Infectious Disease/Microbiology Key Concepts

1. Describe the clinical syndrome(s) associated with the following and indicate the appropriate
antimicrobials to treat them.

Bacteria
Gram positive cocci

Staphylococcus aureus:
 Syndromes
o Skin infections- impetigo, cellulitis, abscesses, carbuncles
o Bacteremia/sepsis- hematogenous spread
o Acute endocarditis- destructive
o Pneumonia- damaging process, cavitations, empyema, effusions
o Osteomyelitis/septic arthritis- hematogenous and traumatic spread
o Food poisoning- 1-8-hour onset, vomiting, preformed toxin
o Toxic shock syndrome- fever, vomiting, diarrhea, diffuse erythematous rash
 Treatments
o Beta lactamase production is common
o Use methicillin, nafcillin, dicloxacillin
o MRSA- vancomycin

Staphylococcus epidermidis:
 Syndromes
o Can form biofilms on IV catheters, damaged/prosthetic heart valves (causing
endocarditis), etc.
 Treatments
o Vancomycin for endocarditis
o Replacement of infected line/valve/etc.

Staphylococcus saprophyticus:
 Syndromes
o Community-acquired UTI in young women (2nd most common after E. coli)
 Treatments
o Trimethoprim-sulfamethoxazole (Bactrim)
o Quinolone such as norfloxacin
o Ceftriaxone

Group A Streptococci (mainly S. pyogenes):

 Syndromes
o Impetigo, cellulitis, erysipelas
o Strep throat
o Bacteremia
 o Septic arthritis/osteomyelitis
o Vaginitis
o Meningitis
o Sinusitis
o Pneumonia
 Treatments
o Penicillin
o Erythromycin and other macrolides
o Cephalosporins
o Clindamycin

Group B Streptococci (mainly S. agalactiae):

 Syndromes
o Mainly affects neonates
 Meningitis
 Sepsis
 Pneumonia
 Treatments
o Prophylaxis- moms with positive cultures receive intrapartum penicillin
o Penicillin treatment of choice in general

Streptococcus viridans:
 Syndromes
o Pharyngitis (strep throat)
o Skin/soft tissue infections- impetigo, cellulitis, necrotizing fascitis
o Scarlet fever
o Toxic shock syndrome
o Rheumatic fever- mitral valve disease follows pharyngitis, not skin infection
o Acute glomerulonephritis- follows both pharyngitis and skin infections
 Treatments
o Penicillin to prevent rheumatic disease
 Does not treat post strep disease or enterococcus

Streptococcus pneumoniae:
 Syndromes
o Lobar pneumonia
o Adult meningitis
o URI (children)
o Otitis media (children)
 Treatments
o Macrolides such as azithromycin
o 3rd generation cephalosporin- ceftriaxone
o Prevention- vaccine
  Adults- 23 valent polysaccharide vaccine
 Children- 7 valent, conjugated to a protein (more robust reaction)

Enterococcus- S. faecalis:
 Syndromes
o Subacute endocarditis
o UTI
o Catheter-related infections
o Meningitis
 Treatments
o Linezolid
o Tigecycline

Enterococcus- S. faecium:
 Syndromes
o Endocarditis
o UTI
o Biliary tract infections
o Catheter-related infections
o Leading cause of vancomycin-resistant enterococci (over S. faecalis)
 Treatments
o Linezolid
o Daptomycin

Gram positive bacilli

Listeria monocytogenes:
 Syndromes
o Neonatal meningitis and sepsis
o Amnionitis
o Meningitis in adults over 60 and immunocompromised
o Mild, self-limited gastroenteritis
 Treatments
o Ampicillin

Gram negative cocci

Neisseria meningitidis:
 Syndromes
o Meningococcemia- fever, arthralgia, myalgia
o Meningitis
o Waterhouse-Friedrichsen- fever, purpura, DIC, adrenal insufficiency, shock,
death
  Treatments
o 3rd generation cephalosporin- ceftriaxone or penicillin G
o Prophylaxis in close contacts- rifampin, ciprofloxacin, or ceftriaxone
 Vaccine for types A, C, and D

Neisseria gonorrhoeae:
 Syndromes
o Males- urethritis, epididymitis, prostatitis
o Females- cervicitis, PID, tubo-ovarian abscess, ophthalmia neonatorum,
o Both- septic arthritis
 Treatments
o Ceftriaxone AND macrolide (azithromycin or doxycycline) for possible chlamydial
coinfection
o Prevention of neonatal blindness- erythromycin eye ointment

Haemophilus influenzae:
 Syndromes
o HaEMOPhilus causes:
 Epiglottitis
 Meningitis
 Otitis media
 Pneumonia
o Also:
o Conjunctivitis
o Bronchitis
 Treatments
o Mucosal infections- amoxicillin  clavulanate
o Meningitis- ceftriaxone
o Prophylaxis for close contacts- rifampin
o Vaccine- type B capsular polysaccharide conjugated to diphtheria toxoid
 Given between 2-18 months age

Gram negative bacilli

Enterobacteriaceae: Escherichia coli:

