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Epstein- Barr virus (
https://t.me/med1917
EBV
lymphocytes (lifelong latent infection) and squamous epithelial cells of oropharynx
(‘aectionately’ termed the ‘kissing disease’).
Presentation Usually asymptomatic infection in childhood. Infectious mononucleosis
50
% of primary infection in adults: sore throat, fever, anorexia, lymphadeno-
in ~
pathy (esp. posterior triangle of neck), palatal petechiae, splenomegaly, hepatomegaly,
jaundice. Malaise is prominent. Resolution of symptoms usually within
Chronic active infection and recurrence are rare. Oncogenicity: see
Diagnosis
• Blood film: lymphocytosis. Atypical lymphocytes (large, irregular nuclei) also
occur in other viral infection (
leukaemia, lymphoma, drug reactions, lead poisoning.
• Heterophile antibody tests (eg Monospot®, Paul– Bunnell) detect non- EBV
heterophile antibodies which are present in ~
autoimmune disease, lymphoma/ leukaemia. Sensitivity from
• Serology: IgM to EBV viral capsid antigen in acute infection. IgG if past infection.
Consider if immunocompromised or negative antibody tests.
• Reverse transcriptase viral PCR.
Treatment Supportive. Seek expert help if severe disease/ immunosuppres-
sion: observational data on the use of antivirals and steroids. Maculopapular rash
with antibiotics, eg amoxicillin.
Cytomegalovirus (
50– 100
% of adults are seropositive depending on socioeconomic and sexual risk.
CMV
) (human herpesvirus 5)
Latent infection: periodic, asymptomatic (but infectious) viral shedding in bodily fluids
including blood transfusion, transplantation (
Presentation Asymptomatic in most. Symptoms mimic infectious mononucleosis
(see earlier in topic) or hepatitis. Severe disease in immunosuppressed (posttransplantation,
hepatitis. Infection in pregnancy is associated with congenital abnormality.
Diagnosis Primary infection in immunocompetent: IgM. Immunosuppressed: quan-
HIV): oesophagitis, gastritis, colitis, retinitis (p
titative nucleic acid amplification testing (
threshold, or rising titre. Invasive disease: tissue
Tre at me nt Given in severe infection/ immunosuppression. Ganciclovir, valganciclovir
(oral bioavailability). Pre- emptive treatment in transplant patients based on
results. Treatment in pregnancy remains unclear. Use
transfusion if immunosuppressed and at risk: transplant,
Other herpes viruses
herpesvirus 6 (
Human
Human herpesvirus 8 (
HHV6
HHV8
Oncogenic viruses
~12% of human cancers are caused by viruses, >80% of these occur in low- and
middle- income countries (
Common traits of oncoviruses:
• Virus is necessary but not sucient to cause cancer.
• Cancers appear in context of chronic infection, taking years– decades to appear.
• Cancers are associated with immunosuppression and chronic inflammation.
Table 9.
12
Oncogenic viruses
Virus Cancers
EBV (HHV
4
) Burkitt’s lymphoma, Hodgkin’s lymphoma, B- cell lymphoma in
immunosuppression, gastric cancer, nasopharyngeal cancer,
HHV
8
HPV
Hepatitis
HTLV-
1
MCV Merkel cell polyomavirusMerkel cell carcinoma
post- transplantation lymphoproliferative disease (
Kaposi’s sarcoma (p
Cancers of: cervix, anus, vulva, penis, head, neck, oropharynx (p
B and C
Hepatocellular carcinoma (p
Human T- lymphotropic virusadult T- cell leukaemia
) (human herpesvirus 4) Virus targets circulating B
2
weeks.
BOX.
CMV, HIV, parvovirus, dengue), toxoplasmosis, typhus,
85
% of sera. False + ve: pregnancy,
CMV + ve donor to CMV –ve recipient).
QNAT) in blood greater than a defined
QNAT, histopathology.
) Roseola infantum, febrile illness without rash.
) Oncogenic (see BOX), Castleman’s disease.
table
9.12
).
396
) and primary eusion lymphoma
282
)
2
nd week.
434
), pneumonitis,
402
QNAT
)
CMV –ve, irradiated blood for
HIV, leukaemia.
PTLD)
401
9 Infectious diseases
9 Infectious diseases
Other viruses
https://t.me/med1917
402
Respiratory tract viruses
Include rhinovirus, coronavirus (
Tra ns mi ss io n b y d ir ec t c on ta ct , i nf ec ted f om ite s, a ir bo rn e d ro pl ets .
Coryza, pharyngitis, croup, bronchiolitis, pneumonia.
antigen detection,
PCR. Tr ea tm en t None in uncomplicated disease/ immunocompe-
tent. Limited evidence for specific treatments in high- risk complicated disease, immunosuppression: cidofovir for adenovirus; aerosolized ribavirin, immunoglobulin,
monoclonal antibody in
Human papilloma virus (
120
HPVs. Pathology:
>
• Skin warts, verrucas (HPV 1, 2). Treatment: none, topical salicylic acid, freezing.
