All Key Facts Deck Flashcards
DOCs for Community Acquired Methicillin Resistant Staph Aureus (CA-MRSA): Skin and Soft Tissue Infections 5
- Bactrim
- Doxycycline, minocycline
- CLindamycin (must get d-test first and it must be negative)
- Linezolid
For more severe SSTIs requiring IV treatment or hospitalization want to cover MRSA and Strep 10 3 preferred
- Vancomycin
- Linezolid, tidizolid
- Daptomycin
- Ceftaroline
- Televancin
- Ortivancin
- Dalbavancin
- Quinupristin/Dalfopristin
- Tigecycline
Nosocomial MRSA 5 3 preferred
- Vanc (consider alternative if MIC >=2
- Linezolid
- Daptomycin (not in pneumonia)
- Rifampin (select infections never used alone)
- Televancin
VRE (E.Faecilis) 7, 3 preferred
- Pen G or ampicillin
- Linezolid
- Daptomycin
- Tigecycline
- Cystitis only: nitro, fosfomycin, doxycyline
VRE E. Faecium 6, 2 preferred
- Daptomycin
- Linezolid
- Quinu/Dalfo
- Tigecycline
- Cystitis only: nitrofurantoin, fosfomycin, doxy
Pseudomonas Coverage 10
Pip, PIME, DIME, comb, combo, C, Q, A, A, Px2
- Pip/Tazo
- Cefepime
- Ceftazidime
- Ceftaz/Avibactam
- Ceftolozane/tazobactam
- Carbapenems (except ertrapenem)
- Cipro, levofloxacin
- Aztreonam
- AMGs
- Colistimethan, polymyxin B
Acinetobacter Baumannii 7
- Carbapenems (except ertra)
- Amp/sul
- Minocycline
- Tigecycline
- Quinolones
- Bactrim
- Polymyxins
Extended Spectrum beta-lactamase producing gram-negative rods (ESBL-GNR), E. Coli, K. pneumoniae, P. Marabilis
6, 3 preferred
- Carbapenems
- Ceftolozane/Tazobactam
- Ceftazidime/avibactam
- Cefepime (high dose)
- AMGs
- Cystitis only: fosphomycin
Carbapenem Resistant Gram- negative rods (CRE)
3
- Ceftazadime/Avibactam
- Colistimethate, polymyxins
Bacteroid Fragilis 7
M,B,Cx2, C, T, O
- Metronidazole
- Beta-lactam/beta-lactamase inhibitor
- Cefotetan, cefoxitin
- Carbapenems
- Tigecycline
- Others: reduced acitivity: clindamycin, moxifloxacin
C. Diff Infections 3 two preferred
- Oral Vanc
- Fidaxomicin
- Metronidazole
Atypical Organisms 5, 3 preferred
- Azithromycin, clarithromycin
- Doxycycline, minocycline
- Quinolones
HNPEK 7, 1 preferred
- Beta-lactam/beta-lactamse inhibitors
- Amoxicillin (if beta-lactamase negative)
- Cephalosporins (except first generation)
- Carbapenems
- Bactrim
- AMGs
- Quinolones
18 Abxs that do not require renal adjustments
Key drugs
- Antistaphylococcus PCNs (dicloxacillin, nafcillin)
- Ceftriaxone
- Clindamycin
- Doxycycline
- Macrolides (azithromycin, and erythromycin only)
- Metronidazole
- Linezolid
OThers:
- CHloramphenicol
- Fidaxomicin
- Minocycline
- Quinu/Dalfo
- Rifaximin
- Rifampin
- Tedizolid
- Tigecycline
- Tinidazole
- Vanco PO only
Pre-operative Abx prophylaxis time line
- If using cefazolin or cefuroxime 60 minutes before incision
- If a quinolone or vanc is used start at 120 minutes before
- Intraoperative: give an additional dose if surgery is >3-4 hours or with major blood loss
- POST-OP: Abx are not usually used if used DC within 24 hours
AOM treatment is kids: when to consider observation
- Try observation fo 2-3 days if symptoms are non-severe (mild otalgia (<48 hours or T< 102.2F)
- Age 6-23 months symptoms are in one ear only
- >= 2 years, symptoms in 1 or both ears
- If symptoms do not improve or worsen use antibiotics
Risk factors for MRSA, MDR resistant Psuedomonas or other MDR pathogens
Risk for MDR pathogens in VAP?