 Syndromes
o EIEC (enteroinvasive)- microbe invades intestinal mucosa and causes necrosis
and inflammation
 Presentation- invasive; dysentery (similar to Shigella)- bloody diarrhea
with WBCs
o ETEC (enterotoxigenic)- produces heat-labile and heat-stabile enterotoxins
 Heat-labile toxin produces cAMP (similar to cholera toxin) = increased Cl-
secretion in gut and H2O efflux
  Heat-stable toxin produces cGMP = decreased resorption of NaCl and
H2O in gut
 No inflammation or invasion
 Presentation: Travelers' diarrhea (watery)
o EPEC (enteropathogenic)- no toxin produced
 Adheres to apical surface, flattens villi, prevents absorption
 Presentation- diarrhea, usually in children
o EHEC (enterohemorrhagic)
 O157:H7 most common serotype in US
 Often transmitted via undercooked meat, raw leafy vegetables
 Shiga-like toxin (inhibits ribosomes at the 60s position): causes hemolytic
uremic syndrome (HUS)
 Anemia
 Thrombocytopenia
 Acute renal failure (due to microthrombi forming on damaged
endothelium)
 Leads to mechanical hemolysis (with schistocytes on peripheral
blood smear), platelet consumption, and decreased renal blood
flow
 Presentation- dysentery (toxin alone causes necrosis and inflammation)
 Treatments
o 3rd generation cephalosporin (ex. ceftriaxone)

Enterobacteriaceae: Klebsiella:
 Syndromes
o Aspiration pneumonia
 In alcoholics and diabetics
 Intestinal flora causes lobar pneumonia when aspirated
 Dark red "currant jelly" sputum (blood/mucus)
o Abscesses in lungs and liver
 Can form cavitary lesions that are TB-like
o Nosocomial UTIs
 Treatments
o Carbapenems
o 3rd generation cephalosporins (ceftriaxone)
o Quinolones

Enterobacteriaceae: Enterobacter:
 Syndromes
o Pneumonia
o UTI
o Nosocomial infections
o Endocarditis
 o Septic arthritis/Osteomyelitis
o Ophthalmic infections
 Treatments
o Carbapenems
o Beta-lactams
o Fluoroquinolones
o Aminoglycosides

Enterobacteriaceae: Proteus:
 Syndromes
o Kidney stones (staghorn calculi in kidney)
 Urease produces NH3 and CO2 from urea, creating an alkaline
environment, which is perfect for precipitation of struvite stones
(composed of ammonia, magnesium, and phosphate)
o UTI
 Treatments
o Sulfonamides

Enterobacteriaceae: Salmonella enteriditis:

 Syndromes
o GI- inflammatory diarrhea
o Gastroenteritis (via cholera-like toxin)
 Treatments
o Antibiotics not indicated, no vaccine

Enterobacteriaceae: Salmonella typhi:

 Syndromes
o GI- constipation followed by diarrhea (“pea soup” diarrhea)
o Typhoid fever
 Rose spots on abdomen
 Constipation
 Abdominal pain
 Fever
o Osteomyelitis in sick cell patients (#1 cause)
 Treatments
o Typhoid fever- ceftriaxone or fluoroquinolone (cipro)
o Oral and IM vaccines

Pseudomonas aeruginosa:
 Syndromes
o Pneumonia- most common gram negative nosocomial pneumonia
o Respiratory failure in CF patients
o UTI- associated with indwelling catheters and nosocomial infection
 o Osteomyelitis
o Otitis externa (swimmers ear)
o Skin lesions- hot tub folliculitis, ecthyma gangrenosum- rapidly progressive,
necrotic cutaneous lesion caused by pseudomonas bacteremia (typically seen in
immunocompromised)
o Sepsis
 Treatments
o Piperacillin + tazobactam
o Aminoglycosides
o Fluoroquinolones

Legionella pneumophila:
 Syndromes
o Legionnaires’ disease
 Severe atypical pneumonia (often unilateral and lobar)
 Hyponatremia
 Fever
 GI symptoms (diarrhea)
 CNS symptoms (headache, confusion)
 Common in smokers and chronic lung disease
o Pontiac fever
 Mild flu-like syndrome
 Usually self-limiting
 Treatments
o Macrolide (erythromycin) or quinolone

Bacteroides spp. (B. fragilis):

 Syndromes
o Peritoneal abscess
o Bacteremia associated with intraabdominal infections
 Treatments
o Clindamycin or metronidazole
o Tigecycline

Miscellaneous bacteria

Bartonella henselae:
 Syndromes
o Cat scratch disease- fever; can involve regional lymph nodes, typically in axilla of
one arm
o Bacillary angiomatosis (in immunocompromised)- fever, chills, headache, raised
red vascular lesions
 Treatments
 o Cat scratch disease- usually self-limited, can be treated with macrolides
(azithromycin)
o Bacillary angiomatosis- doxycycline or macrolides