• Anogenital warts (HPV 6, 11). Treatment: topical podophyllin, imiquimod; ablation.
• Cervical cancer (HPV 16, 18), other cancers (see p
Vaccination in
UK: age
Polyomavirus
100
% exposure. Disease only with immunosuppression: BK virus causes renal trans-
~
plant nephropathy;
JC virus causes progressive multifocal leucoencephalopathy.
Measles
Transmitted by respiratory droplets. Incubation
10– 18
d. Highly contagious: >95% population
coverage needed for ‘herd’ immunity. cases in
Europe since
4
d): fever, conjunctivitis, coryza, diarrhoea, Koplik
2016
. Presentation Prodrome (2–
spots (white spots on red buccal mucosa,
Then generalized, maculopapular rash, classically
face/ necktrunklimbs (
• Secondary infection: bacterial pneumonia, otitis
media, ocular herpes simplex, oral/
• Acute demyelinating encephalitis: 1 in
ally within
ability, headache, conscious level.
• Subacute sclerosing panencephalitis: 5– 10yrs
after infection, disturbances in intellect, person-
2
wks of rash. Seizures, fever, irrit-
ality, seizures, motor dysfunction, decerebration.
No treatment available.
Diagnosis Clinical. IgM. Antigen in saliva/ urine.
Treatment Prevent with vaccination. Human
immunoglobulin within
immune. Supportive. No benefit shown for dexamethasone in encephalitis.
Mumps
Respiratory droplet spread. Incubation
Common cause of encephalitis pre- vaccination.
Prodrome: fever, myalgia, headache. Infection and tender swelling of salivary
glands: parotid > submandibular. Complications: meningoencephalitis, epididymoorchitis if pubertal/ post- pubertal infection (warm, swollen, tender testes
after parotitissubfertility in ~
Diagnosis Clinical. If confirmation needed, eg meningitis/ encephalitis: mumps
ness.
specific IgM/ IgA, PCR. Treatment Supportive.
Rubella (German measles)
Respiratory droplet spread.
conjunctivitis, rhinorrhoea. Rash: generalized, pink, maculopapular. Lymphadenopathy:
occipital, cervical, post- auricular.
1
ma tion in
IgM/ IgG test ing. I mmunoglobulin may viraemia but will not prevent infection.
Vaccinate PRE- pregnancy, live vaccines are contraindicated in pregnancy.
st trimester, sensorineural hearing loss/ retinopathy in 2nd trimester. Oer
p
172
), adenovirus, respiratory syncytial virus (RSV).
Presentation
Diagnosis Clinical. Viral culture,
RSV. For influenza see pp
HPV
)
12– 13
(♀ since
fig
9.17
). Complications:
GI ca ndid ias is.
3
d of exposure in non-
2008
1000
392– 3
, ♂ since
fig
9.16
, usu-
.
401
).
2019
). See p
).
Fig 9.
16
Koplik spots.
Fig 9.
17
Measles rash.
Reproduced from Firth et al.,
Oxford Textbook of Medicine,
with permission from Oxford
403
.
Courtesy of CDC.
– 21d.
Presentation Can be subclinical.
10
%, infertility rare), oophoritis, pancreatitis, deaf-
Presentation Usually mild/ subclinical. Prodrome: fever,
Congenital infection Up to 90% risk of fetal malfor-
2020
University Press.
4
d– 6wks
,
Immunization
https://t.me/med1917
Passive immunity uses preformed antibody to protect against infection. It oers im-
mediate but short- lived protection. Natural passive immunity occurs in the placental
transfer of maternal antibodies to the fetus; acquired passive immunity includes
treatment with immunoglobulin, eg hepatitis
Active immunity follows exposure to an antigen, which generates an adaptive im-
mune response. Natural active immunity occurs following infection. Acquired active
immunity is provided by vaccination. Routine vaccinations in the
table
9.13
. Additional vaccines are oered to specific vulnerable groups (table
Immunosuppression is a contraindication to live vaccines due to the risk of disseminated disease. Includes immunodeficiency, immunosuppressive treatment,
Inactivated vaccines can be given but the antibody response may be less: aim to
2
wks prior to immunosuppressive therapy when possible (or vaccinate whilst
give >
on treatment and considered repeat re- immunization when/ if treatment complete).
Travel Travel advice (food/ drink, insect repellent, malaria prophylaxis, condoms) is
often more important than vaccination. Check routine vaccinations are up to date.
Vaccination depends upon area of travel and planned activities: for up- to- date recommendations see
Table 9.
13
UK vaccination summary (*= live vaccine, † =
Vaccination
Diphtheria + + + + +
Tetanus + + + + +
Pertussis + + + +
Poliomyelitis + + + + +
Haemophilus influenzae
B (Hib)
Hepatitis B + + +
Pneumococcal + + +
Rotavirus* + +
Meningitis
Meningitis
Measles, mumps,
rubella*
Influenza + +
†
HPV
Meningitis
Varicella zoster* +
Table 9.
