Infectious Diseases PART I(1)

8/15/2019 Infectious Diseases PART I(1)

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Infectious Diseases

UTI

W.L. is a 37 years old female. She is in the pharmacy today with a new prescription for Macrobid® (Nitrofuranton macrocrystals) 100mg bid x 5 days. She saw her physician today following dysuria for the last two days and the diagnosis of acute cystitis was made. W.L. is allergic to sulfa. Her medical history shows 3 episodes of cystitis in the last 12 months with the last episode 4 weeks ago. She has moderate kidney dysfunction with CrCl of 42 ml/min. Social history shows that she is

sexually active and had an 8‐months old son who is breastfed. She is currently using spermicide‐coated condom for contraception. shows that W.L. is a smoker of ½ pack per day and a social drinker.


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UTI

All of the following are risk factors for cytitis

EXCEPT:

A) Smoking

B) Female gender

C) Use of spermicide‐containing condoms

D) Sexual activity

E) Diabetes

UTI

Generally, all of the following are risk factors for cystitis EXCEPT:

A) Smoking

B) Female gender

C) Use of spermicide‐containing condoms (change urethral environment)

D) Sexual activity (especially within 48 hours of activity. Important in younger female)

E) Diabetes Other risk factors include: Older age, diseases interfering with voiding (ex. Dementia), and use

of immunosuppressant therapy


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UTI

In addition to dysuria, which of the following

symptoms suggest cystitis?

A) Fever

B) Producing turbid urine

C) Urinary frequency

D) Vaginal itch with thick clear discharge

UTI

In addition to dysuria, which of the following

symptoms suggest cystitis?

A) Fever (for acute nonobstructive

pyelonephritis)

B) Producing turbid urine

C) Urinary frequencyD) Vaginal itch with thin clear discharge

Other symptoms include suprapubic discomfort

and urgency. Urine may have foul smell.


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UTI

Differential points:

• Cystitis: described before. Recurrent but not very frequent

• Pyelonephritis: more frequent than cystitis, flank pain, fever, nausea and vomiting. May develop to bacteremia

• Complicated: mostly men. Associated with

structural/functional changes in UTI or using catheter

UTI

The most common pathogen involved in

development of UTI include:

A) S. saprophyticus

B) K. pneumonniae

C) E. fecalis

D) P. aeruginosaE) E.coli


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UTI

The most common pathogen involved in

development of UTI include:

A) S. saprophyticus

B) K. pneumonniae

C) E. fecalis

D) P. aeruginosa

E) E.coli

UTI

All of the following are objectives of treating

cystitis EXCEPT:

A) Eradicate the causative agent to prevent

recurrence

B) Relieve symptoms of cystitis

C) Prevent complicationsD) Reduce infection spread

E) None of the above


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UTI

All of the following are objectives of treating cystitis EXCEPT:

A) Eradicate the causative agent to prevent recurrence (usually within ≈ 48 hours of starting therapy)

B) Relieve symptoms of cystitis

C) Prevent complications

D) Reduce infection spread


UTI

The pharmacist decided to call the physician to

recommend a change of the Macrobid®. The

rationale for such recommendation is:

A) Potential disulfiram‐like reaction

B) Potential interaction with contraceptive

C) Low kidney functionD) Reduced effect due to smoking

E) Breastfeeding


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UTI

The pharmacist decided to call the physician to recommend a change of the Macrobid®. The rationale for such recommendation is:

A) Potential disulfiram‐like reaction

B) Potential interaction with contraceptive

C) Low kidney function (Contraindicated in patients with CrCl


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UTI

The physician has accepted the recommendation and asked for pharmacists suggestions. All of the following antibiotics can be used in this case EXCEPT:

A) Amoxicillin (Not recommended as empiric therapy, only when susceptibility is known. Clavulanic acid may be added if other agents cannot be used )

B) Cephalexin (ALL cephalosporin are effective)

C) Trimethoprim (not a sulfa drug, no concern)

D) Ciprofloxacin

E) None of the above FIRST LINE AGENTS in general are

nitrofurantoin, SMX/TMP, and

trimethoprime. All considered safe

in breastfeeding women

UTI

The physician, as per your recommendation,

prescribed cephalexin 500mg QID. What is the

duration of therapy in this case?

A) 3 days

B) 5 days

C) 7 daysD) 10 days

E) 14 days


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UTI

The physician, as per your recommendation,

prescribed cephalexin 500mg QID. What is the

duration of therapy in this case?

A) 3 days

B) 5 days

C) 7 days

D) 10 daysE) 14 days

Nitrofurantoin = 5 days

SMX/TMP or TMP = 3 days (unless Sxs > 1

week or recurrent in


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UTI

Which of the following is NOT true about the use of fosomycin in management of UTI?

A) It is used as a single dose of 3 grams

B) Can be used in pregnant patients

C) Should be reserved for cases of moderate to severe pyleonephritis (used ONLY for uncomplicated cystitis)

D) It is as effective as nitrofurantoin

E) Lacks cross‐resistance with other agents

UTI

If the physician would like to consider

prescribing a fluroquinolone, which of the

following is the LEAST appropriate?

