Kari

Schoenwald MMS PA-C

Pearls
!  Lecture not all encompassing…
!  KNOW THE BLUEPRINT topics
!  Pharmacology a very important part of each organ
system-study the drugs and know the mechanisms of
action (16-18% of each topic)
!  The generic name of a drug is always provided. The trade
name is provided in parenthesis after the generic name of
the drug only if it is deemed necessary by NCCPA.
!  During the PANCE, be aware of time
!  Answer every question
!  Time management to be able to read every question
PANCE Blueprint
!  Pneumonias
!  Bacterial
!  Fungal
!  Viral
!  HIV Related
PANCE Blueprint
!  Infectious Diseases
!  Fungal-Candidiasis, Cryptococcosis, Histoplasmosis, Pneumocystosis
!  Bacterial Disease
!  Acute Rheumatic Fever, Botulism, Chlamydia, Cholera, Diptheria, Gonococcal
infections, Salmonellosis, Shigellosis, Tetanus
!  Mycobacterial Disease-Atypical Mycobacterium, Tuberculosis
!  Parasitic Disease-Helminths,Malaria, Pinworms, Toxoplasmosis
!  Spirochetal Disease- Lyme, Rocky Mountain Spotted Fever, Syphillis
!  Viral Disease
!  CMV HIV
!  EBV HPV
!  Eryhthema infectiousum Influenza
!  HSV Measles/Mumps/Rubella
!  Roseola Varicella Zoster
Pneumonias
!  Viral
!  RSV most common cause in peds
!  Influenza (A or B)
!  Seasonal
!  Sudden onset, severe body aches, fever, sore throat
!  Diagnose with rapid test
!  Supportive treatment, zanamivir or oseltamivir
!  Fungal
!  Candida
!  Pneumocystis-will discuss in ID review
Bacterial Pneumonias
!  Classified as community acquired (CAP) or health
care associated
!  Focus on CAP
!  Typicals
!  Streptococcus pneumonia, Haemophilus influenza, Moraxella
catarrhalis
!  Atypicals
!  Legionella pneumophilia, Mycoplasma, pneumoniae,
Chlamydiophila pneumoniae
Community Acquired Pneumonia
!  Clinical presentation-typical
!  Usually > 1 of the following
!  Fever or hypothermia
!  Rigors and sweats
!  Cough –may or may not be productive
!  Shortness of breath
!  Constitutional symptoms

Think Strep pneumo if pleuritic pain, rigors. Haemophilus if
underlying lung disease (COPD, acute exacerbation of chronic
bronchitis, smokers)
Atypicals
!  Mycoplasma
!  Common presentation is cough and fever
!  Bullous myringitis
!  More common in kids and young adults (healthy)
!  Legionella
!  Usually high fever
!  Hyponatremia
!  Diarrhea
!  Appear more ill than what Chest xray looks like
!  Chlamydiophila-similar to mycoplasma but often older
patients
CAP
!  Diagnosis
!  Chest xray- consolidation or infiltrate
!  Case by case
!  Sputum culture
!  Blood cultures
!  CBC (WBC?, left shift?)
!  Ag testing (urine sample)
!  Strep pneumo, Legionella
CAP
!  Treatment
!  Previously healthy, no antibiotics within 3 months
!  Doxycycline
!  Macrolides
!  Comorbidities- diabetes, heart disease, liver, lung or
renal disease, malignancy, alcoholism, asplenia,
immunosuppression, use of antimicrobials within last 3
months
!  Respiratory fluoroquinolones
!  B lactam plus a macrolide