- HAP/VAP
- IV antibiotic use within the last 90 days
- High prevalence of MRSA in the hospital
- Positive MRSA nasal swab
- VAP
- Hospitalization >= 5 days prior to VAP
- Septic shock at the time of VAP onset
- ARDS prior to VAP
- Acute renal replacement therapy (hemodialysis) prior to VAP onset
HAP/VAP Treatment:
What drugs and what do you target if the patient
- HAP without risk of mortality and low MRSA risk
- VAP without risk factors for MDR pathogens or MRSA
- Target Pseudomonas and MSSA
- Pick one
- Pip/tazo
- Cefepime
- Levofloxacin
- Imipenem/cilastatin or meropenem
- Pick one
HAP/VAP Treatment
What to target and what drugs 5 + 2 add ons
- HAP without risk of mortality, but risk of MRSA
- VAP without risk factors for MDR pathogens, but with risk for MRSA
- Pick one for Pseudomonas coverage
- Pip/tazo
- Cefepime, Ceftazidime
- Levofloxacin or Cipro
- Imipenem/cilstatin or meropenem
- Aztreonam
- Plus MRSA
- Vanc
- Linezolid
HAP/VAP Target?
- HAP with a high risk of mortaility or received abx in the past 90 days
- VAP with risk factors for MDR pathogens or >10% resistance to monotherapy
- Target MDR Pseudomonas and MRSA
- Pip/tazo
- Cefepime, Ceftazidime
- Levofloxacin, ciprofloxacin
- Imipenem/cilstatin or meropenem
- Aztreonam
- Tobramycin, gentamicin, amikacin*
- Colistimethate, polymyxin
- Amikacin, Colistimethate and polymyxin B are all used in combination with another pseudomonas agent
MRSA:
- Vanc/linezolid
Latent TB Treatment
Preferred Regimen for Pregnant, HIV, and Children
- Isoniazid, 300 mg po daily (15 mg/kg PO twice weekly) fo 9 months
Latent TB Tx
INH resistant
Rifampin 600 mg daily for 4 months
Not tolerating INH or INH resistant
latent TB this regimen is not recommended for HIV children <2, pregnant women or presumed infection with INH- or rifampin resistant TB
- INH and rifapentine once weekly for 12 weeks
- Rifampin +pyrazinamide is no longer recommended due to risk of hepatotoxicity
Active TB Dx
- Diagnosis must be confirmed with Acid Fast Bacilli stain
- Definitive Dx must be made with PCR or culture results slow growing can take up to 6 wks
Two phases of Active TB treatment
Intensive phase?
- Rifampin
- Isoniazid
- Pyrazinamide
- Ethambutol
- RIPE
- Tx for 2 months
Continuation phase for Active TB treatment?
- Scaled back to 2 drugs depending on drug susceptibility continued for 4 months but can be extended
- Extended to 7 months if
- Evidence of cavitary pulmonary TB and sputum culture remains positive after 2 months of treatment
- If Intensive phase tx did not include pyrazinamide
- IF pt is being treated with once weekly INH and rifapentine and has a positive sputum culture at the end of entensive phase
Tx duration for Latent and Active TB
- 9 months with INH or other regimen
- 2 months of intensive therapy followed by 4-7 months if risk factors are present
Rifampin Contraindications, Safety, and Notes
- Contra: with protease inhibitors
- Side Effects
- Increase LFTs, orange-red discoloration of body secretions, positive coombs test, flu-like symptoms
- Notes:
- Orange discoloration can stain contact lenses
- Rifabutin: dosed at 5 mg/kg/day (300), can replace rifampin to avoid significant drug interactions (HIV and Protease Inhibitors)
Isoniazid INH
- Boxed warning: for severe and fatal hepatitis
- COntra
- Active liver disease
- Warnings:
- Peripheral neuropathy
- Supplement with pyridoxine in breastfeeding or pregnant patients
- SEs:
- Increased LFTs, drug induced lupus erythematosus (DILE), risk of hemolytic anemia (detected with positive coombs test)
- Store oral solution at room temp
Pyrazinamide
Contraindicated: Acute gout, severe hepatic damage
SEs: Increased LFTs, hyperuricemia/gout, GI, Malaise
Ethambutol
- Contraindication: Optic neuritis, use in young, unconscious patients who cant report vision disturbances
- SEs: Optice neuritis (dose related), increased LFTs, decreased visual activity, confusion and hallucinations
RIPE Therapy Take Aways
- Monitor Infection
- Sputum sample for culture
- Chest X ray clear or clearing up?