14
Additional vaccination of specific groups in UK (*= live vaccine)
Vaccination Oered to
BCG*
Hib Hyposplenism, complement disorders
Meningitis
Influenza Hyposplenism,
Pneumococcal Hyposplenism, cochlear implants, complement disorders,
A, B Chronic liver disease, haemophilia, CKD (hepatitis B only)
Hepatitis
Pertussis
http:// www.fitfo rtra vel.nhs.uk/ desti nati ons
B + + +
C +
ACWY +
Infants/ children where TB incidenc e >40/
parent born in country where incidence >
B, ACWY Hyposplenism, complement disorders, high- risk travel
CKD, chronic liver disease, chronic neurological disease, immunosup-
pression, pregnancy
chronic heart disease, chronic respiratory disease,
liver disease, chronic neurological disease, immunosuppression
Pregnancy
B, rabies, tetanus, varicella zoster.
HPV
Age (m= months, y= years)
2m3m4m12m3– 5
+ + + +
DM, chronic heart disease, chronic respiratory disease,
16– 32
weeks (neonatal protection)
6, 11, 16, 18, 31, 33, 45, 52, 58)
y 12y14y >65y70y
+ +
+
100 000
or par ent/ grand-
40/ 100 000
UK are shown in
9.14
HIV.
, TB contac ts
DM,
CKD, chronic
403
).
9 Infectious diseases
9 Infectious diseases
Fungi
https://t.me/med1917
404
Worldwide in fungal infection with new pathogenicity, virulence, and new infective mechanisms. Incidence data limited by failures in recognition and diagnosis. Divided into superficial/ cutaneous and systemic/ invasive.
Superficial/ cutaneous mycoses
• Dermatophytosis Dermatophyte fungi digest keratin. Cause infection of skin and
keratinized structures, eg hair, nails. Presentation: scale and pruritus. Skin lesion
may be annular with central healing, eg ring worm, tinea corporis. Tinea pedis af-
15
fects up to
dry scale on soles. Fungal nail disease = onychomycosis/ tinea unguium: discolour-
ation, nail thickening. Tinea capitis: scalp scaling, alopecia.
• Superficial candidiasis Usually Candida albicans (fig
9.18
% of healthy population: skin erosions and blisters in toe web spaces,
), a commensal in mouth, vagina, and GI tract. Risk
factors: immunosuppression, antibiotic treatment.
Presentation: oropharyngeal— white patches on erythematous background (plaque type); sore, inflamed
areas (erythematous type). GU— soreness, white
patches/ discharge (
interdigital (
• Malassezia Commensals of greasy skin. Presentation: Pityriasis versicolor— scaly
fig
9.20
hypo/ hyperpigmented rash with scaling (
scaling of face, scalp (dandru), anterior chest. Malassezia folliculitis— itchy, follicular rash on back and shoulders ( acne). Can cause sepsis in neonates.
Diagnosis Clinical, microscopy of skin scrapings. Treatment All superficial my-
coses: topical ‘- azole’ antifungal or terbinafine
amphotericin in superficial candidiasis. Tinea capitis: griseofulvin, terbinafine,
itraconazole. Nail infection requires systemic treatment (terbinafine, itraconazole)
confirm diagnosis, and caution re side eects including hepatotoxicity.
Systemic/ invasive mycoses
• Invasive candidiasis Typically occurs in immunocompromised, comorbidity,
ITU settings. Genetic susceptibility likely contributes. Estimated
or
50 000
with
tors for invasive fungal disease (
deaths. Candidaemia in ~7/
of infection, new murmur, muscle tenderness, skin nodules. Diagnosis: (repeated)
blood/ tissue culture.
cient. Trea tm ent : remove all possible catheters. Echinocandins (caspofungin,
anidulafungin, micafungin), fluconazole, amphotericin (liposomal for renal toxicity). Consider fluconazole prophylaxis if risk factors for invasive disease (
Consider empirical treatment if persistent fever, unresponsive to other therapy
(discuss with microbiologist, choice depends on local epidemiology, comorbidity).
• Cryptococcus See HIV, p
immunosuppression, eg
transplant. History may be long, non- specific. Headache, confusion, ataxia, focal
neurological signs, fever, cough, pleuritic pain,
, antigen testing in blood/ CSF (Indian ink
BAL
amphotericin + flucytosine, fluconazole.
• Histoplasmosis Worldwide distribution of Histoplasma, in soil contamin-
ated with bird/ bat faeces. Illness depends on host immunity, estimated ~
Presentation: flu- like symptoms, fever, malaise, cough, headache, myalgia, pneumonia, lung nodules/ cavitation, pericarditis, mediastinal fibrosis/ granuloma (
TB). Diagnosis: serology, antigen testing. Treatment: moderate– severe
sarcoid,
lung disease or any
• Blastomycosis Blastomyces in decomposing matter, mainly USA/ Canada.
Presentation: fever, cough, night sweats,
with immunosuppression: skin, bone,
(cross- reacts with histoplasmosis). Treatment: amphotericin, itraconazole.