A) Ciprofloxacin

B) Ofloxacin

C) NorfloxacinD) Levofloxacin

E) Moxifloxacin


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UTI

If the physician would like to consider prescribing a fluroquinolone, which of the following is the LEAST appropriate?

A) Ciprofloxacin

B) Ofloxacin

C) Norfloxacin

D) Levofloxacin

E) Moxifloxacin (NOT ELIMINATED BY KIDNEY. Also,

no dose adjustment in patients with renal dysfunction)

UTI

Is W.L. candidate for prophylaxis therapy?

A) No, prophylaxis not recommended in female


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UTI

Is W.L. candidate for prophylaxis therapy?

A) No, prophylaxis not recommended in female


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UTI

Management in pregnancy:

• Preferred: amoxicillin (if susceptible, may add clavulanic acid for empiric therapy) nitrofurantoin and cephalexin. Fosfomycin if indicated

• Ceftriaxone: 1st choice as empiric pyelonephritis. Step down when susceptibility is available

• Avoid: – Nitrofurantoin: not near term (see slides)

– SMX/TMP: not in first semester (folate deficiency)

– Avoid FQ

UTI

Final tips:

• In elderly female > 65: FQ or SMX/TMP are preferred (nitrofurantoin may be less effective or more ADR)

• Aminoglycosides: 1st choice in acute pyelonephritis x 3‐4 days followed by oral therapy

• No strong evidence support the use of cranberry

• Prostatitis:

– Acute: Aminoglycosides (1st choice) +/‐ ampicillin and/or cloxacillin

– FQ x 4 – 6 weeks are 1st choice in chronic bacterial prostatitis (SMX/TMP alternative for same duration)


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CAP

CAP

S.Q. is a 62 years old white male who presents to the ER with fever, cough and headache. Cough and headache started three days ago and fever started in the last 24 hours. S.Q. appeared confused. His medical history shows type II diabetes for 20 years and CABG 2 years ago. Medical profile shows Metformin 1000mg po BID, Lantus® 10 units at bedtime, atorvastatin 10mg at bedtime, ramipril 2.5mg daily, clopidogrel 75mg daily. Clarithromycin 500mg twice daily was used 9 weeks ago for treatment of upper respiratory tract infection. Social history shows 40 years of smoking (1 pack per day). Vital signs: T: 38.7, RR: 29, pulse: 104, BP: 128/83. Lung auscultation revealed rhonchi in the left lower lobe. Lab tests showed leukocytosis (20 x 109/L), and BG level of 11mmol/L. Diagnosis of CAP was made by attending physician.


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CAP

Which of the following is the most common causative organism in patients with CAP?

A) Strep. pneumoniae

B) Staph. aureus

C) H. influenza

D) Mycoplasma pneumoniae

E) Chlamydophila pneumoniae

F) The agent depends on where the infection was acquired

CAP

Which of the following is the most common causative organism in patients with CAP?

A) Strep. Pneumoniae (most common in all sites)

B) Staph. aureus

C) H. influenza

D) Mycoplasma pneumoniae

E) Chlamydophila pneumoniaeF) The agent depends on where the infection was

acquired


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CAP

According to the Canadian Guidelines for CAP,

which of the following diagnostic procedures

should be considered under most circumstances:

A) Sputum culture

B) Blood coluture

C) Chest X‐Ray

D) Oxygenation status

E) All of the above

CAP

According to the Canadian Guidelines for CAP,

which of the following diagnostic procedures

should be considered under most circumstances:

A) Sputum culture

B) Blood coluture

C) Chest X‐Ray

D) Oxygenation status

E) All of the above

Unless poor outcome is

suspected, laboratory tests

are not routinely required


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CAP

Which of the following disease severity scores is

used to predict the mortality in patients with CAP

A) PSI

B) CURB‐65

C) SMART‐CO

D) A & B

E) All of the above

F) None of the above

CAP

Which of the following disease severity scores is used to predict the mortality in patients with CAP

A) PSI (Pneumonia‐specific severity of illness. Predicts 30‐day mortality and need for hospitalization (score > 90 ) or treat at home (score ≤ 90) Use if SMART Co


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CAP

All of the following are risk factors for CAP EXCEPT:

A) Smoking

B) Male gender

C) Patients with cardiac diseases

D) Patients with lung diseases

E) Alcoholics

F) Patients on immunosuppressant

CAP

All of the following are risk factors for CAP EXCEPT:

A) Smoking

B) Male gender

C) Patients with cardiac diseases

D) Patients with lung diseases

E) Alcoholics

F) Patients on immunosuppressant


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CAP

Objectives of therapy:

Provide proper treatment based on PSI

Eradicate bacteria

Relief symptoms

Identify, prevent or treat complications

CAP

The physician decided to treat S.Q. as

outpatient. Which of the following antibiotics

would be the first choice?

A) Azithromycin

B) Doxycycline

C) LevofloxacinD) Amoxicillin/clavulanate

E) All of the above are suitable


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CAP

The physician decided to treat S.Q. as outpatient. Which of the following antibiotics would be the first choice?

