Diphtheria ( Corynebacterium diphtheria) Produces exotoxin.

. spread by respiratory secretions Sxs MC pharyngeal - gray membrane covers the tonsils & pharynx, sore throat, malaise and fever leading to toxemia and prostration myocarditis - cardiac arhythmia, heart block, HF neuropathy, CN-diplopia, slurred speech, dysphagia Diagnosis clinical & culture Treatment *antitoxin must be given in ALL cases PCN or Erythromycin or azithromycin or clarithromycin Isolate until 3 consecutive cultures are negative TX all contacts to eradicate carrier states- Erythromycin x 7 days Prevention active immunization. Diphtheria toxoid DtaP; Td

MRSA Staphylococcus aureus is COMMON on the skin. Gram Positive Resistance to the Beta-lactam antibiotics Penicillins ; Cephalosporins; Cephamycins; Carbapenems; Monobactams; Beta-lactamase inhibitors Community associated-MRSA Most often skin and soft tissue infections in young, otherwise healthy individuals Most CA-MRSA strains are sensitive to non-beta-lactam antibiotics Clusters have been noted in: Jails; day care; sport teams; Colleges; Gay men usually skin and soft tissue, LOCALIZED infection PATIENT SAYS THEY HAVE A SPIDER BITE!!!! Management of CA-MRSA simple abscess or boils I&D (sometimes adequate alone) Culture and Sensitivities of drainage! Antibiotic Therapy Emperical therapy pending culture results Clindamycin; Bactrim (TMP-SMX); Tetracycline (doxycyline or minocycline); linezolid ; Topical mupirocin (Bactroban) or altabax you will also see used as well. Healthcare associated-MRSA Severe, invasive disease: Soft tissue infection; Bloodstream infection; Pneumonia *leading cause of surgical site infection Tend to have multidrug resistance Tx Varies IV Vancomycin; IV or PO Clindamycin; IV Daptomycin; IV or PO TMP-SMX Colonization Anterior Nares MC site

VRE

caused by overuse of antibiotics VRE infections frequently found in: urinary tract, at surgical sites, and in the bloodstream

Atypical mycobacterial disease Non-tuberculous mycobacteria Pulmonary:M avium intracellulare (MAC) COPD, bronchiectasis Cutaneous: M marinum Disseminated : M avium AIDS Dx culture & Tx varies Leprosy (Mycobacterium leprae) Organism cannot be grown in culture Diagnosis clinical picture and demonstration of acid fast bacilli in skin Tuberculoid Borderline tuberculoid Mid-borderline tuberculoid Borderline lepromatous Lepromatous (most severe)

Clinical Presentation: Anesthetic skin lesions May be very limited or widespread Mainstays of treatment: dapsone, rifampin, clofazimine

Tuberculosis Mycobacterium tuberculosis Latent TB Patient has positive skin test or IGRA for tuberculosis Tx isoniazid (INH) 300 mg daily x 9 months Can add pyridoxine to prevent peripheral neuropathy in higher risk patients. Active Pulmonary TB Usually reactivation of latent pneumonia, sometimes w/ hx of hemoptysis, cough, weight loss, fever, night sweats Diagnosis Sputum daily x 3 (can stop if one comes back positive); bronchoscopy Cavitary disease HIGHLY infectious Skin test PPD or Mantoux test Read induration, not erythema will be altered by BCG (Bacille Calmette Guerin) vaccine 5 mm + HIV, immunosupp, recent contacts; 10 mm + high risk; 15 mm + low risk Blood Tests Distinguishes b/w TB and BCG vaccine, which PPD does not IGRA assay interferon gamma release assays can be neg w/ active Quantiferon Gold T-spot TB can be neg w/ active Treatment 4 drug regimen INH; Rifampin; Pyrazinamide; Ethambutol After 2 m can adjust If sensitive to INH & rifampin, cont w/ those 2 for 6 m Extrapulmonary TB any organ besides pulmonary. NOT infectious. No isolation. Tx= same Helminth infection Flukes (Trematodes) Schistosomiasis S mansoni; S japonicum; S intercalatum; S mekongi; S hematobium Exposure to fresh water Diagnosis Serology ; Stool studies; Urine microscopy Treatment Praziquantel dose varies with species Other Nematodes ingestion of contaminated soil or produce. Most asymp Ascaris lumbricoides Very common mostly in tropics, but some in temperate regions 15-35 cm long, live in lumen of small intestine; live 10-24 months, Self-limited if no ongoing exposure Clinical Syndromes dyspepsia, loss of appetite, nausea. malnutrition, intestinal obstruction, blockage of pancreatic/bile ducts Diagnosis Stool studies for ova and parasites Treatment - Single dose: Albendazole OR Mebendazole OR Pyrantel pamoate Trichuris trichiura (whipworm) Found in warm humid climates. Adult worms 4 cm in length; live in cecum and ascending colon Clinical Syndromes Heavy infestations: inflamed mucosa, pain, diarrhea, rectal prolapse, anemia Diagnosis Eggs found in stool or worms found in rectal prolapse or colonoscopy Treatment Albendazole or Mebendazole for 3 days. Severe- 5-7 Combination albendazole and ivermectin Necator americanis (hookworm) tropical and subtropical zones. Sporadic cases in SE USA Adult worms 7-13 mm long; upper small intestine. 3-5 years Sxs Acute: epigastric pain, diarrhea, anorexia, eosinophilia. Iron deficiency anemia. Can affect growth and development in children Diagnosis Examination of stool Treatment Single dose albendazole or Mebendazole 100 mg BID x 3 days Strongyloides stercoralis Found in tropics and subtropics. 2.2 mm. upper small intestine Can autoinfect - larvae reenter through bowel wall or perianal skin