See also: Fungi and the lung, p
Fig 9.
18
fig
9.19
). Skin— usually in folds/
).
fig
9.21
). Seborrhoeic dermatitis– —
1– 4
wks. Also topical nystatin and
1000
p
PCR. Candida in respiratory secretions alone is insu-
396
. Causes meningitis, pneumonia. Presentation: usually
HIV, sarcoid, Hodgkin’s, haematological malignancy, post-
CNS involvement: amphotericin, itraconazole.
174
, Pneumocystis jirovecii, p
ICU patients. Presentation: risk fac-
405
), febrile with no microbiological evidence
SOB. Diagnosis: culture blood/ CSF/
CSF
stain less sensitive). Tre at men t:
ARDS. Risk of extrapulmonary disease
GU, CNS. Diagnosis: culture, antigen detection
Candida albicans.
Courtesy of P- Y Guillaume.
250 000
396
.
/ yr
p
399
).
1
%.
Invasive fungal infection
https://t.me/med1917
Invasion: fungus in normally sterile tissues.
Dissemination: infection of remote organs via haematogenous spread.
Suspect an invasive fungal infection in:
1
Any patient with risk factors (table
2
Any systemically unwell patient who fails to respond to antibiotic therapy.
3
Any persistently febrile patient with no microbiological evidence of infection.
Table 9.
15
Risk factors associated with invasive fungal infection.
Risk factor Includes
Infection
Malignancy Neutropenia, mucositis, haematological malignancy
Critical illness Mortality prediction score (eg APACHE), prolonged ITU admis-
Catheter Central venous catheter, urinary catheter, dialysis access, TPN
Transplantation Immunosuppressant medication, recent rejection, graft- versus-
Genetic Hereditary chronic granulomatous disease, abnormalities in
Surgical Major surgery, GI perforation, anastomotic leak, length of
Other comorbidity Any disease managed with immunosuppressive therapy, burns
Source: data from Ramana KV et al., Am J Infectious Diseases and Microbiology
HIV, CMV, TB, colonization/ inadequate treatment of superficial
fungal disease, broad- spectrum antibiotics, prior fungal infection
sion, prolonged ventilation, severe trauma/ pancreatitis
host disease
tumour necrosis factor/ interleukins/ cytokines
transplant operation, delayed closure
9.15
).
2013, 1(4);64– 69
Investigations
• Blood culture: three samples, dierent sites, same sitting, aim total 40– 60mL blood.
• Microscopy + immunohi stoche mistr y/ fluorescence depending on site/ risk.
• Other: antigen/ antibody testing for general (eg mannan, galactomannan) and spe-
cific (eg cryptococcal) fungi; fungal metabolites;
PCR: for typing/ confirmation.
Seek expert advice on empirical treatment, agent depends on local epidemiology.
Facts of life for ‘budding’ mycologists
To the uninitiated, fungi are like bacteria, but their chitin cell walls and their
knack of mitosis puts them in their own kingdom. They are larger than bacteria
8
µm across), and mostly reproduce by budding of germ tubes (fig
(eg
fission. Yeasts occur as single cells or as clusters. Hyphae often occur in a mass
of cells (called moulds). A hyphal cell with cross- walls is called a mycelium. Some
yeasts are dimorphic: single cells at
containing fruiting bodies (hyphae), at room temperature.
37
°C but forming structures called mycelia,
9.22
), not by
405
9 Infectious diseases
.
Fig 9.
19
Candida of the glans.
Courtesy of P- Y Guillaume.
Fig 9.
21
Pityriasis versicolor.
Reproduced from Lewis- Jones (ed),
Paediatric Dermatology
2010
from Oxford University Press.
, with permission
Fig 9.
20
Web- space candida.
Fig 9.
22
Candida albicans blastoconidia.
Courtesy of A Huntley.
Germ tubes emerging from
Courtesy of P- Y Guillaume.
9 Infectious diseases
Healthcare- associated (nosocomial) infection
UTI
https://t.me/med1917
406
Healthcare- associated, or nosocomial, infections include diseases which occur as a
direct result of treatment or contact in a hospital or healthcare setting.
7– 25
% of hospital admissions are complicated by a nosocomial infection resulting
in morbidity, mortality, and cost. The causal microbe may be benign in normal circumstances, but is able to cause disease when the patient:
1
Has been given broad- spectrum antibiotics (eg antibiotic- resistant organisms,
Clostridium difficile colitis).
2
Is unwell/ immunosuppressed (opportunistic infection).
3
Has compromised barriers (indwelling catheter/ line, ventilation, surgery).
Healthcare- associated infection
Catheter- associated
A catheter is inserted in ~20% of hospitalized patients. UTI is the most common
infection acquired as a result of healthcare, accounting for
associated infection. ~
infection is related to method of catheter insertion, duration of catheter, quality
of catheter care, and patient susceptibility.
