Lyme Disease

Stage1:erythemamigrans(redmaculewith
centralclearing)atsiteoftickbite,fever,
headache,malaise
Stage2:earlydisseminated:cardiacblock,
multipleskinlesions,neurological
lesions
Stage3:latedisease:arthritis
SpirocheteB.burgdorferi,transmittedby
Ixodidtickvector
TreatwithDoxycycline(adults),
Amoxicillin(kids)
Toxic Shock Syndrome
Erythroderma:deepred,totalbodysunburn.
Palm/soleflakingin12wks
S.aureusTSSTtoxin
Treatw/IVfluids
Staph Scalded Skin
Diffuseerythema.Nikolskysign(gentle
frictionremovesskin)
S.aureusexfoliativetoxinsA&B
Treatw/IVfluids
RMSF
Rashstartsonpalm/soles(wrists/ankles)and
spreadstowardstrunk.Petechialrash.
Severeprogressivediseasew/possible
meningismus,enephalopathy.
Pancytopenia&hyponatremiacommon
R.rickettsiatransmittedbytickvector
Treatw/Doxycyclineevenforchildren
Kawasaki
Asianchild.Measleslikerash,blanches.
Diffusepatchyerythematous
morbilliform,mostlyontrunk.
Phase1:fever,rash,cervical
lymphadenopathy,oralredness
(strawberrytongue)
Phase2:subacute,fingertipdesquam
Cardiacmanifestations:
CAvasculitisaneuysmsMI
Unknownetiology.
Treatw/IVimmuneglobulintoprevent
coronaryaneurysms
Meningococcemia
Nonblanchingpurpura/petechialrash.
Abruptonsetoffever,chills,malaise,rash.
Canprogresstofulminantsystemic
diseasew/MOF.CaninvadeCNS.
WaterhouseFriderichsenSyndrome.
TreatwithCeftriaxoneorPenicillin
Chemoprophylaxisofhouseholdcontactsw/
Rifampin,Cipro,Ceftriaxone.
Parvovirus B19
Facialrash:erythemainfectiosum
(slappedcheek)
Bodyrash:symmetric,reticularmacularon
trunk,buttocks
Notcontagiousoncerashdevelops
Transientaplasticcrisis(sicklecell)
Chronicerythroidhypoplasia
Supportivetreatment
IVimmuneglobulinforIC
Clinical Meningitis
Meningismus(stiffneck)demonstratedby
Brudzinskissign(flexionofneck
producesflexionofhips),Kernigsign
(painonkneeextensionwhenhip
flexed),Opisthotonos(archedback)
Fever
Alteredmentalstatus
Photophobia
VomitingduetoICP
CSFProfiles:
Bacterial:WBC(PMNs),protein,gluc
Viral:WBC(lymph),protein,nrmlgluc
TB/Fungi:WBC(lymph),protein,gluc
Treatment:
TreatbacterialmeningitiswithCeftriaxone.
ProphylaxisforN.meningitidis&H.influenzae
householdcontacts(Rifampin).
Bacteria that cause
Meningitis
S.pneumoniae:Mostcommonoverall,freqin
veryyoung,elderly.Associatedw/RT
infectionsin1/3,asymptomaticcarriage
in2/3.
N.meningitidis:Mostcommoninolder
childrenandyoungadults,closehousing
(military,college).Overwhelmingsepsis
(purpurafulminans).
L.monocytogenes:Newborns,Tcelldeficient.
Foodborneinfection(unpasteurized
milk).
H.influenzae:Typebformerlymostcommon
causeofmeningitisinkids,but
eradicatedduetoHibconjugatedvaccine
Strepagalactiae(GBS):Neonatalmeningitis
associatedw/maternalgenitaltract
colonization.Elderlyw/chronicdisease.
S.aureus:Rareexceptpostneurosurgeryor
withendocarditis
GNB:Rareexceptnewbornsorpost
neurosurgery.Salmonellabacteremiain
newborns.
Other organisms that
cause Meningitis
Enterovirus,HSV2,HIV,mumps
Granulomatousmeningitis(TB,Cryptococcus,
Coccidiomycosis):subacutepresentation.
BasilarmeningitisCNpalsies
Syphilis,Lymedisease
Noninfectious
(ibuprofin,carcinomatous,vasculitis)
Encephalitis
Cardinalfeature:cognitiondisturbance.
Necrosis&hemmorhagecanoccur.
Priority:Identifytreatabledisease
(treatHSVwithAcyclovir).
HSV1:Latentintrigeminalganglion,or
travelsretrogradeviaolfactorynerves
focalencephalitis(temporallobe).
HSV2(muchlesscommonthanHSV1):
Acquiredfromgenitallesionatbirth,
hematogenousspreaddiffuse
encephalitis.
Zoonotic(Arboviruses:WNV,EEE,St.Louis,
LaCrosse).
Rabies:BatbiteSensoryneuroninfected,
retrogradetraveltoCNS.Classicfinding
ishydrophobia(cantswallowdueto
pharyngealspasm).Raresurvival.
JCVirusPML
Demyelinatingprocesswithout
inflammation
Brain Abscess
Pathogenesis:UsuallyS.aureus
1)Spreadfromotitismediaorsinusistis
2)Hematogenousspread(S.aureus)withRLcardiacshunt
3)Directinfection(trauma,surgery)
Spinal Epidural Abscess
Hematogenousseedingofepiduralspaceor
IVdiscswithspreadtoepidural
Backpainradicularpain
SCimpingement
UsuallyS.aureus
Urgent!Neurosurgicalconsulttoprevent
paralysis
Bacterial Vaccines
Diphtheria:Toxoidgivenwithpertussis&
tetanus,needboostersq10yrs
Pertussis:ContainspertussisAg,toxoid,FHA
fimbrialprotein.Doesnotprovidegreat
protection
Tetanus:Tetanustoxoid,excellentvaccine
Meningococcus:Toomanyserotypes.
Quadrivalentpolysaccharidevaccine
(notforB).Forasplenics,notforkids
under2.QuadrivalentConjugated
vaccinenowrecommendedfor
adolescents.
Chemoprophylaxistoclosecontacts.
H.influenza:ConjugatedvaccineofHib
worksexcellentlyevenininfants,has
practicallyeradicateddisease.
Only1serotype.
Pneumococcus:Over90serotypes,toomany
toeliminatecompletelywithvaccine.
Conjugatevaccine(PCV7)isroutine.
Polysaccharidevaccine(PS23)for
patientsatrisk(notimmunogenicfor
under2).

