| Empiric treatment: | based on experience
(“most likely” microbiological etiology
can be inferred from the clinical symptoms) |
| Preemptive treatment: | „diagnosis-driven treatment”, usually
fungal sepsis (microbiological
evidence of candidiasis without proof of
invasive fungal infection) |
| Targeted (definitive) treatment: | the etiologic pathogen is identified and/or antimicrobial susceptibility is tested |
| Profilaxis:: | using antibiotics for prevention (Neisseria meningitidis) |
| Chemoterapeutic index : | Dosis Tolerata Maxima / Dosis Curata Minima |
| The perfect AB should have… (it is not existing!): | Selective toxicity:
?LD50 and chemoterapeutic index ; ?MIC (MBC)
Bactericid; proper tissue penetration and concentration; wide spectrum, no side effects, no acquired resistance is developed against it |
| Bactericidal antibiotics: | beta-lactams
kinolons, fluorokinolons
glycopeptids
aminoglycosides
rifampicin
metronidazol
nitrofurantoin |
| Bacteriostatic antibiotics: | macrolids
lincosamids
(!!! clindamycin in > 2 g/ die dose is bactericid agains staphylococci)
tetracyclin
chloramphenicol
oxazolidinons
sulfonamids
fidaxomycin, quinipristin, dalfopristin(in combination bactericide) |
| antibiotics mode of action: | Cell wall synthesis inhibitors:beta-lactams ,glycopeptides
Alteration of cell membrane function
Protein synthesis inhibitors
(acting on 30S / 50S ribosome subunit)
Folic acid sythesis inhibitors
Nucleic acid synthesis inhibitors
Miscellaneous |
| Beta-lactams: | targts penicilin binding protein, inhibits transpeptidase
bactriocidal, broad spectrum, synergy with aminoglycocides
time dependant, 3-4 doses /day, low intracellular, prego ok
classes:penicillins ,cephalosporins ,carbapenems ,monobactams |
| Lactamase-labile penicillins: | penicillin-G, penicillin-V), penamecillin
treatment of Spyogenes(both), s.pneumonia(targeted),
subacute bacterial endocarditis gas gangrene
T. pallidum, anthrax, diphtheria |
| Lactamase-stable penicillins: | oxacillin, dicloxacillin, flucloxacillin, nafcillin, temocillin
methicillin (oxacillin) sensitive Staphylococcus aureus (MSSA)
and coagulase-negative staphylococci (MSSE) |
| Broad spectrum penicillins: | aminopenicillins (amoxicillin, ampicillin)
community acquired lower respiratory tract infections
otitis media, enterococcal infections, group B streptococcal infections
,Listeria monocytogenes infection ,bacterial endocarditis prophylaxis ,UTI
carboxipenicillins (carbenicillin, ticarcillin)
ureidopenicillins (piperacillin, azlocillin, mezlocillin) |
| Penicillins combined with lactamase inhibitors: | amoxicillin/clavulanic acid (Augmentin)
ampicillin/sulbactam (Unasyn)
piperacillin/tazobactam (Tazocin) |
| amoxicillin/clavulanic acid (Augmentin) | UTI, soft-tissue infections, skin, cholecystitis
cholangitis, hospital acquired early pneumonia
community acquired upper and lower respiratory tract infections
hospital acquired early pneumonia, cholecystitis, cholangitis
UTI, skin and soft-tissue infections |
| piperacillin/tazobactam (Tazocin) | fever of neutropenic patients, sepsis of unknown origin
neck infections
severe head
complicated UTI
multibacterial skin
soft-tissue infections, intra-abdominal infections, severe community acquired, and nosocomial pneumonia |
| Cephalosporins: | I. gen.: rather Gram-poz
III. gen.: rather Gram-neg
II. gen., IV. gen.: Gram-neg., Gram-poz
V. gen.: ceftaroline, ceftobiprole – anti-MRSA drug
ceftriaxon, cefotaxim, ceftazidim, cefepim: |
| Cephalosporins: | I. gen.: rather Gram-poz
community acquired mild upper respiratory tract
infections, mild skin and soft-tissue infections |
| #Cephalosporins:II. gen., IV. gen.: | Gram-neg., Gram-poz
upper respiratory tract infections, sinusitis, otitis
tonsillopharyngitis, acute exacerbation of COPD
community acquired (not atypical) pneumonia
early nosocomial pneumonia , biliary tract infections
, not complicated UTIskin and soft-tissue infections
Lyme-disease |
| Cephalosporins:V. gen.: | ceftaroline, ceftobiprole – anti-MRSA drug
