ABX TX Flashcards
Anti pseudomonas PCN’s
1) ( Timentin ): ticarcillin + clavulanate
2) ( Zosyn ): piperacillin + tazobactam
Antipseudomonas cephalosporins
1) ceftazidime ( Fortaz, Tazicef )
2) cefipime ( maxipime)
3) cefiderocol ( fertoja) -new
Pseudomans aeruginosa abx
1) anti pseudo PCNS
2) anti pseudo cephs
3) carbapenems
4) fluroquinolones
5) aminoglycosides ( adjunct only )
6 ) monobactam : aztreonam
Neisseria gonorrheae
Ceftriaxone 500 mg single IM -( 1 G if >= 150 kg)
-If also chlamydia - doxycycline 100 mg po bid x 7days
If ceph allergy —> azithromycin 2 G + gentamicin 240 mg IM
Neonatal occcular prophylaxis —> erythromycin op ointment
GBS + to prevent neonatal meningitis
Intrapartum IV tx : PCN G or ampicillin prior to delivery
Mild PCN allergy : IV cefazolin
Severe PCN allergy: IV clindamycin
Impetigo from staph aureus
Mupirocin
2) retapamulin ( altabax)
If severe: systemic abx
MRSA Colonization eradication
Bactroban nasal single use tubes
+
Hibiclens ( 4% chlorhexidine)
IV ABX for MRSA
1st line: vanco
Clindamycin ( iv po )
Linezolid ( zyvox) IV PO
Tedizolid - iv po ( skin only )
Delafloxacin -iv po ( skin only )
Daptomycin ( baxdela) -not for pneumonia
MSSA
Tx with betalactamase resistant PCNs
-dicloxacillin: po
Nafcillin iv
Oxacillin iv
MRSA common abx
Vanco
Bactrim
Doxycycline
Linezolid ( zyvox)
PO outpatient ABX
Bactrim
Doxycycline
Clindamycin
Linezolid ( zyvox )
Tedizolid ( sicextro)
Delafloxacin ( baxdela )
Omadacycline ( nuzyra)
E faecalis / e faecium
Traditional : amp + gent
Newer tx: amp + ceftriaxone
- amp allergy: vanco + genta
VRE: daptomycin , Linezolid …
Corynebacterium diphtheria
Anti toxin + abx
PCN or erythromycin x 7d
Close contact prophylaxis: vax & abx
Erythromycin or pcn g
Listeria monocytogenes
Ampicillin + gent
PCN allergy : bactrim +/- gentamicin
Bacillus antracis
Tx depends on location
Cipro
Clindamycin
Doxycylin
Linezolid
Meropenum
Or a
Combo of ( for CNS)
Neisseria meningitidis
Non neonatal meningitis empiric: ceftriazxone + vanco
- once culture shows meningococcus continue with CEFTRIAXONE
- add ampicillin for listeria coverage in > 50 y/o
———If severe PCN allergy: moxifloxacin + vanco ( for listeria coverage only )
Close contact meningitis tx
Vax and abx prophylaxis:
Rifampin
Cipro
Ceftriaxone
Helicobacter pylori
Guidelines: Tx depends on macrolide resistance
1) triple therapy : clarithromycin + amox ( or metronidazole ) + PPI
2) bismuth quadruple tx : (1st line mostly): metronidazole + tetracycline + bismuth + PPI
3) concomitant therapy : triple therapy + metronidazole
Eradication confirm: - UBT
Haemophilus influenzae
H influ om/sinusitis tx: amoxicillin or augmentin
H influ meningitis or severe ifx: ceftriaxone or cefotaxime
Meningitis close contacts post exposure prophylaxis:
Rifampin/ ceftriaxone / cefotaxime
Prevention: Hib vax
Legionella pneumophila
Macrolides or resp quinolones:
-azithromycin
- resp quinolones in adults :
Bordetella Pertussis
Macrolides ( started within first 3 weeks
Prophylaxis: vax dtap/tdap
Clostridium difficile
Oral vanco -125 mg QID 10 days or Dificid ( fidaxomicin) 200 mg bid x 10 days
- if these 2 unavailable-metronidazole
Fulminant cases( shock, ileus, megacolon) —> vanco 500 mg Qid add IV metronidazole if ileus. Consider rectal vanco
Bezlotoxumab ( zinplava ) : monoclonal ab. Conjunction with abx
Clostridium tetani
Tetanus immune globulin -neutralize unbound toxin.