Borrelia burgdorferi:
 Syndromes
o Lyme disease
 Stage 1- early localized: erythema migrans (typical "bulls-eye"
configuration) is pathognomonic but not always present, flu-like
symptoms
 Stage 2- Stage 2- early disseminated: secondary lesions, carditis, AV
block, facial nerve (Bell) palsy, migratory myalgias/transient arthritis
 Stage 3- late disseminated: encephalopathies (memory difficulty,
lymphocytic meningitis), chronic polyarthritis (migratory)
 Treatments
o 1st line (used in stage 1)- doxycycline
o More severe or later presentations- ceftriaxone
o Pregnant women and children- amoxicillin and cefuroxime

Chlamydophila pneumonia:
 Syndromes
o Atypical pneumonia (transmitted by aerosol)
 A cause of walking pneumonia
 More common in elderly
 Treatments
o Azithromycin (more favored because one-time treatment)
o Doxycycline (+ ceftriaxone for possible concomitant gonorrhea)

Treponema pallidum:
 Syndromes
o Primary syphilis- localized disease
 Painless genital chancre- syphilis locally invades small blood vessels
causing ischemic necrosis and takes out nerves making it painless (heals
in 3-6 weeks if treated)
o Secondary syphilis- disseminated disease
 Constitutional symptoms
 Maculopapular rash (including palms and soles)- occurs weeks-months
after infection
 Condylomata lata (smooth, moist, painless, wart-like white lesions on
genitals)
 Lymphadenopathy
 Patchy hair loss
 Latent syphilis (+ serology without symptoms) may follow
 o Tertiary syphilis
 Gummas (chronic granulomas)
 Aortitis (vasa vasorum destruction- "tree-barking" appearance; can form
aneurysm)
 Neurosyphilis (tabes doraslis, "general paresis")
 Demyelination of nerves and posterior walls of spinal cord,
leading to loss of proprioception and other neurological issues
 Argyll Robertson pupil (constricts with accommodation but is not reactive
to light; also called "prostitute's pupil" since it accommodates but does
not react)
 Signs: broad-based ataxia, + Romberg, Charcot joint, stroke without
hypertension
o Congenital syphilis
 Facial abnormalities such as rhagades (linear scars at angle of mouth),
snuffles (nasal discharge), saddle nose, notched (Hutchinson) teeth,
mulberry molars, short maxilla
 Saber shins- anterior bowing of tibia
 CNVIII deafness
 Treatments
o Penicillin
 If allergic, desensitize them and still use penicillin
o Prevention of congenital syphilis- treat mother early in pregnancy, as placental
transmission typically occurs after first trimester
o Jarisch-Herxheimer reaction- flu-like syndrome (fever, chills, headache, myalgia)
after antibiotics started, due to bacteria (usually spirochetes) releasing toxins

Rickettsia

Rickettsia rickettsii:
 Syndromes
o Rocky Mountain Spotted Fever- headache, fever, rash (vasculitis)- typically starts
at wrists and ankles and then spreads to trunk, palms, and soles
 Treatments
o Doxycycline
o Caution during pregnancy, alternative is chloramphenicol
o Supportive care with vascular collapse

Mycobacteria

Mycobacterium tuberculosis:
 Syndromes
o Tuberculosis- chronic low-grade fever, night sweats, productive cough,
hemoptysis, weight loss
  Treatments
o Prolonged, multiple treatment
 RIPE: rifampin, isoniazid, pyrazinamide, ethambutol

Fungi

Candida spp.:
 Syndromes
o Systemic or superficial fungal infection
o Oral and esophageal thrush (neonates, inhaled steroids, DM, AIDS,
immunocompromised)
o Vulvovaginitis (DM, antibiotics (lower pH), OCPs)
o Diaper rash
o Endocarditis (IVDU)
o Disseminated candidiasis (neutropenic patients)
o Chronic mucocutaneous candidiasis
 Treatments
o Oral/esophageal- nystatin, fluconazole, or caspofungin
o Vaginal- oral fluconazole, topical azole
o Systemic- fluconazole, caspofungin, or amphotericin B
 Azoles for minor infections
 Amphotericin B for major infections

Pneumocystis jiroveci:
 Syndromes
o Most infections are asymptomatic (in healthy people)
o Pneumocystis pneumonia (PCP)- diffuse interstitial pneumonia
 Cough (non-productive), dyspnea, fever
 Diffuse, bilateral ground-glass opacities on CXR/CT
 Treatments
o TMP-SMX (bactrim)
o Pentamidine (use with sulfa allergies)
o Atovaquone
o Prophylaxis- dapsone or any of above
 Start when CD4+ count drops below 200 cells/mm3 in AIDS patients

Aspergillus spp. (fumigatus and flavus):

 Syndromes
o Invasive necrotizing pneumonia (aspergillosis)- In immunocompromised
(especially those with neutropenia from leukemia or lymphoma) or patients with
chronic granulomatous disease
 Invades blood vessels and surrounding tissues and disseminates through
body
  Kidney failure, endocarditis, ring enhancing lesions in brain
 Invades nasal sinus- necrosis around nose
o Aspergillomas
 Solid fungus balls
 In pre-existing lung cavities, especially after TB infections
 Gravity-dependent, will be at bottom of cavity
o Allergic bronchopulmonary aspergillosis (ABPA)
 Wheezing, fever/sweats, migratory pulmonary infiltrate
 May cause bronchiectasis and eosinophilia
 Type I hypersensitivity response associated with asthma and CF
 IgE response
 Aflatoxins- associated with hepatocellular carcinoma
 Peanuts and grain crops associated with aflatoxins produced by A.
flavus
 Treatments
o Less serious infection- voriconazole
o Angioinvasive disease- amphotericin B

