Beruflich Dokumente
Kultur Dokumente
Frank P. Noto, MD
Assistant Professor
Mount Sinai School of Medicine
Internal Medicine Clerkship Site Director
Gram-Positive Cocci
Penicillin G, VK, ampicillin, amoxicillin
Effective against group A streptococcus, most anaerobes (not Bacteroides),
actinomycosis, clostridium (not C. difficile), Listeria, syphilis
Not staph: need beta-lactamase inhibiters (sulbactam, clavulinic acid)!
Ampicillin is effective against E coli (resistance is rising)
Ampicillin and amoxicillin effective for enterococci and Listeria
Gram-Positive Cocci
Semisynthetic penicillinase-resistant penicillins (oxacillin, cloxacillin, dicloxacillin,
nafcillin)
Exclusive Gram-positive coverage, staph and strep
Drug of choice for MSSA, more effective than vancomycin
If you see viridans, must be endocarditis
Bone, heart, joint, skin
Gram-Positive Cocci
Cephalosporins Do not cover LAME
Listeria
Atypicals
MRSA - except ceftraoline
Enteroccus
Gram-Positive Cocci
.
Clindamycin
Excellent strep, staph and anaerobe coverage
Use in penicillin allergy
Use for anaerobic infections above diaphragm
Metronidazole
Use for below diaphragm infections
Use for C. difficile(use Metronidazole for the FIRST recurrence PO vancomycin taper
for 2nd (Fidaxomicin after the 3rd recurrence) PPIs can lead to recurrent c
diff
Stop PPIs in a patient with C idff
Gram-Positive Cocci
Cephalosporins
Allergic cross-reactivity
Only < 5% risk
Ok if rash
Never if anaphylaxis
If minor infection - use macrolide or new fluoroqinlones
Invasive Aspergillus
In patients with neutropenic fevers after 5 DAYS on antibiotics with new pneumonia
Treatment:
1st line Voriconazole
Caspofungin and Amphotericin B may also be used
Neutropenic Fever
ANC less than 500
Monotherapy with an antibiotic that covers pseudomonas only
Gram-Negative Bacilli
Penicillins (piperacillin, ticarcillin, mezlocillin)
Full range of gram-negative Enterobacteriaceae (E coli, Enterobacter, Klebiella,
Citrobacter, Morganella, Proteus, Serratia), plus pseudomonas
Add beta-lactamase inhibitor, tazobactam or clavulanate) to add activity against staph
Gram-Negative Bacilli
Fluoroquinolones
Ciprofloxacin
GOOD: gram-negative coverage, including Pseudomonas
NO: gram-positive coverage
New fluoroquinolones (levofloxacin, gemifloxacin, moxifloxacin)
Very good gram-positive coverage, gram-negative, and atypical (mycoplasma,
chlamydia, Legionella)
Gram-Negative Bacilli
3rd/4th generation Cephalosporins
Full coverage of gram-negative bacilli, such as Enterobacteriaceae (E. coli, Proteus
mirabilis, indole-positive Proteus, Klebsiella, Enterobacter, Serratia, Citrobacter),
Neisseria, and H. influenzae
Only ceftazidime and cefepime (4th gen) will cover pseudomonas
Ceftazidime is not reliable for staph/strep
PO: cifixime = gonorrhea
PO: cefpodoxime
Gram-Negative Bacilli
Aminoglycosides
Good Gram-negative coverage, including pseudomonas
Synergistic with penicillin in treatment of staph
Use for endocarditis
Nephrotoxic and ototoxic
Aztreonam
Only Gram-negative coverage, use in serious infections with severe penicillin allergy
Gram-Negative Bacilli
Carbapenems
(imipenem, meropenem, doripenem, ertapenem)
Full coverage of Enterobacteriaceae, plus Pseudomonas
Plus excellent gram-positive and anaerobic coverage