ceftriaxon, cefotaxim, ceftazidim, cefepim: CSF
require dose modification---> severe renal failure(not ceftriaxone)
resistant: enterococci ,Listeria monocytogenes ,
Legionella pneumophila, Rickettsia, Chlamydia, Mycoplasma
anaerobes, MRSA, MRSE |
| bacteremia: | not clinical diagnosis, bacteria in blood, not illness
treatment not necessary |
| sepsis: | clinical diagnosis, serious, high mortality, need treatment |
| hemoculture: | atleast two sets before antimicrobial treamtent
on percutaneously, one trough vascular access device
when fever or chills, disinfect skin |
| special bacteremia: | s.aureus
candida species |
| s.aureus: | 20-40% mortality
bacteremia>10 days afer therapy, recurrence 60days afer therapy
always should be treated(even one positice hemo)
skin, soft tissue, prosthetic, metastatic infection
bone, joint, abdominal pain, costovertebral angle, protreacted fever, sweats
physical examination:regurgitant murmurs or heart failure,
endocarditis, emboli, fundi, conjunctivae, skin, and digits
neurologic evaluation, Pain |
| s,aureus antibiotics: | Empiric:vancomyci, daptomycin
targeted mssa:naficilin, cefazolin
Duration of treatment
Uncomplicated: 14days intravenous after negative test
Complicated: 4-12 weeks
uncomplicated bacteremia:no endocarditis, no prosthetics, 3-4 days negative culture post treatment , no metastatic infections |
| Candidaemia: | Mortality 20-49%, therapy timing important
One single hc positive test
Prophylaxis(flucumazole),
empiric(fever)
pre empiric(diagnosis)(B-D- glucan detection),
targeted(hemoculture)(isolated candida)(echinocandin, a pH..B,)
Remove catheters IV, TEE, fundoscopy
Candida cultures:Resp: no treatment, urinary : only when symptoms (Pyuria) present |
| endocarditis: | Male :Female ratio 2:1 |
| Pathogens of endocarditis: | Oral:S. sanguis, S. mitis, S. salivarius, S. mutans,
Gemella morbillorum(penicilinG)
Hematogenouas: S. sanginosus, S. intermedius, S. constellatus:
GI: Group D streptococci ,(Penicillin G), E. faecalis E. faecium(vancomycin, gentamicin, tigecyclin, linezolid, ampicilinf/amoxi)
Staph: Saureus, s.lugdunensis(CNS) |
| negative culture (endocarditis): | Intercellular bacteria:(serology, Gene amplification)
Fastidious organisms: HACEK group, brucella, fungi
Prior AB treatment |
| Diagnosis IE: | Suspicion, acute rapidly progressing or subacute or chronic
Fever, chill, poor appetite (90%), murmurs (85%), Vascularand immunological phenomena
TTE, TEE: repeat 7-10 days later if examinations negative or S aureus
, echocardiography(vegetation, abscess, dehiscence and follow up)
Blood cultures: three sets, peripheral vein, virtually all cultures positive |
| Major criteria for IE:(check lec) | Blood culture positive
Endocardial involvement evidence (vegetation, abscess, dehiscence, new regurgitation) |
| Minor criteria for IE: | Predisposition, Fever, vascular phenomena, immunologic phenomena, microbiologic evidence |
| Immunologic phenomena for IE: | Glomerulonephritis
Osler’s nodes
Roth’s spot
RF |
| Treatment, management IE: | Antibiotics
Heart surgery
Follow-upBCs: every day until = 2 consecutive are
negative
Seek for source / complications |
| Antibiotic treatments IE: | , |
| Complications IE : | Heart failure, uncontrolled/persistent infections, systemic embolism, neurological complications(ishchaemic stroke, subarchnoid hemmorhage, toxic encephalopathy), Infectious (mycotic) aneurysms Myocarditis, pericarditis, heart blocks, muskoskeletal, renal failure |
| Prosthetic valve endocarditis: | Early:within one year,staph, fungi, negbacili,
late: after one year, same pathogens
Surgery, rifamp, genta |
| Right-sided IE: | S.aureus
septic pulmonary emboli
Usually large vegetations |
| IE PROPHYLAXIS: | prosthetic valve
previous episode of IE., with CHD(cyanotic CHD), prosthetics,
Only for dental procedures interrupting the gingival
mucosa
Amoxi 2g or Clinda 600 mg 30-60 minutes prior to
Procedure |
| Cns syndromes: | tetani
Rabies
