{ "fever_of_unknown_origin": { "syndrome_name": "Fever of Unknown Origin (FUO)", "definition": "Fever >38.3\u00b0C for more than 3 weeks with no identified cause after 3 outpatient visits or 3 days in the hospital.", "common_consult_questions": [ { "question": "What is the appropriate workup for FUO in this patient?", "required_information": [ "Duration and pattern of fever (intermittent, relapsing, continuous)?", "Presence of localizing symptoms (pain, cough, diarrhea, rash)?", "Basic labs: CBC, ESR/CRP, LFTs, UA, CXR results", "Imaging already performed (CT abdomen/pelvis, echocardiogram)?", "Exposure history: travel, animals, medications, recent procedures?" ] }, { "question": "Could this be an infectious cause of FUO, and how should I narrow the differential?", "required_information": [ "Any risk factors for TB, endocarditis, or occult abscess?", "Immunocompromised state (transplant, chemo, HIV)?", "History of indwelling hardware, prosthetics, catheters?", "Pattern of fevers (e.g., evening spikes)?", "Previous blood cultures, imaging, and serologic testing?" ] }, { "question": "Is empiric antibiotic therapy appropriate in this case of FUO?", "required_information": [ "Hemodynamic stability and severity of illness?", "Evidence of neutropenia or immunosuppression?", "Risk of missing a treatable bacterial infection (e.g., endocarditis)?", "Any signs of localized infection pending further diagnostics?", "Whether antibiotics were already initiated (and response)?" ] }, { "question": "What are the next steps when the initial infectious workup is negative?", "required_information": [ "Whether malignancy or autoimmune processes have been considered?", "Results of ANA, RF, SPEP/UPEP, LDH, ferritin, etc.", "Travel and social history (e.g., TB exposure, brucellosis, strongyloides)", "Occupational exposure or animal contacts", "Review of prior imaging for subtle findings (e.g., occult abscess, sinusitis)" ] }, { "question": "When should I involve other specialties or repeat diagnostics?", "required_information": [ "Timeline of workup and how long fever has persisted", "Previous specialty consults and their findings (e.g., rheum, heme/onc)", "Whether repeat imaging (e.g., PET-CT) has been considered", "Whether patient is deteriorating or remaining stable", "If biopsy of lymph node, liver, or bone marrow is warranted" ] } ] }, "sepsis_source_unclear": { "syndrome_name": "Sepsis \u2013 Source Unclear", "definition": "Life-threatening organ dysfunction caused by a dysregulated host response to infection, where the infectious source is not yet identified.", "common_consult_questions": [ { "question": "What is the most likely source of sepsis in this patient?", "required_information": [ "Complete review of systems and physical exam findings", "Vital signs and organ dysfunction patterns (e.g., AKI, hypotension, AMS)", "Recent procedures or surgeries", "Presence of catheters, drains, or prosthetic devices", "Initial labs (CBC, lactate, creatinine, LFTs) and imaging" ] }, { "question": "What additional diagnostic tests are needed to localize the infection?", "required_information": [ "Blood culture results and timing of collection", "Chest X-ray, urinalysis, abdominal/pelvic CT, echocardiogram if done", "Prior colonization with multidrug-resistant organisms", "Whether advanced imaging (PET-CT, tagged WBC scan) has been considered", "Immune status of the patient (e.g., neutropenia, HIV, biologics)" ] }, { "question": "Are the current empiric antibiotics appropriate? Should they be escalated or de-escalated?", "required_information": [ "Current antimicrobial regimen and duration", "Local antibiogram and known colonization/resistance patterns", "Renal and hepatic function", "Clinical stability or deterioration", "Culture data from any site (if available)" ] }, { "question": "When should we consider source control, and what options are there?", "required_information": [ "Suspected anatomical source (e.g., abscess, infected hardware)", "Imaging findings indicating fluid collections or obstruction", "Presence of indwelling devices (lines, ports, prosthetics)", "Interventional radiology/surgical feasibility and patient risk profile", "Whether prior source control attempts were made" ] }, { "question": "Is this truly sepsis or could this be a non-infectious mimic?", "required_information": [ "Timeline of symptoms and fevers", "Laboratory and culture results (lack of pathogen recovery)", "Exposure to medications or autoimmune diseases", "Consideration of malignancy, adrenal crisis, or vasculitis", "History of similar episodes in the past" ] } ], "key_references": [ { "title": "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021", "url": "https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients/2021" }, { "title": "Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016.", "url": "https://jamanetwork.com/journals/jama/fullarticle/2492881" } ] }, "bacteremia_without_source": { "syndrome_name": "Bacteremia Without a Clear Source", "definition": "Presence of bacteria in the bloodstream without an immediately apparent focus of infection, based on history, exam, and initial workup.", "common_consult_questions": [ { "question": "Is this a contaminant or true bacteremia?", "required_information": [ "Organism identified and number of positive bottles/sets", "Time to positivity (e.g., <24h vs >48h)", "Patient symptoms and signs (fever, hypotension, rigors)", "Presence of central lines or foreign bodies", "Prior blood culture history" ] }, { "question": "What is the likely source of this bacteremia?", "required_information": [ "Full review of systems and physical exam", "Imaging (CXR, abdominal US/CT, echo)", "Presence of prosthetic valves, joints, catheters", "Prior recent procedures or hospitalizations", "Urinalysis, chest imaging, and GI workup if relevant" ] }, { "question": "How should this be managed: empiric treatment, duration, and follow-up?", "required_information": [ "Severity of illness and comorbidities", "Organism susceptibilities (if available)", "Source control status", "Clearance of bacteremia (repeat cultures)", "Patient immune status and disposition plan" ] }, { "question": "Is this bacteremia complicated or uncomplicated?", "required_information": [ "Persistent fever or repeat positive blood cultures", "Imaging evidence of deep infection (e.g., endocarditis, abscess)", "Presence of hardware or vascular grafts", "Response to initial antibiotics", "History of previous similar episodes" ] }, { "question": "Should we pursue an echocardiogram or other deep source imaging?", "required_information": [ "Type of organism (e.g., S. aureus, Enterococcus, Candida, HACEK)", "Cardiac murmur or valve disease", "Any indwelling hardware or prosthetic valve", "Immunocompromised status or injection drug use", "Hemodynamic instability" ] } ], "key_references": [ { "title": "IDSA Guidelines for Management of Bloodstream Infections", "url": "https://www.idsociety.org/practice-guideline/bloodstream-infections/" }, { "title": "Clinical Practice Guidelines for the Management of MRSA Bacteremia", "url": "https://doi.org/10.1093/cid/cir452" } ] }, "mrsa_bacteremia": { "syndrome_name": "MRSA Bacteremia", "definition": "Presence of methicillin-resistant Staphylococcus aureus in the bloodstream, requiring aggressive management due to high risk of complications and mortality.", "common_consult_questions": [ { "question": "What is the appropriate antibiotic regimen for MRSA bacteremia in this patient?", "required_information": [ "Vancomycin MIC and trough levels (or AUC if available)", "Patient\u2019s renal function and allergy history", "Prior MRSA isolates and susceptibilities", "Severity of illness (e.g., ICU, hypotension)", "Line access or tissue penetration concerns" ] }, { "question": "Is this a complicated or uncomplicated MRSA bacteremia?", "required_information": [ "Persistent bacteremia >48\u201372 hours", "Presence of prosthetic material or foreign body", "Imaging evidence of metastatic infection (e.g., abscess, osteomyelitis, endocarditis)", "Clinical response to antibiotics", "Risk factors (e.g., IVDU, immunosuppression)" ] }, { "question": "When and how should follow-up blood cultures be obtained?", "required_information": [ "Date/time of initial positive cultures", "Whether blood cultures have been repeated post-therapy initiation", "Ongoing fever or clinical instability", "Catheter/device status (removed or not)", "Plan for transition to oral or step-down therapy" ] }, { "question": "Is echocardiography indicated in this case? If so, which type?", "required_information": [ "Presence of cardiac murmur or prosthetic valve", "Injection drug use or history of endocarditis", "Persistent bacteremia or embolic phenomena", "Transthoracic echo results (if already performed)", "Feasibility and timing of TEE" ] }, { "question": "What is the optimal duration of therapy and discharge plan?", "required_information": [ "Whether source has been controlled and bacteremia cleared", "Complications identified (e.g., osteomyelitis, endocarditis, epidural abscess)", "Candidate for outpatient parenteral antibiotic therapy (OPAT)?", "Home support and monitoring capabilities", "Any indications for chronic suppressive therapy" ] } ], "key_references": [ { "title": "Clinical Practice Guidelines for the Management of MRSA Bacteremia (Clin Infect Dis 2011)", "url": "https://doi.org/10.1093/cid/cir452" }, { "title": "Vancomycin AUC-based Dosing Guidelines (ASHP/IDSA/SIDP 2020)", "url": "https://www.idsociety.org/practice-guideline/vancomycin/" } ] }, "recurrent_bacteremia": { "syndrome_name": "Recurrent Bacteremia", "definition": "Repeat episodes of bloodstream infection with the same or different organism, occurring after documented clearance or clinical resolution of a prior bacteremia.", "common_consult_questions": [ { "question": "Is this a relapse or a reinfection with a new organism?", "required_information": [ "Time between episodes and whether prior bacteremia fully cleared", "Same organism and susceptibility pattern as prior?", "Prior antibiotic course: duration, adherence, and efficacy", "Presence of residual infected foci (e.g., endovascular or bone involvement)", "Immune status and presence of indwelling hardware" ] }, { "question": "What is the underlying source driving these recurrent bacteremias?", "required_information": [ "Any unaddressed source (e.g., abscess, infected prosthetic material, endocarditis)", "Whether previous source control efforts were adequate", "History of recurrent UTIs, skin infections, or IVDU", "Imaging studies: CT, PET-CT, echo, MRI (e.g., spine, joints)", "Pattern of recurrence (e.g., same site vs different sites)" ] }, { "question": "What additional diagnostics are needed to prevent further recurrence?", "required_information": [ "Serial blood cultures and microbiology trend data", "Previous imaging reviewed for missed infection", "Repeat TEE, spine imaging, or tagged WBC scan considered?", "Serologic or fungal/NTM workup if appropriate", "Host workup for immunodeficiency or neutropenia" ] }, { "question": "Should we remove or replace devices, lines, or hardware?", "required_information": [ "Presence of ports, dialysis catheters, orthopedic hardware, or grafts", "Whether line tips or hardware were cultured previously", "Feasibility and surgical risk of removal", "Device dependence and alternatives (e.g., alternate access)", "Any documentation of biofilm-forming organisms" ] }, { "question": "What is the long-term management plan: suppressive therapy, prophylaxis, or surgery?", "required_information": [ "Chronic suppressive therapy previously attempted?", "Infection risk factors not modifiable?", "Frequency and severity of episodes", "Patient adherence and outpatient follow-up capacity", "Input from surgical teams on source control" ] } ], "key_references": [ { "title": "IDSA Guidelines for Bloodstream Infections", "url": "https://www.idsociety.org/practice-guideline/bloodstream-infections/" }, { "title": "Chambers HF et al. Managing Persistent and Recurrent Staph aureus Bacteremia. NEJM 2009", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra0804625" } ] }, "neutropenic_fever": { "syndrome_name": "Neutropenic Fever", "definition": "Single oral temperature \u226538.3\u00b0C or sustained temperature \u226538.0\u00b0C for over 1 hour in a patient with absolute neutrophil count (ANC) <500 cells/\u00b5L or expected to fall below that threshold imminently.", "common_consult_questions": [ { "question": "What is the appropriate empiric antibiotic regimen for this neutropenic patient?", "required_information": [ "Absolute neutrophil count (ANC) and duration of neutropenia", "Current signs of sepsis or clinical instability", "Known colonization with resistant organisms (e.g., ESBL, VRE)", "Presence of central lines, mucositis, or known sites of infection", "Allergies or prior antibiotic exposure" ] }, { "question": "Does this patient meet criteria for high-risk neutropenic fever (requiring inpatient IV therapy)?", "required_information": [ "Hemodynamic status and signs of organ dysfunction", "Expected duration of neutropenia (e.g., <7 days vs >7 days)", "Comorbidities or evidence of hepatic/renal insufficiency", "Performance status and presence of active malignancy", "MASCC score (if available)" ] }, { "question": "Should antifungal therapy be initiated, and when?", "required_information": [ "Duration of fever despite broad-spectrum antibiotics (typically >4\u20137 days)", "History of fungal infections or antifungal prophylaxis", "Recent imaging (CT chest/sinuses/abdomen) for occult fungal sources", "Symptoms like sinus tenderness, pulmonary nodules, GI ulcers", "Neutropenia severity and duration" ] }, { "question": "What is the appropriate workup to identify the source of infection?", "required_information": [ "Blood cultures from all lumens and peripheral draw", "Urinalysis and urine culture", "Chest imaging and focused CTs if symptoms suggest localized infection", "Skin, mucosa, and perianal exam findings", "Labs (LFTs, LDH, galactomannan, \u03b2-D-glucan if fungal suspicion)" ] }, { "question": "When can antibiotics be de-escalated or discontinued?", "required_information": [ "Clinical response (defervescence, symptom resolution)", "Blood culture results and timing", "Recovery of neutrophil count", "Source identified and controlled", "Duration of fever and any subsequent complications" ] }, { "question": "What are the options for antifungal prophylaxis and when is it indicated?", "required_information": [ "Duration and depth of anticipated neutropenia (<500 cells/\u03bcL for >7 days)", "History of prior fungal infections or colonization", "Underlying malignancy and chemotherapy regimen (AML, allo-HSCT)", "Current mold-active prophylaxis (e.g., posaconazole, voriconazole, isavuconazole)", "Tolerance, drug interactions, and ability to monitor levels (TDM)" ] }, { "question": "How should persistent fever despite broad-spectrum antibiotics be approached?", "required_information": [ "Duration of neutropenic fever (>4\u20137 days) without identified source", "Recent imaging (CT sinuses, chest, abdomen) to rule out occult infection", "Serum and BAL galactomannan, \u03b2-D-glucan assays", "Consideration of empiric antifungal therapy (liposomal amphotericin B or echinocandin)", "Evaluation for mucositis, catheter infections, or fungal sinusitis" ] } ], "key_references": [ { "title": "IDSA Clinical Practice Guideline for Management of Neutropenic Fever in Cancer Patients (2011)", "url": "https://www.idsociety.org/practice-guideline/fever-and-neutropenia/" }, { "title": "Freifeld AG et al. Clinical Infectious Diseases. 2011;52(4):e56-e93.", "url": "https://doi.org/10.1093/cid/cir073" } ] }, "postoperative_fever": { "syndrome_name": "Post-operative Fever", "definition": "Elevated temperature occurring after a surgical procedure, typically within the first 30 days, requiring differentiation between infectious and non-infectious causes.", "common_consult_questions": [ { "question": "Is this fever due to an infection or a non-infectious cause?", "required_information": [ "Timing of fever onset in relation to surgery (e.g., POD 0\u20131 vs POD 4\u20135)", "Surgical procedure type and site", "Clinical signs: localized erythema, drainage, new pain", "Medications (e.g., transfusions, drug reactions)", "Use of foreign material (implants, drains, prosthetics)" ] }, { "question": "What is the most likely infectious source of post-op fever?", "required_information": [ "Incision site findings (e.g., dehiscence, erythema, drainage)", "Presence of indwelling devices (e.g., catheters, central lines)", "Respiratory status: new infiltrates on imaging, intubation history", "Urinary catheter duration and urinalysis findings", "Culture data (blood, urine, wound)" ] }, { "question": "What diagnostics are needed to confirm or rule out infection?", "required_information": [ "Wound exam and cultures (if drainage present)", "Blood cultures x2 from different sites", "CXR or chest CT (for respiratory symptoms)", "Urinalysis and urine culture (esp. if catheterized)", "Cross-sectional imaging (CT abdomen/pelvis) if intra-abdominal source suspected" ] }, { "question": "Should empiric antibiotics be started? If so, which ones?", "required_information": [ "Clinical status: hemodynamics, labs (WBC, lactate)", "Suspected source and likely organisms", "Allergy history and antibiotic exposure", "Facility antibiogram and local resistance patterns", "Culture collection before antibiotic administration" ] }, { "question": "When can empiric antibiotics be stopped or narrowed?", "required_information": [ "Results of cultures and imaging studies", "Resolution of symptoms or signs", "Defervescence and clinical improvement", "No evidence of ongoing infection or source found", "Risk of C. difficile or other antibiotic complications" ] } ], "key_references": [ { "title": "Surgical Site Infection Guidelines (CDC)", "url": "https://www.cdc.gov/infectioncontrol/guidelines/ssi/" }, { "title": "IDSA Guidelines on Skin and Soft Tissue Infections", "url": "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/" }, { "title": "IDSA Guidelines on Intra-abdominal Infections", "url": "https://www.idsociety.org/practice-guideline/intra-abdominal-infections/" } ] }, "tuberculosis": { "syndrome_name": "Tuberculosis (Pulmonary and Latent)", "definition": "Infection caused by Mycobacterium tuberculosis, presenting as active pulmonary TB, extrapulmonary TB, or latent TB infection (LTBI) with risk of reactivation.", "common_consult_questions": [ { "question": "Does this patient have active pulmonary TB?", "required_information": [ "Symptoms: chronic cough, weight loss, fever, night sweats, hemoptysis", "Chest imaging findings (e.g., upper lobe infiltrates, cavitary lesions)", "Sputum AFB smear and NAAT results", "TB exposure history, travel or origin from endemic area", "Immunocompromised status (e.g., HIV, transplant, biologics)" ] }, { "question": "How should an indeterminate or discordant TB test (TST/IGRA) be interpreted?", "required_information": [ "Test type (TST vs QuantiFERON vs T-SPOT) and timing", "Immune status (e.g., lymphopenia, steroid use, HIV)", "BCG vaccination history", "TB exposure risk and pretest probability", "Repetition of test or alternate testing available?" ] }, { "question": "What is the best approach to treating latent TB infection (LTBI)?", "required_information": [ "TB test positivity and radiographic findings", "Prior treatment history for TB or LTBI", "Risk of progression (e.g., immunosuppressed, young age, close contact)", "Liver function and medication contraindications", "Preferred regimen based on adherence potential (e.g., INH x9mo vs 3HP)" ] }, { "question": "Is respiratory isolation required and when can it be discontinued?", "required_information": [ "Symptoms and radiographic suspicion of pulmonary TB", "Number and timing of sputum AFB smears collected", "NAAT results (e.g., Xpert MTB/RIF)", "Whether the patient has received appropriate treatment and for how long", "Risk of nosocomial transmission (e.g., cough strength, aerosol-generating procedures)" ] }, { "question": "What public health actions are required for this TB case?", "required_information": [ "Whether case has been reported to the health department", "Close contacts identified and screened?", "Drug susceptibility testing results (for contact prophylaxis)", "Need for directly observed therapy (DOT)", "Documentation of treatment completion and follow-up plans" ] } ], "key_references": [ { "title": "CDC TB Guidelines \u2013 Core Curriculum and LTBI Treatment", "url": "https://www.cdc.gov/tb/publications/corecurr/default.htm" }, { "title": "CDC LTBI Treatment Guidance", "url": "https://www.cdc.gov/tb/topic/treatment/ltbi.htm" }, { "title": "IDSA/ATS/CDC Guidelines on TB Treatment (2020)", "url": "https://www.idsociety.org/practice-guideline/tuberculosis/" } ] }, "infective_endocarditis": { "syndrome_name": "Infective Endocarditis", "definition": "Infection of the endocardial surface of the heart, typically involving a native or prosthetic valve or cardiac device, caused by bloodstream pathogens such as Staphylococcus aureus, Streptococcus, or Enterococcus.", "common_consult_questions": [ { "question": "Does this patient meet diagnostic criteria for infective endocarditis?", "required_information": [ "Blood culture results (number of positive sets, organism, timing)", "Echocardiogram findings (TTE and/or TEE)", "Duke criteria elements: vascular and immunologic phenomena", "Risk factors: IVDU, prosthetic valves, known murmur, recent procedures", "Signs: fever, new murmur, embolic events (e.g., stroke, splenic infarct)" ] }, { "question": "What is the optimal antibiotic regimen and duration for this patient?", "required_information": [ "Causative organism and susceptibility profile", "Type of valve: native, prosthetic, or device-associated", "Complications: heart failure, conduction abnormalities, abscess", "Route and timing of prior antibiotics", "Renal function, allergies, or drug interactions" ] }, { "question": "Should a transesophageal echocardiogram (TEE) be done or repeated?", "required_information": [ "Indications for TEE (prosthetic valve, poor TTE windows, persistent bacteremia)", "Initial TTE results and image quality", "Organism type (e.g., Staph aureus, Enterococcus, Candida)", "Ongoing fever or concern for intracardiac complications", "Timing of initial vs proposed follow-up TEE" ] }, { "question": "When should surgery be considered in infective endocarditis?", "required_information": [ "Signs of heart failure or severe valve dysfunction", "Size and mobility of vegetations (>10 mm, embolic risk)", "Recurrent embolization despite therapy", "Paravalvular abscess or prosthetic dehiscence on echo", "Persistent bacteremia >5\u20137 days despite appropriate antibiotics" ] }, { "question": "What are the long-term follow-up and secondary prophylaxis recommendations?", "required_information": [ "Completion of therapy and documentation of clearance", "Valve function on repeat echocardiogram", "Education on oral hygiene, IVDU cessation, and signs of recurrence", "Prophylaxis needs for future dental/surgical procedures", "Coordination with cardiology and/or cardiac surgery" ] } ], "key_references": [ { "title": "IDSA/AHA Guidelines for Infective Endocarditis (2015)", "url": "https://www.idsociety.org/practice-guideline/endocarditis/" }, { "title": "Durack DT et al. Modified Duke Criteria. Am J Med. 1994.", "url": "https://doi.org/10.1016/0002-9343(94)90341-7" } ] }, "clostridioides_difficile_infection": { "syndrome_name": "Clostridioides difficile Infection (CDI)", "definition": "Diarrhea caused by Clostridioides difficile toxin production, typically after recent antibiotic exposure, leading to inflammation of the colon and varying degrees of severity.", "common_consult_questions": [ { "question": "Does this patient meet clinical criteria for C. difficile testing?", "required_information": [ "Presence of \u22653 unformed stools in 24 hours", "Recent antibiotic use (within past 12 weeks)", "Hospitalization or healthcare exposure", "Other causes of diarrhea ruled out (e.g., laxatives, tube feeds)", "History of prior CDI" ] }, { "question": "How should we interpret a positive test result?", "required_information": [ "Test method used (e.g., NAAT, EIA for toxin, GDH)", "Symptoms consistent with active infection?", "Known colonization vs true infection?", "Immunosuppressive status or IBD (which may complicate picture)", "Whether patient had recent negative test or multiple tests" ] }, { "question": "What is the optimal treatment regimen for this episode?", "required_information": [ "Severity markers: WBC \u226515,000, creatinine \u22651.5x baseline, hypotension", "Previous episodes and treatment response", "Inpatient vs outpatient setting", "Ability to take oral medications", "Risk factors for fulminant disease (e.g., ileus, megacolon, ICU)" ] }, { "question": "When should we escalate treatment to include surgery or fecal microbiota transplant (FMT)?", "required_information": [ "Clinical signs of severe or fulminant CDI (shock, ileus, megacolon)", "Response to oral vancomycin and IV metronidazole", "CT scan findings of pancolitis or toxic megacolon", "Rising lactate, WBC, or creatinine", "Number of recurrences and severity of prior courses" ] }, { "question": "How do we prevent recurrence and reduce future risk?", "required_information": [ "Number and timing of prior CDI episodes", "Exposure to antibiotics or proton pump inhibitors (PPIs)", "Probiotic use and data (if relevant)", "Consideration for bezlotoxumab or FMT", "Infection control measures and hand hygiene adherence" ] }, { "question": "How should recurrent C. difficile infection (rCDI) be managed?", "required_information": [ "Number and timing of previous CDI episodes", "Previous treatments used (e.g., vancomycin, fidaxomicin, FMT)", "Response and duration of symptom-free interval", "Risk factors for recurrence: age >65, immunosuppression, prior CDI, PPI use", "Options considered: vancomycin taper, fidaxomicin, bezlotoxumab, FMT" ] }, { "question": "When is fecal microbiota transplant (FMT) appropriate?", "required_information": [ "Number of CDI recurrences despite standard therapy", "Patient eligibility and access to FMT provider", "Screening for contraindications (e.g., immunosuppression, severe colitis)", "Preferred route: capsule, colonoscopy, or enema", "Follow-up plan after FMT and need for retreatment" ] } ], "key_references": [ { "title": "IDSA/SHEA Guidelines for CDI (2017 + 2021 Update)", "url": "https://www.idsociety.org/practice-guideline/clostridium-difficile/" }, { "title": "McDonald LC et al., Clinical Practice Guidelines for CDI in Adults and Children. Clin Infect Dis. 2018;66:e1\u2013e48.", "url": "https://doi.org/10.1093/cid/cix1085" } ] }, "community_acquired_pneumonia": { "syndrome_name": "Community-Acquired Pneumonia (CAP)", "definition": "Pneumonia acquired outside of a healthcare setting, typically due to pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, viruses, or atypical organisms.", "common_consult_questions": [ { "question": "Does this patient meet criteria for community-acquired pneumonia, and how should severity be assessed?", "required_information": [ "Symptoms: cough, dyspnea, fever, chest pain, sputum", "Chest X-ray or CT findings confirming consolidation or infiltrates", "CURB-65 or PSI (Pneumonia Severity Index) score", "Comorbid conditions (e.g., CHF, COPD, malignancy)", "Risk factors for aspiration or atypical organisms" ] }, { "question": "What is the appropriate empiric antibiotic regimen for this patient?", "required_information": [ "Inpatient vs outpatient setting", "Allergy history and recent antibiotic use", "Risk factors for MRSA or Pseudomonas (e.g., prior infection, recent hospitalization)", "Local resistance patterns if available", "Renal and hepatic function" ] }, { "question": "Should we consider MRSA or Pseudomonas coverage?", "required_information": [ "Prior respiratory culture or colonization with MRSA/Pseudomonas", "Recent hospitalization or IV antibiotics in past 90 days", "Structural lung disease (e.g., bronchiectasis)", "Severity of pneumonia (ICU admission, mechanical ventilation)", "Rapid diagnostic testing results (e.g., MRSA PCR from nares)" ] }, { "question": "What is the optimal duration of therapy and criteria for switch to oral antibiotics?", "required_information": [ "Clinical response (afebrile, stable vitals, improved symptoms)", "Ability to tolerate oral intake", "No evidence of extrapulmonary complications", "Initial antibiotic response and culture results", "Risk of nonadherence or outpatient barriers" ] }, { "question": "When should we investigate alternative diagnoses or non-response to treatment?", "required_information": [ "Persistence of fever or hypoxia >72 hours after starting therapy", "Radiographic worsening or new infiltrates", "Risk factors for non-infectious mimics (e.g., PE, malignancy, ARDS)", "Consideration of unusual pathogens (e.g., TB, fungal, viral)", "Diagnostic workup completed (e.g., sputum, blood cultures, respiratory PCR)" ] } ], "key_references": [ { "title": "IDSA/ATS Guidelines for Community-Acquired Pneumonia in Adults (2019)", "url": "https://www.idsociety.org/practice-guideline/community-acquired-pneumonia-cap-in-adults/" }, { "title": "Metlay JP et al., Diagnosis and Treatment of Adults with CAP. Am J Respir Crit Care Med. 2019;200(7):e45\u2013e67.", "url": "https://doi.org/10.1164/rccm.201908-1581ST" } ] }, "hospital_acquired_pneumonia": { "syndrome_name": "Hospital-Acquired Pneumonia (HAP)", "definition": "Pneumonia occurring \u226548 hours after hospital admission, not present at time of admission, commonly caused by multidrug-resistant organisms including Pseudomonas aeruginosa, MRSA, and Enterobacterales.", "common_consult_questions": [ { "question": "Does this patient meet diagnostic criteria for HAP?", "required_information": [ "Timing of symptom onset in relation to admission (>48 hours)", "Clinical signs: new cough, sputum, fever, hypoxia, leukocytosis", "New or worsening infiltrate on chest imaging", "Rule out alternative causes (e.g., heart failure, atelectasis)", "Use of ventilator or non-invasive ventilation" ] }, { "question": "What is the appropriate empiric antibiotic regimen for HAP?", "required_information": [ "Risk factors for MDR organisms (e.g., prior antibiotics, ICU stay, structural lung disease)", "Local antibiogram and unit resistance patterns", "Renal/hepatic function, allergies", "Presence of septic shock or high mortality risk", "History of colonization with MRSA, Pseudomonas, ESBL" ] }, { "question": "How should cultures and diagnostics be obtained?", "required_information": [ "Sputum quality and gram stain results (if available)", "Timing and technique of respiratory sample (expectorated, BAL, tracheal aspirate)", "Blood cultures and respiratory viral PCR", "Procalcitonin, if used in your setting", "Prior microbiology and resistance history" ] }, { "question": "When should antibiotics be narrowed or discontinued?", "required_information": [ "Culture and susceptibility results", "Clinical response (defervescence, improving oxygenation)", "Procalcitonin trending if applicable", "Day 5\u20137 clinical reassessment and imaging if needed", "No evidence of new complications or empyema" ] }, { "question": "What is the optimal duration of therapy for HAP?", "required_information": [ "Clinical stability and response to therapy", "Organism identified and site of infection (e.g., cavitary lesion)", "Risk of recurrence or deep-seated infection", "Whether patient is immunocompromised", "Monitoring plan after antibiotic discontinuation" ] } ], "key_references": [ { "title": "IDSA/ATS Guidelines for HAP and VAP (2016)", "url": "https://www.idsociety.org/practice-guideline/hap-vap/" }, { "title": "Kalil AC et al., Clin Infect Dis. 2016;63(5):e61\u2013e111.", "url": "https://doi.org/10.1093/cid/ciw353" } ] }, "aspiration_pneumonia": { "syndrome_name": "Aspiration Pneumonia", "definition": "Pneumonia resulting from the inhalation of oropharyngeal or gastric contents, often in patients with impaired swallowing, altered consciousness, or underlying esophageal dysfunction.", "common_consult_questions": [ { "question": "Does this patient meet clinical and radiographic criteria for aspiration pneumonia?", "required_information": [ "Witnessed or suspected aspiration event", "Risk factors: altered mental status, dysphagia, neurologic disease, intoxication", "Imaging showing dependent lobe infiltrates (e.g., RLL in supine position)", "Symptoms: fever, cough, leukocytosis, foul-smelling sputum", "Exclude other etiologies (e.g., chemical pneumonitis, CAP)" ] }, { "question": "Should anaerobic coverage be included in the empiric regimen?", "required_information": [ "Presence of necrotizing pneumonia, abscess, or empyema", "Poor dentition or periodontal disease", "Clinical severity or ICU admission", "Regimen already