Not MRSA, Enterococcus faecium, or Stenotrophomonas maltophila
Gram-Negative Bacilli
Ertapenem
Does not cover pseudomonas
Approved for intra-abdominal and soft tissue infections
Lower seizure threshold, especially imipenem
Gram-Negative Bacilli
Doxycycline
Early lyme - rash, joint problems, facial palsy
Rikettsiea
Chlamydia
Ehrlichiosis
Trimethoprim-sulfamethoxazole
PCP
Uncomplicated cystitis
Meningitis
Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes: HIV, steroids, lymphoma, leukemia, chemo, neonates and
elderly (> 50)
Cryptococcus
Rocky Mountain Spotted fever mid-Atlantic
Tb, Lyme disease, syphilis
Viruses: entero, HIV, HSV, West Nile, St. Louis
Meningitis:
Fever, photophobia, headache, nuchal rigidity, N/V
AMS, seizures
8th cranial nerve
Petechial rash: Neisseria
CT head if: focal motor deficits, seizures, papilledema, severe AMS,
immunocompromised (HIV, transplant, immunosuppressive meds)
Brain Abscess
Spread from mastoiditis, dental infections, sinusitis, otitis media, bloodstream
Streptococcus: 60 to 70% (viridans streptococci, Streptococcus milleri, microaerophilic
streptococci)
Bacteriodes fragilis: 20 to 30% (high resistance to clindamycin)
Enterobacteriaceae: 25 to 35 %,
Staphylococcus 10%
Headache and fever, focal deficits in 60 %, seizures
CT scan or MRI
Aspiration or excision in essential for gram stain and culture
Brain Abscess
In HIV, 90% are toxoplamosis vs. lymphoma
Treat with pyrimethamine and sulfadiazine for 10 to 14 days
Always need surgical drainage and medical therapy
Combination with penicillin or a third generation cephalosporin and metronidazole
Third generation cephalosporin and Metronidazole (NOT clindamycin) and
vancomycin for sinusitis
Penetrating trauma or after neurosurgery
Vancomycin and a third generation cephalosporin
Encephalitis
Viral: HSV-1, varicella-zoster, CMV, enteroviruses, Eastern and Western equine, St.
Louis, West Nile
Headache and fever with AMS
Lethargy or coma, focal deficits, seizures.
Need LP: PCR for HSV has 98 % sensitivity and 95 % specificity
CT may show temporal lobe involvement.
IV acyclovir
Sinusitis
Maxillary is most common
Facial pain, headache postnasal drainage, purulent drainage, fever, tooth pain
Imaging not usually needed
CT scan if no response to therapy
90% to 98% are caused by viruses
NSAIDs and decongestants
Antibiotics if:
Symptoms last for at least 10 days
If symptoms are severe: fever over 102 and facial pain for three to four successive
days
If symptoms worsen, usually after a viral upper respiratory infection of five
Sinusitis
Haemophilus influenzae and Moraxella catarrhalis
Amoxicillin-clavulanate
Doxycycline or new fluoroquinolone
Pharyngitis
Strep pyogenes, group A beta-hemolytic strep 15 to 20%
Majority are viral
Rapid strep test is 60 to 100% sensitive, but 95% specific
If negative, should confirm with culture
Penicillin, ampicillin or amoxicillin
Macrolides, 1st generation cephalosporins, clindamycin
Influenza
Fever, myalgias, headache, fatigue, coryza, nonproductive cough, sore throat
Rapid antigen detection, swab of nasopharyngeal secretions
Symptomatic therapy
Neuraminidase inhibitors: oseltamivir and zanamivir (48 hours)
Amantadine and rimantadine effective against Influenza A NOT used much
Vaccinate Everyone!
Bronchitis
Acute bronchitis NO antbiotics!!!!
