ID final exam

what is CSF produce and secreted by?

choroid plexus of lateral ventricles

3rd/4th ventricles

meningitis

inflammation of subarachnoid space where CSF resides

what does inflammation of the brain lead to?

encephalitis

brain abscess

meningitis

risk factors

age (infants/elderly)

residing in close quarters

head trauma

CSF leaks

immunosuppressionm

meningitis microbiologic etiology

newborns

streptococcus agalactiae

listeria monocytogenes

meningitis microbiologic etiology

1-23 months

strep pneumoniae

meningitis microbiologic etiology

2-50 years

N.meningitidis

meningitis microbiologic etiology

> 50 years

S.pneumoniae

meningitis microbiologic etiology

neurosurgery penetrating head trauma, CSF shunt

s.aureus

s.epidermis

pseudomonas aeroginosa

meningitis

classical symptoms

nuchal rigidity

fever chills

positive physical signs of meningitidis

brudzinski

kernig

buldging fontanelles in infants

N.meningitidis symptoms

meningococcal rashes

meningitis diagnosis

clinical symptoms

lab tests

lumbar puncture and CSF examination

meningitis

routine lab tests

history / physical exam

blood work

• WBC → +

• C-reaction → +

• serum sodium → LOW

• blood culture → +

CSF examination

lumbar puncture

CSF gram stain -

• + in 50% of cases = DIRECT TARGETED THERAPY

CSF composition

glucose

normal: 30-70 mg/dL

bacteria meningitis: < 50mg / dl

neissera meningitidis

5 strains

A

C

W

Y

B - LESS COMMON

transmitted during close contacts

strep agalactiae (B)

comments

transmission to fetus in birth canal

listeria monocytes

comments

pregnant women population

what can occur as a secondary infection after otitis media and pneumonia?

S.pneumoniae

blood cultures drawn

empiric therapy based on blood cultures

lumbar puncture → CSF analysis and cultures

targeted therapy

how long should inpatient treatment be for meningitis?

IV antibiotics x 6 days with HIGH doses

factors that increase transfer of antibiotics from blood to CSF

inflammation of the meninges

high lipid solubility

lower degree protein binding

how can you over come CSF penetration?

intrathecal administration

bacterial meningitis empiric therapy

neonates < 1 month

ampicillin + aminoglycoside

ampicillin + cefotaxime

bacterial meningitis empiric therapy

infants/children and adults/older adults

3rd gen cephalosporin (cefotaxime OR ceftriaxone) + vancomycin

empiric therapy

penetrating head trauma

vancomycin + cefepime, ceftazidime , meropenem

strep pneumoniae

penicillin MIC < 0.1

medications

penicillin G

ampicillin

strep pneumoniae

penicillin MIC < 0.1-2.0

medications

3rd gen ceph

strep pneumoniae

penicillin MIC < 2

medications

vanco + 3rd gen ceph

neisseria meningitidis

penicillin MIC < 0.1

medications

penicillin G or ampicillin

neisseria meningitidis

penicillin MIC < 0.1-1

medications

3rd gen ceph

haemophilus influenzae

beta-lactamase -

medications

ampicillin

haemophilus influenzae

beta-lactamase +

medications

3rd gen ceph

• cefotaxime

• ceftraixone

• ceftazidime

streptococcus agalactiae (B) / listeria monocytogenes

medications

penicillin G

ampicillin

h. influenzae / neisseria meningitidis

duration of therapy

7 days

strep pneumoniae

duration of therapy

10-14 days

group b strep

duration of therapy

14-21 days

listeria monocytogenes

duration of therapy

> 21 days

gram - bacilli

duration of therapy

21 days

bacterial meningitis

eligibility criteria for outpatient therapy

inpatient 6 days

no fever at least 24-48 hrs

intake by PO

1st dose given under supervision

access to home infusion

what is adj steroid therapy used for?

significant symptoms

fulminant disease

poor prognosis

adj steroid therapy

dexamethasone

strep pneumoniae

vaccination

PPSV 23

PCV 13

neisseria meningitidis

vaccinations

group A,C,W,Y

• menveo

• menactra

group B

• bexsero

• trumemba

h.influenzae

vaccinations

actHIB

Hiberix

pentacel: infants 2-18 months

pedvax : infants 12-15 months

h.influenzae

prophylaxis

rifampin x 4 days

neisseria meningitidis

prophylaxis

rifampin x 2 days

strep agalactiae (B)

prophylaxis

prophylactic agents during labor with + vaginal screening

what temperatures do fungi grow best in?

