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ID BOARD REVIEW 2009

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Title: SKIN AND SOFT TISSUE INFECTIONS Author: David Jay Weber Last modified by: apepp Created Date: 3/18/2000 5:24:23 PM Document presentation format – PowerPoint PPT presentation

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Title: ID BOARD REVIEW 2009


1
ID BOARD REVIEW 2009
  • Amanda Peppercorn, M.D.
  • Assistant Professor of Medicine
  • University of North Carolina at Chapel Hill

2
Toxic Shock Syndrome
  • Group A Strep
  • Any invasive GAS infection (bacteremia, nec fasc,
    gangrenous myositis flesh eating) complicated
    by case definition of TSS
  • Exotoxin superantigens (complicated about 1/3 of
    invasive GAS infections)
  • Associated bacteremia common
  • Staph aureus toxins
  • Food poisoning?staph enterotoxin
  • Staph Scalded Skin?exfoliative toxin
  • CA-MRSA?Panton-valentine leukocidin toxin
  • TSS?TSST-1 superantigen (interact directly with
    invariant region of MHC II molecule with
    activation of up to 20 of all T cells with
    massive cytokine storm)
  • Previous association with tampons
  • Usually MSSA but MRSA has been reported

3
Desquamation
4
TSS Case Definition
  • Fever Tgt38.9C (102.0F)
  • Hypotension
  • SBPlt90 or lt5 percentile by age for childrenlt16
    years of age
  • orthostatic drop in DPBgt15mmHg
  • orthostatic syncope/dizziness
  • Rash diffuse macular erthyroderma
  • Desquamation 1-2 weeks after onset of illness,
    usually palms and soles
  • Multisystem involvement (3 or more)
  • GI (vomiting, diarrhea at onset of illness)
  • Muscular (severe myalgias, elevated CPK)
  • Mucous Membranes (vaginal, oropharyngeal or
    conjunctival hyperemia)
  • Renal (creatininegt2 times ULN or pyuriagt5 WBC)
  • Hepatic (elevated bilirubin or transaminasesgt2
    times ULN
  • Hematologic (plateletslt100K)

5
Treatment
  • Supportive, often hemodialysis, pressors, ICU
    care (intractable hypotension/capillary leak)
  • Strep
  • Emergent surgical debridement if soft tissue
    primary source (pain out of proportion to exam)
  • Empiric Clinda (900 iv q8) imi/dori/meropenem
    or pip/tazo? Taylored PCN G Clinda
  • IVIG
  • ?immunomodulators ex TNFa inhibitors?
  • MSSA clinda oxacillin/naf/cefazolin, IVIG
  • MRSA clinda vancomycin, IVIG

6
NECROTIZING INFECTIONS
  • Necrotizing fasciitis, type 1
  • Mixed infection anaerobes plus strep or GNR
  • Incubation 48-96 h progression hrs days
  • Marked pain, tenderness, swelling, crepitus,
    foul-smelling
  • Necrotizing fasciitis, type 2
  • Grp A strep (flesh-eating bacteria)
  • Incubation 6-48 h progression a few days
  • Often with toxic shock, bullae, no crepitus
  • Pain out of proportion to exam

7
Acute Sinusitis
  • Acute Fever, facial pain, edema, erythema,
    maxillary toothache
  • Subacute Presumed viral sinusitis with no
    improvement in 7d
  • S. pneumoniae H. influenzae M. catarralis
  • Also MRSA, aspergillus, anaerobes from mouth
    flora (rare)
  • Amoxicillin/Clavulanate 875 mg PO Q12h x 10 d
  • Levofloxacin 750 mg PO Q24h x 10 d
  • Reserve antibiotics for patients failing
    decongestant therapy and facial pain, purulent
    discharge and/or severe illness
  • Treatment for full duration of therapy is
    essential to prevent relapses
  • Supportive therapy decongestants and
    antihistamines
  • Complications extension through bone to
    brain?brain abscess
  • Diabetics, immunocompromised think rhinocerebral
    Mucor

8
Actinomycosis
  • Branching filamentous anaerobic gram positive
    rod, higher order bacteria appearance like a
    fungus
  • Characteristic sulfur granules (balls of
    organisms) in tissue/pathology samples
  • Normal part of oral flora
  • Cause oropharyngeal disease (dental abscess, jaw
    osteo, etc)
  • Also cause of uterine infection (IUDs), abdominal
    abscesses
  • Differentiate from nocardia by anaerobic
    principally and modified AFB stain (nocardia,
    actino negative)
  • Treatment PCN, cephalosprins (keflex), clinda