To reduce risk, only catheterize if necessary: Is there obstruction? Do you need
precise urine output monitoring? Remove as soon as possible. See
Infections associated with intravascular access lines
Includes peripheral, central venous, and arterial catheters: tunnelled and non-
60
tunnelled. >
% of bloodstream infections are associated with intravascular devices. Risk is higher with central catheters. Infection can result from introduction
of microbes during insertion, access (eg when giving
crobes elsewhere in the body seeding to the foreign material. Organisms include
Staphylococcus epidermidis (
resistant forms,
MRSA see p
Ensure that vascular access devices are used only when clinically indicated.
Switch to oral treatment (fluid, medication, nutrition) as soon as clinically appropriate. Treatment includes removal/ exchange of the device whenever possible.
Ven til ator - associated pneumonia (
VAP aects up to
20
endotracheal tube interferes with protective upper airway reflexes and facilitates
microaspiration. Risks with non- invasive ventilation. In critical illness, the oropharynx becomes contaminated, commonly with Gram –ve bacteria, due to antibiotic exposure, altered host defences, and changes in mucosal adherence. Access
to the airway occurs via folds in the endotracheal cu and the bacterial biofilm is
then propelled to the distal airways. Organisms include Pseudomonas aeruginosa
p
387
), Enterobacterales (p
(
Clinical diagnosis has sensitivity and specificity. Suspect if new/ persistent in-
filtrates on
leucopenia (<
CXR plus two or more of: purulent sputum, leucocytosis (>
4
≈
109/ L), temperature >38.3°C.
Prevent by reducing colonization (silver- coated endotracheal tubes).
VAP prevention bundle includes:
• Nursing at 30– 45° to as pirati on ris k.
• Wea n o ve ntila tor as s oon as possi ble.
• Minimize ventilator circuit changes.
• Regular subglottic suction.
Surgical site infection
Aects 5% of patients undergoing surgical procedures, contributes to >⅓ of
post- operative deaths. Common organisms include Staphylococcus aureus (
Streptococcus pyogenes (
entry to hollow viscera (
strict asepsis,
MRSA screening and decolonization, hair removal, peri- operative
normothermia, minimally disturbed low adherence/ transparent dressings.
19
50
% of UTIS are associated with a urethral catheter. Risk of
p
384
), Staphylococcus aureus (including meticillin-
384
), Candida spe cies (p
VAP
)
% of all healthcare-
UTI, pp
IV antibiotics), or from mi-
404
), and enterococci (p
292– 3
385
.
).
% of patients admitted to intensive care units. Occurs as the
387
), and Staphylococcus aureus (p
p
384
), and Enterobacterales when surgery involves
p
387
). Prevention methods include hand hygiene,
384
).
12
≈
109/ L),
p
384
),
Clostridium difficile
SIGHT: S
T
missed
https://t.me/med1917
Gram- positive anaerobic bacillus and most common healthcare- associated
pathogen. Part of colonic flora in
ized adults. Disease occurs when it converts to a vegetative (growth) state with
production of enterotoxins
ition by competing colonic flora is lost due to antibiotic exposure.
Presentation Watery diarrhoea, mildfulminant colitis (pseudomembranes on
endoscopy = ‘pseudomembranous colitis’), ileus, toxic megacolon. Consider in
diarrhoea with antibiotic use (usually >
Diagnosis Immunoassay for glutamate dehydrogenase (common antigen) de-
tects all strains of C. difficile. Detection of toxin (toxin immunoassay, toxin gene
nucleic acid amplification) distinguishes infection from carriage.
Management
with soap,
• Mild/ moderate: metronidazole PO (lo cal gu idanc e may us e vanc omycin 1st line).
• Severe (WCC >15 ≈
est immediately.
uspect, Isolate within 2h, Gloves and aprons, Hand wash
109/ L or AKI or colitis or temperature >38.
(injection preparation can be given orally and may be cheaper than capsule) or
fidaxomicin (cost).
• Non- responders: high- dose vancomycin + IV metronidazole, fidaxomicin, IV im-
munoglobulin (no
• Recurrence: (weaning) vancomycin, fidaxomicin, faecal transplantation.
RCT dat a). Su rgical input if evi dence of fu lmina nt col itis.
Management of healthcare- associated infection
Identify Screening (eg hospital admissions for MRSA, CPE) allows isolation and de-
colonization before harm. Be alert to new infections.
Protect Isolate multi- antibiotic- resistant microbes (eg MRSA), highly transmissible
infections (eg norovirus), and high- risk groups including reverse barrier nursing
(avoids transmission to, rather than from, patients, eg neutropenia). Patients with
high- risk infections may need negative- pressure rooms (to prevent potentially infected air leaving the room), or in severe immunosuppression, positive- pressure
rooms (to prevent potentially infected air entering the room). When many patients
have the same nosocomial infection (eg norovirus) they may be barrier nursed together in dedicated bays.
Treat Refer to local guidelines, seek expert help. Initial antibiotic choice may dier
for healthcare- associated infection.