selected (e.g., beta-lactam/beta-lactamase inhibitor)", "Local resistance data and recent culture history" ] }, { "question": "What diagnostics are needed to confirm aspiration pneumonia?", "required_information": [ "Chest X-ray and/or CT scan findings", "Sputum culture and Gram stain if available", "Blood cultures in moderate to severe cases", "Swallow evaluation or speech-language pathology assessment", "Bronchoscopy (if not improving or atypical presentation)" ] }, { "question": "What is the optimal duration and route of antibiotic therapy?", "required_information": [ "Clinical response after 48\u201372 hours", "Site of infection and radiographic resolution", "Tolerability of oral therapy and swallowing status", "Whether deep abscess or empyema is present", "Antibiotic susceptibility profile (if available)" ] }, { "question": "What preventive measures are needed to reduce recurrence risk?", "required_information": [ "Swallow study results and aspiration risk level", "Need for NPO status, thickened liquids, or PEG tube", "Dental hygiene and positioning strategies", "Avoidance of sedatives and other risk medications", "Multidisciplinary plan (e.g., neurology, rehab, speech therapy)" ] } ], "key_references": [ { "title": "IDSA Guidelines on Pneumonia (2019 CAP + 2016 HAP/VAP)", "url": "https://www.idsociety.org/practice-guideline/community-acquired-pneumonia-cap-in-adults/" }, { "title": "IDSA Guidelines on HAP/VAP", "url": "https://www.idsociety.org/practice-guideline/hap-vap/" }, { "title": "Mandell LA et al., Principles and Practice of Infectious Diseases, 9th ed.", "url": "https://www.elsevier.com/books/principles-and-practice-of-infectious-diseases/mandell/978-0-323-48255-4" } ] }, "necrotizing_pneumonia_lung_abscess": { "syndrome_name": "Necrotizing Pneumonia / Lung Abscess", "definition": "A severe form of pneumonia characterized by necrosis and cavitation of lung tissue, or a localized pulmonary suppuration forming an abscess, often due to anaerobes, Staph aureus, Klebsiella, or mixed flora.", "common_consult_questions": [ { "question": "Does this patient have necrotizing pneumonia or a lung abscess?", "required_information": [ "Imaging findings: cavitary lesion with air-fluid level, thick-walled cavity on CT", "Clinical course: persistent fevers, foul-smelling sputum, slow resolution", "Symptoms: productive cough, hemoptysis, weight loss", "History of aspiration risk or recent pneumonia", "Differentiation from TB, fungal infection, malignancy" ] }, { "question": "What is the best empiric antimicrobial regimen for this condition?", "required_information": [ "Risk factors for anaerobic or polymicrobial infection (e.g., aspiration, dental disease)", "Presence of MRSA risk (e.g., post-influenza pneumonia, IVDU)", "Prior antibiotic exposure or cultures", "Patient allergy history and renal function", "Potential need for broader gram-negative coverage (e.g., Klebsiella)" ] }, { "question": "Should we obtain a sample via bronchoscopy or other method?", "required_information": [ "Sputum quality and diagnostic yield", "Risk of bleeding or need for BAL", "Concern for unusual pathogens (e.g., NTM, fungi)", "Feasibility and safety of CT-guided aspiration", "Noninvasive options exhausted (sputum, blood, urine antigens)" ] }, { "question": "When is drainage or surgical intervention indicated?", "required_information": [ "Size and location of abscess (esp. >6 cm or multiloculated)", "Presence of pleural complications (e.g., empyema)", "Lack of improvement after 7\u201310 days of appropriate antibiotics", "Risk of rupture or hemorrhage", "Availability of IR or thoracic surgery" ] }, { "question": "What is the appropriate duration of therapy and monitoring plan?", "required_information": [ "Clinical response and radiographic improvement", "Culture and sensitivity data (if obtained)", "Tolerability of long-course oral therapy", "Risk of relapse or immunocompromised state", "Plan for repeat imaging and follow-up" ] } ], "key_references": [ { "title": "IDSA Guidelines on CAP and Anaerobic Coverage (2019)", "url": "https://www.idsociety.org/practice-guideline/community-acquired-pneumonia-cap-in-adults/" }, { "title": "Bartlett JG. Anaerobic Lung Infections. Clin Infect Dis. 1993;16(Suppl 4):S248\u201355.", "url": "https://doi.org/10.1093/clind/16.Supplement_4.S248" }, { "title": "Mandell LA et al. Principles and Practice of Infectious Diseases, 9th ed.", "url": "https://www.elsevier.com/books/principles-and-practice-of-infectious-diseases/mandell/978-0-323-48255-4" } ] }, "empyema_parapneumonic_effusion": { "syndrome_name": "Empyema / Parapneumonic Effusion", "definition": "Infection-related pleural effusion, ranging from uncomplicated parapneumonic effusion to complicated effusion and frank empyema (pus in pleural space), typically secondary to pneumonia.", "common_consult_questions": [ { "question": "How can we differentiate uncomplicated from complicated effusion or empyema?", "required_information": [ "Chest imaging (CXR, US, or CT) showing loculation or pleural thickening", "Thoracentesis results: fluid pH <7.2, glucose <60 mg/dL, LDH >1,000 IU/L", "Appearance of fluid (purulent, foul-smelling, or hemorrhagic)", "Gram stain or culture results from pleural fluid", "Clinical course (persistent fever, sepsis, or failure to improve)" ] }, { "question": "When should thoracentesis or chest tube placement be performed?", "required_information": [ "Size of effusion and symptoms (dyspnea, pleuritic pain)", "Presence of loculations or free-flowing fluid on ultrasound", "Risk of respiratory compromise or diagnostic uncertainty", "Empyema suspected (frank pus or positive culture)", "Patient stability and comorbid conditions" ] }, { "question": "What empiric antibiotics are appropriate for parapneumonic effusions or empyema?", "required_information": [ "Severity of illness and risk factors for resistant organisms", "Coverage for anaerobes (especially if aspiration or poor dentition)", "Prior respiratory cultures or recent antibiotics", "Local susceptibility data and facility guidelines", "Route and duration of therapy based on drainage status" ] }, { "question": "When should we consult interventional radiology or thoracic surgery?", "required_information": [ "Evidence of multiloculated effusion not responding to antibiotics", "Incomplete drainage with chest tube alone", "Persistent sepsis or respiratory failure", "Large or complex collections with thick rind on imaging", "Need for decortication or VATS" ] }, { "question": "How long should we continue antibiotics and what follow-up is needed?", "required_information": [ "Clinical response and radiologic improvement", "Duration and adequacy of drainage", "Organism identified and susceptibility profile", "Plan for follow-up imaging or repeat thoracentesis", "Resolution of leukocytosis and systemic signs" ] } ], "key_references": [ { "title": "IDSA Guidelines on Community-Acquired Pneumonia (2019)", "url": "https://www.idsociety.org/practice-guideline/community-acquired-pneumonia-cap-in-adults/" }, { "title": "Light RW. Pleural Diseases, 6th ed.", "url": "https://shop.lww.com/Pleural-Diseases/p/9781451148474" }, { "title": "ATS Consensus on Management of Parapneumonic Effusions", "url": "https://doi.org/10.1164/rccm.200711-1774ST" } ] }, "covid19_severe_high_risk": { "syndrome_name": "COVID-19 (Severe or High-Risk)", "definition": "COVID-19 due to SARS-CoV-2 infection in patients with severe disease (e.g., hypoxia, pulmonary infiltrates) or at high risk for complications due to age, comorbidities, or immunosuppression.", "common_consult_questions": [ { "question": "Does this patient meet criteria for severe COVID-19 requiring inpatient treatment?", "required_information": [ "Presence of dyspnea, hypoxia (SpO\u2082 <94% on room air), or respiratory rate >30", "Chest imaging showing bilateral infiltrates", "Risk factors: age >65, obesity, chronic lung/heart disease, cancer, immunocompromised", "Laboratory findings: lymphopenia, elevated CRP/D-dimer/ferritin", "Positive SARS-CoV-2 PCR or antigen test" ] }, { "question": "What is the appropriate antiviral or immunomodulatory treatment plan?", "required_information": [ "Timing of symptom onset (antivirals most effective early)", "Oxygen requirement and inflammatory marker levels", "Contraindications to remdesivir, dexamethasone, or baricitinib", "Use of other immunosuppressants or biologics", "Renal and hepatic function" ] }, { "question": "When should monoclonal antibodies or outpatient antivirals be considered for high-risk patients?", "required_information": [ "Symptom duration <5 days", "Positive test and mild/moderate symptoms", "Eligibility for outpatient therapies (e.g., nirmatrelvir/ritonavir, remdesivir, monoclonals)", "Drug-drug interactions (especially with ritonavir)", "Access to infusion or pharmacy services" ] }, { "question": "How do we manage coinfections or bacterial superinfections in COVID-19?", "required_information": [ "Worsening fever, leukocytosis, or infiltrates after initial improvement", "Sputum cultures, blood cultures, or procalcitonin trends", "Risk factors for multidrug-resistant organisms or aspiration", "Chest CT if not improving", "Hospital course and prior antibiotic exposure" ] }, { "question": "What isolation precautions and public health measures are needed?", "required_information": [ "Symptom onset and timeline for discontinuing isolation", "Testing strategy (e.g., test-based vs symptom-based clearance)", "Immunocompromised status (which may extend isolation needs)", "Setting of care (e.g., LTCF, dialysis center, home)", "Exposure tracing and vaccination status of close contacts" ] } ], "key_references": [ { "title": "NIH COVID-19 Treatment Guidelines", "url": "https://www.covid19treatmentguidelines.nih.gov/" }, { "title": "IDSA COVID-19 Guidelines", "url": "https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/" }, { "title": "CDC Isolation and Precautions for COVID-19", "url": "https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html" } ] }, "hiv_newly_diagnosed": { "syndrome_name": "HIV \u2013 Newly Diagnosed", "definition": "Identification of HIV infection in a previously undiagnosed individual, requiring prompt evaluation for staging, opportunistic infection (OI) screening, and antiretroviral therapy (ART) initiation.", "common_consult_questions": [ { "question": "What baseline labs and staging workup are required for this newly diagnosed HIV patient?", "required_information": [ "Confirmatory HIV testing (e.g., antigen/antibody + HIV-1/2 differentiation)", "HIV RNA (viral load), CD4 count, CD4/CD8 ratio", "CBC, CMP, LFTs, lipid panel", "Hepatitis A, B, C serologies", "TB screening (IGRA or TST), RPR, GC/CT, toxoplasma IgG" ] }, { "question": "When and how should ART be initiated in this patient?", "required_information": [ "Clinical status: symptoms, AIDS-defining illnesses, OI present?", "CD4 count and viral load", "Drug resistance testing and HLA-B*5701 (if considering abacavir)", "Comorbid conditions and renal/hepatic function", "Patient readiness, psychosocial context, and insurance access" ] }, { "question": "Does this patient need empiric prophylaxis for opportunistic infections?", "required_information": [ "CD4 count thresholds: <200 (PJP), <100 (toxoplasma), <50 (MAC)", "History of past infections or positive serologies", "Allergies to TMP-SMX or azithromycin", "TB status and symptom screen", "Risk of Strongyloides or other endemic infections (e.g., travel history)" ] }, { "question": "What are the next steps in counseling and partner services?", "required_information": [ "Disclosure status and support system", "Sexual history and partner exposure risk", "Plans for partner testing and PrEP linkage", "Substance use, mental health, and housing stability", "Education on transmission risk and U=U principles" ] }, { "question": "How should follow-up and linkage to care be coordinated?", "required_information": [ "ART plan and first dose timing", "Referral to HIV specialty care or Ryan White clinic", "Insurance coverage or ADAP enrollment", "Lab monitoring intervals and adherence support", "Patient contact information and follow-up method" ] } ], "key_references": [ { "title": "DHHS Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/whats-new-guidelines" }, { "title": "CDC HIV Testing and Prevention Resources", "url": "https://www.cdc.gov/hiv/guidelines/index.html" }, { "title": "IAS-USA Primary Care Guidelines for Persons with HIV", "url": "https://www.iasusa.org/guidelines/" } ] }, "hiv_with_opportunistic_infection": { "syndrome_name": "HIV with Opportunistic Infection (OI)", "definition": "An HIV-positive individual presenting with an opportunistic infection due to immunosuppression, commonly when CD4 <200 cells/\u00b5L. Common OIs include PJP, cryptococcal meningitis, MAC, CMV, and toxoplasmosis.", "common_consult_questions": [ { "question": "What is the most likely opportunistic infection in this patient based on presentation and CD4 count?", "required_information": [ "CD4 count and HIV viral load", "Clinical symptoms (e.g., dyspnea, altered mental status, fever, diarrhea, visual changes)", "Travel and exposure history", "Prior OI prophylaxis or history of previous infections", "Imaging and laboratory findings (e.g., chest CT, LP, brain MRI, stool or serum PCRs)" ] }, { "question": "What is the appropriate diagnostic workup to confirm or rule out an OI?", "required_information": [ "Blood cultures, CSF studies, antigen testing (e.g., cryptococcal, galactomannan)", "PCR or antigen testing for CMV, MAC, EBV, JC virus, etc.", "Imaging findings (e.g., ring-enhancing lesions, diffuse infiltrates)", "Pathogen-specific stains or biopsies (AFB, silver stain, India ink)", "Sputum DFA for PJP, BAL or tissue biopsy if needed" ] }, { "question": "How and when should antiretroviral therapy (ART) be started or adjusted?", "required_information": [ "Diagnosis and severity of the OI", "Risk of IRIS (e.g., cryptococcal meningitis, TB)", "Timing relative to OI treatment initiation", "Current ART status and resistance profile", "Organ function and potential drug-drug interactions" ] }, { "question": "What is the optimal treatment regimen and duration for the specific OI?", "required_information": [ "Confirmed or strongly suspected organism", "Drug susceptibilities or resistance patterns (if available)", "Renal/hepatic function and medication allergies", "Adherence risk and ability to follow prolonged therapy", "Criteria for secondary prophylaxis or chronic suppression" ] }, { "question": "How should this patient be monitored for treatment response or complications like IRIS?", "required_information": [ "Trends in clinical improvement (e.g., fever, mental status, oxygenation)", "Radiographic changes and lab trends (e.g., fungal antigen titers)", "ART initiation timing and immune reconstitution", "Early signs of paradoxical worsening (suggestive of IRIS)", "Coordination with ID, HIV primary care, and social work" ] } ], "key_references": [ { "title": "DHHS Guidelines on OI Management in Adults and Adolescents", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "CDC Opportunistic Infections Guidelines", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections.html" }, { "title": "IDSA Guidelines on PJP, Cryptococcus, MAC, and Toxoplasmosis", "url": "https://www.idsociety.org/practice-guideline/" } ] }, "cmv_disease_immunocompromised": { "syndrome_name": "CMV Disease in Immunocompromised Hosts", "definition": "Cytomegalovirus (CMV) reactivation or primary infection causing tissue-invasive disease or viremia in immunocompromised individuals (e.g., HIV with CD4 <50, transplant recipients, patients on chemotherapy or biologics).", "common_consult_questions": [ { "question": "Does this patient have CMV disease or asymptomatic viremia?", "required_information": [ "Symptoms: fever, malaise, diarrhea, visual changes, pulmonary or hepatic symptoms", "CMV viral load (PCR) and trend over time", "End-organ signs and abnormal labs (e.g., elevated LFTs, GI bleeding)", "Imaging or endoscopy findings (e.g., colitis, pneumonitis)", "Biopsy with histopathologic confirmation if available" ] }, { "question": "What additional workup is needed to confirm CMV end-organ disease?", "required_information": [ "CMV PCR from blood, CSF, BAL, or tissue-specific fluids", "Tissue biopsy with immunohistochemistry (owl\u2019s eye inclusions)", "Ophthalmologic exam if visual symptoms or CD4 <50", "Colonoscopy or EGD if GI symptoms", "Brain imaging and LP if CNS symptoms" ] }, { "question": "What is the appropriate antiviral treatment strategy?", "required_information": [ "Severity and site of disease (e.g., colitis vs retinitis vs pneumonitis)", "Renal function (for valganciclovir vs IV ganciclovir)", "Prior antiviral resistance or prophylaxis history", "Duration of planned therapy (usually 14\u201321 days minimum)", "Tolerability of oral therapy and GI absorption status" ] }, { "question": "When is preemptive monitoring vs treatment appropriate (e.g., transplant setting)?", "required_information": [ "Current immunosuppressive regimen and CMV risk level (e.g., D+/R\u2212)", "CMV viral load trajectory", "Institution-specific protocols for preemptive therapy", "Prior CMV episodes or prophylaxis interruptions", "Plans for reduction of immunosuppression" ] }, { "question": "How should secondary prophylaxis and follow-up monitoring be handled?", "required_information": [ "Response to initial therapy (symptom resolution, viral load decline)", "Duration of immunosuppression and transplant status", "ART initiation or immune recovery in HIV", "Neutropenia or myelosuppression risk with ganciclovir/valganciclovir", "Interval and modality of follow-up testing (PCR, labs, imaging)" ] } ], "key_references": [ { "title": "IDSA Guidelines for CMV in Solid Organ Transplant (2018)", "url": "https://www.idsociety.org/practice-guideline/cmv/" }, { "title": "DHHS HIV OI Guidelines (CMV Section)", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/cytomegalovirus-cmv-disease" }, { "title": "CDC CMV Resources for Immunocompromised Hosts", "url": "https://www.cdc.gov/cmv/clinical/index.html" } ] }, "toxoplasmosis_immunocompromised": { "syndrome_name": "Toxoplasmosis in HIV or Transplant Patients", "definition": "Reactivation or primary infection with Toxoplasma gondii causing CNS or systemic disease in immunocompromised individuals, especially HIV patients with CD4 <100 or transplant recipients.", "common_consult_questions": [ { "question": "Does this patient have CNS toxoplasmosis or another cause of neurologic symptoms?", "required_information": [ "CD4 count (<100), toxoplasma IgG status", "Neurologic symptoms: headache, confusion, seizures, focal deficits", "Brain MRI findings (multiple ring-enhancing lesions with edema)", "CSF studies and PCR (if LP safe)", "Exclusion of other causes (e.g., lymphoma, TB, PML)" ] }, { "question": "What diagnostic tests confirm toxoplasmosis in immunocompromised patients?", "required_information": [ "Serum toxoplasma IgG (positive indicates prior exposure)", "Brain imaging (MRI preferred over CT)", "CSF PCR for toxoplasma (limited sensitivity)", "Brain biopsy if diagnosis unclear or treatment failure", "Consider serologies in transplant donor/recipient mismatch" ] }, { "question": "What is the recommended treatment regimen and duration for toxoplasmosis?", "required_information": [ "TMP-SMX allergy? If so, consider pyrimethamine + sulfadiazine + leucovorin", "Renal and hepatic function for dosing", "Ability to tolerate oral therapy or need for IV", "Co-administration with ART or immunosuppressants", "Typical treatment: 6-week induction followed by chronic suppression" ] }, { "question": "When should ART or immunosuppression be adjusted during treatment?", "required_information": [ "ART-naive vs already on ART", "Risk of IRIS and timing of ART initiation in CNS infection (start 2\u20133 weeks after treatment start)", "Transplant immunosuppressive regimen and rejection risk", "Drug-drug interactions with pyrimethamine or sulfa drugs", "Immune recovery monitoring plan" ] }, { "question": "How long should secondary prophylaxis continue and when can it be discontinued?", "required_information": [ "CD4 recovery >200 for \u22656 months with suppressed viral load", "Tolerability of TMP-SMX or alternative agents", "Adherence reliability and access to follow-up", "Whether patient has completed full induction and consolidation", "Risk of recurrence or reactivation" ] } ], "key_references": [ { "title": "DHHS HIV OI Guidelines \u2013 Toxoplasma gondii", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/toxoplasma-gondii-encephalitis" }, { "title": "IDSA Transplant Infectious Disease Guidelines", "url": "https://www.idsociety.org/practice-guideline/" }, { "title": "CDC Toxoplasmosis Resources", "url": "https://www.cdc.gov/parasites/toxoplasmosis/health_professionals/index.html" } ] }, "cryptococcal_meningitis_hiv": { "syndrome_name": "Cryptococcal Meningitis in HIV", "definition": "Fungal meningoencephalitis caused by Cryptococcus neoformans or Cryptococcus gattii, typically occurring in patients with CD4 <100 cells/\u03bcL, presenting with subacute CNS symptoms.", "common_consult_questions": [ { "question": "Does this patient have cryptococcal meningitis?", "required_information": [ "Symptoms: headache, fever, neck stiffness, visual changes, altered mental status", "CD4 count <100 or known HIV infection", "Positive serum cryptococcal antigen (CrAg)", "CSF findings: opening pressure, CrAg, India ink, fungal culture, WBC count", "Brain imaging prior to LP (e.g., mass effect, hydrocephalus)" ] }, { "question": "What is the recommended induction therapy regimen?", "required_information": [ "Confirmation of cryptococcal diagnosis from CSF or serum", "Renal function (for amphotericin B and flucytosine dosing)", "Tolerability of oral vs IV therapy", "Availability of liposomal amphotericin vs deoxycholate", "Plan for 2-week induction followed by consolidation and maintenance phases" ] }, { "question": "How should elevated intracranial pressure (ICP) be managed?", "required_information": [ "CSF opening pressure on initial LP", "Neurologic symptoms (e.g., nausea, vision changes, confusion)", "Need for serial therapeutic LPs to reduce pressure", "Contraindications to repeated LP or need for lumbar drain", "Clinical signs of herniation or rapid deterioration" ] }, { "question": "When should ART be initiated in HIV patients with cryptococcal meningitis?", "required_information": [ "Current ART status and adherence history", "CD4 count and viral load", "Risk of IRIS (Immune Reconstitution Inflammatory Syndrome)", "Recommended delay of ART initiation: 4\u20136 weeks after starting antifungal treatment", "Coordination with HIV team for reinitiation plan" ] }, { "question": "What is the appropriate duration of therapy and secondary prophylaxis?", "required_information": [ "Completion of 2-week induction and response to therapy", "Tolerability and adherence to fluconazole consolidation and maintenance", "CD4 recovery and viral suppression on ART", "Monitoring for relapse or IRIS", "When to stop prophylaxis (CD4 >100 for \u22653 months on ART)" ] } ], "key_references": [ { "title": "DHHS HIV OI Guidelines \u2013 Cryptococcosis", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/cryptococcosis" }, { "title": "IDSA Guidelines for Management of Cryptococcal Disease (2010)", "url": "https://www.idsociety.org/practice-guideline/cryptococcal-disease/" }, { "title": "CDC Fungal Infections \u2013 Cryptococcus", "url": "https://www.cdc.gov/fungal/diseases/cryptococcosis/index.html" } ] }, "mac_advanced_hiv": { "syndrome_name": "Mycobacterium Avium Complex (MAC) in Advanced HIV", "definition": "Disseminated MAC infection primarily affecting patients with advanced HIV (CD4 <50 cells/\u03bcL), typically presenting with fever, weight loss, night sweats, and lymphadenopathy.", "common_consult_questions": [ { "question": "Does this patient have disseminated MAC or another opportunistic infection?", "required_information": [ "CD4 count <50 cells/\u03bcL", "Symptoms: fever, weight loss, diarrhea, abdominal pain, lymphadenopathy", "Blood cultures for AFB (multiple sets)", "Imaging findings (e.g., hepatosplenomegaly, lymphadenopathy)", "Stool or bone marrow AFB culture if available" ] }, { "question": "What is the appropriate diagnostic workup for MAC?", "required_information": [ "AFB blood cultures (takes up to 2 weeks to grow)", "Liver, bone marrow, or lymph node biopsy (AFB stain and culture)", "Mycobacterial culture from stool, sputum, or body fluids", "HIV RNA and CD4 count", "Exclude IRIS if newly started on ART" ] }, { "question": "What is the recommended antimicrobial therapy regimen?", "required_information": [ "Typical regimen: macrolide (azithromycin or clarithromycin) + ethambutol", "Consider adding a third agent (e.g., rifabutin) for severe disease or high mycobacterial load", "Drug-drug interactions with ART (especially rifabutin)", "Renal/hepatic function and potential for QT prolongation", "Tolerability of oral vs IV formulations" ] }, { "question": "When should ART be initiated in a patient with MAC?", "required_information": [ "Whether patient is ART-naive or previously on treatment", "Timing of MAC diagnosis relative to ART initiation", "Risk of IRIS and timing (start ART 2 weeks after MAC therapy begins)", "Adherence history and coordination of HIV and MAC therapy", "Current resistance profile and ART options" ] }, { "question": "What is the appropriate duration of MAC therapy and secondary prophylaxis plan?", "required_information": [ "Clinical response and negative follow-up cultures", "Adherence to therapy and immune reconstitution status", "CD4 count recovery >100 for \u22656 months with viral suppression", "Consider stopping therapy after 12 months of treatment + immune recovery", "Plan for secondary prophylaxis in patients not yet reconstituted" ] } ], "key_references": [ { "title": "DHHS HIV OI Guidelines \u2013 MAC", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/mycobacterium-avium-complex-mac-disease" }, { "title": "IDSA Guidelines on Nontuberculous Mycobacterial Infections", "url": "https://www.idsociety.org/practice-guideline/nontuberculous-mycobacterial-infections/" }, { "title": "CDC MAC Resource Summary", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections/mycobacterium-avium-complex.html" } ] }, "tuberculosis_immunocompromised": { "syndrome_name": "Tuberculosis (TB) in Immunocompromised Hosts", "definition": "Active or latent Mycobacterium tuberculosis infection in patients with immunosuppression (e.g., HIV, transplant, biologics), which may present atypically and with increased risk of progression and dissemination.", "common_consult_questions": [ { "question": "Does this immunocompromised patient have active TB?", "required_information": [ "Symptoms: prolonged cough, fever, night sweats, weight loss", "CXR or CT findings (including atypical or lower lobe patterns)", "Sputum AFB smear and culture, NAAT (e.g., Xpert MTB/RIF)", "HIV status and CD4 count (may have less cavitation)", "Travel history or TB exposure risk" ] }, { "question": "What tests are appropriate for diagnosing TB in this patient?", "required_information": [ "IGRA (Quantiferon or T-SPOT) or TST (less sensitive in immunosuppressed)", "Sputum induction, BAL, or gastric aspirate if needed", "Extrapulmonary site evaluation: pleural, CNS, bone, or lymph node TB", "AFB cultures from blood, tissue, or body fluids", "TB PCR from CSF or other sterile sites" ] }, { "question": "What is the appropriate treatment regimen and duration?", "required_information": [ "Susceptibility of isolate (e.g., pan-sensitive vs MDR/XDR TB)", "Tolerability and hepatic function (especially with rifampin or INH)", "Risk of drug interactions with ART or transplant medications", "Treatment setting (hospital vs outpatient DOT)", "Duration: 6 months for uncomplicated pulmonary TB, longer for extrapulmonary" ] }, { "question": "How should ART or immunosuppressants be adjusted during TB therapy?", "required_information": [ "HIV ART regimen and drug-drug interactions (esp. rifampin/rifabutin)", "Timing of ART initiation in new HIV diagnosis with TB (usually within 2 weeks if CD4 <50)", "Risk of IRIS and need for monitoring or corticosteroid use", "Immunosuppressive regimen adjustments for transplant or biologics", "Need for multidisciplinary coordination (ID, transplant, rheum, HIV)" ] }, { "question": "What infection control and public health steps should be taken?", "required_information": [ "Respiratory isolation criteria (AFB smear status, symptoms, radiographic findings)", "Local or state health department notification", "Contact tracing and screening of close contacts", "DOT enrollment and adherence support", "Completion of therapy documentation and follow-up planning" ] } ], "key_references": [ { "title": "CDC Guidelines for TB in HIV and Transplant Populations", "url": "https://www.cdc.gov/tb/topic/populations/hivtb/default.htm" }, { "title": "IDSA Guidelines on Tuberculosis", "url": "https://www.idsociety.org/practice-guideline/tuberculosis/" }, { "title": "DHHS Guidelines for TB/HIV Coinfection", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/tuberculosis" } ] }, "histoplasmosis_immunocompromised": { "syndrome_name": "Histoplasmosis in Immunocompromised Hosts", "definition": "Infection with Histoplasma capsulatum in immunocompromised individuals (e.g., HIV with CD4 <150, transplant, TNF-\u03b1 inhibitors), which may cause pulmonary or disseminated disease.", "common_consult_questions": [ { "question": "Does this patient have histoplasmosis or another fungal infection?", "required_information": [ "Risk factors: HIV with CD4 <150, immunosuppressive therapy, endemic exposure (Ohio/Mississippi River valleys, caves, bird/bat droppings)", "Symptoms: fever, fatigue, cough, hepatosplenomegaly, GI symptoms, rash", "CXR/CT showing diffuse nodules, mediastinal LAD, or miliary pattern", "Antigen testing (urine, serum) and fungal cultures", "Exclusion of cryptococcus, TB, or malignancy" ] }, { "question": "What diagnostic tests are most sensitive for disseminated histoplasmosis?", "required_information": [ "Urine and serum Histoplasma antigen", "Blood cultures for fungi (may take 2\u20134 weeks)", "Liver, bone marrow, or lymph node biopsy (GMS stain, fungal culture)", "Serology (antibody) less sensitive in immunocompromised", "Imaging and clinical correlation to guide testing" ] }, { "question": "What is the appropriate treatment regimen and duration?", "required_information": [ "Severity: mild/moderate vs severe (respiratory failure, CNS, hepatic involvement)", "Amphotericin B (liposomal) for severe cases, then itraconazole for maintenance", "TDM (serum itraconazole levels), LFTs", "Renal/hepatic function for amphotericin tolerance", "Minimum 12-month course for disseminated disease" ] }, { "question": "When should ART or immunosuppressive therapy be initiated or resumed?", "required_information": [ "Current ART or transplant status", "Risk of IRIS if starting ART (typically delay 2\u20134 weeks in severe histoplasmosis)", "Drug interactions with azoles and immunosuppressants", "CD4 count, HIV viral load, or transplant rejection risk", "Need for careful coordination among ID, HIV/transplant, and pharmacy" ] }, { "question": "What is the follow-up plan and criteria for secondary prophylaxis?", "required_information": [ "Clinical response and symptom resolution", "Antigen level monitoring over time (urine/serum)", "CD4 recovery >150 and virologic suppression", "Adherence and access to itraconazole with TDM", "Duration of maintenance therapy and criteria for discontinuation" ] } ], "key_references": [ { "title": "IDSA Guidelines for Histoplasmosis (2007)", "url": "https://www.idsociety.org/practice-guideline/histoplasmosis/" }, { "title": "CDC Histoplasmosis in Immunocompromised Hosts", "url": "https://www.cdc.gov/fungal/diseases/histoplasmosis/health-professionals.html" }, { "title": "DHHS Guidelines on OIs \u2013 Histoplasmosis Section", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/progressive-disseminated-histoplasmosis" } ] }, "candidemia_invasive_candidiasis": { "syndrome_name": "Candidemia and Invasive Candidiasis", "definition": "Bloodstream or deep-seated infection caused by Candida species, often associated with central lines, ICU stays, total parenteral nutrition (TPN), broad-spectrum antibiotics, or immunosuppression.", "common_consult_questions": [ { "question": "Is this true candidemia or a contaminant?", "required_information": [ "Species of Candida (e.g., albicans, glabrata, auris)", "Number of positive blood cultures and time to positivity", "Clinical context (e.g., central line, ICU, abdominal surgery, neutropenia)", "Presence of fever, hypotension, or organ dysfunction", "Prior colonization with Candida" ] }, { "question": "What is the initial management of candidemia?", "required_information": [ "Blood culture results and susceptibilities", "Timing