Infkton

Vad bör du tänka på vid entamöba?

Hur behandlad du entamöba?
Hur behandlas sepsis?

Vad kan campylobakter ge?

Vad heter koleraprofylaxet?

Vilka enteriter ger artrit?

Vilken enterit kan ge erytema nodosum?

Hur behandlad du ETEC?

Shigella?

Vilka symtom har salmonella typhi?

Utredning?

Behanling?

Hur behandlar du listerna?

Vilka bakt ger matförgiftning?

Vilka är de vanligaste att ge turistdiarre?

Doser vid meningit

Symtom vid hjärnabscess

Behandling hjärnasbcess

Triad vid borrelios

Utredning neurborellios

HepB:s alla markörer

Vilka tas vid heaptitmisstanke?

Vilket tyder på vacc?

HIV - smittåtägrder?

Pneumocystis - utred? Beh?

Nekrotiserande fascist - beh?

Septisk artrit - vilka möjliga agens?

Behandling septisk artrit?

Utredning spondylit?

Behandling spondylit?

Behandling protesinfektion?

Diabetesfot behandling?

Malaria iskub?

Symtom malaria?

Utredning? Vad går upp och ner?

Behandling?

Profylax? Namn? Vilken grupp viktig att ge till?

Vilka prover tas rutinmässigt vid tropisk sjukdom?

Dengue - symtom?

Utredning?

Behandling?

Vaccin?

Rickettsie - symtom, utred, beh?

Shistosomiasis - symtom? Beh?

Behandling endokardit?

Anafylaxi/protesendokardit?

Vad kan aktivera en latent tb?

Hur är quantiferon bättre än ppd?

Vad bör pat veta om tbcläkemedeln?

Vad och när bör man följa upp vid tbcbeh?

Vad bör man veta om vaccinet?

Tbc-meningit, behandling +tid? LP-bild? Komplikationer?

Vad kan aktivera CMV? Symtom? Utredning? Behandling? Skador hos barnet?

Sork - symtom? Utred? Beh? Uppfölj?

TBE - symtom? Utred? Beh? Vaccin?

Tularemi - symtom? Utred? Beh?

 

 

Indelning av bakterier

Positiva kocker: Stafhar (sepsis, endokardit, septisk artrit, sår), streppar (tonsillit, erysipleas, sepsis, reumatisk feber, sår om grupp C), pneumokocker (lv, meningit), enterokocker (UVI, endokardit, sår)

Negativa kocker: meningokocker, gonokocker

Positiva stavar: Listerna (meningit, tarm), bacillus (matförgiftn), klostrider (stelkramp, ab-assoc diarre),

Negativa stavar: E-coli, klebsiella, proteus, salmonella, shigella, campylovacter, yersinia, pseudomonas (lv, sår), legionella, bacteroides

Alla aeroba utom klostrider och bakteroides (buk, abscess - majoritet av anaeroba bakteriemier).

 

Antibiotika

Betalaktamer

Penicilliner, cefalosporiner, karbapenemer

Atoxiska och får ges vid graviditet.

Biverkan: Ger rätt milda biverkningar i form av allergi, GI-symtom.

Om allergi till någon av dessa får INGEN betalaktam ges! (korsreaktivitet)

Då ges erytromycin eller klindamycin för streptokocker, klindamycin för stafylokocker.

Pcv - peroralt. Kåvepenin. Pneumokocker, streptokocker ALLTID. Halsfluss, impetigo, erysipelas, pneumokockpneumoni, erytema migrans.

Bensylpc - intravenöst. Svårare infektioner av ovanstående. Vid meningit KRÄVS bensyl-pc, för pcv tar sig ej in i CNS.

Isoxasolylpenicillin = betalaktamasresistent. Heracillin. Denna är po.

För: Staph aureus - där räcker inte penicillin!

Vid Stafylokock-hud/mjukdelsinfketion: Ekvacillin. Denna är iv.

För MRSA ges Vancomycin istället. KNS är också metcillinresistenta.

Cefalosporiner

Oftast till ESBL, VRE, clostridum.

Claforan (sepsis), Ceftazidim (pseudomonas) Cefuroxim (allvarliga ort.infektioner med grampositiv misstanke men där även gramneg måste täckas) Ceftibuten (hög UVI hos gravid)

Karbapenemer

IVA-preparat - väldigt brett.

Ampicillin

Pasteurella, entorkocker, listeriameningit

Klindamycin

2andrahand efter Heracillin för Staphylokocker samt Streptokocker. (Pc-allergi)

Elimineras via levern.

Mecillinam

Distal uvi. Selexid.

Aminoglykosider

Bekteriocid!

Gramnegativ profil, även streptokocker samt staph aureus. Sepsis, endokardit.

Biverkan: Nefrotoxisk. Detta är dosberoende.

Aminoglykosider penetrerar vävnader dåligt, men funkar bra i blodet.

Gentamycin.

Makrolid

Erytromycin

Kinoloner

Ciprofloxacin

. Hög uvi, salmonellasepsis. Bakteriocid!

Negativ inverkan på miljön eftersom de inte bryts ner. Används mot legionella.

Doxycyklin

Neuroborrelios, klamydia, mycoplasma.

Metronidazol

Clostridium difficile.

Antibiotikasvar

Orsaker till uteblivet svar:

- Odränerat fokus

- Fel antibiotika

- Ej bakteriell infektion

SIR-systemet

Sensitiv = Förväntat svar vid normaldos. Intermittent = förväntat svar vid hög dos.

Dalvärde = Värdet innan nästa dos.

UVI

Låg: Cystit. Ger miktionssmärta, trängningar, subfebrilitet, sjukdomskänsla.

