UTI- asymptomatic bacteriuria acute cystitis (infec of bladder) acute pyelonephritis (kidney infec) -Asymptomatic bacteriuria- only treat

at in preg women and patients having GU surgery; tx for preg- nitrofurantoin, amox, amoxclavulanate, cephalexin fosfomyNOT- Bactrim in 1st/3rd trimes, FQ (teratogenic) -dysuria- 90% cystitis if dysuria + freq + NO vag discharge; could also be chlamydia urethritis, other genital infec - cystisis = dysuria + freq/urgency + pyuria + pos culture + hematuria + suprapubic pain [NO vag discharge, NO fever] usualy E.coli, can also be- S.saprophyticis, enterococcus, GNR (Proteus, Klebsiella pnemo) dx- dipstick for pyuria (>10 WBC) and nitrite; tx= nitrofurantoin, TMP/SMX (bactrim), fosfomycin (not for pyelo); altern- FQ - Chlam Urethritis- women- pyuria + neg gram stain/culture + hx of new sex partner; men- dysuria + penile discharge tx=tetracycline, erythro - pyeloneph = sx of cystitis + FEVER + WBC cast in urine [chills, flank pain, N/V]; complications=emphysematous pyelo; perinephric abscess; renal abscess --- tx- uncomp-outpatient FQ/bactrim; comp- IV 1st line B-lacs (ceftriaxone/aminoglyc), if Abresis-broad spec B-lacs -acute prostitis- fever, back pain, dysuria, enlarged/tender gland --- GNR tx=TMP/SMX or FQ -chronic prostitis- clinically silent, gland not usually enlrg; dx by recurrent infec elswere in UT or GN bacteremia in elderly w/o apparent source --- tx=FQ or trimpehorpim -nosocomiaal- catheters, usually hosp pathogens Ab-resis; tx-Pathogenesis- Ascending infection (from GI tract- spread upward by sex. Females> b/c shorter urethra); Hematogenousuncommon except s.aureus (ie-from endocarditis) Host defenses- urine flow, pH, antibacterial prostatic secretions; innate immunity (bac adherence cytokine release, recruits PMNs- ie IL-8- deficiency = > pyelonep) Risk factors- obstruction (congen in male infant; prostatic hypertrophy, stones); stasis of flow (ie-neuro-musc an/l-sc dx, DM, MS); short urethra (in fem- + sex + spermicide use E.col, S.saprophyticus); urinary incont, estrogen deficiency (elderly women) Bac. Virulence- adhesins (ie-pili); O Ags (surface LPS -> fever, pain, sepsis of invasive UTI); K Ags (serum resis?-esp K1); urease (proteus-incrs pH, cytotox, struvite stones); hemolysin (lysis of PMNs?); siderophores (steal Fe from host) Comm uropathogens- E.coli, other GNR Enterobacteriaceae- Proteus, Klebsiella; GP- enterococcus, S.saprophyt usually sens to TMP/SMX Hosp uropaths- E.coli, Klebsiella, Proteus, Providencia, Psuedomonas, Candida usually resis to Abs Sepsis- deleterious host response to infec Sep shock- seps /MOF + fluid non-resp hypotension SIRS- system inflame response synd Infec- org invasion Severe sepsis [=sepsis]- sep w/MO hypoperfus + dysfunc Orgs- Gram pos-45% (S.aurues, strep pneumo, enterococ, GAS, GBS); Gram neg-40%-severity + rate of decline more sever w/GN (Enterocbacteriaceae-E.col, K-E-S grp, P-P-M grp; non-ferm rods- pseudomonas auerig, acinetobacter); cocci- N.men, Hemoph); strict aneorobes-2-5% (bacteroidses, clostridia); Candiad/fung-5% (but w/very high mortality) Pathobio of fever- infec/injury active myeloid cells + secondary active of endothel/mesenchyme pyrogenic cytokines produces IL-1, IL-6, TNF, IFN cytkn deteceted by OVLT cells in brain vessels upreg PG E2a hypothal/thermoreg center incrs set pt (ie-thermostat) heat conserve + incrs heat prod fever Pros- bactercidial, heat shock prs (help cells wishtand Cons- incrs caloric need, incrs myocard work, incr catab, feb stress), iron stress on pathogens, incrs cardiac output, incr seizures, denatures prs, incr fluid loss PMN/phagocytos, inducer Ab response Tx- give Abs w/in 1 hr, give fluids to restore vol- goal= CVP 8-12 mmHg, SVO2 > 70% -- give vasopressors [1-NE; 2nd=DA, vasopres] to maintain BP and organ perfusion Pneumonia Routes of spread- aspiration from oropharynx (strep pneumo); inhalation of aerosolized droplets (m.TB); hematog (ie-IVDUS.aurues from R-sided endocard) Risk factors- Occupation, Hypovent (not strong cough reflex), Inhib of epiglot reflex (drugs, LOC), inhib of muocciliar transport (ie-smoke, asthma), Hosp/disease, Impaired immun; travel hx, exposure to animals Etiology S.pneumo- 35-60% CA lobar, alv filled w/PMNs but not bronchioles/alv); necrosis-abscess + purulent infec of destroyed plueral space (empyema) GNR-Ab resis (Kleb pnemo, Psuedo aeruginosa, E.col)- HALegionella (GNR)-5-10% CA + HA for IC; dif to culture; water elderly/IC/intub necrotizing- PMN + destroy alv source (via biofilm); extrapul sx (seizures, GI) Hib- children/smokers/underlying dx (emphysema) Anaerobes (ie-fuscobac)- aspirate orally w/bad dentition S.aureus- 70% infan/child; HA post resp viral infec -> necrotizing w/abscess +/- empyema lobar/seg, pnuemoatoceles (radioluc in infil b/c distended