Cryptococcus neoformans:
 Syndromes
o Usually asymptomatic
o Can cause pneumonia, bone/skin granulomas
o Dissemination causes cryptococcal meningitis or encephalitis, subacute
 With encephalitis- “soap bubble” lesions in brain
 Treatments
o Amphotericin B + flucytosine, then fluconazole after for cryptococcal meningitis

Histoplasma capsulatum:
 Syndromes
o Histoplasmosis- asymptomatic infection or mild pneumonia in healthy people
o In some, can cause granuloma formation, which can calcify leading to chronic
pulmonary issues
 Nodules especially in hilar regions
o Erythema nodosum- often found on shins
o Palatal/tongue ulcers
o Immunocompromised
 Pneumonia
 Hepatosplenomegaly
 Calcifications in liver and spleen
 Fungus targets the reticuloendothelial system that has a lot of
macrophages (prevalent in the liver and spleen)
 Treatments
o Local infection- fluconazole or itraconazole
 o Systemic infection- amphotericin B

Coccidioides immitis:
 Syndromes
o Healthy people- majority asymptomatic, but in some, can present as self-limited,
acute pneumonia with cough, fever, sweats, and arthralgias (knee pain)
 Radiographs of lung may be unremarkable
 Or may be some cavities and/or nodules
o Erythema nodosum (desert bumps) or multiforme- only associated with healthy
people because from a robust immune response
o Immunocompromised
 Skin and lungs are common sites of infection
 May disseminate to bone
 May disseminate to meninges and cause meningitis
 Treatments
o Local lung infections- azole drugs
o Systemic infection- amphotericin B

DNA viruses

Herpes simplex virus 1 (HSV1):

 Syndromes
o Gingivostomatitis
 Often the first sign of infection
 Widespread inflammation of lips and gums
 More aggressive and more painful
 Often happens in infants
o Keratoconjunctivitis
 Serpiginous corneal ulcers (snake like ulcers) on fluorescein slit lamp
exam
o Herpes labialis (cold sores)
 "Dew drops on rose petal" appearance- clear vesicles, sitting on top of an
erythematous space
o Herpetic whitlow on finger
 Most common in dentists
 Caused by HSV-1 and HSV-2
 Can be transmitted from genitalia to fingers
 "Dew drops on rose petal" rash
o Temporal lobe encephalitis
 Most common cause of sporadic encephalitis
 Altered mental status
 Seizures
 Aphasia
  Bizarre behavior, olfactory hallucinations, change in personality
o Esophagitis
o Erythema multiforme
 HSR- small target lesions usually seen on backs of hands and feet, then
move in centrally
 Appears 1-2 weeks after infection
 Treatments
o No cure
o Prevent breakouts- acyclovir or valacyclovir

Herpes simplex virus 2 (HSV2):

 Syndromes
o Herpes genitalis
 Painful vesicular lesion, with inguinal lymphadenopathy
o Aseptic meningitis in adults and adolescents
o Neonatal herpes
 Treatments
o No cure
o Prevent breakouts- acyclovir or valacyclovir

Cytomegalovirus (CMV):
 Syndromes
o Immunocompetent patients
 Mononucleosis
 Similar to EBV mono
 Sore throat, lymph adenopathy, fatigue
 Negative monospot
o Immunocompromised patients
 Transplant patients
 Pneumonia
 HIV/AIDS patients
 CMV retinitis- full thickness retinal necrosis ("Pizza pie
retinopathy")
o Hemorrhage
o Cotton-wool exudates
o Vision loss
 Esophagitis
o Different from herpes esophagitis because CMV is singular,
deep, and linear ulceration vs. herpes is usually multiple
and shallow ulcerations
 Colitis
o Ulcerations in colonic wall
o Congenital CMV
  Most common fetal viral infection
 Blueberry muffin rash- thrombocytopenia presenting with a petechial
rash (like congenital rubella)
 Hepatosplenomegaly and jaundice
 Sensorineural deafness- damage to inner ear
 Structure abnormalities in the brain:
 Ventriculomegaly
 Intracranial calcifications
o Periventricular calcifications
o Parenchymal calcifications
o Toxoplasmosis also does this
 Can lead to mental retardation and seizures
 Hydrops fetalis- heart failure leading to severe edema
 Often leads to spontaneous abortion
 #1 cause of sensorineural hearing loss in children, mental retardation
from viral infection, and congenital viral infection

 Treatments
o Ganciclovir
o UL97 gene mutation- foscarnet

Varicella-zoster virus (VZV):