Abx: metronidazole IV. Alt: PCN G IV
Benzo: prevent spasm.
Resp support
Alpha/ beta blockade: if needed. Labetalol dual blocker.
Prevention: immunization with td
Bacteroides
B fragilis
DOC: metronidazole
Other abx: carbapenums & betalactams + betalactamase inhibitor
Due to increase resistance to clindamycin & moxifloxacin no longer recommended
Dental ifx: 50% anaerobic but NOT bacteroides
Outpatient : augmentin or clindamycin
Inpatient: ampicillin + sulbactam ( unasyn IV)
Chlamydiae trachomatis / genital chlamydia
Doxycycline 100mg bid x7d
Alternatives: 1 G x 1 ( preferred in pregnancy) or Levofloxacin 500mg daily x 7 days
Expedited partner tx: abstain 7 days
Retest 3 months for re infection
Mycoplasma Pneumoniae
Macrolides or doxycycline
If resistant : 3rd /4th gen quinolones
Treponema pallidum: syphilis
PCN G benzathine ( Bicilin-LA) IM x 1 - early syphilis
Late latent or tertiary syphilis: PCN G benzathine IM weekly x 3 wks
NeuroSyphilis: aqueous PCN G IV Q4h 10-14 d
Borrelia burgdorferi: Lyme disease
Early localized disease: doxycycline 10-14d or
Amox or cefuroxime
Lyme carditis: doxycycline , amoxicillin, or CEFTIN ( cefuroxime ) 14-21 days, if severe IV ceftriaxone 14-21 days
Lmk arthritis : doxy, amoxicillin, ceftin ( cefuroxime) 14-21 days , if severe IV ceftriaxone 28 days
Neurologic Lyme disease : facial palsy : doxy 14-21 days
•meningitis : oral doxy or IV ceftriaxone 14-21 days
Candida Albicans
Yeast
Oropharyngeal -esophageal thrush : nystatin swish and swallow or fluconazole
Vaginal thrush : azole vaginal creams or diflucan
Systemic candidemia : IV echinocandin with po fluconazole as oral step down therapy
Candida diaper rash
Vusion: Rx ointment : 0.25% michonazole + zinc oxide
Next 2 are strong topical corticosteroids ( not recommended but commonly used. Not recommended bc they have steroid and steroids can cause candida )
• mycologist-II : nystatin + triamcinolone
• Lotrisone: betamethasone + clotrimazole
Cryptococcosis
yeast
Meningitis tx: indication with ampho B + flucytosine x2weeks; consolidation with fluconazole
Pneumonia tx: fluconazole or itraconazole
Aspergillus fumigatus
MOLD - found everywhere
DOC : voriconazole ( VFEND)
In severe cases add echinocandin
Coccidioides immitis
Can cause pnemonia ( valley fever ) and meningitis
Tx: fluconazole or itraconazole
Coccidioides immitis
Coccidiodomycosis: Dimorphic funcgus - yeast and mold
Pneumonia ( valley fever) and meningitis
Tx : fluconazole or itraconazole
Other dimorphics
• histoplasma
• blastomyces
Tx :
Mild- itraconazole po
Severe: amphotericin B IV and step down to azole
Antifungals and different types of fungi.
Ampho B really reserved for severe cases bc it has lots of side
Dermatophytes/ trichophytions
Tineas by Trichophytons ( dermatophytosis)
Capitis ( scalp) and Onychomycosis ( nails) : both treated with systemic Rx ( TERBINAFINE ( lamisil or itraconazole ( sopranox))
-scalp: 4- 6 weeks
- toe nails : 12 weeks, finger nails 6 weeks
- LFT at baseline and Q month
* must check LFTs before we start oral systemic antifungal. Then check once a month
For
Versicolor ( thorax), Corporis ( ringworm), cruris ( jock itch) , Pedis ( athletes foot) : all topical OTC anitfungal ( anoles )
topical Rx:
Ciclopirox: 8% lacquer ( penlac )
Efinaconazole ( jublia)
Tavaborole ( kerydin)
* very low success rate for these topicals and they’re expensive
Seasonal influenza
Class is called Neuroaminidase inhibitors:
•oseltamivir ( tamiflu)
Adults: 75 mg po bid x5d
•Plx for adults: 75 mg po 7d ( CDC ) or 10d
Can be used in neonates
Zanamivir ( relenza) : diskhaler ( AVOID In asthma patients )
• Peramivir ( rapivab) : IV 600 mg IV as a single dose.
