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ID 1183 > All Key Facts Deck > Flashcards

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1
Q

DOCs for Community Acquired Methicillin Resistant Staph Aureus (CA-MRSA): Skin and Soft Tissue Infections 5

A
  1. Bactrim
  2. Doxycycline, minocycline
  3. CLindamycin (must get d-test first and it must be negative)
  4. Linezolid
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2
Q

For more severe SSTIs requiring IV treatment or hospitalization want to cover MRSA and Strep 10 3 preferred

A
  1. Vancomycin
  2. Linezolid, tidizolid
  3. Daptomycin
  4. Ceftaroline
  5. Televancin
  6. Ortivancin
  7. Dalbavancin
  8. Quinupristin/Dalfopristin
  9. Tigecycline
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3
Q

Nosocomial MRSA 5 3 preferred

A
  1. Vanc (consider alternative if MIC >=2
  2. Linezolid
  3. Daptomycin (not in pneumonia)
  4. Rifampin (select infections never used alone)
  5. Televancin
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4
Q

VRE (E.Faecilis) 7, 3 preferred

A
  1. Pen G or ampicillin
  2. Linezolid
  3. Daptomycin
  4. Tigecycline
  5. Cystitis only: nitro, fosfomycin, doxycyline
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5
Q

VRE E. Faecium 6, 2 preferred

A
  1. Daptomycin
  2. Linezolid
  3. Quinu/Dalfo
  4. Tigecycline
  5. Cystitis only: nitrofurantoin, fosfomycin, doxy
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6
Q

Pseudomonas Coverage 10

Pip, PIME, DIME, comb, combo, C, Q, A, A, Px2

A
  1. Pip/Tazo
  2. Cefepime
  3. Ceftazidime
  4. Ceftaz/Avibactam
  5. Ceftolozane/tazobactam
  6. Carbapenems (except ertrapenem)
  7. Cipro, levofloxacin
  8. Aztreonam
  9. AMGs
  10. Colistimethan, polymyxin B
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7
Q

Acinetobacter Baumannii 7

A
  1. Carbapenems (except ertra)
  2. Amp/sul
  3. Minocycline
  4. Tigecycline
  5. Quinolones
  6. Bactrim
  7. Polymyxins
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8
Q

Extended Spectrum beta-lactamase producing gram-negative rods (ESBL-GNR), E. Coli, K. pneumoniae, P. Marabilis

6, 3 preferred

A
  1. Carbapenems
  2. Ceftolozane/Tazobactam
  3. Ceftazidime/avibactam
  4. Cefepime (high dose)
  5. AMGs
  6. Cystitis only: fosphomycin
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9
Q

Carbapenem Resistant Gram- negative rods (CRE)

3

A
  1. Ceftazadime/Avibactam
  2. Colistimethate, polymyxins
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10
Q

Bacteroid Fragilis 7

M,B,Cx2, C, T, O

A
  1. Metronidazole
  2. Beta-lactam/beta-lactamase inhibitor
  3. Cefotetan, cefoxitin
  4. Carbapenems
  5. Tigecycline
  6. Others: reduced acitivity: clindamycin, moxifloxacin
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11
Q

C. Diff Infections 3 two preferred

A
  1. Oral Vanc
  2. Fidaxomicin
  3. Metronidazole
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12
Q

Atypical Organisms 5, 3 preferred

A
  1. Azithromycin, clarithromycin
  2. Doxycycline, minocycline
  3. Quinolones
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13
Q

HNPEK 7, 1 preferred

A
  1. Beta-lactam/beta-lactamse inhibitors
  2. Amoxicillin (if beta-lactamase negative)
  3. Cephalosporins (except first generation)
  4. Carbapenems
  5. Bactrim
  6. AMGs
  7. Quinolones
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14
Q

18 Abxs that do not require renal adjustments

A

Key drugs

  1. Antistaphylococcus PCNs (dicloxacillin, nafcillin)
  2. Ceftriaxone
  3. Clindamycin
  4. Doxycycline
  5. Macrolides (azithromycin, and erythromycin only)
  6. Metronidazole
  7. Linezolid

OThers:

  1. CHloramphenicol
  2. Fidaxomicin
  3. Minocycline
  4. Quinu/Dalfo
  5. Rifaximin
  6. Rifampin
  7. Tedizolid
  8. Tigecycline
  9. Tinidazole
  10. Vanco PO only
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15
Q

Pre-operative Abx prophylaxis time line

A
  • 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
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16
Q

AOM treatment is kids: when to consider observation

A
  • 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
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17
Q

Risk factors for MRSA, MDR resistant Psuedomonas or other MDR pathogens

Risk for MDR pathogens in VAP?