A) Azithromycin

B) Doxycycline

C) Clarithromycin

D) Erythromycin

E) Levofloxacin (or moxifloxacin) F) All of the above are suitable

If NOT at risk of

resistance (see next slide)

If NOT at risk of

resistance (see next slide)

CAP

Drug resistant S. pneumoniae is suspected in the following patients:

Patients with comorbidities

Had an antibiotic in the last 3 months

Immunosuppression (drugs or diseases)

Age of 65 years

Alcoholics

Attend day care


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CAP

Rationale for previous answer:

Risk of ↑resistance: Antibiotic in last 3 months, Age 65, attend day care, or comorbidities (DM, chronic cardio/pulmonary conditions , HIV, taking immunosuppressant and alcoholics)

Alternative to FQ

High dose amoxicillin

Amoxi‐Clav + macrolide

Use an antibiotic

different than

the

one

used in the last 3 months

Use an antibiotic

different than

the

one

used in the last 3 months

CAP

Which of the following vaccine should be reviewed with S.Q.?

A. Flu vaccine

B. Pneumococcal vaccine

C. H. influenza type B vaccine

D. Meningococcal vaccine

E. Tetanus vaccineF. A & B

G. All of the above


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CAP

Which of the following vaccine should be reviewed with S.Q.?

A. Flu vaccine (Annually)

B. Pneumococcal vaccine (Q5Y. Prevent sepsis, meningitis, bacteraemic pneumonia, pleural empyema and bacteraemia)

C. H. influenza type B vaccine (NOT required for SQ. Prevents otitis media, sinusitis, bronchitis and other respiratory tract disorders)

D. Meningococcal vaccine (prevents meningitis)

E. Tetanus vaccine (Q 10 years)

F. A & BG. All of the above

CAP

All of the following factors should be considered when assessing the need for ICU admission EXCEPT:

A. SBP

B. Fever

C. Chest X ray showing multiple lobes affected

D. Confusion

E. Respiratory rate F. O2 saturation

G. Tachycardia


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CAP

All of the following are anti‐pseudomonal beta

lactams EXCEPT

A. Cefepime

B. Piperacillin/tazobactam

C. Meropenem

D. Imiprenem

E. None of the above

ALSO: azetreonam,

ceftazidime and piperacillin.

IN CAP: They are used IV to

treat ICU patients with

suspected P.aeruginoa

+ EITHER:

IV Aminoglycosides + IV

Ciprofloxacin OR IV

macrolides

IV Ciprofloxacin

ALSO: azetreonam,

ceftazidime and piperacillin.

IN CAP: They are used IV to

treat ICU patients with

suspected P.aeruginoa

+ EITHER:

IV Aminoglycosides + IV

Ciprofloxacin OR IV

macrolides

IV Ciprofloxacin

CAP

When MRSA is the suspected organism in CAP,

all of the following antibiotics can be effective

EXCEPT:

A. Tigecycline

B. Vancomycin

C. DaptomycinD. Linezolid



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CAP

When MRSA is the suspected organism in CAP,

all of the following antibiotics can be effective

EXCEPT:

A. Tigecycline (effective, but no clear role)

B. Vancomycin

C. Daptomycin (inactivated by lung surfactants)

D. LinezolidE. None of the above

CAP

When should the patient step down to oral

therapy?

• Improved cough and SOB

• Leukocytes is within normal range

• Able to take oral antibiotic and no concerns

regarding drug absorption• Temp


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CAP

When should SQ be discharged?

• No complications (drug, disease, and

comorbidities)

• RR ≤ 24

• HR


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Vaginal Symptoms

A 29 year old female is in the pharmacy to buy

some Canesten® (clotrimazole cream) for vaginal

use. The pharmacist asked her several questions

to assess her condition to confirm the diagnosis

and if self ‐therapy is recommended

Vaginal Symptoms

All of the following symptoms suggest vaginal candidiasis EXCEPT:

I. Odorous discharge

II. Itch

III. White curdy discharge

A) I only

B) III only

C) I and II

D) II and III

E) I, II, and III


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Vaginal Symptoms

All of the following symptoms suggest vaginal

candidiasis EXCEPT:

I. Odorous discharge (bacteria infection (fishy) and

trichomonas)

II. Itch (candida and trichomonas)

III. White curdy discharge (white – yellow and frothy

in trichomonas and yellow‐ grey in bacterial

infection)

pH is normal in candida ( 4.5) in trichomonas and bacterial infection. Inflammation

is also present in candida and trichomonas but not

bacterial

Vaginal Symptoms

To assess the need for referral, the pharmacist

may ask all of the following questions EXCEPT:

A) Is this your first time to have these symptoms?

B) Are you pregnant?

C) Do you have any fever or pelvic pain?

D) When the last time you go these symptoms?

E) Are you sexually active?

F) None of the above


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Vaginal Symptoms

To assess the need for referral, the pharmacist may ask all of the following questions EXCEPT:A) Is this your first time to have these symptoms?

B) Are you pregnant?

C) Do you have any fever or pelvic pain?

D) When the last time you go these symptoms? (refer is


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Vaginal Symptoms

What is the main source of candida in the body?