of source control (e.g., central line removal)", "Empiric antifungal choice (usually echinocandin)", "Patient\u2019s renal/hepatic function and drug interactions", "Daily blood cultures until clearance confirmed" ] }, { "question": "What additional workup is required for candidemia?", "required_information": [ "Dilated ophthalmologic exam within first week (rule out endophthalmitis)", "Transthoracic echocardiogram (TTE), possibly TEE (rule out endocarditis)", "Imaging of abdomen or other suspected deep sites", "Repeat blood cultures every 24\u201348 hours until negative", "Risk factors for invasive candidiasis (e.g., GI perforation, neutropenia)" ] }, { "question": "When can antifungal therapy be de-escalated or transitioned to oral agents?", "required_information": [ "Species identification and susceptibility (e.g., fluconazole-susceptible)", "Duration since first negative culture (treatment usually \u226514 days from clearance)", "Source control achieved and no end-organ involvement", "Absence of ocular, cardiac, or bone involvement", "Patient stability and oral absorption ability" ] }, { "question": "What is the appropriate follow-up and prevention strategy?", "required_information": [ "Completion of minimum 14-day therapy from negative culture", "Repeat ophthalmology and echocardiography if abnormalities were noted", "Avoidance of unnecessary antibiotics or central lines", "Antifungal prophylaxis only in high-risk populations (e.g., BMT)", "Monitoring for relapse in immunocompromised or critically ill patients" ] } ], "key_references": [ { "title": "IDSA Guidelines for Candidiasis (2016)", "url": "https://www.idsociety.org/practice-guideline/candidiasis/" }, { "title": "CDC Candidemia and Candida auris Resources", "url": "https://www.cdc.gov/fungal/diseases/candidiasis/candidemia.html" }, { "title": "CDC Candida auris Overview", "url": "https://www.cdc.gov/fungal/candida-auris/" }, { "title": "Clinical Practice Points from Mycoses Study Group", "url": "https://www.mycosesstudygroup.org" } ] }, "endemic_mycoses": { "syndrome_name": "Endemic Mycoses (Histoplasmosis, Blastomycosis, Coccidioidomycosis)", "definition": "Infections caused by geographically restricted dimorphic fungi, particularly affecting immunocompromised or previously healthy individuals following environmental exposure in endemic regions.", "common_consult_questions": [ { "question": "Does this patient have an endemic mycosis or another cause of illness (e.g., TB, malignancy)?", "required_information": [ "Geographic exposure history (e.g., Mississippi/Ohio River Valley for histo, Southwest US for cocci, Great Lakes for blasto)", "Environmental risk: soil disruption, bat/bird droppings, outdoor labor", "Clinical presentation: subacute fever, cough, weight loss, skin lesions, joint pain", "CXR or CT: nodules, hilar/mediastinal lymphadenopathy, miliary pattern", "Differential includes TB, lymphoma, sarcoidosis, fungal infection" ] }, { "question": "What diagnostic tests confirm an endemic fungal infection?", "required_information": [ "Urine and serum antigen testing (especially for histo and blasto)", "Serology (complement fixation, immunodiffusion for cocci)", "Fungal cultures from sputum, BAL, skin lesions, blood", "Tissue biopsy: granulomas, GMS stain with yeast forms or broad-based budding", "PCR or molecular tests if available" ] }, { "question": "What is the initial treatment plan and how should it be tailored by severity?", "required_information": [ "Disease severity: mild/moderate vs severe or disseminated", "CNS or bone/joint involvement", "Amphotericin B for severe/disseminated disease; itraconazole or fluconazole for mild to moderate", "Duration: 6\u201312 months depending on pathogen and response", "Monitoring for side effects, TDM (e.g., itraconazole levels)" ] }, { "question": "How do we distinguish between acute, chronic, and disseminated disease?", "required_information": [ "Duration of symptoms and extent of systemic involvement", "Lung findings: cavity or mass vs diffuse interstitial pattern", "Immune status (HIV, transplant, steroids, TNF-\u03b1 inhibitors)", "Laboratory evidence: antigen burden, pancytopenia, LFTs", "Extrapulmonary findings: mucocutaneous lesions, bone pain, hepatosplenomegaly" ] }, { "question": "What is the long-term follow-up and recurrence prevention strategy?", "required_information": [ "Plan for tapering or completing antifungal therapy (usually \u22656 months)", "Monitoring antigen levels (urine/serum) serially", "Immune reconstitution and relapse risk", "Chronic suppressive therapy in persistently immunocompromised", "Repeat imaging and symptom review every 3\u20136 months" ] } ], "key_references": [ { "title": "IDSA Guidelines for Histoplasmosis, Blastomycosis, Coccidioidomycosis", "url": "https://www.idsociety.org/practice-guideline/histoplasmosis/" }, { "title": "CDC Fungal Diseases by Region", "url": "https://www.cdc.gov/fungal/diseases/index.html" }, { "title": "Mycoses Study Group Educational Resources", "url": "https://www.mycosesstudygroup.org" } ] }, "strongyloidiasis_hyperinfection": { "syndrome_name": "Strongyloidiasis and Hyperinfection", "definition": "Intestinal nematode infection caused by Strongyloides stercoralis, which can persist asymptomatically for decades and cause life-threatening hyperinfection or disseminated disease in immunosuppressed individuals.", "common_consult_questions": [ { "question": "Does this patient have chronic strongyloidiasis or hyperinfection syndrome?", "required_information": [ "Epidemiologic risk: tropical/subtropical exposure, Southeast US, veterans, immigrants", "History of walking barefoot, farming, sanitation exposure", "Immunosuppression: corticosteroids, HTLV-1, transplant", "Symptoms: chronic GI (diarrhea, bloating), skin rash, eosinophilia (may be absent in hyperinfection)", "Signs of hyperinfection: sepsis, pulmonary infiltrates, meningitis, gram-negative bacteremia" ] }, { "question": "What is the appropriate diagnostic workup?", "required_information": [ "Strongyloides IgG serology (most sensitive in chronic infection)", "Stool O&P (low sensitivity; may require 3 samples)", "Stool agar culture or molecular testing if available", "BAL, sputum, or duodenal aspirate microscopy in hyperinfection", "Blood cultures for enteric gram-negative bacteria" ] }, { "question": "How is treatment chosen for chronic vs hyperinfection cases?", "required_information": [ "Chronic infection: ivermectin PO x 2 days (or longer if immunosuppressed)", "Hyperinfection: ivermectin daily until symptoms resolve and tests are negative (often >7 days)", "Consider parenteral or rectal ivermectin if ileus or poor absorption", "Albendazole is second-line and less effective", "Hold or reduce immunosuppressive therapy when possible" ] }, { "question": "When should presumptive treatment be given without confirmation?", "required_information": [ "Pending immunosuppression (e.g., steroids, chemotherapy, transplant)", "Epidemiologic exposure risk and positive eosinophilia or serology", "Inability to test or delayed turnaround time", "Seronegative but symptomatic with suggestive imaging", "Life-threatening sepsis or ARDS with unclear source" ] }, { "question": "How should we monitor for cure and prevent recurrence?", "required_information": [ "Symptom resolution and stool/sputum clearance", "Repeat serology at 6\u201312 months if initially positive", "Reinfection risk if patient returns to endemic areas", "Avoiding barefoot exposure, soil contact, and untreated water", "Counseling immunosuppressed patients about testing before high-dose steroids" ] } ], "key_references": [ { "title": "CDC Strongyloides Guidelines", "url": "https://www.cdc.gov/parasites/strongyloides/health_professionals/index.html" }, { "title": "IDSA Guidelines on Helminth Infections in Immunocompromised Hosts", "url": "https://www.idsociety.org/practice-guideline/" }, { "title": "Tropical Medicine Updates \u2013 Strongyloidiasis in Immunosuppressed", "url": "https://www.ajtmh.org/" } ] }, "vre_cre_infection_colonization": { "syndrome_name": "VRE or CRE Colonization and Infection", "definition": "Multidrug-resistant gram-positive or gram-negative bacterial infections caused by Vancomycin-Resistant Enterococcus (VRE) or Carbapenem-Resistant Enterobacterales (CRE). These organisms are associated with high morbidity, limited treatment options, and strict infection control implications.", "common_consult_questions": [ { "question": "Is this colonization or true infection with VRE or CRE?", "required_information": [ "Source of isolate: surveillance swab vs clinical site (e.g., urine, blood, wound)", "Symptoms of infection vs asymptomatic colonization", "Host factors: neutropenia, recent surgery, devices (lines, catheters)", "Laboratory trends: leukocytosis, fever, inflammatory markers", "Culture site and pathogen virulence (e.g., KPC, E. faecium)" ] }, { "question": "What are the appropriate antibiotic options based on susceptibility?", "required_information": [ "Species and resistance mechanism (e.g., vanA/vanB, KPC, NDM, OXA-48)", "Susceptibility to linezolid, daptomycin (VRE); ceftazidime-avibactam, meropenem-vaborbactam, fosfomycin, tigecycline (CRE)", "Site of infection (CNS, bloodstream, urinary)", "Drug toxicities and monitoring requirements (e.g., CPK for daptomycin, marrow suppression for linezolid)", "Availability of synergy (e.g., aminoglycosides, double carbapenem strategies)" ] }, { "question": "What infection control and isolation measures are needed?", "required_information": [ "Type of resistance (VRE or CRE) and local policies", "Contact precautions and private room availability", "Whether patient is colonized or infected", "History of clearance or negative screening cultures", "Notification of public health if CRE (depending on jurisdiction)" ] }, { "question": "When should screening or decolonization be considered?", "required_information": [ "Hospital policy for high-risk units (e.g., ICU, transplant)", "Exposure in known outbreaks or epidemiologic links", "Consider rectal swab or PCR for VRE/CRE colonization", "Decolonization generally not recommended except in specific outbreaks", "Ongoing need for infection prevention measures" ] }, { "question": "What is the duration of therapy and when can it be narrowed or stopped?", "required_information": [ "Site of infection and source control status", "Clinical response (defervescence, lab markers, repeat cultures)", "Microbiologic clearance (e.g., blood culture sterilization)", "Immunocompetence and comorbidities", "Whether oral step-down or suppressive therapy is appropriate" ] } ], "key_references": [ { "title": "IDSA Guidance on Antimicrobial Agents for Resistant Gram-Negative Infections", "url": "https://www.idsociety.org/practice-guideline/amr-gn/" }, { "title": "CDC Guidance on CRE and VRE Surveillance and Management", "url": "https://www.cdc.gov/hai/organisms/cre/index.html" }, { "title": "CDC VRE Overview", "url": "https://www.cdc.gov/hai/organisms/vre/vre.html" }, { "title": "Clinical Practice Guidelines for the Management of Multidrug-Resistant Gram-Negative Bacilli (2021)", "url": "https://doi.org/10.1093/cid/ciab1013" } ] }, "fever_in_returning_traveler": { "syndrome_name": "Fever in the Returning Traveler", "definition": "Febrile illness in a person returning from international travel, often to tropical or subtropical regions. Requires systematic evaluation for vector-borne, parasitic, bacterial, and viral infections based on geography and exposures.", "common_consult_questions": [ { "question": "What are the key exposures and geographic risks in this patient\u2019s travel history?", "required_information": [ "Countries and regions visited, including layovers", "Urban vs rural, freshwater exposure, caves, farms, health care settings", "Vaccinations and malaria prophylaxis history", "Activities: hiking, swimming, insect bites, unpasteurized food", "Timing of symptom onset relative to travel" ] }, { "question": "What is the broad differential diagnosis for fever in this returning traveler?", "required_information": [ "Incubation period and symptom profile (e.g., rash, arthralgia, jaundice, diarrhea, neuro)", "Malaria (P. falciparum vs non-falciparum)", "Dengue, chikungunya, Zika", "Typhoid/paratyphoid fever", "Rickettsial infections (e.g., African tick bite fever)", "Leptospirosis, schistosomiasis, strongyloidiasis", "TB, HIV, COVID, viral hepatitis" ] }, { "question": "What initial diagnostic tests should be ordered?", "required_information": [ "Thick and thin malaria smears x3 and/or rapid diagnostic test (RDT)", "CBC with differential, LFTs, creatinine, LDH", "Blood cultures x2, urinalysis", "Travel-specific serologies or PCR (e.g., dengue, chikungunya, typhoid, leptospira)", "CXR or imaging if systemic signs" ] }, { "question": "When should empiric treatment be initiated before full workup returns?", "required_information": [ "Concern for P. falciparum malaria or hemodynamic instability", "Regional resistance patterns for empiric antimalarials (e.g., atovaquone-proguanil, artesunate, doxycycline)", "Clinical suspicion of typhoid or rickettsial illness", "Risk of sepsis in patients from endemic regions", "Immunocompromised host or prior tropical exposures" ] }, { "question": "What follow-up and public health actions are needed?", "required_information": [ "Need for notification of local health department (e.g., malaria, dengue)", "Screening of close contacts if disease is transmissible (e.g., TB, viral hemorrhagic fevers)", "Advice on preventing future travel-related infections", "Vaccination updates and long-term management of sequelae", "Coordination with travel medicine or tropical disease specialist" ] } ], "key_references": [ { "title": "CDC Yellow Book \u2013 Travel-Associated Infections", "url": "https://wwwnc.cdc.gov/travel/yellowbook" }, { "title": "GeoSentinel Surveillance Network Data", "url": "https://wwwnc.cdc.gov/travel/page/geosentinel" }, { "title": "IDSA Guidelines for Evaluation of Fever in the Returning Traveler", "url": "https://www.idsociety.org/practice-guideline/" } ] }, "tickborne_illnesses": { "syndrome_name": "Tickborne Illnesses (Ehrlichiosis, Anaplasmosis, Babesiosis)", "definition": "Vector-borne infections transmitted by ticks, primarily in the U.S. during spring\u2013fall, often presenting with nonspecific febrile illness and varying severity depending on pathogen and host immune status.", "common_consult_questions": [ { "question": "What are the likely pathogens based on geography and clinical features?", "required_information": [ "Travel or exposure in endemic areas (e.g., Midwest, Northeast, Southeast)", "Seasonality and known tick bites or outdoor activities", "Fever, myalgias, cytopenias, transaminitis (Ehrlichia/Anaplasma)", "Hemolysis, jaundice, splenomegaly (Babesia)", "Rash (common with Ehrlichia, rare with Anaplasma)" ] }, { "question": "What is the appropriate diagnostic workup for these infections?", "required_information": [ "CBC (look for leukopenia, thrombocytopenia), LFTs, LDH", "Blood smear (morulae in WBCs for Anaplasma/Ehrlichia; Maltese cross for Babesia)", "PCR for Ehrlichia, Anaplasma, and Babesia", "Serologies (may be negative early; more useful for convalescent diagnosis)", "Blood cultures to rule out sepsis mimics" ] }, { "question": "What is the empiric treatment while awaiting test results?", "required_information": [ "Suspected Ehrlichia or Anaplasma: doxycycline (standard empiric choice)", "Suspected Babesia (esp. hemolysis, asplenia, severe anemia): atovaquone + azithromycin (mild), clindamycin + quinine (severe)", "Risk factors for severe disease (e.g., immunocompromised, elderly, splenectomy)", "Duration: typically 7\u201310 days for Ehrlichia/Anaplasma; 7\u201310+ days for Babesia", "Consider dual therapy if co-infection suspected (e.g., Lyme + Anaplasma + Babesia)" ] }, { "question": "When should hospitalization or specialist consultation be considered?", "required_information": [ "Severe disease (organ dysfunction, altered mental status, respiratory failure)", "High parasitemia in Babesia (>10%) or signs of hemolytic crisis", "Need for exchange transfusion in Babesiosis", "Failure to improve within 48\u201372 hours of therapy", "Coinfections or unclear diagnosis" ] }, { "question": "What is the long-term follow-up and recurrence risk?", "required_information": [ "Immunocompromised patients (e.g., HIV, cancer) at risk for relapse", "Repeat PCR or blood smear if symptoms recur", "Consider chronic Babesia infection in persistent symptoms", "Follow-up CBC/LFTs to ensure resolution", "Education on tick prevention and potential for co-infection with Lyme or other pathogens" ] } ], "key_references": [ { "title": "CDC Tickborne Disease Guidelines", "url": "https://www.cdc.gov/ticks/diseases/index.html" }, { "title": "IDSA/AAN/ACR 2021 Guidelines for Prevention and Treatment of Tickborne Diseases", "url": "https://www.idsociety.org/practice-guideline/tickborne-disease/" }, { "title": "American Journal of Tropical Medicine and Hygiene Reviews on Tickborne Coinfection", "url": "https://www.ajtmh.org/" } ] }, "infections_in_pwid": { "syndrome_name": "Infections in Persons Who Inject Drugs (PWID)", "definition": "Infectious complications associated with injection drug use, including bacteremia, endocarditis, soft tissue infections, osteomyelitis, and hepatitis. These patients may present with complex medical and psychosocial needs.", "common_consult_questions": [ { "question": "What is the likely infection source and optimal diagnostic approach?", "required_information": [ "Symptoms: fever, localized pain/swelling, murmurs, neurologic changes", "Injection practices: frequency, site rotation, substances used", "Physical exam: track marks, skin/soft tissue infections, heart murmur, Janeway lesions", "Blood cultures x2 and echocardiogram (TTE, consider TEE)", "Imaging for suspected septic emboli, osteo, abscess, or joint infection" ] }, { "question": "How should empiric antibiotics be selected?", "required_information": [ "Coverage for MSSA/MRSA, Streptococci, gram-negatives, anaerobes (if abscess/polymicrobial)", "Local resistance patterns and recent culture history", "History of treatment failures or allergies", "Suspected site (e.g., cellulitis vs vertebral osteo vs endocarditis)", "Plan for narrowing after culture results" ] }, { "question": "How should duration and setting of therapy be determined (IV vs oral, inpatient vs outpatient)?", "required_information": [ "Diagnosis (e.g., uncomplicated bacteremia vs endocarditis or osteo)", "Stability and response to treatment", "Access to outpatient parenteral antibiotic therapy (OPAT) or oral alternatives", "Adherence support (e.g., case management, peer navigator)", "Risk of line misuse and strategies (e.g., midline, oral step-down)" ] }, { "question": "When should multidisciplinary teams be engaged?", "required_information": [ "Social determinants of health (e.g., housing, insurance, mental health)", "Readiness for substance use disorder (SUD) treatment", "Involvement of addiction medicine, social work, psychiatry", "Planning for safe discharge and harm reduction support", "Risk of readmission, overdose, or loss to follow-up" ] }, { "question": "What screening and preventive care should be offered?", "required_information": [ "HIV, HBV, and HCV serologies (and linkage to care if positive)", "Vaccination: HAV, HBV, Tdap, influenza, COVID", "Offer of PrEP if HIV-negative and ongoing exposure risk", "Naloxone prescription and harm reduction counseling", "Connection to syringe exchange or mobile health units" ] } ], "key_references": [ { "title": "IDSA Clinical Practice Guidelines on Infective Endocarditis and OPAT", "url": "https://www.idsociety.org/practice-guideline/endocarditis/" }, { "title": "IDSA OPAT Guidelines", "url": "https://www.idsociety.org/practice-guideline/outpatient-parenteral-antimicrobial-therapy-opat/" }, { "title": "CDC SSP and SAMHSA Harm Reduction Resources", "url": "https://www.cdc.gov/ssp/" }, { "title": "AHA Scientific Statement: Infective Endocarditis in PWID", "url": "https://doi.org/10.1161/CIR.0000000000000764" } ] }, "esbl_producing_infections": { "syndrome_name": "ESBL-Producing Gram-Negative Infections", "definition": "Infections caused by extended-spectrum \u03b2-lactamase (ESBL)-producing E. coli, Klebsiella, or other Enterobacterales that hydrolyze penicillins and cephalosporins, leading to resistance and requiring tailored antimicrobial therapy.", "common_consult_questions": [ { "question": "How is an ESBL-producing organism confirmed and reported?", "required_information": [ "Culture and susceptibility results (resistant to 3rd-gen cephalosporins)", "Confirmatory phenotypic ESBL testing (e.g., clavulanate synergy) or molecular PCR", "Organism identified (E. coli, Klebsiella pneumoniae, Enterobacter cloacae, etc.)", "Infection site: urine, blood, intra-abdominal, pulmonary, etc.", "Risk factors: prior antibiotic exposure, healthcare contact, travel" ] }, { "question": "What empiric and definitive therapy should be used?", "required_information": [ "Site and severity of infection", "Risk for multidrug-resistant pathogens", "Empiric choice: carbapenem (e.g., ertapenem for non-ICU UTI/intra-abdominal; meropenem for severe)", "Definitive therapy options: carbapenem vs non-carbapenem beta-lactam/beta-lactamase inhibitors (e.g., ceftolozane-tazobactam, ceftazidime-avibactam) if susceptible", "Step-down oral options: fosfomycin, nitrofurantoin, or fluoroquinolones (if susceptible)" ] }, { "question": "Can a non-carbapenem agent be used safely for step-down or oral therapy?", "required_information": [ "Susceptibility to fluoroquinolones, TMP-SMX, or fosfomycin", "Source controlled and patient clinically improving", "Adequate oral absorption and adherence support", "Risk of recurrence or persistent bacteremia", "ID or stewardship guidance on oral beta-lactams in low-risk scenarios" ] }, { "question": "How long should therapy continue and when can it be de-escalated?", "required_information": [ "Clinical syndrome (e.g., cystitis vs pyelonephritis vs bacteremia)", "Timing of culture clearance and source control", "Response to initial therapy and inflammatory markers", "Evidence of metastatic infection or complications", "Opportunity to narrow based on MIC data or clinical improvement" ] }, { "question": "What infection control or surveillance steps are needed?", "required_information": [ "Healthcare exposure or outbreak settings", "Prior colonization or repeat infections with ESBL organisms", "Local epidemiology and resistance tracking (CRE risk overlap)", "Need for contact precautions or screening in high-risk settings", "Counseling on hygiene, avoidance of unnecessary antibiotics" ] } ], "key_references": [ { "title": "IDSA Guidance on Antimicrobial Agents for Resistant Gram-Negative Infections", "url": "https://www.idsociety.org/practice-guideline/amr-gn/" }, { "title": "CDC CRE and ESBL Resource Hub", "url": "https://www.cdc.gov/hai/organisms/cre/index.html" }, { "title": "International Consensus on ESBL and Carbapenem-Sparing Therapy", "url": "https://doi.org/10.1016/j.cmi.2020.01.017" } ] }, "ntm_infections": { "syndrome_name": "Nontuberculous Mycobacterial (NTM) Infections", "definition": "Infections caused by non-Mycobacterium tuberculosis species (e.g., Mycobacterium avium complex [MAC], M. abscessus, M. kansasii), often chronic, indolent, and difficult to treat due to inherent drug resistance and need for prolonged multidrug regimens.", "common_consult_questions": [ { "question": "What is the clinical significance of this NTM isolate?", "required_information": [ "Site of infection (lung, skin/soft tissue, bloodstream, lymph node)", "Clinical symptoms: cough, weight loss, fever, fatigue, non-healing wounds", "Imaging findings (e.g., nodules, bronchiectasis, cavitary disease)", "Microbiology: species identification, repeated isolation from sterile vs non-sterile sites", "Differentiating colonization from active infection (esp. pulmonary MAC)" ] }, { "question": "What is the appropriate diagnostic workup?", "required_information": [ "Sputum cultures (\u22652 positive), BAL culture, or biopsy from affected site", "Imaging: chest CT (esp. middle lobe/lingula bronchiectasis, cavitary lesions)", "AFB smear and culture, plus speciation with drug susceptibility testing", "HIV status, CD4 count if applicable", "Other immune workup (e.g., IL-12/IFN-\u03b3 axis, CF testing, structural lung disease)" ] }, { "question": "What is the appropriate treatment regimen for this NTM species and disease site?", "required_information": [ "MAC: azithromycin/clarithromycin + ethambutol + rifampin (non-cavitary disease: 3x/week; cavitary: daily)", "M. abscessus: macrolide + IV amikacin + additional agents (e.g., cefoxitin, imipenem, tigecycline)", "M. kansasii: rifampin + ethambutol + isoniazid", "Duration: often 12 months after culture conversion", "TDM, liver/kidney function, macrolide resistance (esp. in M. abscessus)" ] }, { "question": "When is surgery or procedural intervention needed?", "required_information": [ "Persistent localized disease not improving despite therapy", "Severe hemoptysis, cavitary lesions, or necrotizing nodules", "Localized skin/soft tissue infection with abscess or sinus tracts", "Line-related NTM bloodstream infection requiring catheter removal", "Multidisciplinary review with pulmonary, ID, surgery" ] }, { "question": "What is the follow-up and monitoring plan during prolonged therapy?", "required_information": [ "Monthly sputum cultures until culture conversion and clearance", "Audiology, vision testing, and laboratory monitoring (ethambutol, rifampin, amikacin toxicities)", "Imaging every 3\u20136 months to monitor cavitary/nodular disease", "Adherence and management of adverse effects", "Prevention counseling in susceptible patients (e.g., avoid aerosolized water, soil exposure)" ] } ], "key_references": [ { "title": "ATS/IDSA Guidelines on NTM Pulmonary Disease (2020)", "url": "https://doi.org/10.1164/rccm.202008-3408ST" }, { "title": "CDC NTM Resources", "url": "https://www.cdc.gov/nontuberculousmycobacteria/" }, { "title": "NTMinfo.org \u2013 Patient and Provider Resources", "url": "https://www.ntminfo.org" } ] }, "prosthetic_joint_infection": { "syndrome_name": "Prosthetic Joint Infections (PJI)", "definition": "Infection of an artificial joint, typically involving the hip or knee, caused by skin flora (e.g., Staphylococcus aureus, CoNS), Cutibacterium, or gram-negative organisms. PJI requires combined medical and surgical management.", "common_consult_questions": [ { "question": "Does this patient meet criteria for prosthetic joint infection?", "required_information": [ "Symptoms: pain, swelling, warmth, drainage, limited range of motion", "Timing of onset: acute (<3 months), delayed (3\u201312 months), or late (>12 months)", "Joint aspiration findings: WBC >3,000/\u03bcL, PMNs >80%, positive culture", "Sinus tract communicating with prosthesis", "Operative findings or intraoperative cultures" ] }, { "question": "What is the optimal surgical approach (DAIR vs explant vs 2-stage)?", "required_information": [ "Duration of symptoms (<3 weeks generally eligible for DAIR)", "Stability of prosthesis and absence of sinus tract", "Organism involved and susceptibility", "Host factors: immune status, prior surgeries, functional status", "Surgical team input on reimplantation timing and approach" ] }, { "question": "What empiric and definitive antibiotics are appropriate?", "required_information": [ "Gram stain and culture data from joint aspirate or intraoperative samples", "Coverage for Staphylococcus aureus (MSSA/MRSA), Streptococcus, gram-negatives", "Empiric: vancomycin + ceftriaxone or cefepime (if concern for GNR)", "Definitive: biofilm-active agents (e.g., rifampin with anti-staph backbone in DAIR cases)", "Duration: 6 weeks IV +/- oral suppression depending on surgery type" ] }, { "question": "When is chronic suppressive therapy indicated?", "required_information": [ "Retained hardware and inability to complete curative surgery", "Recurrent infection or high-risk host with limited surgical options", "Oral agent options with activity against the causative organism", "Monitoring for resistance, drug toxicity, and patient adherence", "Goals of care and shared decision-making" ] }, { "question": "What is the long-term follow-up strategy?", "required_information": [ "CRP/ESR monitoring post-treatment", "Symptom surveillance (pain, drainage, mobility)", "Repeat imaging if new concerns arise", "Multidisciplinary collaboration with ortho, ID, PT", "Education on signs of recurrence and activity restrictions" ] } ], "key_references": [ { "title": "IDSA Guidelines for Prosthetic Joint Infection (2013)", "url": "https://www.idsociety.org/practice-guideline/prosthetic-joint-infection/" }, { "title": "AAOS/IDSA PJI Management Algorithms", "url": "https://www.aaos.org/globalassets/about/bylaws-library/pji_guideline.pdf" }, { "title": "MSIS Diagnostic Criteria for PJI (Musculoskeletal Infection Society)", "url": "https://www.msis-na.org/" } ] }, "device_associated_infections": { "syndrome_name": "Device-Associated Infections (Ports, Pacemakers, LVADs)", "definition": "Infections involving cardiovascular or implantable devices (e.g., central venous catheters, cardiac implantable electronic devices, left ventricular assist devices), which often require a combination of antimicrobial therapy and device management.", "common_consult_questions": [ { "question": "Is this a true device-related infection or unrelated bacteremia?", "required_information": [ "Clinical signs at device site: erythema, drainage, tenderness, erosion", "Persistent or recurrent bacteremia despite antibiotics", "Organism type (e.g., S. aureus, CoNS, Candida, gram-negatives)", "Imaging if applicable (e.g., echocardiography for lead vegetation, CT chest/abdomen/pelvis)", "Time from device placement and known breaches" ] }, { "question": "What is the recommended diagnostic approach for different devices?", "required_information": [ "Blood cultures (always from peripheral site + device if present)", "Device site cultures if draining", "Echocardiogram (TEE preferred for CIEDs)", "LVAD: CT or nuclear medicine studies (e.g., gallium, WBC scan)", "Consider device pocket exploration if clinical suspicion high" ] }, { "question": "What is the preferred antimicrobial regimen and duration?", "required_information": [ "Causative organism and resistance profile", "Site of infection: bacteremia, pocket infection, endovascular, driveline", "Device type: tunneled catheter, pacemaker, ICD, LVAD", "MRSA: vancomycin or daptomycin; MSSA: cefazolin or nafcillin", "Duration: 2\u20136 weeks depending on removal, organism, and site" ] }, { "question": "When is device removal necessary and how should it be timed?", "required_information": [ "Persistent bacteremia >72 hours", "S. aureus, Candida, Pseudomonas, or polymicrobial infections", "Pocket infection or erosion", "Imaging evidence of lead or device infection", "Risk of recurrent infection vs procedural risks" ] }, { "question": "What is the follow-up and reimplantation plan?", "required_information": [ "Duration of antibiotic course completed", "Documentation of bacteremia clearance (2 negative blood cultures >24h apart)", "Device reimplantation: typically after \u226514 days (if no pocket infection) or \u22654\u20136 weeks (if endocarditis or abscess)", "Plan for antimicrobial prophylaxis at reimplantation", "Ongoing monitoring and outpatient care coordination" ] } ], "key_references": [ { "title": "IDSA Clinical Practice Guidelines on CIED Infections (2010)", "url": "https://www.idsociety.org/practice-guideline/cied-infections/" }, { "title": "AHA Scientific Statement on Management of CIED Infections", "url": "https://doi.org/10.1161/CIR.0000000000000549" }, { "title": "IDSA/AST Guidelines for LVAD Infections (2023)", "url": "https://www.idsociety.org/practice-guideline/" } ] }, "infections_after_sot": { "syndrome_name": "Infections After Solid Organ Transplant (SOT)", "definition": "Infectious complications in solid organ transplant recipients, influenced by timing post-transplant, net state of immunosuppression, and exposures. Common infections include opportunistic viruses (e.g., CMV, BK), bacterial sepsis, fungal infections, and donor-derived pathogens.", "common_consult_questions": [ { "question": "What is the likely infection based on time since transplant?", "required_information": [ "Type of organ transplanted (kidney, liver, lung, heart)", "Timing: <1 month (surgical/bacterial), 1\u20136 months (opportunistic), >6 months (community or chronic viral reactivation)", "Immunosuppressive regimen (e.g., calcineurin inhibitors, MMF, prednisone, mTORi)", "CMV donor/recipient serostatus", "Prophylaxis history (e.g., valganciclovir, TMP-SMX, antifungals)" ] }, { "question": "What workup should be initiated in a febrile or symptomatic SOT recipient?", "required_information": [ "Full infectious