Hög: Pyelonefrit. Ger feber, dunkömhet över njurloger, illamående, kräk.

Riskfaktorer: Kvinna, KAD, prostataproblem, resurin, östrogenbrist.

Etiologi låg: E-coli och S saprofyticus.

Eitilogi hög/sjh: E-coli, Klebsiella, Proteus.

Nittrittest: Påvisar E-coli, men ej övrigs.

Odling: Män, hög hos kvinna, sjukhuspatienter, gravida, terapisviktande, recidiv.

När ska ABU behandlas? Vid gravid kvinna, och inför urologiskt ingrepp.

KONTROLLODLA efteråt: Män, gravida, pyelonefrit.

Beh distal UVI kvinna

Mecillinam (Selexid) 200 mgx3 i 3 dagar. (50+ får i 5-7 dagar) el

Nitrofurantoin 50 mg x 3 i 5 dagar. Båda ok till gravid i kort kur.

Vid

Recidiv

Odla och resistensbestäm! Tänk klamydia. UL, resurin, cystoskopi?

Beh låg uvi garvid kvinna

Nifrofurantoin, mecillinam

Beh låg UVI hos män

Odla + resistensbestäm. Tänk uretrit (gonokockodla, PCR klamydia)

Ciprofloxacin 500 mg x 2 i 14 dagar. Kontrollodla efteråt!

Beh pyelonefrit

Ciprofloxacin el cefotaxim i 10-14 dagar. Cipro ffa bra hos män pga hög penetrans till prostata.

Beh pyelonefrit gravid kvinna

Ceftibuten (cefalosporin)

Urosepsis

Frossa, hypotoni, feber, takykardi, diarre. Odla!

Cefotaxim (Claforan) el engångsdos aminoglykosid

Sterila lokaler

Blod, liktor, ledvätska, urin

 

Luftvägsinfektioner

Agens

Pneumokocker

- akut insjuknande, torrhosta som blir purulent, and-korrelerad bs. Lobärt infiltrat. Blododla, sputumodla, NPH om ej sputum, antigen i urin.

Mycoplasma

- långsam insjukning, långdragen torrhosta, ej superhög feber. CRP lågt. Interstitiella infiltrat, ej alveolära som pneumokocker. Inkubinationstid 3 veckor. PCR på NPH. Men ett positivt svar kan vara gammal infektion eller en ÖLI*. Ofta familjeinsjukn!

Hemofilus

influenzae - vid KOL

Legionella

- hög feber, diarre, hyponatremi, hematuri, förvirring!. Bilaterlainfiltrat. Smittar ej mellan människor. PCR, antigentest i urin.

S aureus - efter influensa

Noskomomiala agens: E-coli, Klebsiella, Pseudomonas. Då behövs gramnegativt antibiotika för att täcka även dessa!

* Mykoplasma ger oftare ÖLI än pneumoni.

Pneumoni

Diagnos: Symptom + röntgen. Men om klinisk bild klar behövs ej rtg.

Symtom: Feber, hosta, trötthet, takypne, rassel, nedsatta andljud. EJ SNUVA.

Bronkit

Symtom: Hosta, ibland snuva, 3-4 v i tid.

Agens: Ofta rhinovirus.

Beh: Ej antibiotika, även om bakterier. Om exacerbation (ökad andning, ökad sputum, ökad sputumpurulens) ges Amoxicillin o Doxyferm i växelbruk.

Influensa

Symptom: Plötsligt insjuknande, hög feber, muskelvärk, huvudvärk, torrhosta, snuva.

CRP ej skyhögt. Inkubinationstid 1-3 dagar.

Diagnos: PCR på nasofarynxaspirat.

Beh: Enkelrum! Tamiflu om äldre, kronisk hjärtlungsjd, allvarlig sjukdom, om på sjukhus.

CRB65

Om konfusion, respiration >30, blodtryck<90, samt över 65. Två poäng eller fler betyder sjukhusvård.

Antibiotika

Standard: Pcv 1g x 3 i 7 dagar

Allergi: Doxycyklin 200 mg i 1-3 dagar, sen 100 mg en dag.

Om insjuknande efter influensa: Cefotaxim 1gx3 (S aureus)

CRB65 2: Bensylpc 3gx3

CRB65 3-4: Cefotaxim 1gx3 + Erytromycin/Ciprofloxacin för att täcka legionella

Mycoplasma: Erytromycin / Doxycyklin.

Legionella: Levofloxacin 750mgx1 i 10 dar eller Erytromycin.

Vaccinering bör ges till

65+, hjärt/lungsjuka, immunsupprimerade, instabil diabetes, leversvikt, njursvikt…

Diff influensa

/pneumokockpneumoni

Influensan kan ha snuva, muskelvärk, ej skyhögt CRP, ej röntgenbild.

Diff pneumokocker/mycoplasma

Mykoplasma har mer långdraget insjuknande, CRP ej så hög, en mer torr hosta, interstitiella infiltrat.

Diff influensa/mykoplasma

Influensa har mer akut insjuknande, muskelvärk, ej röntgenbild. Båda kan ha torrhosta och huvudvärk samt diskret CRP.

Diff övre luftväg/pneumoni

Övre luftväg har halsont, snuva, heshet.

 

Sepsis

Kriterier: HF >90, AF >20, temp<36>38, LPK<4>12.

Svår sepsis: Tillkomst av BT <90, laktat >1.

Speitsk chock: Svarar ej på vätska.

Omhändertagande

AF, BT, HF, temp, urinproduktion, medvetande

CRP, LPK,

Blodgas

Krea,

ASAT, ALAT, albumin

TPK, PK, APTT

BEH:

Syrgas, vätskebolus (om lågt BT, BE<-5, laktat)

Odla + antibiotika (inom 60 min!)