 Syndromes
o Chicken pox (left)- fever, headache, wide-spread rash (Xanthan)
 Vesicular rash- "dew drops on a rose"
 Lesions/rashes are at different stages of healing
o Shingles (right, aka Herpes zoster)
 Reactivated form
 "Dew drop on a rose" appearance (vesicles on an erythematous base)
 Reactive, and travels down the dorsal root sensory fibers in a dermatome
pattern = dermatomal distribution (usually thoracic/lumbar)
 Rarely cross the midline- if it does cross, means it is disseminated VZV
and probably immunocompromised
 Complication- post-herpetic neuralgia
 Pain, even after the rash subsides
 Herpes Zoster Ophthalmicus- CN V1 distribution branch (trigeminal
nerve) involvement leads to vision loss
o Encephalitis
o Pneumonia
o Congenital varicella syndrome-
 Limb hypoplasia
 Cutaneous scarring in a dermatomal pattern
 Treatments
 o Chicken pox-
 Vaccine- live, attenuated vaccine
 Treatment- acyclovir
 Children 12+
 Adults
 Immunocompromised
o Shingles-
 Vaccine- Zoster vaccine, live, attenuated virus; recommended for adults
>60
 Don't give to immunocompromised patients, BUT can give to HIV
patients if CD4 >200
 Treatment- acyclovir, famcyclovir, or valcyclovir

Epstein-Barr virus (EBV):

 Syndromes
o Mononucleosis
 Fever
 Hepatosplenomegaly- due to T cell proliferation
 Pharyngitis- with tonsillar exudates
 Tender lymphadenopathy (especially posterior cervical nodes)
o Risk factor for 3 cancers:
 B cell lymphoma (HL mixed cellularity)
 NHL (Burkett lymphoma)
 Endemic (African)- Large jaw lesion, swelling
 Sporadic- ileocecal involvement and peritoneum (common
translocation is t8:14)
 Nasopharyngeal carcinoma- Asian people
o Oral hairy leukoplakia
 Commonly seen in HIV
 Not a pre-cancerous lesion
 Often lateral lesions of tongue, can't scrap off tongue
 Treatments
o Avoid contact sports until resolution (due to risk of splenic rupture)
 Splenomegaly in 50-60% of people infected
o Bad treatment- If think it is strep pharyngitis because presents with sore throat:
use of amoxicillin/ampicillin with mono can cause characteristic maculopapular
rash
 Rash is not an allergic reaction

Adenovirus:
 Syndromes
o Febrile pharyngitis/tonsillitis- sore throat
o Acute hemorrhagic cystitis- bladder infection leading to gross hematuria
 o Conjunctivitis- "pink eye"
o Pneumonia
 Treatments
o Vaccine- live, attenuated
 Only indicated for military recruits

Parvovirus B19:
 Syndromes
o Aplastic crisis in sickle cell disease
 Bone marrow has a cobweb look
o "Slapped cheek" rash in children (erythema infectiosum or fifth disease)
 Low grade fever that lasts a week, then becomes a lacy reticular pattern
that goes down the body (differentiated from Roseola)
o Baby in utero- hydrops fetalis (fetal anemia and HF) and death of fetus
 Same hydrops fetalis seen in alpha-thalassemia when fetus only makes
Hb Barts
o Adults- Pure RBC aplasia and rheumatoid arthritis-like symptoms (joint pain,
arthritis, and soreness; sometimes edema, associated with school teacher)

Enteroviruses:
 Polioviruses, Coxsackie A & B, and Echovirus

RNA viruses

Influenza A:
 Syndromes
o Influenza
 “A” causes epidemics and pandemics (antigenic shift and drift)
 Transmission via respiratory droplets
 Flu season- December-February
 Myalgias, fever, non-productive cough
o Fatal bacterial superinfections
 Most commonly S aureus, S pneumoniae, and H influenzae
 Causing pneumonia
o Reyes syndrome-
 Aspirin associated with treatment of flu causing encephalitis and
hepatomegaly
 Will uncouple mitochondria proton gradient along the ETC in the hepatic
cells
o Guillen Barre Syndrome-
 Ascending paralysis
 CSF: finding high protein with low WBCs
 Treatments
 o Amantadine, rimantadine- inhibit M2 (no viral uncoating)
 No longer recommended treatment because of high level of resistance
o Tamiflu (oseltamivir/anamivir)- NA inhibitor blocking release of virus
 Must be given early in the course, < 72 hours after infection
o Vaccine-
 Reformulated vaccine ("flu shot")- contains viral strains most likely to
appear during the flu season, due to the virus' rapid genetic change
 Injectable- killed virus most frequently used
 Trivalent- 2 A stains, 1 B strain
 Quadrivalent- 2 A strains, 2 B strains
 Nasal- live, attenuated vaccine contains temperature-sensitive mutant
that replicates in the nose but not in the lung
 Typically given around October
 Children can receive vaccine starting after age of 6 months

Paramyxovirus: measles virus:

 Syndromes
o Measles
 1st- Prodromal fever
 Cough
 Coryza- runny/stuffy nose
 Conjunctivitis
 2nd- Koplik spots (bright red spots with blue-white center on buccal
mucosa)
 3rd (1-2 days later)- maculopapular rash that starts at the head/neck and
spreads downward
 Confluence rash- starts as small dots then starts blending together
o Complications:
 SSPE (subacute sclerosing panencephalitis)- occurs years later- history of
measles as a child or never vaccinated (immigrated to US), then 5-15
years later, development of personality changes, seizures, myoclonus,
ataxia, coma/death
 Encephalitis (1:2000)
 Giant cell pneumonia (rarely, in immunosuppressed)
o
 Treatments
o Vitamin A supplementation can reduce morbidity and mortality from measles,
particularly in malnourished children
o Vaccine: MMR, live attenuated
 Don't give to pregnant women
o No treatment for SSPE (anti-measles antibodies are in the CSF)

Paramyxovirus: respiratory syncytial virus (RSV):

  Syndromes
o Bronchiolitis in babies (infants < 6 months)
o Pneumonia (#1 cause in infants)
o Rhinitis
o Pharyngitis
 Treatments
o Ribavirin- can be used to treat adults, but not indicated for children or pregnant
women
o Palivizumab- monoclonal antibody against F protein
 Prevents pneumonia caused by RSV infection in premature infants

Retrovirus: HIV-1:
 Syndromes
o HIV
 Acute infection
 Flu or mono-like, fever, cervical lymphadenopathy, tonsils may be
enlarged
 Lasts a few weeks
 Latent infection
 Virus in replicating in the lymph nodes
 Last up to 10 years
o AIDS-
 </= 200 CD4+ cells/mm3 (normal is 500-1500)
 HIV positive with AIDS-defining condition (ex: PCP)
 Diffuse large B-cell lymphoma
 CD4+ percentage <14%
 Treatments
o HAART- highly active antiretroviral therapy
 Often initiated at time of HIV diagnosis
o Combination therapy (3 drugs) to prevent resistance- 2 NRTIs and preferably an
integrase inhibitor
o NRTI
 Zidovudine best for pregnant patients
o NNRTI
o Protease inhibitor
o Fusion inhibitor- maraviroc (CCR5 inhibitor)

Protozoa

Plasmodium falciparum:
 Syndromes
o Malaria
 Fever
  Headache
 Anemia
 Splenomegaly
o P falciparum specifically
 Severe
 Irregular fever patterns
 Parasitized RBCs occlude capillaries in brain (cerebral malaria), kidneys,
lung
 Treatments
o If sensitive- chloroquine, which blocks Pasmodium heme polymerase
o If resistant- mefloquine or atovaquone/proguanil (Malarone)
 Use these for prophylaxis
o If life-threatening- IV quinidine or artesunate (test for G6PD deficiency)
 Side effect- cinchonism, including tinnitus

Helminths

Ascaris lumbricoides:
 Syndromes
o Obstruction at ileocecal valve
o Biliary obstruction
o Intestinal perforation
o Malnutrition and respiratory symptoms
 Treatments
o Bendazoles
o Don't give microtubule inhibitors to pregnant women

Strongyloides stercoralis (threadworm):

 Syndromes
o Vomiting
o Diarrhea
o Epigastric pain (may mimic peptic ulcer)
 Treatments
o Ivermectin or bendazoles
2. Describe the mechanisms of action, toxicities, and antimicrobial spectrum of the following
drugs.

Penicillins

Penicillin
 Beta-lactam antibiotic
 MOA- Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-
binding proteins (PBPs), which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis.
Bacteria eventually lyse.
 Toxicities- allergy, serum sickness-like reaction (type III hypersensitivity reaction)
 Antimicrobial spectrum
o Drug of choice for
 Strep pneumoniae
 Strep viridans
 Enterococci
 Listeria
 Syphilis
 N. meningitidis
o Good alternative for
 Bacillus anthracis
o Reduced/limited efficacy for
 Moraxella catarrhalis
 H. influenzae

Ampicillin
 MOA- Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-
binding proteins (PBPs) which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis.
Bacteria eventually lyse.
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Strep pneumoniae
 Strep viridans
 Enterococci
 Listeria
 N. meningitidis
o Good alternative for
  Bacillus anthracis
o Reduced/limited efficacy for
 Enterobacteriaceae
 M. catt/ H. influenzae
o Notable lack of activity for
 Pseudomonas
 Acinetobacter

Ampicillin-sulbactam
 MOA- Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-
binding proteins (PBPs) which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis.
Bacteria eventually lyse. The addition of sulbactam, a beta-lactamase inhibitor, to
ampicillin extends the spectrum of ampicillin to include some beta-lactamase-producing
organisms.
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Enterobacteriaceae
 M. catt/ H. influenzae
o Good alternative for
 Strep pneumoniae
 Strep viridans
 Enterococci
 Listeria
 Bacillus anthracis
 N. gonorrhoeae
o Reduced/limited efficacy for
 Staph aureus
o Notable lack of activity for
 Pseudomonas
 Acinetobacter