Poliomyelitis-syndromes (acute flaccide paralysis)
Guillain-Barré syndrome
Slow viral infections (SSPE-morbilli; PRPE-rubella; PML-JC virus)
Prion diseases |
| Meningitis: | means the inflammation of the arachnoidea, WBC is eleveted in the CSF
WBC > 5/ul , CSF protein > 0,5 g/l, CSF glucose < 0,6-2,5 mmol/l |
| Pleocytosis: | Meningitis
lumbar puncture (traumatic)
After GM seizures
Encephalitis
Brain abscess
Real CSF WBC = blood WBC X CSF RBC
blood RBC |
| Meningitis guideline: | Immediate lumbar puncture(do ct for ICP)
Steroids before antibiotic
Liquor examination
Hemoculture
Antibiotics
(!TIME!) |
| When do we delay lumbar puncture: | Airways breathing and circulation security
Clinical signs of bleeding
Elevate ICP (CT) |
| The meningitis pathogens(IMPORTANT): | Community acquired: pneumoniae MOST, N. meningitidis ,GBS (S. agalactiae), H. influenzae, Listeria monocytogenes LEAST
Post operative:Gram-neg. enteric bacteria 38% MOST, Streptococcus, S. aureus, CNS
S. pneumoniae, L. monocytogenes, N. meningitidis LEAST |
| Empiric treatment meningitis: | Ceftriaxon – ALWAYS
Plus Vancomicin : always except NEONATES
Plus Rifampicin: if steroid is added to Vanco
Plus Ampicillin: if Listeria is suspected (> 50 years, ID)
Antipseudomonas antibiotic (Ceftazidim, Cefepime or Meropenem):
postoperative, posttraumatic, ID
Always parenteral, maximal dose, 7-28 days. Steroids before AB
prevention: vaccination, chemprophylaxis, screening for GBS |
| Listeria: | ood, milk, cheese, 30days incubation, kids and pregnant women, 50yrs>
Ampicillin(!), vancomycin
Lower fever, light GOT symptoms, Meningitis/meningoencephalitis, Rhombencephalitis
Absccesses in the thalamus and brainstem Intrauterin
Endocarditis, sepsis |
| Brain abscess: | Direct spread(tooth, otitis)
Direct inoculation (trauma)
Hematite boys spread(lung,skin)
cyantotic vitium, pulm.AVM |
| Brain abscess symptoms | pic |
| Diagnosis abscess: | LP, CT
MRI better and faster
Hemocultur(gram staining, culture, special staining, histology)( tbs, Nocardia, Actinomycosis, fungi)
Serology (toxoplasma, cysticerca, criptococcus) |
| Abscess management: | 2,5 cm should be drained (aspirated or operated)
and cultured, NATIVE PUS + transport material, Focus of origin shoud be seeked and cultured (and drained ifneeded). In case of elevated ICP steroid shoud be given.
Empiric 1: ear toot paransal: metronidazole + ceftriaxon(2-8W)
Empiric 2: hematogenous: metronidazole + ceftriaxon + vanc—> Flucloxacillin
Empiric 3: postoperative: vanco—> flucloxa + Ceftazidim or Cefepime or Meropenem (anti pseudomonas) |
| Intra thecal antibiotics: | Vancomycin 5-20 mg
Gentamycin 1-8 mg
Tobramycin 5-20 mg
Amikacin 5-50 mg, Polymyxin B 5 mg
Colistin 10 mg
Quinupristin/Dalfopristin 2-5 mg
Teicoplanin |
| Penetrant ABS to brain: | i.v. in maximal (elevated) doses for 4-8 weeks
Penicillin Flucloxacillin, Meropenem Rifampicin, Cefotaxim Ceftriaxon
Ceftazidim TMP/SMX Vancomycin Linezolid, Metronidazole FQ (Cipro, Moxi)
Daptomycin, AmphoB Voriconazole |
| Discitis, vertebral osteomyelitis, epidural abscesses pathomechanism: | Hematogenous, direct spread(psoas, bowel, aorta,..), direct inoculation
S. aureus(MOST), Gram-negative enteric bacteria, Pseudomonas, Candida, Strepto, tbc
Brucella, Burkholderia, Salmonella, Entamoeba stb.(rare) |
| Discitis, vertebral osteomyelitis, epidural abscesses diagnosis: | Elevated We (100% > 20 mm/h; 80% > 100 mm/h)
Elevated CRP 87%
Elevated WBC 60%
back pain, fever, neurological deficit, concomittant
infection, RFs, Elevated inflammatory parameters X-ray, CT(only late) HC, biopsy (needle, open)
Find the focus
Seek for endocarditis(patient has heart disease, heart symptoms) |
| Discitis, vertebral osteomyelitis, epidural abscesses therapy: | Empiric: Vanco + Cefotaxim or Ceftriaxon or Ceftazidim or Cefepime or
Cipro
Anti anaerobic: metronidazol or clindamycin
Targeted treatment
Follow up: pers os, MRI control |
| Encephalitis pathomechanism: | HSV, St. Louis, West Nile LCMV, Rabies stb
Listeria, Lyme, Rickettsia stb.)
