Step 2 Infectious Disease

Frank P. Noto, MD
Assistant Professor
Mount Sinai School of Medicine
Internal Medicine Clerkship Site Director

Remember, not freak out over ID.

Best of luck!!!!
It is not as bad as you think.
Remember
Think organ organism antibiotic
Notice that I keep referring to the same themes over and over again:
MSSA: nafcillin, oxacillin, dicloxacillin, cloxaillin OR 1st generation cephalosporins
(cefazolin or cephalexin)
MRSA: Vancomycin,
daptomycin, if resistant or allergic to vanco (NOT for pneumonia, check CPK)
bacteremia, endocarditis, cellulitis
linezolid, (do NOT give SSRIs, watch platelets) cellulitis, PNA
tedizolid
tigecycline (use for ESBL E coli that is resistant to imipenem, NOT cover pseudomonas)
Quinupristin/dapfopristin
Ceftaroline (5th generation) community acquired MRSA pneumonia and cellulitis
telavancin,
Dalbavancin IV one dose on day one and another does on day 8!!
Oritavancin IV one dose!! Skin infections

Mild MRSA skin infections: TMP/SMX, doxy, clindamycin

Group A strep strep throat penicillin, amoxicillin, amp (cephalexin, clindamycin,
macrolide for allergy)
Serious skin infections due to Group A Strep penicillin AND clindamycin
Enterococcus amp AND gent

Strep viridins penicillin or ceftriaxone plus gent

Gram-Positive Cocci
Penicillin G, VK, ampicillin, amoxicillin
Effective against group A streptococcus, most anaerobes (not Bacteroides),
actinomycosis, clostridium (not C. difficile), Listeria, syphilis
Not staph: need beta-lactamase inhibiters (sulbactam, clavulinic acid)!
Ampicillin is effective against E coli (resistance is rising)
Ampicillin and amoxicillin effective for enterococci and Listeria

Gram-Positive Cocci
Semisynthetic penicillinase-resistant penicillins (oxacillin, cloxacillin, dicloxacillin,
nafcillin)
Exclusive Gram-positive coverage, staph and strep
Drug of choice for MSSA, more effective than vancomycin
If you see viridans, must be endocarditis
Bone, heart, joint, skin

Gram-Positive Cocci
Cephalosporins Do not cover LAME
Listeria
Atypicals
MRSA - except ceftraoline
Enteroccus

1st Gen - cefazolin, cefdroxil, cephalexin,

2nd Gen Cephamycins : {cefoxitin, cefotetan} ONLY cephalosporin to cover
anaerobes
cefuroxime, cefprozil, cefaclor
Coverage same as semisynthetic penicillins, plus some Gram-negative
1st proteus mirabilis, klebsiella, E coli
2nd - Providencia, Haemophilus, Klebsiella, Enerobactor, Citrobacter, Morganella,
indole-positive-Proteus, Moraxella catarrhalis
Gram-Positive Cocci
Cephalosporins
If treating purely gram positive infection, use 1st generation, 2nd is too broad.
Always narrow your coverage!

Gram-Positive Cocci
.
Clindamycin
Excellent strep, staph and anaerobe coverage
Use in penicillin allergy
Use for anaerobic infections above diaphragm
Metronidazole
Use for below diaphragm infections
Use for C. difficile(use Metronidazole for the FIRST recurrence PO vancomycin taper
for 2nd (Fidaxomicin after the 3rd recurrence) PPIs can lead to recurrent c
diff
Stop PPIs in a patient with C idff
Gram-Positive Cocci
Cephalosporins
Allergic cross-reactivity
Only < 5% risk
Ok if rash
Never if anaphylaxis
If minor infection - use macrolide or new fluoroqinlones

Serious infections - aztreonam for gram negative, plus vancomycin, linezolid,

daptomycin for gram-positive
Daptomycin, linezolid, tigecycline can be used for VRE

Extended-Spectrum Beta-Lactamases (ESBL): E coli and Kleseilla

Acinetobacter baumannii
Very resistant gram negatives : First line is imipenem: but now have some resistance
Use Tigecycline for resistance to these organisms
Tigacyline covers ESBL gram-negative, not pseudomonas.
Ceftolazone/tazobactam ESBL and MDR pseudomonas, complicated UTIs and intraabdominal infections
Ceftazidime/avibactam ESBL
KPC carbapenemase (very resistant) GI and serious skin infections
Macrolides
Mild gram-positive infections
Atypical infections
Do not use for serious gram-positive infection

Invasive Aspergillus
In patients with neutropenic fevers after 5 DAYS on antibiotics with new pneumonia
Treatment:
1st line Voriconazole
Caspofungin and Amphotericin B may also be used

Neutropenic Fever
ANC less than 500
Monotherapy with an antibiotic that covers pseudomonas only

