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p2 year > antimicrobial stewardship, sti, covid, global health > Flashcards

antimicrobial stewardship, sti, covid, global health Flashcards

1
Q

antimicrobial stewardship

A

coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal drug regimen including dosing, duration of therapy, and route of administration

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2
Q

goals of antimicrobial stewardship

A
  • optimize clinical outcomes
  • minimize toxicity and AEs
  • reduce infection costs
  • prevent resistance
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3
Q

what is the biggest reason we need stewardship?

A

resistance

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4
Q

two ways resistance spread?

A

animals
humans after antibiotic course

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5
Q

resistant pathogens of threat

A

urgent:
1) carbapenem-resistant acinetobacter
2) carbapenem-resistant enterobacterales
- klebsiella (KPC), enterobacter

serious:
3) ESBL (extended-spectrum beta lactamase) producing enterbacerales
- klebsiella, enterobacter
4) vancomycin-resistant enterococcus (VRE)
5) multidrug resistant pseudomonas aeruginosa
6) methicillin resistant staph aureus (MRSA)

concerning:

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6
Q

does bacterial colonization mean we treat?

A

not always –> colonization does not mean infection
*catheters will always grow bacteria!!!

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7
Q

problems with antibacterial prescribing

A
  • low threshold to prescribe
  • broad spectrum empiric therapy never deescalated
  • suboptimal regimens used –> want narrowest spectrum!!
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8
Q

consequences of inappropriate antibiotic therapy

A

patient:
- inadequate treatment
- AEs
- allergic reactions
- superinfections
- resistance
- selection for problem pathogens like c diff

society:
- resistance
- collateral damage (ruin natural biome –> c diff)
- inc healthcare costs

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9
Q

benefits of antimicrobial stewardship

A
  • improve patient outcomes
  • dec AEs
  • minimize resistance/maximize susceptibility
  • resource optimization
  • reduce healthcare cost without dec quality of care
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10
Q

UTI treatment requirements

A

NOT if bacteria in urine but not symptoms (asymptomatic bacteriuria)

UNLESS
1) pregnant
2) urologic procedure (inc risk goes into blood during procedure)

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11
Q

UTI symptoms that indicate treatment

A

ONLY
1) dysuria (painful/burning urination)
2) inc frequency
3) inc urgency
4) superpubic pain

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12
Q

IV MRSA options

A
  • vancomycin
  • linezolid
  • daptomycin
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13
Q

PO pseudomonas options

A

ONLY fluoroquinolones
- ciprofloxacin
- levofloxacin
- delafloxacin

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14
Q

linezolid considerations

A
  • toxicity if use more than 2 weeks (bone marrow suppression)
  • SSRI interaction
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15
Q

CDC 7 core elements of hospital antimicrobial stewardship programs (ASP) essentials

A

1) hospital leadership commitment
2) accountability
3) pharmacy expertise
4) action
5) tracking
6) reporting
7) education

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16
Q

linezolid DDI

A

SSRIs

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17
Q

daptomycin DDI

A

statins

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18
Q

pharmacy based stewardship interventions

A

a) document indication
b) IV to PO switch
c) dose adjust/optimization
d) time sensitive automatic stop orders
e) penicillin allergy assessment
f) detection/prevention of antibiotic DDIs
g) formulary restriction and preauthorization

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19
Q

duration of antibiotics for a complicated intra-abdominal infection with adequate source control?

A

4 days
STOP-IT trial!

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20
Q

what type of allergy can Bactrim cause

A

type IV –> delayed, cell-mediated (T cells) not antibody mediated!!