Nafcillin
 MOA- Interferes with bacterial cell wall synthesis during active multiplication, causing
cell wall destruction and resultant bactericidal activity against susceptible bacteria;
resistant to inactivation by staphylococcal penicillinase
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Staph aureus
o Reduced/limited efficacy for
 Strep pneumoniae
  Strep viridans
o Notable lack of activity for
 Enterococci
 Pseudomonas
 Acinetobacter

Piperacillin-tazobactam
 MOA- Piperacillin inhibits bacterial cell wall synthesis by binding to one or more of the
penicillin-binding proteins (PBPs); which in turn inhibits the final transpeptidation step
of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis.
Bacteria eventually lyse. Piperacillin exhibits time-dependent killing. Tazobactam inhibits
many beta-lactamases, including staphylococcal penicillinase; it has only limited activity
against class 1 beta-lactamases other than class 1C types.
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Enterobacteriaceae
 Pseudomonas
 Acinetobacter
o Good alternative for
 Strep pneumoniae
 Strep viridans
 Enterococci
 Listeria
 Bacillus anthracis
 N. meningitidis
 N. gonorrhoeae
 M. catt/ H. influenzae
o Reduced/limited efficacy for
 Staph aureus

Cephalosporins
 MOA for all- Cephalosporins inhibit bacterial transpeptidases (aka penicillin binding
proteins, or PBP), which are important enzymes that cross-link peptidoglycan strands to
create a thick peptidoglycan mesh layer. Transpeptidases are specific for the D-ala-D-ala
sequence on peptidoglycan precursor strands. Cephalosporins mimic this sequence and
bind irreversibly. Destruction of the peptidoglycan cell wall disrupts the bacterial cell’s
osmotic stability and causes subsequent bacterial cell death

Cefazolin
 1st generation
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
  Staph aureus
o Reduced/limited efficacy for
 Strep pneumoniae
 Strep viridans
 Enterobacteriaceae
o Notable lack of activity for
 Enterococci
 Vancomycin-resistant enterococci (VRE)

Cefoxitin
 2nd generation
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Enterobacteriaceae
o Reduced/limited efficacy for
 Strep pneumoniae
 Strep viridans
 Staph aureus
o Notable lack of activity for
 Enterococci
 Vancomycin-resistant enterococci (VRE)

Ceftriaxone
 3rd generation
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Strep pneumoniae
 Strep viridans
 Enterobacteriaceae
 N. meningitidis
 N. gonorrhoeae
 M. catt/ H. influenzae
o Good alternative for
 Staph aureus
 Syphilis
o Notable lack of activity for
 Enterococci
 Vancomycin-resistant enterococci (VRE)
 Pseudomonas
 Acinetobacter
Ceftazidime
 3rd generation
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Enterobacteriaceae
 Pseudomonas
 Acinetobacter
 M. catt/ H. influenzae
o Notable lack of activity for
 Enterococci
 Vancomycin-resistant enterococci (VRE)

Cefepime
 4th generation
 MOA-
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Enterobacteriaceae
 N. meningitidis
 N. gonorrhoeae
o Good alternative for
 Strep pneumoniae
 Strep viridans
 Staph aureus
 Pseudomonas
 Acinetobacter
 M. catt/ H. influenzae
o Notable lack of activity for
 Enterococci
 Vancomycin-resistant enterococci (VRE)

Ceftaroline
 5th generation
 MOA-
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
o Good alternative for
o Reduced/limited efficacy for

Monobactams
Aztreonam
 MOA- less susceptible to β-lactamases and works by preventing peptidoglycan cross-
linking by binding to penicillin binding protein 3
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Enterobacteriaceae
 Pseudomonas
 Acinetobacter
 N. meningitidis
 N. gonorrhoeae
 M. catt/ H. influenzae
o Notable lack of activity for
 Strep pneumoniae
 Strep viridans
 Enterococci
 Vancomycin-resistant enterococci (VRE)
 Staph aureus
 MRSA
 Listeria
 Bacillus anthracis

Carbapenems

Imipenem
 MOA- Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-
binding proteins (PBPs); which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis.
Bacteria eventually lyse
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Strep pneumoniae
 Strep viridans
 Enterococci
 Enterobacteriaceae
 Pseudomonas
 Acinetobacter
 N. meningitidis
 N. gonorrhoeae
 M. catt/ H. influenzae
o Reduced/limited efficacy for
 Staph aureus
  Listeria

Meropenem
 Same as imipenem

Ertapenem
 MOA-
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Strep pneumoniae
 Strep viridans
 Enterobacteriaceae
 M. catt/ H. influenzae
o Reduced/limited efficacy for
 Staph aureus
o Notable lack of activity for
 Enterococci
 Pseudomonas
 Acinetobacter

Glycopeptides and others for gram positive infections

Vancomycin
 MOA- Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization
through binding tightly to D-alanyl-D-alanine portion of cell wall precursor; no activity
against gram negatives because too large to cross the outer cell membrane and inhibit
the inner peptidoglycan.
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Strep pneumoniae (PCN resistant meningitis)
 MRSA
o Good alternative for
 Strep viridans
 Enterococci
 Staph aureus