If indwelling catheter, add vancomycin for MRSA

Gram-Negative Bacilli
Penicillins (piperacillin, ticarcillin, mezlocillin)
Full range of gram-negative Enterobacteriaceae (E coli, Enterobacter, Klebiella,
Citrobacter, Morganella, Proteus, Serratia), plus pseudomonas
Add beta-lactamase inhibitor, tazobactam or clavulanate) to add activity against staph
Gram-Negative Bacilli
Fluoroquinolones
Ciprofloxacin
GOOD: gram-negative coverage, including Pseudomonas
NO: gram-positive coverage
New fluoroquinolones (levofloxacin, gemifloxacin, moxifloxacin)
Very good gram-positive coverage, gram-negative, and atypical (mycoplasma,
chlamydia, Legionella)
Gram-Negative Bacilli
3rd/4th generation Cephalosporins
Full coverage of gram-negative bacilli, such as Enterobacteriaceae (E. coli, Proteus
mirabilis, indole-positive Proteus, Klebsiella, Enterobacter, Serratia, Citrobacter),
Neisseria, and H. influenzae
Only ceftazidime and cefepime (4th gen) will cover pseudomonas
Ceftazidime is not reliable for staph/strep
PO: cifixime = gonorrhea
PO: cefpodoxime
Gram-Negative Bacilli
Aminoglycosides
Good Gram-negative coverage, including pseudomonas
Synergistic with penicillin in treatment of staph
Use for endocarditis
Nephrotoxic and ototoxic
Aztreonam
Only Gram-negative coverage, use in serious infections with severe penicillin allergy
Gram-Negative Bacilli
Carbapenems
(imipenem, meropenem, doripenem, ertapenem)
Full coverage of Enterobacteriaceae, plus Pseudomonas
Plus excellent gram-positive and anaerobic coverage
Not MRSA, Enterococcus faecium, or Stenotrophomonas maltophila

Gram-Negative Bacilli
Ertapenem
Does not cover pseudomonas
Approved for intra-abdominal and soft tissue infections
Lower seizure threshold, especially imipenem

Gram-Negative Bacilli
Doxycycline
Early lyme - rash, joint problems, facial palsy
Rikettsiea
Chlamydia
Ehrlichiosis
Trimethoprim-sulfamethoxazole
PCP
Uncomplicated cystitis

Meningitis
Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes: HIV, steroids, lymphoma, leukemia, chemo, neonates and
elderly (> 50)
Cryptococcus
Rocky Mountain Spotted fever mid-Atlantic
Tb, Lyme disease, syphilis
Viruses: entero, HIV, HSV, West Nile, St. Louis
Meningitis:
Fever, photophobia, headache, nuchal rigidity, N/V
AMS, seizures
8th cranial nerve
Petechial rash: Neisseria
CT head if: focal motor deficits, seizures, papilledema, severe AMS,
immunocompromised (HIV, transplant, immunosuppressive meds)

DO NOT delay treatment: start empiric antibiotics

Meningitis
Normal cell count is < 5
Bacterial: cell count in thousands all neutrophils
High protein and low glucose
Gram stain is positive only 50 to 70%
Cell count of several dozen to hundreds with lymphocytes: viral, Lyme, Tb, syphilis,
fungal, Rikettsia
Meningitis
Treatment
Ceftriaxone and vancomycin
Ampicillin if over 50 or 3 months old, HIV, steroids, hematologic malignancies,
pregnancy
Meningitis
Cryptococcus: amphotericin B, followed by fluconazole in HIV for life or until increase
in CD4 count to > 100 for 3 to 6 months on HAART
Cryptococcus neoformans: India ink and crypto antigen titer
Tb, treat for 9 -12 months
Meningitis
Steroids in Tb and streptococcus meningitis
Dexamethasone 15-20 minutes before or with antibiotics
Neurocysticercosis
Ingestion of Taenia solium, also called the pork tapeworm
China, Southeast Asia, India, sub-Saharan Africa, and Latin America
Prevalence of cysticercosis in Mexico is between 3.1 and 3.9 percent
CT scan: calcified and uncalcified cysts, as well as distinguishing active and inactive
cysts. Cystic lesions can show ring enhancing and focal enhancing lesions.
Albendazole

Brain Abscess
Spread from mastoiditis, dental infections, sinusitis, otitis media, bloodstream
Streptococcus: 60 to 70% (viridans streptococci, Streptococcus milleri, microaerophilic
streptococci)
Bacteriodes fragilis: 20 to 30% (high resistance to clindamycin)
Enterobacteriaceae: 25 to 35 %,

Staphylococcus 10%
Headache and fever, focal deficits in 60 %, seizures
CT scan or MRI
Aspiration or excision in essential for gram stain and culture
Brain Abscess
In HIV, 90% are toxoplamosis vs. lymphoma
Treat with pyrimethamine and sulfadiazine for 10 to 14 days
Always need surgical drainage and medical therapy
Combination with penicillin or a third generation cephalosporin and metronidazole
Third generation cephalosporin and Metronidazole (NOT clindamycin) and
vancomycin for sinusitis
Penetrating trauma or after neurosurgery
Vancomycin and a third generation cephalosporin

Encephalitis
Viral: HSV-1, varicella-zoster, CMV, enteroviruses, Eastern and Western equine, St.
Louis, West Nile
Headache and fever with AMS
Lethargy or coma, focal deficits, seizures.
Need LP: PCR for HSV has 98 % sensitivity and 95 % specificity
CT may show temporal lobe involvement.
IV acyclovir

Sinusitis
Maxillary is most common
Facial pain, headache postnasal drainage, purulent drainage, fever, tooth pain
Imaging not usually needed
CT scan if no response to therapy
90% to 98% are caused by viruses
NSAIDs and decongestants

