ACP American College of Physicians® INTERNAL MEDICINE | Doctors for Adults MKSAP16 Medical Knowledge Self-Assessment Program9 Infectious Disease All New Content, Including 108 Multiple-Choice Questions > -a ' _fc _H_d_^__ * _ m CUMULATIVE INDEX 16 AMA PRA » Category 1 Credits™ available until Dec. 31, 2015. A /^ T) American College of Physicians^ 1 JlV__>JL internal medicine | Doctors for Adidts MKSAP16 Medical Knowledge Self-Assessment Program® Infectious Disease Welcome to the Infectious Disease Section of MKSAP 16! Here, you will find updated information on central nervous system infection, skin and soft tissue infection, community- acquired pneumonia, tick-borne disease, urinary tract infection, Mycobacterium tuberculosis and nontuberculous mycobacte rial infection, sexually transmitted infection, health care-associated infection, HIV infection, and many other clinical chal lenges. All of these topics are uniquely focused on the needs of generalists and subspecialists outside of infectious disease. The publication of the 16th edition of Medical Knowledge Self-Assessment Program heralds a significant event, culminating 2 years of effort by dozens of leading subspecialists across the United States. Our authoring committees have strived to help internists succeed in Maintenance of Certification, right up to preparing for the MOC examination, and to get residents read}' for the certifying examination. xMKSAP 16 also helps you update your medical knowledge and elevates standards of self-learning by allowing you to assess your knowledge with 1,200 all-new multiple-choice questions, including 108 in Infectious Disease. MKSAP began more than 40 years ago. The American Board of Internal Medicine's examination blueprint and gaps between actual and preferred practices inform creation of the content. The questions, refined through rigorous face-to-face meetings, are among the best in medicine. A psychometric analysis of the items sharpens our educational focus on weaknesses in prac tice. To meet diverse learning styles, we offer MKSAP 16 online and in downloadable apps for PCs, tablets, laptops, and smartphones. We are also introducing the following: High-Value Care Recommendations: The Infectious Disease section starts with several recommendations based on the important concept of health care value (balancing clinical benefit with costs and harms) to address the needs of trainees, practicing physicians, and patients. These recommendations are part of a major initiative that has been undertaken by the American College of Physicians, in collaboration with other organizations. Content for Hospitalists: This material, highlighted in blue and labeled with the familiar hospital icon (□), directly addresses the learning needs of the increasing number of physicians who work in the hospital setting. MKSAP 16 Digital will allow you to customize quizzes based on hospitalist-only questions to help you prepare for the Hospital Medicine Maintenance of Certification Examination. We hope you enjoy and benefit from MKSAP 16. Please feel free to send us any comments to [email protected] or visit us at the MKSAP Resource Site (mksap.acponline.org) to find out how we can help you study, earn CME, accumulate MOC points, and stay up to date. I know I speak on behalf of ACP staff members and our authoring committees'when I say we are honored to have attracted your interest and participation. Sincerely, Patrick Alguire, MD, FACP Editor-in-Chief Senior Vice President Medical Education Division American College of Physicians Infectious Disease Committee Wayne State University Corporate Medical Director, Infection Prevention, Allan R. Tunkel, MD, PhD, MACP, Editor2 Epidemiology and Antimicrobial Professor of Medicine Stewardship, Detroit Medical Center Drexel University College of Medicine Detroit, Michigan Chair, Department of Medicine Monmouth Medical Center Fred A. Lopez, MD, FACP2 Long Branch, New Jersey Richard Vial Professor and Vice Chair Department of Medicine Thomas Fekete, MD, FACP, Associate Editor1 Louisiana State University Health Sciences Center Professor of Medicine New Orleans, Louisiana Chief, Infectious Diseases Section of Infectious Diseases Annette C. Reboli, MD, FACP2 