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21
Q

type I allergies

A

IgE mediated –> release histamine and other mediators from mast cells and basophils

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22
Q

severe penicillin allergy definition and options

A

definition
- anaphylaxis, hives, SOB, serious skin reaction (SJS, TENS, DRESS)

options
- alternate agent
OR
- desensitize IF no other non beta-lactam option

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23
Q

non-severe penicillin allergy definition and options

A

definition
- skin rash

options
- challenge a cephalosporin or carbapenem

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24
Q

penicillin cross reactivity with cephalosporins

A

very low
1st gen is more reactive than 3rd and 4th gen
check R1 side chain

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25
Q

penicillin cross reactivity with carbapenems

A

very low
check R1 side chain

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26
Q

penicillin cross reactivity with aztreonam

A

NONE –> CAN USE IF SEVERE PENICILLIN ALLERGY!

BUT caution if ceftazidime or cefiderocol allergy

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27
Q

cephalosporin cross reactivity with aztreonam

A

SAME SIDE CHAIN: ceftazidime, cefiderocol
therefore do not use if allergy to these ones!

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28
Q

penicillin allergy alternatives

A
  • vancomycin
  • fluoroquinolones
  • clindamycin
  • aztreonam

BUT inc cost, inc MDR, inc AE risk, inc c diff risk

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29
Q

how to assess penicillin allergy?

A

what happened? –> severity
when? –> dec overtime
anything similar?
check inpatient and outpatient for similar

**if have taken similar and tolerated after the documented allergy –> probably less severe, can use again!

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30
Q

penicillin skin testing

A

1) puncture testing (superficial)
histamine (+ control), saline (- control), penicillin
think PPD
2) intradermal testing (deeper)
3) low dose PO penicillin or amoxicillin

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31
Q

when do you use penicillin skin testing

A

type 1 hypersensitivities (IgE mediated)

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32
Q

desensitization process

A
  • TEMPORARILY allows drug toleration
  • ONLY if alternatives cannot be used
  • start low dose, double every 15 min if tolerating
  • IV preferred, could do SQ or PO
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33
Q

which drugs get formulary restricted?

A
  • broad spectrum
  • last resort
  • if have shortage
  • expensive
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34
Q

biggest rule of stewardship

A

use the most narrow spectrum that will treat the infection

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35
Q

empiric treatment steps

A

1) identify the most likely pathogen based on location and type of infection
2) select antibiotic based on the pattern of susceptibility for that most likely pathogen
- antibiogram!

STILL ORDER THE CULTURE!

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36
Q

what is an antibiogram

A

susceptibility rates of bacteria OVER A DEFINED PERIOD OF TIME
- % of organism isolates that were susceptible

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37
Q

definitive treatment steps

A

the culture gives exact organism AND ITS EXACT SUSCEPTIBILITY
therefore, use that and consider PK parameters and if can get to site of infection

NO ANTIBIOGRAM!!

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38
Q

MSSA drugs of choice

A

nafcillin (IV)
oxacillin
dicloxacillin
cefazolin (IV)
cephalexin

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39
Q

MRSA drugs of choice

A

ceftaroline
vancomycin
daptomycin
linezolid

in addition (if community acquired):
bactrim
clindamycin
doxycycline

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40
Q

pneumonia 3 most common organisms

A

SMH

strep pneumo
morax catt
h influenzae

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41
Q

streptococci drugs of choice

A

penicillins
cephalosporins
vancomycin

only if strep pneumoniae:
levofloxacin
moxifloxacin
NOT CIPRO –> DOESN’T COVER!

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42
Q

what do cephalosporins not cover?

A

LAME
listeria
acinetobacter
MRSA (except ceftaroline)
enterococcus

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43
Q

enterococci drugs of choice

A

ampicillin
vancomycin
daptomycin
linezolid

NOT CEPHALOSPORINS

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44
Q

what does ertapenem not cover?

A

ertAPEnem
acinetobacter
pseudomonas
enterococcus

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45
Q

pseudomonas drugs of choice

A

piperacillin/tazobactam
cefepime
ceftazidime
cefiderocol
carbapenems (not ert)
aztreonam
aminoglycosides
fluoroquinolones (not moxi) –> only po option!