Antibiotics if:
Symptoms last for at least 10 days
If symptoms are severe: fever over 102 and facial pain for three to four successive
days
If symptoms worsen, usually after a viral upper respiratory infection of five
Sinusitis
Haemophilus influenzae and Moraxella catarrhalis
Amoxicillin-clavulanate
Doxycycline or new fluoroquinolone

Pharyngitis
Strep pyogenes, group A beta-hemolytic strep 15 to 20%
Majority are viral
Rapid strep test is 60 to 100% sensitive, but 95% specific
If negative, should confirm with culture
Penicillin, ampicillin or amoxicillin
Macrolides, 1st generation cephalosporins, clindamycin

Influenza
Fever, myalgias, headache, fatigue, coryza, nonproductive cough, sore throat
Rapid antigen detection, swab of nasopharyngeal secretions
Symptomatic therapy
Neuraminidase inhibitors: oseltamivir and zanamivir (48 hours)
Amantadine and rimantadine effective against Influenza A NOT used much
Vaccinate Everyone!
Bronchitis
Acute bronchitis NO antbiotics!!!!
Acute inflammation of tacheobroncheal tube
Mostly viral, M. pneumonia, C. pneumoniae

Chronic bronchitis COPD exacerbation:

Streptococcus pneumonia, H. influenzae, Moraxella
Cough with sputum
May have low grade fever
Discolored suggest bacterial etiology
Bronchitis
Cough with sputum, no fever and a normal CXR

Acute exacerbations of chronic bronchitis can be treated with amoxicillin, doxycycline,

TMP/SMZ
Repeat infections should get amoxicillin/clavulinate, macrolide, 2nd or 3rd generation
cephalosporin, new fluoroquinolones

Lung Abscess
90% have anaerobes involved
Peptostreptococus, Prevotella, Fusobacterium are most common
85 to 90% have periodontal disease or aspiration
Fever, cough, sputum, chest pain
Putrid, foul-smelling sputum and a more chronic cough
Several weeks of weight loss, anemia, fatigue
Lung Abscess
CXR will show thick-wall cavity
Need aspiration of abscess for diagnosis
Clindamycin is first line
Penicillin
Most respond to antibiotics and do not need drainage

Pneumonia
Sixth leading cause of death
Risk factors: DM, ETOH, smoking, malnutrition, immunosuppression
Most common: Community-acquired pneumonia
Strep pneumonia (15-35%)
Haemophilus (2-10%)
Atypical Legionella (15%)

Mycoplasma (10%)
Chlamydia (5-10%)
Viral
Pneumonia
Haemophilus influenzae - smokers, COPD
Mycoplasma -healthy
Legionella - air conditioning
Pneumocystis jiroveci - HIV
Coxiella burnetti (Q-fever) - exposure to animals
Klebsiella - alcoholics
Staphylococcus aureus - post influenza
Coccidioidomycosis - southwest (Arizona)
Pneumonia
Chlamydia psittaci - birds
Histoplasma capsulatum - bird droppings, spelunking, bats
Bordetella pertussis - cough with whoop and post-tussive vomiting
Francisella tularensis - hunters, rabbits
Avian infuenza - Southeast Asia
Bacllus anthracis, Yersina pestis Francisella tularensis - bioterrorism
Pneumonia
Cough, fever, sputum production, dyspnea
Klebsiella - current jelly
Rales, rhonchi, dullness to percussion, egophony
RR, hypoxia leads to hyperventilation
CXR-lobar PNA S. pneumonia
Interstitial infiltrates - PCP, viral, atypical
Sputum for Gram stain and culture
Pneumonia
Treatment
Severity:
Hypoxia, PO2 < 60 (< 94%),
RR > 30
Confusion, uremia, hypotension
High fever, leukopenia, tachycardia, hyponatremia
Outpatient
empiric therapy
Macrolide or new fluoroquinolone

Pneumonia
Treatment:
Inpatient
New fluorquinolones, or
2nd or 3rd generation cephalosporins (ceftriaxone, cefuroxime) with macrolide or doxy,
or
Beta-lactam/beta-lactamase combination, with macrolide or doxy

Community-Acquired MRSA pneumonia

Think about it and cover it when you have:
Necrotizing or cavitary pneumonia
IV drug users
Severe pneumonia requiring admission to the ICU
Empyema
Gram-positive cocci in clusters on sputum Gram stain
Recent antimicrobial therapy
Recent influenza-like illness (they love this on USMLE, almost as much I love beer!!)
Community-Acquired MRSA pneumonia use ONE of the following :
Ceftriaxone and Vancomycin and azithromycin

OR Linezolid and ceftriaxone and azithromycin

OR Clindamycin and ceftriaxone and azithromycin
OR Ceftaroline (the one and only cephalosporin to cover MRSA) and azithromycin

Hospital (ventilator) -Acquired Pneumonia

After 48-72 hours in the hospital
After 5 days, you must cover MDR organisms
Pseudomonas, Klebsiella, E coli
MRSA
MUST give 2 for pseudomonas and one for MRSA 3 antibiotics total!!
Ceftazidime OR
Cefepime OR
Pipercillin/tazobactam OR
Ticarcillin/clavulinate OR
Imipenem, meropenem, doripenem OR
Aztreonam the answer when serious gram negative infection with anaphylactic
reaction to penicillin
PLUS
Cipro (or levofloxacin)
Or
Gentamycin (or any aminoglycoside) not in renal failure