Acute inflammation of tacheobroncheal tube
Mostly viral, M. pneumonia, C. pneumoniae
Lung Abscess
90% have anaerobes involved
Peptostreptococus, Prevotella, Fusobacterium are most common
85 to 90% have periodontal disease or aspiration
Fever, cough, sputum, chest pain
Putrid, foul-smelling sputum and a more chronic cough
Several weeks of weight loss, anemia, fatigue
Lung Abscess
CXR will show thick-wall cavity
Need aspiration of abscess for diagnosis
Clindamycin is first line
Penicillin
Most respond to antibiotics and do not need drainage
Pneumonia
Sixth leading cause of death
Risk factors: DM, ETOH, smoking, malnutrition, immunosuppression
Most common: Community-acquired pneumonia
Strep pneumonia (15-35%)
Haemophilus (2-10%)
Atypical Legionella (15%)
Mycoplasma (10%)
Chlamydia (5-10%)
Viral
Pneumonia
Haemophilus influenzae - smokers, COPD
Mycoplasma -healthy
Legionella - air conditioning
Pneumocystis jiroveci - HIV
Coxiella burnetti (Q-fever) - exposure to animals
Klebsiella - alcoholics
Staphylococcus aureus - post influenza
Coccidioidomycosis - southwest (Arizona)
Pneumonia
Chlamydia psittaci - birds
Histoplasma capsulatum - bird droppings, spelunking, bats
Bordetella pertussis - cough with whoop and post-tussive vomiting
Francisella tularensis - hunters, rabbits
Avian infuenza - Southeast Asia
Bacllus anthracis, Yersina pestis Francisella tularensis - bioterrorism
Pneumonia
Cough, fever, sputum production, dyspnea
Klebsiella - current jelly
Rales, rhonchi, dullness to percussion, egophony
RR, hypoxia leads to hyperventilation
CXR-lobar PNA S. pneumonia
Interstitial infiltrates - PCP, viral, atypical
Sputum for Gram stain and culture
Pneumonia
Treatment
Severity:
Hypoxia, PO2 < 60 (< 94%),
RR > 30
Confusion, uremia, hypotension
High fever, leukopenia, tachycardia, hyponatremia
Outpatient
empiric therapy
Macrolide or new fluoroquinolone
Pneumonia
Treatment:
Inpatient
New fluorquinolones, or
2nd or 3rd generation cephalosporins (ceftriaxone, cefuroxime) with macrolide or doxy,
or
Beta-lactam/beta-lactamase combination, with macrolide or doxy
PLUS
Vancomycin OR
Linezolid
Pneumonia
Pneumonia Vaccine
> 65, serious underlying lung, cardiac, liver, renal disease, steroids, HIV,
splenectomized, diabetics, hematological malignancies.
Re-dose in 5 years if severely immunocompromised
Tuberculosis
Mycobacterium tuberculosis
Tuberculosis
Active: Productive cough, fever, weight loss, night sweats
Lymph node, meningeal, GI, GU - extrapulmonary sites
CXR - apical infiltrates or cavities, effusions, calcified nodules
Sputum staining for acid-fast bacilli (need 3 negative to rule out Tb), culture takes 4-6
weeks
Tuberculosis
Treatment
Isoniazid, rifampin, pyrazinamide, ethambutol for 2 months or when sensitivity is back
Continue INH and rifampin for 4 more months
Tuberculosis
Latent Tb positive PPD or positive quantiferon gold or the interferon-gamma release
assays (IGRAs) (check this instead of PPD in patients who received the BCG)
With a negative chest X-ray
> 5 mm: close contacts, HIV, abnormal CXR consistent with old Tb, steroid use or
organ transplant recipients
> 10 mm: healthcare workers, prisoners, NH residents, immigrants (5 years), homeless,
immunocopromised (hematologic malignancies, DM, dialysis, IV drug users)
> 15 mm: low risk
Positive PPD and negative CXR: 9 months of INH
If positive CXR, collect sputum for AFB
*
Viral Hepatitis
Hepatitis A and E
Oral/fecal route
Incubation 2-6 weeks, Acute infection for days to weeks
Hepatitis B, C, D
Parental route
B and C can be chronic
Viral Hepatitis
Presentation
Acute - jaundice, dark urine, light stools, fatigue, malaise, tender enlarged liver
Hepatitis B
Surface Ag = infected
Surface Ag + IgM Core Ab = acute infection
Surface Ag + IgG Core Ab= chronic infection
Core Ab:
IgM = acute infection
IgG = 1) chronic infection (if Hep Bs Ag), or
2) recovery (if Hep Bs Ab)
Hepatitis B
Surface Ab = vaccinated
Resolution of infection = Hep Bs Ab, IgG Hep Bc Ab (exposed, recovered, and immune
- 95%)
Window period = Hep Bc IgG antibody and Hep Be antibody (2-6 weeks between the
loss of surface antigen and development of surface antibody)
Hep Be Ag = high replication rate and highly infectious
Viral Hepatitis
Treatment
Acute hepatitis - supportive care.