HSV
HSV2:Genital.Veryprevalent.
Prodrome(localizeditchingbeforegrowthof
vesicles)common.
AsymptomaticsheddingofHSV
DoublestrandedlinearDNAvirus.
DiagnosewithDFA(DirectFlourescenceAb)
orTzanck.
TreatwithAcyclovir
Chancroid
Painfululceration,noinduration,sharply
demarcated.Purulentbase
Buboe:painfulinguinaladenitis.Usually
largeandunilateral.
Haemophilusducreyi
DiagnosedbyrulingoutHSV/Syphilis
Veryrare
Syphilis
Primarysyphilis:Chancre:painless
ulceration,welldefined,indurated.
Smalltomoderatelymphadenopathy.
SecondarySyphilis:Systemicdisseminationof
spirochete.Constitutionalsymptoms:
malaise,sorethroat,CNSinvolvement,
glomerulonephritis,hepatitis,arthritis,
etc.Maculopapularrashonpalmand
soles.Condylomatalata.
TertiarySyphilis:
Benign:Gumma
Neurosyphilis:tabesdorsalis
CV:aortitis,aorticaneurysm
Treponemapallidum.Canhavetransplacental
transmission.
Earlysyphilis<1year:
Incubating:nosymptoms
Primary:Chancre,lymphadenopathy.
Secondary:Systemic:greatimitator
EarlyLatent:uptoday365
Latesyphilis>1year:
Latelatent:
Tertiary:Gumma,Neuro,CV
Diagnosis:
VDRL:falsepositiveswithpregnancy
FTAABS:Confirmatorytest
Treatment:Penicillin.
JarischHerxheimerreaction:febrile
reactiontopenicillin
Gonococcal
Urethritis/Cervicitis
HighrateofcoinfectionswithChlamydia
10%ofmenasymptomatic
75%ofwomenasymptomatic
Male:dysuria,mucoiddischarge,tender
inguinaladenopathy
Female:dysuria,purulentcervicaldischarge,
suprapubicdiscomfort,red&swollen
cervix
N.gonorrhea
Diagnosis:
DNAprobemostcommonthesedays.
UrethralGramstain:lotsofWBCswith
gramdiplococciinsidepolys.
Non-Gonococcal Urethritis
Dysuriawithmucoidorwaterydischarge 50%Chlamydiatrachomatis
Diagnosis:lotsofWBCsandnoevidenceof
GConurethralgramstain.
Vaginosis
Commonsymptoms:vaginaldischarge,
vulvaritchingandirritation
Bacterialvaginosis:Replacementofnormal
H2O2producingLactobacilluswith
anaerobes,Gardnerellavaginalis,and
Mycoplasmahominis.
NotcausedbyGardnerella.
Malodorous(fishy),white,
noninflammatorydischarge.
Diagnosis:Cluecells,absenseofgram
positiverods(lactobacillus).pH
Candidiasis:mostcommonform.Thickwhite
dischargeplasteredagainswallsof
vaginaandcervix
Trichomoniasis:Strawberrycervix(little
petechiaoncervix,startstobleedeasily.
PROMwithpregnancy.
Malodorous,yellowgreendischarge.
Menasymptomatic.
Diagnosis:pearshapedorganisms,
pH(>4.5).


Impetigo
Verysuperficial,sitsondeadsquamous.
Noscarring.Betweenstratumcorneum
&granulosum
Honeycoloredcrust
S.aureus(95%)orGAS
Treattopicallyunlesssevere
Folliculitis, Furuncle,
Carbuncle
Folliculitis:Aroundhairfollicule
Furuncle(boil):Spreadofpusinto
subcutaneoustissue
Carbuncle:Enlarged,multiplecoalescent
furuncles,connectingsubcutaneously
S.aureus
P.aeruginosa:hottubfolliculitis
Cellulitis
Infectiousinflammationofskinand
subcutaneoustissues.
Etiology:Lymphedema,trauma,obesity
Clinical:Systemicsymptoms:malaise,fever,
chills.Redhotskin,edema,painful.
hemolotyicstrepmostcommon
S.aureuslesscommon(ifwound)
Treatment:pusdrainage,antibiotics
Erysipelas
Cellulitisinvolvinglymphaticsmarked
edema
Brightredboiledlobsterskin.
Fever,chills,malaisecommonlyprecedeskin
findings.
GAS
Treatment:IVantibiotics(initiallyalsocover
staph),hospitalization,elevationto
decreaseedema.
P. multocida Cellulitis
Catbite(dogstoo)
Rapidonset
Red,edematous,extremelypainful,thin
exudatefromwound
Pasteurellamultocida
Streptococcal Gangrene
Oftenoccurswithunderlyingdisease
(DM,AIDS,transplants)ortrauma
Vascularocclusionnecrosis
fascialspread
Secondarybateremia,shocksepsis
Eschar:darkblue/blackskin
GASmostcommon,GBSrarely
Treatment:LargedosePenicillinGIV+
Clindamycin,surgicaldebridement
Progressive Synergistic
Necrotizing Fasciitis
DM:Fourniersgangrene(perinealinfection)
occursspontaneously
Elderly:Decubitiulcer
Vascularocculsionnecrosis
fascialspread
Subcutaneous,fascialinfection.
Canleadtobacteremia,SIRS
Fecalflora(GNR,anaerobes),Strep,
Enterococcus,Staph(occasionally)
CrepitanceonXRay
Treatment:surgicaldebridement,broad
spectrumantibiotics
Clostridial Myonecrosis
Deep,devitalizinginjuries
Sporesgerminate(anaerobic)
vascularocclusionnecrosis
Deeppain,canhavenormalskin
Canleadtobacteremia,SIRS
ManyspeciesofClostridia
CrepitanceonXRay
Treatment:surgicaldebridement,broad
spectrumantibiotics