Ny blodgas. Om ej svar på vätska: IVA!

När kontakta IVA?

Medvetandesäkning, hög AF, laktatstegring, fortsatt hypotoni, saturationsäkning, anuri, DIC

Övrig behandling

KAD - bort

Abscess - debrideras

Vilket

antibiotika

Oklart fokus: Cefotaxim

Oklart fokus + spetisk chock: Cefotaxim 1gx3 + aminoglykosid 5 mg/kg x 1

Pneumoni: Cefotaxim + erytromycin (mycoplasma)

UVI: Cefotaxim + gentamycin

Meningit: Cefotaxim + ampicillin

5 organsystem drabbas ffa vid sepsis:

Lungor - kolla AF, blodgas

Njurar - kolla krea, urinprov

Lever - ASAt, ALAT, albumin

CNS - medvetande

Koagulation - TPK, PK, APTT, Dic

 

Gastroenteriter

Anamnes - Avföringfrekvens, volymer, konfiuration, blod, slem. Utland,
mat, läkemedel, ab, feber, kräk, magont
Status - Bt, puls, urin - ger dehydreringsstatus. Buk.
Symtom
Tunntarmsdiarrer: Vattentunna siarrer, dehydrering,
Colondiarrer: Blod i bajs, feber, magont, diarré
Utreda: F-odling för de 4. Pcr för resten. Mikroskopi för Giardiacystor, amöbor.
Tunntarmspatogener: Rotavirus, ETEC, Colera
Blandbild: Salmonella, Yersinia, Campylobacter
Colonpatogener: Shigella, EHEC, Clostridier
Agens
Campylobacter - allra vanligast. Inkub upp till 1v. Kan ge reaktiv artrit, GaillainBarre.
Entamöba - I mat vatten o sex. 2-6v. Kan vara asymp eller ge fulminant colonbild. kan ge leverabscess. Ta serologi om leverabscess! Annars cystor i faeces. Beh Metronidazol.
Etec - om turistat o vattentunn.
Salmonella - reptiler. Kan ge reaktiv artrit.
Salmonella typhi - insjukn 2v. Ibland bara förstoppning. Influensaliknande ibland. Buksnärta, relativ bradykardi, septiska embolier, mjältförstoring. Kan ge tarmperforation. Blod o faecesodling. Ska behandlas med ciprofloxacin.
Cholera - hypotoni. Ducoral som resevaccin.
Giardia - insjuknande tar veckor till månader. Om månader efter resan lite gasig, viktnedgång, tänk Giardia. Ta cystor i faeces. Ge tinidazol.
Yersinia - Vanlig i Sverige. Griskött, vatten. Kan ge reaktiv artrit, erytema nodosum.
Shigella - Blodig. Då man blir väldigt sjuk rekommenderas behandling, ciprofloxacin. Komplikationer är HUS, toxisk dilatation av colon.
Ehec - Köttfärs. Ger blodig bild och risk för HUS. BARN med bloddiarre är ofta EHEC. PCR. EJ BEHABDLING!
Hus: Njursvikt, trombocytopeni, hemolytisk anemi.
Clostridier: Ffa vid ab. Upp till 6v efter avslutad kur. Slemdiarre. Kan ge toxisk megakolon och ileus. Gör toxinpåvisning. Beh: Metronidazol, Vanco om recidiv eller
terapiresistens.

Listeria - mat, vakuumförpackat. Friska kan palla, dock ej gravida, gamla, immunsuppade!! Ampicillin.
Konsekvenser: Reaktiv artrit ges av Yersinia, Shigella, Salmonella veckor efter magbesvären. Vid ett sånt artritfall ska serologi tas, och det ska frågas om tidigare magbesvär.
Behandling: Claforan om dålig (blodig diarre, feber) och du ej har odlingssvar än.
Giardia - Tinidazol. Amöba - Metronidazol. Listerna - Ampicillin. Salmonella typhi Ciprofloxacin. Shigella - Ciprofloxacin. Clostrider - Metronidazol.

Viral enterit
Rotavirus - vattenbild. Vanligast för spädisar.
Calicivirus - kräk o diarré. Frisk efter 1-3 d. Smittfri 48h efter senaste spyan eller diarren.
Adenovirus el astrovirus - milt, barn.




Matförgiftning
1-6h. S aureus, clostridium peefringens, bacillus cereus. Ingen diagnostik, ingen behandling.

Turistdiarre

3 vanligast agens: Campylobakter, salmonella, ETEC.

Beh: Nej! Endast vid svår feber och blodig diarre, då Cefotaxim.

 

Meningit

Ökat ICP, hypotension, vaskulit pga inflammation, inflammation ger alla ischemi vilket ger celldöd. Bakteriell invasion av cochlean ger hörselskada.

Oftast bakteriell, - Meningokocker eller Pneumokocker. För äldre och barn även Listera och E-coli.

Viral - HSV2

Symtom

Triad: Illamående, feber, huvudvärk.

Nackstyvhet, kramper, medvetandesänkning. Pos Lasegues test.

Medvetandsänkning innebär ofta bakteriell genes.

Petechier (går ej att trycka bort) innebär ofta meningokocker.

Meningokock purpura fulminans är ett avancerat stadium där man tappar tår, fingrar, nästipp med mera.

Kan även vara septisk bild!

Om luftvägsbild/otit, tänk pneumokocker.

Utredning

LP - högt cellantal (>1500), många poly, högt laktat och lågt glukos tyder på bakterier.

Sp - odla, PCR.

Blod - odla.

CRP - högt tyder på bakterier.