Hospital Acquired Pneumonia
!  Symptoms >48 hours after admission
!  Ventilated patients at high risk
!  Mortality rate is 20-50%
!  Pseudomonas is the most common organism, others
include Staph aureus, Klebsiella, E coli and
Enterobacter
!  DX with sputum culture and gram stain, chest xray
!  Treatment:Cefepime, Piperacillin/Tazobactam,
Carbapenems
Fungal Infections
!  Candidiasis
!  Vaginal
!  Vulvar itching,erythema, white discharge (usually odorless)
!  Dx KOH prep-hyphal elements present
!  Treatment- topical azole x 1-7 days or fluconazole 100-200 mg
po x 1 dose
!  Esophageal
!  Dysphagia/odynophagia, reflux
!  Dx with EGD
!  Treatment-fluconazole 200 mg po qday x 14 days
Candida Infections
Candida infections
!  Classification
!  C albicans-susceptible to fluconazole
!  Nonalbicans yeast-some have resistance to fluconazole
(C glabrata and C krusei)

!  Emerging resistance- Candida auris-resistant to all

antifungals available.
Pneumocystosis
!  PCP(pneumocystis pneumonia) formerly Pneumocystis
carinii, now known as Pneumocystis jiroveci
!  Most common opportunistic infection in AIDS patients
!  CD4 count<200
!  Symptoms-fever, shortness of breath, tachypnea,
nonproductive cough, hypoxia
!  Diagnosis
Chest xray-bilateral interstitial infiltrates
Sputum Silver Stain-gold standard test
Silver stain being replaced by PCR testing on sputum-more
sensitive
Pneumocystis
Pneumocystocis
!  Treatment
!  Trimethoprim sulfamethoxazole IV high dose (15-20
mg /kg divided q 6-8 hours
!  Add steroids if PaO2 is <70 mm Hg
Histoplasmosis
!  Exposure to bird droppings and bat guano in Ohio
River region
!  Can disseminate in immunosuppressed (AIDS)
!  Most infections asymtpomatic but can present with
cough and respiratory symptoms, fever
!  Diagnosis: biopsy, serology
!  Treatment-azole antifungals, amphotericin B in
disseminated cases
Blastomycosis
!  Exposure to soil in the Ohio River region
!  Can disseminate in all –no immunosuppression
necessary
!  Symptoms- most asymptomatic but can present with
respiratory symptoms. Skin nodules in those that
disseminate
!  Diagnosis: Serology, biopsy
!  Treatment-azole antifungals, amphotericin B in
dissemination
Blastomycosis
Cryptocococcosis
!  Cryptococcus neoformans
!  Most common cause of fungal meningitis- HIV
!  Symptoms: neck stiffness, headache, fever
!  Diagnosis: India Ink stain on CSF-gold standard but
now being replaced by cryptococcal ag testing on
spinal fluid
!  Treatment: referral to ID
India Ink Stain
Viral infections
!  Varicella Zoster Virus-Chicken Pox
!  Respiratory spread more than by direct contact with
skin lesions
!  Dormant in dorsal root ganglia-Herpes Zoster-shingles
!  Both are clinical diagnosis
Herpes Zoster
!  Dermatomal, does not cross midline
!  Vesicular, painful lesions
!  Prodrome of numbness, burning, tingling in area of
erruptions
!  Can disseminate
!  Post herpetic neuralgia common complication
!  Treatment:
!  Valacyclovir, acycolvir, famcyclovir in mild to moderate
cases
!  Disseminated-Acyclovir
Epstein Barr Virus
!  Mono
!  symptoms: fatigue, malaise, fever, severe sore
throat,adenopathy, splenomegaly
!  <20 years of age
!  Maculopapular rash in 5-10%, add aminopenicillin
>90%(?)
!  Diagnosis:clinical exam, atypyical lymphocytes on
CBC, Heterophile agglutination test (IgM only)
!  Treatment-supportive, avoid contact sports – risk of
splenic rupture
Cytomegalovirus
!  Similar presentation to mono
!  Usually in age >20 years
!  CMV retinitis- most common cause of AIDS related
blindness
!  Dx serology, biopsy
!  Treatment-supportive
ganciclovir in severe cases
HIV
!  Risk-anyone who is sexually active or injects drugs
!  Retrovirus-Reverse transcriptase changes viral RNA
>proviral DNA