workup: blood cultures, urine, respiratory PCR, CXR or CT, stool studies", "Targeted tests based on symptoms and timing (e.g., CMV PCR, BK PCR, EBV load, fungal diagnostics)", "Drug levels and immunosuppression review", "Donor-derived infection reporting if recently transplanted", "Consultation with transplant infectious diseases team" ] }, { "question": "How should empiric therapy be selected and adjusted?", "required_information": [ "Site and severity of infection (e.g., pneumonia, GI, graft site, CNS)", "History of prior colonization or resistant organisms", "Use of prophylaxis and breakthrough infections", "Organ function for drug dosing and toxicity", "Need for adjustment of immunosuppression" ] }, { "question": "How is CMV managed in transplant patients?", "required_information": [ "CMV serostatus (D+/R\u2212 = highest risk)", "Prophylaxis vs preemptive strategy used", "Symptoms (e.g., fever, cytopenia, colitis, hepatitis)", "Quantitative CMV PCR and trend", "Treatment plan (e.g., valganciclovir or IV ganciclovir, duration, secondary prophylaxis)" ] }, { "question": "What preventive strategies are essential in SOT care?", "required_information": [ "Vaccination status (pre- and post-transplant updates)", "Prophylaxis adherence (CMV, PCP, fungal)", "Environmental risk avoidance (e.g., gardening, construction dust, pet birds)", "Travel precautions and latent TB screening", "Coordination with transplant ID and primary care" ] } ], "key_references": [ { "title": "AST ID Guidelines for SOT Recipients", "url": "https://www.myast.org/guidelines" }, { "title": "IDSA Guidelines on Opportunistic Infections in Transplant", "url": "https://www.idsociety.org/practice-guideline/" }, { "title": "CDC Transplant Infectious Disease Resource Hub", "url": "https://www.cdc.gov/transplantsafety/" } ] }, "infections_after_hsct": { "syndrome_name": "Infections After Hematopoietic Stem Cell Transplant (HSCT)", "definition": "Infectious complications in hematopoietic stem cell transplant recipients (autologous or allogeneic), driven by timing, neutropenia, graft-versus-host disease (GVHD), and immune reconstitution status.", "common_consult_questions": [ { "question": "What is the likely infection based on transplant type and post-transplant timeline?", "required_information": [ "Type: autologous vs allogeneic transplant", "Time since transplant: <30 days (bacterial/HSV), 30\u2013100 days (CMV/fungal/adenovirus), >100 days (encapsulated bacteria, VZV, Pneumocystis, NTM)", "GVHD presence and treatment (especially steroids)", "Conditioning regimen and graft source" ] }, { "question": "What diagnostic workup is indicated in a febrile or symptomatic HSCT recipient?", "required_information": [ "Neutropenia status and ANC", "Blood cultures, urinalysis, chest imaging, respiratory PCR panel", "Serum CMV PCR, EBV viral load, fungal biomarkers (galactomannan, \u03b2-D-glucan)", "GI panel for diarrhea (e.g., C. difficile, adenovirus, norovirus)", "Consider LP and neuroimaging if neurologic symptoms or mental status changes" ] }, { "question": "How should empiric therapy be approached in neutropenic or immunosuppressed HSCT recipients?", "required_information": [ "Antimicrobial prophylaxis (fluoroquinolone, antifungal, antiviral)", "Empiric antipseudomonal beta-lactam for febrile neutropenia", "Add anti-MRSA or antifungals based on clinical status", "Consider early ganciclovir if high-risk for CMV syndrome", "Modify based on culture results, drug levels, and clinical response" ] }, { "question": "What is the management of CMV, EBV, or adenovirus reactivation?", "required_information": [ "Serial PCR results and viral load trends", "Symptom correlation: CMV (GI, hepatitis, retinitis), EBV (PTLD), adenovirus (GI, hemorrhagic cystitis)", "First-line therapy (e.g., ganciclovir or valganciclovir for CMV, reduction in immunosuppression)", "CMV prophylaxis strategy (letermovir vs preemptive monitoring)", "EBV-associated PTLD: consider rituximab, biopsy confirmation" ] }, { "question": "What long-term prevention and vaccination strategy should be implemented?", "required_information": [ "Pneumocystis prophylaxis (e.g., TMP-SMX until at least 6 months or off steroids)", "Antiviral prophylaxis (acyclovir or valacyclovir for HSV/VZV)", "Antifungal prophylaxis in allogeneic transplants or GVHD", "Revaccination schedule starting 6\u201312 months post-transplant", "Environmental precautions and travel counseling" ] } ], "key_references": [ { "title": "IDSA Guidelines for Infection Prevention in Cancer Patients and HSCT Recipients", "url": "https://www.idsociety.org/practice-guideline/" }, { "title": "NCCN Guidelines on Prevention and Treatment of Infections in Cancer and HSCT", "url": "https://www.nccn.org/professionals/physician_gls/default.aspx" }, { "title": "CDC Guidelines on HSCT Recipient Safety", "url": "https://www.cdc.gov/hai/settings/outpatient/stem-cell.html" } ] }, "cellulitis": { "syndrome_name": "Cellulitis (Non-Purulent and Purulent)", "definition": "Bacterial infection of the dermis and subcutaneous tissue. Can present as non-purulent (usually Streptococcus spp.) or purulent (typically Staphylococcus aureus, including MRSA). Requires evaluation for deeper involvement and need for systemic therapy.", "common_consult_questions": [ { "question": "Is this truly cellulitis or an alternative diagnosis?", "required_information": [ "Unilateral erythema, warmth, swelling, tenderness", "Absence of fluctuance or abscess (suggests non-purulent)", "Bilateral findings or non-tender swelling may suggest lymphedema, venous stasis, contact dermatitis, or DVT", "History of prior cellulitis, trauma, or skin breakdown", "Immunocompromised status or unusual host factors" ] }, { "question": "What is the appropriate empiric antibiotic regimen?", "required_information": [ "Non-purulent: target Streptococcus (e.g., cefazolin, ceftriaxone, amoxicillin-clavulanate)", "Purulent or abscess-forming: include MRSA coverage (e.g., TMP-SMX, doxycycline, clindamycin, or vancomycin if IV needed)", "Consider GNR/anaerobic coverage for diabetic, immunocompromised, or perineal cases", "Oral vs IV depends on systemic signs, comorbidities, and response to prior therapy", "Local resistance patterns and allergy history" ] }, { "question": "When is imaging or further diagnostic evaluation needed?", "required_information": [ "Lack of clinical improvement after 48\u201372 hours", "Suspicion for deeper infection (e.g., abscess, necrotizing fasciitis, osteomyelitis)", "Recurrent cases or systemic toxicity", "Immunocompromised host with atypical presentation", "Use of ultrasound or CT to detect abscess or fluid collection" ] }, { "question": "How long should therapy continue and when can it be de-escalated?", "required_information": [ "Typical duration: 5\u20137 days if responding clinically", "Consider oral step-down when stable", "Non-severe MRSA infection: can often switch to TMP-SMX or doxycycline if susceptible", "Monitor for leukocytosis, fever resolution, and improving erythema", "Recurrence may warrant decolonization or address predisposing factors" ] }, { "question": "What preventive measures are needed for recurrent cellulitis?", "required_information": [ "Skin care and hygiene counseling", "Control of predisposing factors: tinea pedis, lymphedema, venous stasis", "Consider suppressive antibiotics (e.g., low-dose penicillin) if \u22653 episodes/year", "Evaluate for immune deficiency in atypical or recurrent cases", "MRSA decolonization (e.g., mupirocin + chlorhexidine) if recurrent abscesses" ] } ], "key_references": [ { "title": "IDSA Guidelines for Skin and Soft Tissue Infections (2014)", "url": "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/" }, { "title": "CDC MRSA Management Resources", "url": "https://www.cdc.gov/mrsa/community/index.html" }, { "title": "NEJM Review on Cellulitis and Erysipelas", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1807050" } ] }, "abscess": { "syndrome_name": "Abscess (Skin, Perirectal, Breast, etc.)", "definition": "Localized collection of pus within dermis or subcutaneous tissue, often caused by Staphylococcus aureus (including MRSA). Management involves source control (incision and drainage) and consideration of adjunctive antibiotics based on severity and patient risk factors.", "common_consult_questions": [ { "question": "Is this lesion truly an abscess or another entity (e.g., cellulitis, cyst, necrotizing fasciitis)?", "required_information": [ "Physical exam: fluctuant, tender, erythematous mass", "Pain out of proportion or systemic toxicity", "History of prior abscesses or recent trauma/injection", "Imaging (ultrasound or CT) if deep, large, or unclear etiology", "Location (e.g., perirectal, breast, groin, axilla)" ] }, { "question": "Is incision and drainage (I&D) indicated, and what is the best method?", "required_information": [ "Size and location of abscess", "Accessibility and patient stability", "Whether point-of-care ultrasound confirms fluid pocket", "Setting (e.g., bedside, OR, interventional radiology)", "Need for sedation or procedural support" ] }, { "question": "Are antibiotics indicated in addition to drainage?", "required_information": [ "Signs of systemic infection (fever, leukocytosis)", "Cellulitis beyond abscess margins", "Multiple lesions or recurrent MRSA", "Immunosuppression, diabetes, or very young/elderly", "Coverage for MRSA (e.g., TMP-SMX, doxycycline, clindamycin, vancomycin)" ] }, { "question": "What is the follow-up and wound care plan?", "required_information": [ "Need for packing or not (based on cavity size and drainage)", "Recheck within 24\u201348 hours for worsening erythema or inadequate drainage", "Patient education on warm compresses and hygiene", "Reinforcement of return precautions if systemic signs develop", "Referral to wound care or surgical follow-up in select cases" ] }, { "question": "What should be done in the setting of recurrent or complicated abscesses?", "required_information": [ "History of prior MRSA infections or colonization", "Family or household contact with similar infections", "Hygiene practices and communal exposure risks", "MRSA decolonization protocol (e.g., nasal mupirocin, chlorhexidine washes)", "Consider immunodeficiency or hidradenitis suppurativa evaluation" ] } ], "key_references": [ { "title": "IDSA Guidelines for SSTI (2014)", "url": "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/" }, { "title": "CDC MRSA Skin Infection Management", "url": "https://www.cdc.gov/mrsa/community/treatment/index.html" }, { "title": "NEJM Review: Management of Skin Abscesses", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1706792" } ] }, "necrotizing_fasciitis": { "syndrome_name": "Necrotizing Fasciitis", "definition": "Life-threatening soft tissue infection involving deep fascia with rapid progression, tissue necrosis, and high mortality. Early recognition and surgical debridement are critical. Often polymicrobial or caused by Streptococcus pyogenes, Clostridium spp., or MRSA.", "common_consult_questions": [ { "question": "How can necrotizing fasciitis be differentiated from cellulitis or abscess?", "required_information": [ "Pain out of proportion to exam", "Rapid progression of erythema, edema, or bullae", "Systemic toxicity (fever, hypotension, altered mental status)", "Skin changes: dusky color, crepitus, ecchymosis, skin anesthesia", "Imaging (CT or MRI) suggesting fascial air, fluid, or thickening" ] }, { "question": "What is the optimal diagnostic and surgical strategy?", "required_information": [ "Immediate surgical consultation\u2014do not delay for imaging if suspicion is high", "OR findings: \u201cdishwater\u201d fluid, lack of bleeding, gray necrotic fascia", "CT scan: fascial gas, fluid tracking, muscle involvement", "Labs: WBC, CRP, lactate, LRINEC score (limited utility in high-risk cases)", "Blood cultures, intraoperative tissue cultures, Gram stain" ] }, { "question": "What empiric antibiotics should be started immediately?", "required_information": [ "Broad coverage for polymicrobial and monomicrobial causes", "Start: Vancomycin or linezolid (MRSA); Piperacillin-tazobactam or carbapenem (GNR/anaerobes); Clindamycin (toxin suppression for Strep pyogenes, Clostridium)", "Modify based on culture results and surgical findings", "Adjust dosing for renal/liver function" ] }, { "question": "How should postoperative care and antibiotic duration be managed?", "required_information": [ "Daily wound exams and serial debridement as needed", "Duration: 2\u20133 weeks or until no further debridement needed and clinical stability achieved", "Transition to targeted therapy once cultures finalize", "Assess for secondary infections or sepsis complications", "Coordination with surgery, wound care, and ICU teams" ] }, { "question": "What are risk factors and preventive considerations in high-risk patients?", "required_information": [ "Diabetes, immunosuppression, malignancy, cirrhosis", "Recent trauma, surgery, or injection drug use", "Hospital or ICU exposures (nosocomial NF)", "Education on early recognition in prior cases or high-risk populations", "Support for recovery, including physical therapy and reconstructive planning" ] } ], "key_references": [ { "title": "IDSA Guidelines for Skin and Soft Tissue Infections (2014)", "url": "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/" }, { "title": "NEJM Clinical Review: Necrotizing Fasciitis", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1803670" }, { "title": "CDC Clinical Guidelines for Group A Streptococcal Infections", "url": "https://www.cdc.gov/groupastrep/diseases-hcp/index.html" } ] }, "diabetic_foot_infection": { "syndrome_name": "Diabetic Foot Infection (DFI)", "definition": "Soft tissue or bone infection of the foot in a patient with diabetes, often resulting from ulceration or trauma. Requires assessment of vascular supply, depth of involvement, and systemic signs to guide management.", "common_consult_questions": [ { "question": "How can we differentiate colonization from true infection?", "required_information": [ "Clinical signs of infection: erythema, warmth, swelling, purulence, foul odor", "Systemic signs: fever, leukocytosis, elevated CRP", "Probe-to-bone test, presence of deep or undermining ulcer", "Imaging findings (plain film, MRI) suggesting osteomyelitis", "Culture from deep tissue or bone vs surface swab" ] }, { "question": "What diagnostic workup should be done for suspected osteomyelitis or deep tissue involvement?", "required_information": [ "Plain X-ray (look for periosteal reaction, erosions)", "MRI with contrast if suspecting osteo or abscess", "Labs: ESR, CRP, WBC", "Bone biopsy or deep tissue culture if available", "Vascular assessment: pulses, ankle-brachial index (ABI), toe pressures" ] }, { "question": "What empiric antibiotics should be started and when should they be adjusted?", "required_information": [ "Mild: oral agents covering gram-positive cocci (e.g., cephalexin, amoxicillin-clavulanate)", "Moderate to severe: IV therapy covering MSSA, MRSA (if prior MRSA), gram-negatives, anaerobes", "Considerations for: prior cultures, recent antibiotic exposure, hospitalization, renal function", "De-escalate based on cultures and clinical improvement", "Duration: 1\u20132 weeks (soft tissue), 4\u20136 weeks (osteomyelitis)" ] }, { "question": "When is surgical consultation or debridement required?", "required_information": [ "Signs of abscess, necrosis, or gangrene", "Foul-smelling or draining wounds despite antibiotics", "Failure to improve clinically", "Need for amputation or limb salvage", "Coordination with wound care and podiatry for ongoing management" ] }, { "question": "What are the key components of long-term prevention and follow-up?", "required_information": [ "Glycemic control and diabetes management", "Offloading footwear and ulcer prevention strategies", "Vascular referral if ischemia or poor healing suspected", "Routine foot exams and patient education", "Follow-up with wound care and ID if chronic or recurrent" ] } ], "key_references": [ { "title": "IDSA Guidelines for Diabetic Foot Infections (2012)", "url": "https://www.idsociety.org/practice-guideline/diabetic-foot/" }, { "title": "IWGDF Guidelines", "url": "https://iwgdfguidelines.org/" }, { "title": "NEJM Review on Diabetic Foot Ulcers and Infections", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1915543" } ] }, "infected_pressure_ulcer": { "syndrome_name": "Infected Pressure Ulcer", "definition": "Localized infection of a pressure-induced skin breakdown, most commonly over bony prominences. Often polymicrobial and associated with biofilm, chronic wound flora, and risk for osteomyelitis.", "common_consult_questions": [ { "question": "How can we distinguish colonization from true infection?", "required_information": [ "Clinical signs: increased erythema, warmth, swelling, purulent drainage, foul odor", "Delayed healing despite good wound care", "Presence of systemic signs (fever, leukocytosis, delirium in elderly)", "Worsening of wound depth or necrosis", "Deep tissue culture vs superficial swab" ] }, { "question": "Is osteomyelitis present beneath this pressure ulcer?", "required_information": [ "Positive probe-to-bone test", "Elevated ESR/CRP and leukocytosis", "Plain X-rays: cortical erosion or periosteal reaction", "MRI: marrow edema, cortical destruction", "Bone biopsy or intraoperative cultures if diagnosis unclear" ] }, { "question": "What empiric antibiotic therapy is appropriate?", "required_information": [ "Likely polymicrobial flora: gram-positive (MSSA, MRSA), gram-negative, anaerobes", "Recent culture history or hospital exposure", "Coverage: vancomycin + ceftriaxone/metronidazole or ampicillin-sulbactam", "Modify once cultures finalize or no deep tissue infection identified", "Avoid long-term antibiotics for colonization alone" ] }, { "question": "What are the indications for surgical consultation or debridement?", "required_information": [ "Non-healing or worsening ulcer despite optimized medical care", "Suspected or confirmed necrotic tissue, osteomyelitis, or abscess", "Functional impairment or concern for deeper spread (fascia, muscle, bone)", "Need for closure, flap, or graft planning", "Coordination with plastic surgery, wound care, and rehab" ] }, { "question": "What strategies can prevent recurrence or further complications?", "required_information": [ "Optimization of offloading and turning schedules", "Pressure redistribution (e.g., specialty mattresses, cushions)", "Nutritional support and glycemic control", "Wound care follow-up and dressing protocol", "Patient and caregiver education on skin monitoring and hygiene" ] } ], "key_references": [ { "title": "IDSA Guidelines for Pressure Ulcer Infections (2014)", "url": "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/" }, { "title": "NEJM Review on Pressure Ulcers", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1806380" }, { "title": "NPUAP/EPUAP Pressure Injury Guidelines", "url": "https://npiap.com/" } ] }, "post_surgical_wound_infection": { "syndrome_name": "Post-Surgical Wound Infection", "definition": "Infection occurring at or near a surgical incision within 30 days of the procedure (or 90 days if implant involved). Classified as superficial incisional, deep incisional, or organ/space. Requires assessment for systemic signs and wound complications.", "common_consult_questions": [ { "question": "Is this a surgical site infection (SSI) or normal postoperative inflammation?", "required_information": [ "Timing since surgery (typical SSI occurs within 5\u201330 days)", "Signs: increasing erythema, warmth, purulent drainage, separation of wound", "Fever or systemic symptoms", "Comparison to baseline postoperative appearance", "Imaging if concern for deep collection or organ/space involvement" ] }, { "question": "What diagnostic evaluation is indicated?", "required_information": [ "Wound exam and documentation of drainage, erythema, and separation", "Culture of purulent material if present", "Blood cultures if febrile or hemodynamically unstable", "Wound ultrasound or CT scan to evaluate for abscess or fluid collection", "Surgical consultation if dehiscence or signs of deep infection" ] }, { "question": "What empiric antibiotics should be initiated?", "required_information": [ "Type of surgery (clean vs clean-contaminated vs contaminated)", "Coverage for Staphylococcus aureus (MSSA/MRSA) is standard", "Broader gram-negative/anaerobic coverage if intra-abdominal or pelvic procedure", "Consider local antibiogram, allergy profile, renal function", "Adjust based on cultures and wound source control" ] }, { "question": "When is surgical intervention or drainage necessary?", "required_information": [ "Failure to improve with antibiotics", "Abscess formation, wound dehiscence, or ongoing drainage", "Implant involvement or concern for prosthetic infection", "Fascia or deeper tissue involvement (organ/space infection)", "Coordination with surgery for debridement, washout, or removal" ] }, { "question": "What follow-up and prevention strategies should be considered?", "required_information": [ "Wound care plan (dressing changes, packing, negative pressure if applicable)", "Diabetes control, smoking cessation, and nutritional optimization", "Use of perioperative prophylaxis in future surgeries", "MRSA screening/decolonization if recurrent SSIs", "Patient education on signs of recurrence or worsening" ] } ], "key_references": [ { "title": "CDC Definitions of Surgical Site Infections (SSI)", "url": "https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf" }, { "title": "IDSA Guidelines for Skin and Soft Tissue Infections (2014)", "url": "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/" }, { "title": "SHEA/IDSA Compendium of Strategies to Prevent SSI", "url": "https://www.shea-online.org/index.php/journal-news/compendium" } ] }, "animal_bite_wound_infection": { "syndrome_name": "Animal Bite Wound Infection", "definition": "Infections resulting from mammalian bites (dog, cat, human), often polymicrobial and involving skin flora, anaerobes, and fastidious organisms like Pasteurella multocida or Eikenella corrodens. Requires timely wound evaluation and prophylactic or therapeutic antibiotics.", "common_consult_questions": [ { "question": "What is the initial wound evaluation and infection risk assessment?", "required_information": [ "Type of animal (dog, cat, human) and bite location", "Time since injury and whether it was washed/debrided", "Depth of wound (superficial vs puncture vs crush)", "Risk of bone, joint, or tendon involvement", "Host risk factors (e.g., immunosuppression, diabetes, asplenia)" ] }, { "question": "When are antibiotics indicated for animal bite wounds?", "required_information": [ "Indications for prophylaxis: hand wounds, deep puncture, crush injuries, facial wounds, immunocompromised host", "Infected wounds: signs of erythema, purulence, swelling, systemic signs", "Standard empiric therapy: amoxicillin-clavulanate", "Alternatives: doxycycline or TMP-SMX + metronidazole or clindamycin (if penicillin allergy)", "Duration: 3\u20135 days prophylactic, 7\u201310 days if infected" ] }, { "question": "What diagnostic workup is needed if deeper infection is suspected?", "required_information": [ "Plain films to assess for foreign bodies, fractures, or gas", "Ultrasound or CT if abscess, tendon sheath involvement, or joint space suspected", "Culture only from clinically infected wounds", "Tetanus vaccination status and rabies risk assessment", "Joint aspiration if bite near a prosthetic or native joint" ] }, { "question": "When should rabies post-exposure prophylaxis (PEP) be considered?", "required_information": [ "Animal type and local rabies prevalence", "Wild or unvaccinated domestic animal, especially bats, raccoons, skunks, foxes", "Provoked vs unprovoked bite", "Animal available for quarantine or testing?", "PEP: Rabies vaccine + rabies immunoglobulin for naive patients" ] }, { "question": "What are the long-term follow-up and preventive considerations?", "required_information": [ "Wound healing and signs of delayed infection", "Consider plastic surgery if scarring or complex wound closure needed", "Counseling on animal behavior, supervision of pets, and wound hygiene", "Public health reporting if applicable (especially for rabies, exotic species)", "Immunization review and bite documentation" ] } ], "key_references": [ { "title": "IDSA Guidelines for Animal Bite Wounds (2003)", "url": "https://academic.oup.com/cid/article/36/11/1481/348269" }, { "title": "CDC Rabies Post-Exposure Guidelines", "url": "https://www.cdc.gov/rabies/medical_care/index.html" }, { "title": "NEJM Review on Mammalian Bites", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1800866" } ] }, "sti_workup": { "syndrome_name": "Sexually Transmitted Infections (STI) Workup", "definition": "Evaluation of individuals for known or suspected sexually transmitted infections (STIs), which may be symptomatic or asymptomatic. Includes bacterial, viral, and protozoal pathogens, with consideration for co-infection, partner management, and public health reporting.", "common_consult_questions": [ { "question": "What is the appropriate diagnostic evaluation for STI symptoms or screening?", "required_information": [ "Symptoms: discharge, dysuria, ulcers, rash, abdominal/pelvic pain", "Anatomic sites of exposure: oral, genital, rectal", "NAAT testing (preferred): Chlamydia trachomatis, Neisseria gonorrhoeae (urine, pharynx, rectum)", "Serology: HIV, syphilis (RPR/treponemal), HBV, HCV, HSV-2 (if recurrent or atypical)", "Wet prep or rapid antigen for Trichomonas vaginalis (females); Gram stain for urethral discharge (males)" ] }, { "question": "What empiric therapy is appropriate while awaiting results?", "required_information": [ "Urethritis/cervicitis: ceftriaxone 500 mg IM + doxycycline 100 mg BID x 7 days", "Vaginitis: metronidazole or fluconazole depending on suspected etiology", "Genital ulcers: acyclovir (for HSV), benzathine penicillin G (if syphilis suspected), azithromycin (for chancroid where prevalent)", "Sexual assault or high-risk exposure: empiric treatment for GC/CT/trichomonas + HIV PEP if indicated", "Test-of-cure indicated in pregnancy or for pharyngeal GC" ] }, { "question": "How should syphilis be staged and treated?", "required_information": [ "RPR titer and treponemal antibody result", "Symptoms: chancre, rash, mucous patches, alopecia, neuro-visual symptoms", "HIV status and prior treatment history", "CSF testing if neurologic/ocular symptoms or treatment failure suspected", "Benzathine penicillin G standard for early/late syphilis; IV penicillin for neurosyphilis" ] }, { "question": "How should partner notification and treatment be handled?", "required_information": [ "Timing of last sexual contact(s) and partner symptoms", "Treat all recent partners for GC/CT within 60 days, or last partner if longer", "Public health reporting requirements", "Expedited partner therapy (EPT) legality and availability", "Partner follow-up for HIV/STI screening and PrEP eligibility" ] }, { "question": "What are follow-up and prevention recommendations?", "required_information": [ "Retesting in 3 months for GC/CT due to high reinfection risk", "Offer HIV PrEP for at-risk individuals", "HPV vaccination (up to age 45 if indicated)", "Education on condom use, STI testing frequency, and symptom recognition", "Linkage to sexual health clinics and partner services" ] } ], "key_references": [ { "title": "CDC 2021 STI Treatment Guidelines", "url": "https://www.cdc.gov/std/treatment-guidelines/default.htm" }, { "title": "USPSTF STI Screening Recommendations", "url": "https://www.uspreventiveservicestaskforce.org/" }, { "title": "WHO STI Management Guidelines", "url": "https://www.who.int/publications/i/item/9789241549714" } ] }, "pelvic_inflammatory_disease": { "syndrome_name": "Pelvic Inflammatory Disease (PID)", "definition": "Infection of the upper female reproductive tract (uterus, fallopian tubes, ovaries) often caused by sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoeae, or endogenous anaerobes and gram-negative bacteria. Prompt diagnosis and treatment are essential to prevent long-term sequelae.", "common_consult_questions": [ { "question": "What are the diagnostic criteria for PID?", "required_information": [ "Lower abdominal or pelvic pain in sexually active female", "Cervical motion tenderness, adnexal tenderness, or uterine tenderness on exam", "Supporting findings: cervical mucopurulent discharge, elevated WBCs on wet prep, fever, elevated CRP/ESR", "Exclude other causes: appendicitis, ectopic pregnancy, ovarian torsion", "Consider transvaginal ultrasound if diagnosis unclear" ] }, { "question": "What is the appropriate empiric treatment regimen for PID?", "required_information": [ "Mild/moderate PID (outpatient): Ceftriaxone 500 mg IM \u00d71 + doxycycline 100 mg BID \u00d714 days \u00b1 metronidazole 500 mg BID \u00d714 days", "Severe PID (inpatient): IV cefotetan/cefoxitin + doxycycline OR clindamycin + gentamicin", "Switch to oral after 24\u201348 hours of improvement", "Treat sexual partners for GC/CT" ] }, { "question": "When should hospitalization be considered?", "required_information": [ "Severe illness, nausea/vomiting, high fever", "Pregnancy", "TOA (tubo-ovarian abscess) or peritonitis", "Failure of outpatient treatment within 48\u201372 hours", "Inability to tolerate oral therapy or ensure follow-up" ] }, { "question": "What complications or alternative diagnoses should be ruled out?", "required_information": [ "Tubo-ovarian abscess: fever, adnexal mass, leukocytosis, pain out of proportion", "Fitz-Hugh\u2013Curtis syndrome: RUQ pain and liver capsule inflammation", "Ectopic pregnancy: rule out with pregnancy test and transvaginal ultrasound", "Endometritis or pelvic abscess (esp. post-procedure)", "Recurrent PID risk if partner not treated" ] }, { "question": "What are the follow-up and preventive strategies for PID?", "required_information": [ "Re-evaluate clinically within 72 hours (esp. outpatient treatment)", "Retesting for GC/CT in 3 months", "Partner notification and treatment", "Counsel on condom use, STI screening, and contraception", "Consider HIV/PrEP evaluation and HPV vaccination" ] } ], "key_references": [ { "title": "CDC 2021 STI Guidelines \u2013 PID Section", "url": "https://www.cdc.gov/std/treatment-guidelines/pid.htm" }, { "title": "ACOG Committee Opinion on PID Diagnosis and Management", "url": "https://www.acog.org/" }, { "title": "NEJM Review: Pelvic Inflammatory Disease", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1700689" } ] }, "epididymitis_orchitis": { "syndrome_name": "Epididymitis / Orchitis", "definition": "Inflammation of the epididymis and/or testicle, often due to bacterial infections in sexually active men or urinary tract pathogens in older men. Requires differentiation from testicular torsion and tailored antibiotic therapy based on age and risk factors.", "common_consult_questions": [ { "question": "What is the likely etiology based on age and sexual history?", "required_information": [ "Age <35 years: likely STI-related (Chlamydia, Gonorrhea)", "Age >35 or with urinary symptoms: enteric gram-negative rods (E. coli)", "Insertive anal intercourse: broader gram-negative and anaerobic pathogens", "Recent urologic instrumentation or catheterization", "Trauma or heavy lifting may mimic infectious presentation" ] }, { "question": "What diagnostic tests should be performed?", "required_information": [ "Urinalysis and urine culture", "NAAT for N. gonorrhoeae and C. trachomatis", "Scrotal ultrasound with Doppler (to rule out torsion, abscess, or mass)", "Physical exam: swelling, tenderness, pain relief with elevation (Prehn\u2019s sign)", "HIV and syphilis screening if STI suspected" ] }, { "question": "What is the appropriate empiric treatment regimen?", "required_information": [ "Age <35 or STI risk: ceftriaxone 500 mg IM \u00d71 + doxycycline 100 mg BID \u00d710 days", "Insertive anal sex: ceftriaxone + levofloxacin or ofloxacin", "Age >35 or UTI-related: levofloxacin 500 mg daily \u00d710\u201314 days or TMP-SMX if sensitive", "Adjust based on culture results and response to treatment", "Supportive care: scrotal elevation, NSAIDs, activity restriction" ] }, { "question": "When should hospitalization or further evaluation be considered?", "required_information": [ "Severe pain, high fever, or systemic illness", "Failure to respond within 48\u201372 hours", "Suspicion of abscess or testicular infarction", "Inability to tolerate oral antibiotics", "Suspicion of alternative diagnoses (e.g., torsion, tumor)" ] }, { "question": "What follow-up and counseling should be provided?", "required_information": [ "Reassess pain and swelling within 1 week", "Sexual partner evaluation and treatment if STI confirmed", "Abstain from sex until symptom resolution and partner treated", "STI prevention education: condoms, testing frequency", "Consider follow-up ultrasound