Om misstänkt meningit men kontrandikering mot LP: Gör CT, om denna ej visar högt ICP är det fritt fram att göra LP!

Behandling

Om grumlig likvor:

1. Cefotaxim 3gx4 + Ampicillin 3gx4 (den sistnämnda täcker Listeria)

2. Betametason - ska ges samtidigt som antibiotika, EJ efter!

Alla med HSV2-meningit (samt VCZ hos immunsupp) ska ha acyklovir.

Om svaret visar meningokocker à Byt till bensyl-pc

Konsekvenser

50% får inga konsekvenser.

18% får hörselnedsättning. I övriga kognitiva besvär och trötthet, ibland jobbyte, pareser, epilepsi. Skicka till neuro-rehab!!

Encephalit

Viral - TBE, enterovirus, HSV1, VCZ, EBV, HIV.

Virala CNS-infektioner är dock alltid ett kontinuum meningit--encefalit.

HSV1-encefalit brukar ej presentera med samtidiga munblåsor.

HSV2-meningit brukar ofta presentera med samtidiga genitala blåsor (första gånger)

Symptom

Huvudvärk, feber, kramper, medvetandesänk, personlighetsförändring, agressvitet, konfusion.

Fokalneurologi ska få dig att tänka snarare encefalit än meningit.

Utslag - enterovirus, VCZ

Myalgià bättreà meningit - enterovirus, TBE

Smittsamhet à enterovirus/meningokocker

Temporallobsencefalit - HSV1 (ger ofta personlighetsförändring, förvirring)

Recidiverande meningit - HSV2

Pares skuldra - TBE

Utredning

LP - celler, protein, glukos, laktat, odling, PCR för enterovirus, HSV, VCZ

LP svarar på om det är meningit eller ej. Celler >5 = meningit. >1500 = bakteriell.

Serum - igM för TBE

CT

MR - bäst på att visa encefalit! Om medvetandesänkt, samti kognitiv svikt, tänk encefalit. Gör MR! Visar t.ex. temporballobsförändringar vid HSV1-encefalit.

Du får göra CT innan acyklovir om det bara är några timmars väntetid på CTn.

EEG - typisk bild vid HSV1

Behandling

Alla med misstänkt encefalit ska ha acyklovir iv. Alla med HSV2-meningit också.

Det man är rädd för är just HSV1-encefalit.

Övriga virus (när väl diagnosticerade) - ej beh. Avstigmatisera, hem, alvedon.

Vid illamående: antiemetika. Vid smärta: analgetika. Vid dehydrering: dropp.

Om recidiverande HSV2-meningit - ge acyklovir att ta med hem och ta vb.

Om meningokocker: Ciprofloxacin i engångsdos till folk pet bor med/hängt med mkt på sistone.

Diff meningit/encefalit:
Meningit ger triaden, encefalit ger fokalneurologi.

Diff viral/bakteriell meningit

Om jättesjuk: bakteriell. Om ej lika sjuk: virus. Om medvetandesänkt: bakteriell. Om petechier: bakteriell.

Hjärnabscess

Symtpom

Mer smygande huvudvärk. Ej kaboom. Låg feber. Kramper. Illamående. Fokalneuro.

Etiologi

Spridning från tand, kirurgi, endokardit, lunga.

a-streptokocker, bacteroides, S-aureus.

Utredning

CT/MR

SR o LPK kan vara ua!!

Blododling

Tandlälarbedömning om tandmisstanke

TEE om endokarditmisstanke

LP kontraindicerat!

Behandling

Kirurgi

- viktigast

Cefotaxim + metronidazol (lipidlöslig)

Steroider vid inklämning eller medvetandesäkning

Antiepileptika om kramp

 

Borrelia

Erytema migrans -

1-4v efter bettet.

Borreliaartrit -

Veckor-månader efter bettet. Ofta knä.

Akrodermatit -

Mån-år efter bettet

Neuroborrelios -

2v-6 mån efter bettet.

Symtom

Facialipares, radikulit (nervpåverkan med utstrålande smärta i armar och ben), subakut meningit (huvudvärk, subfebril, viktnedgång)

Trötthet, domningar, huvudvärk, nackvärk, subfebrilitet. Långdragen bild.

Utredning

EM - kliniskt. EJ serologi!

Akrodermatit/borreliaartrit - Serologi (IgM) Borrelia-PCR på ledvätska om artrit.

Neuroborrelios - Serologi. Även LP (viral bild) med antikroppstagning.

CRP, SR - ua

Behandling

Erytema migrans - PcV

EM + feber / Neuroborrelios - Doxycyklin po 14 dagar

Hepatiter

- alla ska smittskyddsanmälas! Vid hepatit: Sparsamt med alkohol, paracetamol

Prodromalstadium: Trötthet, sjukdomskänsla, illamående, aptitlöshet

Ikteriskt stadium: Gulhet

När det kommer en gul patient:

Anamnes: Resor, sex, missbruk, transfusioner, alkohol, vaccinerad mot heppar?

Prover: ALAT, ASAT, INR, bilirubin, ALP, gamma-GT, albumin. Anti-HAV-igM, anti-Hbc-IgM. Ej nåt för hepC eftersom den aldrig är akut. (Gulhet = akut)

(Diff: Autoimmun hepatit. Ffa om ung kvinna. Ta ANA, AMA, SMA. Beh: Kortison, azatioprin.)

HepA

Alltid akut. Smittar fekooralt. Inkub 3v. Smittar 2v före och 2 v efter ikterisk fas.

Diagnostik: anti-HAV IgM (aktiv sjukdom,borta efter 6mån), anti-HAV igG (utläkt/vaccinerad)

Behandling: Nej. Om INR är ok kan pat gå hem efter provtagning.