I. Mouth

II. Skin

III. Vagina

A) I only

B) III only

C) I & II only

D) II & III onlyE) I, II and III

Vaginal Symptoms

All of the following non drug measures should help vaginal candidiasis EXCEPT:A. Reduce sugar intake

B. Eat unsweetened yogurt.

C. Wear cotton underwear.

D. Avoid pantyhose or tights every day.

E. After using the toilette, wipe from front to back

F. Change wet or damp clothes as soon as possible.

G. Use feminine hygiene sprays

H. None of the a


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Vaginal Symptoms

All of the following non drug measures should help vaginal candidiasis EXCEPT:A. Reduce sugar intake

B. Eat unsweetened yogurt.

C. Wear cotton underwear.

D. Avoid pantyhose or tights every day.

E. After using the toilette, wipe from front to back

F. Change wet or damp clothes as soon as possible.

G. feminine hygiene sprays (avoid irritants: douche, deodorants, tampons, perfumed toilet paper, bubble bath)

H. None of the above.

Vaginal Symptoms

NOTES on management of vaginal candidiasis: Topical azoles antifungal are the 1st choice (safe in pregnancy

and breastfeeding. A longer duration of 7 – 14 weeks is required for pregnancy)

Topical treatment is as effective as oral therapy

Duration of azole therapy depends on preference and experience

Use anfungal agents at bedme (retenon and ↓ leak)

Avoid intercourse during treatment

Treatment ↓ the eff ect of spermicides and barriers for duration + 3 days after

Cream can be applied vaginally + externally for itch


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Vaginal Symptoms

NOTES on management of vaginal candidiasis: Continue treatment if menses starts

Boric acid vaginally 300‐600mg daily x 14 days then daily x 5 days/month x 6 months is 90% effective (2nd choice. NOT in pregnancy)

If no improvement x 1 week refer to physician

Single dose of fluconazole 150mg is available OTC (not for pregnant or breastfeeding). Can be used to prevent antibiotic‐induced candidiasis (once weekly for duration)

Probiotics do not appear effective

Skin Infections


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Skin Infections

• Head lice

• Athletic foot

• Fungal Nail infections

• Diabetic foot infection

• Bacterial skin infection

• Rosacea

Head Lice

• Permethrin 1% cream rinse: 1st choice ≈ 100% efficacy. (apply x 10 minutes to towel‐dried hair) . High ovicidaleffect. Residual activity x 2 weeks. Second treatment in 7 days. If treatment fails use a different class. Used for as young as 2 months of age.

• Pyrethrins + Piperonyl butoxide: Apply to dry hair x 10 minutes. Not for ragweed allergy. Low ovicidal, and no residual effec. Repeat in 7‐10 days

• Lindane: apply to dry hair x 4 minutes. Repeat in 7 – 10 days. Contraindicated in seizures (neurotoxicity). Use with caution in children


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Head Lice

• Isopropyl myristate: Apply to dry hair x 10 minutes then rinse rep. in 7 days. Dissolve wax. Used for children > 2 years of age. Itch may continue after treatment. Protect the eye . After rinsing, patient can wash his hair.

• Removing nits: soak in 3% ‐ 5% white vinegar for 30 – 60 minutes OR use commercial formic acid rinse.

• Treatment failure: Review proper use of the drug.

If appropriate use was demonstrated, recommend an agent from a different class.

Head Lice

• Resistant cases (topical therapy fails) : permethrin 5% overnight covered in shower cap , oral ivermectin, of SMX/TMP BID x 10 days + permethrin application on day 1and 7

• Pregnancy: permethrin and pyrethrine+Piperonyl butoxide appear to be safe in pregnancy and lactation (lindane and ispropyl

myristate have no data)

• Tee tree oil was used but associated with prepubertal gynecomastia in boys.


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Head Lice

• Non drug measures: vacuum furniture, wash

cloth and bedlinning in hot water for 15

minutes or store in a plastic bag for 2 weeks.

Combs should be washed with hot water for

15 minutes or washed with anti‐lice shampoo.

Athlete’s Foot

Symptoms of the athlete’s foot include all of the following EXCEPT:

A. Interdigital macerated fissures with odor

B. Tenderness and inflammationof the immediate area surrounding the toenail

C. Inflammation and diffuse scaling on the sole

D. Vesicle near the instep and on the plantar surface

E. Weeping lesions on the sole of the foot


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Athlete’s Foot

Symptoms of the athlete’s foot include all of the following EXCEPT:

A. Interdigital macerated fissures with odor

B. Tenderness and inflammationof the immediate area surrounding the toenail

C. Inflammation and diffuse scaling on the sole

D. Vesicle near the instep and on the plantar surface

E. Weeping lesions on the sole of the foot

Athlete’s Foot

All of the following are reasons to refer a patient

with athlete’s foot to physician EXCEPT

A. Patient appears malnourished

B. A 10 years old child

C. Patient has a discolored toenail

D. The interdigital lesions as painfulE. Patient describes instep pain


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Athlete’s Foot

All of the following are reasons to refer a patient

with athlete’s foot to physician EXCEPT

A. Patient appears malnourished

B. A 10 years old child

C. Patient has a discolored toenail

D. The interdigital lesions as painful

E. Patient describes instep painDM, immunocompromised, cancer, elderly, severely inflamed

lesions with oozing purulent material are criteria for referral

Athlete’s Foot

All of the following non drug measures can help patients with athlete’s foot EXCEPT:

A. Wash feet daily in lukewarm water using a fragrance‐free mild soap and rinse well

B. Do not soak feet for more than 10 minutes.

C. Use a clean soft towel to dry feet carefully particularly between toes

D. Use a absorbent bath mat

E. Wear socks made of natural, absorbent materials and change them daily

F. Wear well‐ ventillated shoes


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Athlete’s Foot

All of the following non drug measures can help patients with athlete’s foot EXCEPT:

A. Wash feet daily in lukewarm water using a fragrance‐free mild soap and rinse well

B. Do not soak feet for more than 10 minutes.

C. Use a clean soft towel to dry feet carefully particularly between toes

D. Use a absorbent bath (mat that can be disinfected)

E. Wear socks made of natural, absorbent materials and

change them

daily

F. Wear well‐ ventillated shoes (ex. Leather or canvas)

Avoid walking barefoot in pools and shower areas and do

not share personal items

Athlete’s Foot

Treatment tips: Apply topical preparations twice daily to the affected area x 4

weeks (Sxs usually resolve in 2 weeks but cream should be used for 2 more weeks to prevent recurrence)

Extend the application area for 2 cm beyond the lesions

Topical preps are NOT for children


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Nail infection (Onychomycosis)

Non drug measures:

Similar to athlete’s foot PLUS

Ensure nails are clean and cut short

Avoid sharing personal tools such as nail clippers or footwear

Use gloves to protect nail when hands are in water for long time

Apply moisturizer on cracked skin to decrease fungus entry


Drug therapy:

Terbinafine:

1st choice (6‐12 wks for fingernail and 12‐24 wks for toenail. Patients > 40Kg: 250mg daily

Continuous (NO pulse)

Itraconazole: (second choice. Preferred if yeast or non‐dematophyte infection suspected)

Can be used (200mg daily x 6 wks (finger) and 12 wks(toe) or PULSATED (200mg BID 1wk/month x 2 cycles for finger 3 cycles for toe)


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Drug therapy:

Fluconazole

Not first line

Longer duration (12‐16 wks (finger) and 18‐26 wks

(toe)


NOTES:

Topical agents are used in very early symptoms with superficial white onychmycosis (SWO)

Ciclopirox: limited efficacy, possible adherence issue because of use instructions, and does not add to terbinafine monotherapy.

Pregnancy: insufficient evidence delay treatment

Breastfeeding: drug go in breast milk avoid

Recurrence is common but does not warrant prophylactic systemic therapy.

Ketoconazole and griseofulvin lack evidence

Toenail culture is important for diagnosis


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Bacterial Skin infection

Infection Notes and therapy

Impetigo Causative: S. aureus

Topical: mupirocin or fucidic acid x 7 – 10 days

No improvement on topical therapy after 48 hours

or systemic infection (ex. Fever) oral antibiotic

(based on notes next slide)

Folliculitis Causative: S. aureus or P.aeruginosa

Stepwise treatment: Use antiseptic x 1 0 days

mupirocin, fucidin, or clindamycin oral

Bacterial Skin infectionInfection Notes and therapy

Ersipelas Causative: S. aureus

First line: oral (penicillin or cephalexin) or IV

(penicillin G or cefazolin) . Allergy to penicillin

vancomycin

Second line: IV or PO clindamycin

Third line: Macrolides or cloxacillin

Bites Pasteurella multocids

Treatment: amoxicllin/clavulanic acid (Clindamycin + any of FQ, SMX/TMP or doxycycline are

alternative)


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Bacterial Skin infection

Infection Notes and therapy

Cellulitis S. aureu s, beta‐meloyltic streptococci and H.influenza

(


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Rosacea

All of the following non‐drug measures would

help a patient with rosacea?

A) Avoid vinegar

B) Avoid extreme cold weather

C) Avoid using steroids on face

D) Do not rink undiluted liquor


Rosacea

All of the following non‐drug measures would

help a patient with rosacea?

A) Avoid vinegar

B) Avoid extreme cold weather

C) Avoid using steroids on face

D) Do not rink undiluted liquor E) None of the above

Heat

Spice

Alcohol

Steroids

StressHot beverage

Astringents

Sun exposure

Heat

Spice

Alcohol

Steroids

StressHot beverage

Astringents

Sun exposure

AVOIDAVOID

Heat

Spice

Alcohol

Steroids

StressHot beverage

Astringents

Sun exposure

AVOID


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Rosacea

Which of the following antibiotics is used for

management of rosacea?

A) Fucidic acid

B) Clindamycin

C) Erythromycin

D) Metronidazole

E) All of the above

Rosacea

Which of the following topical antibiotics is used

for management of rosacea?

A) Fucidic acid (Drops for eye symptoms)

B) Clindamycin (for papulopustular symptoms)

C) Erythromycin (for papulopustular symptoms)

D) Metronidazole (1st choice)E) All of the above

Azelaic acid and sulfacetamide are also used


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Rosacea

Which of the following is NOT true about using

metronidazole for management of rosacea?

A. Symptoms may relapse when treatment stops

B. Significant relief may take 2 – 3 weeks

C. Oral tetracycline can be added for moderate to

severe symptoms

D. Dryness is more pronounced with gel form


Rosacea

Which of the following is NOT true about using metronidazole for management of rosacea?