Prevent Modify risk factors, eg nutrition, post- operative incentive spirometry to
reduce pneumonia risk. Use/ convert to narrow- spectrum antibiotics whenever possible. Remove catheters, intravascular access devices, and wean o ventilators as
soon as clinically appropriate. Take measures to person- to- person transmission:
1
Hand hygiene. Wash hands before and
after each patient contact (
Alcohol- based gels are helpful but soap
is needed to kill C. difficile spores.
2
Personal attire. In the UK there is a
bare- below- the- elbows policy. Long hair
should be tied back. In areas where infection risk is particularly high (theatre,
ICU), sta change into scrubs on arrival.
3
Personal protective equipment (PPE). Used
for isolated patients and during procedures. Includes gloves, aprons, caps, respiratory protection/ mask according to risk, eg
FFP
3
respirators in aerosolized infection.
4
Procedures. Strict aseptic techniques for any procedure which breaches the
body’s defences including insertion/ maintenance of invasive devices,
sions, wound care.
5
Environment. Should be clean and safe, with eective decontamination.
System interventions Up- to- date infection guidelines, audit, education, training.8
2– 5
% of healthy adults, and 20– 40% of hospital-
A and B, causing colitis. Typically happens when inhib-
72
h), especially if marked neutrophilia.
5oC): vancomycin PO
fig
9.23
).
Fig 9.
washing hands.
Contains public sector information licensed
under Open Government Licence v
wha tdot heyk now.com/ requ est/ 21861/ respo nse/ 56086/
Most frequently
missed
Frequently
missed
Less frequently
23
Areas commonly missed when
3.0
att ach/ 3/ 04072 Hand Hygiene 5 1.1.pdf
IV infu-
, www.
407
9 Infectious diseases
9 Infectious diseases
Sexually transmitted infection (
STI
Table
9
.
16
Overview of urethritis and vaginal discharge
STI
Presentation Diagnosis Treatment Other
https://t.me/med1917
408
STIS6 are common with increasing rates of diagnosis: ~×
N. gonorrhoeae, genital herpes, and syphilis since
25
adults (<
yrs) and MSM. For HIV, see pp
Taking a sexual history
• Symptoms : urethral discharge, dysuria, genital skin problems, testicular pain/
swelling, peri- anal or anal symptoms in
problems, abdominal pain, dyspareunia, unusual vaginal bleeding (post- coital,
intermenstrual, consider referral for urgent colposcopy).
• Exposure Sexual contacts within last 3 months including sex of partner(s), type of
contact (oral, vaginal, anal), insertive or receptive contact in contraceptive method
(properly used?), type and duration of relationship, symptoms in partner(s), risk
factors for
history in all. Ask men whether they have ever had sex with another man.
• Other Last menstrual period, menstrual pattern, date of last cervical cytology
(smear). Current contraceptive, concordance. Current/ recent antimicrobial
therapy.
intimate partner violence. Do not be afraid to ask for help: ‘Everything you tell
HIV/ hepatitis in partner(s), whether partner(s) can be contacted. STI
HPV vaccine history. There may be disclosure of non- consensual sex, or
me today is confidential unless you tell me something that worries me about your
safety, at which point I may need to discuss this with another health professional
in order to keep you safe.’
Examination
: retract foreskin, inspect urethral meatus for discharge, scrotal contents/ tenderness/ swelling (stand patient up). : vulval examination (lithotomy), speculum
of vagina/ cervix, bimanual examination for adnexal tenderness, abdomen/ pelvis
for masses. In all: genito- anal area, proctoscopy if anal symptoms, inguinal lymph
nodes, oral mucosa if orogenital sex. Use a chaperone and document their name.
Urethritis/ vaginal discharge See table
Genital warts Caused by human papilloma virus (HPV). See p
Genital ulcer(s)
• Genital herpes HSV. Presentation: flu- like prodrome, then vesicles/ papules around
genitals, anus, throat. These burst, forming painful shallow ulcers. Also urethral
discharge, dysuria, urinary retention, proctitis. Diagnosis:
gesia, topical lidocaine. Antivirals within
• Syphilis Treponema pallidum. Presentation:
1
Primary: <90d after inoculation (median 3wk). Maculepapuletypically pain-
less ulcer (chancre). Central slough, defined rolled edge. Highly infectious.
2
Secondary: dissemination ~4– 10wks after chancre. Rash (maculopapular in 50–
75
%, on palms/ soles in 11– 70%), mucous patches, condyloma lata (raised, pale
plaques, often flexural), fever, headache, myalgia, lymphadenopathy, hepatitis.