VZV, mumpsz, morbilli stb
Malaria |
| Encephalitis Signs and symptomes: | Change in mental status, Epilepsia, Focal neurological signs, Headache, Fever, Nausea, vomiting, Meningeal signs
CSF, Serology, CT, MR(important)
EEG, Brainbiopsy
Acyclovir i.v. IMMEDIATELY (cont. if HSV
or VZV proven)
ICP controll |
| Rhinositis: | Commonly viral
Bacterial
Fungal
Rhinovirus, Enterovirus, Coronavirus, Influenza parainfluenza, RSV, Adenovirus
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella
catarrhalis, Staphylococcus aureus (MSSA and MRSA)
Aspergillus |
| Nasopharyngitis: | Mostly viral
Rhinoviruses, Coronaviruses, Influenza and parainfluenza,
Adenoviruses, Enteroviruses, Orthomyxoviruses, Paramyxoviruses,
RSV, EBV, Bocavirus, Varicella, Rubella. |
| Pharyngitis: | Mostly viral
Bacterial
Group A streptococci, Group C and G streptococci (infants,
immunocompromised), Neisseria gonorrhoeae, Corynebacterium,
Mycoplasma pneumoniae, Chlamydia pneumoniae, Anaerobic
Bacteria |
| Infectious Mononucleosis clinical symptoms: | Triad fever, pharyngitis, adenopathy
Nasopharyngeal secretion transmission
live, spleen, lymph nodes, CD8+ cytotoxic T cells
1-2M incubation,
nonspecific symptoms
Specific symptoms: lymphadenopathy, pharyngitis, periorbital edema (bilateral upper-lid), palatal petechiae, hepatosplenomegaly, rash
Infectious Mononucleosis |
| Infectious Mononucleosis diagnosis: | Heterophile antibodies tests Blood picture
anti EBV antibodies:
Infectious Mononucleosis treatment:
Non specific, supportive, Monitor patients with extreme tonsillar hypertrophy,
hemolytic anemia, thrombocytopenia, CNS
involvement, or extreme tonsillar enlargement warrant
corticosteroid therapy! Sub-culture for bacterial superinfection |
| Streptococcus Pyogenes: | Spread by respiratory droplets
Diagnosis: Throat cultures(posterior pharynx and tonsils), Rapid antigen detection tests
Treatment: antibiotics after confirmation
!Penicillin V, Amoxicillin, Macrolides! |
| Epiglottis: | supraglottic region
Mostly bacterial: Haemophilus influenzae, H. parainfluenzae, Streptococcus
pneumoniae, and group A streptococci, also Staphylococcus
aureus, mycobacteria
Non bacterial: Thermal, chemical, foreign body ingestion
Clinical: odynophagia/dysphagia, fever, hot
potato voice! Tripod position, drooling, hypoxia, respiratory distress, pain to
palpation of larynx, mild irritative cough |
| Epiglottis management: | Airways, intubation, tracheostomy or even cricothyrotomy Give humidified oxygen
dexamethasone therapy or budesonide aerosols
Do blood and epiglottic cultures
Start antibiotic therapy!