- All RIPE Drugs:
- Increase LFTs including total bilirubin
- Rifampin
- Orange-red secretions
- Strong Cyp450 inducer (rifabutin is used if unacceptable DDIs)
- Flu-like symptoms
- Isoniazid (INH)
- Peripheral neuropathy give with pyridoxine (B6)
- Watch for DILE
- Rifampin and INH:
- Take on an empty stomach
- RIsk of hemolytic anemia (identified by a positive coombs test)
- Pyrazinamide:
- Increase uric acid do not use with active gout
- Ethambutol
- Visual damages
- Confusion/hallucinations
- Pyrazinamide and Ethambutol
- Increase dosing interval with renal impairment
Treatment duration and therapy for Infective Endocarditis?
- Vanc and Ceftriaxone empriric
- Gent for synergy
- 4-6 wks IV
Gentamicin synergy what is the dosing and target?
- Traditional dosing
- Peak 3-4 mcg
- Trough <1
Einfective endocarditis treatment based on organism
- Viridans group strep: pen or ceftriaxone (+-) gent if PCN allergy use Vanc mono
- Staphylococci (MSSA): NAfcillin opr Cefazolin (+ gent and rifampin if prosthetic valve)
- If PCN allergy use Vanc with gent and rifampin
- MRSA: Vanco + gent and rifampin if prosthetics
- Enterococci: Pen or Ampicillin + gent for all
- Allergy Vanc + gent
- If VRE use dapto or linezolid
IE dental procedure prophylaxis cardiac conditions and treatment options
- Prosthetic heart valve or heart valve repair with artificial material
- Hx of endocarditis
- Heart transplant with abnormal heart valve
- Certain congenital heart defects
- Oral Amoxicillin 2 g 20-30 minutes before procedure
- NPO: Amp 2 g or cefazolin
- PCN allergy: Clinda or azithromycin
- NPO and PCN Allergy: Cefazolin or ceftriaxone clinda
Drug of choice for SBP and treatment duration
Alternative?
Ceftriaxone 5-7 days
Bactrim, oflocaxin and or ciprofloxacin
Mild to moderate intraabdominal reactions
Pathogens and possible regimens?
