Board Review ID Bacteria Part 2

1. Board ReviewID Bacteria Part 2

2. Pasteurella multocida • Most commonly seen in cat or dog bites • Will see erythema, swelling, tenderness, LAD • Treatment of Choice – Penicillin • Alternative – Ampicillin, Augmentin, Cefuroxime • PCN Allergy - Azithromycin, Bactrim

3. Borrelia burgdorferi • Lyme Disease • Usually don’t tell you about the tick • Clinical symptoms • Fever, arthritis, rash • Arthritis is usually pauciarticular – large joints • Antibodies are not positive for 4-6 weeks so don’t wait!! • Lab Test – enzyme assay, Western blot • Know that it can be confused with JRA • Treatment of Choice – Doxycycline • Alternative • Children < 8 – PCN and Erythromycin

4. A Hard One! • Patient with Lyme Disease develops sepsis like picture • Fever, chills, hypotension • What is the name? • Jarish-Herxheimer • What is the cause? • Treatment causes lysis of organism and release of endotoxin

5. Yersina Pestis • Bubonic Plague is seen in Western US • Presenting symptoms are fever and painful lymphadenitis • Tests • Confirmed with culture • CDC has antibody assay • Treatment • Streptomycin • Gentamicin • May need to drain abscesses

6. Previously healthy 7 year old went to a group picnic with chicken salad the day prior to developing watery loose stools, vomiting and fever. • Diagnosis – • Salmonella • Treatment – • Supportive • What if I took out “previously healthy” and said “patient with ALL getting chemo” • Amoxil, Bactrim or cefotaxime

7. Salmonella • Mode of transmission • Contaminated food • Clinical Manifestations • Fever, diarrhea, abdominal cramps • Increased WBC, blood, mucus and whites in stool • Can have asymptomatic carriers • Lab testing • Stool culture • Treatment of Choice • Healthy children – supportive • Immunosuppressed or very young (< 3mos) • Bactrim, Amoxil • Know that in an healthy individual you don’t have to treat! Contact Precautions

8. Shigella • Mode of transmission • Person to person • Clinical symptoms • If you have it you will have symptoms • Fever, SEIZURES • Diarrhea – blood, mucus, whites • Left shift on differential • Lab Tests • Culture, PCR, DFA are available • Treatment • Bactrim, Ampicillin

9. What about daycare?? Do we treat them? Not unless they have symptoms. Otherwise just strict hand washing!!!

10. What is the bug that mimics appendicitis???? Yersina

11. Yersina enterocolitica • Mode of transmission • Contaminated pork • Clinical symptoms • “mimic appendicitis” • Fever and diarrhea • Lab Tests • Stool cultures • Treatment • None required • Immunocompromised or septicemia – Bactrim, Aminoglycocides • Isolation • CONTACT

12. Diarrhea in child that lives on a farm???? Campylobacter

13. Campylobacter • Clinical Features • Diarrhea, abdominal pain, fever, malaise • Bloody stools • Transmission • Chickens, turkeys, farm animals, unpasteurized milk • Tests • Stool culture • Management • Erythromycin or Azithromycin • * Family working on a farm CONTACT

14. H pylori • Chronic Gastritis • Epigastric pain, nausea, vomiting, hematemesis, heme + stools • Diagnosis • Culture • Histological – nodular antrum, lymphoid hyperplasia • Urease breath test • Serology • Stool antigen should disappear when treated • Treatment – Triple therapy 14 days • PPI + Clarithromycin + ( Amoxil or Metronidazole) • Risk Factors • Developing country, poor socioeconomic status, family overcrowding

15. E Coli

16. E Coli – enterohemorrhagic (STEC) • Diagnosis • Shiga toxin in stool • Culture • Remember can also cause ? • HUS • Renal failure • Thrombocytopenia • Hemolytic anemia • Treatment • Antibiotics were thought to increase risk of developing HUS • Recent studies have disputed this • Most still don’t treat

17. Pseudomonas • Otitisexterna • Hot tub folliculitis • Puncture wound – nail in shoe • Cystic Fibrosis • Burns • Immunocompromised patients • Treatment CEFTAZ