Acute HIV Syndrome
!  Uncommon presentation of HIV
!  Early after exposure, mono or flu like illness
!  More severe-more likely to need hospitalization
!  Rash 40-80% of cases, no exposure to
aminopenicillins
!  Mucocutaneous ulcers
Acute HIV
HIV
!  Most common presentation is asymptomatic for years
!  Found via screening
!  Historic screening test ELISA followed by Western
Blot confirmation
!  Newer test-
!  Combination/4th generation/Ag-Ab test
!  Now confirmed with HIV rna- “viral load”
HIV Meds
!  Nucleoside Reverse Transcriptase Inhibitors(NRTI)-
usually choose 2
!  Older
!  Zidovudine (AZT)

!  Lamivudine(3TC)
!  Newer
!  Emtricitibine
!  Tenofovir
Combination pill of above called Truvada

HIV meds
!  Non nucleoside Reverse Transcriptase Inhibitors
(NNRTIs)
!  1st generation
!  Nevirapine

!  Efavirenz
!  2nd generation
!  Etravirine
!  Rilpivirine

HIV meds
!  Protease Inhibitors-end in ‘navir
!  Rinonavir
!  Nelfinavir
!  Fosemrenavir
!  Lopinavir
!  Atazanavir
!  Durunavir
HIV meds
!  Integrase Inhibitors
!  Reltagravir
!  Elvitegravir
!  Dolutegravir
Combinations for first line therapy
!  2 NRTI’s + 1 NNRTI
!  Emtricitabine/Tenofovir/Efavirenz=Atripla
!  2 NRTI’s + Integrase inhibitor
!  Emtricitabine/Tenofovir + Raltegravir = Truvada plus
Isentress
!  Emtricitabine/Tenofovir +Elvitegravir/
Cobiscistat=Stribild
!  Newer formulations-Descovy and Odefsey- both utilize
tenofovir alafenamide for tenofovir component
HIV meds Adverse Effects
!  NRTIs
!  AZT- bone marrow suppression
!  ABC- hypersensitivity reaction- do not rechallenge
!  NNRTIs
!  Rash
!  Efavirenz CNS disengagement
!  Pis
!  Nausea/ diarrhea
!  Lipodystrophy/metabolic side effects
HIV CD4 counts/prophylaxis
!  <200 PCP
!  Trimethoprim sulfamethoxazole
!  <100 Toxoplasmosis reactivation
!  Trimethoprim sulfamethoxazole
!  <50 atypical mycobacterial infection
!  Azithromycin
Tick borne diseases
!  Lyme Disease
!  Spirochete Borrelia burgdorferi
!  Transmitted by Ixodes tick
!  Most cases from Northeastern/Midwestern states
!  Connecticut, Delaware, Maine, Maryland, Massachusetts,
Minnesota, New Jersey, New Hampshire, New York,
Pennsylvania, Virginia, Wisconsin
Lyme Disease
!  Stage I
!  Early infection
!  Constitutional symptoms
!  Fever, chills, myalgias,fatigue
!  Dermatologic findings
!  Erythema migrans
!  Site of tick bite
!  Red papule with centrifugal spread and central clearing
!  Stage 2
!  Early infection-disseminated
!  Cardiac and neurologic symptoms-cranial nerve palsy or
meningitis
!  Stage 3-persistent-never treated
!  Chronic arthritis in 60%
Lyme
!  Diagnosis: clinical-presence of erythema migrans in
an endemic area
!  ELISA- western blot confirmation
!  Treatment
!  Doxycycline >8yrs of age
!  Amoxicillin <8 yrs of age
!  What about lyme meningitis?