PLUS
Vancomycin OR
Linezolid

Pneumonia
Pneumonia Vaccine
> 65, serious underlying lung, cardiac, liver, renal disease, steroids, HIV,
splenectomized, diabetics, hematological malignancies.
Re-dose in 5 years if severely immunocompromised

Tuberculosis
Mycobacterium tuberculosis

Tuberculosis
Active: Productive cough, fever, weight loss, night sweats
Lymph node, meningeal, GI, GU - extrapulmonary sites
CXR - apical infiltrates or cavities, effusions, calcified nodules
Sputum staining for acid-fast bacilli (need 3 negative to rule out Tb), culture takes 4-6
weeks
Tuberculosis
Treatment
Isoniazid, rifampin, pyrazinamide, ethambutol for 2 months or when sensitivity is back
Continue INH and rifampin for 4 more months
Tuberculosis
Latent Tb positive PPD or positive quantiferon gold or the interferon-gamma release
assays (IGRAs) (check this instead of PPD in patients who received the BCG)
With a negative chest X-ray
> 5 mm: close contacts, HIV, abnormal CXR consistent with old Tb, steroid use or
organ transplant recipients
> 10 mm: healthcare workers, prisoners, NH residents, immigrants (5 years), homeless,
immunocopromised (hematologic malignancies, DM, dialysis, IV drug users)
> 15 mm: low risk
Positive PPD and negative CXR: 9 months of INH
If positive CXR, collect sputum for AFB

*
Viral Hepatitis
Hepatitis A and E
Oral/fecal route
Incubation 2-6 weeks, Acute infection for days to weeks
Hepatitis B, C, D
Parental route
B and C can be chronic

Viral Hepatitis
Presentation
Acute - jaundice, dark urine, light stools, fatigue, malaise, tender enlarged liver

Hep C can cause cryoglobulinemia

Hep B associated with PAN
Hep D can only be co-infected with B
Viral Hepatitis
Diagnosis
ALT higher than AST
High bilirubin
Alkaline phosphatase and GGT less elevated
High PT in severe disease
Check pcr-RNA viral load for hep C to access activity

Hepatitis B
Surface Ag = infected
Surface Ag + IgM Core Ab = acute infection
Surface Ag + IgG Core Ab= chronic infection
Core Ab:
IgM = acute infection
IgG = 1) chronic infection (if Hep Bs Ag), or
2) recovery (if Hep Bs Ab)
Hepatitis B
Surface Ab = vaccinated
Resolution of infection = Hep Bs Ab, IgG Hep Bc Ab (exposed, recovered, and immune
- 95%)
Window period = Hep Bc IgG antibody and Hep Be antibody (2-6 weeks between the
loss of surface antigen and development of surface antibody)
Hep Be Ag = high replication rate and highly infectious

Viral Hepatitis
Treatment
Acute hepatitis - supportive care.
Chronic hep B Tenofovir (can cause fanconi syndrome) and Entecavir preferred.
interferon, adofovir, lamivudine, telbivudin (these agents have more resistance)
Cirrhosis - liver transplant
Needle stick hep B - hep B Immunoglobulin and vaccine if not immune

Chronic Hepatitis C

Antibody to hepatitis C with elevated viral load for hepatitis

C RNA by PCR
Genotype 1 and 4:
Ledipasvir-sofosbuvir or sofobuvir-simeprevir+/- ribavirin
Genotype 2 and 3:
sofosbuvir and ribavirin

Sexually Transmitted Infections (STIs)

Urethritis
Purulent discharge, dysuria, urgency, frequency
Neisseria gonorrhea
Nongonococcal
Chlamydia trahcomatis (50%)
Ureaplasma urealyticum (20%)
Mycoplasma hominis (5%)
Trichomonas (1%)
HSV (rare)
*
*

STIs: Gonorrhea
Disseminated Gonorrhea
Classic triad of dermatitis, migratory polyarthritis, and tenosynovitis
Skin findings
Small macules or hemorrhagic pustules on an erythematous base located on palms
and soles or on the trunk AND elsewhere on the extremities

STIs: Gonorrhea
Diagnosis
Blood smear shows gram-negative, coffee bean-shaped intracellular diplococci
Culture for gonorrhea
Serology for Chlamydia by swabbing urethra, or
Ligase chain reaction test of urine
STIs: Gonorrhea
Treatment
One dose of ceftriaxone IM or cefixime PO and azithromycin PO
Alternative is doxycycline for 7 days
(NOT FQ)
Fever, discharge, leukocytosis, lower abd pain
CERVICAL MOTION TENDERNESS, adnexal tenderness or uterine tenderness!!
Diagnosis
Culture on Thayer-Martin for gonococcus and Gram stain of discharge

STIs: PID
Treatment
Single dose IM ceftriaxone and oral doxycycline for 2 weeks
OR
Ofloxacin and metronidazole (both oral) for 2 weeks
Hospitalize if high WBC or fever
Treat with doxycycline and cefoxitin or cefotetan

Syphillus
Spirochetes are Gram-negative bacteria that are long, thin, helical and motile via axial
filaments (a form of flagella)
Primary infection
Chancre in 3rd week and disappears in 10-90 days, painless lymphadenopathy
Secondary infection
Cutaneous rash during 6-12 weeks - symmetric, more on flexor and volar surfaces,

condylomata lata, papaules at mucocutaneous junctions

STIs: Syphilis (Treponema Pallidum)
STIs: Syphilis
Latent
Asymptomatic, 1/3 develop tertiary
Tertiary or late
3-20 years later - gumma in any tissue
Neurological and CV manifestations (aortitis)