Chronic hep B Tenofovir (can cause fanconi syndrome) and Entecavir preferred.
interferon, adofovir, lamivudine, telbivudin (these agents have more resistance)
Cirrhosis - liver transplant
Needle stick hep B - hep B Immunoglobulin and vaccine if not immune
Chronic Hepatitis C
STIs: Gonorrhea
Disseminated Gonorrhea
Classic triad of dermatitis, migratory polyarthritis, and tenosynovitis
Skin findings
Small macules or hemorrhagic pustules on an erythematous base located on palms
and soles or on the trunk AND elsewhere on the extremities
STIs: Gonorrhea
Diagnosis
Blood smear shows gram-negative, coffee bean-shaped intracellular diplococci
Culture for gonorrhea
Serology for Chlamydia by swabbing urethra, or
Ligase chain reaction test of urine
STIs: Gonorrhea
Treatment
One dose of ceftriaxone IM or cefixime PO and azithromycin PO
Alternative is doxycycline for 7 days
(NOT FQ)
Fever, discharge, leukocytosis, lower abd pain
CERVICAL MOTION TENDERNESS, adnexal tenderness or uterine tenderness!!
Diagnosis
Culture on Thayer-Martin for gonococcus and Gram stain of discharge
STIs: PID
Treatment
Single dose IM ceftriaxone and oral doxycycline for 2 weeks
OR
Ofloxacin and metronidazole (both oral) for 2 weeks
Hospitalize if high WBC or fever
Treat with doxycycline and cefoxitin or cefotetan
Syphillus
Spirochetes are Gram-negative bacteria that are long, thin, helical and motile via axial
filaments (a form of flagella)
Primary infection
Chancre in 3rd week and disappears in 10-90 days, painless lymphadenopathy
Secondary infection
Cutaneous rash during 6-12 weeks - symmetric, more on flexor and volar surfaces,
STIs: Syphilis
Other long-term sequelae
Argyll Robertson pupil
Small, irregular, reacts to accommodation, but not to light
Tabes dorsalis
3 to 20 years after infection
Pain, ataxia, sensory changes, loss of tendon reflex
STIs: Syphilis
Diagnosis
Screening = VDRL, RPR
More specific
FTA-ABS (Fluorescent Treponemal Antibody absorption)
MHA-TP
Darkfield of chancre
Neurosyphilis
FTA of CSF is more sensitive than a VDRL
Treatment
Primary/secondary/early latent (less than one year)
Penicillin G, IM times one
Tertiary (gummas, CV manifestations) /
Late latent (more than one year, VDRL or RPR titers elevated >1:8 without symptoms)
Penicillin G, IM once a week for 3 weeks
STIs: Syphilis
Treatment (contd)
Neurosyphilis (includes ocular syphilis)
Penicillin IV for 10 to 14 days
UTIs
Treatment
3rd generation cephalosporin, fluoroquinolone, amp and gent
10-14 days of antibiotics
Do not use TMP/SMZ for empiric therapy due to up to 20% resistance
Skin Infections
Cellulitis
Infection involving subcutanous tissue
Localized pain, erythema, edema, warmth
Most commonly: Staph and group A Strep (GAS), Strep pyogenes
Dicloxacillin or cephalexin
If life-threatening diabetic foot infection: must cover gram negatives and anaerobes:
Use imipenem and vanco!!
Skin Infections
Cat bites and dog bites
Pasteurella multocida
Resistant to dicloxacillin and nafcillin
Dog and human bites
Fusobacterium, Bacteroides, Eikenella corrodens
DOGS capnocytaphia (life threatening in aspenic patients)
Augmentin (amoxicillin/clavulanate)
Oral clindamycin + fluoroquinolone
Oral clindamycin + tetracycline
Oral clindamycin + trimethoprim/sulfamethoxazole (pediatric)
Skin Infections
Necrotizing Fasciitis
Immediate Surgical debridement is most important!!
Group A strep
Penicillin G (or 1st or 2nd generation cephalosporin) plus clindamycin
Mixed aerobes and anaerobes
Vancomycin PLUS
1) piperacillin-tazobactam or
2) cefepime and metronidazole or
3) meropenem or imipenem
PLUS clindamycin (to stop group A strep toxin production)
Skin Infections
Gas Gangrene
Fever, severe pain and swelling, crepitus
Deep cuts and black tar heroine
X-ray feathery gas pattern
Clostridium perfringens
Penicillin plus clindamycin
Surgical debridement and hyperbaric oxygen
Vibrio vulnificus
Fisherman, Gulf of Mexico
Cirrhosis (HEMOCHROMOTOSIS) and poorly controlled DM
Osteomyelitis
Treatment
Wound drainage and debridement
IV Antibiotics for 6 weeks, get sensitivities
Chronic OM treat for 12 weeks
DM - 30% gram negative cipro (only oral abx can be used for OM)
Septic Arthritis
Monoarticular, swollen, hot, tender, erythematous, decreased ROM
Joint aspirate
Cell count >50,000-PMN, low glucose
2000-20,000 = inflammatory
Culture positive in 90-95%
Gonococcal - Polyarticular in 50%
Tenosynovitis, effusions less common
Migratory, petechiae
Septic Arthritis
Diagnosis
Culture cervix, rectum, urethra, pharynx
Only 50% positive cultures
Therapy
Joint aspiration and antibiotics
Empiric
VANCOMYCIN and CEFTRIAXONE!!!!