A
  • 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
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18
Q

HAP/VAP Treatment:

What drugs and what do you target if the patient

  1. HAP without risk of mortality and low MRSA risk
  2. VAP without risk factors for MDR pathogens or MRSA
A
  • Target Pseudomonas and MSSA
    • Pick one
      • Pip/tazo
      • Cefepime
      • Levofloxacin
      • Imipenem/cilastatin or meropenem
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19
Q

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
A
  • Pick one for Pseudomonas coverage
    • Pip/tazo
    • Cefepime, Ceftazidime
    • Levofloxacin or Cipro
    • Imipenem/cilstatin or meropenem
    • Aztreonam
  • Plus MRSA
    • Vanc
    • Linezolid
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20
Q

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
A
  • 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
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21
Q

Latent TB Treatment

Preferred Regimen for Pregnant, HIV, and Children

A
  • Isoniazid, 300 mg po daily (15 mg/kg PO twice weekly) fo 9 months
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22
Q

Latent TB Tx

A

INH resistant

Rifampin 600 mg daily for 4 months

Not tolerating INH or INH resistant

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23
Q

latent TB this regimen is not recommended for HIV children <2, pregnant women or presumed infection with INH- or rifampin resistant TB

A
  • INH and rifapentine once weekly for 12 weeks
  • Rifampin +pyrazinamide is no longer recommended due to risk of hepatotoxicity
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24
Q