Temple University Medical School Founding Vice Dean Philadelphia, Pennsylvania Professor of Medicine Cooper Medical School of Rowan University Karen C. Bloch, MD, MPH » Cooper University Hospital Assistant Professor Camden, New Jersey Department of Infectious Disease and Preventive Medicine Division of Infectious Diseases Vanderbilt University Medical Center Editor-in-Chief Nashville, Tennessee Patrick C. Alguire, MD, FACP1 Senior Vice President, Medical Education Patricia D. Brown, MD, FACP1 Associate Professor of Medicine American College of Physicians Division of Infectious Diseases Philadelphia, Pennsylvania Wayne State University School of Medicine Chief of Medicine Deputy Editor-in-Chief Detroit Receiving Hospital Philip A. Masters, MD, FACP1 Detroit, Michigan Senior Medical Associate for Content Development Larry M. Bush, MD, FACP2 American College of Physicians Affiliated Professor of Biomedical Sciences Philadelphia, Pennsylvania Charles E. Schmidt College of Medicine Florida Atlantic University Senior Medical Associate for Content Boca Raton, Florida Development Affiliated Associate Professor of Medicine University of Miami-Miller School of Medicine Cynthia D. Smith, MD, FACP2 JFK Medical Center American College of Physicians Palm Beach County, Florida Philadelphia, Pennsylvania Michael Frank, MD, FACP1 Professor of Medicine Infectious Disease Clinical Editor Residency Program Director Mary Jane Barchman, MD, FACP2 Vice Chair for Education Department of Medicine Infectious Disease Reviewers Medical College of Wisconsin Milwaukee, Wisconsin Robert D. Arbeit, MD2 Richard A. Fatica, MD1 Keith S. Kaye, MD, MPH, FACP2 Gloria T. Fioravanti, DO, FACP1 Professor of Medicine John D. Goldman, MD, FACP1 Conflicts of Interest Duane R Hospenthal, MD, PhD, FACP1 The following committee members, reviewers, and ACP Richard H. Moseley, MD, FACP1 staff members have disclosed relationships with commercial Mark E. Pasanen, MD, FACP1 companies: Robert D. Arbeit, MD Infectious Disease Reviewer Employment Representing the American Society for Idera Pharmaceuticals Clinical Pharmacology & Therapeutics Stock Options/Holdings Kevin Leary, MD, FACP1 Idera Pharmaceuticals Mary Jane Barchman, MD, FACP Infectious Disease ACP Editorial Staff Speakers Bureau Novartis Margaret Wells', Managing Editor Sean McKinney1, Director, Self-Assessment Programs Larry Bush, MD, FACP John Haefele1, Assistant Editor Speakers Bureau Cubist, Sanofi-Pasteur ACP Principal Staff Keith S. Kaye, MD, MPH, FACP Patrick C. Alguire, MD, FACP1 Speakers Bureau Cubist, Merck, Pfizer, OrthoMcNcil Senior Vice President, Medical Education Consultantship D. Theresa Kanya, MBA1 Merck, Pfizer, OrthoMcNcil, Forest Pharmaceuticals, Vice President, Medical Education Theradoc Research Grants/Contracts Sean McKinney1 Merck, Pfizer, Cubist, Sage Products, Inc. Director, Self-Assessment Programs Fred A. Lopez, MD, FACP Margaret Wells1 Royalties Manajjinjj Editor UpToDate Valerie Dangovetsky1 Annette C. Reboli, MD, FACP Projjra m A dm in istra tor Research Grants/Contracts Becky Krumm1 Merck, Pfizer, T2 BioSystems, Astellas Senior Staff Editor Royalties UpToDate Ellen McDonald, PhD1 Other Senior Staff Editor Pfizer, Merck Katie Idell1 Cynthia D. Smith, MD, FACP Senior Staff Editor Stock Options/Holdings Merck and Company Randy Hendrickson1 Production Administrator/Editor Allan R. Tunkel, MD, PhD, MACP Megan Zborowski1 Employment Food and Drug Administration Staff Editor Research Gra n ts/Con tracts Linnea Donnarumma1 UpToDate Assistant Editor Other NIH, Infectious Diseases Society of America John Haefele1 Assistant Editor Acknowledgments Developed by the American College of Physicians The American College of Physicians (ACP) gratefully acknowledges the special contributions to the development 1. Has no relationships with any entity producing, marketing, re-selling, or distributing and production of the 16th edition of the Medical health care goods or services consumed by, or used on, patients. Knowledge Self-Assessment Program® (MKSAP® 16) made 2. Has disclosed relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. See below. by the following people: IV Graphic Services: Michael Ripca (Technical earn