STIs: Syphilis
Other long-term sequelae
Argyll Robertson pupil
Small, irregular, reacts to accommodation, but not to light
Tabes dorsalis
3 to 20 years after infection
Pain, ataxia, sensory changes, loss of tendon reflex
STIs: Syphilis
Diagnosis
Screening = VDRL, RPR
More specific
FTA-ABS (Fluorescent Treponemal Antibody absorption)
MHA-TP
Darkfield of chancre
Neurosyphilis
FTA of CSF is more sensitive than a VDRL
Treatment
Primary/secondary/early latent (less than one year)
Penicillin G, IM times one
Tertiary (gummas, CV manifestations) /
Late latent (more than one year, VDRL or RPR titers elevated >1:8 without symptoms)
Penicillin G, IM once a week for 3 weeks

STIs: Syphilis
Treatment (contd)
Neurosyphilis (includes ocular syphilis)
Penicillin IV for 10 to 14 days

Doxycycline for penicillin G-allergy in primary and secondary

Pregnant or neurosyphilis must be desensitized
STIs
HSV
Vesicles become eroded and painful
Itching and soreness precede
PCR (NOT tzanck culture)
Acyclovir, valacyclovir, famciclovir
UTIs
Cystitis
Dysuria, frequency, urgency, suprapubic pain
Urinalysis for WBC, RBC, nitrites, Gram-neg infxn
Urine culture with >100,000 is confirmation, but not necessary
Trimethoprim/sulfamethoxazole, nitrofurantoin, or quinolone for 3 days
7 days if DM or complicated-stones, strictures, obstruction, pregnant, men
No quinolones in pregancy
UTIs
Pyelonephritis
Obstruction due to tumor, stricture, calculi, PBH, neurogenic bladder, or vesicoureteral
reflux
E. coli most common. Also Proteus, Klebsiella, Enterococcus.
Candida in immunocompromised or with Foley cath
Symptoms: Fever, chills, flank pain, n/v, CVA tenderness, urinary complaints
Diagnosis: urinalysis and urine cultures
Always get cultures before starting antibiotics!

UTIs
Treatment
3rd generation cephalosporin, fluoroquinolone, amp and gent
10-14 days of antibiotics
Do not use TMP/SMZ for empiric therapy due to up to 20% resistance

Skin Infections
Cellulitis
Infection involving subcutanous tissue
Localized pain, erythema, edema, warmth
Most commonly: Staph and group A Strep (GAS), Strep pyogenes
Dicloxacillin or cephalexin

If life-threatening diabetic foot infection: must cover gram negatives and anaerobes:
Use imipenem and vanco!!

If CA-MRSA think about when you see:

purulent drainage/abscess, MSM, prisoners, athletes, American Indians
Treatment:
bactrim, clindamycin, vancomycin, linezolid, ceftaroline, or doxycycline

Skin Infections
Cat bites and dog bites
Pasteurella multocida
Resistant to dicloxacillin and nafcillin
Dog and human bites
Fusobacterium, Bacteroides, Eikenella corrodens
DOGS capnocytaphia (life threatening in aspenic patients)

Augmentin (amoxicillin/clavulanate)
Oral clindamycin + fluoroquinolone
Oral clindamycin + tetracycline
Oral clindamycin + trimethoprim/sulfamethoxazole (pediatric)

Skin Infections
Necrotizing Fasciitis
Immediate Surgical debridement is most important!!
Group A strep
Penicillin G (or 1st or 2nd generation cephalosporin) plus clindamycin
Mixed aerobes and anaerobes
Vancomycin PLUS
1) piperacillin-tazobactam or
2) cefepime and metronidazole or
3) meropenem or imipenem
PLUS clindamycin (to stop group A strep toxin production)

Skin Infections
Gas Gangrene
Fever, severe pain and swelling, crepitus
Deep cuts and black tar heroine
X-ray feathery gas pattern
Clostridium perfringens
Penicillin plus clindamycin
Surgical debridement and hyperbaric oxygen

Vibrio vulnificus
Fisherman, Gulf of Mexico
Cirrhosis (HEMOCHROMOTOSIS) and poorly controlled DM

Dark bullous lesions

Wound infections leading to septicemia
3rd generation cephalosporin (ceftazidime, cefotaxine, ceftriaxone)
AND
doxycycline or ciprofloxacin
LIFE THREATENING!!!!

Bone and Skin Infections

Osteomyelitis
Presentation
Pain, erythema, edema, tenderness
X-ray (1st test)
Periosteal elevation, 50-75% of bone loss before abnormal, takes 2 weeks
ESR
Normal value strongly against OM, used to follow up treatment
Bone and Skin Infections
Osteomyelitis
Diagnosis
Bone biopsy and culture is the best test (not swabs of sinus tract or ulcer)
Never culture the draining sinus tract!!!!
CT, indium, gallium
Not as sensitive or specific
CT scan MRI
Bone scan is crapy!!
MRI allows for better differentiation between bone and soft tissue
Always get MRI if you can
Cannot get MRI if patient has metal get CT scan

Bone and Skin Infections

Osteomyelitis
Treatment
Wound drainage and debridement
IV Antibiotics for 6 weeks, get sensitivities
Chronic OM treat for 12 weeks
DM - 30% gram negative cipro (only oral abx can be used for OM)