Active TB Dx

A
  • 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
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25
Two phases of Active TB treatment Intensive phase?
* Rifampin * Isoniazid * Pyrazinamide * Ethambutol * RIPE * Tx for 2 months
26
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
27
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
28
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)
29
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
30
Pyrazinamide
Contraindicated: Acute gout, severe hepatic damage SEs: Increased LFTs, hyperuricemia/gout, GI, Malaise
31
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
32
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
33
Treatment duration and therapy for Infective Endocarditis?
* Vanc and Ceftriaxone empriric * Gent for synergy * 4-6 wks IV
34
Gentamicin synergy what is the dosing and target?
* Traditional dosing * Peak 3-4 mcg * Trough \<1
35
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
36
IE dental procedure prophylaxis cardiac conditions and treatment options
1. Prosthetic heart valve or heart valve repair with artificial material 2. Hx of endocarditis 3. Heart transplant with abnormal heart valve 4. Certain congenital heart defects 5. Oral Amoxicillin 2 g 20-30 minutes before procedure 6. NPO: Amp 2 g or cefazolin 7. PCN allergy: Clinda or azithromycin 8. NPO and PCN Allergy: Cefazolin or ceftriaxone clinda
37
Drug of choice for SBP and treatment duration Alternative?
Ceftriaxone 5-7 days Bactrim, oflocaxin and or ciprofloxacin
38
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
39
High severity of intraabdominal infection ICU patients
* PEK, CAPES, Pseudomonas, anaerobes, strepto +- entero * Carbapenems excepts erta * pip tazo * + metro combos
40
Treatment for impetigo and cellulitis
* Cephalexin 250 QID (if numerous lesions) * Cephalexin 500 QID
41
Folliculitis Treatmen
Cephalexin if systemic signs non responsive use bactrim or doxy
42
Mild to Moderate Purulent infection
* Bactrim or Doxy
43
Severe purulent SSTI
* Duration 7-14 days * Vanc (goal trough 10-15) * Dapto * Linezolid * Ceftaroline * Vancins
44
Nectrotizing facitits
* Vanc + beta lactam (pip/tazo, imipene/cilstatin or meropenem)
45
Monotherapy options for diabtetic foot infection without MRSA
* Amp/sulbactam * pip/tazo * carbapenem * 7-14 days or longer
46
Combo therapy if MRSA is suspected for diabetic foot infections
* Vanc * Plu * Ceftaz, cefepime, pip/tazo, aztreonam, carbapenems (not ertra)
47
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
48
UTI cystitis symptoms
1. Urgency and frequency, including nacturia 2. Dysuria 3. Suprapubic heaviness 4. Hematuria
49
Upper UTI (pyelonephritis)
* Flank/costovertibral angle pain * Abdominal pain
50
Vaginal Candida Albicans Fungal
* Extremely itchy with white thick discharge
51
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
52
Acute uncomplicated pyelonephritis
* If local quinolone resistance \<=10% * Cipro 7 days * Levo 5 days * If resistance \> 10% use ceftriaxone or AMG
53
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
54
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
55
First episode non severe C/Diff
* Oral vanc * OR Fidaxamicin 10 days
56
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
57
Subsequent C.Diff episodes
* Vanc tapered and pulse regimen * VANC then rifaximin * Fecal transplant
58
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
59
Syphilis treatment regardless or activity
* Pen G benzathine IM * or Doxy * Pregnant patients with PCN allergy should be desensed with Bicllin (Pen G Bezathine)
60
Nuerosyphilis Treatment
* Pen G aqueous crystalline * Or Pen G procaine
61
Gonorrhea treatment
Ceftriaxone plus Azithromycin or Doxy
62
Chalmydia treatment
* Azithromycin or Doxy
63
Bacterial vaginosis
* metronidazole * or metro gel * or Clinda cream * Dont douche
64
Trichomoniasis
* Metro or * Tinidazole
65
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
66
Rocky Mountain Spotted Fever Rickettsia g negative
Doxy
67
Typhus
Doxy
68
Lyme Disease
* Doxy * Amox * Cefuroxime
69
Ehrlichiosis
* Doxy
70
Tularemia
Gentamicin or tobra
71
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
72
Ampho B drug interaction
* Increase risk of digoxin toxicity due to hypokalemia * NSAIDs and nephro drugs cisplatin, cyclosporin, flucytosine
73
Flucytosine is only recommened?
In combination with ampho B SEs: Dose related myelosupression Treatment of invasive crytpococcal meningitis, Candida infection
74
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
75
What is Acyclovir dosing based off of ?
IBW even if overweight
76
Immunocompromised states include? 5 types
1. HIV patients CD4 \< 200 2. Systemic steroids for 14 days or longer at prednisone equivalence \>=20 mg/day 3. Asplenia 4. USe of immunosuppressant therapy 5. Use of chemotherapy
77
Major risk factor for developing opportunistic infections
ANC \<500
78
Pneumocystic Pneumonia
* BActrim DS PO daily * or dapsone * or dapsone + primethamine +leucovorin * DC once CD4 \>=200 for 3 months on ART
79
Taxoplasmosis with CD4 \<100
* Bactrim * Alt * Dapsone + pyrimethamine + leucoveurin or Atovoquone * CD$ count \> 200 for 3 months on ART
80
MAC CD4 \<50
* Azithromycin * CD4 \> 100 for 3 months on ART
81
Key features of NRTIs: 6
1. Renal dose adjustment required expect for abacavir 2. No CYP interactions 3. Take without regard to meals except didanosine 4. Warning lactic acidosis and hepatomegaly with steatosis (zidovudine, stavudine, didanosine \> others) 5. Abacavir: hypersensitivity reactions test for HLA-B\*5701 6. Tenofovir toxicities: nephrotoxicity, osteoporosis, fanconi syndrome, thought to be decreased with tenofovir alafenamide
82
When can you rechallenge abacavir:
Never
83
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
84
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
85
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
86
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
87
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
88
Class interactions with NNRTIs?
* Avoid with St. Johns, avanafil, Viekra, and Viekra XR *
89
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
90
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 *
91
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
92
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
93
What Protease Inhibitors are used as boosters in HIV?
* Ritonavir * Cobicistat
94
Key Features of PIs 11
1. Generic names end in navir 2. Primarily CYP450 drug interaction 3. No renal dosage adjustment needed but many combos have dose adjustments 4. Hepatoxicity (highest risk with tipranavir) 5. Taken with a protease booster (ritonavir or cobicistat) to increase PI levels 6. Metabolic abnormalities such as hyperlipidemia, lipohypertrophy (atazanavir darunavir 7. Increased CVD risk (lowest with atazanavir, darunavir) 8. GI upset take with food to decrease exceptions (fosamprenavir and lopinavir/ritonavir) 9. Bleeding events (in pts with haemophilia) 10. ECG changes (changes saquinavir/ritonavir, lipinavir/ritonavir and atazanavir/ritonavir) 11. Rash including SJS/TEN
95
Integrase Strand Transfer Inhibitors: Key Features 7
1. Generic ends in tegravir 2. No dose adjustment needed 3. Do not start Stribild if CrCl\<70 4. Genvoya or Biktarvy if CrCl\<30 5. No CYP interactions themselves but combos will 6. Increased CPK greater with raltegravir 7. HA, insomnia 8. 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 9. H2RAs and PPIs do not interact
96
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
97
Fusion Inhibitors
* Enfuvirtide * SC injection * Local injection site reaction in 98% of patients
98
CD4 Directed Post attachment HIV inhibitor
Indicated for MDR-HIV who are failing current therapy Ibalizumab-iuyk (Trogarzo) Wisk of IRIS

ID 1183 (19 decks)

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