Osteomyelitis
Canbesecondarytohematogenousspread
(tometaphysisoflongbonesinchildren
orvertebralbodiesinelderly)or
contiguoustoinfectiouspenetration.
Osteolysisvialocalcytokines.Infection
occlusionavascularnecrosis
Vascularspreadtoperiostiumnewbone
formation(involucrum)
Hematogenousspread:Constitutional
symptoms,localpain&tenderness
acutely,butchronicosteomyelitisdoesnt
havesystemiccomplaints.
DirectInfection:Orthopedicsurgery,trauma,
sternotomypostcardiacsurgery.Canbe
duetononhealingulcerssecondaryto
vasculardisease&neuropathy(DM).
Staphaureus(mostly),Strep:usuallyvia
skin/softtissueinfection.
Canbehematogenousordirect.
CoagulasenegativeStaph,MRSA:(hemat)
nosocomial,IDU
GNB:(hemat)elderly(UTI)
vertebralosteomyelitis
Salmonella:Sicklecell
P.aeruginosa:(direct)nailintofoot(through
sole)
Oralflora:(direct)fistintomouth
Diagnosis:XRaycantdetectchangesuntil
day10.MRIisbest.
Therapy:IVantibiotics&surgery(required
fordirectinfection,maybenecessaryfor
hematogenouslyspreadinfectionifno
responsetoantibiotics)
Pyarthrosis
Acuteinflammationofsynovialmembraneof
joint.Rapidjointdestruction:
Necrosisofsynovialcells
mucinleadstofriction.
Etiology:Hematogenous(mostcommon),
directinnoculation(trauma),orspread
fromosteomyolitis(infants)
Joints:Mostlymonoarticular,largejoints.
Localsymptoms:painful,immobilejoint.
Diagnosis:radiologynormal.WBCinjoint
(polys),lowsugar,nocrystals(ruleout
goutandpseudogout)
Prompttreatmentnecessary!Drainage,high
doseIVantibioticsforweeks.
Staphaureusmostcommon.
N.gonorrhoeae:sexually(very)active:Acute
pustularrash,migratorypolyarthralgias,
monoarticulararthritis,tenosynovitis=
disseminatedgonococcalinfection.
IVDrugUsers(IDU)cangetoddbugsin
oddjoints:S.aureus+GNB
UTIs
Acutecystitis:Bladderinfection.Dysuria,
frequency,urgency.Shorttreatment.
Acutepyelonephritis:Infectioninkidneyor
upperurinarytract.Symptomsofacute
cystitis+fever,chills,flankpain.
Longtreatment.
Chronicpyelonephiritis:Calycealdilation
andcorticalscarringfromchronic
bacterialinfections.Rarethesedays.
Acutelobarnephronia:Radiologicaltermfor
focalpyelonephritis.Parenchymatous
inflammationandnecrosisinlobeof
kidney.
Asymptomaticbacteriainurinalysis:Treatif
lessthan5yrsoldtoavoidpotential
renalscarring.
Catheterassociatedinfections:Fevercanbe
onlyclinicalsymptom.Ifduetocandida,
stopantibioticsandremovecatheter.
Gramnegativerods:Mostcommon.E.coli,
Klebsiellapneumonia,Proteusmirabilisin
normalhosts.
Grampositivecocci:Lesscommon.Staph
saprophyticus(coagulasenegative)in
sexuallyactivewomen,Enterococcus
faecalisafterinstrumentation.
Staphaureusonlywithbacteremia.
Diagnosis:Urinalysishaspositiveleukocyte
esterase.Urine/bloodculturesifsystemic
symptoms
TherapyofUTI:TMPSulfa(3daysif
uncomplicated,14daysto6weeksif
complicated).Imageurinarytractifno
response.
Renalabscess:UsuallyasconsequenceofS.
aureusbacteremia.
Xanthogranulomatouspyelonephritis:Very
rarechronicinfection.Localizedor
diffusereplacementofrenalparenchyma
byinflammatorycellsandlipidladen
macrophages.Maymimicrenalcell
carcinoma,TB,orabscess.Treatwith
surgeryorlongtermantibiotics.
Sterilepyuria:LookfornonbacterialSTDsor
TB.
Acuteurethralsyndrome:NoactiveUTI,but
irritativevoidingsymptoms.
Vaginitis:Maycausesymptomssimilarto
UTI.
Prostatitis:Acutebacterial,Chronicbacterial,
Chronicnonbacterial
GAS Pharyngitis
Canleadtorheumaticfever
rheumaticheartdisease
Theonlyformofacutepharyngitisforwhich
antibiotictherapyisdefinitelyindicated
Severesorethroat,mayhaveexudative
pharyngitis,enlargedtenderanterior
cervicalnodes.
Nohoarsness,rhinorrhea,orcough
GroupAhemolyticStrep
Carriersarefrequent,butGASstrainsin
carrierslackMproteinandvirulence
factors.
Canbedifficulttodiagnosebecauseacarrier
canhaveaviralsorethroat.
Therapy:Preventrheumaticfever!Canstart
therapyuptoday9ofstartofsymptoms
(noeffectonglomerulonephritis).
Penicillinisdrugofchoice.
Erythromycinifpenicillinallergic.
Suppurative GAS sequelae
Peritonsillarabscess:Quinsysorethroat:hotpotatovoice
Rarespreadtocavernoussinuscerebralveinthrombosis,meningitis
Cervicaladenitis,Mastoiditis(canprogresstomeningitis),Pneumonia
Hematogenousseedingbones,joints,etc
Toxic GAS sequelae
ScarletFever(scarlatina):Erythrogenictoxin.
Clinically:fever,headache,vomiting.
48hourslater:diffuseerythematous
sandpaperyrash.
Severesepsis/toxicshocksyndrome.
Oftenwithrhabdomyolysis.
Cluestoscarletfever:
Pastiasline:accentuatedskinfolds
Circumoralpallor
Strawberrytongue:bigpapillae
Raspberrytongue:red,cracked
Nonsuppurative GAS
sequelae
RheumaticFever:Onlyfollowspharyngitis.
Onset15weeksafterpharyngitis,but
Choreamaybeginupto6monthslater.
Jonescriteriafordiagnosis:
2majorOR1major+2minors.
valvularrheumaticheartdisease
Glomerulonephritis:CanfollowanyGAS
infection.Immunecomplexreaction,self
limitedacuteglomerulonephritis.Rarely
progressestochronicrenalfailure.
MajorJonesCriteria:arthritis,carditis,chorea,
erythemamarginatum,subcutaneous
nodules
MinorJonesCriteria:arthralgia,increasedPR
interval,fever,highESR