Or vancomycin and anything that covers gram negatives like gentamycin
Endocarditis
Infective endocarditis
Acute
S. aureus, normal valves
Large bulky vegetations
Rapid onset with fever
Abscess and rapid valve destruction
Endocarditis
Embolic, especially lung
Subacute
Viridans most common
Abnormal valves
Risk factors:
Endocarditis
Native valves:
Streptococcus viridans 50-60 %
Endocarditis: Treatment
ID organism
Empiric: Vancomycin (or daptomycin ) and gentamicin
Strep viridans: Penicillin 4 weeks OR penicillin or ceftriaxone PLUS gentamicin
for 2 weeks
Vancomycin or ceftriaxone for pen-allergic
Enterococcal
Penicillin or ampicillin AND gentamicin for 4-6 weeks
Vancomycin AND genatmicin for 4-6 weeks for pen-allergic
Endocarditis: Treatment
Surgery (high yield)
CHF, recurrent septic emboli, regurgitation that affects hemodynamic functions,
vegetation larger that 10 mm
Fungal, extravalvular infection (AVB, purulent pericarditis), prosthetic valve
obstruction, recurrent infection or persistent bacteremia, abscess or fistula
Endocarditis
Prophylactics high yield
-prosthetic valves, history of IE, most congenital malformations, especially cyanotic
lesions if not repaired.
-dental procedures
NO prophylaxis:
-Urinary, GI,
Acute Pericarditis
Chest pain is sharp. Improved with sitting forward
Pericardial friction rub. Low grade fever
Tamponode: pulsus paradoxus: 10 mm Hg drop in BP with inspiration. Distended neck
veins, tachycardia, hypotension
EKG: diffuse ST elevations
PR depressions
Echo to look for effusions
Acute Pericarditis
NSIADS
Colchicine for recurrence
Pericardiocentesis and pericardial window if large effusions causing tamponade
Lyme Disease
Borrelia budorferi
Ixodes scapularis
3 -30 days: erythema migrans, fever, chills, myalgias
7th cranial nerve, facial paralysis (Bells palsy)
Meningitis, encephalitis, memory loss
AV heart block, myocarditis, pericarditis
Joint involvement months to years later- 60 %, migratory polyarthritis
Lyme disease
Serologic testing-ELISA with western blot. May be negative early in disease and can
not distinguish between old and new disease.
Minor disease treat with doxycyline or amoxicillin
Cardiac (high degree AVB and PR > 3 s) and serious neurological manifestations
(meningitis) treat with IV ceftriaxone, cefotaxime,
Ehrlichiosis
.
Vector:
American dog tick
Deer tick
Lone Star tick
Ehrlichiosis
Fevers (90 %)
Headaches (>85%)
Rigors (60%)
Nausea (40%) Vomiting (40%), Anorexia (40%)
Fatigue.
A rash is uncommon
lymphopenia, and/or thrombocytopenia
Abnormal liver enzymes are found in 86% of patients.
Ehrlichiosis
Doxycycline
Babesiosis
Babesia microti, a parasite of small rodents
Northeastern United States
Babesia divergens
Ixodes scapularis is the carrier
Fever, fatigue, headache, arthralgia, and myalgia
Nausea, vomiting
Abdominal pain
Anemia
Thrombocytopenia, splenomegaly
Babesiosis
Diagnosis
Parasite on Giemsa-stained blood smears
An indirect immunofluorescent antibody test for B microti antibody is detectable within
Babesiosis
Treatment
Mild illness: oral atovaquone plus azithromycin for 710 days
Clindamycin plus quinine is the second choice
HIV
HIV infects subset of T lymphocytes called CD4 cells, causing a decrease in the CD4
count, increasing the risk for opportunistic infections and certain malignancies.
