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Micro - Opportunistic Infections (ii) (Patient Management (do specialised…
Micro - Opportunistic Infections (ii)
Opportunist Bacteria
endogenous
S epidermidis
S aureus
E coli
Enterococci (incl VRE)
M TB
exogenous
S aureus (incl MRSA)
enterobacteriaecae
P aeruginosa
Listeria
Atypical mycobacteria
Opportunist Viruses
herpes
can be latent + then reactivate
HSV1+2
VZV (latent in neurons, returns as shingles in old age)
CMV (colitis, pneumonitis, retinitis)
polyomaviruses
latent in kidney + lymphoid tissues
JC virus - progressive multifocal leukoencephalopathy
BK virus - esp in renal + stem cell transplant recipients
parvovirus B19: profound RBC aplasia - persistent anaemia
Hep B: chronic carriage, latent then reactivation
Opportunist Fungi
Candida
candidaemia
mucositis
oesophagitis
Aspergillus Fumigatus
Dx: BAL
lower RTIs
Cryptococcus Neoformans
meningitis
meningoencephalitis
pneumoncystis jirovecii
pneumonia
bilat interstitial shadow
severe dyspnoea
v specific Tx: co-trimoxazole
Opportunist protozoa
toxoplasma gondii
cerebral toxoplasmosis (cerebral abscess)
cytosporium parvum (severe diarrhoea)
Patient Management
high index of suspicion
be thorough: repeat assessments + investigations (e.g. x3 blood cultures)
have knowledge of common + uncommon pathogens
keep in mind could be polymicrobial
logical + rational antibiotic use
remove unnecessary devices
remember serology tests can be -ve due to immunosuppression
do specialised tests
high resolution CT for pul aspergillosis
PCR for CMV
BAL for PCP, CMV, HSV
top 3 causes of neutropenic BSI
gram +ve cocci
use prophylactic antibiotics + beware of longterm intravasc devices
gram -ve bacilli
high mortality
e coli, p aeruginosa
candida
Tx of neutropenic fever
against pseudomonas: piptazobactam + gentamicin
against gram +ve: glycopeptide (e.g. vancomycin)
anti fungal: caspofungin
antiviral/anti-PCP: ganciclovir +/- cotrimoxazole
keeping Txing until temp settles
Managing invasive fungal disease
Dx: high res CT
if confirmed as pul aspergillosis: prolonged voriconazole + therapeutic drug monitoring
empiric Tx = amphotericin (broad anti fungal)
Prevention
high standard of asepsis
patient + carer education
appropriate prophylaxis (vaccine + antimicrobial)
protective isolation