Rocky Mountain Spotted Fever
!  Rickettsia rickettsii
!  Influenza prodrome followed by fever/chills,
headache and myalgia
!  Macular rash appears first on wrists and ankles then
spreads centrally
!  Treatment is doxycycline even in kids

Review Anaplasmosis, Ehrlichiosis and Babesia

Malaria-mosquito borne
!  Transmitted by Anopheles mosquito
!  5 types
!  Plasmodium vivax
!  Plasmodium malariae
!  Plasmodium falciparum
!  Plasmodium ovale
!  Plasmodium knowlesi
!  Travel history is key
Malaria
Malaria
!  Symptoms
!  Periodic fever and chills
!  Headache, splenomegaly, myalgia
!  Diagnosis-thick and thin blood smears
!  Prophylaxis-atovaquone/proguanil,mefloquine,
doxycycline, chloroquine(Central America and parts
of Northern South America) Primaquine(P vivax
areas)
!  Treatment: atovaquone/proguanil mainstay
STI’s
!  Classify as discharges or ulcers
!  Discharge
!  Gonorrhea
!  Chlamydia
!  Trichomonas
!  Ulcers
!  Syphilis
!  HSV
Gonorrhea
!  Neisseria gonorrhoeae-urethritis/cervicitis
!  Profuse yellow discharge
!  Women often asymptomatic until more advanced-
PID
!  Gold Standard test-gram stain-gram negative
diplococci intracellular
!  Test of choice NAAT(nucleic acid amplification test)
!  Treatment-Ceftriaxone 250 mg IM x 1 AND
Azithromycin 1 gram po x 1
Chlamydia
!  Urethritis/cervicitis (classified as nongonococcal)
!  Often asymptomatic in men and women
!  Most common reportable STI
!  Screening of women annually if <25 years of age
!  Diagnose with NAAT
!  Treatment: Azithromycin 1 gram po x 1 dose OR
doxycycline 100 mg po bid x 7 days
Syphilis (ulcerative)
!  The great imitator
!  Treponema pallidum
!  Active infection staging
!  Primary
!  Recent infection
!  Chancre-painless ulcer
!  Secondary
!  Weeks to few months
!  Maculopapular rash-dissemination-body wide including palms of
hands and soles of feet
!  Tertiary
!  Months to years
!  Neurosyphilis
Syphilis lesions
Syphilis
!  Latent Infection
!  Early Latent
!  Acquired <1 or equal to 1 year ago
!  Late Latent
!  Acquired > 1 year ago
Diagnosis
!  DFA-Dark field exam of lesion exudate-may be best in
early infection
!  Nontreponemal serology
!  VDRL
!  RPR
!  Treponemal serology
!  FTA-Fluorescent treponemal antibody
!  Syphilis antibody

!  Once treponemal tests positive, will remain positive

Treatment
!  Benzathine penicillin G (Bicillin LA) treatment of
choice
!  2.4 million unit IM x 1 dose
!  Recheck RPR at 3-6 months for response to therapy
!  PCN allergy
!  Ceftriaxone or doxycycline
Herpes Simplex Virus
!  Incurable, latent in sensory ganglia
!  Subclinical shedding
!  Recurrent
!  Painful, vesicular ulcerations-prodrome common
!  Mucosal surfaces
!  HSV1- prefers oral mucosa
!  HSV2-prefers genital mucosa
!  Both can cause ocular disease, meningoencephalitis,
esophagitis. HSV 1 associated with Bell’s Palsy
HSV diagnosis
!  Gold standard-Tzank smear
!  Intranuclear inclusions and multinucleated giant cells
!  Serology-difficult to interpret due to prevalence of
HSV 1
!  Culture- viral
Treatment
!  Acyclovir
!  Valacyclovir
!  Famcyclovir

!  Daily suppression if >6/yr

!  Treatment does not cure the disease
HPV-Human Papillomavirus
!  Most common nonreportable STI
!  Classification
1)Genital warts
HPV 6 and 11
Low risk for neoplasia except anogenital
warts=condylomata acuminata-high risk
name alert-condyloma lata-syphillis
2)Cervical or anal dysplasia
HPV 16 and 18
High risk