URI = Common Cold
Nasalirritation,congestion,rhinorrhea.
Usuallyafebrile.
Rhinoviruses(Picornaviruses:SSlinearRNA)
Coronoviruses
Mid respiratory tract
infection
Croup=laryngotracheobronchitis:
Respiratorystridor&barkingseallike
cough
Parainfluenza,adenovirus,influenza
Treatwithsingledosedexamethasone.
Lower respiratory tract
infection
Bronchiolitisininfants:Progressivecough,
wheezing,tachypnea.
HyperinflationonCXR.
Canbesevereinfection,especiallyifheart
defect,premature,immunosuppressed.
RSV
Treatment:RSVimmuneglobulininhighrisk
(notwithcyanoticheartdisease)
Influenza = classic viral
syndrome
Symptomsofthreesyndromesabove+fever,
chills,headach,myalgia,hackingcough
Complications:
Pneumonia+/bacterialsuperinfection
CNSsyndromes:GuillainBarr
Reyessyndromeinchildrenw/aspirin
InfluenzaA:antigenicdrifts(yearly
outbreaks)&shifts(pandemics)
InfluenzaB:moregastroenteritis
InfluenzaAtreatment:
Amantadine/Rimantadine
InfluenzaA&Btreatment:
Oseltamavir/Zanamivir
Vaccine(3types)exists:70%effective
Otitis Media
Mostcommonunderage2
Diagnosis:Requiresbothinflammation&
fluidinmiddleear.Bacterialotitismedia
hasbulgingeardrum&purulentfluid
behindit.
Pathogenesis:ViralURIcausesEustachian
tubeobstruction
Suppurativecomplications:Mastoiditis
Viral,bacterial,orboth.
S.pneumoniae:with age
H.influenzae(NT>>typeB): with age
Moraxellacatarrhalis
Therapy:Amoxicillin
Sinusitis
Facialpain,uppermolarpain,fever,swelling
ofnearbytissues,tendernessto
percussion.
Suppurativesequelaeofteninvolve
Staphaureus.
Diagnosis:Maxillarysinuspuncturegold
standard.SinusCT.XRay,opaque
transillumination.
Complications:Spreadtoskull,brain.
S.pneumoniae,H.influenzae,
Moraxellacatarrhalis
Sometimesvirusesinvolved
Therapy:Amoxicillin
Pharyngitis
Nonexudative:virusesormycoplasma
Exudative:hemolyticstrep
EBV(infectiousmononucleosis)
Diphtheria
Adenovirus(#1inchildren<3)
Vincentsangina(fusospirochetes)
Arcanobacteriumhemolyticum
Epiglottitis
Rarethesedays(Hibvaccine).
Diagnosis:cherryredepiglottisontongue
depression.
Immediatemanagement!
H.influenzae
Clinical Hepatitis
Incubation:nosymptoms
Preicteric:
Initially:nonspecificmalaise,fever.
Later:nausea,tastechange,RUQpain.
AST/ALT
Icteric:~25%
Jaundice,AST/ALT,bilirubin
Feveruncommon
Convalescence+/Chronicity
Sometimes,youseeimmunecomplexdisease
inpreictericorchronicphase:
PA,glomerulonephritis,etc.
Sometimes,youseefulminanthepatitis:
Liverfailurewithencephalopathy
Hepatitis A, E
Short(~4week)incubation,nochronicity
Serology:IgMantiHAV/HEV
HEVonly:40%mortalityinpregnancy
HAVonly:Inactivatedvaccineavailable.
Immuneglobulincanalsobeusedfor
prevention.
HAV:Picornavirus:SSlinear,unenveloped
RNA
HEV:Calcivirus:SSlinear,unenveloped
RNA
Fecaloraltransmission
(vowelshityourbowels)
Hepatitis B
Longincubation,~10%chronicity,but
highchronicityforneonates
Serology:IgMantiHBcforacuteinfection
HBsAg:surfaceAg
Appearsduringincubationphase.
Continuedpresence=chronicity.
HBcAg:coreAg
HBeAg:coreAg,infectivity
IgGantiHBs:providesimmunity
inducedbyvaccinationorinfection
IgGantiHBc:persistsforlife
antiHBe:reductionininfectivity
Treatment:Interferon
antiretrovirals(Lamivudine,Adefovir)
forfulminantinfection
Vaccine:Recombinantvaccineisenvelope
proteinexpressedinyeast.
HBV:DS,partiallycircular,envelopedDNA
NotaretrovirusbuthasRT.
Blood&sexualtransmission.