3
Ter t i a ry : 20– 40yrs after infection. Neurosyphilis: aseptic meningitis, focal neuro-
logical deficits, seizures, psychiatric symptoms, Argyll Robertson pupil (
tabes dorsalis (areflexia, extensor plantar reflex, dorsal column deficits, Charcot
joints). Gummatous syphilis: destructive granulomata in skin, mucous membranes,
bones, viscera. Cardiovascular: aortitis, aortic regurgitation/ aneurysm. Diagnosis:
PCR. Serology: non- specific (RPR, VDRL) sensitive in early infection then decline; spe-
cific (T. p al l id um as antigen, eg
Tre at m en t: parenteral benzylpenicillin (eg benzathine penicillin
on stage. Procaine benzylpenicillin boosted with probenecid in
• Lymphogranuloma venerum Chlamydia trachomatis. Presentation: mostly MSM
in UK. Painless papule/ ulcerlymphadenopathy, fever, arthritis, pneumonitis.
Direct transmission to rectal mucosa causes haemorrhagic proctitis: pain, rectal
bleeding/ discharge, tenesmus. Diagnosis:
• Tropical infections Chancroid (Haemophilus ducreyi), granumola inguinale
(Klebsiella granulomatis). Presentation: both cause genital ulceration and
lymphadenitis with spread of infection into overlying tissue (pseudobubo).
Diagnosis: H. ducreyi
)
2
for Chlamydia trachomatis,
2010
394– 99
9.16
5
d: aciclovir, valaciclovir, famciclovir.
TPHA, TPPA) reacts in early infection and persists.
PCR. Treatment: doxycycline.
PCR, Donovan bodies in tissue. Treatment: azithromycin.
. Prevalence highest in young
. For hepatitis B and C, see p
MSM. : vaginal discharge, vulval skin
274
.
402
.
PCR. Treatment: anal-
IM), duration depends
CSF disease.
.
p68),
409
https://t.me/med1917
DM,
Pharyngeal and rectal infection may be asymp-
d.
7
mg doxycycline BD for
100
NAAT) on:
Nucleic acid amplification test (
PID), salpingitis,
tomatic. Complications:
: pelvic inflammatory disease (
g PO (single
days
1
2
mg BD for
500
dose) then
Alternative: azithromycin
: vulvovaginal swab— can be done by
patient. Endocervical swabs and urine
infertility, ectopic pregnancy, reactive arthritis,
perihepatitis (Fitz- Hugh– Curtis syndrome)
: epididymo- orchitis, reactive arthritis
treatment. Avoid sexual intercourse
until treatment complete
GUM: partner tracing, screening,
samples less sensitive
: first- pass urine
Oral/ anal swabs if oral/ anal sex
434
p
Eye disease see
% ciprofloxacin resist-
4
.
36
Antibiotic resistance (
g IM. Ciprofloxacin
1
Ceftriaxone
NAAT) on:
Nucleic acid amplification test (
ance in UK) Complications:
mg PO if sensitive. Complicated
500
: vaginal swab or endocervical swab.
HIV transmission,
PID, salpingitis, infertility, ectopic pregnancy
: epididymitis, prostatitis,
:
GUM: partner tracing, screening,
disease: add doxycycline ± metronida-
zole.
Urine samples less sensitive
: first- pass urine
reactive arthritis; infective endocarditis, dissemin-
ated gonococcal infection
treatment. Avoid sexual intercourse
until treatment complete
Culture (endocervical/ urethral swab
prior to antibiotics) for sensitivity
NGU refers to a pattern of infection rather
First episode as for Chlamydia
Polymorphonuclear leucocytes on
%) and Mycoplasma genitalium
50
–
11
than a cause. The main causes are Chlamydia
trachomatis (
trachomatis. Recurrent: metronida-
zole + azithromycin/ moxifloxacin
microscopy of urethral swab. Needs
testing for chlamydia, gonorrhoea, and
%)
50
–
6
(
depending on first treatment
UTI
Mycoplasma genitalium. Exclude
Pregnancy: risk of preterm delivery, low
g single dose or
2
Metronidazole (
NAAT, culture, microscopy (mobile
HIV transmission
Elevated vaginal pH alters vaginal flora: anaerobic
birth weight
May enhance
d course). GUM: partner tracing,
7
–
5
Oral or vaginal metronidazole, or
screening, treatment. Avoid sexual
intercourse until treatment complete
trichomonads)
Gram stain to examine vaginal flora
STI
bacteria. Not sexually transmitted but associated
with
vaginal clindamycin
5
.
4
(predominance/ absence of lactobacilli),
clue cells, vaginal pH >
Very common. No evidence for treatment of sexual
- Azoles: pessary, eg clotrimazole,
Microscopy and culture for Candida
immunosuppressed
partners. Risk: pregnant, antibiotic therapy,
9 Infectious diseases
cream if vulval symptoms, oral
fluconazole if severe
)
404
p
(
Often asymptomatic: detected
on screening
: dyspareunia, dysuria, post-
coital/ inter- menstrual bleeding,
vaginal discharge
Presentation Diagnosis Treatment Other
Overview of urethritis and vaginal discharge
16
.