HPV
!  Diagnosis
!  Acetowhitening test
!  PAP smear
!  HPV DNA probe
HPV treatment
!  Warts treatment
!  Patient administered
!  imiquimod
!  Provider administered
!  cryotherapy
HPV vaccines
!  Guardasil 4 and 9-ages 9-26 male and female
!  Guardasil 4 covers types 6,11,16,and 18
!  Guardisil 9 covers same + 31, 33, 45, 52, and 58
Orthopedic Infections
!  Osteomyelitis
!  most caused by Staph aureus
!  Classifications
!  Hematogenous seeding
!  More common in children

!  ALWAYS r/o tumor in children

!  Contiguous spread
!  Common in adults

!  Spread from soft tissue infection

!  Often polymicrobial

Osteomyelitis
!  Symptoms vary depending on patient factors/
bacteria/site of infection
!  Often pain is present
Osteomyelitis
!  DX
!  Imaging-xray, MRI, labelled WBC scan
!  Blood cultures and bone biopsy mainstay of definitive
diagnosis
!  Culture of sinus tract NOT indicative of causative organism
!  ESR/CRP non specific markers
Osteomyelitis imaging
Osteomyelitis treatment
!  Standard of care is 6 weeks of IV antibiotic therapy
targeted to Staph or organism cultured on bone biopsy
!  IV antibiotics with Staph coverage?
!  Nafcillin
!  Ceftriaxone

MRSA coverage
Vancomycin
Daptomycin

Treatment improved by debridement of bone
Infectious Arthritis
!  Joint or joint space infection
!  Bacteremia is a common source
!  Staph aureus is most common
!  Symptoms-hot,red, swollen joint. Painful.
!  Dx: Fluid culture/Blood culture
!  Treatment: drainage and coverage for Staph or culture
specific organism
Infectious Arthritis
Infectious arthritis
!  Gonococcal
!  Dissemination of STI
!  Common cause of infectious arthritis in those age <35
!  Symptoms: fever, migratory polyarthralgias,
tenosynovitis and derm findings-nodules and pustules
!  Dx: Culture of synovial fluid or drainage from skin
lesions
!  Treatment: Ceftriaxone plus doxycyline
Disseminated Gonoccocal
Infectious Arthritis
Endocarditis
!  Bacterial growth on valves or myocardium
!  Classification
!  Left Sided-most cases(mitral)
!  Right Sided-IVDU, Staph aureus (tricuspid )
!  Acute –appear septic-Staph
!  Subacute-smoldering
!  Nonspecific symptoms-cough, shortness of breath, fever,
arthralgias
!  Native valve
!  Prosthetic Valve
Vegetations
Endocarditis
!  Organisms
!  Native Valve
!  Viridans strep(0ral flora)
!  Enterocci
!  Staph aureus
!  HACEK organisms
!  Prosthetic Valve
!  Early (<2 months) Staph
!  Late (>2 months) similar to native valve endocarditis
Endocarditis
!  Symptoms: 90% have murmurs
!  Cough, fever,
!  Congestive heart failure most common complication
!  Systemic emboli-spleen and kidney
!  Peripheral lesions-Janeway lesions, Osler nodes,
splinter hemorrhages, conjunctival petechiae
!  Diagnosis
!  Duke Criteria
!  Blood Cultures
!  Echocardiogram-TEE more sensitive than TTE

Endocarditis
!  Treatment
!  Empiric until blood culture data available
!  Vancomycin + Ceftriaxone
!  Vancomycin + Gentamicin
!  Surgical-Valve replacement in some cases

Endocarditis Prophylaxis
!  Indicated for:
!  Prosthetic cardiac valve or material
!  Previous endocarditis
!  Congenital heart disease
!  Cardiac transplant

Amoxicillin 2 grams po x 1 , 1 hour prior to procedure is

preferred
Alt: cephelexin 2 g po x1 or clindamycin 600 mg po x1
Neurologic Infections
!  Meningitis
!  Typically respiratory droplet spread
!  Mucosa to mucosa
!  Strep pneumo has highest mortality
!  Meningoencephalitis
!  Sporadic or seasonal etiology
!  Sporadic – HSV
!  Seasonal- Insect –mosquito or tick
!  West Nile Virus-flaccid paralysis