COver PEK, anarobes, and streptococci +- enterococci
Cefoxitin
Etrapenem
Moxifloxacin
(cefazolin, cefuroxime, or ceftriaxone) + metronidazole
Cipro or Levo plue moxi
High severity of intraabdominal infection ICU patients
- PEK, CAPES, Pseudomonas, anaerobes, strepto +- entero
- Carbapenems excepts erta
- pip tazo
- metro combos
Treatment for impetigo and cellulitis
- Cephalexin 250 QID (if numerous lesions)
- Cephalexin 500 QID
Folliculitis Treatmen
Cephalexin if systemic signs
non responsive use bactrim or doxy
Mild to Moderate Purulent infection
- Bactrim or Doxy
Severe purulent SSTI
- Duration 7-14 days
- Vanc (goal trough 10-15)
- Dapto
- Linezolid
- Ceftaroline
- Vancins
Nectrotizing facitits
- Vanc + beta lactam (pip/tazo, imipene/cilstatin or meropenem)
Monotherapy options for diabtetic foot infection without MRSA
- Amp/sulbactam
- pip/tazo
- carbapenem
- 7-14 days or longer
Combo therapy if MRSA is suspected for diabetic foot infections
- Vanc
- Plu
- Ceftaz, cefepime, pip/tazo, aztreonam, carbapenems (not ertra)
UTI diagnosis
- Urinalysis positive when evidence of pyuria (positive leukocyte esterase, or >10 WBC
- And bacteruria (>= 10^5 in asymptomatic patients 10^3 in males, 10^2 in symptomatic females and catheter patients
UTI cystitis symptoms
- Urgency and frequency, including nacturia
- Dysuria
- Suprapubic heaviness
- Hematuria
Upper UTI (pyelonephritis)
- Flank/costovertibral angle pain
- Abdominal pain
Vaginal Candida Albicans
Fungal
- Extremely itchy with white thick discharge
Acute uncomplicated cystitis treatment
- Nitro 100 mg PO BID with food for 5 days
- or BActrim x 3 days resistance to E/Coli >=20%
- Fosfomycin 3 grams
- Dont use moxi
- Can add phenazopyridine for pain
Acute uncomplicated pyelonephritis
- If local quinolone resistance <=10%
- Cipro 7 days
- Levo 5 days
- If resistance > 10% use ceftriaxone or AMG
Phenazopyridine dosing and everything
- Max of 2 days
- Take with glass of water or immediately after food to minimize GI
- Do not use in pts with renal impairment or liver disease
- Can cause red orange coloring of the urine
Bacturia in pregnancy >=10^5
Beta lactams preferred (augmentin or an oral ceph)
Nito/bactrim and fosfomycin can be considered
Quinolones should not be used
First episode non severe C/Diff
- Oral vanc
- OR Fidaxamicin
10 days
2nd episode first reccurence C.Diff
- If vanc used first use FDX
- If metro used first use Vanc
- Pulsed taper if vanc or FDX was ysed
Subsequent C.Diff episodes
- Vanc tapered and pulse regimen
- VANC then rifaximin
- Fecal transplant
Travelers Diarrhea Treatment
- Preferred Tx if fever or blood in stool or pregnant or peds:
- Azithromycin 1-3 days
- Otherwise pick
- Cipro
- Levo
- Ofloxacin
- Rifaximin
Syphilis treatment regardless or activity
- Pen G benzathine IM
- or Doxy
- Pregnant patients with PCN allergy should be desensed with Bicllin (Pen G Bezathine)
Nuerosyphilis Treatment
- Pen G aqueous crystalline
- Or Pen G procaine
Gonorrhea treatment
Ceftriaxone
plus
Azithromycin
or Doxy
Chalmydia treatment
- Azithromycin or Doxy
Bacterial vaginosis
- metronidazole
- or metro gel
- or Clinda cream
- Dont douche
Trichomoniasis
- Metro or
- Tinidazole
PCN Pregnancy Puzzler
- PCN is only used for syphilis during pregnancy syphillis must be treated
- If syphilis and has allergy
- Confirm allergic reaction with skin test
- Desens
- Treat with IM PCN G benzathine
- Also recommended for HIV syphilis pts
Rocky Mountain Spotted Fever
Rickettsia g negative
Doxy
Typhus
Doxy
Lyme Disease
- Doxy
- Amox
- Cefuroxime
Ehrlichiosis
- Doxy
Tularemia
Gentamicin or tobra
Ampho B deoxylate conventional
- Boxed warning doses should not exceed 1.5 mg/kg/day can result in cardiopulmonary arrest
- SEs: Infusion related, decreased K, MG, nephrotoxicity
- Conventional required premedication: APAP or NSAID, diphenhydramine or hydrocortisone
- Meperidine to decrease rigors duration
- NS bolus to decrease nephrotoxicity
- Liposomal has fever side effects and nephrotoxicity
Ampho B drug interaction
- Increase risk of digoxin toxicity due to hypokalemia
- NSAIDs and nephro drugs cisplatin, cyclosporin, flucytosine
Flucytosine is only recommened?