9
STI
Chlamydia
trachomatis
Table
: dysuria, urethral discharge
%
10
% ,
50
Urethral/ vaginal discharge,
dysuria
Asymptomatic:
Neisseria
gonorrhoeae
, most pharyngeal/ rectal
infection
Urethral discharge, dysuria,
urethral discomfort. Only assess
Non-
gonococcal
symptomatic patients/ visible
discharge for urethritis
NGU)
urethritis
(
%), itch
70
%),
70
: asymptomatic (~
discharge
: vaginal discharge (~
Trichomonas
vaginalis
Thin , whit e, fishy - smelling vaginal
Bacterial
%
50
discharge. No itch or soreness
Asymptomatic in ~
vaginosis
Genital itch, burning, cot-
tage cheese- like discharge,
Genital
candidiasis
dyspareunia
9 Infectious diseases
Fever in the returning traveller
https://t.me/med1917
410
Exclude malaria in all travellers from the tropics (p
Exclude HIV in all (p
Most travellers have self- limiting illnesses potentially acquired in UK. Look for
tropical infection
Consider the need for early isolation and PPE.
9 but remember usual dierentials, including sepsis (qSOFA score).
History Where Detailed geography of travel (table
When Dates of travel, time of symptom onset, duration of symptoms (table
urban).
9.18
).10 Risks and activities Bites, diet, fresh- water exposure (schistosomiasis, lepto-
spirosis), dust exposure, sexual activity, game parks (tick typhus, anthrax, trypanosomiasis), farms, caves (histoplasmosis, rabies, Ebola), unwell contacts. Higher risk
in those visiting friends and relatives in lower- income countries.
Associated symptoms
• Respiratory: S. pneumoniae, H. influenzae, legionella, influenza, viral respiratory
SARS, MERS), TB, HIV- associated disease, melioidosis.
disease (
• Neurological: malaria, meningococcal meningitis, HIV, syphilis, Lyme disease,
leptospirosis, brucellosis, tick- borne encephalitis, relapsing fever, trypanosomiasis.
• Gastrointestinal: traveller’s diarrhoea, malaria, VHF, enteric fever, cholera, dengue.
Table 9.
17
Dierential diagnosis by geography
Area of travel Common Occasional Rare but do not miss
Sub- Saharan
Africa
South- East
Asia
South and
Central Asia
Middle East
Mediterranean
North Africa
South
America
Caribbean
Eastern
Europe
Australia
North America
Table 9.
Incubation period Infections
Short <10d
Medium
Long >
Chronic fever <
Malaria (
HIV (pp
Rickettsiae (
Malaria (
Chikungunya (
Dengue (
Enteric fever (
Malaria (
Dengue (
Enteric fever (
Malaria (
Dengue (
Enteric fever (
18
Dierential diagnosis according to incubation time
10– 21
d
21
d
14
d
412– 15
394
).
pp
412– 15
)
)
p
418
412– 15
p
416
)
p
411
412– 15
)
p
411
412– 15
)
p
411
)
)
)
)
)
)
)
)
Schistosomiasis (
Amoebiasis (
Brucellosis (
Dengue (
Enteric fever (
Leptospirosis (
Melioidosis (
Chikungunya (
Visceral leishmaniasis
(
Brucellosis (
Q- fever (p
Zika (
Brucellosis (
Leptospirosis (
Zika (
Lyme disease (
Dengue (
Q fever (p
Rickettsiae (
Lyme disease (
Rickettsiae (
p
p
416
p
p
419
)
p
420
p
417
)
p
p
417
)
p
416
420
p
p
394– 99
pp
p
416
pp
p
416
pp
p
416
Dengue, chikungunya, gastroenteritis, relapsing fever, rickettsiae
Malaria, HIV, brucellosis, enteric fever, leptospirosis, melioidosis,
Q- fever, coccidioidomycosis, VHF, Chagas’ disease, trypanosomiasis
Malaria, HIV, TB, viral hepatitis, brucellosis, schistosomiasis,
amoebic liver abscess, trypanosomiasis, visceral leishmaniasis
TB, HIV plus opportunistic infection, pyogenic deep- seated ab-
scess, infective endocarditis, brucellosis, enteric fever, fungal
infection, schistosomiasis, visceral leishmaniasis,
).
9.17
)10 including setting (rural/
Other arbovirus (
p
430
)
p
428
)
420
)
420
)
420
)
)
418
418
Try pa n os om ia si s (
)
VHF (pp
Visceral leishmaniasis
p
411
)
p
(
Hanta virus (
p
421
)
387
)
Japanese encephalitis
p
(
Rickettsiae (
Scrub typhus (
p
416
)
VHF (CCHF) (pp
Rickettsiae (
Japanese encephalitis
p
(
Visceral leishmaniasis
)
p
(
)
Trypansomiasis (
p
421
)
Hanta virus (
Yellow fever (
p
418
) Hanta virus (p
Tick- borne encephalitis
p
(
Melioidosis (
)
Melioidosis (
p
418
)
)
419
433
433
419
433
)
)
)
)
)
422– 3
PE
p
p
p
p
)
p
418
418
p
p
387
387
p
422
p
418
422– 3
422
416
422
p
p
)
)
)
)
416
)
)
)
419
419
)
)
)
)
)
)
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