three credits per hour for participating in MKSAP 16 Administrator/Graphic Designer) and Willie-Fetchko under Section 3. MKSAP 16 will enable Fellows to earn up Graphic Design (Graphic Designer). to 75% of their required 400 credits during the 5-year MOC cycle. A Fellow can achieve this 75% level by earning Production/Systems: Dan Hoffmann (Director, Web 100 of the maximum of 174 AMA PRA Category 1 Services & Systems Development), Neil Kohl (Senior Credits™ available in MKSAP 16. MKSAP 16 also meets Architect), and Scott Hurd (Senior Systems multiple CanMEDS Roles for RCPSC MOC, including that Analyst/Developer). of Medical Expert, Communicator, Collaborator, Manager, MKSAP 16 Digital: Under the direction of Steven Spadt, Health Advocate, Scholar, and Professional. For informa Vice President, ACP Digital Products & Services, the digital tion on how to apply xMKSAP 16 CME credits to RCPSC version of MKSAP 16 was developed within the ACP's iMOC, visit the MKSAP Resource Site at Digital Product Development Department, led by Brian mksap.acponline.org. Sweigard (Director). Other members of the team included Sean O'Donnell (Senior Architect), Dan Barron (Senior The Royal Australasian College of Systems Analyst/Developer), Chris Forrest (Senior Software Physicians CPD Program Developer/Design Lead), Jon Lacing (Senior Web Application Developer), Brad Lord (Senior Web In Australia, MKSAP 16 is a Category 3 program that Developer), John McKnight (Senior Web Developer), may be used by Fellows of The Royal Australasian College and Nate Pershall (Senior Web Developer). of Physicians (RACP) to meet mandatory CPD points. Two CPD credits are awarded for each of the 174 AMA The College also wishes to acknowledge that many other PRA Category 1 Credits™ available in MKSAP 16. More persons, too numerous to mention, have contributed to the information about using MKSAP 16 for this purpose is production of this program. Without their dedicated efforts, available at the MKSAP Resource Site at mksap.acponline this program would not have been possible. .org and at www.racp.edu.au. CPD credits earned through MKSAP 16 should be reported at the MyCPD Introducing the MKSAP Resource Site site at www.racp.edu.au/mycpd. (mksap.acponline.org) The MKSAP Resource Site (mksap.acponline.org) is a Continuing Medical Education continually updated site that provides links to MKSAP 16 The American College of Physicians is accredited by the online answer sheets for print subscribers; access to Accreditation Council for Continuing Medical Education MKSAP 16 Digital, Board Basics® 3, and MKSAP 16 (ACCME) to provide continuing medical education for Updates; the latest details on Continuing Medical physicians. Education (CME) and Maintenance of Certification (MOC) in the United States, Canada, and Australia; The American College of Physicians designates this endur errata; and other new information. ing material, MKSAP 16, for a maximum of 174 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation ABIM Maintenance of Certification in the activity. Check the MKSAP Resource Site (mksap.acponline.org) for the latest information on how MKSAP tests can be used to Up to 16 AMA PRA Category 1 Credits™ are available from December 31, 2012, to December 31, 2015, for the apply to the American Board of Internal Medicine for MKSAP 16 Infectious Disease section. Maintenance of Certification (MOC) points. RCPSC Maintenance of Certification Learning Objectives In Canada, MKSAP 16 is an Accredited Self-Assessment The learning objectives of MKSAP 16 are to: • Close gaps between actual care in your practice and pre Program (Section 3) as defined by the Maintenance of Certification Program of The Royal College of Physicians ferred standards of care, based on best evidence • Diagnose disease states that are less common and some and Surgeons of Canada (RCPSC) and approved by the Canadian Society of Internal Medicine on December 9, times overlooked and confusing • Improve management of comorbid conditions that can 2011. Approval of Part A sections of MKSAP 16 extends from July 31, 2012, until July 31, 2015. Approval of Part B complicate patient care • Determine when to refer patients for surgery or care by sections