Vaccinering: Ja. Ev profylax i form av gammaglobulin till hushåll om pat är pos.

Smittskyddsåtägrd: Ej laga mat. Smittanmäl enligt smittskyddslag.

HepB

Blir sällan kronisk. Kan ge hepatocellulär cancer som konsekvens.

Inkub 3 mån. Smittar 8v innan ikterisk fas, sedan 8 v efter utläkning/livslångt om den inte läker.

Diagnostik: Hbs-Ag (betyder att du smittar, att sjd är aktiv), anti-Hbs (betyder att sjukdomen läkt ut eller är vaccinerad), anti-Hbc-IgM (betyder akut sjukdom, neg after 6 mån), anti-Hbc IgG (betyder att du någon gång blivit infekterad, stannar livslångt)

Akut: HbsAg, Hbc-IgM, Hbc-IgG

Kronisk: HbsAg, Hbc-IgG

Utläkt: anti-Hbs, Hbc-IgG

Vaccinerad: Hbs-Ag

Behandling: Om kronisk: nukleotidanaloger.

Smittskyddsåtgärd: Ej ligga förrän 6-mån-kontroll om HbsAg då negativ.

Smittspåra, vaccinera sexpartners! Smittskyddsanmäl enligt smittskyddslagen.

HepC

Ffa denna ofta asymptomatisk!

Blodtestas sedan -92, innan dess kunde man få hepC bia transfusion. Dessa kan visa sig först nu i nutid, så fråga om 80-talstransfusioner.

Blir oftast kronisk. Ger risk för levercancer, men levern måste bli cirrotisk först isf.

Inkub: Fet?

Symtom: Misstänk vid skum ALAT-stegring. TPK ofta låg vid hepC!

Diagnostik: Anti-HCV. Om dessa är positiva, ta HCV-RNA (PCR). Anti-HCV indikerar infektion, och HCV-RNA indikerar aktiv sjukdom. Om den förstnämnda är positiv men den sistnämnda negativ krävs ingen behandling (=utläkt).

Om positiv HCV-RNA, ta ett till efter 6 mån. Om då pos: Ja, du har hepC.

Cirrosdiagnostik: Biopsi eller nya fibroscan, där stötvåg mäter leverns elasticitet.

Behandling: Mycket händer på denna front, behandling ändras.

Ålder och alkohol är sämsta prognostiska faktorerna, smittas du vid hög ålder har du högre risk för cirros.

HIV

Symtom: Feber, utslag, lymfkörtelsvullnad, halsont, munsvamp.

Lab: Anemi, låga LPK, låga TPK

Snabbtest: 20 min. Svar direkt.

Annat test: Antigen+antikropp. Antigen pos 14d efter exposition, antikropp 3 mån efter. Antigen täcker då fönstret mellan, innan ak bildats.

Aids-opportunister: Tb, candidaesofagit, pneumocystis, varicella zoster

Pneumocystis: Trötthet, dyspne vid ansträngning. Perihilära infiltrat bilateralt. Pneumothorax. Sputum-PCR för diagnos. Trimsulfa är behandling, ev kortikosteroider också.

Beh: Proteashämmare, integrashämmare, transkriptashämmare, fusionshämmare. Kombo.

Smittåtgärder: Smittspåra! Anmäl enligt smittskyddslagen, upplys om smittskyddslagen och säkert sex och upplysningsplikt, behandla,

Smittrisk mor-barn om ej åtgärd: 25%

Smittrisk mor-barn om smittskyddsåtgärd: <1%

Impetigo


Gula krustor. Eventuellt bara rodnad som sen blir sår.
Agens: S aureus
Behandling: Tvål o vatten. Heracillin om svårt.

Follikulit
Inflammation i hårsäck
Furunkel - Follikulit med abscess i hud
Karbunkel - Flera furunklar i sammansättning
Agens: S aureus
Behandling: Incision om abscess. Kloxacillin ibland.

Erysipelas
Risk är trauma, ingrepp, fetma, dm. Akut insjuknande med
feber o frossa, kräk.
Agens: streptokocker gr A
Utreda: Odling endast om sår
Behandling: Bensylpc, el kåve om ej inlägg. Ben i högläge!
Risk: Lymfödem. Därför högläge.

Cellulit
Inflammation även i subcutis. Mindre avgränsade än erysupelas, kan dock
sitta på ben som erysipelas. Ofta är barriärakada boven.
Agens: både aureus o strepA. Gramneg om perineum, pneumokocker om fejan.
Behandling: Kloxacillin. Ofta iv, detta är en dålig pat.
Högläge av extremitet, incision om abscess.

Nekrotiserande fasciit
Ofta ser det ok ut men känns ont.
Risk: sår, DM, bett, missbruk...
Utred: Blodla! Sårodla. CK o myoglobin om samtidig myosit. StrepAtest från sår. CT.
Beh: Akut kirurgi med odling medan man slevar. Impinem + klindamycin.

Bett
Hund o Kat: Pasteurella
Utred: Odla
Behandling: (Amoxicillin-Klavulansyra,) Bensylpc po.

Kan behövas ortopedkonsult för ev septisk artrit!

Leder


Septisk artrit
Svullen, varm led. endast en. Predisp är operation, artros, artrit, DM, mm. Pyrofosfatartrit kan bli septisk artrit!
Anamnes: Ingrepp, trauma, magbesvär (diff reaktiv artrit m shigella, campylobacter, yersinia), tiazid (ökar urat), feber, missbruk, ledbesvär, RA, DM, malignitet, tandingrepp,
protes.
Agens: KNS om postop. Annars S aureus, streptokocker.
Utred: Punktion. Odling, LPK med diff, glukos, kristaller, laktat. Blododla x 2!