A. Symptoms may relapse when treatment stops

B. Significant relief may take 2 – 3 weeks (12 weeks)

C. Oral tetracycline can be added for moderate to severe symptoms (lowest cost among oral antibiotics)

D. Dryness is more pronounced with gel form (If dryness

develop: switch patient to cream, use prn emolient, and use of sunscreen also decrease dryness)

E. None of the above Used BID x 9 weeks than prn


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Rosacea

In pregnancy and lactation

• Topical azelaic acid, metronidazole, erythromycin, and

clindamycin are considered safe in pregnancy and

lactation

• Oral erythromycin is safe in pregnancy and lactation

(except estolate salt which can cause hepatotoxicity)

• Tetra‐, doxy, and mino‐cycline may affect bone growth in

1st trimester. May be safe in breastfeeding but NOT for

long term use (may cause teeth staining = tetracycline teeth)

Rosacea

Notes

• Female use green‐tinted foundation

• Antibiotics are used for their anti0inflammatory effect

(not antibacterial because no infection is involved)

• Cyclosporine eye drops is safe in eye symptoms but

expensive

•

Oral isotretinion is reserved for facial edema, resistant cases, and phymatous (nasal involvement)


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Traveler's Health

Traveler's Health

• Travelers’ diarrhea

• Malaria prevention


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Traveler's Health

The most cases of traveler’s diarrhea in adults

are due to:

A. Giardia intestinalis

B. Norovirus

C. Escherichia coli

D. Clostridium botulinum

E. Enterococcus faecalis

Traveler's Health

The most cases of traveler’s diarrhea in adults

are due to:

A. Giardia intestinalis

B. Norovirus

C. Escherichia coli

D. Clostridium botulinumE. Enterococcus faecalis

Other common causes:

Salmonella, Shigella and

Campylobacter and rotavirus

Other foodborne infections:

All in the list PLUS

Hepatitis A Vibrio vulnificus

Listeria(listeriosis)

Clostridium (botulisms)


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Traveler's Health

Vaccines Recommended for travelers

chicken pox (varicella) Type B H. influenzae mumps

cholera Hepatitis A & B pneumonia

diphtheria HPV polio

tick‐borne encephalitis influenza rabies

German measles (rubella) meningitis tetanus

whooping cough (pertussis) typhoid measles

Japanese encephalitis

http://travel.gc.ca/travelling/health‐safety/vaccines

Malaria


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Malaria

S.O. is a 49 years old patient. He is in the

pharmacy today with a prescription for malaria

prophylaxis. He is travelling tomorrow to south

America. This prescription is likely for:

A) Chloroquine sulfate

B) Hydroxychloroquine sulfate

C) MefloquineD) Primaquine

Malaria

S.O. is a 49 years old patient. He is in the pharmacy today with a prescription for malaria prophylaxis. He is travelling tomorrow to south America. This prescription is likely for:

A) Chloroquine sulfate (weekly, 1‐2 wks prior, during exposure and 4 wks after. Alternative dose is 1000mg loading dose can be used)

B) Hydroxychloroquine sulfate (same as chloroquine)

C) Mefloquine (same as chloroquine. Alternative dose is 1tab po qd x 3 days then weekly)

D) Primaquine (start 1 day prior to exposure, daily while exposed + 3 days after)


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Malaria

Other meds:

Doxycycline: 1 day prior, while exposed and

for 4 weeks after

Atovaquone/proguanil: 1 day prior, while

exposed and for 1 week after

Malaria

Non drug measures:

Use DEET‐containing mosquito repellent q4‐6h between dusk and dawn (30% concentration for


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Malaria

The selection of the antimalarial drug should

depend on:

I. Weather at destination

II. Altitude of destination

III.The destination

A) I only B) III only C) I & II only

D) II & III only E) I, II and III

Malaria

The selection of the antimalarial drug should

depend on:

I. Weather at destination

II. Altitude of destination

III.The destination

A) I only B) III only C) I & II onlyD) II & III only E) I, II and III

Consider also drug factors (such as resistance)

and patient’s factors (age, allergy, etc.)


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Malaria

Chloroquine should be avoided in:

I. Patients with psoriasis

II. Patients with Hx of seizures

III.Pregnant females



Malaria

Chloroquine should be avoided in:

I. Patients with psoriasis

II. Patients with Hx of seizures

III.Pregnant females



Safe in pregnancy. Worsen psoriasis and seizures and

also psychosis. Same applies to hydroxychloroquine


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Malaria

S.O. will travel with his wife and 4 years old son

whose weight is 18 Kg. All of the following

agents can be used for the son EXCEPT:

A) Doxycycline

B) Chloroquine

C) Mefloquine

D) Atovaquine/proguanilE) None of the above

Malaria

S.O. will travel with his wife and 4 years old son

whose weight is 18 Kg. All of the following agents

can be used for the son EXCEPT:

A) Doxycycline (not for 5 Kg)



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Malaria

NOTES

Causative: P. faciparum

Mosquitos are more attracted to pregnant female and malaria cause more mortality, fetal death, premature labor and anemia

Chloroquine is the 1st choice and safe in pregnancy and breastfeeding.

