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CID - Coggle Diagram
CID
HIV
complications:
pneumocystis pneumonia (PCP) aka AIDS pneumonia
dry cough, fever, SOB, chest tightness, diffuse infiltrate on chest xray, arterial blood O2 desaturation
treatment: trimethoprim-sulfamethoxazole, atovaquone, pentamidine
cryptococcus neoformans
primarily a CNS infection, headache, fever, malaise, AMS
diagnosis: CSF
treatment: amphotericin B IV, LP, fluconazole maintenance therapy daily, no ART or steroids for at least first 2 weeks
histoplasma capsulatum
fever, weight loss, constitutional symptoms, respiratory complaints, AMS, hepatosplenomegaly, adenopathy, cytopenias
diagnosis: blood/tissue culture, tissue histology, urine/serum antigen testing
treatment: amphotericin B (acute), itraconazole (mild acute), itraconazole (chronic)
mycobacterium avium-intracellularae complex (MAC)
fever, malaise, weight loss, diarrhea, anemia, pancytopenia
diagnosis: blood/tissue culture, tissue histology
treatment: multi-drug regimen based upon clarithromycin/azithromycin; ethambutol +/- rifamycin and macrolide; >12 months
toxoplasma gondii
focal neurologic deficit, seizures, AMS
diagnosis: presence of antibodies, abnormal imaging (ring-enhancing lesions), tissue histology
treatment: sulfadiazine + pyrimethamine; clindamycin + pyrimethamine; clarithromycin/azithromycin/atovaquone + pyrimethamine; dapsone + pyrimethamine
mycobacterium tuberculosis
typical TB presentation
diagnosis: sputum specimens for acid-fast staining & culture
regular TB treatment
cytomegalovirus retinitis
decreased visual acuity, floaters, field cut
diagnosis: visual diagnosis by ophthalmologist
treatment: valgancyclovir, ganciclovir, foscarnet, cidofovir
rarely seen anymore
other: hep C, hep B, herpes, HPV, JC virus, syphilis & other STIs, cancer (kaposi, lymphomas, anal/genital), psychiatric disease, substance use
Chronic HIV & CD4 Cell counts:
200<CD4<500 --> toward lower end of range the incidence of minor HIV-related infections and other symptoms increases (oral/mucosal candidiasis, herpes zoster, dermatitis, fatigue, diarrhea); very symptomatic pts may develop an OI at this level
100<CD4<200 --> AIDS diagnosis based upon CD4 count under 200 due to higher risk of Pneumocystis jiroveci pneumonia (PCP)
CD4<100 --> increasing high risk for all opportunistic infections
CD4>500 --> associated with few, if any, symptoms and no opportunistic infections
CD4 count --> the major indicator of immune function; check every 3-6 months
HIV RNA --> critical in determining response to ART
treatment:
currently, a combination of at least 3 antiretroviral drugs administered chronically
8 classes: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, entry inhibitors (fusion, CCR5, attachment, post-attachment), integrase inhibitors
early consistent treatment
causes of failure: patient factors, drug resistance, suboptimal adherence, ARV toxicity & intolerance, pharmacokinetic problems, provider experience
cost: $40-45k; insurance covers
long term prognosis --> related to the degree of control of the virus and degree of immunosuppression when therapy started; if started early and adhered to without problems, survival approaching that of uninfected population
Immune Reconstitution Syndrome:
already being treated for OI (TB, MAC, cryptococcal disease), then start HAART, and have clinical deterioration/recurrence of symptoms
don't stop HAART! may require steroids if symptoms severe
Acute Retroviral Syndrome:
meningoencephalitis or aseptic meningitis, peripheral neuropathy or radiculopathy, facial palsy, Guillain-Barre syndrome, brachial neuritis, cognitive impairment or psychosis
transmission: sex, blood, vertical transmission, occupational exposure
PrEP --> vulnerable people use as part of an HIV drug regimen on a daily basis to prevent HIV (Truvada, Descovy)
prevention opportunities: abstinence, correct & consistent condom use, male circumcision, PrEP/PEP, treatment of STIs, decreased sexual partners, decreased sharing of needles, prevention of mother-to-child transmission
everyone should be tested for HIV at least once in their lifetime; all pts 13-64 & pts with TB or seeking treatment for STI
annual screening for high risk persons
HIV is a virus; AIDS is the syndrome that results from the virus damaging the immune system
Bacteremia/Sepsis
bacteremia
the presence of viable bacterial organisms in the blood
sources:
community-acquired: PNA, urinary tract, meningitis, skin/soft tissue, heart valve, other, unknown
nosocomial: catheter, urinary tract, PNA, skin/soft tissue/wound, other, unknown
infection = invasion of normally sterile tissue by organisms, resulting in pathology
Systemic Inflammatory Response Syndrome (SIRS)
the systemic response to injury, including sepsis, trauma, burns, etc
defined by 2 or more of the following: temp >38 degrees C or <36 C, HR >90bpm, RR >20/min, pCO2 <32mmHg, WBC >12.0, <4.0, or >10% immature forms (bands)
sepsis
life-threatening organ dysfunction caused by dysregulated response to infection
defined by at least two criteria + infection: RR >22, AMS (GCS <13), SBP <100mmHg
severe: SIRS + infection + one of the following: SBP <90mmHg, MAP <65, SBP decrease >40mmHg, Cr >2.0 mg/dL, bilirubin >2.0mg/dL, platelet count <100K, INR >1.5, aPTT >60sec, lactate >2mM