25C-35C

pathogenic yeasts

pathophysiology

inhalation of conidia

opportunistic yeasts

pathophysiology

hematogenous dissemination

opportunistic molds

pathophysiology

ubiquitous mold resides in soil, vegetation, water, air

occurs in sev immunocompromised

dermatophytoses

yeasts requiring keratin for growth

• trichophyton

• epidermophyton

• microsporum

dermatophyte

transmission

contact

moist conditions

dermatophyte

risk factors

prolonged exposure to sweat

intertriginous folds

sharing personal belongings

close living quarters

dermatophytoses

clinical presentation

warm moist areas

ringworm

nails appear chalky, dull, brittle, crumbly

tinea manuum

location

palmar surface of hands

tinea cruris “athletes foot”

location

medial aspect of upper thigh

tinea corporis

location

entire body

RING WORMS

tinea capitis

location

scalp

mostly school aged children

tinea pedis

symptoms

white

macerated

cracked

itching

how does tinea pedis occur ?

hot weather

exposure to surface reservoirs

• locker room floors

tinea unguium (onychomycosis)

location

nails, toenails more common

tinea unguium

risk factors

increasing age

diabetes

lymphatic drainage

ill-fitting shoes

sports participation

fungus general approach

mild-mod treatment

topical therapy

fungus general approach

severe treatment

oral therapy

tinea capitis

treatment

oral treatment

tinea corporis/cruris

treatment

hydrocortisone 2.5%

tinea pedis/manuum

treatment

may require prolonged treatment

onchomycosis

removal of nail bed → topical therapy

topical therapy if infection is less than 50% of nail plate

onchomycosis

systemic therapy (1st line)

1st line : oral terbinafine

alt: itraconazole

onchomycosis

topical therapy

ciclopirox

amorolfine

systemic antifungal agents

amp b

azole fungals

echinocandins

flucytosine

amphotericin B

fungizone (AmB-D)= IV

lipid associated

• Amphotec (ABCD)

• Abelcet (ABLC)

• AmBisome (LAMB)

how can nephrotoxicity be reduced when administering Amp B?

1L normal saline

fungizone (AmB-D)

chronic toxicities

anorexia

vomiting

phlebitis

fungizone (AmB-D)

infusion-related toxicites

chills

fever

pre-medicate with ibuprofen

meperidine → reduce N/V

which AmpB is true liposomal formulation

LAMB (Ambisome)

which formulation has the highest infusion-related reactions?

amphotec

fluconazole

AE

reversible alopecia

voriconazole

AE

abnormal vision

itraconazole

AE

GI side effects

do not use for onchomycoses

ketoconazole

AE

gynecomastia

isavuconazole

AE

infusion related reactions

embryo-fetal toxicity

what dosage forms are available via IV?

echinocandins

flucytosine

clinical use

candidiasis

cryptococcosis

usually used in COMBO with amp B

candida risk factors

central venous catheters

broad specttrum antibiotics

immunosuppression

oral thrush

ICS common

AIDS

cancer

oral candidiasis

initial treatment

clotrimazole (topical)

nystatin

oral candidiasis

severe or refractory treatment

fluconazole

fluconazole refractory disease

treatment

itraconazole

voriconazole

candidemia

treatment

fluconazole for pts who are not critically ill

new drug approved for invasive candidemia and candidiasis

rezafungin

18+ yrs

what is aspergillus?

ubiquitous mold

aspergillosis

risk factors

neutropenia

organ transplants

immunosuppressed

similar to asthma

invasive pulmonary aspergillosis

treatment

voriconazole

6-12 weeks

what is cryptococcus species ?

encapsulated yeast

• c.neoformans

• c.gatti

found in pigeon droppings

CNS / Lungs

pulmonary cryptococcus

mild-mod treatment

fluconazole