Behandling: Ekvacillin 2gx3. Efter 5-7 dagar o feberfri ges po enligt odlingssvar, i 4-6 v. Diabetiker/buk/ urinfokus ska ha Cefotaxim 1gx3. Kontakta dessutom alltid ortoped för ev spolning!

Artriter i ledvätska
Sept - fet lpk, hög laktat, låg glukos
Artros - ok
Kristall - hursom
Reaktiv artrit - hög LPK

Spondylartrit
Artrit i ryggrad. Oftast länd. Sprider sig alltid kota för kota. (om ej: misstänk Tb.)
Agens: S aureus, streppar.
Predisp: Missbruk, DM, ingrepp, trauma, malignitet.
Symtom: Ryggont, feber, utdraget, dunkömhet.
Utred: MR ländrygg, i andrahand scint. (EJ CT) Om MR visar spondylit: MR-ledd kotbiopsi där du tar för odlingx2, Tb-PCR, cytologi för malignitet, svampodling. Blododla alltid!!
Behandling:
Septisk - Beh innan stick.
Ej så sjuk - stick innan behandling.
à Ekvacillin 4gx3. Cefotaxim om buk/urinfokus. Iv i 1-4 v, sen po 3 mån.
Risker: Infektionen kan gå in i duran, så gör dagligt neurostatus.

Protesinfektion
Tidig: S aureus
>3 mån: KNS
Om längre än 2 år: Vad som.
Risk: Biofilmbildning är ett problem vid protes, så bredare åb behövs!
Utred: Djup odling, stick i frisk hud. 5 djupa biopsier, innan ab och sedan 2v efter antibiotikafrihet. Blododla om septisk.
Beh: om S aureus: Kloxacillin 2g x 3 iv i 1-2 v sen Rifampicin o Ciprofloxacin.

Detta i 3 mån (höft) el 6 mån (knä)
Uppfölj: Biopsier djupa 2v efter antibiotikafrihet.

Infekterad diabetesfot
Utred: Rtg, odla ytligt o djupt. Blododla. Kontakta kirurgen! Kärlutredning.
Ytligt: S aureus, strep. Kloxacillin.
Djup: Täck gramneg. Karbapenem.
Komplikation: Plantarabscess.

Immunsupp
Upprepade nedre luftvägsinfektioner, sinuiter, tarminfektioner, långdragen subfebrilitet: Tänk Ig-brist. G för luftväg, A för tarm.
Utred: Elfores, Ig subklasser.
Beh: IgG subcutant.

Neutropeni


Medfödd är tex Kostmanns, annars cytostatika el leukemi, kortison, leversjd.
Profylax för folk med cytostatika: Acyklovir (ökad risk för herpesreaktivering), Ciproxin (täcker gtamneg vilka är de allra farligaste!)

Neutropen feber
Beh: Blododla + karbapenem.
Om feber persisterar: Odla om. Överväg Ct, svampodling.
Så länge pat är stabil finns ingen anledning att byta ab.
Svamp: Candida ger sepsis, Asbergillus ger pneumoni o sinuit, täta runda infiltrat på CT.

Malaria

Flera subtyper. (falciparum, vivax, ovale, )

Falciparum är den farligaste och vanligaste.

Inkub: 1v-3 mån för falciparum. Upp till år för andra.

Smitta: Myggor i tropiken, samt blodstransfuion.

Symtom: Feber, frossa.

För typer som ej är falciparum är det ett typiskt varannan-dag-insjuknande, med frossaà feberà svettningà ok. Sen nästnästa dag samma igen.

För falciparum: Cerebrala (blickdeviation, öppna ögon, pareser, kramp, medvpåverkan) respiratoriska (acidos, hyperventilering, andningsinsuff), anemi. Även influensasymtom som hosta, led/muskelvärk, trötthet, huvudvärk, diarre, kräkning, urogenitalsymptom.

Risk: Mjältruptur kan ske.

Utredning: Blod i mikroskop. Tjock droppe för påvisning av malaria, tunt utrsyk för att bestämma subtyp. Snabbtest för akuten finns, svarar bara på om malaria eller ej.

CRP, laktat, krea - går upp vid malaria

Glukos, Hb, TPK - går ner vid malaria.

Behandling: Riamet. Vätska mot acidos, respirator ev, krampbeh.

Profylax: Finnes men ger ej heltäckande skydd, alltså , inget vaccin. Malarone, tas när kommit hem. Speciellt viktigt för gravida att ta profylax! Finns grav-varianter. Det man vill undvika är ceberal malaria.

Immunitet: Vid sickelcellsanemi eller många genomgångna malarieinfektioner.

Andra

tropiska sjukdomar

Utredning: Malaria-snabbtest, Dengue-PCR, blododla x 2 för tyfoidfeber, cystor o maskägg i faeces vid GI-symtom.

Dengue

4 subtyper. Myggsmitta. Feber, hv, muskelvärk, influensabild. Ger rödprickigt exantem på bröst, i armhålor. Kan ge hemorraghisk dengue med blödning från GI, urin och inre organ, konjunktivit, ledvärk. Kan ge ascites. Genomgången infektion ger immunitet mot den subtypen. PCR. Symtomatisk behandling. Inget vaccin!!

Gula

febern

Samma mygga, samma virus. Ter sig som Dengue men blir oftare hemorraghisk. Här finns vaccin.

Rabies

Hund,katt,fladdermusbett. Ont vid såret, stickningar, domningar. Tas vaccin innan symtom 100% klarar sig. Om symtom à 100% dödlighet.

