA
as sensitive but more specific
BCG vaccine or chemotherapy does not cross-react
one blood draw, no need for return, multi-step
used in place of (and not in addition to) the TST
TST
preferred in children < 5
cheaper
reaction influenced by BCG, atypical mycobacteria
Latent Tuberculosis Infection (LTBI)
Treatment
Isoniazid (INH) x 9 months
(remember to add pyridoxine [B6])
or
Rifampin x 4 months
TB Natural History
In Normal Host:
If TB infected:
5% risk of disease in first 2 years
+ 5% risk of disease throughout life
= 10% overall risk of active disease
In HIV infected:
5-10% risk/year of active disease
 Tuberculosis
Extremely rare in U.S. outside certain groups
Recent immigrants, homeless alcoholics, prisoners, HIV/AIDS, HCW,
transplant recipients, folks on dialysis or w/ silicosis, close contacts
of TB infected
Presents like other chronic lung infections
Fever, cough, sputum, weight loss, signs of consolidation on exam
Diagnostics
CXR can show apical infiltrates, cavity formation
Acid-fast stain, mycobacterial culture
Pleural biopsy in presence of effusion is single most accurate test
Direct probes are help in smear positive patients
Treatment summary:
>Start 4 drug therapy w/
isoniazid, rifampin,
pyrazinamide and
ethambutol (+B6)
>At 2 months, sensitivities
known, can usually
drop to INH and
rifampin
>Treat for 6 months total if
no cavitation
>Add steroids for TB pericarditis,
meningitis (9-12m)
>Cavitation calls for 9m total
>Pregnant? Cant take PZA,
therefore 9 m total
>SE: all hepatotoxic; also
PZA=>hyperuricemia
EMB=>optic neuritis
INH=>neurotoxicity MMWR 2003
 Nocardia vs. Actinomyces
Both are gram positive branching rods
Nocardia is acid fast (weak);
Actino is not
Nocardia: abscesses;
Actino: sulfur granules, sinus tracts
Nocardia:immunocompromised;
Actino: normal, or maybe poor dentition, IVDU
Both get lung, but Nocardia CNS;
Actino mandible
Nocardia treat with TMP-SMX;
Actino with PCN
 Tick Borne Diseases

RMSF
Lyme
Ehrlichiosis
Southern Tick Associated Rash Illness
Babesiosis
Tularemia
Relapsing Fever
Rocky Mountain Spotted Fever
Caused by Rickettsia rickettsii
Dermacentor variabilis
Ticks need to attach for 6-10 hours
Seasonal variation: spring and early summer most likely times
Incubation period ~ 7 days (3-12 days), followed by fever (94%),
headache(88%), myalgia (85%), and vomiting (60%)
2-6 days later: petechial rash (83%), cough, electrolyte abnormalities,
thrombocytopenia, elevated transaminases
Initial diagnosis clinical (+/- skin biopsy not useful after 48 hrs doxycycline);
confirmed by convalescent antibody titer at 14-21 days
Treatment: doxycycline
Death in 1-3% of those treated compared with 30% in untreated patients
(death due to ARDS, mycocarditis, ARF, encephalopathy)
 Lyme Disease
Borrelia burgdorferi transmitted by nymph of
deer tick (Ixodes sp.)
Tick has to feed for 1-2 days for transmission
Reservoir: white-footed mouse
Most common in Northeast, MN, WI
Stage I: erythema migrans (target rash) occurs
in 80% patients erythematous rash with
central clearing (bulls eye appearance),
myalgias, arthralgias, headaches,
lymphadenopathy
Stage II: early disseminated disease: neurologic
disease including meningitis and cranial nerve
palsies, myocarditis (heart block)
Stage III: late or chronic disease: arthritis (large
joints), chronic subtle neurologic manifestations
(encephalopathy, peripheral neuropathy)
 Lyme Disease Diagnosis and Treatment