9
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10
Physiology and Resistance Mechanisms of S aureus
  • S aureus is a virulent human pathogen with the
    ability to elaborate a range of virulence factors
    and toxins gram positive cocci in clusters
  • Resistance to methicillin first appeared in 1961,
    attributed to inheritance of a mecA gene found on
    the mobile staphylococcal cassette chromosome mec
    (SCCmec)
  • Genetic analysis suggests that mecA has been
    transferred to S aureus over 20 times, resulting
    in 5 major lineages
  • MecA gene cassette leads to genetic alteration of
    penicillin binding protein, conferring
    resistance to all penicillin and cephalosporin
    family of antibiotics

WTAwall teichoic acid PVLPanton-Valentine
leukocidin CHIPchemotaxis inhibitory protein.
Zetola N et al. Lancet Infect Dis.
20055275-286. Deresinski S. Clin Infect Dis.
200540562-573. Foster TJ. J Clin Invest.
20041141693-1696.
11
COMPARISONCA-MRSA AND HA-MRSA
CA-MRSA HA-MRSA
Clinical spectrum Skin and soft tissue Respiratory tract, UTI, bloodstream infections
Epidemiology Clusters and outbreaks in closed populations Healthcare-associated outbreaks
Underlying condition Dermatological HAI risk factors
Age group Younger Older
Race/ethnicity
Resistance pattern Susceptible to multiple antibiotics Resistant to multiple antibiotics
Genotype sccMec IV sccMec I, II, or III
Virulence PVL present PVL absent
Diederen BMW, et al. JID 200652157-168
12
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13
Risk Factors for CA-MRSA
  • Athletes (close phyical contact)
  • Military personnel
  • Children
  • Native Americans
  • HIV
  • MSM
  • Prisoners
  • Young sexually active
  • Family members (dont forget to ask!)
  • Majority of patients have no identifiable risk
    factors

14
Syphilis
  • Early primary--painless chancre, secondary
    (weeks to couple months after primary)rash
    (infectious) rarely pustular, condyloma lata (MM,
    moist areas) and systemic sx (fever, HA, malaise,
    LAD), early latent (first year)
  • Late late latent, tertiary (gummas,
    cardiovascular, neurosyphilisuveitis, ocular
    nerve damage, dementia, paresis, tabes dorsalis,
    meningitis, cranial neuropathies)
  • HIV primary and secondary can overlap
  • Syphilis a reportable disease
  • Treatment earlyIM PCN, doxy as alternative,
    neurosyphilisIV PCN x 14 days
  • Response to treatment 4 fold decrease in
    VDRL/RPR at 1 year

15
Palmar involvementsecondary syphilis
16
Labial Condyloma Lata, Secondary Syphilis
17
CDC ISOLATION GUIDELINES
  • Isolation Precautions
  • Standard precautions
  • Airborne precautions
  • Special airborne precautions
  • Droplet precautions
  • Contact precautions
  • Protective precautions

18
STANDARD PRECAUTIONS
  • Hand hygiene Before and after each patient
    contact after gloves removed
  • The wearing of artificial fingernails or
    extenders is prohibited (based on CDC guidelines)
  • Gloves When touching contaminated items (blood,
    body fluids, secretions, excretions)
  • Mask, eye protection, face shield Whenever
    splashes or sprays of body fluids possible
  • Gown Whenever splashes or sprays of body fluids
    possible

19
AIRBORNE PRECAUTIONS
  • Isolation
  • Private negative pressure room
  • Direct out exhausted air
  • N95 respirator
  • Representative pathogens
  • M. tuberculosis
  • Varicella, Zoster (immunocompromised)
  • Measles

20
SPECIAL AIRBORNE PRECAUTIONS
  • Isolation
  • Airborne eye shields
  • Representative pathogens
  • Avian influenza
  • Monkeypox
  • SARS Co-V
  • Smallpox
  • Viral hemorrhagic fever (e.g., Ebola, Lassa)

21
DROPLET PRECAUTIONS
  • Isolation
  • Private room
  • Mask
  • Representative pathogens
  • Invasive N. meningitidis
  • RSV
  • Bordetella pertussis
  • Rubella, Mumps
  • Group A streptococcal pharyngitis
  • Invasive H. influenzae

