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| 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 |
| 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 |
| 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 |
| Tick borne diseases: | Lyme disease Babesiosis TIBOLA tick borne lymphadenopathy Erlichiosis Rickettsial diseases Q fever Tularaemia Tick borne encephalitis |