Hepatitus D
RequiresHBV
Chronicinfectionscommon
RNAsatellitevirus(defective)
Hepatitis C
Mediumincubation,highchronicity
Serology:antiHCVnotreliable
Treatment:Interferon,Ribavirin
Flavivirus:SSlinearenvelopedRNA
Bloodtransmission(muchlesssexual).
EBV Mononucleosis
ClassicalTriad:Fever,sorethroat
(pharyngitis),lymphadenopathy
Rashwithampicillin
Neutropenia,thrombocytopenia,
mildtransaminases
PositiveheterophilAb(monospot)test.
Atypicallymphocytes
(activatedcirculatingcytotoxicTcells)
Herpesvirus:DSlinearenvelopedDNA
Complicationsofacuteillness(rare):splenic
rupture(avoidcontactsports),upper
airwayobstruction,GuillianBarr,
Xlinkedlymphoproliferativedisorder
Longtermcomplications:
Burkittslymphoma
Nasopharyngealcarcinoma
Oralhairyleukoplakia(HIV+)
Bcelllymphomas(HIV+,IC)
Antibiotics High-Yield
S.aureus:Nafcillin,Vancomycin
P.multocida:Ampicillin
H.influenzae:Ceftriaxone,Amoxicillin
P.aeruginosa:NOTCeftriaxone
Clostridia:PenicillinG
N.gonorrhoeae:Ceftriaxone
S.pneumoniae:Ceftriaxone,Vancomycin
S.pyogenes:PenicillinG,Ceftriaxone
GNB:3
rd
genCephalosporinor
Flouroquinolone
E.coli:TMPSulfa
Rickettsia:Doxycycline
Penicillins
PenicillinG:streptococci,enterococci
Nafcillin:staph(rhymeswithNaf)
Ampicillin:H.influenzae
Piperacillin:P.aeruginosa
Mechanism:inhibitcellwallsynthesis.Blocks
transpeptidasecrosslinkingofcellwall,
activatesautolyticenzymes.
AE:hypersensitivity
Cephalosporins
1stgen:Cefazolin:staph
2ndgen:CefuroximeH.influenzae
3rdgen:Ceftriaxone:H.influenzae,GNB
P.aer3rdgen:Ceftazidime:P.aer,GNB
4thgen:Cefepime:Pseudomonas(P.aer)
Mechanism:lactams.Inhibitcellwall
synthesislikepenicillinsbutareless
susceptibletopenicillinases.Bactericidal.
AE:hypersensitivity
Other -lactams
Imipenem:Staph,GNB,P.aer,anaerobes
(includingB.fragilis)
Aztreonam:AerobicGNB,H.flu,P.aer
AmpicillinSulbactam:Staph,H.flu,B.frag
Mechanism:inhibitcellwallsynthesis
Imipenemalwaysadministeredwithcilastatin
Aminoglycosides
Gentamicin:GNB,P.aer
Allaminoglycosideshave4syllablenames.
Mechanism:Inhibitproteinsynth(30S).
Synergisticwithlactams.
AE:Nephrotoxic,ototoxic.
lowtherapeutic:toxicratio
Quinolones
Levofloxacin:GNB,P.aer,Campylobacter,
Legionella
Mechanism:DNAtopoisomerase
AE:GItoxicity,hypersensitivity,
tendonrupture
Macrolides
Erythromycin:Campylobacter,Legionella,
Mycoplasma,Chlamydia
Allmacrolideshave5syllablenames.
NotethatLegionella,Mycoplasma,and
Chlamydiaallcauseatypicalpneumonia.
Mechanism:inhibitproteinsynth(50s)
AE:nausea,vomiting.
Contraindicatedtousew/nonsedating
antihistamines.
Ototoxicwithhighdose.
Reversibleabnormalrenalfunction.
Tetracyclines
Tetracycline:Anaerobes,Spirochetes,
Rickettsia,Chlamydia,Mycoplasma
Mechanism:inhibitproteinsynth(30s)
AE:Bonediscoloration.Notforpregnancy!
Sulfonamides-
Trimethoprim
SulfaTMP:staph,H.flu,Pneumocystiscarinii,
NOTP.aer
UsedtotreatuncomplicatedUTIs
Sulfonamidesmechanism:blocksynthesisof
folatefromPABA
TMPmechanism:blocksreductionoffolate
foruseinnucleotidesynthesis
AE:Hypersensitivity,rash,GItoxicity,
granulocytopenia,hemolysisw/G6PD
deficiency

Vancomycin
Vancomycin:Mostgrampositives,MRSA,
S.pneu,Enterococci
Mechanism:inhibitcellwallsynthesis.
(Inhibitscellwallmucopeptide
formationbybindingDalaDalaportion
ofcellwallprecursors.)
AE:Rareredmansyndrome(histamine)
Clindamycin
Clindamycin:Anaerobes,B.frag,Staph Mechanism:inhibitsproteinsynthesis(50S),
inhibitstranslocase
AE:pseudomembranouscolitis
Metronidazole
Metronidazole:GNB,B.frag,C.diff Mechanism:formstoxicmetabolites
AE:DisulframlikeEtOHintolerance.
Inhibitsmetabolismoforalanticoags.
CNStoxicity
Rifampin
Rifampin:Meningococci,Mycobacteria
Alwaysusedincombinationunless
prophylaxis
(singlesitemutationresistance)
Mechanism:inhibitsRNApolymerase
AE:orangefluids,
enhancesclearanceofotherdrugs
New Agents/Classes
Linezolid,Daptomycin:MRSA,vancresistantenterococci,gramposititives
Typical Pneumonia:
Clinical
Pneumococcal:quickonset,singleshaking
chill,suddenfever,pleuriticchestpain,
productivecough.Communityacquired.
Complications:sometimesbacteremia.
Staphaureus:gradualonset,verysevere,rapid
progression.IVusersorpostviral
influenza.Complications:lungabscess,
empyema,bacteremia,endocarditis.

H.influenzae:fever,productivecough.
COPDers,children.
MixedAnaerobic:foulsmellingsputum.
Alteredconsciousnes,dysphagia.
Complications:empyema,abscesses.
GNB:acuteillnesswithconfusion,chills,
sometimesbacteremicshock.Mostly
nosocomial(KlebsiellaifalcoholicorIC).
Complication:pleuraleffusion.
Atypical Pneumonia:
Clinical
Mycoplasma:Insidiousonset,drycough.
Collegekids.
Viral:Nosputumproduction,like
mycoplasmapneumonia.