Sxs Acute: may have localized pruritic rash from larval penetration; eosinophilia w/ or w/o pulm sxs; Diarrhea and abdominal pain Hyperinfection syndrome: immunocomp pts mult organ systems & high mortality Diagnosis stool, sputurm, tissue, serologic Treatment Ivermectin 2 days or Albendazole 10 -14 days

Tapeworms (Cestodes) Taenia saginata (beef tapeworm) 10 meters long usually asymp Taenia solium (pork tapeworm) 2-8 meters long; live 10-20 years usually asymp; can cause invasive disease: cysticercosis Hymenolepis nana 15-50 mm long diarrhea, cramping, anorexia in children Diphyllobothrium latum (fish tapeworm) 25 m long; live up to 30 years usually asymptomatic; non-specific (weakness, dizziness, salt craving, diarrhea, intermittent abdo sxs) Echinococcus (hydatid cyst) liver, other organs allergic reactions from cyst leakage Invasive Syndromes neurocysticercosis seizures, mass effect Diagnosis Stool examination for ova, proglottids Invasive disease: radiologic appearance + risk factors Serologic studies: T solium, echinococcus Treatment Praziquantel single dose 5-10 mg/kg, except H nana 25 mg/kg Niclosamide 2 gram single dose (adults), chewed

Pinworms (Enterobius vermicularis) roundworm, or nematode Adult worms are loosely attached to the mucosa, primarily inhabit cecum and appendix area. Scratching or handling bedclothes. eggs swallowed & hatch in duodenum; larvae cecum & mature in 3-4 wks. Live 30-45 days. Sxs Local itching; weight loss; enuresis; irritability. Scratching causes excoriations & impetigo. Migration can cause vulvovaginitis, diverticulitis, appendicitis, cystitis, & granulomatous reactions. Diagnosis Scotch-tape prep in early morning. 3 tries over 3 consecutive nights are 90% successful. Treatment: Single doses of: Albendazole OR Mebendazole OR Pyrantel pamoate Repeat 2-4 weeks later reinfection/autoinfection common & Treat household members Entamoeba histolytica Common in US, and in travelers Sxs 1. Acute diarrhea 2. Amebic dysentery 3. Amebic liver abscess 4. Asymptomatic stool carriage Amebiasis Dx NOT stool for o&p; PCR or antigen detection in stool or abscess fluid; Serology Treatment Diarrhea: Metronidazole plus paromomycin or diloxanide furoate Liver abscess: metronidazole or tinidazole + paromomycin or diloxanide Asymptomatic: paromomycin or diloxanide Human Granulocytic anaplasmosis Often co-transmitted with Lyme, sometimes babesiosis. Common in northeast US & upper Midwest Sxs Fever, HA, malaise, myalgias. Rarely NV, diarrhea, stiff neck, arthralgias, confusion Labs: Thrombocytopenia; Leukopenia; Mild anemia; Increases in hepatic transaminases Diagnosis: Blood smear & PCR of blood Treatment: Doxycycline Erythema infectiosum (fifth disease) Parvovirus B19. Day care/young kids Respiratory secretions, saliva, placenta, blood products. Incubation 4-14 d. Sxs Slapped CHEEK RASH - large, bright red, erythematous patches bilaterally- warm non-tender Face rash fades, then symmetrical, macular, lacy, erythematous rash on the extremities

Kidsexanthematous illness, erythema infectious; Circumoral pallor; Malaise, HA, pruritis Immunocompromisedtransient aplastic crisis and pure red blood cell aplasia Adultslimited nonerosive symmetric polyarthritis Chloroquineexacerbates erythrovirus-related anemia Pregnancypremature labor, hydrops fetalis, fetal loss Dx clinical confirmed by elevated anti-erythrovirus IgM (serum) or with PCR (serum or marrow) Treatment Immunosuppressed patientsIVIG ; Intrauterine transfusionsevere fetal anemia