18. Treponema pallidum- acquired • Clinical manifestations • Primary • Painless ulcer - chancre • Secondary – 1-2 mos later • Rash, mucocutaneous lesions, LAD • Fever, malaise, sore throat, arthralgia • Latent • Seropositive, but no signs • Lab test • Definitive diagnosis – visualization of spirochetes on dark field mic. • Non-Treponemal • RPR, VDRL, ART • Treponemal (+ for life) • FTA-ABS , TP-PA • Don’t forget CSF!!! • Check with untreated syphilis > 1yr • VDRL, FTA-ABS • Treatment • PCN

19. Treponema pallidum - congenital • IgG will cross the placenta • Clinical features • Macular papular rash, HSM, peeling skin, LAD, edema, hemolytic anemia, thrombocytopenia If untreated – will see Sniffles, bullous lesions, osteochondritis, Hutchinson teeth, keratitis, frontal bossing, mulberry molars, saddle nose, 8th nerve deafness. Hutchinson Triad – Interstitial keratitis Eight cranial nerve deafness Hutchinson teeth

20. Evaluation of Babies • Know the serologic status for ALL babies prior to d/c • If mom is + • Careful exam • Nontreponemal test • Make sure to do the same one as the mom, so you can compare • ** further eval if mom has 4 fold increase or if baby is 4 times mom • Workup • Physical exam • Nontreponemal test • VDRL of CSF (include cell count and protein) • Long bone xrays • CBC

21. Do we tap everyone?? • Anything on exam suggestive of Syphilis • Nontreponemal test fourfold higher than mom’s • Positive darkfield or fluorescent antibody test

22. Pick your brain… • You see a baby in the newborn nursery. When looking at mom’s labs you notice she is +RPR. • What are you thinking? • What should you do? • Continuing to investigate you see mom’s FTA-ABS is negative. Do you want to test the baby? Should we give the baby PCN? • The baby’s RPR comes back +, now what • FTA-ABS -

23. Clarify!!

24. Quiz • Infant born with congenital syphilis. Mom was treated with Erythromycin 2 months prior to delivery. What if any treatment should the infant receive? • If mom treated > 1month prior to delivery no treatment of baby is required • BUT – it has to be with PCN to cross the placenta Treat the baby with Penicillin

25. Treat or not to Treat… • Treatment of Choice – Penicillin G • ALWAYS: neruosyphilis, pregnancy, congenital • Answer will be Desensitization (no alternatives) • Newborns • Physical, labs, or radiologic evidence of active disease • Positive placenta or umbilical cord test using darkfield • Reactive VDRL in CSF • Serum nontreponemal test that is fourfold higher than mom’s • Or if you can’t exclude infection - TREAT

26. Those who are Safe • Healthy appearing babies who’s mom completed the right dose of PCN greater than FOUR weeks before delivery • Mom had appropriate serological response to treatment • Infant has a nontreponemal titer the same or less than fourfold the maternal titer • Mom had no evidence of reinfection • Treat with a single dose of PCN or • Follow PE and titers closely until they are titers are negative

27. What if mommy didn’t get it exactly right? • 1. Don’t know PCN dose • 2. Mom got something other than PCN • 3. Treatment given within 28 days of birth • Asymptomatic babies with less than four fold increase • 2 choices: • 1. Normal full workup: CSF, optho, xrays, blood counts • Single dose of PCN G • 2. Treat for 10 days with PCN G

28. Mycobacterium tuberculosis • Transmission - airborn • Clinical manifestations • Cough, fever, growth delay, wt loss, night sweats • Lab test • Skin Test • Xray- hilar/mediastinal LAD • AFB • sputum > 5 years old • Early morning gastric aspirate • Isolation • Droplet

29. Check the BUMP…

30. What if it is positive? • What is the next step? • CXR • If CXR is negative, do you treat? • Yes • With what? • Isoniazid • How long? • 9 months

31. Remember! • What is the deal with delayed immunizations and TST??? • Can’t give it with the measles vaccine. Why? • Will decrease your response to TST • If you need to do TST – should delay vaccine 4-6 weeks • No evidence to show you need to do it with varicella, but you can assume you need to delay as well

32. My mommy has TB Baby Treatment: Isoniazid 3-4 mos Place PPD if + evaluate for active disease - continue therapy for 9 mos - and mom treated appropriately can stop baby meds

33. Extrapulmonary TB • Meningitis • Lymphadenitis • Bones • Joints • Skin