In combination with ampho B
SEs: Dose related myelosupression
Treatment of invasive crytpococcal meningitis, Candida infection
Azole antifungal take aways
- Class effects
- Increase LFTs
- All have risk of QT prolongation except isavuconazium
- FLuconazole
- The only one that needs renal adjustmetns at CrCl<=50 reduce dose by half
- Narrower spectrum covers C. Albicans well
- Useful for nonpregnancy vaginal candidiasis
- C. glabrata and C. Krusei (inherent resistant)
- Voriconazole
- DOC for Aspergillis
- Monitor for visual changes and phototoxicity
- Posaconazole and isacuconazonium
- Active against molds including aspergillis and Zygomycetes
- Posaconazole tablet and suspension are not equal
What is Acyclovir dosing based off of ?
IBW even if overweight
Immunocompromised states include? 5 types
- HIV patients CD4 < 200
- Systemic steroids for 14 days or longer at prednisone equivalence >=20 mg/day
- Asplenia
- USe of immunosuppressant therapy
- Use of chemotherapy
Major risk factor for developing opportunistic infections
ANC <500
Pneumocystic Pneumonia
- BActrim DS PO daily
- or dapsone
- or dapsone + primethamine +leucovorin
- DC once CD4 >=200 for 3 months on ART
Taxoplasmosis with CD4 <100
- Bactrim
- Alt
- Dapsone + pyrimethamine + leucoveurin or Atovoquone
- CD$ count > 200 for 3 months on ART
MAC CD4 <50
- Azithromycin
- CD4 > 100 for 3 months on ART
Key features of NRTIs: 6
- Renal dose adjustment required expect for abacavir
- No CYP interactions
- Take without regard to meals except didanosine
- Warning lactic acidosis and hepatomegaly with steatosis (zidovudine, stavudine, didanosine > others)
- Abacavir: hypersensitivity reactions test for HLA-B*5701
- Tenofovir toxicities: nephrotoxicity, osteoporosis, fanconi syndrome, thought to be decreased with tenofovir alafenamide
When can you rechallenge abacavir:
Never
NRTI drug interactions?
- Ribavirin and didanosine Increased risk of pancreatitis and liver failure
- Ribavirin and Zidovudine severe anemia
- Didanosine and Stravudine increased risk of peripheral neuropathy and pancreatitis
- Avoid didanosine and tenofovir combinations due to increased resistance
- Allopurinol can increase didanosine concentrations and is contraindicated
- Avoid emtricabine and lamivudine combination
- Avoid zidovudine and stravudine combinations
- Methadone can increase zidovudine levels
- Caution with sofosbuvir/ledipasvir with stribild due to increased tenofovir disoproxil
- Tenofovir alafenamide is a P-gp substrate avoid rifampin and St. Johns Wort with descovy, genvoya, Odefsey, and symtuza
NNRTI Key Features:
- No renal adjustments needed (avoid Atripla and Complera if CrCl < 50)
- Primarily CYP inducers (exceptions: efavirenz and inducer > inhibitor, rilpivirine is a substrate
- Hepatotoxicity and rash including SJS/TEN (nevirapine > other NNRTIs)
- Monitor for erythema, facial edema, skin necrosis, blisters and tongue swelling.
- Food requirements:
- With food: etravirine, rilpivirine
- Without food: Efavirenz
- Efavirenz CNS effects are decreased when given at bedtime on an empty stomach
- Rilpivirine: QT prolongation, depression suicidality
Efavirenz: Sustiva
- 600 mg daily
- Serious psychiatric symptoms , CNS symptoms ( generally resolve in 2-4 wks) convulsions, QT prolongation
- SEs: CNS effects (impaired concentration, abnormal dreams, confusion, dizziness) rash
- Should not be used with abacavir/lamivudine or emtricibine in pts pre-treatment HIV viral load >100,000
Rilpivirine:
- 25 mg daily with meals
- Requires acidic environment for absorption: Dont use with PPIs separate from H2RAs and Antacids
- Contraindicated with PPIs, rifampin, rifapentine, carbamazepine, dexamethasone (more than 1 dose)
- SEs: depressdive disorder, mood changes, insomnia
- Notes: Higher rates of failure if viral load > 100,000 and or CD4 < 200
Nevirapine
- Boxed warning for hepatotoxicity
- Serious skin reactions SJS/TEN
- increased LFTs
- Requires a lead in period of 14 days may reduce skin reactions
- DO not initiate in women with CD4 count >250 or men >400 due to increased risk of hepatotoxicity
Class interactions with NNRTIs?