if no improvement" ] } ], "key_references": [ { "title": "CDC 2021 STI Guidelines \u2013 Epididymitis Section", "url": "https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm" }, { "title": "AUA Guidelines on Acute Scrotum and Orchitis", "url": "https://www.auanet.org/" }, { "title": "NEJM Clinical Review on Scrotal Emergencies", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1911826" } ] }, "pyelonephritis": { "syndrome_name": "Pyelonephritis", "definition": "Upper urinary tract infection involving the renal parenchyma and pelvis. Presents with fever, flank pain, and systemic symptoms, often caused by E. coli or other Enterobacterales. May be complicated by obstruction, bacteremia, or renal abscess.", "common_consult_questions": [ { "question": "What clinical findings and diagnostics confirm pyelonephritis?", "required_information": [ "Symptoms: fever, chills, flank pain, nausea/vomiting, dysuria, frequency", "Costovertebral angle (CVA) tenderness", "Urinalysis: pyuria, bacteriuria, WBC casts (if available)", "Urine culture with antimicrobial sensitivities", "Blood cultures if febrile or systemic signs" ] }, { "question": "When is imaging necessary in pyelonephritis?", "required_information": [ "Lack of clinical improvement after 48\u201372 hours of therapy", "Concern for obstruction, stones, or abscess", "History of nephrolithiasis or structural urologic abnormalities", "Severe or relapsing infections", "Imaging modality: CT abdomen/pelvis with contrast (preferred); renal ultrasound if concern for obstruction in pregnancy or avoiding radiation" ] }, { "question": "What is the appropriate empiric antibiotic therapy?", "required_information": [ "Severity of illness and need for hospitalization", "Oral outpatient: ciprofloxacin or levofloxacin (if local resistance <10%), or TMP-SMX (if susceptible)", "IV inpatient: ceftriaxone, cefepime, piperacillin-tazobactam, or ertapenem (if ESBL risk)", "Adjust based on urine culture and sensitivities", "Typical duration: 5\u20137 days (fluoroquinolone), 10\u201314 days (beta-lactams)" ] }, { "question": "What are criteria for complicated pyelonephritis or need for hospitalization?", "required_information": [ "Pregnancy, diabetes, immunosuppression, CKD, urinary tract obstruction", "Urosepsis or hemodynamic instability", "Inability to tolerate oral antibiotics or fluids", "Inadequate outpatient follow-up", "High risk of multidrug resistance (recent antibiotics, healthcare exposure)" ] }, { "question": "What is the follow-up strategy after treatment?", "required_information": [ "Symptom resolution and afebrile status within 48\u201372 hours", "No routine test-of-cure unless pregnant or persistent/recurrent symptoms", "Address risk factors for recurrence (hydration, hygiene, anatomic abnormalities)", "Consider urology referral if recurrent pyelonephritis or structural concern", "Reinforce medication adherence and early return for worsening symptoms" ] } ], "key_references": [ { "title": "IDSA Guidelines for Diagnosis and Treatment of Uncomplicated and Complicated UTI (2011)", "url": "https://www.idsociety.org/practice-guideline/urinary-tract-infection-uti-in-adults/" }, { "title": "CDC UTI Treatment Recommendations", "url": "https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/index.html" }, { "title": "NEJM Review: Pyelonephritis in Adults", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1604482" } ] }, "recurrent_uti": { "syndrome_name": "Recurrent Urinary Tract Infection (UTI)", "definition": "Repeated episodes of symptomatic UTI, defined as \u22652 infections in 6 months or \u22653 in 12 months. May be due to reinfection, relapse, or risk factors like incomplete bladder emptying, anatomic abnormalities, or hormonal changes.", "common_consult_questions": [ { "question": "What defines a recurrent UTI and what evaluation is needed?", "required_information": [ "Number and timing of prior episodes", "Documentation of positive urine cultures during symptoms", "Reinfection (different organism) vs relapse (same organism within 2 weeks)", "Risk factors: menopause, diabetes, sexual activity, incomplete emptying, catheter use", "Consider post-void residual, renal ultrasound, or cystoscopy if red flags" ] }, { "question": "How should antibiotic prophylaxis or self-treatment be approached?", "required_information": [ "Frequency and severity of infections", "Candidate for post-coital prophylaxis (e.g., 1 dose nitrofurantoin or TMP-SMX)", "Low-dose nightly prophylaxis options (nitrofurantoin, TMP-SMX, cephalexin)", "Risks of resistance, adverse effects, and C. difficile", "Use of symptom-based self-start therapy for select patients" ] }, { "question": "What non-antibiotic prevention strategies are effective?", "required_information": [ "Vaginal estrogen therapy in postmenopausal women", "Hydration and voiding practices", "Cranberry prophylaxis (capsules > juice)", "Avoiding spermicides and unnecessary catheter use", "Address constipation or pelvic floor dysfunction" ] }, { "question": "When should urology or gynecology referral be considered?", "required_information": [ "Hematuria, obstruction, stones, recurrent pyelonephritis", "Suspected anatomic or functional urinary tract abnormality", "Refractory to prophylaxis or unclear etiology", "Need for cystoscopy or urodynamic evaluation", "Recurrent infection with multidrug-resistant organisms" ] }, { "question": "What is the role of urine testing and culture in recurrence?", "required_information": [ "Avoid screening or treating asymptomatic bacteriuria (except pregnancy or urologic procedures)", "Always send urine culture during symptomatic episodes before treatment", "Track resistance patterns to guide future empiric therapy", "Avoid repeat testing after symptom resolution", "Educate on when to seek care and provide urine collection guidance" ] } ], "key_references": [ { "title": "IDSA Guidelines for Recurrent UTI in Women (2019)", "url": "https://www.idsociety.org/practice-guideline/urinary-tract-infection-uti-in-adults/" }, { "title": "CDC UTI Stewardship Guidance", "url": "https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/index.html" }, { "title": "NEJM Review: Recurrent UTIs in Women", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1905840" } ] }, "urosepsis": { "syndrome_name": "Urosepsis", "definition": "Life-threatening organ dysfunction due to a dysregulated host response to urinary tract infection. Most commonly caused by ascending E. coli or other gram-negative infections; may be associated with obstruction, catheter use, or recent urologic procedures.", "common_consult_questions": [ { "question": "What criteria define urosepsis and how is it diagnosed?", "required_information": [ "Source: known or suspected UTI (e.g., pyelonephritis, prostatitis, obstructive uropathy)", "Sepsis: suspected infection + organ dysfunction (e.g., hypotension, altered mental status, elevated lactate)", "SOFA or qSOFA score if available", "Symptoms: fever, flank pain, dysuria, urgency, CVA tenderness", "Labs: blood and urine cultures, lactate, CBC, BMP, LFTs, coagulation panel" ] }, { "question": "What empiric antimicrobial therapy should be initiated?", "required_information": [ "Broad-spectrum coverage including E. coli, Klebsiella, Enterococcus, Pseudomonas (if risk factors)", "Examples: cefepime, piperacillin-tazobactam, or carbapenem for ESBL risk", "Vancomycin if MRSA or catheter-related source is suspected", "Tailor based on local antibiogram, allergy history, and prior culture data", "Adjust therapy once cultures and susceptibilities return" ] }, { "question": "What is the role of source control in urosepsis?", "required_information": [ "Hydronephrosis or obstructive uropathy: urgent decompression (e.g., nephrostomy tube, stent)", "Catheter-associated infection: remove or replace urinary catheter", "Perinephric or renal abscess: imaging-guided drainage or surgical evaluation", "Prostatitis: avoid prostatic massage; choose drugs with good prostate penetration", "Coordination with urology/interventional radiology as needed" ] }, { "question": "When should ICU-level care be considered?", "required_information": [ "Septic shock (hypotension requiring vasopressors, lactate \u22652 despite fluids)", "Multiorgan dysfunction (e.g., respiratory, renal, hepatic failure)", "Altered mental status or rapidly deteriorating clinical picture", "High SOFA or NEWS2 score", "Need for close monitoring and fluid resuscitation" ] }, { "question": "What is the follow-up plan after stabilization?", "required_information": [ "Duration of therapy: typically 7\u201314 days depending on source and response", "De-escalation to oral antibiotics if improving and cultures support it", "Repeat imaging if no improvement within 48\u201372 hours", "Evaluate for and correct predisposing conditions (e.g., stones, BPH, instrumentation)", "Outpatient follow-up for imaging and urology referral as needed" ] } ], "key_references": [ { "title": "IDSA Sepsis and UTI Guidelines", "url": "https://www.idsociety.org/practice-guideline/urinary-tract-infection-uti-in-adults/" }, { "title": "Surviving Sepsis Campaign Guidelines (2021)", "url": "https://www.sccm.org/SurvivingSepsisCampaign/Home" }, { "title": "NEJM Review: Sepsis and Septic Shock", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1808165" } ] }, "asymptomatic_bacteriuria": { "syndrome_name": "Asymptomatic Bacteriuria (ASB)", "definition": "The presence of \u226510\u2075 CFU/mL of one or more organisms in urine without signs or symptoms of a urinary tract infection. Often found incidentally and usually does not require treatment.", "common_consult_questions": [ { "question": "What defines asymptomatic bacteriuria vs a symptomatic UTI?", "required_information": [ "Presence of bacteria in urine culture without dysuria, urgency, frequency, flank pain, fever, or suprapubic discomfort", "No systemic signs attributable to urinary infection", "In elderly, altered mental status alone is not a UTI symptom unless accompanied by focal signs", "Evaluate for alternative causes of symptoms" ] }, { "question": "When should asymptomatic bacteriuria be treated?", "required_information": [ "Indications to treat ASB: pregnancy, prior to urologic procedures with anticipated mucosal bleeding (e.g., TURP)", "Do NOT treat ASB in: elderly patients without symptoms, patients with indwelling catheters (unless symptomatic), diabetic, spinal cord injury, or transplant recipients (unless early post-op or symptomatic)", "Base treatment on culture results and sensitivities if indicated" ] }, { "question": "What is the appropriate workup if ASB is discovered?", "required_information": [ "Confirm absence of urinary symptoms", "Evaluate for inappropriate ordering of urine cultures (avoid 'pan-culturing')", "Review recent antibiotic use, catheter status, and risk for MDR organisms", "Educate care team on stewardship principles and when to test", "Consider imaging only if recurrent infection or structural concern" ] }, { "question": "How does catheter use affect interpretation and management?", "required_information": [ "Bacteriuria is nearly universal after several days of catheterization", "Do not treat unless there are new symptoms (fever, flank pain, hematuria, delirium with other signs)", "Replace catheter if symptomatic and send urine from fresh sample", "Avoid routine surveillance cultures", "Promote early removal of catheter if no longer indicated" ] }, { "question": "What are best practices for stewardship and prevention of overtreatment?", "required_information": [ "Educate staff to avoid ordering urine cultures in absence of symptoms", "Avoid dipstick testing in catheterized or asymptomatic patients", "Use local guidelines and decision-support to limit inappropriate treatment", "Document reasoning clearly when withholding antibiotics", "Avoid prolonged or broad-spectrum antibiotics for ASB" ] } ], "key_references": [ { "title": "IDSA Guidelines for ASB (2019)", "url": "https://www.idsociety.org/practice-guideline/asymptomatic-bacteriuria/" }, { "title": "CDC Core Elements of Antibiotic Stewardship", "url": "https://www.cdc.gov/antibiotic-use/core-elements/index.html" }, { "title": "NEJM Review: Asymptomatic Bacteriuria", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1808059" } ] }, "prostatitis": { "syndrome_name": "Prostatitis (Acute and Chronic)", "definition": "Inflammation and/or infection of the prostate gland. Acute bacterial prostatitis presents with systemic and urinary symptoms; chronic prostatitis may be inflammatory or non-inflammatory and is often associated with pelvic discomfort.", "common_consult_questions": [ { "question": "How is prostatitis diagnosed and classified?", "required_information": [ "Acute bacterial prostatitis: sudden onset fever, chills, dysuria, perineal pain, urinary retention", "Chronic bacterial prostatitis: recurrent UTI with same organism, pelvic discomfort", "Chronic pelvic pain syndrome: symptoms without infection or inflammation", "DRE: tender, boggy, swollen prostate (avoid vigorous exam)", "Urinalysis and urine culture before antibiotics" ] }, { "question": "What is the appropriate antibiotic therapy?", "required_information": [ "Acute bacterial prostatitis: Empiric: fluoroquinolone (cipro/levo) or TMP-SMX; Duration: 2\u20134 weeks (longer if bacteremia or systemic symptoms)", "Chronic bacterial prostatitis: Fluoroquinolone or TMP-SMX for 4\u20136 weeks", "Consider suppressive therapy for recurrent episodes", "Adjust based on culture and sensitivity results", "Avoid macrolides and beta-lactams due to poor prostatic penetration" ] }, { "question": "When should imaging or further diagnostics be performed?", "required_information": [ "Urinary retention, severe symptoms, or no improvement after 48\u201372 hours", "Suspect abscess: perineal pain, fluctuance, persistent fever", "Pelvic CT or transrectal ultrasound for abscess or anatomical abnormalities", "Post-void residual or bladder scan for retention", "HIV testing or STI screening if at risk" ] }, { "question": "When is hospitalization or urology consultation needed?", "required_information": [ "Inability to tolerate oral intake or hemodynamic instability", "Urinary retention requiring catheter (prefer suprapubic over Foley if acute prostatitis)", "Suspected abscess or sepsis", "Chronic symptoms unresponsive to antibiotics", "Concern for prostate cancer or need for biopsy (after infection cleared)" ] }, { "question": "What is the long-term management and prevention strategy?", "required_information": [ "Complete full antibiotic course to reduce recurrence risk", "Monitor for recurrence with cultures during symptomatic episodes", "Address voiding dysfunction or BPH if contributing", "Avoid unnecessary prostate manipulation during active infection", "Consider referral for chronic pelvic pain evaluation if no infection" ] } ], "key_references": [ { "title": "CDC Guidelines on Prostatitis Management", "url": "https://www.cdc.gov/std/treatment-guidelines/prostatitis.htm" }, { "title": "AUA White Paper on Prostatitis Syndromes", "url": "https://www.auanet.org/guidelines/" }, { "title": "NEJM Review: Prostatitis and Chronic Pelvic Pain", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1712105" } ] }, "uti_in_pregnancy": { "syndrome_name": "Urinary Tract Infection in Pregnancy", "definition": "Symptomatic or asymptomatic bacteriuria in pregnancy poses a higher risk of progression to pyelonephritis and adverse maternal/fetal outcomes. Requires prompt diagnosis and safe, effective antibiotic therapy.", "common_consult_questions": [ { "question": "How is a UTI diagnosed and classified in pregnancy?", "required_information": [ "Symptoms: dysuria, urgency, frequency, suprapubic pain, fever, flank pain", "Asymptomatic bacteriuria (ASB): \u226510\u2075 CFU/mL without symptoms (screening recommended in all pregnancies)", "Pyelonephritis: systemic signs (fever, chills, CVA tenderness, nausea/vomiting)", "Urinalysis and urine culture: presence of pyuria and bacteriuria", "Exclude STIs if symptoms overlap" ] }, { "question": "What antibiotics are safe and effective during pregnancy?", "required_information": [ "Safe oral options: Nitrofurantoin (avoid at term), Amoxicillin-clavulanate, Cephalexin, Fosfomycin (single dose, lower efficacy for some organisms)", "Avoid fluoroquinolones and TMP-SMX in first trimester and near term", "Adjust based on culture/sensitivity and gestational age", "Duration: 5\u20137 days for cystitis; 10\u201314 days for pyelonephritis" ] }, { "question": "What is the management of pyelonephritis in pregnancy?", "required_information": [ "Admit for IV antibiotics: ceftriaxone, cefepime, or ertapenem (if ESBL risk)", "Monitor for preterm labor and fetal status", "Transition to oral therapy once afebrile and improving", "Total treatment duration: 10\u201314 days", "Repeat urine culture 1\u20132 weeks after completion" ] }, { "question": "When should screening and follow-up cultures be obtained?", "required_information": [ "Screen all pregnant individuals once in first trimester", "Test of cure for all treated ASB and symptomatic UTI", "Monthly urine cultures for remainder of pregnancy if ASB or UTI documented", "Consider suppressive therapy if recurrent infections" ] }, { "question": "What are long-term strategies for prevention and recurrence?", "required_information": [ "Adequate hydration and regular voiding", "Address constipation or incomplete bladder emptying", "Vaginal estrogen not used in pregnancy", "Suppressive therapy (e.g., nightly nitrofurantoin) in recurrent cases", "Postpartum counseling on UTI risk and future screening" ] } ], "key_references": [ { "title": "IDSA Guidelines for UTI and ASB in Pregnancy", "url": "https://www.idsociety.org/practice-guideline/asymptomatic-bacteriuria/" }, { "title": "ACOG Practice Bulletin No. 91: UTI in Pregnancy", "url": "https://www.acog.org/" }, { "title": "NEJM Review: Urinary Tract Infections in Pregnancy", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1704826" } ] }, "hematuria_with_positive_urine_culture": { "syndrome_name": "Hematuria with Positive Urine Culture", "definition": "Presence of visible or microscopic blood in the urine with a concomitant positive urine culture. While hematuria may occur during cystitis, persistent or gross hematuria warrants evaluation for underlying structural, malignant, or nephrologic causes.", "common_consult_questions": [ { "question": "Is the hematuria likely related to the UTI or another etiology?", "required_information": [ "Symptoms: dysuria, frequency, urgency, suprapubic pain", "Presence of fever, flank pain (suggesting pyelonephritis)", "Resolution of hematuria with infection treatment", "Risk factors for malignancy: smoking, age >35, occupational exposure", "Anticoagulation use or bleeding diathesis" ] }, { "question": "What is the appropriate initial workup?", "required_information": [ "Urinalysis with microscopy: RBC morphology, casts, pyuria", "Urine culture with sensitivities", "Renal function tests (BUN, creatinine)", "Imaging: CT urogram (preferred) or renal ultrasound if suspect stone or mass", "Cystoscopy referral if gross hematuria or persistent microscopic hematuria after infection resolves" ] }, { "question": "How should antibiotics be selected and what is the treatment duration?", "required_information": [ "Pathogen identified and susceptibility", "Empiric options: nitrofurantoin, TMP-SMX, beta-lactams or fluoroquinolones (based on risk/age/site)", "Duration: 3\u20135 days for uncomplicated cystitis, 7\u201314 days for pyelonephritis", "Consider broader spectrum if obstruction, structural abnormality, or recurrent UTI" ] }, { "question": "When is urology or nephrology referral indicated?", "required_information": [ "Persistent hematuria after treatment of infection", "Gross hematuria or visible clots", "Recurrent UTIs with hematuria", "Abnormal imaging (mass, hydronephrosis, stones)", "Proteinuria or RBC casts on microscopy (suggesting glomerular cause)" ] }, { "question": "What are follow-up steps to ensure resolution and exclude serious pathology?", "required_information": [ "Repeat urinalysis after antibiotic course (typically 2\u20134 weeks)", "Ensure negative culture and absence of hematuria", "Educate on hydration, avoidance of bladder irritants, and follow-up plans", "Complete any pending imaging or cystoscopy evaluations", "Consider urine cytology if cancer risk factors are present" ] } ], "key_references": [ { "title": "AUA Guidelines for Hematuria Evaluation (2020)", "url": "https://www.auanet.org/guidelines/" }, { "title": "IDSA UTI Guidelines", "url": "https://www.idsociety.org/practice-guideline/urinary-tract-infection-uti-in-adults/" }, { "title": "NEJM Review: Hematuria in Adults", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1913881" } ] }, "cauti": { "syndrome_name": "Catheter-Associated Urinary Tract Infection (CAUTI)", "definition": "Symptomatic UTI in a patient with a current or recent indwelling urinary catheter (within 48 hours of symptom onset), with positive urine culture and no alternative source of infection.", "common_consult_questions": [ { "question": "How is CAUTI diagnosed and how does it differ from colonization?", "required_information": [ "Fever, suprapubic tenderness, costovertebral angle tenderness, or delirium without other cause", "Positive urine culture with \u226510\u00b3 CFU/mL of \u22651 bacterial species", "Symptoms must not be explained by other infections", "Asymptomatic bacteriuria is common and should not be treated", "Avoid relying on urine odor or cloudiness alone" ] }, { "question": "What is the appropriate workup for suspected CAUTI?", "required_information": [ "Remove or replace the catheter before obtaining urine culture", "Blood cultures if febrile or septic", "Assess for signs of obstruction or bladder retention", "Review recent antimicrobial exposure", "Consider renal/bladder imaging if sepsis or anatomic abnormality suspected" ] }, { "question": "How should empiric antibiotic therapy be selected?", "required_information": [ "Local antibiogram and patient-specific resistance history", "Empiric: ceftriaxone, cefepime, piperacillin-tazobactam, or carbapenem (if ESBL or MDRO risk)", "Coverage for Enterobacterales, Pseudomonas (if risk), and Enterococcus if catheter long-term", "Vancomycin only if concern for MRSA hematogenous source", "Narrow therapy when susceptibilities available" ] }, { "question": "When is catheter removal or replacement indicated?", "required_information": [ "Always replace or remove catheter if possible in the setting of CAUTI", "Evaluate whether catheter is still necessary", "Intermittent catheterization preferred if long-term management needed", "Avoid routine catheter change in absence of symptoms" ] }, { "question": "What prevention and stewardship strategies should be emphasized?", "required_information": [ "Avoid unnecessary catheter use (indications: retention, end-of-life care, surgery, strict I/O)", "Use closed drainage system and secure catheter properly", "Remove catheter as early as possible", "Educate on avoiding \u201cpan-culturing\u201d and treating ASB", "Document appropriate indication and catheter care in EMR" ] } ], "key_references": [ { "title": "IDSA Guidelines for CAUTI (2010)", "url": "https://www.idsociety.org/practice-guideline/cauti/" }, { "title": "CDC/NHSN Surveillance Criteria for CAUTI", "url": "https://www.cdc.gov/nhsn/acute-care-hospital/cauti/index.html" }, { "title": "NEJM Review: Catheter-Associated Urinary Tract Infections", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp1908258" } ] }, "uti_in_spinal_cord_injury": { "syndrome_name": "Urinary Tract Infection in Spinal Cord Injury (SCI)", "definition": "UTIs in persons with spinal cord injury often present atypically and are frequently associated with intermittent or indwelling catheterization, neurogenic bladder, or urinary stasis. High recurrence and resistance risk requires targeted treatment and prevention.", "common_consult_questions": [ { "question": "What are the signs and symptoms of UTI in spinal cord injury patients?", "required_information": [ "Fever, malaise, increased spasticity, autonomic dysreflexia", "Cloudy or foul-smelling urine alone is not diagnostic", "New incontinence or leakage from catheter", "Abdominal or back pain (may be absent due to sensory deficits)", "Rule out other sources of infection and triggers for dysreflexia" ] }, { "question": "How should a UTI be diagnosed in SCI patients?", "required_information": [ "Symptoms or changes from baseline must be present", "Urine culture obtained from clean catch, intermittent catheter, or newly placed catheter", "Avoid screening or treating asymptomatic bacteriuria", "Blood cultures if febrile or systemic signs present", "Imaging if obstruction, stones, or pyelonephritis is suspected" ] }, { "question": "What empiric antibiotic therapy is appropriate?", "required_information": [ "Review past culture and susceptibility data", "Frequent pathogens: E. coli, Klebsiella, Pseudomonas, Enterococcus", "Empiric options: nitrofurantoin, TMP-SMX, cefdinir, or oral fosfomycin for uncomplicated cases", "IV ceftriaxone, cefepime, or carbapenem if recent MDRO history or systemic illness", "Adjust based on susceptibilities and renal function" ] }, { "question": "When is hospitalization or broader evaluation needed?", "required_information": [ "Sepsis, bacteremia, or hemodynamic instability", "Failure of outpatient therapy", "High fever, persistent dysreflexia, or leukocytosis", "Concern for abscess, stones, or upper tract involvement", "Urology involvement if anatomical issues or repeated retention" ] }, { "question": "How can recurrence be prevented in SCI patients?", "required_information": [ "Ensure appropriate catheter hygiene and drainage system", "Encourage intermittent catheterization over indwelling if feasible", "Consider bladder irrigation or catheter change if biofilm suspected", "Prophylactic antibiotics only in select cases with recurrent febrile UTI", "Encourage hydration, bowel management, and bladder scans to avoid retention" ] } ], "key_references": [ { "title": "SCI UTI Management Guidelines (VA/DOD/Paralyzed Veterans of America)", "url": "https://pva.org/publications/" }, { "title": "CDC Guidelines on UTI in Neurogenic Bladder", "url": "https://www.cdc.gov/antibiotic-use/community/pdfs/UTI-in-Neurogenic-Bladder-HCP.pdf" }, { "title": "NEJM Clinical Review: Neurogenic Bladder and UTIs", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp2113819" } ] }, "emphysematous_uti_pyelonephritis": { "syndrome_name": "Emphysematous UTI and Pyelonephritis", "definition": "A severe necrotizing infection characterized by gas formation in the bladder wall (emphysematous cystitis) or renal parenchyma (emphysematous pyelonephritis). Most commonly seen in diabetic or immunocompromised patients and carries high morbidity.", "common_consult_questions": [ { "question": "What clinical and imaging findings suggest emphysematous UTI or pyelonephritis?", "required_information": [ "Fever, flank or abdominal pain, altered mental status", "Lower UTI symptoms: dysuria, urgency, hematuria (emphysematous cystitis)", "CVA tenderness, nausea, hypotension (emphysematous pyelonephritis)", "CT abdomen/pelvis: gas in bladder wall, renal parenchyma, or collecting system", "KUB may show gas but less sensitive than CT" ] }, { "question": "What patient populations are at highest risk?", "required_information": [ "Uncontrolled diabetes mellitus (major risk factor)", "Immunosuppressed individuals (transplant, steroids, malignancy)", "Neurogenic bladder or chronic urinary retention", "Recent instrumentation or catheter use", "Female > male for emphysematous cystitis" ] }, { "question": "What is the appropriate antibiotic regimen?", "required_information": [ "Broad-spectrum IV antibiotics initially: Cefepime, piperacillin-tazobactam, or carbapenem (if ESBL risk)", "Coverage for E. coli, Klebsiella, Proteus, and anaerobes", "Add vancomycin if concern for Enterococcus or catheter-related MRSA", "De-escalate based on culture/susceptibilities", "Typical duration: 10\u201314 days or longer if systemic complications" ] }, { "question": "When is surgical or procedural intervention needed?", "required_information": [ "No clinical improvement within 48\u201372 hours", "Large gas/fluid collections or abscess requiring drainage", "Urinary tract obstruction: consider nephrostomy or stent placement", "Emphysematous pyelonephritis with sepsis or necrosis may require nephrectomy", "Urology or interventional radiology consultation" ] }, { "question": "What are follow-up steps and recurrence prevention strategies?", "required_information": [ "Diabetes control and glycemic monitoring", "Repeat imaging to confirm resolution if symptoms persist", "Address structural abnormalities (stones, obstruction)", "Remove or change indwelling catheter if present", "Outpatient follow-up with urology or nephrology if indicated" ] } ], "key_references": [ { "title": "IDSA Guidelines for Complicated UTI and Pyelonephritis", "url": "https://www.idsociety.org/practice-guideline/urinary-tract-infection-uti-in-adults/" }, { "title": "NEJM Review: Emphysematous Pyelonephritis", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcpc1212254" }, { "title": "Urology Textbook Reference on Emphysematous UTIs", "url": "https://www.auanet.org/" } ] }, "fourniers_gangrene": { "syndrome_name": "Fournier\u2019s Gangrene (Necrotizing Genital Infection)", "definition": "A rapidly progressive necrotizing fasciitis of the perineum, scrotum, or genital region. Often polymicrobial, with a high mortality rate. Requires urgent surgical debridement and broad-spectrum antibiotics.", "common_consult_questions": [ { "question": "What are the clinical features and risk factors for Fournier\u2019s gangrene?", "required_information": [ "Severe pain out of proportion to exam, erythema, swelling, crepitus", "Rapid progression of tissue necrosis or black eschar", "Fever, tachycardia, hypotension, or altered mental status", "Risk factors: diabetes, obesity, immunosuppression, recent instrumentation or trauma", "Physical exam: genital, perineal, or lower abdominal involvement" ] }, { "question": "What diagnostic workup supports the diagnosis?", "required_information": [ "Clinical suspicion is paramount; do not delay for imaging", "CT scan: fascial gas, fluid collections, subcutaneous emphysema", "Labs: CBC, lactate, creatinine, CRP, blood cultures", "Fournier\u2019s Gangrene Severity Index (FGSI) for prognostic assessment", "Send tissue cultures and blood cultures before antibiotics if possible" ] }, { "question": "What empiric antibiotic regimen should be started?", "required_information": [ "Start immediately: Vancomycin (MRSA coverage), Piperacillin-tazobactam or carbapenem (gram-negatives and anaerobes), Clindamycin (toxin suppression for Streptococcus pyogenes)", "Modify based on wound culture and sensitivity", "Duration: typically 2\u20133 weeks or longer, tailored to extent of disease and surgical findings" ] }, { "question": "When and how should surgical intervention be performed?", "required_information": [ "Emergent surgical debridement required", "Multidisciplinary approach: urology, general surgery, infectious diseases, wound care", "Repeat debridements often needed within 24\u201348 hours", "Delay in surgery increases mortality significantly", "May require colostomy or urinary diversion in extensive cases" ] }, { "question": "What are critical elements of follow-up and supportive care?", "required_information": [ "ICU admission for hemodynamic monitoring and support", "Wound care with negative pressure therapy or skin grafts", "Glycemic control and nutritional optimization", "Antibiotic de-escalation when feasible", "Psychological support due to disfigurement and trauma" ] } ], "key_references": [ { "title": "IDSA Guidelines for Necrotizing Soft Tissue Infections", "url": "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/" }, { "title": "NEJM Case Review: Fournier's Gangrene", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcpc2007520" }, { "title": "Surgical Infection Society Consensus Guidelines", "url": "https://journals.lww.com/surgicalinfections/pages/default.aspx" } ] }, "inguinal_lymphadenitis_buboes": { "syndrome_name": "Inguinal Lymphadenitis and Buboes (e.g., LGV, Chancroid)", "definition": "Painful or fluctuant inguinal lymphadenopathy, often unilateral, associated with genital ulcerative disease. May result from sexually transmitted infections such as Chlamydia trachomatis (LGV), Haemophilus ducreyi (chancroid), or less commonly tularemia, TB, or plague.", "common_consult_questions": [ { "question": "What are the likely causes of inguinal buboes in a patient with genital lesions?", "required_information": [ "History of recent sexual contact (especially in endemic or travel settings)", "Presence of genital ulcer: painful (chancroid) vs painless (LGV, syphilis)", "Laterality: LGV and chancroid often unilateral", "Systemic