of MKSAP 16 extends from December 31, 2012, to December 31, 2015. Fellows of the Royal College may subspecialists • Pass the ABIM Certification Examination Permission/Consent for Use of Figures • Pass the ABIM Maintenance of Certification Examination Shown in MKSAP 16 Infectious Disease Multiple-Choice Questions Target Audience Figure shown in Self-Assessment Test Item 25 reproduced • General internists and primary care physicians with permission from the Massachusetts Medical Society. • Subspecialists who need to remain up-to-date in internal From Baker DJ, Reboli AC. [Images in Clinical Medicine]. medicine N Engl J Med. 1997;998. Copyright © 1997 Massachusetts • Residents preparing for the certifying examination in Medical Society. internal medicine • Physicians preparing for maintenance of certification in Disclosure Policy internal medicine (recertification) It is the policy of the American College of Physicians (ACP) to ensure balance, independence, objectivity, and scientific Earn "Same-Day" CME Credits Online rigor in all of its educational activities. To this end, and con For the first time, print subscribers can enter their answers sistent with the policies of the ACP and the Accreditation online to earn CME credits in 24 hours or less. You can Council for Continuing Medical Education (ACCME), con submit your answers using online answer sheets that are tributors to all ACP continuing medical education activities provided at mksap.acponline.org, where a record of your are required to disclose all relevant financial relationships MKSAP 16 credits will bc available. To earn CME credits, with any entity producing, marketing, re-selling, or distrib you need to answer all of the questions in a test and earn a uting health care goods or services consumed by, or used score of at least 50% correct (number of correct answers on, patients. Contributors are required to use generic names divided by the total number of questions). Take any of the in the discussion of therapeutic options and are required to following approaches: identify any unapproved, off-label, or investigative use of commercial products or devices. Where a trade name is 1. Use the printed answer sheet at the back of this book to record your answers. Go to mksap.acponline.org, access used, all available trade names for the same product type are also included. If trade-name products manufactured by the appropriate online answer sheet, transcribe your answers, and submit your test for same-day CME credits. companies with whom contributors have relationships are There is no additional fee for this service. discussed, contributors are asked to provide evidence-based citations in support of the discussion. The information is 2. Go to mksap.acponline.org, access the appropriate online reviewed by the committee responsible for producing this answer sheet, directly enter your answers, and submit text. If necessary, adjustments to topics or contributors' your test for same-day CME credits. There is no addi roles in content development are made to balance the dis tional fee for this service. cussion. Further, all readers of this text are asked to evaluate 3. Pay a $10 processing fee per answer sheet and submit the the content for evidence of commercial bias and send any relevant comments to [email protected] so that printed answer sheet at the back of this book by mail or future decisions about content and contributors can be fox, as instructed on the answer sheet. Make sure you cal culate your score and fax the answer sheet to 215-351- made in light of this information. 2799 or mail the answer sheet to Member and Customer Service, American College of Physicians, 190 N. Resolution of Conflicts Independence Mall West, Philadelphia, PA 19106-1572, To resolve all conflicts of interest and influences of vested using the courtesy envelope provided in your MKSAP 16 interests, the ACP precluded members of the content-cre slipcase. You will need your 10-digit order number and ation committee from deciding on any content issues that 8-digit ACP ID number, which are printed on your pack involved generic or trade-name products associated with ing slip. Please allow 4 to 6 weeks for your score report to