Bone and Skin Infections

Osteomyelitis
Treatment
Empiric therapy (low yield)
1) piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid
2) Third or fourth generation cephalosporin with metronidazole
3) Clindamycin plus cipro or levofloxacin
If concern or proof of MRSA
Vancomycin, linezolid or daptomycin
Bone and Skin infections
Septic Arthritis
Nongonococcal
Gram positive (>85%)
S. aureus (60%)
Streptococcus (15%)
Pneumococcus (5%)
Gram negative (10-15%)

Septic Arthritis
Monoarticular, swollen, hot, tender, erythematous, decreased ROM
Joint aspirate
Cell count >50,000-PMN, low glucose
2000-20,000 = inflammatory
Culture positive in 90-95%
Gonococcal - Polyarticular in 50%
Tenosynovitis, effusions less common
Migratory, petechiae

Septic Arthritis
Diagnosis
Culture cervix, rectum, urethra, pharynx
Only 50% positive cultures
Therapy
Joint aspiration and antibiotics
Empiric
VANCOMYCIN and CEFTRIAXONE!!!!
Or vancomycin and anything that covers gram negatives like gentamycin

Endocarditis
Infective endocarditis
Acute
S. aureus, normal valves
Large bulky vegetations
Rapid onset with fever
Abscess and rapid valve destruction
Endocarditis
Embolic, especially lung
Subacute
Viridans most common
Abnormal valves
Risk factors:

Endocarditis
Native valves:
Streptococcus viridans 50-60 %
Endocarditis: Treatment
ID organism
Empiric: Vancomycin (or daptomycin ) and gentamicin
Strep viridans: Penicillin 4 weeks OR penicillin or ceftriaxone PLUS gentamicin
for 2 weeks
Vancomycin or ceftriaxone for pen-allergic

MSSA: Nafcillin PLUS (5 days of) gentamicin for 4-6 weeks

Cefazolin or vancomycin PLUS gentamicin for pen-allergic

MRSA: Vancomycin for 4-6 weeks

Enterococcal
Penicillin or ampicillin AND gentamicin for 4-6 weeks
Vancomycin AND genatmicin for 4-6 weeks for pen-allergic
Endocarditis: Treatment
Surgery (high yield)
CHF, recurrent septic emboli, regurgitation that affects hemodynamic functions,
vegetation larger that 10 mm
Fungal, extravalvular infection (AVB, purulent pericarditis), prosthetic valve
obstruction, recurrent infection or persistent bacteremia, abscess or fistula

Endocarditis
Prophylactics high yield
-prosthetic valves, history of IE, most congenital malformations, especially cyanotic
lesions if not repaired.
-dental procedures
NO prophylaxis:
-Urinary, GI,

-corrected pulmonary shunts, rheumatic valves, HOCM,

-MVP with regurgitation, repaired intra-cardiac defects
Endocarditis
Amoxicillin, if allergic, clindamycin, macrolide or cephalexin

Acute Pericarditis
Chest pain is sharp. Improved with sitting forward
Pericardial friction rub. Low grade fever
Tamponode: pulsus paradoxus: 10 mm Hg drop in BP with inspiration. Distended neck
veins, tachycardia, hypotension
EKG: diffuse ST elevations
PR depressions
Echo to look for effusions

Acute Pericarditis
NSIADS
Colchicine for recurrence
Pericardiocentesis and pericardial window if large effusions causing tamponade

Lyme Disease
Borrelia budorferi
Ixodes scapularis
3 -30 days: erythema migrans, fever, chills, myalgias
7th cranial nerve, facial paralysis (Bells palsy)
Meningitis, encephalitis, memory loss
AV heart block, myocarditis, pericarditis
Joint involvement months to years later- 60 %, migratory polyarthritis

Lyme disease
Serologic testing-ELISA with western blot. May be negative early in disease and can
not distinguish between old and new disease.
Minor disease treat with doxycyline or amoxicillin
Cardiac (high degree AVB and PR > 3 s) and serious neurological manifestations
(meningitis) treat with IV ceftriaxone, cefotaxime,

Ehrlichiosis
.
Vector:
American dog tick
Deer tick
Lone Star tick
Ehrlichiosis
Fevers (90 %)
Headaches (>85%)
Rigors (60%)
Nausea (40%) Vomiting (40%), Anorexia (40%)
Fatigue.
A rash is uncommon
lymphopenia, and/or thrombocytopenia
Abnormal liver enzymes are found in 86% of patients.
Ehrlichiosis
Doxycycline

Babesiosis
Babesia microti, a parasite of small rodents
Northeastern United States
Babesia divergens
Ixodes scapularis is the carrier
Fever, fatigue, headache, arthralgia, and myalgia
Nausea, vomiting
Abdominal pain
Anemia
Thrombocytopenia, splenomegaly
Babesiosis
Diagnosis
Parasite on Giemsa-stained blood smears
An indirect immunofluorescent antibody test for B microti antibody is detectable within

24 weeks after the onset of symptoms and persists for months

Diagnosis can also be made by polymerase chain reaction

Babesiosis
Treatment
Mild illness: oral atovaquone plus azithromycin for 710 days
Clindamycin plus quinine is the second choice