Linezolid
 MOA- acts by inhibiting protein synthesis by binding to the 50S subunit and preventing
formation of the initiation complex.
 Toxicities-
 Antimicrobial spectrum
 o Drug of choice for
 Vancomycin-resistant enterococci (VRE)
o Good alternative for
 Strep viridans
 Enterococci
 Staph aureus
 MRSA
o Reduced/limited efficacy for
 Strep pneumoniae
Daptomycin
 MOA- cyclic lipopeptide that functions to cause rapid depolarization of the cell
membrane. This acts to cause disruption of protein, DNA, RNA synthesis and eventual
cell death.
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Enterococci
 Vancomycin-resistant enterococci (VRE)
 Staph aureus
 MRSA
o Reduced/limited efficacy for
 Strep pneumoniae
 Strep viridans
Lincosamides

Clindamycin
 MOA- inhibits bacterial protein synthesis by specifically binding on the 50S subunit and
affecting the process of peptide transfer (translocation); also suppresses
peptidyltransferase activity
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Strep viridans
o Reduced/limited efficacy for
 Strep pneumoniae
 Staph aureus
 MRSA

Macrolides

Azithromycin
  MOA- bind to the 50S ribosomal subunit and blocks amino-acyl transpeptidation and
translocation, and can be remembered with "macroslides." Macrolides
are bacteriostatic and acts to inhibit chain elongation and ultimately protein synthesis.
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 M. catt/ H. influenzae
o Good alternative for
 Strep viridans
 Legionella
 Chlamydophila
 Mycoplasma
o Reduced/limited efficacy for
 Strep pneumoniae
 N. meningitidis

Sulfonamides

Trimethoprim-sulfamethoxazole
 MOA- Trimethoprim is bacteriostatic alone, and functions by inhibition of dihydrofolate
reductase, which converts dihydrofolic acid to tetrahydrofolic acid, an essential
precursor for thymidine, methionine, and purines. Sulfonamides act as competitive
inhibitors of dihydropteroate synthase (DHPS). In bacteria, DHPS converts PABA into
dihydrofolate (DHF), which is then reduced by dihydrofolate reductase (DHFR) into
tetrahydrofolate (THF). Sulfonamides effectively deplete methionine, purines, and
thymidine.
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Listeria
 M. catt/ H. influenzae
o Reduced/limited efficacy for
 Strep pneumoniae
 Strep viridans
 Vancomycin-resistant enterococci (VRE)
 Staph aureus
 MRSA
 Enterobacteriaceae

Aminoglycosides

Gentamycin
  MOA- act by: binding to the 30S ribosomal subunit, causing irreversible inhibition of
initiation complex; causing misreading of mRNA, leading to mistranslated proteins; and
blocking translocation
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Strep viridans*
 Enterococci*
o Good alternative for
 Enterobacteriaceae
 Pseudomonas
 Acinetobacter
o Reduced/limited efficacy for
 Vancomycin-resistant enterococci (VRE)
*Added to endocarditis treatment for synergy

Quinolones
 MOA for all- Fluoroquinolones are bactericidal and act by direct entry via cell membrane
porins and inhibition of DNA gyrase (topoisomerase II) and topoisomerase IV.

Ciprofloxacin
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Bacillus anthracis
 Legionella
 Chlamydophila
 Mycoplasma
o Good alternative for
 Enterobacteriaceae
 Pseudomonas
 Acinetobacter
 M. catt/ H. influenzae
o Reduced/limited efficacy for
 N. meningitidis
 N. gonorrhoeae
o Notable lack of activity for
 Strep pneumoniae
 Strep viridans

Moxifloxacin
 Toxicities-
 Antimicrobial spectrum
 o Drug of choice for
 Strep pneumoniae*
 Legionella
 Chlamydophila
 Mycoplasma
o Good alternative for
 Strep viridans
 Staph aureus
 Enterobacteriaceae
 M. catt/ H. influenzae
o Reduced/limited efficacy for
 N. meningitidis
o Notable lack of activity for
 Pseudomonas
 Acinetobacter
*PCN resistant, not meningitis

Levofloxacin
 Toxicities-
 Antimicrobial spectrum
o Drug of choice for
 Strep pneumoniae*
 Legionella
 Chlamydophila
 Mycoplasma
o Good alternative for
 Strep viridans
 Staph aureus
 Enterobacteriaceae
 Pseudomonas
 Acinetobacter
 M. catt/ H. influenzae
o Reduced/limited efficacy for
 N. meningitidis
*PCN resistant, not meningitis

Tetracyclines
 MOA for all- Tetracyclines are bacteriostatic and act by binding to the 30S bacterial
ribosome subunit and preventing attachment of aminoacyl-tRNA.

Doxycycline
 Toxicities-
 Antimicrobial spectrum
 o Drug of choice for
o Good alternative for
o Reduced/limited efficacy for

Tigecycline
 Toxicities-
 Antimicrobial spectrum
o Good alternative for
 Legionella
 Chlamydophila
 Mycoplasma
o Reduced/limited efficacy for
 Strep pneumoniae
 Strep viridans
 Enterococci
 Vancomycin-resistant enterococci (VRE)
 Staph aureus
 MRSA
 Enterobacteriaceae