!  St Louis Encephalitis

!  LaCrosse Encephalitis
Meningitis
!  Classified as Bacterial or Aseptic
!  Symptoms
!  Fever
!  Neck stiffness, nuchal rigidity
!  Kernig’s and Brudzinski signs
!  Sever headache
!  Altered mental status
!  Rash with meningococcemia
Meningitis
!  Diagnosis
!  CSF findings
!  Blood cultures
!  Physical exam
Bacterial Meningitis
!  Preterm to <1 month
!  Strep agalactiae- group B strep
!  E coli
!  >1 month to 50 years
!  Strep pneumoniae
!  Neisseria menigitidis
!  Haemophilus influenza-more rare now due to
childhood immunization
!  >50 years
!  Strep pneumoniae
CSF interpretation
Lab finding Bacterial Aseptic
Opening pressure Increased Normal or minimal
increase
WBC count Increased (100-1000s) Normal to slightly
increased (10-100s)
Cell differential PMN Lymph
Glucose Decreased Normal
Protein Increased Normal to minimal
increase
Culture and gram stain Positive Negative
Meningitis
!  Treatment
!  Empiric until culture
ceftriaxone + vancomycin + ampicillin (listeria)

Aseptic- discontinue antibiotics once culture is negative

HSV PCR – empiric acyclovir (10mg/kg IV q 8 hours),
discontinue if HSV PCR negative.
Dermatologic Infections
!  Erysipelas
!  Infection of epidermis and dermis
!  Strep pyogenes or Staph
!  Rapid onset, glistening erythema of face
!  Treatment: Penicillin,cephalosporins (1st generation)
!  Cellulitis
!  Involves epidermis, dermis and connective tissue
!  Staph and Strep main causative agents
!  Fever, chills, erythema and edema
!  Usually involves extremities
!  Lymphangitis possible
!  Treatment: cephelexin, trimethoprim sulfa, doxycycline

Erysipelis and Cellulitis
Abscesses
!  Folliculitis
!  Small pustules
!  Staph
!  Treat with warm compresses
!  Furuncle
!  Boils
!  Firm, painful, erythematous nodules
!  Staph aureus/MRSA
!  I and D +/- antibiotics
!  Carbuncle- coalescence of abscess
!  Large
!  Fever, erythematous, fluctuant to indurated
!  I and D
!  Antibiotics-which ones?
Necrotizing Skin and Soft Tissue
infections
!  Always a surgical emergency ie surgery first,
antibiotics second
!  Significant risk of loss of life or limb
!  Necrotizing fasciitis
!  Fournier’s gangrene
!  Gas Gangrene
Necrotizing fasciitis
!  Classically caused by Strep pyogenes
!  Involves subcutaneous fat and fascia/SPARES
MUSCLE
!  Appear septic, starts with erythematous area and
rapidly spreads
!  Surgical emergency

Necrotizing fasciitis
Fournier’s gangrene
!  Necrotizing infection of the perineum
!  Males more than females
!  Diabetes is a risk factor
!  Starts with trivial redness or itching, then septic
appearing
!  Usually polymicrobial with anaerobes
!  Surgical emergency followed by antibiotics targeted to
organism
Fournier’s gangrene
Gas gangrene
!  Clostridium perfringens
!  Febrile /Septic appearing patient
!  Anaerobic organism produces gas=crepitus at site of
infection
!  Trauma or post GI surgery often part of history
!  Involves subcutaneous fascia/fat AND muscle
!  Surgical emergency and followed by antibiotics
covering anaerobes (which?)
Gas Gangrene
Infectious Diarrhea
Characteristic Non inflammatory inflammatory
volume Large/watery Small/mucus
blood Negative, no PMNs Positive, abundant PMNs
symptoms Nausea Cramping/fever
Noninflammatory
!  Norovirus
!  Staph
!  Bacillus cereus
!  Vibrio cholera
!  Giardia
!  Cryptosporidium