be emailed back to you. Be sure to include your email proprietary entities with which these committee members had relationships. In addition, content was based on best address for a response. evidence and updated clinical care guidelines, when such If you do not have a 10-digit order number and 8-digit ACP evidence and guidelines were available. Contributors' dis ID number or if you need help creating a username and pass closure information can be found with the list of contribu word to access the MKSAP 16 online answer sheets, go to tors' names and those of ACP principal staff listed in the mksap.acponline.org or email [email protected]. beginning of this book. VI Hospital-Based Medicine mechanical, including photocopy, without the express con sent of the ACP. MKSAP 16 is for individual use only. Only For the convenience of subscribers who provide care in hos one account per subscription will be permitted for the pur pital settings, content that is specific to the hospital setting has been highlighted in blue. Hospital icons (Q) highlight pose of earning CME credits and MOC points/credits and for other authorized uses of MKSAP 16. where the hospital-only content begins, continues over more than one page, and ends. Unauthorized Use of This Book Is Educational Disclaimer Against the Law Unauthorized reproduction of this publication is unlaw The editors and publisher of MKSAP 16 recognize that the ful. The ACP prohibits reproduction of this publication development of new material offers many opportunities for or any of its parts in any form either for individual use or error. Despite our best efforts, some errors may persist in for distribution. print. Drug dosage schedules are, we believe, accurate and in accordance with current standards. Readers are advised, The ACP will consider granting an individual permission however, to ensure that the recommended dosages in to reproduce only limited portions of this publication for MKSAP 16 concur with the information provided in the his or her own exclusive use. Send requests in writing to product information material. This is especially important in MKSAP® Permissions, American College of Physicians, 190 cases of new, infrequently used, or highly toxic drugs. N. Independence Mall West, Philadelphia, PA 19106-1572, Application of the information in MKSAP 16 remains the or email your request to [email protected]. professional responsibility of the practitioner. MKSAP 16 ISBN: 978-1-938245-00-8 The primary purpose of MKSAP 16 is educational. (Infectious Disease) ISBN: 978-1-938245-09-1 Information presented, as well as publications, technologies, Printed in the United States of America. products, and/or services discussed, is intended to inform subscribers about the knowledge, techniques, and experi For order information in the U.S. or Canada call 800- ences of the contributors. A diversity of professional opinion 523-1546, extension 2600. All other countries call 215- exists, and the views of the contributors are their own and 351-2600. Fax inquiries to 215-351-2799 or email to not those of the ACP. Inclusion of any material in the pro [email protected]. gram does not constitute endorsement or recommendation by the ACP. The ACP does not warrant the safety, reliabil Errata and Norm Tables ity, accuracy, completeness, or usefulness of and disclaims Errata for MKSAP 16 will be available through the MKSAP any and all liability for damages and claims that may result from the use of information, publications, technologies, Resource Site at mksap.acponline.org as new information becomes known to the editors. products, and/or services discussed in this program. MKSAP 16 Performance Interpretation Guidelines with Publisher's Information Norm Tables, available July 31, 2013, will reflect the knowledge of physicians who have completed the self- Copyright © 2012 American College of Physicians. All assessment tests before the program was published. These rights reserved. physicians took the tests without being able to refer to the This publication is protected by copyright. No part of this syllabus, answers, and critiques. For your convenience, the publication may be reproduced, stored in a retrieval system, tables are