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46
Q

acinetobacter drugs of choice

A

VERY RESISTANT –> need susceptibilities!!
ampicillin/sulbactam (the sulbactam is active)
cefiderocol
meropenem

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47
Q

penicillinases drugs of choice

A

*add a beta-lactamase inhibitor
amox/clavulanate
ampi/sulbactam
piper/tazobactam

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48
Q

cephalosporinases drugs of choice

A

carbapenems

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49
Q

ESBL drugs of choice

A

carbapenems
piperacillin/tazobactam

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50
Q

CRE (carbapenem resistant enterobacteriacae) drugs of choice

A

cefiderocol

if KPC (klebsiella):
ceftazidime /avibactam
meropenem/vaborbactam
imipenem/cilastatin/relebactam

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51
Q

oral anaerobes drugs of choice

A

above diaphragm
peptostreptococcus, prevotella

CLINDAMYCIN
amox/clav, ampi/sulb, pip/tazo
carbapenems

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52
Q

intestinal anaerobes drugs of choice

A

below diaphragm
Bacteriodes –> B. fragilis

METRONIDAZOLE
amox/clav, ampi/sulb, pip/tazo
carbapenems

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53
Q

c diff drugs of choice

A

1st: fidaxomicin PO
2nd:
vancomycin PO
metronidazole IV (if fulminant)

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54
Q

HECK Yes organisms

A

Hafnia alvei
Enterobacter cloacae
Citrobacter freundii
Klebsiella aerogenes
Yersinia enterocolitica

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55
Q

HECK Yes organisms drugs of choice

A

cefepime
piperacillin/tazobactam ??
carbapenems

AVOID 3rd gen cephalosporins –> ceftriaxone

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56
Q

what do you avoid in HECK Yes organisms? why?

A

ceftriaxone (3rd gen cephal)

inducible AmpC
- appear S on report, after exposure will inc AmpC beta lactamases and get resistant

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57
Q

which HECK Yes organisms are highest risk for inducible AmpC

A

ECK
enterobacter cloacae
citrobacter freundii
klebsiella aerogenes

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58
Q

what is the only case you can use ceftriaxone in AmpC organsism?

A

to treat uncomplicated cystitis

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59
Q

syphilis risk factors/more common in

A

men
black
20-29 yrs

60
Q

what is unique about syphilis?

A

STAGES!! (3)

61
Q

cause and transmission of syphilis

A

cause: spirochete –> treponema pallidum
transmission: direct mucocutaneous contact aka sexual transmission

62
Q

syphilis stage 1

A

primary
- chancre at infection site –> genitals (penis, vagina, rectum, anus) OR lips/mouth
- symptomatic OR asymptomatic
**epidermal/local signs and symptoms

63
Q

syphilis stage 2

A

secondary
- only 25% develop second stage (NOT ALL)
- develops within 6 months
- rash, lymphadenopathy, fatigue, organ involvement, fever, rash
- 75% risk of hematogenous dissemination (bacteremia)
**systemic signs and symptoms

64
Q

syphilis stage 3

A

latency
early latency
- within 1-2 years
- asymptomatic
late latency
- complicated organ involvement
- CV, gummoatous lesions
- **neurosyphilis of brain and spinal cord (neurologic complications)

65
Q

syphilis asymptomatic screening/Dx

A

screen if risk factors
- acquisition: black, male, 20-29
- transmission: pregnant

66
Q

syphilis symptomatic screening/Dx

A

if risk factors (transmission, acquisition)
then presumptive Dx
- 2 tests
- treponemal: if every infected
- nontreponemal: if active infection

67
Q

primary, secondary, early latency syphilis treatment

A

benzathine penicillin G
IM into butt
2.4 million U
x1

68
Q

late latency syphilis treatment

A

benzathine penicillin G
IM into butt
2.4 million U
qweek for 3 weeks total!!!