22
CONTACT PRECAUTIONS
  • Isolation
  • Gloves
  • Gowns
  • Representative pathogens
  • Clostridium difficile
  • HSV
  • Varicella/zoster
  • VRE, MRSA
  • MDR pathogens (resistant to two or more classes
    of pathogens)

23
BOARD REVIEW QUESTIONSINFECTION CONTROL
  • 42 TB airborne, removal isolation
  • 61 Varicella airborne contact
  • 88 Tularemia no person-to-person
  • 113 C. difficile contact enhanced
    environmental cleaning (spores)

24
POST-EXPOSURE PROPHYLAXIS
  • Animal bite wound
  • Anthrax
  • Avian influenza
  • Diphtheria
  • Hepatitis A
  • Hepatitis B
  • HIV
  • Human bite wound
  • Influenza A
  • Influenza B
  • Measles
  • Meningococcal infection
  • Monkey bite (B virus)
  • Monkeypox
  • Pertussis (whooping cough)
  • Rabies
  • Smallpox
  • Syphilis
  • Tuberculosis (TB)
  • Varicella (chickenpox)
  • Zoster (shingles)

25
POST-EXPOSURE PROPHYLAXISUSING VACCINES
  • Hepatitis B lt7 days (alternative HBIG)
  • Measles lt3 days (alternative Ig)
  • Rabies ASAP (plus RIG) prior to symptoms
  • Tetanus Post-wound (no time limit)
  • Small Pox lt4 days
  • Varicella lt4 days (alternative VZIG or
    acyclovir)
  • Outbreak control Hepatitis A, pertussis,
    meningococcal
  • May need to be provided with an immunoglobulin
    preparation

26
POST-EXPOSURE PROPHYLAXIS USING ANTI-INFECTIVES
  • Animal bite Amoxacillin-sulbactam x 5 days
  • Influenza Oseltamivir or zanimivir
  • Lyme disease can offer Doxy 200 mg x 1 (with
    many caveatsdefinite Ixodes, long
    attachment36hrs, high endemic region20 ticks
    with disease, present within 72hrs, adults and
    childrengt8, non-pregnant)
  • Meningococcus Ciprofloxaxin 400 mg (alternative
    ceftriaxone IM)
  • Pertussis Azithromycin x 5 days (alternative
    TMP-SMX for 7-14 days)
  • HIV combination antiretrovirals, data supports
    starting ASAP, no benefit after 72 hours (CDC 36
    hours)

27
NO POST-EXPOSURE PROPHYLAXIS
  • Adenovirus conjunctivitis
  • Hepatitis C
  • Mumps
  • Parvovirus B19
  • Rubella
  • Severe acute respiratory distress syndrome (SARS)

28
PATHOGENS ASSOCIATED WITH SKIN AND SOFT TISSUE
INFECTIONS
Cat bite Pasteurella sp (P. multocida), Franciscella tularensis
Dog bite P. multocida, Capnocytophaga canimorsus, CDC group EF-4
Human bite Eikenella corrodens, Fusobacterium, streptococci, Preotella, etc.
Rat bite Spirillum minor (systemic Streptobacillus moniliformis)
Snake bite Aeromonas hydrophila
Shark bite Vibrio carchariae
Pig bite Erysipilothrix rhusiopathiae
Animal hides Bacillus anthracis, Franciscella tularensis
29
PATHOGENS ASSOCIATED WITH SKIN AND SOFT TISSUE
INFECTIONS
Injection drug use S. aureus, Clostridium sp., E. corrodens, Grp A strep
Salt water injury Vibrio Vulnificus
Fresh water injury Aeromonas hydrophila
Fish tank exposure Mycobacterium marinum
Fishmonger Erysipilothrix rhusiopathiae, Streptococcus iniae
Medicinal leeches A. hydrophila, Aeromonas sobria, Vibrio fluvialis
Hot tubs Pseudomonas aeruginosa
Plant/soil exposure Sporotrichosis
Soil contamination Nocardia, Clostridium sp., Serratia
30
TREATMENT OF MRSA ORAL THERAPY
  • Oral regimens (use only after susceptibility
    testing)
  • Linezolid (expensive)
  • Clindamycin (use only if erythromycin susceptible
    or D test performed to confirm susceptibility)
  • Trimethoprim-sulfamethoxazole
  • Minocycline
  • Monitoring
  • Daptomycin CPK each week stop if CPK gt5x ULN
    (symptomatic) or gt10x ULN (asymptomatic) or gt1000
    U/L
  • Linezolid CBC with platelets each week do not
    treat gt28 days