If chloroquine resistance is suspected, mefloquine, primaquine, doxycycline or atovaquone/proguanil can be used (only mefloquine can be used if patient is pregnant)

Mefloquins: 1st choice for pregnant female visiting chloroquine –resistant area (If mefloquine‐resistance is suspected, no safe choice is available for pregnant female).

Mefloquine‐resistant areas: Doxycycline and atovaquone/proguanil are effective (primaquine can also be used)

Mfloquine is CI in patients with anxiety, depression psychosis or seizures (worsen these conditions).

Doxycycline: for mefloquine‐ resisatant strains. CI in pregnancy

Primaquine for P.vivax strain and chloroquine – resistant strains. CI in pregnancy and in patients with G‐6‐PD deficiency due to serious hemolytic anemia

Atovaquone/Proguanil: better ADR profile (mainly GIT such as use stomach and mouth ulcers, cough and insomnia). CI in pregnancy and renal dysfunction

If the patient develops fever in the first 3 months after returning (and up to 1 year) malaria should be suspected and dealt with as emergency

Osteomyelitis


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Osteomyelitis

What is the most common microorganism in

osteomyelitis?

A) Group A streptococci

B) P. aeruginosa

C) S. aureus

D) Gram –ve enteric bacilli

E) H. influenza

Osteomyelitis

What is the most common microorganism in

osteomyelitis?

A) Group A streptococci (children – blood)

B) P. aeruginosa (penetrating wound)

C) S. aureus (all sources/ages except GU

infection)D) Gram –ve enteric bacilli

E) H. influenza


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M.S. is an 11 year‐old girl. She comes to the ER today with her mother. She did not go to school today because of fever and a new onset of increasing leg pain. M.S. explained that the pain started about 3 days ago when the upper right leg started to hurt but the pain got worse last night. M.S. denied any injury to the area. Physical examination revealed that the pain is localized over the distal femur without any knee involvement. of the area did not show any visible signs of trauma, swelling or warmth. Laboratory assessment shows WBC count of 6,000 x 108cells/mm3 (normal, 5,000–10,000), with a normal WBC differential. ESR is 73 mm/h (normal: 0 – 15) A plain X‐ray Plain radiographic studies of the left leg are normal, but the erythrocyte sedimentation rate (ESR) is 62 mm/hour (normal, 0–15). The family physician was contact for a full medical history. M.S. medical history was not significant except for two episodes of acute otitis media at age 6 and 9. Two blood cultures are obtained, and M.S. was sent with a prescription for acetaminophen for pain and directions for bed rest.

3 days later, M.S. comes back to the hospital with severe pain in the right leg, fever of 39.2. The results of the blood cultures just became available and are positive for

MSSA. Laboratory assessment shows an elevated level of CRP of 15mg/dl (normal is 2). An MRI was performed and showed an inflammation in the right femur.

Which of the following should be used as the

initial IV antibacterial agent?

A. IV cloxacillin

B. IV ceftazidime + gentamicin

C. IV Cefotaxime

D. IV VancomycinE. IV Penicillin


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Which of the following should be used as the initial

IV antibacterial agent?

A. IV cloxacillin (for MSSA – also IV cefazolin and IV

clindamycin can be used)

B. IV ceftazidime + gentamicin (for P.aeruginosa)

C. IV Cefotaxime (for gram –ve enteric bacilli)

D. IV Vancomycin (for MRSA. Linezolid????)

E. IV Penicillin (Streptococcus A/B)

Other definitive IV therapy:

Mixed aerobic/anerobic bacteria:

IV Carbapenem

IV moxifloxacin

IV piperacillin/tazobactam

IV amoxicillin/

clavulanic acid


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For how long should the treatment continue?

A. 10 days

B. 2 weeks

C. 3 weeks

D. 6 weeks

E. There is no definite duration

For how long should the treatment continue?

A. 10 days

B. 2 weeks

C. 3 weeks

D. 6 weeks (minimum 4 weeks, 6 weeks is the

preferred duration)E. There is no definite duration

10 – 14 days for OM following a

penetrating wound


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After 7 days of IV therapy, the physician would like to send M.S. home with a prescription for oral antibiotic to complete therapy at home. Which of the following oral antibiotics can be used in M.S. case

A. Clindamycin

B. Cloxacillin

C. Cephalexin

D. Amocillin/clavulanic acid

E. All of the above

After 7 days of IV therapy, the physician would like to send M.S. home with a prescription for oral antibiotic to complete therapy at home. Which of the following oral antibiotics can be used in M.S. case

A. Clindamycin

B. Cloxacillin

C. CephalexinD. Amocillin/clavulanic acid

E. All of the above

Can be used as a step down

therapy in MSSA following initial

IV cloxacillin


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Osteomyelitis

Other step‐down therapy

Community acquired MRSA Clindamycin (otherwise continue IV at home)

Streptococcus A/B penicillin, amoxicillin, clindamycin

P. aeruginosa Ciprofloxacin in adults (NO step‐down in children. Continue IV)

Mixed aerobic/anerobic Ciprofloxacin + Clindamycin OR amoxi/clav

No step‐down in neonates

Osteomyelitis

Switching from IV to oral

↓hospital stay, risk of nosocomial infecon and complications of IV administration

Criteria: Patient is generally better

Normal temperature

Inflammation and tenderness subside

Not a neonate Can give large oral dose (ADR, palatability)

Immune‐competent

Adherence is expected


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Osteomyelitis

NOTES:

• C‐reactive protein and Erythrocyte Sedimentation Rate (ESR) are used for assessment.