RSV
Respiratory Syncytial Virus
Just a cold virus
Prevention:
Monthly IM injection : synagis ( palivizumab: monoclonal ab) during RSV season
Hepatitis
Herpesvirus
• Tx: Acyclovir, famciclovir, valacyclovir. Lessens duration of symptoms. Best if started early
• a complication of zoster. This is after rash is gone. Neuralgia is nerve pain. We use medications that calm down the nerves. Post Herpetic Neuralgia: 10-15%. Gabapentin, Pregabalin ( lyrica), TCAs ( nortrityline), lidocaine 5% patch, capsaicin, prednisone
Epstein Barr virus ( EBV ) and cytomegalovirus ( CMV )
Other members of the herpesvirus family. Can cause Mono ( mononucleosis: pharyngitis, fever, lassitude, lymphadenopathy, lymphocytois, splenomegaly, anemia, thomobcytopenia in young.
EPV: mono: Avoid contact sports: spleen gets big and if it hit it can rupture and cause spleen hemorrhage. No tx.
CMV:
Tx: ganciclovir, valganciclovir, cidofovir, foscarnet.
Ifx, usually with immonocompromised. If healthy patient ifx, looks like mono. If immunocompromised, can be dangerous.
Infective endocarditis
Think empiric first
Once specified then choose?
Empiric : vanco IV ± gram ( - ) coverage
If MSSA or strep : Oxacillin/ Nafcillin + gentamicin are great.
Pathogen specific therapy 4- 6 weeks IV
Dental prophylaxis : are done in certain cardiac patients ( prosthetic heart valves, history of IE, cardiac transplant, valvulopathy) CHD ( mitral valve prolapse does NOT require prophylaxis ).
- amoxicillin 2 grams PO 30 - 60 mins prior to procedure.
If PCN allergy
-Cephalexin ( mild allergy ) , ( severe allergy) : azithromycin or clarithromycin 500 mg PO or doxycycline 100 mg PO. If unable to take PO —> cefazolin or ceftriaxone 1G IM /IV
- clindamycin no longer recommended.
Cellulitis / Erysipelas / Abscess
All bacterial skin infections
Augmentin ( alternative: doxycycline ) : 3- 5 days + Td/Tdap
Intra abdominal infections
Generally post surgical
Empiric tx: single agent regimens : ertapenem ( Invanz ) or zosyn ( piperacillin-tazobactam )
Combo: Levaquin / cipro + metronidazole
Prophylaxis : Cefazolin ( Ancef ) ± Metronidazole
Alternatives: Cefotetan or Cefoxitin
Acute Gastroenteritis
Tx:
•If norovirus/ rotavirus: supportive tx.
•If bacterial ( febrile )
ABX: short course: quinolones, rifaximin( goes through GI and kills in GI but not absorbed) or azithromycin + supportive
•Giardia( type of diarrhea: hiking, camping, drank from river or lake. Bloated mild diarrhea but doesn’t go away ) : Tx w/metronidazole
•Clostridium difficile( not really acute gastroenteritis ) , colitis after recent abx use tx / w oral vanco or Dificid
Diverticulosis / diverticulitis
Tx: abx to cover E. Coli and B. Fragilis
Cipro/levo + Metronidazole
Bactrim + Metronidazole
Augmentin sometimes
Osteomyelitis
Empiric tx?
Out pt tx:
Empiric Tx: Vancomycin + either Ceftriaxone or Ceftazidime
Tx outpatient : IV abx via PICC line for at least 6 weeks
• MSSA: Nafcillin, Oxacillin, Ceftriaxone
• MRSA : vanco, daptomycin
• gram (-) cipro, levo, cefepime, ceftazidime, ceftriaxone
• enterococcus : ampicillin, vancomycin, daptomycin
• Streptococus: PCN G, Ampicillin, Ceftriaxone
UTI and Pyelonephritis
Tx:
•Acute cystitis: bactrim( used for cys and pyelo avoid in first trimester and at end ( term ). Good for prostatitis and pyelo) , Nitrofurantoin( 1st line. Dont use if CrCl < 30. DONT USE FOR pregnant patients at term; macrobid good for first trimester). Dont give for prostatis ( ineffective ) ) , fosfomycin ( rarely used. Good if multi drug resistant bacteria).
• Pyelonephritis: bactrim, urinary quinolones, ( cipro/levo)
( can you use cipro and levo for acute cystitis. You shouldn’t. You dont want resistance in these.