HIV

HIV infects subset of T lymphocytes called CD4 cells, causing a decrease in the CD4
count, increasing the risk for opportunistic infections and certain malignancies.
MSM, IV drug users, heterosexual intercourse
10 year lag between contracting HIV and the first symptoms
CD4 count drops 50-100 uL/year
Normal CD4 count is 700/mm3
HIV: Opportunistic Infections
Pneumocystis jiovecii
Trimethoprim-sulfamethoxazole (first line)
Dapsone and trimethoprim
Primaquine and clindamycin
Atovaquone
Pentamidine IV
Steroids if PaO2 < 70 or A-a gradient of > 35 mm Hg

HIV: Opportunistic Infections

Pneumocystis jiovecii
Prophylaxis (< 200)
TMP/SMZ PO
Dapsone
Atovaquone
Aerosolized pentamadine
Discontinue if CD4 over 200 for 6 months
HIV: Opportunistic Infections

Cytomegalovirus (HHV-5) (CD4 < 50)

Retinitis: blurry vision, double vision, any disturbances
Colitis: diarrhea
Esophagitis: odynophagia, fever, CP, ulcers
Encephalitis: AMS, cranial nerve defects
Fundoscopy: retinitis: yellowish-whitish granules with perivascular hemorrhages and
exudates
Biopsy-intra-nuclear inclusion bodies (owls eyes)
HIV: Opportunistic Infections
Cytomegalovirus (HHV-5) (CD4 < 50)
Valganciclovir oral and intravitreal ganciclovir
IV ganciclovir CNS infections
Cidofovir
Foscarnet
HIV: Opportunistic Infections
Cytomegalovirus (HHV-5) (CD4 < 50)
Ganciclovir - neutropenia
Cidofovir - renal toxicity
Foscarnet - renal failure

HIV: Opportunistic Infections

Mycobacterium avium complex (CD4 < 50)
Inhaled or ingested
Fevers, night sweats, wasting, anemia, diarrhea
Blood cultures
Bone marrow, liver, other body tissue cultures
Therapy: clarithromycin and ethambutol +/- rifabutin
Prophylaxis (CD4< 50): azithromycin PO weekly or clarithromycin 2 X a day
HIV: Opportunistic Infections
Toxoplasmosis (CD4 < 100)
Headache, confusion, seizures, focal deficits
CT or MRI show ring enhancing lesion with edema and mass effect
Diagnosis is the shrinkage with treatment!
Toxo serology and CSF polymerase chain reaction to T. gondii, IgG will be positive
Brain biopsy if no shrinkage in 2 weeks
HIV: Opportunistic Infections
Toxoplasmosis (CD4 < 100)
Pyrimethamine and sulfadiazine

Clindamycin and Pyrimethamine in sulfa allergies

Give with leucoveorin to prevent bone marrow suppression
Prophylaxis: TMP/SMZ or Dapsone/ Pyrimethamine
HIV: Opportunistic Infections
Crypotococcosis ( CD4 < 100)
Meningitis: fever, headache, malaise
LP with India ink and cryptococcus antigen
Serum cryptococcus antigen
High titer and high opening pressure: worse prognosis
Amphotericin B IV and flucytosine for 1014 days, then fluconazole PO for
maintenance until CD4 is above 100 for 3 to 6 months

HIV: Vaccines
Pneumococcus, influenza and hepatitis B
If CD4 is over 200 give varicella vaccine
HIV: CD4 cell count
700 or above: normal
200 to 500: oral thrush, Kaposi, Tb, Zoster, lymphoma
100 to 200: PCP, dementia, progressive multifocal leukoencephalopathy, histoplasmosis
and coccidiomycosis
< 100: toxoplasmosis, Cryptopoccus, cryptosporidiosis, disseminated herpes simplex
< 50: CMV, MAC, CNS lymphoma

HIV: Viral load

Best method to monitor adequate response the therapy on HAART: goal is undetectable
viremia
High viral load indicates that the CD4 count will drop more rapidly
Viral sensitivity testing should be done if patient is failing HAART or pregnant patient
who has not been fully suppressed on meds
HIV: Antiretroviral Therapy
Nucleoside Reverse Transcriptase Inhibitors
Zidovudine (AZT) - leukopenia, anemia, GI
Didanosine DDI - pancreatitis, peripheral neuropathy, lactic acidosis
Stavudine (D4T) - periperhal neuropathy
Lamivudine

Emtricitabine
Tenofovir - nucleotide analog
HIV: Antiretroviral Therapy
Nucleoside Reverse Transcriptase Inhibitors
Abacavir (NOT A PI, A is for AIDS) - hypersensitivity-rash, fever, N/V, sob, muscle
aches
Zalcitabine - pancreatitis, peripheral neuropathy, lactic acidosis
HIV: Antiretroviral Therapy the A is for AIDS before the vir!!!
Protease Inhibitors
Hyperlipidemia, hyperglycemia, elevated LFTs
Lipoatrophy, redistribution to neck and abdomen
Nelfinavir - GI
Indi navir - nephrolithiasis, hyperbilirubinemia
Rito navir GI
Darunavir navir
Nelfi navir
Fosamprenavir

HIV: Antiretroviral Therapy

Protease Inhibitors
Saqui navir - GI
Amprenavir
Lopi navir /Ritonavir - diarrhea
Ataza navir - diarrhea, hyperbilirubinemia
Tipranavir