Influenza Highly contagiousrespiratory droplets Type Asubtypes from hemagglutinin (H) and neuraminidase (N) Main current virusesH1N1 and H3N2 subtypes and type B. Abrupt onsetFC, malaise, myalgias, cough substernal soreness, HA, stuffiness, nausea Elderlymay present with only lassitude, confusion Mild pharyngeal infection, flushed face, conjunctival redness, cervical lymphadenopathy Labsleukopenia, may see leukocytosis; proteinuria; isolate virus from throat swabs, nasal washings, cell cultures Rapid assaysnasal or throat swabs60-80% sensitivity Complicationsnecrosis of respiratory epitheliumsecondary bacterial infections sinusitis, otitis media, purulent bronchitis, pneumonia Treatmentbed rest, analgesics, cough medicine Treat - suggestive clinical infection or lab confirmed & high risk for complications No proven benefit of antivirals after 48 hrs, but should consider if patient is hospitalized Neuraminidase inhibitorsinhaled zanamivir or oral oseltamivir Measles Rubeola (nine-day or red measles) Acute systemic paramyxovirus Inhalation of infective droplets. Highly contagious from 4 days prior to the rash until 4 days after. Incubation period 9-10 days Clinical Presentation Fever (40-40.6 C) Malaise, coryza, dry cough, conjunctivitis, photophobia Koplik spots (tiny, bluish-white dots surrounded by red halos) on the buccal mucosa Rash appears about 4 days after onset usually lasts 5-6 days Pinhead-sized papules brick-red, irregular, blotchy blanching maculopapular exanthem may become uniform erythema Begins at hairline & spreads cephalocaudally & involves palms & soles Erythematous pharynx with yellowish tonsillar exudate; Coated tongue; systemic lymphadenopathy; Splenomegaly LabsLeukopenia, thrombodytopenia, proteinuria Can culture virus from nasopharyngeal washings and blood IgM measles bodies or 4x rise in serum hemagglutination inhibition, fluorescent antibody staining of respiratory or urinary epithelial cells Treatment Generalisolation until week following rash onset; bed rest until afebrile High dose vitamin Amaintains GI and respiratory mucosa Preventionimmunization (12-15 mo, 4-6 yrs) CI in pregnancy or immunosuppression Report all cases to public health. Mumps Paramyxovirus Spread by respiratory droplets. Incidence highest in spring. Incubation 14-21 days Children MC affected. THINK: If the question says immigration, adoption or no vaccines!!! Clinical Presentation 1/3 asymp Parotid tenderness, swelling usually bilateral Trismus; Fever, malaise, HA, can also have swelling of the testicles Complications Meningitis/encephalitis ; OrchitisMC extra salivary site adults; PancreatitisMC cause of pancreatitis in kids Labsmild leukopenia, amylasemia (from salivary glands), mild kidney function abnormalities

CSFpleiocytosis, hypoglorrhachia Diagnosisusually characteristic clinical picture Isolate of virus from swab of the duct of the parotid or other affected salivary gland Can isolate virus from CSF early in aseptic meningitis Nucleic acid amplificationmore sensitive than viral culture but limited availability Elevated IgM--diagnostic Txisolate till swelling subsides, bed rest till afebrile; symptomatic relief; Topical compresses

Roseola infantum (exanthem subitum) Primary HHV6children 6-36 months; major cause of infantile febrile seizures Symptoms include fever usually >39; anorexia; irritability; these sxs usually subside in 72 hours As fever defervenscences, usually erythematous, maculopapular rash appear on the trunk and then spread to the extremities, face, scalp, and neck HHV6 encephalitishippocampus, amygdala, limbus Symptomatic HHV6 is rare in adultsmono-like illness (primary) or encephalitis (reactivated) Can see infection during pregnancy / congenital transmission Reactivated diseasegraft rejection, graft-versus-host disease May cause fulminant hepatic failure and acute decompensation of chronic liver disease in children Rubella (german measles) Systemic diseasetogavirus transmitted by inhalation of infective droplets One attack usually confers permanent immunity Clinical Presentation Fetaldevastating Postnatally acquiredinnocuousup to 50% asymptomatic Fever, malaise, tender suboccipital adenitis, coryza Arthritis Early posterior cervical and postauricular lymphadenopathy Erythema of palate and throat Fine pink maculopapular rash on face, trunk & extremities in rapid progression (2-3 days) and fades quickly1 day in each area Labsleukopenia Diagnosiselevated IgM antibody, isolation of virus, 4x or greater rise in IgG Exposure during pregnancyimmediate hemagglutination-binding rubella antibody level Infection during 1st trimestercongenital rubella in 80% Congenital rubellaeye disease, microphthatlmia, hearing deficits, psychomotor retardation, heart defects, organomegaly, maculopapular rash Younger fetus at infectionmore severe illness. High mortality rate & permanent defects Second trimesterdeafness Postinfectious encephalopathymortality rate 20% Treatmentsymptomatic (acetaminophen) Preventionlive attenuated rubella virus vaccineoften in combo w/ measles, mumps, & varicella Try to immunize girls prior to menarche & Do not give immunization during pregnancy Catheter-associated UTI Enterococci & streptococci group B Surgical site infections Enterococci Central line associated infections S. epidermidis