•Acute cystitis in pregnancy: beta lactams ( Augmentin, keflex, Cefpodoxime, Cefdinir ) or fosfomycin. Macrobid is an option if not at term.
•Pyelonephritis in pregnancy: IV ceftriaxone( most popular ) , cefipime, aztreonam
Warfarin patient: cant use bactrim ( increase INR ) , quinolones ( INR monitor )
Urinary quinolones avoided in pregnancy.
Outpatient adult Community -acquired Pneumonia ( CAP ) Empiric Therapy
1) healthy patients( adult. Stable. Not short of breath. Osat> 95 96 or 97. Can take pills at home) w/o comorbidities:
Amoxicillin high dose ( 1 G. PO TID) or doxycycline or a macro like ( only if local resistance rate < 25% )
2) patients with comorbidities:
Combo therapy: PO B lactam: Augmentin or Cefpodoxime or Cefuroxime + macrolide or doxycycline
Monotherapy: a respiratory fluroquinolone ( levo, moxi, Gemi, dela ( these are respiratory quinolones))
Comorbidities include: Chronic Heart Disease, lung, liver, renal diseases, DM, alcoholism, malignancy, or asplenia
Inpatient adult Community acquired Pneumonia ( CAP )
Pediatric CAP
Outpatient: high dose amoxicillin 1st line
Macrolide if mycoplasma ( atypicals)
Inpatient: IV ampicillin, PCN G, Ceftriaxone, Cefotaxime, ± macrolide if mycoplasma
Hospital -acquired and ventilator associated Pneumonia ( HAP and VAP)
Empiric
Risk for MDR:
Empiric Tx:
No risk MDR: 1 anti-pseudomonal agent : Zosyn, Cefepime, or levofloxacin
Risk for MDR: 2 anti-pseudomonal agents + 1 anti-MRSA agent
( zosyn, cefepime, Ceftazidime, imipenem, meropenem, or aztreonam
PLUS
An Aminoglycoside agent ( amikacin or genta or tobra )
PLUS
1 anti mRSA ( Vanco, linezolid, or telavancin )
Meningitis
Empiric Tx: Ceftriaxone + vanco
Add ampicillin > 50 y/o. Dexamethasone beneficial
Neonatal Meningitis :
Empiric amp+ gent ( or cefotaxime)
Empiric if admitted from the community ( amp + gent + cefotaxime)
STI ( sexually transmitted Infections )
Chlamydia:
Doxy 100 bid x7d
Alt: levofloxacin 500 mg daily x7 days,
Azithromycin 1 g x1 ( preferred if pregnant)
Gonorrhea:
•Ceftriaxone 500 mg single dose IM injection ( 1 gram if ≥ 150 kg )
If chlamydia too : doxy 100 bid x7d
Syphilis:
-Benzathine PCN G IM 2.4 MU IM x1 for 1° or 2°
If PCN allergy doxy for 14 to 28 days
If PCN allergy and pregnant, then best to desensitize patient for PCN bc we cant doxycycline.
Genitalia herpes: tx : acyclovir, famciclovir , valacyclovir ( dont see Gancyclovir)
Also may need for suppression: lower dosages of same meds but taken daily. Also helps reducing transmission to partner.
Trichomonas: metronidazole or tinidazole
HPV : vax, if warts ( imiquimod ( aldara) , podofilox, trichloracetic acid ) or freeze them ( cryotherapy)
Scabies
Tx:
Elimite Cream ( permethrin 5% )
Oral ivermectin ( stromectol ) off label
Topical sulfur 6-33% is primarily tx of infants < 2 months
Apply neck to toe, wash off in 8 to 14 hours, may repeat in 1 to 2 weeks. Night they put this on, this the night they do laundry of everything. Put cream on and sleep with it. Location of where you put it depends on itch. Usually everywhere neck to toe. If children then scalp to toe. For whatever reason it doesn’t like adult faces. For children it does affect them.
Topical premethrin safe for most. Not fda approved for below 2 months so use for topical sulfur.
Pinworm
Anal itching. Intestinal nematode. Tiny white string.
Treat whole family.
Mebendazole ( emverm) single tab 100 mg po x1
Albendazole 400 mg x1
Tx:
•Acute cystitis: bactrim, Nitrofurantoin, fosfomycin
• Pyelonephritis: bactrim, urinary quinolones, ( cipro/levo)
( can you use cipro and levo for acute cystitis. You shouldn’t. You dont want resistance in these.