Legionella:~1weekincubation,systemic
symptoms.Drycough.Nopersonto
personspread.COPDers.
Chlamydia:Drycough,nosputum.Psittacosis
frombirds;Chlamydiapneumoniaein
collegekids.
Treatment of Pneumonias
Pneumococcal:Ceftriaxone,Levofloxacin.
NOTpenicillin(toomuchresistance).
Staphaureus:Nafcillin
H.influenzae:Ceftriaxone,TMPSulfa,Levo,
Macrolide
MixedAnaerobic:Clindamycin,
drainemypema
GNB:Aminoglycoside
PLUSpiperacillin/ceftriaxone
Mycoplasma:Macrolide
Viral:Amantadine/Rimantadine
Oseltamivir/Zanamivir
Legionella:Macrolide,Rifampin
Chlamydia:
Psittacosis:Tetracycline.
Chlamydiapneumoniae:
TetracyclineorMacrolide

Endocarditis
Clinicalfeatures:Fever,murmur,normocytic
anemia,leukocytosis,ESR,microscopic
hematuria.
Cutaneousmanifestations:Petechiae,Oslers
nodes,Janewaylesions(rednontender
maculesonpalms/soles),purpuricskin
lesionswithstaphABE.
Drugaddicts:Tricuspidinvolvement,lung
emboli
SBE:MostlyStrepviridans.Strepbovis(Group
D)associatedwithcoloncancer
ABE:MostlyStaphaureus
Treatment:IVantibiotics46weeks
S.viridans:Penicillin/Ceftriaxone
Enterococcus:Penicillin+Gentamicin
NOTCephalosporins
Staph:Nafcillin/oxacillin
HACEK(mouthflora):Ceftriaxone
Onetimeprophylaxis:
S.viridans(Dentalwork):Amoxicillin
Enterococcus(GIsurgery):Amp+Gent
Bacterial Food Poisoning
Staphenterotoxins:Shortincubation,common
C.perfringens:Previouslycookedmeat,~12
hrsincubation
B.cereus:Fromrice
Neurotoxinsoftoxicdinoflagelates:
Fish&shellfishpoisoning.
AcuteGIsymptomsw/paresthesias
Generally,antibioticsareofnovalue.
Treatdiarrheawithfluids.
Bacterial GI Infections
Salmonella:Gastroenteritis.Osteomyelitis(especiallysicklecell).Typhoid(enteric)feverwith
S.typhisplenomegaly&rosespots(redblanchingmaculesonabdomen).
Asymptomaticcarrierpossible(convalescentceasesafter6months,orchroniccarrier
gallbladder).Donttreatgastroenteritis(unlesssicklecellpt).TreatTyphoidfeverwith
TMPSulfa.Vaccineavailable
Shigelladysenteriae:Shigatoxin.Bloodydiarrhea.Treatwithfluids,TMPSulfa.
UnlikeSalmonellagastroenteritis,antibioticseliminatesorganismexcretioninstool
Campylobacter:Mostcommonbacterialdiarrhea.Canbebloody.
Vibriocholera:Smallintestinelooksnormal,butvoluminousricewaterstool.Treatwithfluids.
Vibrioparahemolyticus:Rawshellfish
E.coli:
ETEC:SimilartoCholeratoxin,Travellersdiarrhea.TMPSulfa.
EIEC:Developingcountries,rareinUS.TMPSulfa.
EHEC:O157:H7producesbloodycolitis.HUSinchildren.Shigaliketoxin
DONTgiveantibiotics:increasesriskofHUSinchildren
EPEC
Clostridiumdifficile:antibiotic(Clindamycin)associatedpseudomembranouscolitis
Parasitic GI Infections
Entamoebahistolyticum:Amebiasis:bloody
diarrhea.TreatwithMetronidazole.
Findtrophozoites(notcysts)instool.
Giardialamblia:Giardiasis:waterydiarrhea,
canlastweeks.St.Petersburg.
TreatwithMetronidazole.
Findcysts(nottrophozoites)instool.
Cryptosporidium:SimilartoGiardiasis,
especiallyw/AIDS.
HappenedinMilwaukee.
Noeffectivedrugtherapy.
Isosporabelli:AIDSpatients.
TreatwithTMPSulfa.
Viral GI Infections
MostimportantcauseofdiarrheainUS
Calciviruses(Norwalk):smallintestinal
illness.Nolonglastingimmunity.
Explosivediarrhea&vomiting.
Rotaviruses:infants/youngchildren.
Topcauseofdiarrhealdeathin
developingnations.
Astroviruses:pediatricdiarrhea,AIDS
Inflammatory Diarrhea
Bacteria:
Salmonella
Campylobacterjejuni
Shigella
Yersiniaenterocolitica
Clostridiumdifficile
Vibrioparahemolyticus
EIEC,EHEC
Parasites:
Entamoebahistolytica
LocalizedtoColon,Ilium
Dysentericdiarrhea
Fecalleukocytesoftenpresent
Non-inflammatory
Diarrhea
Viruses:
Rotavirus
Norwalk
EntericAdenovirus(40,41)
Astrovirus
Parasites:
Giardialamblia
Cryptosporidium
Bacteria:
Vibriocholerae
Localizedtoproximalsmallintestine
Waterydiarrhea
Fecalleukocytesusuallyabsent
HIV Transmission &
Pathogenesis
HIVisalwaystransmissable,evenifplasmalevelsareundetectable.
Receptors:Virusgp160bindstoCD4PLUSchemokinecoreceptor(CCR5orCXCR4).
CCR5:earlydisease.Changesincelltropismduringprogressionofinfectionduetoswitch
fromCCR5toCXCR4.CXCR4morewidelyexpressedonTcellsincludingnaveTcells.
Deletion/mutationinhumanCCR5geneconfersresistancetoHIVinfectionbecauseCCR5
isacoreceptorthatallowsMtropicvirustogetintocells.
HIVinfectsCD4+cells:Tcells,Macrophages,andDendriticcells(Langerhanscellsin
mucosa).gp120bindstoCD4.
HIVPhenotypes:R5CCR5coreceptor;X4CXCR4corecepror;R5X4CCR5&CXCR4
Retroviruses Review
LTR:Genomicregulatoryregionfortranscriptionofintegratedretroviruses(DNA)
(Psi):Packagingsignal,requiredforvirionRNAtobeincorporatedintovirusparticles
PBS:Primerbindingsite.tRNAbindshereandprimesreversetranscription
HIV Review
CladeBofHIV1dominantforminUS
Lentivirusesaremorecytolyticthanotherretroviruses,canlysehostcells.Theyoftencause
latentdisease,andcaninfectnondividingcells
tat:EnhancesHIVexpressionbymRNAsynthesisfromproviralLTR
nef:DownregulatesMHCIandCD4.Perturbshostcellsignallingandactivation.
Essentialforpathogenesisinvivo.
vif:DegradeshostantiviralproteinAPOBEC3G.
vpr:1)Traffickingtoviralcoreforintegration.2)AlsohaltscellcycleinG2.
vpu:1)DownregulatesCD4,allowsnewlysynthesizedenvelopeglycoproteinstobeassembled
ontobuddingvirions.2)Increasesthereleaseofbuddingvirions.
rev:SimilartoHTLVsrex:alterssplicingsounsplicedorsinglysplicedmRNAproduced.
Whenrevisexpressed,productionofviralparticlesincreases
Review of HIV Structure