31
BOARD REVIEW QUESTIONSSKIN
  • 68 Osteo in drug user
  • 71 Human bite
  • 83 Cat bite
  • 85 IDU joint infection
  • 94 SA infection
  • 107 - NTM

32
CAP PATHOGENS
Outpatient Inpatient (non-ICU) Inpatient ICU
S. pneumoniae M. pneumoniae H. influenzae C. pneumoniae Respiratory viruses S. pneumoniae M. pneumoniae C. pneumoniae H. Influenzae Legionella spp. Aspiration Respiratory viruses S. pneumoniae S. aureus Legionella spp. Gram-negative bacilli H. influenzae
Influenza A and B, adenovirus, RSV,
parainfluenza
Mandell LA, et al. Clin Infect Dis 200744(suppl
2)27-72
33
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34
CAP THERAPY OUTPATIENTS
  • Previously healthy and no risk factor for DR-SPn
  • No recent antibiotics Macrolide (I),
    doxycycline (III)
  • Recent antibiotics FQ, advanced macrolide
    high-dose amoxicillin, advanced macrolide
    high-dose amoxicillin/clav
  • Comorbidities Chronic heart, lung, liver, or
    renal disease
  • No recent antibiotics Advanced macrolide, FQ
  • Recent antibiotics FQ (I), ?-lactam macrolide
    (I), ?-lactam doxycycline (II) ?-lactam high
    dose amoxicillin or amox-clav
  • Regions with gt25 high level macrolide resistant
    SPn use alternative agent

35
CAP THERAPY INPATIENTS, NON-ICU
  • Non-ICU
  • FQ (I)
  • ?-lactam macrolide (I)
  • ?-lactam cefotaxime, ceftriaxone, ampicillin
  • ICU
  • ?-lactam FQ (I)
  • ?-lactam cefotaxime, ceftriaxone,
    ampicillin-sulbactam
  • ?-lactam advanced macrolide (II)
  • ?-lactam cefotaxime, ceftriaxone,
    ampicillin-sulbactam
  • Advanced macrolide azithromycin or
    clarithromycin

36
Pneumococcus
  • 50 resistance at UNC to all macrolides
    (mechanism alteration of ribosome binding site)
  • Vanc susceptible--universal
  • Resistance an issue for
  • Beta-lactams (penicillins, cephalosporins, and
    carbapenems) 20 PCN R, 5 Cephalosporin R
  • Macrolides (erythromycin, azithromycin,
    clarithromycin and lincosamines (clindamycin)
  • Tetracyclines and folate inhibitors
    (trimethoprim-sulfamethoxazole TMP-SMX)
  • Fluoroquinolones (ciprofloxacin, levofloxacin,
    gemifloxacin, moxifloxacin)
  • Meningitis vanc (to cover R pneumococcus), ctx
    (better CNS penetration, good for meningococcus
    and pneumoncoccus), steroids (particularly for
    pneumococcus, to prevent hearing loss and other
    long term complications) although steroids may
    decrease CNS penetration of vancomycin
    ampicillin for young and old and
    immunocompromised (to cover listeria)
  • No steroids in places with HIV prevalence and
    presumed meningitis

37
BROAD SPECTRUM ANTIBIOTICS
  • Carbapenems Imipenem, meropenem (not ertapenem)
  • Coverage GPC, GNRs, P. aeruginosa, anaerobes
  • Holes MRSA, Listeria, Legionella
  • Piperacillin-tazobactamn (not ticar/clav or
    amp/sulbactam)
  • Coverage GPC, GNRs, P. aeruginosa, anaerobes,
    enterococci
  • Holes MRSA, Listeria, Legionella
  • Tigecycline
  • Coverage GPC (including MRSA, VRE), GNRs
    (including ESBL producers and Acinetobacter),
    anaerobes
  • Holes Pseudomonas aeruginosa, Proteus spp.