Diagnosis:
Stage I: clinical based on characteristic rash and compatible
history; serology usually NEGATIVE at this time
Stage II, III: ELISA, Western blot
High false positive rate
Treatment:
Stage I, Bells palsy: amoxicillin or doxycycline for 14-21 days
Arthritis: amoxicillin or doxycycline for 28 days
Cardiac, neurological manifestations: ceftriaxone IV for 21 days
 Ehrlichiosis
Due to rickettsia-like bacteria
Two forms:
Monocytic South Central USA (HME)
Granulocytic Upper Midwest,
Northeast (HGE)
S&S: fever, HA, cytopenias,
elevated AST, +/- rash in HME
Diagnosis:
Serology, PCR
Inclusions in WBC (morula) low
sensitivity
Treatment: doxycycline
Has been called spotless RMSF
Other Zoonoses
Q Fever
Brucellosis
Leptospirosis
Malaria
Leishmaniasis
Cysticercosis
 Q Fever Coxiella burnetii
Reservoir: livestock
Exposures: aerosols from infected animals, esp. slaughter
house, after birthing; drinking contaminated birthing
products
S&S: fever, headache, myalgia, cough, N/V, abdominal pain
Clinical manifestations: granulomatous hepatitis, culture
negative endocarditis, pneumonia
Diagnosis: serology: seroconversion usually detected 7-15
days after onset of illness
Treatment: doxycycline, long duration for endocarditis:
minimum of 18 months!
 Brucellosis Brucella sp.
Brucella sp.: B. abortus (cow), B. suis (pig), B. melitensis
(goat), B. canis (dog)
Risk factor: consumption of unpasteurized dairy products,
especially Mexican goat cheese
Clinical manifestations: non-specific febrile illness; enteric
fever (fever + abdominal pain), septic arthritis, sacroiliitis,
hepatitis, splenitis, meningitis, endocarditis, orchitis,
hematologic disorders
Diagnosis: blood/marrow cultures (slow-growing); serology
Treatment: doxycycline + (rifampin or streptomycin)
 Leptospirosis Leptospira interrogans
Infects many domestic and wild animals
Human infection after exposure to environmental sources, such as animal
urine, contaminated water or soil, or infected animal tissue. Portals of
entry include cuts or abraded skin, mucous membranes or conjunctiva.
Think of if flu-like illness and environmental exposure (eco-challenge,
adventure racing, triathalon, whitewater rafting)
Usually contamination arises from infected rat and dog urine
S&S: fever, myalgias, headache, N/V, conjunctival suffusion, meningitis,
nephritis/ATN, hepatitis (high bilirubin, minimal increase in transaminases);
pneumonia
**Weils syndrome: more severe hepatitis, renal involvement
Diagnosis: clinical, serology (IgG ELISA, MAT: microscopic agglutination),
blood, urine, and CSF cultures
Treatment: PCN G, doxycycline
 Malaria
Common cause of fever in returned travelers
Presents w/ fever, chills, malaise, HA, myalgias, GI symptoms
Symptoms cyclical, due to w/ rupture of parasitized RBC (48-72h)
Signs: hemolytic anemia, splenomegaly, hypoglycemia,
thrombocytopenia, transaminitis, indirect hyperbilirubinemia,
hemoglobinuria
For P. falciparum, 1-2 weeks after infection; longer for others
Order thick and thin blood smears on all febrile travelers from
endemic areas
 Malaria
P. falciparum
widespread, drug-resistant, lethal
high parasitemia (>1%), can have >1
parasite per RBC, banana-shaped
gametocytes, paucity of mature
schizonts
P. vivax
widespread, less virulent
often see gametocytes and schizonts
P. ovale
much less common
often see gametocytes and schizonts
P. malariae
much less common
often see gametocytes and schizonts
P. vivax and ovale can relapse
(dormant liver stages/hypnozoites)
 Malaria - Treatment
P. falciparum P. vivax, ovale
Preferred Blood stage treatment
-Quinine + doxycycline Chloroquine
-Quinine + suladoxine- Eradication of the
pyrimethamine hypnozoite stage is
Alternative necessary to prevent
-Quinine + clindamycin relapses
-Mefloquine Primaquine
-Atovaquone/proguanil
 Bioterrorism Agents: Anthrax
Other forms, but pneumonic/inhalational for BT
Fever, chills, malaise, fatigue, N/V, cough, respiratory
disease, shock, and death within 24-36 hours of severe
symptoms
Inhalational mediastinal widening
Incubation period: range 2-50 days; 4-6 days if inhaled
Diagnosis: gram stain, culture, ELISA, blood, skin,
pleural fluid, CSF
Standard isolation precautions
Chemoprophylaxis: cipro 500 bid x 60d; alt: doxy,
amoxicillin
Anthrax: Cutaneous and Inhalational
Boxcar-shaped gram positive rod

Mediastinal widening
 Bioterrorism: Botulism
Clostridium botulinum
Neurotoxin of spore-forming Clostridium botulinum
Inhalational: Incubation period 12 hours to several days
Key clinical features:
cranial nerve palsies (ptosis, diplopia, dysphagia)
followed by symmetrical descending flaccid paralysis
patients are afebrile, alert, and oriented
Death usually due to respiratory failure
Standard isolation precautions
Bioterrorism: Plague Yersinia pestis
Primary pneumonic plague rare, think aerosolized, BT
Incubation 1-3 days
Fulminant pneumonia- watery, bloody sputum in previously
healthy persons
Septic shock, DIC
Diagnosis: gram stain of blood or sputum (small gram
negative coccobacillus) bipolar staining (safety-pin); DFA
at Public Health lab
Infection control: transmissible person-to-person by
respiratory droplets gown, glove, and droplet precautions
(also need eye protection if aerosols anticipated)
 Bioterrorism: Tularemia
Francisella tularensis
Humans are accidental hosts, following contact with infected
animals (especially rabbits and other rodents)
Some occupations confer risk for tularemia; they include
laboratory workers, landscapers, farmers, veterinarians,
hunters, trappers, cooks, and meat handlers.
If bioterrorism event, probably airborne delivery
Symptoms after 3-5 days or as long as 2 weeks
Fever, chills, HA, myalgias, arthralgias, diarrhea, dry cough
Can progress to pneumonia w/ pleuritic CP, hemoptysis, respiratory
failure
Not spread person to person, so no need for isolation
 Bioterrorism: Smallpox
Contact and Airborne Precautions Necessary
CDC Major Criteria
Febrile prodrome occurring 1-4 days before rash onset: fever and
at least one of the following: prostration, HA, backache, chills,
vomiting, or severe abdominal pain
Classic smallpox lesions: deep, firm/hard, round, well-
circumscribed; may be umbilicated or confluent
Lesions are in the same stage of development on any one part of
the body (i.e. face or arm)
CDC Minor Criteria
Centrifugal distribution: greatest concentration of lesions on face
and distal extremities
First lesions on oral mucosa or palate, face, forearms
Patient appears toxic
Slow evolution: lesions evolve from macules to papules to pustules
over days
Lesions on palms and soles (majority of cases)
Appearance of Smallpox Lesions