Inflammatory
!  E coli 0157
!  C diff
!  Shigella
!  Campylobacter
!  Salmonella

!  Do NOT use anti peristaltic agents

Non inflammatory
!  Norovirus
!  Most common cause of gastroenteritis in US
!  Spread through contaminated food/water and food
handlers
!  Fever, diarrhea, vomiting
!  Self limiting-highly contagious
!  Supportive care-hydration
!  Pearl kids =vomiting/adults=diarrhea
Staph aureus food poisoning
!  Toxin produced by bacteria that causes illness
!  Classic picnic with foods left out too long(potato
salad, custard based foods)
!  Rapid onset (1-6 hours after eating contaminated
food) nausea/vomiting/diarrhea
!  Supportive care, usually resolves within 24 hours

!  Bacillus cereus-same symptoms as above but rice is

the culprit
Cholera
!  Vibrio cholera
!  Contaminated food and water-poor sanitary
conditions
!  Can also occur with ingestion of contaminated
shellfish
!  “rice water stool” presentation
!  Profuse watery diarrhea, fever
!  Treatment mainstay IV fluids
!  Azithromycin or cipro decrease length of duration.
More resistance issues with cipro
Giardia
!  Most common parasitic etiology of infectious diarrhea
in US
!  Associated with outdoor activities
!  Symptoms: diarrhea/ extreme flatulance
!  Dx stool ag
!  Treatment metronidazole or tinidazole
Cryptosporidia
!  Fecal to oral transmission
!  Cholera like presentation
!  Self limited but can be life threatening in
immunosuppressed
!  Diagnosis stool ag
!  Treatment refer to ID
Inflammatory
!  E coli 0157
!  High risk of hemolytic uremic syndrome-(acute renal
failure + thrombocytopenia+ hemolytic anemia) life
threatening
!  Associated with undercooked hamburger but any food
now suspect
!  Bloody diarrhea and abdominal pain. Often afebrile
!  Diagnose with stool culture or PCR
!  Supportive treatment- antibiotic usage controversial
C diff
!  Antibiotic prior history important but now not
essential
!  Any antibiotic can cause
!  Fever, abdominal pain, mucus in stool, fecal
incontinence
!  Dx Cdiff toxin pcr
!  Treatment metronidazole first line but may need to
utilize ORAL vancomycin
Shigella
!  Food and water
!  Abrupt bloody diarrhea, abdominal pain, tenesmus
!  Daycare center association
!  Stool culture
!  Treatment fluoroquinolones for adults, azithromycin
for kids
Campylobacter
!  Most common cause of bacterial diarrhea
!  Associated with raw chicken/ hard meats
!  Fever,watery –bloody diarrhea, abdominal cramping
and pain
!  Associated with post infectious Guillain Barre
syndrome
!  Diagnose with stool culture
!  Treat with macrolide
Salmonella
!  Gastroenteritis type
!  S typhimurium, S enteritidis
!  US
!  Contaminated food and water
!  Reptile contact
!  Fever, diarrhea, abdominal cramping
!  Tx fluoroquinolones
!  Enteric fever type (Typhoid fever)
!  Travel history is key
!  Headache, fever, constipation more common than diarrhea
!  Stool culture diagnosis
!  Tx fluoroquinolones, ceftriaxone if returning Indian traveler
due to resistance issues
Miscellaneous parasites
!  Schistosomiasis
!  Fresh water exposures in developing countries
!  Carried by snails
!  Schistosomiasis haemotobium associated with bladder
cancer
!  Tapeworm
!  Beef-Taenia saginata
!  Pork-Taenia solium
!  Associated with neurocysticircosis
!  New onset seizure
!  Amoeba
!  Entamoeba histolytica
!  Liver abscess-dark brown fluid “chocolate milk”
Neurocystircercosis
Parasitic infections
!  Treatment is mebendazole or albendazole for worms
!  Metronidazole for protozoans-(giardia, amoeba)