Tyfoidfeber

Salmonella typhi. Smittar via mat och vatten. Längre iskub än Dengue, 1-2v.

Influensa, roseoler, sepsis.

Infleunsabild med feber, huvudvärk, muskelvärk, illamående, diarre, samt roseoler (“finnar“), kan utvecklas till sepsisbild. Mjältförstoring. Utred med blodoling, sedan faeces och urinodling. Behandling: Cipro/cefo.

Brucellos

B-symtom och anamnes på opastöriserade ostar. Även artriter mm. Odla blod, led,CNS.

Rickettsia

Svarta sår, konjunktivit. Mygga. Doxyferm.

Giardia

Långdragen GI, gaser. Viktnedgång. Utred med cystor, maskägg. Behandling tinidazol.

Entamöba

Asymptomatisk till bloddiarre. Leverabscess-risk! Metronidazol.

Leishmania

Fula sår som ej läker, gärna underben. Soldater. Lever/mjältförstoring.

Spring,spol,hakmaskar - Mebendazol. Bandmaskar - Praziquantel.

Shistosomiasis/billharrzia - Anafylaxi el blödning,cirros,cancer. Hematuri. Praziquantel.

Endokardit

Predisponerande faktorer: Protesklaff, pacemaker, missbruk, gammal endokardit, vitier,
Symtom: Feber, blåsljud, septiska emboli i hud,lunga, CNS - med utslag, dyspne och neurologiska symtom som följd.
Utredning: CRP, blåsljud, TEE, Rtg Cor/pulm, CT vid neurologi, blododla, EKG. Endokardit syns inte på EKG, men rytmrubbningar där kan innebära att infektionen gått utanför klaffarna vilket kan vara indikation för akut hjärtkirurgi!
Diagnos: 2 major eller 1 major o 3 minor.

Major: Fynd i odling, TEE med typisk bild.

Minor: Otypiskt odlingsfynd, ej typisk TEE (men tex sklerotiska klaffar), feber, predisposition, embolier.
Agens:
S aureus - Både nativ klaff och protes. Även på oskadd klaff. AKUT insjuk m hög feber.
Alfastreppar - På protesklaff. Långsamt insjuknsnde med B-symtom. Tandingrepp.
Enterokocker, kns, hacek.
Lokalisation Vänster: Vanligast. Ger emboli i CNS, mjälte, hud.

Lokalisation Höger: Iv missbruk. Ger septiska embolier i lunga.
Behandling: Staph A kan uteslutas (b-symtom, tandanamnes, låg feber): BensylPc 3gx4 + aminoglykosid 3-5 mg/kg.
Staph A kan ej uteslutas: Ekvacillin 3gx4 + aminoglykosid
Lätt Pc-allergi: Claforan 3gx3 + aminoglykosid
Anafylaxi på pc: Vancomycin 30 mg/kg initialt, + aminoglykosid
Protesendokardit: Vancomycin initialt (för att täcka KNS) + Aminoglykosid
Protes m S aureus: Vancomycin + AG + rifampicin. (obs interaktion med Waran som man har vid protes, man kan behöva sätta ut temporärt o ge Fragmin)
Vid protes ALLTID 6v behandling.
Operationindikation: Terapiresistens, hjärtsvikt, stor emboli, om organismen är svamp

Tb

 

Endast 10% av de som smittas med Tb blir sjuka. En latent Tb kan dock aktiveras av diabetes, immunsuppression, cytostatika, rökning.

Symtom: Långvarig hosta (ibland med sputum/blod), nattsvettningar, avmagring, subfebrilitet, svullna lymfkörtlar. Bröstsmärta. Man kan även få Tb i rygg, skelett, hjärna, buk, med symtom därifrån.

Anamnes: Var ifrån kommer du, var varit, immunsupprimering, sjukdomar, rökning, B-symtom, produktiv hosta, någon annan sjuk, någon annan med Tb?

Status: Lungor: Lyssna framtill (lungapex sitter där), candida i mun, lgll, avmagring?

Utredning: Sputumprover x 3(BAL om ej får tag i sputum) där man tar för odling, mikroskopi, PCR. Negativ PCR utesluter ej tb!

PPD

- kan göras för riskpersoner utan symtom, men denna skiljer ej på vaccinering och infektion. Blir även falskt negativ vid immunsupprimering el spridd Tb.

Quantiferontest

- som PPD fast i blod. Quantiferon ger ej utslag vid vaccinering. PPD/quantiferon skiljer dock ej på latent och aktiv Tb.

HIV

-test - alltid vid misstänkt Tb, dessa går ihop!!

Lungröntgen

- visar infiltrat, kaverner apikalt, svullna lgll intratorakalt, ffa hilärt.

Lymfkörtkelpunktion

- Odling, PCR, mikroskopi, PDA (cancer).

Behandling: Lång! 6 mån. 12 vid CNSengagemang. IPRE. Isoniazid, pyrazinamid, rifampicin, etambutol första två mån, endast rifampicin och isoniazid efter 2 mån. Resistensbestäm.

Info vid behandling: Röd urin är en biverkan. Rifampicin kan interagera med waran, b-block m.m.

Smittsamhet: Vid sputumpositiv Tb (där man ser Tb i mikroskop) är det hög smittsamhet. Även vid sputumneg finns smittrisk. Latent Tb smittar EJ. Barn smittar EJ.

Smittskyddsåtgärder: Isolera! Ha på dig tspeciell tb-mask. Smittskyddsnamäl, informera pat om att han är skyldig att behandlas, och att isoleras, och har rätt till konstandsfri undersökning och behandling. Fråga anhöriga om symtom, gör lungrötngen på dem om symtom, annars PPD på dem.