Hemorrhagic-type variola major lesions. Death

usually ensued before typical pustules developed.
 Food-borne Illness
Secondary to bacteria, viruses, parasites or ingestion of bacterial toxins
Remember to report to Department of Health
Often nausea, vomiting, diarrhea and/or abdominal pain
Timing can be helpful
1-6 hours: Staph aureus, Bacillus cereus (preformed enterotoxins)
8-16 hours: Clostridium perfringens, B. cereus
16-72 hours: Campylobacter, Salmonella, Shigella, E. coli, Yersinia, Vibrio
Associations
Rice Bacillus cereus
Potato salad, cream pastries, poultry Staph
Home-canned foods Clostridium perfringens
Honey Clostridium botulinum
Apple cider, undercooked hamburgers - STEC
 Infectious Diarrhea
Classified
Community-acquired
Healthcare-associated
Persistent (>7d)
If healthy
Bacteria/viral infection self-limited regardless of treatment
Greater than 7 days duration suggestive of parasitic infection or
noninfectious etiology
Who gets stool culture?
Yes, if diarrhea present for >72h (esp. if fever, bloody or mucoid stools)
No, if present > 1 week, or if starts more than 3d after admission
What grows?
Salmonella, Shigella, Campylobacter, (EHEC if ordered)
 Infectious Diarrhea Associations
Bloody stools (EHEC, Shigella, Salmonella, Campylobacter, Entamoeba)
Raw eggs and reptiles (Salmonella)
Recent abx or hospitalization (C diff)
Seafood/seawater (Vibrio)
Travel (ETEC, EAEC, parasites)
Cruise ship (norovirus)
Hikers (Giardia)
Freshwater (Aeromonas, Plesiomonas)
Pork chitterlings or pseudoappendicitis (Yersinia)
Puppy/kitten w/ diarrhea, chicken salad (Campylobacter)
Daycare centers (Shigella, Giardia, rotavirus, norovirus)
Guillain-Barre Syndrome (Campylobacter)
Pathogens Treatment
S. Aureus, B. Cereus None
Non-typhoid Salmonella spp. None
(Treat if severe illness, elderly, bacteremic, prosthetics, valvular
disease, atherosclerotic disease, IC, malignancy)
Shigella Oral quinolone
(Always treat, 3 days, or 7 days if IC)
Campylobacter Azithromycin X 1-3 days
(Treat only if severe illness, high fever, gross blood, elderly,
pregnant or IC)
Yersinia Oral quinolone X 3 days
(Treat only if IC, bacteremic or pseudoappendicitis syndrome)

ETEC (travelers diarrhea) Oral quinolone X 1-3 days

EHEC: Shiga toxin-producing E. coli None avoid, as can precipitate HUS
(including O157:H7)
Entamoeba histolytica Metronidazole 750 mg tid X 7-10 d
Then paromomycin 500 mg tid X 7 d
Giardia spp. Metronidazole 250-500 mg tid X 7-10 d
 Clostridium difficile infection
Most commonly presents after extended antibiotic use (any kind)
Clindamycin, FQ, cephalosporins most common offenders
Increasingly severe secondary to more virulent strain
(NAP1/BI/O27)
Signs and symptoms include
Foul-smelling, watery diarrhea w/ mucous, cramping, tenesmus, abd.
tenderness
Fever in 15%; if present, severe
Complications: toxic megacolon, perforation, sepsis
 Clostridium difficile infection
Diagnosis toxins in stool
EIA up to 30% false negative (so x3); PCR more sensitive and specific (x1)
Dont test formed stools, dont test for clearance
Treatment
Wash hands with soap and water (not ETOH)
Stop inciting antibiotics if possible
Oral metronidazole for mild-mod disease, repeat same if relapse (20%)
Severe (wbc>15, colitis on CT, low albumin, fever) =>PO vancomycin
Severe w/ MOF, ileus or toxic megacolon =>PO vanco, IV metro, surgery
consult
Have you had more than enough?

The End.