38
BROAD SPECTRUM ANTIBIOTICS USES
  • Sepsis of unknown etiology (GPC, GNR)
  • Neutropenic fever (GNR, PA, SA)
  • Severe intra-abdominal infections (GNR,
    Enterococcus, anaerobes)
  • Gangrenous soft tissue infections (diabetic)
    (GNR, PA, SA)
  • Known resistant pathogens (ESBL, Acinetobacter,
    Burkholderia, Pseudomonas)

39
Endocarditis
  • Updated Duke Criteria 2-1/3-5 (major/minor
    criteria)
  • Major sustained bacteremia by organism known to
    cause endocarditis (SA, S viridans, enterococcus,
    HACEK, CNS with pv), endocardial involvement seen
    by echocardiogram (vegetation, abscess OR new
    valvular regurgitation)
  • Minor predisposing condition (PPM/vascath, HD,
    IVDA), fever, vascular signs (septic emboli,
    janeway lesions, mycotic aneurysms), immune
    complex phenomena (osler nodes, roth spots,
    glomerulonephritis) blood culture not meeting
    standard criteria
  • Categories native valve (bicuspid,
    calcification, prior endocarditis, any valvular
    disease), prosthetic valve (high mortality, need
    rifampin/gent, often requires surgery), IDU (can
    use shorter course of treatment with right sided)
  • Culture negative q fever, brucella, bartonella,
    legionella, chlamydia, HACEK, nutritionally
    deficient strep
  • Indications for valve surgery persistent
    bacteremia, refractory CHF, myocardial
    abscess/purulent pericarditis, difficult
    organisms (PsA, yeast, MRSA), recurrent septic
    embolic complications, large vegetation

40
Tuberculosis
  • PPD treatment
  • gt5mm HIV, immunosuppressed (TNF inhibitor,
    prednisone 15 mg/d x 1 month), known close
    contact
  • gt10mm all other high risk populations
    (prisoners, healthcare worker, RF, homeless,
    immigrants, DM, malignancy, hx gastrectomy,
    malnutrition, etoh, long-term care)
  • gt15mm everyone else
  • Treatment rule out active disease by CXR and
    symptom screening
  • TB considerations BCG (no change in
    interpretation, esp if gt5 years ago), prophylaxis
    and treatment in setting of MDR
  • Primary disease?dissemination?control or active
    disease (lungs, LNs, pleurisy, CNStuberculomas,
    basilar meningitis, GI, GUuterine, kidneys,
    bonePotts disease, neck LNScrofula), HIV,
    miliary

41
AHA Guidelines for Endocarditis Prophylaxis 2007
Update
  • IE is much more likely to result from frequent
    exposure to random bacteremias associated with
    daily activities (eg, tooth brushing) than from
    bacteremia caused by a dental, gastrointestinal,
    or genitourinary procedure.
  • Prophylaxis may prevent an exceedingly small
    number of cases of IE, if any, in individuals who
    undergo these procedures.
  • The risk of antibiotic-associated adverse events
    exceeds the benefit, if any, from prophylactic
    antibiotic therapy.
  • Maintenance of optimal oral health and hygiene
    may reduce the incidence of bacteremia from daily
    activities and is therefore more important than
    prophylactic antibiotics for a dental procedure
    to reduce the risk of IE.

42
Updates
  • Patients with the following cardiac conditions
    were considered to meet this criterion
  • Prosthetic heart valves, including bioprosthetic
    and homograft valves
  • Prosthetic material used for cardiac valve repair
  • A prior history of IE
  • Unrepaired cyanotic congenital heart disease,
    including palliative shunts and conduits.
  • Completely repaired congenital heart defects with
    prosthetic material or device, whether placed by
    surgery or by catheter intervention, during the
    first six months after the procedure.
  • Repaired congenital heart disease with residual
    defects at the site or adjacent to the site of
    the prosthetic device.
  • Cardiac "valvulopathy" in a transplanted heart.
    Valvulopathy is defined as documentation of
    substantial leaflet pathology and regurgitation

43
  • No longer indicated  Common valvular lesions for
    which antimicrobial prophylaxis is no longer
    recommended include bicuspid aortic valve,
    acquired aortic or mitral valve disease
    (including mitral valve prolapse with
    regurgitation and those who have undergone prior
    valve repair), and hypertrophic cardiomyopathy
    with latent or resting obstruction
  • Procedures that may result in transient
    bacteremia and are recommended for prophylaxis  
  • All dental procedures that involve manipulation
    of either gingival tissue or the periapical
    region of teeth or perforation of the oral
    mucosa.
  • Procedures of the respiratory tract that involve
    incision or biopsy of the respiratory mucosa
  • Procedures in patients with ongoing GI or GU
    tract infection
  • Procedures on infected skin, skin structure, or
    musculoskeletal tissue
  • Surgery to place prosthetic heart valves or
    prosthetic intravascular or intracardiac
    materials.