!Third-generation cephalosporins! |
| Laryngotracheitis(croup): | Mostly viral
Bacterial: Group A streptococci, Corynebacterium , H. influenza, Chlamydia
pneumoniae, Mycoplasma pneumoniae, Moraxella catarrhalis dry cough and hoarseness! |
| Pertussis (whooping cough): | Incubation period around 1-2 weeks
Catarrhal, paroxysmal, convalescent
acute coughing lasting at least 14 days, post-tussive vomiting, whooping cough
Nasopharyngeal aspiration for culture, PCR, blood tests !macrolides! |
| Influenza: | !Orthomyxoviridae!
Surface proteins Neuraminidase (N) and Hemagglutinin (H) High fever, sore throat, myalgia, retroorbital headache,
nausea, vomiting diarrhea, pneumonia
RT-PCR or viral culture of nasopharyngeal or throat
secretions, Rapid antigen tests
Type A viruses Drift and Shift = Pandemics / Seasonal epidemics
Type B viruses Drift = Seasonal epidemics Neuraminidase inhibitors:
Oseltamivir, and Zanamivir |
| Antigenic Drift: | small changes mutations in the genes of influenza viruses
that can lead to changes in the surface proteins of the virus: HA and NA |
| Antigenic Shift: | Abrupt, major change in an influenza virus, resulting in new
HA and/or new HA and NA proteins |
| Bronchitis: | Caused by same infectious agents causing URTIs
viruses(influenza A and B, parainfluenza, respiratory syncytial virus,
and coronavirus) or bacteria (Mycoplasma species, Chlamydia
pneumoniae, Streptococcus pneumoniae, Moraxella catarrhalis, and
H.influenzae)
non-infectios: Allergens, |
| Bronchitis clinicals: | cough after URTI FOOD 10-15 days
Sputum, Fever not common, URTI symptoms, diffuse wheezes, accessory muscles used |
| brobchitis diagnosis: | Blood tests, chest X-rays, Sputum cytology, Spirometry or in specific
cases bronchoscopy (foreign body, tumor, TB) |
| Pneumonia treatment: | Outpatient setting, non-complicated: beta lactam or macrolide or doxycycline or moxifloxacin
Outpatient complicated: Outpatient complicated fluoroquinolone or beta-lactam plus a macrolide Inpatient setting non-ICU: Beta-lactam + macrolide |
| Tuberculosis: | 2-12 weeks incubation
Diagnosis: Mantoux tuberculin skin test, interferon gamma
release assay, Xrays, cultures, ELISA, PCR.. |
| Zoonoses: | infections where there is either a
proof or a strong circumstantial evidence for
transmission between animals and man |
| Plague/ Pestilence/black death: | Yersinia pestis , G- bipolar rod,
Enterobacteriaceae family
reservoir – rodents
vector- flea; Trtmnt: streptomycin, gentamycin
Alt: ciprofloxacin, doxycycline, chloramphenicol |
| Forms of plague: | Bubonic
Septicaemi
Pneumonic |
| Ebola: | Affects humans and primates (monkeys, gorillas,
chimpanzees).
Vector: fruit bats |
| Anthrax/malignant pustule: | Contagious, septic disease of herbivorous animals, which can spread from infected animals
or with contaminated animal products to humans
Bacillus anthracis, G+, rod-shape, spore-forming, facultative anaerob
Spores are capable to survive decades in soil or corpses, resistant.
2 exotoxins: lethal toxin and oedema toxins Incubation: 1-7 days
Bioterrorism |
| Anthrax routes: | Cutaneous anthrax
Inhalation/ Pulmonary anthrax: !MOST DEADLY!
Gastointestinall anthrax
Injection anthrax |
| Anthrax Abs: | Ciprofloxacin, clindamycin, PenicillinG,
meropenem, rifampin, doxycyclin, levofloxacin |
| west nile virus transmission: | And dogs
Early summer and autumn |
| west nile virus clinical: | asymptomatic 80%
flu like, lymphadenopathy, diarrhoea,
exanthema
Only 1% neuroinfection: serosus meningitis, encephalitis,
poliomyelitis |
| etiological classification of zonooses: | . |
| reservoir classification of zonooses reservoirs: | . |
| zonooses classification According to ode of transmission: | . |
| modes of transmission: | . |
| tick borne diseases: | lyme disease
Babesiosis
TIBOLA tick borne lymphadenopathy
Erlichiosis
Rickettsial diseases
Q fever
Tularaemia
Tick borne encephalitis |