Clinical Stages of HIV

Disease

PrimaryHIVInfection(PHI):Inmucosalinfection,Dendriticcellsplayprimaryrole.DCSIGN
receptorisaCtypelectinreceptorthatbundsglycoproteins,includingHIVgp120.
DendriticcellstransportboundHIVtoregionallymphnodesandefficientlytransferHIV
toCD4+TCells.
AcuteHIV(Retroviral)Syndrome:Widespreaddisseminationofvirus23weeksafterPHI.
ELISAdetectableAb37weeksafterPHI.Symptomaticfluormononucleosislike
seroconversionassociatedwithfasterprogressiontoAIDS.Canhaveabnormallabs
(leukopenia,thrombocytopenia,LFTs).
GutAssociatedLymphoidTissue(GALT)CD4+TCellsinfected.
ClinicalLatency:Individualasymptomatic,butvirusisreplicating.DeclineinCD4+cells,
reducedcellularimmunity,dysregulatedAbproduction:
IgG,IgESLElikeautoimmunesyndromes,hypersensitivitypneumonia
AdvancedDisease:HIVvirusitselfcancause:
Neurologicaldisease:Dementia(infectedmicroglia),myelopathy,peripheralneuropathy
Renaldisease:Collapsingglomerulonephritis
Immunedeficiency:CD4+loss,disorganizationofsecondarylymphoidtissue
Host Cellular Response to
HIV Determines Viral Set
Point
CD8+TcellskillinfectedCD4+cells,
releasecytokines
HIVspecificAb:Neutralization,ADCC
Roleoflonglivedcells:Macrophagesare
longlivedcellsthatvirusinfectswithout
killing.HIVvpr&nefgenescause
Macrophagestoactasreservoirforviral
persistence.
MemoryTcellsarethelongestliving
cellsthatcanbeinfectedwithHIVand
alsoactasreservoir.
Theseresponsescanmodulatethevirallevel
todeterminethesetpointofviral
replicationduringclinicallatency.
Sourceofvirusthatcanbemeasuredfrom:
1)VirusfromactivatedCD4+cells.Can
bestoppedwithHAARTtherapy.
2)Virusreleasedfromstablereservoirs
(memTcellsandmacrophages).Release
continuesevenwithHAARTtherapy.
Viralload=speedoftrain
CD4+count=lengthoftrackremaining
Correlations of Disease
with CD4 count
CD4>500:Bacterialsinusitis,pneumonia,
HSV,TB,pyoderma
CD4200500:Herpeszoster,Thrush,
KaposisSarcoma
CD450200:CandidaEsophagitis,PCP,
Cryptosporidiosis,Histo,
ExtrapulmonaryTB,NHL
CD4<50:CMV,Cryptococcosis,MAC,PML,
Toxo,CNSlymphoma
TB: Pathogenesis
Twostageprocess.
1)Developmentoftuberculosisinfection.AirborninfectionBacilliproducelocalized
pneumonia(lowerlobe)&spreadtohilarLN(Gohncomplex)systemicinfection
controlledbycellmediatedimmunitypositivePPD.Initialinfectionusuallymildor
asymptomatic.TBlivesinmacrophages.
2)Progressiontotuberculosisdisease(10%).Granulomatousinflammation(fibrocaseous
cavitarylesioninupperlobes).Causedbyreactivation.ThisistheclassicalactiveTB.
TB: Respiratory, Local LN
Manifestations
TBpneumonia:Veryinfectious
LaryngealTB:Infectedvocalcords,very
infectious
TBpleuraleffusion
HIV/AIDS:CXRisnotdiagnostic
Scrofula:Painfulcervicaladenitis.Canalsobe
causedbyatypicalTB
TB: Disseminated infection
(host cant contain
infection)
MiliaryTB:Failuretocontaineitherearlyor
latedissemination.Milletseed
appearanceofgranulomataonCXR.
Canleadtorespiratorydistress,
meningitis(10%),liver,bonemarrow
(pancytopeniaORleukemoidreaction).
CrypticmiliaryTB:disseminatedTB
butwithoutmilletseedpattern(Eleanor
Roosevelt).AIDSpts.
CNSTB:Meningitisleadstoscarring:CN
palsy,paralysis,confusion,w/aseptic
meningitis.
CSF:Lymphs,protein,glucose.Rare
acidfastorganisms.
GenitourinaryTB:Symptomsmirrorlocal
infection:Abacteriuricdysuria,
hematuria,flankpain.Abnormal
pyelogram.Canpalpatemassin
epididymisinmales.
Bone&Joints:
1)Osteomyolitis:Highbloodflowto
metaphyses.Pottsdisease:lower
thoracicvertebralinvolvement.Can
causeparavertebralabscess.
2)Arthritis.
Pericarditis(rare);IntestinalTB(mimics
Crohns)
AdrenalTB:Addisons,calcifiedadrenal.
Positive PPD
LatentTB:PositivePPD,NOevidenceof
activedisease.Ifhighrisk,treatto
preventprogressiontoactivedisease.
AllptswithposPPDreceiveCXR.IfCXR
normalANDasymptomaticlatent.
Quantiferon:measureofcellularimmunity,
morespecificthanPPD.
TB Diagnosis & Treatment
Diagnosis:Sputummicroscopy,AFBculture,
rapidDNAprobetesting,drug
susceptibilitytesting(slow).
Treatment:4drugcombination:
Isoniazid,Rifampin,Pyrazinamide,
Ethambutol/Streptomycinfor8weeks.
Rule:4drugsfor2monthsthen2drugs
for4months.

Viral Vaccines
MMR(Measles,Mumps,Rubella):live
attenuated.Measlesis2doses.Vaccine
hasnolinktoautism.
VZV:liveattenuated.2doses.CautioninIC,
pregnant.
Smallpox:livevirus.Localinfection/
adenopathy.Canhaveseverereaction.
Influenza(FluMist):liveattenuated,cold
adaptedtorestrictreplication.
ContraindicatedforIC,pregnant,
asthmatic,eggallergic.