HIV: HAART
Only statins safe with HAART are
Rouvastatin
Pravastatin
HIV: Antiretroviral Therapy
Non-Nucleoside Reverse Transcriptase Inhibitors
Efavirenz - neurological, somnolence, confusion, psychiatric
Nevirapine - rash, hepatotoxicity

Delavirdine - rash
Rilpivirine
HIV: Antiretroviral Therapy
When to start?
CD4 < 500
What to start?
2 nucleosides and one protease inhibitor or
2 nucleosides with efavirenz or
2 nucleosides with 2 protease inhibitors
Emtricitabine, Tenofovir, and Efavirenz
HIV: Antiretroviral Therapy
Guidelines
2 NRTIs with NNRTI or PI
Boosted PI: PI with ritonavir: alone: modest efficacy and significant drug interactions
Low dose in combination with other PIs gives the other PI a boosted PI: last
longer and increases the chances of success.
Never pick Ritonavir as the answer if it is the only PI

Raltegravir A for AIDS before vir

Integrase inhibitor
Used for resistance to reverse transcriptase inhibitors or protease inhibitors
HIV: Antiretroviral Therapy
Goal of therapy
Drop of at least 50% of viral load in the first month!

HIV: Antiretroviral Therapy

Pregnant patients:
Start triple therapy IMEDDIATLEY regardless of CD4 count
2530% will be positive without treatment
Women with low CD4 and high viral load should get triple therapy
C-section if not controlled (viral load over 1000)
Start therapy as soon as you know the patient is pregnant
Efavirenz is teratogenic
HIV

Post exposure prophylaxis

AZT, lamivudine, nelfinavir or another 3 drug regiment for 4 weeks
Neutropenic fever = pseudomonas!!!!!!
Psuedomonas:
Cover in 1)neutropenic fever
2)nosocomial and ventilator associated pneumonia
3)burns
4)cystic fibrosis
5)ONLY serious diabetic foot infections or when the patient is soaking the foot in a hot
tube!!
Not need to cover in mild diabetic foot infections!!
Ceftazidime 3rd generation
Cefepime 4th generation
Pipercillin/tazobactam
Ticarcillin/clavulinate
Imipenem, meropenem, doripenem
Aztreonam the answer when serious gram negative infection with anaphylactic
reaction to penicillin

Cipro and gentamycin DO cover pseudomonas but we prefer a Beta-lactam if we do not

have sensitives (Beta-lactams are Best )

Ceftriaxone is a 3rd generation cephalosporin (NOT COVER pseudomonas!!) it is the

answer for:
1) Community acquired pneumonia that needs be admitted WITH a macrolide or
doxycycline
2) Meningitis WITH vancomycin and maybe add ampicillin for listeria
3) Pyelonephritis
4) Septic arthritis WITH vancomycin
5) Lyme disease with AV block or meningitis
6) Spontaneous bacterial peritoneal treatment or prophylaxis in a cirrhotic with
bleeding varices
7) Gonorrhea (with azithro or doxy for chlamydia )
8) Vibrio vulnificus with doxy or cipro

9) GI infections with metro

Intraadominal infections:
1)ascending cholantitis
2)diverticlulitis
3)cholecystitis
Must cover gram negative and anaerobes (especially B fragilis)
Can use ANY of the following:
1) Cipro and metronidazole
2) Ceftriaxone or cefotaxime and metronidazole (avoid ceftriaxone in biliary disease
causes biliary sludge)
3) Amp/sulbactam
4) Ertepenem
5) Pipercillin/tazobactam
6) Moxifloxicin

B fragilis is resistant to clindamycin !!

Spontaneous bacterial peritonitis cover E coli and pneumococcus cefotaxime or
ceftriaxone
Give prophylaxis with norfloxin, cipro or TMP/SMX for life after one episode

Lower yield :

Q-fever
Coxiella burnetti
Inhalation of placenta of cattle, sheep and goats
Atypical pneumonia, hepatitis, endocarditis, hepatomegaly
Doxycycline
Rocky Mountain Spotted Fever
Rickettsia rickettsi

Wood tick in mid-Atlantic coast, Midwest

3-5 days after camping
Triad
1) Abrupt onset of fever, 2) headache and 3) rash (erythematous maculopapules) on
wrists and ankles (palms and soles)
Confusion, lethargy, irritability, stiff neck
GI symptoms
Dx: Biopsy of lesion / Rx: Doxycycline

Tetanus
Complication of wounds caused by Clostridium tetani, a Gram-positive rod
Tonic spasms of muscles, respiratory arrest, dysphagia, irritability, stiff neck and
extremities
Lock jaw
High mortality
Tetanus toxoid
Wound care, debridement
Antitoxin tetanus immunoglobulin
Rx: Penicillin 10-14 days
Blastomycosis
Rotting organic material
Southeast and central US
Inhalation of decaying wood
Immunocompetent
Pulmonary with fever, cough weight loss
Disseminates anywhere-skin most common

Blastomycosis
Isolation of fungus in sputum, pus, or biopsy
Amphotericin for severe disease
Itraconazole or ketoconazole for mild disease for 6-12 months
Toxic Shock syndrome
Staph aureus (toxin TSST-1)
Tampons, sponges, surgical wounds
Hypotension, fever, mucosal changes, desquamative rash on hands and feet.
GI, renal, hepatic symptoms
Nafcillin/oxacillin