symptoms: fever, malaise, anorectal pain (LGV proctocolitis)", "Travel history and exposure to non-STI pathogens (tularemia, TB)" ] }, { "question": "What diagnostic tests should be ordered?", "required_information": [ "NAAT for Chlamydia trachomatis (LGV genotypes) and Neisseria gonorrhoeae", "HSV and syphilis serologies", "Ulcer swab for HSV PCR and Haemophilus ducreyi culture (if available)", "HIV test", "Aspiration or biopsy of lymph node if atypical presentation or concern for TB/plague" ] }, { "question": "What is the recommended empiric and definitive treatment?", "required_information": [ "LGV: doxycycline 100 mg BID \u00d7 21 days", "Chancroid: azithromycin 1 g \u00d71 OR ceftriaxone 250 mg IM \u00d71", "Treat sexual partners empirically while awaiting results", "Adjust based on lab confirmation and sensitivity", "Avoid aspiration/incision unless fluctuant and symptomatic" ] }, { "question": "When is surgical drainage or further evaluation indicated?", "required_information": [ "Large, fluctuant buboes causing severe pain or risk of rupture", "Failure of improvement after 3\u20135 days of appropriate therapy", "Suspected non-STI cause (e.g., TB, tularemia, Bartonella)", "Referral to surgery, ID, or public health for complex presentations", "Excisional biopsy only if malignancy or chronic lymphadenitis suspected" ] }, { "question": "What are the follow-up and public health considerations?", "required_information": [ "Test-of-cure typically not required for LGV unless symptoms persist", "Reportable disease notification to local health department", "Partner notification and testing (within 60 days or last partner)", "Risk reduction counseling, PrEP consideration, and STI screening", "Consider retesting in 3 months due to reinfection risk" ] } ], "key_references": [ { "title": "CDC 2021 STI Guidelines \u2013 LGV and Chancroid Sections", "url": "https://www.cdc.gov/std/treatment-guidelines/default.htm" }, { "title": "WHO STI Diagnostic Atlas", "url": "https://www.who.int/publications/i/item/9789241546263" }, { "title": "NEJM Review on Genital Ulcer Disease", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1502330" } ] }, "syphilis": { "syndrome_name": "Syphilis (Primary, Secondary, Tertiary)", "definition": "A chronic systemic infection caused by Treponema pallidum. Presents in stages: primary (chancre), secondary (rash, mucosal lesions), latent, and tertiary (cardiovascular, neurologic). Neurosyphilis and ocular syphilis can occur at any stage.", "common_consult_questions": [ { "question": "How is syphilis staged based on clinical and serologic findings?", "required_information": [ "Primary: painless ulcer (chancre) at site of exposure, regional lymphadenopathy", "Secondary: diffuse rash (often palms/soles), mucous patches, alopecia, systemic symptoms", "Latent: positive serology without symptoms", "Tertiary: aortitis, gummas, tabes dorsalis, general paresis", "Confirmatory tests: RPR/VDRL (nontreponemal), FTA-ABS or TP-PA (treponemal)" ] }, { "question": "What is the appropriate treatment based on stage and setting?", "required_information": [ "Primary/secondary/early latent (<1 year): benzathine penicillin G 2.4 million units IM \u00d71", "Late latent or unknown duration: benzathine penicillin G weekly \u00d73 doses", "Neurosyphilis or ocular syphilis: aqueous penicillin G IV 18\u201324 million units/day \u00d710\u201314 days", "Penicillin allergy: doxycycline 100 mg BID \u00d714\u201328 days (except in pregnancy or neurosyphilis \u2014 desensitize)", "Jarisch-Herxheimer reaction education" ] }, { "question": "What is the role of lumbar puncture and when is it indicated?", "required_information": [ "Neurologic symptoms (headache, cranial nerve palsy, hearing loss, vision changes)", "Treatment failure or persistently high RPR titer", "HIV+ patients with neurologic signs or CD4 <350 and RPR >1:32", "CSF: elevated protein, WBCs, positive CSF-VDRL (specific)" ] }, { "question": "How should follow-up and serologic monitoring be performed?", "required_information": [ "RPR titers at 6, 12, and 24 months", "Fourfold decline by 6\u201312 months expected (earlier in HIV-negative)", "Persistent titers may represent serofast state; re-evaluate for reinfection or neurosyphilis", "HIV screening at diagnosis and repeat as needed", "Retreatment required if inadequate response or re-exposure" ] }, { "question": "What are the partner management and public health steps?", "required_information": [ "Sexual partners from past 90 days (primary), 6 months (secondary), 1 year (early latent) should be tested and treated", "Reportable disease: notify local/state health department", "Offer HIV, HBV, HCV testing", "Educate on prevention, PrEP, condom use", "Consider retesting in 3\u20136 months for reinfection" ] } ], "key_references": [ { "title": "CDC 2021 STI Guidelines \u2013 Syphilis Section", "url": "https://www.cdc.gov/std/treatment-guidelines/syphilis.htm" }, { "title": "IDSA HIV Primary Care Guidance on Syphilis", "url": "https://www.idsociety.org/practice-guideline/hiv-primary-care/" }, { "title": "NEJM Review on Syphilis", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp2117063" } ] }, "neurosyphilis_ocular_syphilis": { "syndrome_name": "Neurosyphilis and Ocular Syphilis", "definition": "Invasion of Treponema pallidum into the central nervous system (neurosyphilis) or the eye (ocular syphilis). Can occur at any stage of syphilis. May present as meningitis, tabes dorsalis, cognitive decline, or visual changes.", "common_consult_questions": [ { "question": "What symptoms and findings raise suspicion for neurosyphilis or ocular syphilis?", "required_information": [ "Neurologic: headache, meningismus, cranial nerve palsies, sensory deficits, stroke in young adults", "Psychiatric: personality change, memory loss, mood disturbances", "Ocular: uveitis, optic neuritis, vision loss, retinal vasculitis", "Auditory: tinnitus, hearing loss, vertigo", "History of syphilis or high-risk sexual exposure" ] }, { "question": "What diagnostic tests are necessary to confirm the diagnosis?", "required_information": [ "Lumbar puncture: elevated WBCs (>5), elevated protein, reactive CSF-VDRL (specific), CSF FTA-ABS (sensitive but not specific)", "Serum RPR and treponemal test (FTA-ABS or TP-PA)", "Fundoscopy and ophthalmologic exam for ocular findings", "Audiologic evaluation if otic symptoms", "HIV testing if not already done" ] }, { "question": "What is the recommended treatment for neurosyphilis and ocular syphilis?", "required_information": [ "Aqueous crystalline penicillin G 18\u201324 million units/day IV (3\u20134 million units IV q4h or continuous infusion) \u00d710\u201314 days", "Alternative (if non-compliance): procaine penicillin G 2.4 million units IM daily + probenecid 500 mg PO QID \u00d710\u201314 days", "No proven oral regimen for neurosyphilis", "Desensitize and treat with IV penicillin if allergic", "Steroids may be considered in severe ocular inflammation to reduce Jarisch-Herxheimer risk (with ID/ophthalmology guidance)" ] }, { "question": "What are criteria for follow-up and treatment response?", "required_information": [ "Repeat lumbar puncture at 6-month intervals until normalization (especially if initial abnormalities present)", "RPR titers at 3, 6, 12, and 24 months", "Fourfold decline in RPR expected by 6\u201312 months", "CSF-VDRL may remain reactive despite clinical cure", "Ophthalmology follow-up if ocular disease" ] }, { "question": "When should ID, ophthalmology, or neurology be consulted?", "required_information": [ "All suspected or confirmed neurosyphilis or ocular syphilis cases", "Persistent or relapsed symptoms", "Unclear diagnosis or atypical neurologic presentation", "Need for corticosteroid use or complex monitoring", "Co-infection with HIV or other STIs" ] } ], "key_references": [ { "title": "CDC 2021 STI Guidelines \u2013 Neurosyphilis and Ocular Syphilis", "url": "https://www.cdc.gov/std/treatment-guidelines/syphilis.htm" }, { "title": "NEJM Clinical Review: Neurosyphilis", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp2014330" }, { "title": "IDSA HIV Primary Care Guidelines on CNS Infections", "url": "https://www.idsociety.org/practice-guideline/hiv-primary-care/" } ] }, "genital_and_disseminated_hsv": { "syndrome_name": "Herpes Simplex Virus (Genital and Disseminated)", "definition": "Genital herpes is a common sexually transmitted infection caused by HSV-1 or HSV-2. It may present with painful genital ulcers or be asymptomatic. Disseminated HSV can occur in immunocompromised or pregnant patients, leading to systemic illness.", "common_consult_questions": [ { "question": "How is genital HSV diagnosed and differentiated from other ulcers?", "required_information": [ "Painful vesicles or ulcers on genital or perianal region", "First episode more severe: fever, malaise, lymphadenopathy, dysuria", "Recurrent episodes typically milder, localized", "Swab from base of lesion for HSV PCR (preferred) or viral culture", "Type-specific serology for HSV-1 and HSV-2 if PCR unavailable or lesion resolved" ] }, { "question": "What is the treatment approach for initial, recurrent, and suppressive therapy?", "required_information": [ "Initial episode: acyclovir 400 mg TID, valacyclovir 1 g BID, or famciclovir \u00d77\u201310 days", "Recurrent: same agents for 3\u20135 days (start within 1 day of symptoms)", "Suppressive therapy: daily acyclovir or valacyclovir if \u22656 outbreaks/year or for partner protection", "Adjust for renal function and consider longer duration if immunocompromised", "Treat sexual partners only if symptomatic or newly diagnosed" ] }, { "question": "What are signs and management of disseminated or severe HSV?", "required_information": [ "Disseminated HSV: hepatitis, pneumonitis, encephalitis, viremia", "Risk groups: immunocompromised (transplant, HIV), pregnancy (especially 3rd trimester)", "Systemic symptoms: fever, elevated transaminases, coagulopathy, hypotension", "Initiate IV acyclovir 10 mg/kg q8h (adjusted for renal function)", "Monitor CBC, CMP, and consider lumbar puncture for HSV encephalitis" ] }, { "question": "What considerations apply to HSV in pregnancy and delivery?", "required_information": [ "Risk of neonatal HSV highest in primary maternal infection at term", "Suppressive therapy (valacyclovir 500 mg BID) starting at 36 weeks for known HSV", "Cesarean delivery if active genital lesions or prodrome at time of labor", "Neonatal testing and empiric treatment if exposure suspected" ] }, { "question": "What is the role of counseling, testing, and partner management?", "required_information": [ "Discuss asymptomatic shedding and transmission risk", "Offer type-specific serology to partners (if discordant status unknown)", "Condom use reduces transmission but not 100%", "Educate about prodrome symptoms and early treatment", "Encourage disclosure and shared decision-making in sexual partnerships" ] } ], "key_references": [ { "title": "CDC 2021 STI Guidelines \u2013 Genital Herpes Section", "url": "https://www.cdc.gov/std/treatment-guidelines/herpes.htm" }, { "title": "NEJM Review: Genital Herpes", "url": "https://www.nejm.org/doi/full/10.1056/NEJMcp2005565" }, { "title": "ACOG Practice Bulletin: Management of HSV in Pregnancy", "url": "https://www.acog.org/" } ] }, "hpv_anogenital_warts": { "syndrome_name": "Human Papillomavirus (HPV) and Anogenital Warts", "definition": "HPV is the most common sexually transmitted infection, with low-risk types (6, 11) causing anogenital warts and high-risk types (16, 18, etc.) associated with cancers. Anogenital warts are benign lesions, usually painless, and may recur despite treatment.", "common_consult_questions": [ { "question": "How are anogenital warts diagnosed and differentiated from other lesions?", "required_information": [ "Clinical diagnosis: soft, flesh-colored papules or plaques", "Locations: penis, vulva, perineum, perianal, cervix", "Differential: molluscum contagiosum, condyloma lata (syphilis), neoplasia", "No role for routine HPV typing in diagnosis of warts", "Biopsy if atypical appearance, pigmentation, ulceration, or treatment failure" ] }, { "question": "What are the recommended treatment options for anogenital warts?", "required_information": [ "Patient-applied: imiquimod, podofilox, sinecatechins", "Provider-applied: cryotherapy, trichloroacetic acid (TCA), surgical excision, electrocautery", "Treatment choice depends on lesion size, location, patient preference, pregnancy", "Multiple treatments often required; recurrence is common", "Avoid podofilox and sinecatechins in pregnancy" ] }, { "question": "How should recurrent or treatment-resistant warts be managed?", "required_information": [ "Repeat or alternate treatment modality", "Combination therapies (e.g., cryotherapy + imiquimod)", "Assess immune status (e.g., HIV)", "Refer to dermatology or gynecology for persistent disease", "Consider biopsy for exclusion of VIN/AIN/Bowenoid papulosis if concern for dysplasia" ] }, { "question": "What is the role of HPV vaccination in treatment and prevention?", "required_information": [ "9-valent HPV vaccine (Gardasil 9) prevents types causing warts and most cervical/anal cancers", "Routine vaccination recommended through age 26; up to age 45 based on shared decision-making", "Not therapeutic but may reduce recurrence post-treatment", "Encourage vaccination of partners and adolescents" ] }, { "question": "What counseling and screening should be provided for patients and partners?", "required_information": [ "HPV is common; most sexually active people are exposed", "Condom use reduces but does not eliminate transmission", "No need for routine STI testing based solely on presence of warts", "Recommend cervical cancer screening per guidelines", "Partner evaluation/treatment not required unless symptomatic" ] } ], "key_references": [ { "title": "CDC 2021 STI Guidelines \u2013 HPV and Anogenital Warts", "url": "https://www.cdc.gov/std/treatment-guidelines/hpv.htm" }, { "title": "NEJM Review: HPV Infection and Anogenital Disease", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1912192" }, { "title": "ACOG Guidance on HPV Vaccination", "url": "https://www.acog.org/" } ] }, "hepatitis_b_evaluation_management": { "syndrome_name": "Hepatitis B Virus (HBV) Evaluation and Management", "definition": "HBV is a DNA virus causing acute and chronic hepatitis. Chronic HBV infection can lead to cirrhosis, hepatocellular carcinoma, and liver failure. Screening, vaccination, monitoring, and treatment depend on virologic markers and liver function.", "common_consult_questions": [ { "question": "How is HBV infection diagnosed and staged?", "required_information": [ "Serologic panel: HBsAg, anti-HBs, anti-HBc (total and IgM), HBeAg, anti-HBe", "HBV DNA (quantitative) for active replication", "ALT/AST, bilirubin, INR for liver function", "Distinguish: acute (HBsAg + IgM anti-HBc), chronic (HBsAg >6 months), resolved (anti-HBc + anti-HBs)", "Check HIV, HCV, and HDV co-infection" ] }, { "question": "When is antiviral treatment indicated?", "required_information": [ "Chronic HBV with elevated ALT and HBV DNA >2,000 IU/mL (HBeAg-negative) or >20,000 IU/mL (HBeAg-positive)", "Evidence of fibrosis or cirrhosis (e.g., FibroScan, biopsy, platelet count, FIB-4)", "Immunosuppression or chemotherapy candidates (start prophylaxis)", "Pregnancy with high viral load (>200,000 IU/mL): treat in 3rd trimester to prevent perinatal transmission", "First-line: tenofovir (TDF or TAF), entecavir (avoid lamivudine or adefovir monotherapy)" ] }, { "question": "What is the recommended monitoring strategy for untreated patients?", "required_information": [ "ALT and HBV DNA every 6\u201312 months", "Monitor for HBeAg seroconversion (if initially positive)", "HCC screening: liver ultrasound \u00b1 AFP every 6 months if cirrhotic, Asian men >40, women >50, African ancestry, or family history of HCC", "Annual fibrosis assessment if non-cirrhotic", "Monitor for HDV if HBsAg+ and high-risk exposure" ] }, { "question": "How should close contacts and household members be managed?", "required_information": [ "Screen all household and sexual contacts: HBsAg, anti-HBs, anti-HBc", "Vaccinate non-immune individuals with 3-dose series (or 2-dose if Heplisav-B)", "Consider post-exposure prophylaxis with HBIG + vaccine if recent exposure", "Educate on transmission routes: blood, sexual, vertical; not spread through casual contact" ] }, { "question": "What are special considerations in co-infection or immunosuppressed patients?", "required_information": [ "HIV: use tenofovir-based regimen for dual suppression", "HCV: treat HCV first; monitor for HBV flare", "Immunosuppressive therapy (e.g., rituximab, steroids, transplant): initiate prophylactic antiviral therapy", "HDV: refer for RNA testing and potential trial therapies", "Monitor for HBV reactivation even in resolved infection (anti-HBc+ only)" ] } ], "key_references": [ { "title": "AASLD Guidelines for HBV (2018 update)", "url": "https://www.aasld.org/publications/practice-guidelines-0" }, { "title": "CDC Adult HBV Screening and Vaccination Guidance", "url": "https://www.cdc.gov/hepatitis/hbv/index.htm" }, { "title": "NEJM Review: Hepatitis B Virus Infection", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1902872" } ] }, "hepatitis_c_evaluation_treatment": { "syndrome_name": "Hepatitis C Virus (HCV) Evaluation and Treatment", "definition": "HCV is an RNA virus causing acute and chronic hepatitis. Chronic infection may lead to cirrhosis and hepatocellular carcinoma. Highly curable with direct-acting antiviral (DAA) therapy. Screening, fibrosis staging, and genotype testing guide management.", "common_consult_questions": [ { "question": "How is HCV diagnosed and staged?", "required_information": [ "Screen with anti-HCV antibody (reflex to HCV RNA if positive)", "Confirm chronic infection with detectable HCV RNA >6 months", "Assess fibrosis: FIB-4, FibroScan, APRI, or biopsy", "HCV genotype rarely needed with pan-genotypic therapy", "Baseline labs: CBC, CMP, INR, HIV/HBV screen, pregnancy test (if applicable)" ] }, { "question": "Who is eligible for DAA treatment and what are the options?", "required_information": [ "All patients with chronic HCV are eligible, including those with HIV, CKD, and compensated cirrhosis", "Pan-genotypic options: Glecaprevir/pibrentasvir (Mavyret): 8 weeks (12 if cirrhotic), Sofosbuvir/velpatasvir (Epclusa): 12 weeks", "Avoid sofosbuvir in CrCl <30 unless specialist oversight", "Defer treatment if uncontrolled substance use impairs adherence only" ] }, { "question": "What are monitoring requirements before, during, and after treatment?", "required_information": [ "Baseline: viral load, fibrosis score, CBC, LFTs", "During: minimal labs unless decompensation or drug interaction concern", "End-of-treatment HCV RNA optional", "SVR12 (HCV RNA 12 weeks post-treatment) = cure", "If cirrhotic: continue HCC surveillance and avoid alcohol" ] }, { "question": "What precautions and follow-up are needed for special populations?", "required_information": [ "Cirrhosis: screen for HCC every 6 months with US \u00b1 AFP", "HIV co-infection: coordinate ART to avoid interactions", "Pregnancy: defer treatment, screen infants if HCV RNA+", "Post-transplant: treat to prevent reinfection", "Avoid proton pump inhibitors with velpatasvir if possible" ] }, { "question": "How should reinfection, relapse, or treatment failure be managed?", "required_information": [ "Reinfection risk: injection drug use, unprotected sex, re-exposure", "Distinguish relapse (within 12 weeks) vs reinfection (after SVR)", "Resistance testing and salvage therapy (e.g., sofosbuvir/velpatasvir/voxilaprevir)", "Educate on harm reduction and linkage to care", "Consider referral to hepatology for complex cases" ] } ], "key_references": [ { "title": "AASLD/IDSA HCV Treatment Guidelines", "url": "https://www.hcvguidelines.org/" }, { "title": "CDC HCV Screening and Care Guidance", "url": "https://www.cdc.gov/hepatitis/hcv/index.htm" }, { "title": "NEJM Review: Hepatitis C Virus Infection", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra2101194" } ] }, "acute_hiv_and_screening": { "syndrome_name": "Acute HIV Infection and HIV Screening", "definition": "Acute HIV infection is the earliest phase of HIV, occurring 2\u20134 weeks post-exposure, often presenting as a mononucleosis-like illness. Early diagnosis is critical for transmission prevention and prompt ART initiation. Routine screening is essential for early detection.", "common_consult_questions": [ { "question": "What are signs and symptoms of acute HIV, and when should it be suspected?", "required_information": [ "Fever, fatigue, pharyngitis, rash (trunk, maculopapular), lymphadenopathy, myalgias", "Mucocutaneous ulcers, diarrhea, headache, aseptic meningitis", "Exposure history: condomless sex, needle sharing, STI diagnosis, PEP/PrEP failure", "Occurs ~2\u20134 weeks post-exposure; symptoms last ~1\u20133 weeks", "Suspect in mono-like illness with negative EBV/CMV testing" ] }, { "question": "What tests confirm acute HIV infection?", "required_information": [ "Initial: 4th-generation HIV Ag/Ab test (detects p24 antigen + antibodies)", "If positive: confirm with HIV-1/2 differentiation immunoassay", "If indeterminate or negative but suspicion high: HIV-1 RNA (viral load)", "CD4 count and baseline labs once confirmed", "Do not delay ART if clinical suspicion is strong and RNA is positive" ] }, { "question": "Who should be screened for HIV and how often?", "required_information": [ "Routine: everyone age 13\u201364 at least once", "Annual or more frequent: MSM, people who inject drugs, sex workers, those with STI, hepatitis, or high-risk partners", "Pregnancy: first prenatal visit, 3rd trimester if high risk", "Settings: ED, urgent care, STI clinics, inpatient admissions", "Rapid HIV testing appropriate for high-risk exposures or linkage settings" ] }, { "question": "When should ART be initiated and how is linkage to care managed?", "required_information": [ "Start ART immediately once diagnosis is confirmed or strongly suspected", "Preferred initial regimens: INSTI-based (e.g., bictegravir/TAF/FTC or dolutegravir + TAF/FTC)", "Delay only if suspicion of cryptococcal meningitis or TB with CNS involvement", "Link to HIV specialty care within 1\u20133 days", "Coordinate with social work, case management, and HIV navigation teams" ] }, { "question": "What counseling and partner management should be offered?", "required_information": [ "Educate on transmission, window period, and treatment-as-prevention (U=U)", "Notify and test recent sexual and needle-sharing partners (last 60 days minimum)", "Offer PEP for exposed partners if within 72 hours", "Consider PrEP for at-risk but uninfected contacts", "Screen for STIs, HBV, HCV, and TB" ] } ], "key_references": [ { "title": "CDC HIV Screening and Testing Guidelines (2023)", "url": "https://www.cdc.gov/hiv/guidelines/testing.html" }, { "title": "DHHS Guidelines for Antiretroviral Therapy", "url": "https://clinicalinfo.hiv.gov/en/guidelines" }, { "title": "NEJM Review: Acute HIV Infection", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra2101110" } ] }, "hiv_virologic_failure_and_resistance": { "syndrome_name": "HIV with Virologic Failure and Drug Resistance", "definition": "Virologic failure is defined as inability to achieve or maintain suppression of viral replication (HIV RNA <200 copies/mL) on antiretroviral therapy (ART). Causes include poor adherence, drug resistance, or pharmacokinetic issues.", "common_consult_questions": [ { "question": "How is virologic failure defined and assessed?", "required_information": [ "HIV RNA >200 copies/mL on two consecutive measurements", "Prior history of full suppression, followed by rebound", "Assess adherence, drug interactions, regimen history, and absorption issues", "Recent resistance testing (genotypic or archived) if viremia >500\u20131,000 copies/mL", "Review ART regimen potency and history of virologic response" ] }, { "question": "What are the common causes of virologic failure?", "required_information": [ "Suboptimal adherence or missed doses", "Drug-drug interactions (e.g., calcium with INSTIs, rifampin with NNRTIs)", "Resistance mutations due to prior incomplete suppression", "Incorrect dosing or treatment interruptions", "Malabsorption syndromes or drug toxicity" ] }, { "question": "What is the role of resistance testing and how is it interpreted?", "required_information": [ "HIV Genotype: preferred test if viral load >500\u20131,000 copies/mL", "Archived DNA resistance: useful when viral load is suppressed or <500", "Interpret mutations with Stanford HIV Drug Resistance Database or expert consultation", "Guide regimen adjustment using resistance profile and treatment history", "Consider tropism testing if CCR5 inhibitor is being considered" ] }, { "question": "How should ART be modified in the setting of virologic failure?", "required_information": [ "Use at least 2\u20133 fully active agents based on resistance profile", "Prefer integrase inhibitor-based regimens (e.g., dolutegravir + 2 NRTIs or optimized backbone)", "Include new class agents if multidrug resistance (e.g., ibalizumab, fostemsavir, lenacapavir)", "Avoid functional monotherapy or regimens with archived resistance", "Ensure improved adherence support (case management, mental health)" ] }, { "question": "What monitoring and counseling should be provided?", "required_information": [ "Recheck HIV RNA and CD4 count within 4 weeks of regimen change", "Address barriers to adherence: stigma, housing, substance use, pill burden", "Educate on transmission risk with viremia (U\u2260U)", "Screen and treat STIs; reassess PrEP eligibility for partners", "Reinforce lifelong commitment to therapy and follow-up" ] } ], "key_references": [ { "title": "DHHS Guidelines for ART and Virologic Failure", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv" }, { "title": "IAS-USA Antiretroviral Drug Resistance Tables", "url": "https://www.iasusa.org/" }, { "title": "NEJM Review: Drug-Resistant HIV", "url": "https://www.nejm.org/doi/full/10.1056/NEJMra1905343" } ] }, "hiv_cns_opportunistic_infections": { "syndrome_name": "CNS Opportunistic Infections in HIV", "definition": "Central nervous system infections in people with advanced HIV (CD4 <100) may include toxoplasmosis, cryptococcal meningitis, progressive multifocal leukoencephalopathy (PML), CMV encephalitis, and neurosyphilis. Prompt diagnosis and targeted therapy are critical to reduce morbidity and mortality.", "common_consult_questions": [ { "question": "What are the most common CNS OIs and their clinical features?", "required_information": [ "Toxoplasmosis: headache, confusion, seizures, focal deficits", "Cryptococcal meningitis: subacute headache, fever, nausea, photophobia", "PML (JC virus): progressive cognitive/motor deficits, aphasia, ataxia", "CMV encephalitis: altered mental status, cranial nerve palsies, ventriculitis", "Neurosyphilis: meningeal signs, cognitive decline, cranial neuropathy" ] }, { "question": "What is the recommended diagnostic workup for suspected CNS OIs?", "required_information": [ "Brain MRI with contrast (preferred): ring-enhancing lesions, white matter changes", "LP (if no mass effect): opening pressure, CSF cell count, protein/glucose", "CSF studies: Cryptococcal Ag, VDRL (neurosyphilis), JC virus PCR (PML), CMV PCR", "Serum toxoplasma IgG, serum CrAg (if CD4 <100)", "HIV viral load, CD4 count" ] }, { "question": "What are the empiric and targeted treatments?", "required_information": [ "Toxoplasmosis: pyrimethamine + sulfadiazine + leucovorin or TMP-SMX \u00d76+ weeks", "Cryptococcus: amphotericin B + flucytosine induction \u00d72 weeks, then fluconazole", "PML: optimize ART; no specific treatment for JC virus", "CMV: IV ganciclovir or foscarnet", "Neurosyphilis: IV penicillin G \u00d710\u201314 days", "Start ART timing: delay 2\u20134 weeks for cryptococcal meningitis, start sooner for others" ] }, { "question": "When is brain biopsy or IR consult needed?", "required_information": [ "No improvement in 10\u201314 days of empiric toxo therapy", "Atypical imaging (solitary lesion, no ring enhancement)", "Negative serologies or CSF diagnostics", "Consider lymphoma or TB", "Multidisciplinary discussion with neurology and neurosurgery" ] }, { "question": "What is the approach to follow-up and secondary prophylaxis?", "required_information": [ "Suppressive therapy until immune reconstitution (CD4 >200 \u00d76 months)", "Toxo: TMP-SMX daily", "Crypto: fluconazole", "Monitor for IRIS (especially crypto, CMV)", "Repeat imaging/labs based on response", "Adherence support and ART coordination critical for long-term control" ] } ], "key_references": [ { "title": "DHHS Guidelines for OI Management in HIV", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "CDC HIV CNS Infection Summary", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections.html" }, { "title": "NEJM Reviews: Cryptococcal Meningitis, Toxoplasmosis, PML", "url": "https://www.nejm.org" } ] }, "hiv_esophageal_opportunistic_infections": { "syndrome_name": "Esophageal Opportunistic Infections in HIV", "definition": "Esophageal infections in people with advanced HIV (CD4 <200) commonly include Candida, HSV, and CMV. Presents with odynophagia, dysphagia, and retrosternal pain. Diagnosis is typically clinical for candidiasis but may require endoscopy for others.", "common_consult_questions": [ { "question": "What are the common esophageal OIs and their presentations?", "required_information": [ "Candida esophagitis: white plaques on tongue/throat, odynophagia, dysphagia", "HSV esophagitis: shallow ulcers, severe odynophagia, oral herpetic lesions", "CMV esophagitis: large linear ulcers, deeper pain, may have colitis or retinitis", "Others: pill esophagitis, idiopathic aphthous ulcers, bacterial causes", "Evaluate CD4 count, symptom duration, ART status" ] }, { "question": "When is empiric treatment appropriate vs endoscopy?", "required_information": [ "Empiric fluconazole (200 mg daily x14\u201321 days) appropriate if classic Candida signs and no alarm symptoms", "Proceed to EGD with biopsy if: No improvement within 5\u20137 days of antifungals, Severe odynophagia without oral thrush, Suspicion for HSV/CMV, or alternative diagnoses", "Coordinate with GI for tissue PCR, histology, immunostains" ] }, { "question": "What are the treatment regimens for each esophageal OI?", "required_information": [ "Candida: fluconazole 200 mg/day x14\u201321 days; IV if unable to tolerate PO", "HSV: acyclovir 400 mg PO 5x/day or valacyclovir 1 g TID x14\u201321 days", "CMV: ganciclovir IV 5 mg/kg BID or valganciclovir PO 900 mg BID x14\u201321 days", "Adjust duration based on response and CD4 recovery", "Monitor for drug side effects (e.g., neutropenia with ganciclovir)" ] }, { "question": "When should prophylaxis or secondary prevention be considered?", "required_information": [ "No prophylaxis recommended for Candida or HSV", "CMV prophylaxis not routinely given unless recurrent or systemic disease", "Resume suppressive therapy if recurrence prior to immune recovery", "Suppressive acyclovir in frequent HSV reactivations or IRIS" ] }, { "question": "What is the ART timing and IRIS consideration?", "required_information": [ "Start ART within 2 weeks for most esophageal OIs", "In CMV esophagitis with other severe manifestations (e.g., retinitis), delay ART 2 weeks", "Monitor for immune reconstitution inflammatory syndrome (IRIS) \u2013 especially with CMV", "Supportive care: hydration, pain control, nutrition" ] } ], "key_references": [ { "title": "DHHS OI Guidelines for HIV (Esophageal OIs)", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "NEJM Review: Candida and CMV Esophagitis in HIV", "url": "https://www.nejm.org" }, { "title": "CDC Opportunistic Infection Quick Reference", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections.html" } ] }, "hiv_pulmonary_opportunistic_infections": { "syndrome_name": "Pulmonary Opportunistic Infections in HIV", "definition": "In people with advanced HIV (especially CD4 <200), pulmonary infections are a major cause of morbidity and mortality. Most common causes include Pneumocystis jirovecii pneumonia (PCP), tuberculosis, and endemic fungi (e.g., histoplasmosis). Prompt recognition and targeted therapy are essential.", "common_consult_questions": [ { "question": "What are the typical presentations of pulmonary OIs in HIV?", "required_information": [ "PCP: subacute dyspnea, dry cough, fever, hypoxia, bilateral infiltrates", "TB: cough, fever, night sweats, weight loss; upper lobe cavitary disease (if CD4 >200), atypical/normal CXR (if CD4 <200)", "Histoplasmosis: fever, cough, pancytopenia, diffuse infiltrates, often disseminated", "Cryptococcus, CMV, aspergillus: in severe immunosuppression or with IRIS", "Assess ART status, prophylaxis, TB exposure history, travel (histoplasmosis, coccidioidomycosis)" ] }, { "question": "What diagnostic tests are