• C‐reactive protein is a protein produced by the liver. The level of CRP level increases in the acute (early) phase of inflammation.

• ESR is used to detect inflammation. ESR increases when inflammation exist

• Acute OM onset 1 week or recurrent

Prevention of Endocarditis


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Symptoms of Endocarditis

Fever Paleness Arthralgia Hematuria

Dyspnea Chills Back pain Splenomegaly

Persistent cough Night sweats Skin lesions Osler's nodes

SOB Headache Weight loss Petechiae

Pleuritic chest pain Weakness Fatigue

TREATMENT Normal Valve Prosthetic valveStaphylococci

6 weeks in

normal valve and

at least 6 weeks

in prosthetic

MSSA: Cloxacillin + Cefazolin +/‐

gentamicin (1st 3 – 5 days)

MRSA: Vancomycin (or allergy to

penicillin)

MSSA: Cloxacillin +

Rifampin + gentamicin

MRSA: Vancomycin +

Rifampin + gentamicin

Streptococci

4 weeks in

normal valve (2

if use

gentamicin)

Penicillin‐sensitive : Penicillin or

Ceftriaxone +/‐ gentamycin x 4 wks (2 if

using gentamicin)

Penicillin – resistant: Penicillin or

Ceftriaxone + gentamycin (1st 2 wks) x 4

weeks

Allergy to penicillin: Vancomycin x 4 wks

Penicillin or ceftriaxone

+/‐ gentamicin x 6 wks

Allergy to penicillin:

vancomycin x 6 wks

Eneterocci Standard: Ampicillin or Penicillin G + gentamicin x 4‐6 wksStandard + allergy to penicillin: vancomycin + gentamicin x 6 wks

Resistant to gentamicin: Use streptomycin to replace gentamicin

(same duration as above)

Resistant to penicillin: Vancomycin + gentamicin x 6 wks

Resistant to standard therapy: linezolin, dalfopristin/quinupristin,

impinem/cilastatin


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Patients who need endocarditis prophylaxis:

Have prosthetic valve or valve repair

History of endocarditis

Recipient of heart transplantation

Patients with congenital heart diseases


Prophylactic antibiotic (adults)

Standard: amoxicillin PO 2 g 1 hour pre‐op

Allergic to penicillin Mild: Cephalexin (2 g), Clindamycin (600mg), Azithromycin

(500mg) and clarithromycin (500mg)

Severe: same as above EXCEPT NO cephalexin

Unable to swallow: IV or IM ampicillin (2g), Ceftriaxone (1g) or Cefazolin (1g)

Allergy + cannot swallow: Mild reaction: IV or IM Cefazolin (1g), Ceftriaxone (1g) and

Clindamycin (600mg)

Severe reaction: IV or IM clindamycin (600mg)


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Acute otitis media

References:

• Forgie S, Zhanel G, Robinson J. Management

of acute otitis media. 15. Paediatr Child

Health

2009;14(7):457‐64.


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AOM

Non drug measures:

• Watchful waiting for 48‐72 hours for all children > 6 months of age with

– mild – moderate symptoms (temperature


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AOM

All of the following bacteria are commonly

involved in AOM EXCEPT:

A. Streptococcus pneumoniae

B. Mycoplasma pneumoniae

C. Haemophilus influenzae

D. Moraxella catarrhalis

The other 3 are the most common. M. Catarrhalis has the

highest resolution rate. Resistance mechanisms differ. S. Pneumoniae (penicillin binding protein ↑ dose), H. influenza

and M. Catarrhalis (beta lactamase add beta lactamase

inhibitor)

AOM

All of the following factors are associated with

high risk of resistance EXCEPT:

A. Lack of spontaneous resolution

B. Attending daycare

C. Lack of response to antibiotic by day 3

D. Antibiotic use in last 3 monthsE. Recurrence of symptoms within 10 – 28 days

following antibiotic therapy


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AOM

All of the following factors are associated with

high risk of resistance EXCEPT:

A. Lack of spontaneous resolution

B. Attending daycare

C. Lack of response to antibiotic by day 3

D. Antibiotic use in last 3 months

E. Recurrence of symptoms within 10 – 28 days following antibiotic therapy (recent AOM )

AOM

Drug therapy:

1st choice: Low dose amoxicillin (40mg/Kg in 2 –3 divided doses)

Resistance suspected: High dose amoxicillin (75–90 mg/Kg in 2 – 3 divided

doses)

Amoxicillin/clavualnic acid

2

nd

generation cephalosporin: less resistance but less effective (ceftriaxone most effective but IV)

Allergy to penicillin: Clarithromycin, azithromycin, or clindamycin


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AOM

Duration of therapy:

From 6 weeks to

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Infectious Diseases PART I(1)

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