Uppföljning: Efter 6 mån. Lungröntgen + kliniskt. SR, Hb, ASAT, ALAT, (läkemedlen levertoxisk) synundersökning (etambutol kan ge blindhet)

Vaccin: levande vaccin. Skyddar främst barn. Får ej ges till immunsupprimerade.

Profylax: Isoniazid till utsatta.

Miliär tb: Alltid lungengagemang, prickigt på rtg. PPD ibland falskt neg,

Tbc-meningit: Beh 12 mån + kortison. LP med mono, men laktat. Risk för hydrocephalis.

CMV

En gång infekterad, har man viruset latent! Kan reaktiveras av graviditet, sjukdom, läkemede.

Smitta: Kyssar, Sex, blodtransfusion, fekooralt, vertikalt. Småbarn smittar mkt!!

En kvinna som får CMV under grav för över CMV i 50% av fallen. En kvinna som får en gammal CMV reaktiverad under graviditeten har inte lika stor risk.

Risk: Immunsupp.

Symtom: Ofta asymp hos immunkompetenta. Annars svullna lgll, subfebrilitet, hepatitsymtom. Hos immunsupp: Pneumoni, hepatit, gastro, encefalit, Retinit.

Utred: Serologi med igG o igM.

Behandling: Ingen för immunkompetenta. gancyklovir för immunbristade. Ingen behandling finns för att minska risken under graviditet att överföra, däremot kan barnet få behandling när det fötts.

Komplikationer hos barnet: Hörsel-, synnedsättningar.

Bältros

Måste haft vattkoppor innan.

Symtom: Feber, allmänsymtom. Ensidigt bälte av blåsor.

Utred: Klinisk diagnos. HIV-test.

Beh: Valacyklovir om <72h efter blåsuppkomst.

Sork

- anmälspliktg!

Puumalavirus.

I norr! Sprids luftburet, inandas damm från sork.

Anamnes: Jägare, städat uthuset, sommarstugan.

Symtom: Influensalikt, hematuri, proteinuri, dimsyn, näsblod, annan blödning, mindre urin initialt, hosta, mycket urin i slutfasen. Ryggsmärta, bukont. Feberà hypotensionà Anurià oliguri. Dunkömhet. Petekier i gom, hud.

Lab: TPK låg, ALAT/ASAT hög. Krea hög, Crp ok. Urinsticka.

Utred: Serologi, IgM mot Puumalavirus.

Beh: Symtomatisk

Uppfölj: Njurvärde

Immunitet: Genomgången infektion nger immunitet.

Tularemi

Feber, körtel, svårläkt sår, skogsanamnes. Immunitet av genomgången inf.

Utred: Sår-PCR, serologi. Beh: Ciprofloxacin.

TBE

Anamnes: Fästingområde? Vaccinerad? Bifasiskt insjukn?

Inkub: 1v-1mån

Symtom: Influensaliknande, ev diarre à bättre à hög feber och CNS-påverkan. (Huvudvärk, konfusion, balans, pares, ataxi, medvpåverkan)

Utredning: LP (viral bild), serum-IgM

Behandling: Symtomatisk

Komplikationer: 40% får kvarstående problem; kognitiva problem, koncentration, minne, ataxi, tremor.

Vaccin: Ja. Encepur el FSME.

Vaccinsvikt: Händer. Ofta falskt neg IgM. Skicka då till SMI. Ta sen nytt igM efter 2-4 v.

Bullös impetigo - heracillin po 1000 mg x 3, 1v

Kondylom - pdofyllotixin kräm 2 ggr i 3 dar

Klamydia - doxyferm 200 mg sen 100 mg dag 2-9. Smittspåra, smittskyddsnmäl, uppf 4 v

Klamydia + grav - amoxicillin 500 mg x 3 i 7 dagar

Rosacea - metronidazol kräm el azelainsyragel. Flera månader. Ev limecyklin po

Mollusk - emma-kräm o skrap

Skabb - tenutex i ett dygn, kutan emulsion.

Herpes zoster - valacivlocir 1g x 3 i 7 dar

DLE - steroider 3, ev protopic

Eryspielas - inlägg, bensylpc 1-3 g tills feberfri + 1 dag. Sen 2 v po

Intertrig - kalibad v vätska. Kortimyk, ev pevisone (är 2a)

Pyoderma gangrenosum - tnfa-hämmare. Vilken komorb? IBD.

Borrelia - kåvepenin, 1gx3 10 dagar

Atopi vuxna - 2-kräm, locobase. Ev Uvab

Sek inf eksem - odling o svamp. Vid s aurues heracillin 10 dagar.

Lichen - grupp 3 kräm. Protopicgel i mun. Ev po steroider. Ev uvb.

Follikulit - heracillin 10 dar

Anafylaxi - adrenalin 1mg/ml 0,5 ml. Solucort 200 mg. tavegyl 2 m.

Tinea cruris - cortimyk

Tinea pedis - terbinafingel i gång i en vecka

Tinea capitis - terbinafin po för vuxna

Pityryasis versicolor - ketokonazolschampo el ketkonazol po

Seb eksem - cortimyik (gr 1) i feja o ketokonazolschampoo (hår) + betnovatlösning (hår)

Pso - daviboet kräm kropp o daivobetgel huve. Först ev avfjälla me salicylsyra. Ev uvb el puva

Derm herpetiformis - Dapsone po.

Erythema multforme - prednisolon po. Två orsaker: inf o lm.

Pustolosis palmoplantaris - 3kräm el daivobet

 

Terbinafin - gel

1 g¨ång i en vecka. Fötter ben.

Tinea - kräm: 1 gång i en vecka. PO: alltid 2-4 v. pedis kan vara upp till 6v.

 

 


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