RF: bacteremia, age >65yo, immunosuppression, DM, obesity, cancer, CAP, genetics (polymorphisms)
25% polymicrobial, 30% culture negative, 25% multi-drug resistant
common: fever, rigors, myalgias, tachycardia, tachypnea (resp. alkalosis), hypoxemia, proteinuria, leukocytosis (left shift, toxic granules), eosinopenia, hypoferremia, irritability, lethargy, mild liver function abnormalities, hypertriglyceridemia in DM
uncommon: hypothermia, shock, lactic acidosis, ARDS, azotemia, oliguria, leukopenia, leukemoid reaction, thrombocytopenia, DIC, anemia, stupor, coma, overt UGI bleed, cutaneous lesions, hypoglycemia
management: rapid initiation of appropriate antimicrobial therapy, removal/drainage of infected foci, fluid resuscitation/pressors; treat specific manifestations, enteral nutrition, stress ulcer prevention, skin care, DVT prophylaxis, secondary infection prevention
prognosis depends on complications (shock, DIC, renal failure, ARDS), specific organism, site of infection in bacteremia, antibiotic therapy (prior use, appropriate therapy, interval to onset of therapy), age, severity of illness score, genetic polymorphisms
septic shock = sepsis + tissue hypoperfusion
Rational Therapeutics
Definition: prescribing drugs in a manner that maximizes clinical effect (maximizing efficacy and minimizing toxicity), functional status, and overall patient satisfaction, at the lowest possible total cost
Principles:
the outcomes of a therapeutic decision are most likely to be optimized when the decision takes into account the factors that make each patient different
set the legitimately expected clinical effects of therapy BEFORE starting therapy; use those objectives to monitor drug effects and to signal the need for changes in therapy
each patient is unique in response to particular drugs: therefore, each patient poses unique challenges to the health care provider
the elderly patient is at risk of entering a vicious cycle in which the patient is more likely to receive drugs, more likely to develop adverse drug reactions, and potentially more likely to receive even more drugs to treat the unrecognized adverse drug effect
the renal function of a patient must be known to prescribe drugs wisely; understand a drug's route of clearance, as well as the route of clearance of any active or toxic metabolites, before prescribing it
because liver disease produces so many alterations in physiology, it is difficult to accurately predict he effects of liver disease on a particular drug's kinetics
failure to establish a firm diagnosis makes therapeutic plans difficult, especially in critically ill patients; when empiric drug treatment is necessary, it is even more important that data be carefully gathered and form the basis of sound decisions
aggressive, early, broad-spectrum empiric treatment before a diagnosis is made may be either essential or foolish; aggressive, invasive and thorough efforts to establish a firm diagnosis before beginning treatment may be essential or foolish; the clinician must consciously balance the risks and benefits of treatment and diagnostic studies in the dynamic state posed by the patient’s disease and the unique interaction of features in each patient
even when a drug has been used for years for recognized indications, we should not be surprised when new data surface documenting a new form of drug-induced toxicity; in fact, it is likely that increased experience with a drug will not only lead to new indications of the drug's use, but also provide data that older indication may not be justified
although a clinician's recent personal experience is important, it can lead to the clinician's overestimating the frequency of his/her most recently recognized adverse drug reaction and underestimating what he/she has not recently seen
choosing appropriate endpoints of efficacy may not be straightforward, but should be done prospectively as often as possible; targets and goals can change as our understanding of the disease or the drug change over time; patients may stress endpoints related to cost, functional status, or overall satisfaction, even as clinicians traditionally select endpoints related to pharmacological effect and quantitative evidence of reduction in the severity of illness
only when the clinician approaches each drug prescription as the beginning of a therapeutic experiment of uncertain outcome, and not as a concluding act to an office visit, will the chances that the experiment will be as safe, effective and productive as possible be maximized
approach to the elderly:
1) extra efforts to establish a diagnosis
2) detailed drug history
3) clinical pharmacology in the elderly
4) frequently re-evaluate
5) consider non-pharmalogical approaches
6) individualize therapy
7) pick endpoints carefully
8) maintain alliance with patient
factors that inhibit the practice of rational therapeutics:
knowing the diagnosis with reasonable certainty
understanding the pathophysiology of the pt's disease
understanding the pharmacology of possible drugs
optimizing selection of drug and dose -- including the option of NO drug
selecting and following appropriate endpoints
the therapeutic alliance between clinician and patient