44
Botulism gram positive anaerobic rod, toxin
releasing, spore producing, with bioterrorism
potential
  • The modern syndrome of botulism occurs in five
    forms, differentiated by the mode of acquisition
    2
  • Food-borne botulism ingestion of food
    contaminated by preformed botulinum toxin
  • Infant botulism the ingestion of clostridial
    spores that then colonize the host's
    gastrointestinal (GI) tract and release toxin
    produced in vivo
  • Wound botulism infection of a wound by
    Clostridium botulinum with subsequent in vivo
    production of neurotoxin
  • Adult enteric infectious botulism or adult
    infectious botulism of unknown source similar
    to infant botulism in that toxin is produced in
    vivo in the GI tract of an infected adult host.
  • Inhalational botulism the form that would occur
    if aerosolized toxin was released in an act of
    bioterrorism.
  • Cranial neuropathies, symmetric descending
    paralysis, no fever, no sensory loss
  • The differential diagnosis for food-borne, wound,
    and adult enteric botulism includes myasthenia
    gravis, Lambert-Eaton myasthenic syndrome (LEMS),
    tick paralysis, Guillain-Barré syndrome,
    poliomyelitis, stroke, and heavy metal
    intoxication. Less likely diagnoses include
    tetrodotoxin and shellfish poisoning and
    antimicrobial-associated paralysis
  • Dx clinical syndrome, EMG studies, reportable
    disease, stool studies, serum toxin assays
  • Treatment supportive (most need intubation),
    antitoxin (equine trivalent anti-toxin for gt1
    year of age, botulism immunoglobulin for
    infants), PCN G for wound botulism

45
Giardia
  • Flagellated protozoan parasite
  • Cysts (live in environment), trophozoites
    (reproductive form)--pear-shaped, binucleate,
    multi flagellated organisms,measures 9-15 µm
    long, 5-15 µm wide, and 2-4 µm thick
  • Worldwide, food-borne, water-borne,
    person-person, especially children in developing
    countries
  • Other common GI parasite is Cryptosporidium
    parvumGiardia and Crypto problem in normal hosts
    and important in HIV and immunocompromised (less
    common protozoan is E. histolytica)
  • Dx stool O and P (cyst and troph), stool
    antigenic testing (ELISA)

46
Giardia trophozoite
47
Giardiasis
  • 60 asymptomatic
  • Diarrhea that is sudden in onset and may be
    initially watery 90 percent
  • Malaise 85 percent
  • Foul-smelling and fatty stools (steatorrhea) 70
    percent
  • Abdominal cramps and bloating 70 percent
  • Flatulence 75 percent
  • Nausea 70 percent
  • Weight loss 65 percent
  • Vomiting 30 percent
  • Fever 10 percent
  • Manifestations often wax and wane over many
    months
  • Malabsorptionlactase (causes lactose
    intolerance), vitamin A, B12, folate, etc

48
Miscellaneous
  • Remember syphilis!!
  • African tick feverR. africae (look for eschars,
    early fever/myalgias)Amblyoma tick, doxycycline
  • Other tick borne diseasesR. rickettsia (dog
    tick, RMSF), Erlichia (deertickIxodes or lone
    star tick), Borrelia (Lyme, Ixodes), Babesia
    (protozoa looks like malaria, only in NE, fatal
    in asplenic pts, Ixodes)
  • Anthraxcutaneous (Edema toxin), eschar also
    inhalational (hemorrhagic, widened mediastinum)
    and GI (ingestion of infected animal)
  • Candidemia
  • Smallpox versus Chickenpoxdegree of fever and
    early timing of systemic symptoms, stage of
    lesions
  • Drugs
  • daptomycin contraindicated for MRSA pneumonia,
    follow CPK
  • Linezolidthrombocytopenia, bone marrow
    suppression, serotonin syndrome
  • HIV medsabacavir (fatal hypersensitivity
    syndrome, HLA B5701), protease inhibitorselevated
    lipids, DM, nucleoside RTIsmitochondrial
    toxicity (lipodystrophy, visceral adiposity,
    myalgias, neuropathy), nevirapine (fatal liver
    disease esp in women with high CD4)

49
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