HAV:killed(formalininactivated).
FDAapprovedfor>1yo.
Polio:killed(livenolongeravailable)
Rabies:killed
Influenza(shot):killed.trivalentsplitvirus.
Recommendedforallpregnantwomen
duringfluseason.
HBV:HBsAgsubunit.Recommendedforall
infants.Nolinktoseizures,Guillian
Barr,MS,SIDS
Nocausalrelationshipbetweenthimerosal
containingvaccinesandautism.
Standard precautions
Appliestoallpatients:requiresallbloodtobehandledasifinfected.
Airborne precautions
Disseminationbyparticles<5minsize
TB,Measles,Chickenpox,Smallpox
Negativepressureisolationroom
Doorkeptclosedwithpostedsign
Patientcanleaveroomonlyinemergency,
wearingsurgicalmask
Droplet precautions
Disseminationbyparticles>5minsize
Many,includingAdenovirus,Anthrax,H.flu,
Influenza,N.meningitidis,Pertussis,
pneumonicPlague,GAS
Privateroomwithsign
Doorclosed
Allpersonsenteringroommustwearsurgical
mask
Patientmustwearsurgicalmaskwhen
leavingroom
Contact Precautions
Antibioticresistantorganisms
(MRSA,VRSA,VRE,ESBL+Klebsiella)
C.diff
Rotavirus
Privateroomwithsign
Glovesmustbewornonenteringroom
Gownswornfordirectpatientor
environmentalcontact
Removegowns/gloveswhenleavingpatient
room
Surgical Site Infection
Prevention
Limitdamagepriortosurgery
Adminprophylacticantibiotics120and30minspriortosurgery
Goodsurgicaltechnique
Maintainhightissueoxygenation2hrsfollowingabdominalsurgery
TightcontrolofhyperglycemiainSICU
Laboratory manifestations
of Sepsis
Leukocytosis(WBC>12,000)withleftshift(presenceofbands)
Toxicgranulations,Dhlebodies
Thrombocytopenia
Pathophysiology of Sepsis
SepsiscausedbyGramnegatives(LPS,DNA),
Grampositives(lipoteichoicacid,
peptidoglycans,toxins),Fungi,and
Viruses
LPSrecognizedbyreceptorcomplex:
CD14,TLR4,andMD2
Organisms which cause
cryptogenic sepsis
Cryptogenicsepsis(child):Meningococcus,Listeriamonocytogenes,GBS
Cryptogenicsepsis(adult):Meningococcus,S.aureus
Cryptogenicsepsis(adultIVDU):S.aureus,GNB
Risks of getting diseases
from blood exposure
HIV:1/300

HCV:1/50
HBV:~1/25ifHBeAg(),or~1/4if(+)
HIV PEP (Post-exposure
prophylaxis)
Empiricaldata:treatmentfor10daysnot
enough.28daysareenough.
PEPshouldbeofferedassoonaspossible,
andadministeredfor4weeks.
DonotgiveEfavirenztopregnantwomen.
HBV PEP
CangiveHBVvaccineandHBIG(shouldbe
administeredwithin24hours).
Lamivudineiseffecive
HBC PEP
Thereisnone!Youreoutofluck.
HIV Treatment
Maximizeadherence:
95%topreventresistance
ManyP450interactions
Mustusemedicationsfromdifferentclassis
(NRTI,NNRTI,PI).
Startandstopallmedicationsatthesame
time.
SideeffectsofHAART:
*lacticacidosis
*hepatotoxicity
*hyperglycemia
*fatmaldistribution,hyperlipidemia
*bleedingdisorders,rash
*osteoporosis
Hereditary
Immunodeficiencies
LeukocyteAdhesionDeficiency:Abnormalityinintegrinproteins.Delayedseparationof
umbilicalcord.Impairedwoundhealingwithoutpus.
ChronicGranulomatousDisease:Diminishedrespiratoryburst.Problemswithcatalase
positiveorganismssuchasS.aureus,Serratiamarcesens,Aspergillusfumagatus.
BrutonsAgammaglobulinemia:Bcelldisease,noantibody.Problemswithencapsulated
bacterialikeS.pneumo,H.flu.
Acquired
Immunodeficiencies
Neutropenic(i.e.cancerchemotherapy):Susceptibletotheirownfloralivinginskinorgut.
*Feveralwaysindicatesinfection:treatimmediately,andcontinuetreatmentuntilno
longerneutropenic.
*Earlyinfections:bacterial;Lateinfections:fungal.
Organtransplantrecipients:TcellMacrophageaxissuppression(Graftrejectionmedicine).
*Susceptibletovirusesandintracellularbacteria(ListeriaorTB),orparasites(Tgondii).
*Earlyinfections:complicationsofsurgery.
*Middleinfections:Intracellularpathogens(CMV)
*Lateinfections:Continuedsusceptibilitytointracellularpathogens.Tgondii,PCP.
Listeriamostcommoncauseofmeningitis.Fungi(Crypto,Histo,Blasto,Coccidio)
Bonemarrowrecipients:
*Neutropenicphase:Seeaboveforneutropenia.MayalsodevelopsevereHSV1dueto
lackofTcells.
*Immunosuppressivephase.SubjecttoCMV13monthsposttransplant.
Patientswithphysicalabnormality/barrier.
Cytokineinibitors:Allowslatentinfectionstoreactivate(TB!)
Treatment of IC patients
with infection
Prophylactictreatment:Automaticallytreat
beforeanysymptoms.Treatpatientson
theexpectationthattheywilldevelop
infectioniftheyarenottreated.Example:
SulfaTMPforPCPprophylaxisinorgan
transplantrecipient.
Empirictreatment:Withsymptoms,treatfor
stereotypicalorganismswithoutculture
results.
Preemptivetreatment:Treatonbasisof
laboratoryfinding.Example:TreatCMV
withganciclovirinbonemarrow
transplantpatientwithhighCMVPCR
inserum.
Specifictherapy:Optimalapproach.
Treatmentbasedoncultureresults.