Mycoplas pneumo- 35% young adults walking pneumonia + sore throat, HA, N/V Chlaydia- C.psittacocis from birds; C.pneumo 10% walking pneumo (all ages); C.trachom-infant pneumo

M.TB + MAC- chronic granuloatmous cavitary pneumo (but see this more often in IC and they dont have enough of CMI response to form granuloma-so will have full blow infec)

Alveolar infiltrate-bacterial (strep pneumo, staph. Aureus) alveoli filled w/exudate, bronchi spared; ground-glass appearance; air bronchograms; consolidation Interstitil-viral or PCP; inflam confined to insterstitium, summation of linear densities, reticulo-nodular pattern; rales w/o consolidatoin Lobar (Hib, K.pneumo)- 1+ full lobes w/alv infiltrate; consolidation Broncopneumo- 1+ segments w/alv process; rales w/o consold Empyemas (infected effusion)- Hib, S.auerus- low pH + incr pr and LDH of fluid = exudate Abscess- Stap, GNR, anaerobes; air-fluid level! Diagnostic testing- CXR, gram stain of sputum, O2 status (pulse oximetry or arterial blood gas); 2 blood cultures (usually low yield- <20%); serology for non-culturable (ie-legionella, mycoplasma, chlamydia); rapid diag test (urinary Ag for legionella and S.pneumo) CA Outpatient S.pneumo, mycoplasma, Chlamydia, Legioenalla, viruses Macrolide or Doxycycline or FQ CA Inpatient- S.pneumo, Hib, Polymicrob anaerobes, Aerob GNR, Legionella, S.aurues, Chlamydia 1) ES Cephalosporin or Blactam + Macrolide OR 2) FQ alone HA/CA (aspiration)- Anaerobes, Aerob GNR 1 ) FQ +/- clinda/metronidazole/B-lactam ICU (intub)- Aerob GNR, S.aureus, Psuedomonas, Acinetobac 1)B-lactam; 2) 3rd gen anti-psuedomon cephalosporin + cirpofloxacin PreventionPneumovax- 23 serotypes of capsular Ags for s.pneumo- efficacy 44-61%; reduce severity of disease; recommended forimmnocompetent w/chronic illness (CVD, DM, cirrhosis) or >65y.o; IC; 12 y/os w/crhonic illness; Prevnar 13- pr-conjug pneumococcal vac for infants- protects against ear and resp infections GI Infections ID- Shig (10-100)>C.jej>Salm>E.col>V.chol ETEC- LT,ST (plasmid encoded); 5-10dy incub 1-5 dys non-inflam watery D (low F-30%, V-25%) EHEC- Stx; incub 3-4dy blood/non-blood diarrhea 7dys-HUS (renal, thrombocytopenia, hemolytic anemia) Non-typh Salmn-Gastroent, Enteric Fev, focal sup infec (arteritis, meningitis, osteomyel, plueropulm); Non-supp infec (chrnc carry in biliary); Non-infec (reactive arthritis) C.jejuni (20y.o)-bloody D + F + Ab-pain (non-infec sx-reactive arthritis, GB); C.fetus-IC, bacteremia+vasc infec C.dif- Enterotox A; Cytotox B Rota-Winter Vom; <2y.o, watery D w/o F; Noro-yr round; explos watery D + V Dx- fecal leukocytes=inflam D (shig, C.jej, EIEC, STEC, salm); stool cult-salm, shig, C.jej; EIA/PCR-C.dif, EIA-Rota TX- V.chol (azithro, doxycyc), Shigella (TMP/SXT, ciproflox), S.typhii (cetriax, ciproflox) [not ETEC, C.jej, non-typh Salm, E.coli O157:H7]