available in a printable PDF file through the or transmitted in any form or by any means, electronic or MKSAP Resource Site at mksap.acponline.org. VII Table of Contents Central Nervous System Infections Urinary Tract Infections Meningitis 1 Epidemiology and Microbiology 29 Viral Meningitis 1 Diagnosis 29 Bacterial Meningitis 2 Management 30 Focal Central Nervous System Infections 6 Cystitis in Women 30 Brain Abscess 6 Recurrent Urinary Tract Infections in Women 30 Cranial Subdural Empyema 7 Acute Pyelonephritis 31 Spinal Epidural Abscess 8 Asymptomatic Bacteriuria 31 Encephalitis 8 Acute Prostatitis 31 Herpes Simplex Encephalitis 9 West Nile Virus Encephalitis 10 Mycobacterium tuberculosis Infection Introduction 31 Prion Diseases of the Central Nervous System Introduction 11 Epidemiology 31 Pathophysiology 32 Creutzfeldt-Jakob Disease 11 Clinical Manifestations 32 Variant Creutzfeldt-Jakob Disease 12 Diagnostic Testing 32 Tuberculin Skin Test 33 Skin and Soft Tissue Infections Interieron-y Release Assays 33 Introduction 12 Culture and Other Microbiologic Tests 34 Community-Associated Methicillin- Resistant Staphylococcus aureus 13 Radiographic Imaging 34 Necrotizing Fasciitis 14 Treatment 34 Toxic Shock Syndrome 15 Multidrug-Resistant and Extensively Drug-Resistant Animal Bites 16 Tuberculosis 36 Human Bites 17 Prevention 36 Diabetic Foot Infections 17 Nontuberculous Mycobacterial Infections Community-Acquired Pneumonia Mycobacterium avium Complex Infection 37 Epidemiology 18 Mycobacterium kansasii 38 Microbiology 1° Rapidly Growing Mycobacteria 38 Diagnosis 1 * Management 20 Fungal Infections Site of Care 20 Systemic Candidiasis 39 Antibiotic Therapy 21 Clinical Manifestations and Diagnosis 39 Complications 22 Treatment 39 Follow-up 23 Aspergillosis and Aspergilloma 40 Tick-Borne Diseases Mucormycosis 40 Cryptococcosis 41 Lyme Disease 24 Babesiosis 27 Blastomycosis 41 Southern Tick-Associated Rash Illness 27 Histoplasmosis 42 Ehrlichiosis and Anaplasmosis 28 Coccidioidomycosis 42 Rocky Mountain Spotted Fever 28 Sporotrichosis 42 Sexually Transmitted Infections Travel Medicine Introduction 43 Malaria 61 Cervicitis and Urethritis 43 Typhoid Fever 63 Chlamydia trachomatis Infection 43 Travelers' Diarrhea 63 Neisseria gonorrhoeae Infection 43 Dengue Fever 64 Complications of Cervicitis and Urethritis 44 Hepatitis A Virus Infection 64 Pelvic Inflammatory Disease 44 Rickettsial Infection 64 Brucellosis 65 Epididymitis 44 Treatment 45 Travel-Associated Fungal Infections 65 Genital Ulcers 46 Infectious Gastrointestinal Syndromes Herpes Simplex Virus Infection 46 Syphilis 47 Campylobacter Infection 67 Chancroid 48 Shigella Infection 67 Lymphogranuloma Venereum 48 Salmonella Infection 67 Genital Warts 48 Escherichia coli Infection 68 Yersinia Infection 69 Vibrio Infection 69 Osteomyelitis Clostridium difficile Infection 69 Pathophysiology and Classification 49 Viral Gastroenteritis 71 Clinical Manifestations 49 Parasitic Infections 71 Diagnosis 50 Giardia Infection 71 Imaging Studies 50 Cryptosporidium Infection 72 Laboratory Studies 50 Amebiasis 72 Bone Biopsy 50 Treatment 50 Infections in Transplant Recipients Evaluation and Management of Diabetes Mcllitus-Associated Osteomyelitis 51 Introduction 72 Evaluation and Management of Vertebral Antirejection Drugs in Transplant Recipients 72 Osteomyelitis 51 Posttransplantation Infections 73 Timeline and Type of Transplant 73 Fever of Unknown Origin Specific Posttransplantation Infections 75 Introduction 52 Prevention of Infections in Transplant Recipients 76 Causes 53 Evaluation 54 Hospital-Acquired Infections Epidemiology 76 Prevention jj Primary Immunodeficiencies Introduction 55 Catheter-Associated Urinary Tract Infections 77 Selective IgA Deficiency 55 Diagnosis 78 Common Variable Immunodeficiency 55 Treatment 78 Prevention 78 Abnormalities in the Complement System 55 Surgical Site Infections 79 Bioterrorism Diagnosis 79 Treatment 79 Introduction 56 Prevention 79 Anthrax 57 Central Line-Associated Bloodstream Infections 80 Smallpox (Variola) 58 Diagnosis 80 Plague 58 Treatment 81 Botulism 59 Prevention 81 Tularemia 59 Hospital-Acquired Pneumonia and Ventilator- Viral Hemorrhagic Fever 60 Associated Pneumonia 82