- Avoid with St. Johns, avanafil, Viekra, and Viekra XR
*
Efavirenz DIs
- Inhibitor of 2C8/9 and 2C19
- Inducer of 3A4
- Avoid carbamazepine, flibanserin, itraconazole, ketoconazole, midazolam (PO), posaconazole, simprevir, Zepatier, adjust doses for both voriconazole and efavirenz
Etravirine DIs
- Moderate inhibitor of 2C9, 2C19 and moderate inducer of 3A4
- Major sustrate of 3A4 2C9, and 2C19
- Avoid clopidogrel, carbamazepine, filbanserin, phenobarbital, phenytoin, rifampin, simprevir, Zepatier
*
- Avoid clopidogrel, carbamazepine, filbanserin, phenobarbital, phenytoin, rifampin, simprevir, Zepatier
Rilpivirine DIs
- Contraindicated with strong 3A4 inducers
- Carbamazepine, oxcarb, phenobarbital, rifampin, phenytoin, systemic dexamethasone > 1 dose and PPIs
- Caution with other acid suppressants separate H2RAs and Antacids
Methadone and NNRTIs
and Hormonal Contraceptives
- Methadone levels can be decreased by efavirenz and nevirapine, possible methadone withdrawal
- Efavirenz anf Nivirapine can also decrease efficacy of hormonal contraceptives
What Protease Inhibitors are used as boosters in HIV?
- Ritonavir
- Cobicistat
Key Features of PIs 11
- Generic names end in navir
- Primarily CYP450 drug interaction
- No renal dosage adjustment needed but many combos have dose adjustments
- Hepatoxicity (highest risk with tipranavir)
- Taken with a protease booster (ritonavir or cobicistat) to increase PI levels
- Metabolic abnormalities such as hyperlipidemia, lipohypertrophy (atazanavir darunavir
- Increased CVD risk (lowest with atazanavir, darunavir)
- GI upset take with food to decrease exceptions (fosamprenavir and lopinavir/ritonavir)
- Bleeding events (in pts with haemophilia)
- ECG changes (changes saquinavir/ritonavir, lipinavir/ritonavir and atazanavir/ritonavir)
- Rash including SJS/TEN
Integrase Strand Transfer Inhibitors: Key Features 7
- Generic ends in tegravir
- No dose adjustment needed
- Do not start Stribild if CrCl<70
- Genvoya or Biktarvy if CrCl<30
- No CYP interactions themselves but combos will
- Increased CPK greater with raltegravir
- HA, insomnia
- Interaction with polyvalent cations separate (should be taken 2 hours before or 6 hours after cation containing antacids, laxative, sucralfate, iron or calcium buffer supplemements, No dose separation needed for raltegravir
- H2RAs and PPIs do not interact
CCR5 Antagonists:
- Maraviroc
- Must get tropism test prior to initiation, Maraviroc only works in patients with CCR5 tropic disease (pts must be negative for CXCR4- or dual/mixed tropic disease
- Boxed warning for hepatotoxicity
- Contraindicated in pts with severe renal impairment CrCl<30 taking potent 3A4 inhibitors
Fusion Inhibitors
- Enfuvirtide
- SC injection
- Local injection site reaction in 98% of patients
CD4 Directed Post attachment HIV inhibitor
Indicated for MDR-HIV who are failing current therapy
Ibalizumab-iuyk (Trogarzo)
Wisk of IRIS