MSM, IV drug users, heterosexual intercourse
10 year lag between contracting HIV and the first symptoms
CD4 count drops 50-100 uL/year
Normal CD4 count is 700/mm3
HIV: Opportunistic Infections
Pneumocystis jiovecii
Trimethoprim-sulfamethoxazole (first line)
Dapsone and trimethoprim
Primaquine and clindamycin
Atovaquone
Pentamidine IV
Steroids if PaO2 < 70 or A-a gradient of > 35 mm Hg
HIV: Vaccines
Pneumococcus, influenza and hepatitis B
If CD4 is over 200 give varicella vaccine
HIV: CD4 cell count
700 or above: normal
200 to 500: oral thrush, Kaposi, Tb, Zoster, lymphoma
100 to 200: PCP, dementia, progressive multifocal leukoencephalopathy, histoplasmosis
and coccidiomycosis
< 100: toxoplasmosis, Cryptopoccus, cryptosporidiosis, disseminated herpes simplex
< 50: CMV, MAC, CNS lymphoma
Emtricitabine
Tenofovir - nucleotide analog
HIV: Antiretroviral Therapy
Nucleoside Reverse Transcriptase Inhibitors
Abacavir (NOT A PI, A is for AIDS) - hypersensitivity-rash, fever, N/V, sob, muscle
aches
Zalcitabine - pancreatitis, peripheral neuropathy, lactic acidosis
HIV: Antiretroviral Therapy the A is for AIDS before the vir!!!
Protease Inhibitors
Hyperlipidemia, hyperglycemia, elevated LFTs
Lipoatrophy, redistribution to neck and abdomen
Nelfinavir - GI
Indi navir - nephrolithiasis, hyperbilirubinemia
Rito navir GI
Darunavir navir
Nelfi navir
Fosamprenavir
HIV: HAART
Only statins safe with HAART are
Rouvastatin
Pravastatin
HIV: Antiretroviral Therapy
Non-Nucleoside Reverse Transcriptase Inhibitors
Efavirenz - neurological, somnolence, confusion, psychiatric
Nevirapine - rash, hepatotoxicity
Delavirdine - rash
Rilpivirine
HIV: Antiretroviral Therapy
When to start?
CD4 < 500
What to start?
2 nucleosides and one protease inhibitor or
2 nucleosides with efavirenz or
2 nucleosides with 2 protease inhibitors
Emtricitabine, Tenofovir, and Efavirenz
HIV: Antiretroviral Therapy
Guidelines
2 NRTIs with NNRTI or PI
Boosted PI: PI with ritonavir: alone: modest efficacy and significant drug interactions
Low dose in combination with other PIs gives the other PI a boosted PI: last
longer and increases the chances of success.
Never pick Ritonavir as the answer if it is the only PI
Intraadominal infections:
1)ascending cholantitis
2)diverticlulitis
3)cholecystitis
Must cover gram negative and anaerobes (especially B fragilis)
Can use ANY of the following:
1) Cipro and metronidazole
2) Ceftriaxone or cefotaxime and metronidazole (avoid ceftriaxone in biliary disease
causes biliary sludge)
3) Amp/sulbactam
4) Ertepenem
5) Pipercillin/tazobactam
6) Moxifloxicin
Lower yield :
Q-fever
Coxiella burnetti
Inhalation of placenta of cattle, sheep and goats
Atypical pneumonia, hepatitis, endocarditis, hepatomegaly
Doxycycline
Rocky Mountain Spotted Fever
Rickettsia rickettsi
Tetanus
Complication of wounds caused by Clostridium tetani, a Gram-positive rod
Tonic spasms of muscles, respiratory arrest, dysphagia, irritability, stiff neck and
extremities
Lock jaw
High mortality
Tetanus toxoid
Wound care, debridement
Antitoxin tetanus immunoglobulin
Rx: Penicillin 10-14 days
Blastomycosis
Rotting organic material
Southeast and central US
Inhalation of decaying wood
Immunocompetent
Pulmonary with fever, cough weight loss
Disseminates anywhere-skin most common
Blastomycosis
Isolation of fungus in sputum, pus, or biopsy
Amphotericin for severe disease
Itraconazole or ketoconazole for mild disease for 6-12 months
Toxic Shock syndrome
Staph aureus (toxin TSST-1)
Tampons, sponges, surgical wounds
Hypotension, fever, mucosal changes, desquamative rash on hands and feet.
GI, renal, hepatic symptoms
Nafcillin/oxacillin