recommended for evaluation?", "required_information": [ "CXR or chest CT (PCP: ground-glass; TB: nodular/cavitary; fungal: miliary or nodular)", "ABG or pulse oximetry to assess hypoxia", "Induced sputum or BAL for PCP DFA or PCR", "TB workup: AFB smear/culture, NAAT (e.g., Xpert MTB/RIF)", "Serum and urine Histoplasma antigen, fungal cultures", "HIV viral load, CD4 count, beta-D-glucan (PCP), serum CrAg (if CD4 <100)" ] }, { "question": "What are the recommended treatments for key pulmonary OIs?", "required_information": [ "PCP: TMP-SMX (IV or PO based on severity) x21 days + prednisone taper if A\u2013a gradient >35 or PaO\u2082 <70", "TB: RIPE x2 months, then continuation phase x4+ months; adjust for ART and drug interactions", "Histoplasmosis: liposomal amphotericin B \u00d71\u20132 weeks, then itraconazole x12 months", "Modify regimens for renal or hepatic dysfunction", "Prophylaxis: TMP-SMX if CD4 <200; discontinue when CD4 >200 for \u22653 months on ART" ] }, { "question": "When should ART be initiated in the setting of pulmonary OIs?", "required_information": [ "PCP, histoplasmosis: initiate ART within 2 weeks of diagnosis", "TB: start ART within 2 weeks if CD4 <50, within 8 weeks otherwise", "Monitor for IRIS (esp. TB and histo) \u2014 may require corticosteroids or ART delay", "Avoid overlapping toxicities and CYP450 interactions (e.g., rifampin with certain ART)" ] }, { "question": "What follow-up and secondary prevention are required?", "required_information": [ "Adherence to ART and OI therapy critical", "Repeat imaging if clinical deterioration", "Duration of secondary prophylaxis depends on CD4 recovery", "Counsel on TB exposure avoidance, infection control", "Monitor for relapse, IRIS, and drug side effects (e.g., cytopenias, hepatotoxicity)" ] } ], "key_references": [ { "title": "DHHS OI Guidelines for HIV \u2013 Pulmonary Infections", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "CDC TB/HIV Coinfection Management Guidance", "url": "https://www.cdc.gov/tb/topic/basics/tbhiv.htm" }, { "title": "NEJM Reviews: PCP, TB, Histoplasmosis in HIV", "url": "https://www.nejm.org" } ] }, "hiv_gi_opportunistic_infections": { "syndrome_name": "GI Opportunistic Infections in HIV", "definition": "Gastrointestinal infections in people with advanced HIV (CD4 <100) can cause severe diarrhea, abdominal pain, or weight loss. Common pathogens include Cryptosporidium, CMV, Mycobacterium avium complex (MAC), and microsporidia.", "common_consult_questions": [ { "question": "What are the most common GI OIs in advanced HIV and their presentations?", "required_information": [ "Cryptosporidium: watery diarrhea, weight loss, cramps; often persistent and relapsing", "CMV colitis: bloody diarrhea, abdominal pain, fever; often with concurrent CMV esophagitis or retinitis", "MAC (disseminated): fever, night sweats, weight loss, abdominal pain, diarrhea, hepatosplenomegaly", "Microsporidia/Isospora: chronic diarrhea, wasting, steatorrhea", "CD4 count <100 (often <50 for MAC and CMV), ART history, exposures" ] }, { "question": "What diagnostic workup is recommended?", "required_information": [ "Stool studies: O&P \u00d73, acid-fast staining, Cryptosporidium antigen or PCR, microsporidia special stains", "CMV: colonoscopy with biopsy and histology/immunostain (owl\u2019s eye inclusions)", "MAC: blood cultures (AFB), stool AFB, bone marrow or liver biopsy if disseminated", "Labs: CBC (anemia), LFTs (alk phos), HIV viral load, CD4 count, blood cultures", "Consider TB testing in endemic areas or systemic signs" ] }, { "question": "What are the treatments for key GI OIs?", "required_information": [ "Cryptosporidium: supportive care; ART essential for clearance; nitazoxanide may help with mild disease", "CMV colitis: IV ganciclovir or oral valganciclovir x21 days; consider maintenance if CD4 <100", "MAC: azithromycin or clarithromycin + ethambutol \u00b1 rifabutin (if severe); continue x12 months and until CD4 >100 for \u22656 months", "Microsporidia/Isospora: albendazole (for microsporidia), TMP-SMX (for isospora)", "ART initiation crucial for immune restoration" ] }, { "question": "When should ART be initiated or delayed in GI OIs?", "required_information": [ "Begin ART early in most GI OIs to restore mucosal immunity", "Delay ART by 2 weeks in CMV colitis if severe or high risk of IRIS", "Monitor closely for IRIS flares post-ART (especially with MAC, CMV)", "Evaluate for drug interactions (e.g., rifabutin with ART, ganciclovir cytopenias)" ] }, { "question": "What is the approach to follow-up and secondary prevention?", "required_information": [ "Monitor for resolution of diarrhea and weight gain", "Re-check CD4 and HIV viral load 1\u20133 months after ART start", "MAC prophylaxis: azithromycin if CD4 <50 and not yet on ART", "Repeat colonoscopy if symptoms recur or diagnosis unclear", "Reinforce adherence, food/water hygiene, and supportive care" ] } ], "key_references": [ { "title": "DHHS OI Guidelines for GI Infections in HIV", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "CDC Opportunistic Infections in HIV \u2013 GI Summary", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections.html" }, { "title": "NEJM Review: Cryptosporidiosis, CMV Colitis, MAC", "url": "https://www.nejm.org" } ] }, "hiv_dermatologic_opportunistic_infections": { "syndrome_name": "Dermatologic Opportunistic Infections in HIV", "definition": "In advanced HIV (often CD4 <200), dermatologic manifestations may include Kaposi sarcoma (KS), varicella zoster virus (VZV), deep fungal infections, molluscum contagiosum, and severe HSV or bacterial skin infections. Cutaneous findings may reflect systemic disease or IRIS.", "common_consult_questions": [ { "question": "What are the characteristic dermatologic OIs in HIV and how do they present?", "required_information": [ "Kaposi sarcoma: violaceous papules/plaques, often on oral mucosa, face, legs; may involve lung or GI tract", "Disseminated VZV: dermatomal then widespread vesicular rash; risk of pneumonitis, encephalitis", "Fungal skin infections: histoplasmosis, cryptococcosis, sporotrichosis with nodular/ulcerative lesions", "Molluscum contagiosum: multiple, large, umbilicated lesions, often facial/genital", "HSV: chronic, large, painful perianal or orolabial ulcerations" ] }, { "question": "What diagnostic tests are needed for skin OIs?", "required_information": [ "Skin biopsy with histopathology and stains (e.g., GMS, PAS, HHV-8 IHC for KS)", "VZV or HSV PCR from vesicle swab", "Fungal culture and serology if nodular/deep lesions", "CD4 count, HIV viral load", "Imaging (CXR, endoscopy) if systemic KS suspected" ] }, { "question": "What are the treatments for key dermatologic OIs?", "required_information": [ "Kaposi sarcoma: ART alone may cause regression; systemic chemo (liposomal doxorubicin) if visceral or extensive disease", "VZV: IV acyclovir if disseminated/severe; oral valacyclovir for mild cases", "Fungal skin infections: amphotericin B or itraconazole depending on severity and organism", "HSV: acyclovir or valacyclovir x14\u201321 days; adjust duration based on healing", "Start ART to support immune recovery for all conditions" ] }, { "question": "What are IRIS considerations and when is ART timing important?", "required_information": [ "Start ART within 2 weeks for most skin OIs", "Monitor for IRIS in KS (worsening lesions, edema), VZV, and fungal infections", "Treat underlying OI before or concurrently with ART", "Consider short-course steroids for severe IRIS (e.g., KS-related edema)" ] }, { "question": "How should follow-up, prevention, and patient counseling be managed?", "required_information": [ "Monitor lesion response to treatment and ART", "Screen for other OIs (e.g., CrAg if CD4 <100)", "TB and STI screening if ulcers or systemic findings", "Educate on hygiene, wound care, transmission risk (HSV/VZV)", "Reinforce adherence and ART durability" ] } ], "key_references": [ { "title": "DHHS OI Guidelines \u2013 Dermatologic and Cutaneous Manifestations in HIV", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "NEJM Reviews: Kaposi Sarcoma, VZV, HSV in HIV", "url": "https://www.nejm.org" }, { "title": "CDC HIV-Related Skin Disease Summary", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections.html" } ] }, "hiv_ocular_opportunistic_infections": { "syndrome_name": "Ocular Opportunistic Infections in HIV", "definition": "Ocular complications in people with advanced HIV (CD4 <100) include CMV retinitis, ocular toxoplasmosis, HSV/VZV retinitis, and HIV microvasculopathy. CMV retinitis is the most common sight-threatening OI and may be asymptomatic early.", "common_consult_questions": [ { "question": "What are the key ocular OIs in HIV and their clinical presentations?", "required_information": [ "CMV retinitis: painless vision loss, floaters, flashing lights, retinal necrosis; often unilateral at first", "Ocular toxoplasmosis: blurred vision, eye pain, photophobia, 'headlight in fog' retinal lesion", "HSV/VZV retinitis (ARN/PORN): rapid vision loss, retinal necrosis, severe inflammation; VZV more common in PORN", "HIV microvasculopathy: cotton wool spots, not vision-threatening", "High suspicion if CD4 <100, especially <50" ] }, { "question": "What is the recommended diagnostic evaluation?", "required_information": [ "Immediate ophthalmologic evaluation with dilated fundus exam", "Fundus photography, fluorescein angiography if needed", "Vitreous or aqueous fluid PCR for CMV, HSV, VZV, toxoplasma (in uncertain cases)", "Labs: CD4, HIV viral load, serum CMV PCR", "Avoid lumbar puncture unless CNS symptoms (e.g., CMV encephalitis)" ] }, { "question": "What are the treatment options for ocular OIs?", "required_information": [ "CMV retinitis: Oral valganciclovir 900 mg BID \u00d72\u20133 weeks, then 900 mg daily; intravitreal ganciclovir or foscarnet for sight-threatening lesions", "Ocular toxoplasmosis: pyrimethamine + sulfadiazine + leucovorin \u00b1 intravitreal clindamycin", "HSV/VZV retinitis: IV acyclovir or ganciclovir \u00b1 intravitreal injections", "Avoid corticosteroids unless under ophthalmologic guidance", "ART initiation after ~2 weeks of therapy to avoid IRIS in CMV" ] }, { "question": "What are IRIS considerations and when should ART be started?", "required_information": [ "For CMV retinitis: delay ART by 2 weeks to avoid IRIS-associated retinal detachment", "For toxoplasmosis/HSV/VZV: start ART within 2 weeks unless CNS or severe inflammation", "Monitor for worsening inflammation and vision loss", "Coordinate closely with ophthalmology during ART initiation" ] }, { "question": "What follow-up and prevention measures are required?", "required_information": [ "Weekly to biweekly ophthalmology visits initially", "Continue maintenance therapy until CD4 >100 for \u22653\u20136 months", "Educate on symptoms of recurrence or contralateral eye involvement", "Screen both eyes even if unilateral symptoms", "Counsel on ART adherence, hygiene, and avoiding exposures" ] } ], "key_references": [ { "title": "DHHS Guidelines: CMV and Ocular OIs in HIV", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "NEJM Review: CMV Retinitis and Ocular Toxoplasmosis in HIV", "url": "https://www.nejm.org" }, { "title": "CDC HIV-Related Eye Disease Summary", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections.html" } ] }, "hiv_hematologic_opportunistic_infections": { "syndrome_name": "Hematologic Opportunistic Infections in HIV", "definition": "In advanced HIV (especially CD4 <100), hematologic complications may result from opportunistic infections such as parvovirus B19, MAC, histoplasmosis, and CMV. Manifestations include anemia, pancytopenia, and bone marrow suppression.", "common_consult_questions": [ { "question": "What are common hematologic OIs and how do they present?", "required_information": [ "Parvovirus B19: pure red cell aplasia (low retic, normal WBC/platelets), fatigue, pallor", "MAC (disseminated): anemia, elevated alk phos, fever, hepatosplenomegaly, bone marrow infiltration", "Histoplasmosis: pancytopenia, fevers, hepatosplenomegaly, lymphadenopathy, bone marrow suppression", "CMV: leukopenia, thrombocytopenia; marrow involvement or IRIS", "Evaluate for drug-related cytopenias (e.g., zidovudine, ganciclovir)" ] }, { "question": "What diagnostic evaluation should be performed?", "required_information": [ "CBC with differential and reticulocyte count", "HIV viral load, CD4 count, serum ferritin, folate, B12, LDH, haptoglobin", "Parvovirus B19 PCR (not IgM) in advanced HIV", "Blood cultures for AFB (MAC), Histoplasma antigen (urine/serum)", "Bone marrow biopsy if persistent unexplained cytopenias or concern for infiltrative disease" ] }, { "question": "What are the treatment options for hematologic OIs?", "required_information": [ "Parvovirus B19: IVIG 400 mg/kg/day \u00d75 days; ART to restore immunity", "MAC: azithromycin or clarithromycin + ethambutol \u00b1 rifabutin; continue \u226512 months", "Histoplasmosis: liposomal amphotericin B, then itraconazole \u00d712 months", "CMV: ganciclovir or valganciclovir; monitor for cytopenias", "Supportive care: transfusions, growth factors (e.g., G-CSF, EPO)" ] }, { "question": "When should ART be started or adjusted?", "required_information": [ "ART is essential to immune reconstitution for all hematologic OIs", "Start ART within 2 weeks for most infections unless risk of IRIS (e.g., MAC with high burden)", "Consider holding or adjusting ART if marrow-toxic (e.g., zidovudine, stavudine)", "Drug-drug interactions (e.g., rifabutin with protease inhibitors)" ] }, { "question": "What follow-up and secondary prevention are needed?", "required_information": [ "Monitor CBC, retic count, CD4, HIV RNA monthly", "Continue MAC prophylaxis if CD4 <50", "Repeat parvovirus PCR if anemia recurs; relapse possible if ART interrupted", "Reinforce adherence to ART and antifungal/antimycobacterial regimens", "Assess marrow recovery with repeat counts and symptom improvement" ] } ], "key_references": [ { "title": "DHHS OI Guidelines \u2013 Hematologic and Bone Marrow Complications in HIV", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "CDC Opportunistic Infections in HIV Summary", "url": "https://www.cdc.gov/hiv/clinicians/treatment/opportunistic-infections.html" }, { "title": "NEJM Review: Parvovirus B19, MAC, Histoplasmosis in HIV", "url": "https://www.nejm.org" } ] }, "pulmonary_nodules_in_hiv": { "syndrome_name": "Evaluation of Pulmonary Nodules in Immunocompromised or HIV+ Patients", "definition": "Pulmonary nodules in people with HIV (especially CD4 <200) can be caused by infections (e.g., TB, fungal, NTM), malignancy (e.g., Kaposi sarcoma, lymphoma, lung cancer), or inflammation. Nodules may be solitary or multiple, cavitary or solid, and require careful evaluation.", "common_consult_questions": [ { "question": "What are the common causes of pulmonary nodules in HIV+ patients?", "required_information": [ "Infectious: TB (especially if upper lobe, cavitary), fungal (histoplasmosis, cryptococcosis, coccidioidomycosis), NTM, bacterial abscesses (Staph, Pseudomonas)", "Malignant: Kaposi sarcoma (diffuse/peribronchial nodules), Non-Hodgkin lymphoma, Primary lung cancer", "Inflammatory/IRIS-related: Sarcoid-like reactions, pneumonitis" ] }, { "question": "What is the appropriate diagnostic approach to a new nodule?", "required_information": [ "Imaging: High-resolution CT chest", "Lab workup: HIV viral load, CD4 count, TB testing (Quantiferon, TST, sputum AFB smear/culture, NAAT), serum CrAg, Histoplasma antigen, fungal and AFB blood cultures", "Bronchoscopy with BAL if multiple or bilateral nodules", "Percutaneous biopsy or VATS for solitary or enlarging nodules not explained by labs" ] }, { "question": "When is empiric treatment vs biopsy appropriate?", "required_information": [ "Empiric antifungals or anti-TB therapy only if high clinical suspicion and delay in tissue sampling", "Biopsy strongly recommended for solitary/enlarging nodule, negative serologies, or malignancy suspicion" ] }, { "question": "What are key considerations for managing infection-related nodules?", "required_information": [ "TB: RIPE x6 months; ensure susceptibility and adherence", "Fungal: itraconazole for histo/blasto; fluconazole or amphotericin B depending on severity", "Cryptococcus: check CSF and serum CrAg", "Continue ART with close monitoring; delay only if CNS involvement or severe IRIS risk" ] }, { "question": "What follow-up and monitoring are needed for pulmonary nodules?", "required_information": [ "Serial CT imaging if indeterminate: repeat in 3\u20136 months depending on size", "Monitor CD4 and HIV viral load every 1\u20133 months", "Oncology referral if biopsy confirms malignancy", "Reassess if new nodules appear on ART (consider IRIS)", "Maintain screening for TB and fungal exposures if at risk" ] } ], "key_references": [ { "title": "IDSA Guidelines for Fungal and TB Workup in HIV", "url": "https://www.idsociety.org" }, { "title": "DHHS OI Guidelines for Lung Infections in HIV", "url": "https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection" }, { "title": "NEJM Review: Pulmonary Nodules in Immunocompromised Hosts", "url": "https://www.nejm.org" } ] }, "pulmonary_nodules_in_immunocompetent": { "syndrome_name": "Pulmonary Nodules in Immunocompetent Patients", "definition": "Pulmonary nodules are defined as discrete, rounded opacities <3 cm in diameter seen on imaging. In immunocompetent individuals, they may be incidental or symptomatic. Causes include malignancy, granulomatous infections, hamartomas, or inflammatory lesions.", "common_consult_questions": [ { "question": "What are the major causes of pulmonary nodules in immunocompetent adults?", "required_information": [ "Malignant: Primary lung cancer, metastases", "Infectious: Granulomatous (histoplasmosis, TB, coccidioidomycosis, blastomycosis), round pneumonia", "Benign: Hamartoma, AVM, intrapulmonary lymph node, rheumatoid nodules, sarcoidosis" ] }, { "question": "What is the recommended initial evaluation and imaging strategy?", "required_information": [ "Initial Imaging: non-contrast chest CT", "CT Characteristics: size, shape, border, calcification, growth rate, solid/subsolid/ground-glass", "Review prior imaging for \u22652 years stability" ] }, { "question": "When is PET-CT, biopsy, or surgical referral indicated?", "required_information": [ "PET-CT for nodules \u22658 mm with intermediate\u2013high malignancy risk", "Biopsy (CT-guided or bronchoscopic) for peripheral or solitary nodules without benign features", "Surgical resection for high-risk or growing lesions or nondiagnostic biopsy" ] }, { "question": "How should incidental pulmonary nodules be managed based on risk?", "required_information": [ "Low-risk (<6 mm, nonsmokers): no follow-up", "Intermediate (6\u20138 mm): repeat CT in 6\u201312 months", "High-risk (>8 mm, smoker, upper lobe): PET-CT, biopsy, or surgical evaluation", "Follow Fleischner Society Guidelines for management" ] }, { "question": "When should infectious or inflammatory causes be considered?", "required_information": [ "Endemic mycoses region travel or residence", "TB exposure: IGRA or TST", "Autoimmune history (RA, GPA, sarcoidosis)", "Serologies and fungal antigens for bilateral or cavitary nodules", "Empiric treatment only after thorough workup or high suspicion" ] } ], "key_references": [ { "title": "Fleischner Society Pulmonary Nodule Guidelines (2017)", "url": "https://www.fleischner.org/guidelines/2017-nodule-guidelines" }, { "title": "ACCP Guidelines for Pulmonary Nodule Evaluation", "url": "https://www.chestnet.org" }, { "title": "NEJM Review: Solitary Pulmonary Nodules", "url": "https://www.nejm.org" } ] }, "intra_abdominal_fluid_collection": { "syndrome_name": "Intra-abdominal Fluid Collection (Abscess or Complex Fluid)", "definition": "Intra-abdominal fluid collections include abscesses, infected hematomas, or bilious/pancreatic collections. These may arise postoperatively, post-perforation, or from hematogenous spread. Management requires source identification, drainage when feasible, and targeted antimicrobial therapy.", "common_consult_questions": [ { "question": "What are common causes and risk factors for intra-abdominal collections?", "required_information": [ "Post-surgical (e.g., anastomotic leak, contaminated laparotomy)", "Post-perforation (e.g., diverticulitis, appendicitis, peptic ulcer rupture)", "Biliary or pancreatic leaks (e.g., post-ERCP, necrotizing pancreatitis)", "Hematogenous seeding (e.g., bacteremia, endocarditis)", "Immunocompromised status (e.g., malignancy, transplant, diabetes)" ] }, { "question": "What imaging modalities and findings confirm diagnosis?", "required_information": [ "CT abdomen/pelvis with IV contrast: rim-enhancing collection, gas locules, fluid-fluid levels", "Ultrasound: useful for superficial collections or interventional guidance", "Evaluate size, complexity, multiloculation, proximity to organs", "Assess for signs of adjacent organ involvement or communication (e.g., fistula)" ] }, { "question": "When is drainage indicated and what options are available?", "required_information": [ "Collections >3\u20135 cm", "Clinical sepsis or persistent fever", "Infected appearance on imaging (gas, loculations)", "Image-guided percutaneous drainage (preferred if feasible)", "Surgical drainage (if inaccessible, multiloculated, or associated with bowel perforation)", "IR consult for complex drainage planning" ] }, { "question": "What is the appropriate antimicrobial strategy?", "required_information": [ "Empiric coverage: Gram-negative rods, anaerobes, enterococci", "Empiric options: cefepime + metronidazole, piperacillin-tazobactam, or carbapenem", "Adjust based on drainage or blood cultures", "Consider ESBL, VRE, or Candida in healthcare-associated or refractory cases", "Duration: 4\u20137 days if source controlled; 10\u201314+ days if ongoing leak or poor response" ] }, { "question": "What is the approach to follow-up and non-resolving collections?", "required_information": [ "Repeat imaging in 3\u20135 days if symptoms persist", "Monitor WBC, CRP, cultures, drain output", "Reassess for missed source (e.g., bowel leak, fistula)", "ID and surgery co-management in complex or recurrent cases", "Consider fungal coverage or repeat drainage if persistent" ] } ], "key_references": [ { "title": "IDSA Guidelines: Intra-abdominal Infections (2017)", "url": "https://www.idsociety.org/practice-guideline/intra-abdominal-infections/" }, { "title": "SIS/IDSA Guidelines for Management of Complicated IAI", "url": "https://journals.lww.com/surgicalinfections" }, { "title": "NEJM Review: Intra-abdominal Abscesses and Drainage Strategies", "url": "https://www.nejm.org" } ] }, "peritonitis": { "syndrome_name": "Peritonitis (Spontaneous or Secondary)", "definition": "Peritonitis refers to inflammation of the peritoneal lining, typically due to infection. It may be spontaneous (SBP, usually in cirrhosis) or secondary to a visceral perforation, ischemia, or surgical complication. Management involves early antibiotics, source control, and fluid resuscitation.", "common_consult_questions": [ { "question": "How is peritonitis classified and what are the typical causes?", "required_information": [ "Spontaneous bacterial peritonitis (SBP): cirrhotics with ascites, caused by enteric organisms", "Secondary peritonitis: perforated bowel, post-surgical leaks, ischemic bowel", "Dialysis-associated peritonitis (PD patients): Staph, Strep, Gram-negatives" ] }, { "question": "What is the diagnostic approach to suspected peritonitis?", "required_information": [ "Paracentesis: PMN \u2265250 cells/mm\u00b3 for SBP; culture, albumin, protein, glucose", "CT abdomen/pelvis with contrast for free air, abscess, or bowel wall defects", "PD effluent analysis: WBC >100 with \u226550% neutrophils" ] }, { "question": "What are the appropriate empiric antibiotics?", "required_information": [ "SBP: cefotaxime or ceftriaxone; fluoroquinolones or piperacillin-tazobactam alternatives", "Secondary peritonitis: cefepime + metronidazole, piperacillin-tazobactam, or carbapenems", "PD peritonitis: IP vancomycin + ceftazidime or cefepime", "Consider ESBL, VRE, or candida coverage in high-risk cases" ] }, { "question": "When is surgery or drainage required?", "required_information": [ "SBP: surgery not typically required unless perforation suspected", "Secondary peritonitis: surgical consult for perforation, ischemia; IR drainage if abscess present", "Persistent infection despite antibiotics = uncontrolled source" ] }, { "question": "What are follow-up and secondary prophylaxis strategies?", "required_information": [ "Repeat paracentesis at 48 hrs for SBP", "SBP prophylaxis: norfloxacin, ciprofloxacin, TMP-SMX in high-risk patients", "Albumin for SBP with renal dysfunction (1.5 g/kg day 1, 1 g/kg day 3)", "Monitor for complications: hepatorenal syndrome, bacteremia, sepsis", "PD catheter removal if refractory or relapsing peritonitis" ] } ], "key_references": [ { "title": "IDSA/SIS Guidelines for Intra-abdominal Infection", "url": "https://www.idsociety.org/practice-guideline/intra-abdominal-infections/" }, { "title": "AASLD Guidelines for SBP in Cirrhosis", "url": "https://www.aasld.org/publications/practice-guidelines" }, { "title": "ISPD Guidelines for PD-Related Peritonitis", "url": "https://ispd.org" }, { "title": "NEJM Review: Spontaneous and Secondary Peritonitis", "url": "https://www.nejm.org" } ] }, "cholecystitis": { "syndrome_name": "Cholecystitis (Acute, Acalculous, and Complicated)", "definition": "Cholecystitis is inflammation of the gallbladder, typically caused by obstruction of the cystic duct (calculous). Acalculous cholecystitis occurs in critically ill patients. Infected or gangrenous cholecystitis may progress to perforation or abscess. Diagnosis is clinical and radiographic; treatment includes antibiotics and source control.", "common_consult_questions": [ { "question": "What are the types and typical presentations of cholecystitis?", "required_information": [ "Acute calculous cholecystitis: RUQ pain, fever, Murphy\u2019s sign, leukocytosis", "Acalculous cholecystitis: occurs in ICU patients with trauma, burns, sepsis, TPN", "Complicated cholecystitis: gangrene, perforation, emphysematous changes, abscess", "Associated findings: gallstones, wall thickening, pericholecystic fluid, gallbladder distension" ] }, { "question": "What imaging is preferred for diagnosis?", "required_information": [ "RUQ ultrasound: first-line test; stones, wall thickening (>3 mm), sonographic Murphy\u2019s sign", "HIDA scan: non-visualization of gallbladder = obstruction", "CT abdomen: assesses for complications (gas, perforation, abscess, surrounding fluid)", "MRCP: if concern for choledocholithiasis or biliary obstruction" ] }, { "question": "When is surgical or procedural intervention indicated?", "required_information": [ "Laparoscopic cholecystectomy: preferred treatment in surgical candidates, within 72 hrs", "Percutaneous cholecystostomy: for unstable or non-operative patients", "Repeat imaging or drainage if persistent fever or abscess suspected post-procedure" ] }, { "question": "What empiric antibiotics should be initiated?", "required_information": [ "Target enteric Gram-negatives and anaerobes", "Ceftriaxone + metronidazole, Piperacillin-tazobactam, or Ertapenem", "Broader spectrum (e.g., cefepime + metronidazole or carbapenems) if healthcare-associated", "Duration: 4\u20137 days after source control or 7\u201310 days if non-operative" ] }, { "question": "How should follow-up and recurrence be managed?", "required_information": [ "Re-evaluate drain output and cultures if cholecystostomy placed", "Monitor LFTs and imaging for resolution", "Elective cholecystectomy after stabilization may be needed", "Counsel on recurrence risk if gallbladder remains in place", "Consider biliary imaging if recurrent symptoms or persistent cholestasis" ] } ], "key_references": [ { "title": "Tokyo Guidelines for Cholecystitis (2018 Update)", "url": "https://www.journal-of-hepatology.eu" }, { "title": "IDSA Guidelines for Complicated Intra-abdominal Infections", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Acute Cholecystitis", "url": "https://www.nejm.org" } ] }, "leukocytosis_evaluation": { "syndrome_name": "Evaluation of Leukocytosis", "definition": "Leukocytosis is defined as a white blood cell (WBC) count >11,000/\u03bcL. It may be reactive (due to infection, inflammation, stress), neoplastic (hematologic malignancy), or drug-related. The approach involves distinguishing the underlying cause based on pattern, severity, and clinical context.", "common_consult_questions": [ { "question": "What are the main categories and causes of leukocytosis?", "required_information": [ "Infectious: bacterial, fungal, viral, parasitic", "Inflammatory: autoimmune diseases, post-surgical, trauma", "Malignancy: acute/chronic leukemias, myeloproliferative neoplasms", "Medications: corticosteroids, epinephrine, G-CSF, lithium", "Stress or physiologic: seizures, burns, hemolysis, hemorrhage, dehydration" ] }, { "question": "How should the type of leukocytosis be differentiated?", "required_information": [ "Neutrophilia: bacterial infections, steroids, stress", "Lymphocytosis: viral infections, CLL", "Eosinophilia: parasites, allergies, drug reactions", "Monocytosis: chronic infections, malignancy", "Basophilia: suggests CML or other MPN if persistent" ] }, { "question": "What diagnostic workup is indicated for new or persistent leukocytosis?", "required_information": [ "CBC with differential and smear: assess left shift, toxic granulation, blasts", "Basic labs: CMP, CRP, ESR, LDH, uric acid", "Peripheral smear for morphology and dysplasia", "Consider: cultures, imaging, ANA/RF, JAK2, BCR-ABL testing" ] }, { "question": "When should hematology be consulted?", "required_information": [ "WBC >50,000\u2013100,000/\u03bcL without clear cause", "Presence of blasts or persistent left shift", "Unexplained eosinophilia or basophilia", "Suspicion of leukemia or MPN", "No resolution after 2\u20134 weeks or worsening trends" ] }, { "question": "What is the general approach to management and follow-up?", "required_information": [ "Treat underlying infection, inflammation, or medication cause", "Discontinue inciting drugs if possible", "Repeat labs in 3\u20137 days if stable", "Longitudinal monitoring for unexplained leukocytosis", "Escalate for bone marrow biopsy if no diagnosis or progressive counts" ] } ], "key_references": [ { "title": "UpToDate: Evaluation of Leukocytosis in Adults", "url": "https://www.uptodate.com" }, { "title": "NEJM Review: Leukocytosis and Diagnostic Pitfalls", "url": "https://www.nejm.org" }, { "title": "ASH Guidelines on Myeloid Malignancy Evaluation", "url": "https://www.hematology.org" } ] }, "eosinophilia_evaluation": { "syndrome_name": "Evaluation of Eosinophilia", "definition": "Eosinophilia is defined as an absolute eosinophil count (AEC) >500 cells/\u03bcL. It is categorized as mild (500\u20131,500), moderate (1,500\u20135,000), or severe (>5,000). Causes include allergic, parasitic, drug-induced, autoimmune, and neoplastic conditions.", "common_consult_questions": [ { "question": "What are the major categories and causes of eosinophilia?", "required_information": [ "Allergic/atopic: asthma, allergic rhinitis, eczema, drug hypersensitivity", "Infectious: helminths (Strongyloides, Schistosoma, Toxocara), visceral larva migrans", "Autoimmune/vasculitis: EGPA, hypereosinophilic syndrome (HES)", "Neoplastic: Hodgkin lymphoma, T-cell lymphomas, CML, eosinophilic leukemia", "Other: adrenal insufficiency, sarcoidosis, hyper-IgE syndrome" ] }, { "question": "What initial workup is recommended for new or persistent eosinophilia?", "required_information": [ "CBC with differential and smear: assess for blasts or dysplasia", "Basic labs: CMP, LDH, ESR/CRP", "Stool O&P \u00d73, Strongyloides IgG (especially before steroids)", "ANA, ANCA, IgE level if systemic symptoms", "CXR or CT chest/abdomen if unexplained or constitutional symptoms", "Travel or exposure history (parasites, TB-endemic regions)" ] }, { "question": "When should eosinophilia trigger urgent evaluation or treatment?", "required_information": [ "Severe eosinophilia (>5,000) with end-organ damage (e.g., myocarditis, pneumonitis, hepatitis)", "Constitutional symptoms: weight loss, night sweats, fever", "Signs of vasculitis or HES: neuropathy, pulmonary infiltrates, skin nodules", "Strongyloides risk: treat presumptively before steroids if immunosuppressed" ] }, { "question": "When should hematology or infectious disease be consulted?", "required_information": [ "Persistent moderate\u2013severe eosinophilia with no clear cause", "Concern for malignancy, atypical lymphocytes, or blasts", "Suspected HES or EGPA", "Travel-related exposures or concern for parasitic infection" ] }, { "question": "How should eosinophilia be monitored and managed over time?", "required_information": [ "Treat underlying cause (infection, allergy, neoplasm)", "Monitor AEC every 2\u20134 weeks if mild, more frequently if moderate\u2013severe", "Repeat imaging if initial abnormalities present", "Taper corticosteroids slowly if used", "Bone marrow biopsy if persistent unexplained eosinophilia" ] } ], "key_references": [ { "title": "UpToDate: Evaluation of Eosinophilia in Adults", "url": "https://www.uptodate.com" }, { "title": "NEJM Review: Hypereosinophilic Syndromes", "url": "https://www.nejm.org" }, { "title": "CDC Guidance on Parasitic Causes of Eosinophilia", "url": "https://www.cdc.gov/parasites/" } ] }, "schistosomiasis": { "syndrome_name": "Schistosomiasis (Acute and Chronic)", "definition": "Schistosomiasis is a parasitic disease caused by trematodes (Schistosoma haematobium, mansoni, japonicum), transmitted via freshwater exposure in endemic regions. It can present acutely (Katayama fever) or chronically with urinary, hepatic, or intestinal disease.", "common_consult_questions": [ { "question": "What are the key clinical syndromes of schistosomiasis?", "required_information": [ "Acute (Katayama syndrome): fever, cough, urticaria, eosinophilia, 2\u20138 weeks post-exposure", "Chronic intestinal: abdominal pain, diarrhea, hepatosplenomegaly, portal hypertension (S. mansoni, japonicum)", "Chronic urinary: hematuria, bladder wall thickening, obstruction, SCC risk (S. haematobium)", "Consider in travelers, migrants, or deployed military" ] }, { "question": "How is schistosomiasis diagnosed?", "required_information": [ "Stool or urine microscopy for eggs (multiple samples may improve sensitivity)", "Serology (IgG ELISA) for travelers with low parasite burden", "Urine PCR or antigen testing (if available)", "Imaging: bladder US, abdominal US/CT for fibrosis or splenomegaly", "Eosinophilia often present in acute phase" ] }, { "question": "What is the treatment of schistosomiasis?", "required_information": [ "Praziquantel 40\u201360 mg/kg divided in 1\u20132 doses depending on species", "Repeat dosing in 2\u20134 weeks may be needed", "Treat confirmed or seropositive cases, even if asymptomatic", "Consider corticosteroids for severe Katayama fever" ] }, { "question": "When should specialist referral be considered?", "required_information": [ "Invasive or complicated disease (e.g., urologic obstruction, portal hypertension)", "Unclear diagnosis or negative eggs but persistent symptoms", "Neurologic involvement (rare spinal cord disease)", "Hepatology or urology for chronic sequelae" ] }, { "question": "How should patients be monitored post-treatment?", "required_information": [ "Recheck eosinophil count and symptom resolution at 1\u20133 months", "Serology may remain positive after cure; not reliable for response", "Follow-up imaging for chronic complications", "Education on avoiding freshwater exposure in endemic regions" ] } ], "key_references": [ { "title": "CDC Yellow Book: Schistosomiasis", "url": "https://www.cdc.gov/parasites/schistosomiasis" }, { "title": "WHO Guidelines for the Prevention and Control of Schistosomiasis", "url": "https://www.who.int" }, { "title": "NEJM Review: Schistosomiasis in Travelers and Migrants", "url": "https://www.nejm.org" } ] }, "neurocysticercosis": { "syndrome_name": "Neurocysticercosis", "definition": "Neurocysticercosis is a parasitic CNS infection caused by the larval stage of Taenia solium, acquired via fecal-oral ingestion of eggs. It is the leading cause of acquired epilepsy worldwide. Presentation varies by lesion number, location, and stage (viable, degenerating, calcified).", "common_consult_questions": [ { "question": "What are the common presentations and risk factors for neurocysticercosis?", "required_information": [ "Seizures (most common), headaches, hydrocephalus, focal neurologic deficits", "Intraventricular cysts may cause obstructive hydrocephalus or Bruns syndrome", "Epidemiology: endemic in Latin America, sub-Saharan Africa, India, Southeast Asia", "History of exposure to tapeworm carriers or travel to endemic areas" ] }, { "question": "How is neurocysticercosis diagnosed?", "required_information": [ "Brain MRI preferred over CT: identifies cysts, scolex, edema, calcifications", "CT head useful for detecting calcified lesions", "Serology: EITB for multiple cysts; serum/CSF antigen or antibody testing", "CSF analysis if ventriculitis or hydrocephalus suspected (avoid in mass effect)", "Use Del Brutto diagnostic criteria when needed" ] }, { "question": "What is the treatment strategy based on lesion type?", "required_information": [ "Viable or degenerating cysts: albendazole \u00b1 praziquantel x10\u201314 days + corticosteroids", "Calcified cysts: no antiparasitic therapy; seizure control only", "Intraventricular or subarachnoid cysts: neurosurgical consultation; possible shunt or endoscopic removal" ] }, { "question": "When should antiparasitic treatment be avoided or delayed?", "required_information": [ "Elevated intracranial pressure, hydrocephalus, or mass effect", "Multiple cyst burden with edema", "Start steroids first, delay antiparasitics until stable", "Monitor in neurocritical care setting" ] }, { "question": "What is the role of follow-up and seizure management?", "required_information": [ "Long-term AEDs if seizures persist; taper if seizure-free for \u22652 years", "Repeat MRI in 6\u201312 months", "Calcifications may remain; no re-treatment needed", "Screen/treat tapeworm carriers in household", "Patient education on hygiene and food safety" ] } ], "key_references": [ { "title": "CDC Guidelines for Neurocysticercosis", "url": "https://www.cdc.gov/parasites/cysticercosis" }, { "title": "IDSA/ASTMH Guidelines for Parasitic CNS Infections", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Neurocysticercosis", "url": "https://www.nejm.org" } ] }, "amebic_liver_abscess": { "syndrome_name": "Amebic Liver Abscess", "definition": "Amebic liver abscess is a potentially serious complication of Entamoeba histolytica infection, typically following intestinal amebiasis. It is more common in endemic regions and travelers. Prompt diagnosis and treatment can prevent rupture or secondary bacterial infection.", "common_consult_questions": [ { "question": "What are the clinical features and risk factors for amebic liver abscess?", "required_information": [ "Fever, RUQ pain, tender hepatomegaly, chills", "History of diarrhea or dysentery in prior weeks (may be absent)", "Travel to or emigration from endemic areas (e.g., Mexico, India, Southeast Asia)", "Male gender, alcohol use, and immunosuppression as risk factors", "No biliary obstruction or gallstones (helps differentiate from pyogenic abscess)" ] }, { "question": "What is the diagnostic approach to suspected amebic liver abscess?", "required_information": [ "Liver imaging (US or CT): hypoechoic abscesses, usually right lobe", "Serologic testing: E. histolytica antibody (very sensitive after day 7)", "Stool O&P: often negative", "Aspirate: anchovy-paste appearance, sterile on bacterial culture, PCR if available", "Rule out pyogenic abscess (blood cultures, source control history)" ] }, { "question": "What is the treatment for amebic liver abscess?", "required_information": [ "Metronidazole 750 mg PO or IV TID \u00d7 7\u201310 days", "Follow with luminal agent (e.g., paromomycin 25\u201335 mg/kg/day \u00d7 7 days)", "Avoid drainage unless: >10 cm, left lobe, no response in 5\u20137 days, or diagnostic uncertainty" ] }, { "question": "How is amebic abscess distinguished from pyogenic abscess?", "required_information": [ "Amebic: endemic exposure, young male, no biliary source, sterile aspirate, positive serology", "Pyogenic: older, comorbidities, biliary/GI source, polymicrobial culture", "Management differs: pyogenic needs source control + broad-spectrum antibiotics" ] }, { "question": "What is the follow-up and prevention strategy?", "required_information": [ "Monitor improvement and imaging in 2\u20134 weeks if severe or non-resolving", "Ensure luminal clearance with paromomycin after metronidazole", "Educate on food/water hygiene and travel precautions", "Screen household contacts if multiple symptomatic or recent endemic exposure" ] } ], "key_references": [ { "title": "CDC Yellow Book: Amebiasis and Liver Abscess", "url": "https://www.cdc.gov/parasites/amebiasis" }, { "title": "NEJM Review: Amebic Liver Abscess", "url": "https://www.nejm.org" }, { "title": "IDSA Guidelines for Management of Parasitic Infections", "url": "https://www.idsociety.org" } ] }, "ebv_reactivation_mononucleosis": { "syndrome_name": "Epstein-Barr Virus (EBV) Reactivation and Mononucleosis Syndromes", "definition": "EBV is a ubiquitous herpesvirus that causes infectious mononucleosis and is associated with reactivation syndromes in immunosuppressed patients. It can also mimic malignancy or trigger autoimmune complications. EBV DNAemia must be interpreted in clinical context.", "common_consult_questions": [ { "question": "What are the clinical presentations of primary vs reactivated EBV?", "required_information": [ "Primary infection: fever, pharyngitis, lymphadenopathy, fatigue, splenomegaly, rash", "Reactivation: often asymptomatic; possible fever, cytopenias, elevated LFTs", "Complications: hepatitis, hemolytic anemia, myocarditis, Guillain-Barr\u00e9, HLH" ] }, { "question": "How is EBV diagnosed and differentiated from other causes?", "required_information": [ "Monospot: positive in most adolescents/adults with primary infection", "EBV-specific serologies: VCA IgM (acute), VCA IgG + EBNA (past), VCA IgM + no EBNA (primary)", "EBV PCR: detects DNAemia, primarily useful in immunosuppressed settings" ] }, { "question": "What is the role of EBV viral load in clinical decision-making?", "required_information": [ "Not clinically useful in immunocompetent hosts", "Used in SOT/BMT patients to monitor risk for PTLD", "High or rising loads warrant further evaluation in at-risk patients" ] }, { "question": "What are EBV-associated syndromes that require intervention?", "required_information": [ "Mononucleosis: supportive care only", "EBV hepatitis/pancytopenia: rule out HLH or drug-induced cause", "Transplant viremia: reduce immunosuppression, consider rituximab if PTLD risk", "Chronic active EBV or HLH: hematology referral" ] }, { "question": "How should EBV-positive patients be monitored or followed up?", "required_information": [ "Avoid contact sports for \u22653 weeks due to splenic rupture risk", "Monitor CBC, LFTs, symptoms", "Serial PCR in transplant patients at risk for PTLD", "Avoid unnecessary antivirals or empiric antibiotics" ] } ], "key_references": [ { "title": "CDC Mononucleosis and EBV Factsheet", "url": "https://www.cdc.gov/epstein-barr" }, { "title": "IDSA Guidelines for EBV Monitoring in Transplant Patients", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Epstein-Barr Virus\u2013Related Disease", "url": "https://www.nejm.org" } ] }, "infective_myositis_pyomyositis": { "syndrome_name": "Infective Myositis or Pyomyositis", "definition": "Infective myositis refers to inflammation or infection of skeletal muscle, often caused by bacteria (pyomyositis), viruses, or parasites. Pyomyositis is most common in tropical climates but occurs increasingly in immunocompromised or trauma patients in temperate settings.", "common_consult_questions": [ { "question": "What are the typical clinical presentations of pyomyositis or myositis?", "required_information": [ "Localized muscle pain, swelling, fever", "May resemble cellulitis or deep vein thrombosis", "Most often affects thigh, gluteal, or paraspinal muscles", "Immunocompromised hosts may have multifocal or subtle symptoms" ] }, { "question": "What are the most common pathogens and risk factors?", "required_information": [ "Staphylococcus aureus (including MRSA): most common", "Streptococci, Gram-negatives in immunocompromised", "Anaerobes or polymicrobial in trauma or adjacent infection", "Risk factors: trauma, injection drug use, HIV, malignancy, diabetes, recent viral infection (e.g., influenza)" ] }, { "question": "How is the diagnosis confirmed?", "required_information": [ "MRI with contrast: most sensitive test for muscle edema and abscess", "CT scan: detects fluid collection or gas", "Ultrasound: for superficial lesions or guiding aspiration", "Aspiration or biopsy: Gram stain, culture (aerobic/anaerobic), AFB/fungal stains if needed", "Blood cultures: may be positive in 15\u201330% of cases" ] }, { "question": "What is the management approach?", "required_information": [ "Empiric antibiotics: vancomycin \u00b1 ceftriaxone or cefepime", "Broaden coverage based on host factors (e.g., diabetes, trauma)", "Drainage: percutaneous or surgical if abscess or poor response", "Duration: 2\u20133 weeks; longer if multifocal or immunocompromised" ] }, { "question": "What complications and follow-up should be monitored?", "required_information": [ "Monitor for compartment syndrome or necrotizing fasciitis", "Repeat imaging if no improvement in 72 hours", "Adjust antibiotics based on culture results", "Physical therapy after resolution to restore function", "Reassess for underlying immunosuppression if severe or recurrent" ] } ], "key_references": [ { "title": "IDSA Guidelines for Skin and Soft Tissue Infections", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Bacterial Pyomyositis", "url": "https://www.nejm.org" }, { "title": "CDC Infectious Muscle Disease Summary", "url": "https://www.cdc.gov" } ] }, "clostridial_soft_tissue_infection": { "syndrome_name": "Clostridial Soft Tissue Infections (Gas Gangrene)", "definition": "Clostridial myonecrosis ('gas gangrene') is a rapidly progressive, life-threatening soft tissue infection caused primarily by Clostridium perfringens or Clostridium septicum. It leads to muscle necrosis, systemic toxicity, and requires emergent surgical intervention.", "common_consult_questions": [ { "question": "What are the typical clinical presentations and risk factors for gas gangrene?", "required_information": [ "Sudden onset of severe pain, swelling, bullae, crepitus", "Skin discoloration, foul-smelling serosanguinous discharge", "Rapid progression to systemic shock and multiorgan failure", "Risk factors: trauma/surgery, injection drug use, malignancy, diabetes, vascular disease" ] }, { "question": "How is gas gangrene diagnosed?", "required_information": [ "Clinical diagnosis: critical to act on suspicion", "Imaging: X-ray or CT showing soft tissue gas", "Lab findings: hemolysis, leukocytosis, elevated CK, acidosis", "Gram stain: large Gram-positive rods, few WBCs", "Surgical exploration is often required for confirmation and treatment" ] }, { "question": "What is the management of gas gangrene?", "required_information": [ "Immediate surgical debridement or amputation if needed", "Antibiotics: high-dose penicillin + clindamycin", "Alternatives: carbapenems or piperacillin-tazobactam if polymicrobial concern", "Supportive care: fluids, vasopressors, organ support", "Hyperbaric oxygen therapy (HBOT): consider as adjunct if available" ] }, { "question": "When should other necrotizing infections be considered in the differential?", "required_information": [ "Polymicrobial necrotizing fasciitis (e.g., Fournier\u2019s gangrene)", "Group A Streptococcal necrotizing myositis", "Aeromonas or Vibrio vulnificus in aquatic injuries", "Gram stain, tissue culture, surgical findings help differentiate" ] }, { "question": "What follow-up and long-term management is needed?", "required_information": [ "Serial debridements often required", "Antibiotic duration: 10\u201314 days post-source control", "Monitor for bacteremia or metastatic complications", "Rehabilitation, prosthetics if limb loss", "Education on wound care and infection prevention" ] } ], "key_references": [ { "title": "IDSA Guidelines for Skin and Soft Tissue Infections", "url": "https://www.idsociety.org" }, { "title": "CDC Toxin-Producing Clostridium Infections", "url": "https://www.cdc.gov" }, { "title": "NEJM Review: Clostridial Myonecrosis (Gas Gangrene)", "url": "https://www.nejm.org" } ] }, "post_surgical_fever": { "syndrome_name": "Post-Surgical Fever (Early vs. Late Onset)", "definition": "Postoperative fever is common and often self-limited, but may signal infection or other complications. A structured approach distinguishes between non-infectious and infectious causes based on timing, associated signs, and surgical context.", "common_consult_questions": [ { "question": "What are the typical causes of early (<5 days) vs. late (>5 days) postoperative fever?", "required_information": [ "Early: cytokine-mediated response, atelectasis, transfusion reaction, drug fever, early SSI, aspiration pneumonia", "Late: surgical site infection, catheter-related infection, pneumonia, UTI, C. difficile, deep collections or anastomotic leak" ] }, { "question": "How should a systematic evaluation be performed?", "required_information": [ "Use the '5 W's': Wind, Water, Wound, Walk, Wonder drugs", "Vitals and physical exam including surgical/wound/line sites", "Labs: CBC, UA, blood cultures if ill-appearing", "Imaging: CXR if respiratory symptoms, CT if abdominal tenderness or signs of sepsis", "Evaluate for hemodynamic instability or mental status change" ] }, { "question": "When is empiric antibiotic therapy indicated?", "required_information": [ "Not indicated for isolated fever in stable patients without localizing signs", "Indicated in setting of instability, suspected sepsis, or deep infections", "Avoid empiric therapy unless strong indication to minimize resistance and C. difficile" ] }, { "question": "What are red flags that suggest a need for urgent imaging or surgical re-exploration?", "required_information": [ "Fever with hypotension, increasing abdominal girth, peritonitis, or wound dehiscence", "Leukocytosis with bandemia, lactic acidosis", "Purulent, feculent, or bilious drain output", "New arrhythmia, ileus, respiratory distress", "Sudden mental status change in elderly" ] }, { "question": "How should recurrent or prolonged post-op fevers be managed?", "required_information": [ "Reassess for rare causes: drug fever, CLABSI, deep abscess", "Remove unnecessary catheters or drains", "Consult ID or surgery for persistent fever >7 days", "Consider nuclear scan or repeat CT if unclear", "Multidisciplinary approach for complex cases" ] } ], "key_references": [ { "title": "CDC Surgical Site Infection Guidelines", "url": "https://www.cdc.gov/hai/ssi/ssi.html" }, { "title": "IDSA Guidelines for Evaluation of Fever in Hospitalized Patients", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Postoperative Fever", "url": "https://www.nejm.org" } ] }, "infective_endophthalmitis": { "syndrome_name": "Infective Endophthalmitis", "definition": "Endophthalmitis is a vision-threatening intraocular infection involving the vitreous or aqueous humor. It can be exogenous (e.g., post-surgical, post-trauma) or endogenous (hematogenous spread from distant infection). Prompt diagnosis and ophthalmology referral are critical.", "common_consult_questions": [ { "question": "What are the common causes and presentations of endophthalmitis?", "required_information": [ "Exogenous: post-surgical (cataract, injection), trauma", "Endogenous: hematogenous spread from IVDU, endocarditis, candidemia", "Symptoms: eye pain, decreased vision, floaters, hypopyon, red eye, lid edema" ] }, { "question": "What pathogens are typically involved?", "required_information": [ "Exogenous: Coagulase-negative staph, Staph aureus, viridans strep, Pseudomonas, Candida", "Endogenous: Candida spp., Staph aureus, Strep spp., Gram-negatives", "Polymicrobial in trauma or IVDU cases" ] }, { "question": "How is endophthalmitis diagnosed?", "required_information": [ "Ophthalmologic exam: slit-lamp, fundus exam, visual acuity", "B-scan ultrasound if view obscured", "Vitreous/aqueous tap for Gram stain, culture, PCR", "Blood cultures and systemic workup for endogenous", "Urgent ophthalmology consult required" ] }, { "question": "What is the appropriate management strategy?", "required_information": [ "Empiric intravitreal antibiotics: vancomycin + ceftazidime \u00b1 amphotericin B", "Systemic antibiotics for endogenous: IV vancomycin + cefepime or fluconazole", "Pars plana vitrectomy for severe cases", "Avoid corticosteroids unless advised by ophthalmology" ] }, { "question": "How should follow-up and systemic evaluation be managed?", "required_information": [ "Daily ophthalmology follow-up for visual acuity and response", "2\u20134 weeks systemic therapy for endogenous fungal", "Search for hematogenous source: blood cultures, echo, imaging", "Remove infected catheters or hardware", "Counsel on visual prognosis and rehabilitation" ] } ], "key_references": [ { "title": "AAO Preferred Practice Pattern: Endophthalmitis", "url": "https://www.aao.org" }, { "title": "IDSA Guidelines on Endogenous Endophthalmitis", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Endophthalmitis", "url": "https://www.nejm.org" } ] }, "infected_aortic_graft": { "syndrome_name": "Infected Aortic Graft or Endovascular Infection", "definition": "Infected aortic grafts or endovascular infections (e.g., aortic endograft, stent, or native aorta) are rare but serious infections often presenting subacutely. They require high suspicion, multimodal imaging, prolonged antibiotics, and often surgical intervention.", "common_consult_questions": [ { "question": "What are the typical presentations and risk factors for aortic graft infections?", "required_information": [ "Fever, abdominal/back pain, weight loss, malaise", "Leukocytosis, elevated CRP/ESR", "Signs of sepsis, pseudoaneurysm, or fistula (e.g., GI bleed)", "Risk factors: recent vascular surgery, bacteremia, immunosuppression, diabetes, atherosclerosis" ] }, { "question": "What pathogens are most commonly involved?", "required_information": [ "Staphylococcus aureus, coagulase-negative staphylococci", "Gram-negatives: Salmonella spp., Pseudomonas", "Enterococcus, Candida spp. in immunocompromised", "Polymicrobial in bowel erosion or aortoenteric fistula" ] }, { "question": "How is an infected aortic graft diagnosed?", "required_information": [ "Blood cultures before antibiotics", "CT angiography: perigraft air, fluid, pseudoaneurysm, graft disruption", "FDG-PET/CT: useful for low-grade infection", "Tagged WBC scan as alternative", "Tissue cultures from operative or guided sampling" ] }, { "question": "What is the treatment strategy?", "required_information": [ "Surgical: explantation + bypass preferred; endovascular salvage if high risk", "Antibiotics: empiric vancomycin + cefepime \u00b1 metronidazole; tailored IV \u22656 weeks", "Lifelong suppressive therapy if graft retained", "Multidisciplinary approach: ID, vascular surgery, radiology" ] }, { "question": "What is the approach to monitoring and secondary prevention?", "required_information": [ "Serial imaging (CT or PET-CT) to monitor", "Oral suppressive therapy if graft not explanted", "Monitor labs and antibiotic toxicities", "Patient education on recurrence signs", "Long-term follow-up with ID and vascular surgery" ] } ], "key_references": [ { "title": "IDSA Guidelines on Vascular Graft Infections", "url": "https://www.idsociety.org" }, { "title": "SVS Guidelines on Aortic Graft Infection", "url": "https://vascular.org" }, { "title": "NEJM Review: Infected Aortic Grafts and Endovascular Infections", "url": "https://www.nejm.org" } ] }, "prosthetic_valve_lvads": { "syndrome_name": "Prosthetic Valve Endocarditis (PVE) or LVAD-Associated Infections", "definition": "Prosthetic valve endocarditis (PVE) and left ventricular assist device (LVAD) infections are high-mortality infections involving foreign cardiac hardware. They require aggressive antimicrobial therapy, complex imaging, and often surgical or device management.", "common_consult_questions": [ { "question": "What are the risk factors and presentations for PVE or LVAD infection?", "required_information": [ "PVE: Early (<1 yr) perioperative or nosocomial; Late (>1 yr) hematogenous", "Fever, murmur, embolic signs, valve dehiscence", "LVAD: driveline infections (redness, drainage), pump/pocket infections, sepsis without source" ] }, { "question": "What are the most common pathogens?", "required_information": [ "PVE: Staph aureus, coagulase-negative staph, Enterococcus, Streptococcus, Candida, Corynebacterium", "LVAD: Staph aureus, Pseudomonas, Candida, CoNS; polymicrobial possible in chronic driveline infections" ] }, { "question": "How is the diagnosis confirmed?", "required_information": [ "Blood cultures: \u22653 sets before antibiotics", "Echocardiography: TEE preferred for prosthetic valves", "PET/CT or tagged WBC scan for prosthetic material", "Modified Duke Criteria (adjusted for prosthetic materials)" ] }, { "question": "What is the treatment strategy?", "required_information": [ "Empiric: vancomycin + cefepime; consider rifampin after cultures stable", "Targeted: 6 weeks IV therapy based on organism", "Surgical: for dehiscence, embolism, CHF, uncontrolled bacteremia", "LVAD: consider device replacement, debridement if systemic" ] }, { "question": "How is long-term management handled?", "required_information": [ "Suppressive oral therapy in non-surgical candidates", "Monitor CRP, cultures, imaging for response", "LVAD patients may need lifelong suppression", "Close monitoring of drug interactions (e.g., rifampin with anticoagulation)", "Multidisciplinary care: cardiology, surgery, ID, heart failure team" ] } ], "key_references": [ { "title": "AHA/ACC Guidelines on Endocarditis and Cardiac Device Infection", "url": "https://www.heart.org" }, { "title": "IDSA Guidelines on Prosthetic Valve and Endovascular Infections", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Endocarditis on Prosthetic Valves and LVADs", "url": "https://www.nejm.org" } ] }, "gastrointestinal_tuberculosis": { "syndrome_name": "Gastrointestinal Tuberculosis (GI TB)", "definition": "GI TB is an extrapulmonary manifestation of Mycobacterium tuberculosis infection affecting any part of the gastrointestinal tract, most commonly the ileocecal region. It may mimic inflammatory bowel disease, malignancy, or other infections.", "common_consult_questions": [ { "question": "What are the common presentations and risk factors for GI TB?", "required_information": [ "Chronic abdominal pain, weight loss, fever, night sweats, diarrhea or constipation", "Ileocecal mass, strictures, or bowel obstruction", "GI bleeding, perforation, or fistula (late presentation)", "Risk factors: TB-endemic area, HIV, malnutrition, immunosuppression, prior TB" ] }, { "question": "What are the common sites and forms of GI TB?", "required_information": [ "Ileocecal TB (most common): mass, stricture, mucosal ulceration", "Peritoneal TB: ascites, fever, distension, low SAAG ascites", "Esophageal, gastric, or anorectal TB: rare, may mimic malignancy", "Lymphadenitis or fistulas: retroperitoneal/mesenteric nodes" ] }, { "question": "How is GI TB diagnosed?", "required_information": [ "CT abdomen/pelvis: ileocecal thickening, necrotic lymph nodes, ascites", "Endoscopy/colonoscopy with biopsy: granulomas, AFB, TB PCR", "Ascitic fluid: high protein, lymphocytes, ADA >33 U/L", "AFB cultures and Xpert MTB/RIF from biopsy or fluid" ] }, { "question": "What is the treatment for GI TB?", "required_information": [ "RIPE therapy: 2 months intensive phase, 4\u20137 months continuation phase", "Total duration: 6\u20139 months", "Surgery: only for obstruction, perforation, or unclear diagnosis" ] }, { "question": "What are key considerations for follow-up and monitoring?", "required_information": [ "Monitor clinical and nutritional recovery", "Repeat imaging if non-resolving obstruction or diagnostic uncertainty", "HIV testing and immune status evaluation", "Counsel on adherence and screen household contacts", "Steroids not routinely needed unless obstruction or severe peritonitis" ] } ], "key_references": [ { "title": "WHO Guidelines for Tuberculosis Management", "url": "https://www.who.int" }, { "title": "CDC Extrapulmonary TB Guidelines", "url": "https://www.cdc.gov/tb" }, { "title": "NEJM Review: Gastrointestinal Tuberculosis", "url": "https://www.nejm.org" } ] }, "febrile_neutropenia_non_oncology": { "syndrome_name": "Febrile Neutropenia in Non-Oncology Patients", "definition": "Febrile neutropenia refers to fever in a patient with an absolute neutrophil count (ANC) <1500/\u03bcL, especially <500/\u03bcL, in a non-oncology context (e.g., autoimmune disease, drug-induced, viral suppression). It is a medical emergency that requires rapid evaluation and empiric antibiotics.", "common_consult_questions": [ { "question": "What are common causes of neutropenia in non-oncology patients?", "required_information": [ "Infections: viral suppression (e.g., EBV, CMV, HIV, influenza), sepsis-induced marrow suppression", "Drugs: antibiotics, antipsychotics, antithyroid agents, immunosuppressants", "Autoimmune: lupus, Felty syndrome, aplastic anemia", "Nutritional: B12 or folate deficiency", "Congenital or idiopathic cases" ] }, { "question": "What is the initial workup for febrile neutropenia?", "required_information": [ "Vital signs, sepsis screen", "CBC with differential, CMP, lactate, CRP/ESR", "Blood cultures \u00d72, urinalysis, CXR", "Peripheral smear for blasts or dysplasia", "Viral and autoimmune panel if unexplained", "Comprehensive medication review" ] }, { "question": "When should empiric antibiotics be initiated?", "required_information": [ "ANC <500/\u03bcL and fever \u226538.0\u00b0C", "Empiric: cefepime, piperacillin-tazobactam, or meropenem", "Add vancomycin if catheter/skin/pulmonary source", "Antifungals/antivirals reserved for high-risk or persistent fever" ] }, { "question": "How should neutropenia be further evaluated or managed?", "required_information": [ "Repeat CBC to assess recovery", "Bone marrow biopsy if prolonged or pancytopenia", "Consider G-CSF for sepsis or drug-induced cases", "Stop or modify offending medications" ] }, { "question": "What is the approach to monitoring and follow-up?", "required_information": [ "Daily CBCs until recovery", "De-escalate antibiotics after 48 hours if stable and afebrile", "Discharge criteria: afebrile \u226548 hours, improving ANC", "Outpatient workup for underlying etiology", "Patient education on fever precautions" ] } ], "key_references": [ { "title": "IDSA Guidelines on Febrile Neutropenia", "url": "https://www.idsociety.org" }, { "title": "NEJM Review: Neutropenia in Non-Oncology Patients", "url": "https://www.nejm.org" }, { "title": "CDC Antimicrobial Recommendations for Neutropenic Fever", "url": "https://www.cdc.gov" } ] }, "ntm_skin_soft_tissue": { "syndrome_name": "Non-Tuberculous Mycobacterial (NTM) Skin and Soft Tissue Infections", "definition": "NTM skin and soft tissue infections are caused by environmental mycobacteria (e.g., M. abscessus, fortuitum, chelonae, marinum) and typically occur after trauma, cosmetic procedures, injections, or aquatic exposures. They are often indolent but require prolonged therapy and sometimes surgical debridement.", "common_consult_questions": [ { "question": "What are the typical clinical presentations and risk factors?", "required_information": [ "Indurated nodules, plaques, ulcers, or sinus tracts", "Often chronic or slow-growing over weeks", "Risk factors: trauma, tattoos, cosmetic surgery, nail salons, aquariums, immunosuppression" ] }, { "question": "Which NTM species are most commonly involved?", "required_information": [ "Rapid growers: M. abscessus, M. chelonae, M. fortuitum", "Water-associated: M. marinum (\u2018fish tank granuloma\u2019)", "Slow growers: M. ulcerans (Buruli ulcer, tropical)" ] }, { "question": "How are NTM infections diagnosed?", "required_information": [ "Tissue biopsy: culture, AFB stain, histopathology", "PCR or sequencing for speciation and susceptibility", "Imaging (e.g., ultrasound or MRI) for deep infection", "Notify lab to use mycobacterial media and extended culture time" ] }, { "question": "What is the treatment approach?", "required_information": [ "Antibiotics based on susceptibility testing", "Empiric: macrolide + amikacin \u00b1 imipenem or cefoxitin", "Avoid monotherapy to prevent resistance", "Duration: typically 4\u20136 months", "Surgical debridement or drainage often required" ] }, { "question": "How should monitoring and follow-up be conducted?", "required_information": [ "Monitor clinical response and drug toxicity (e.g., ototoxicity)", "Repeat imaging if non-resolving lesions", "Re-culture persistent or recurrent infections", "Involve ID or NTM specialist for complex cases", "Report to public health if part of outbreak or linked to clinical procedure" ] } ], "key_references": [ { "title": "IDSA Guidelines for NTM Infections (2020)", "url": "https://www.idsociety.org" }, { "title": "CDC Guidance on Atypical Mycobacterial Skin Infections", "url": "https://www.cdc.gov" }, { "title": "NEJM Review: NTM Skin and Soft Tissue Infections", "url": "https://www.nejm.org" } ] } }