69
Q

neurosyphilis and ocularsyphilis treatment

A

1st: aqueous crystalline penicillin G
IV
18-24 million U /day –> continuous IV or 3-4 mill U q4h
10-14 days!

2nd: aqueous crystalline penicillin G
IM into butt
2.4 million U
QD
+
probenecid
PO
500 mg QID
both for 10-14 days!

70
Q

what does chlamydia commonly impact/cause in men and women?

A

women
- impacts cervix
- cervicitis
- could be PID, urethritis –> serious

men
- nongonococcal urethritis

71
Q

chlamydia risk factors/most common in

A

women
15-24
black

72
Q

treatment for chlamydia

A

1st: doxycycline 100mg po BID x 7 days

2nd: azithromycin 1g po x1

73
Q

treatment for chlamydia in pregnancy

A

1st: azithromycin 1g po x1

74
Q

gonorrhea symptom onset

A

appear LATER –> within 10 days

75
Q

gonorrhea presentation

A

urethritis
cervicitis
PHARYNGITIS
pid

76
Q

what can untreated gonorrhea lead to?

A

bacteremia (hematogenous dissemination)
arthritis
meningitis

77
Q

gonorrhea risk factors/more common in

A

men
black

78
Q

unique about gonorrhea

A

pharyngitis
later onset of symptoms (w/i 10 days)
high resistance to antibiotics

79
Q

first line gonorrhea treatment

A

1st: ceftriaxone 250mg IM x 1

80
Q

first line gonorrhea treatment if PCN allergy

A

azithromycin 2g PO x1
+
gentamicin 240mg IM x 1

81
Q

first line gonorrhea treatment in pregnancy

A

ceftriaxone 250mg IM x1
+
azithromycin

82
Q

first line gonorrhea treatment in disseminated infection

A

ceftriaxone qd for >7 days
THEN
cefixime + azithromycin

83
Q

is PID medically urgent?

A

YES

84
Q

inpatient PID treatment

A

cefotetan/cefoxitin IV
+
doxycycline PO

+ metronidazole IF abcesses

14 days

85
Q

outpatient PID treatment

A

ceftriaxone/cefoxitin (+ probenecid) IM x1
+
doxycycline PO

+ metronidazole IF abcesses
14 days

86
Q

can you change the dosage form of PID treatment

A

yes, can change to PO throughout treatment

87
Q

what is EPT used for

A

chlamydia ONLY
(and gonorrhea ig lol)

88
Q

EPT chlamydia treatment

A

azithromycin 1g PO x1

89
Q

EPT gonorrhea

A

cefixime 400mg PO x1
+
azithromycin 1g PO x1

90
Q

when do you screen for chlamydia or gonorrhea

A

if sexually active and have s/s

91
Q

what Dx/screening test is used for gonorrhea and chlamydia

A

NAATs (nucleic acid amplification tests)

ALWAYS test for both if testing for one!! –> similar s/s, common coinfection!

92
Q

importance of communicable disease

A

**MOST IMPORTANT CONTRIBUTOR TO MORTALITY AND MORBIDITY HISTORICALLY
- decline in North
- are infectious diseases –> most are treatable and cureable
- POVERTY plays huge role

93
Q

major international health organizations

A
  • WHO
  • world bank - intergovernmental agency
  • multilateral agencies: UN, UNICEF
94
Q

measures of global health

A

1) morbidity
- disease state, disability, poor health due to any cause
- incidence, prevalence, incidence of developing new medical condition
2) mortality
- number of deaths adjusted to population per time
3) disability adjusted life years (DALY)
- measures time lived with disability and time lost due to premature mortality
4) quality adjusted life years (QALY)
- expected survival + expected QOL
- measures the value placed on expected years of survival

95
Q

other social determinants of health that impact global health

A
  • vulnerable settings
  • primary healthcare
  • non-communicable diseases
  • mental health
  • air pollution and climate change
  • maternal and child health
  • nutrition
  • injuries
  • sexual and gender violence
96
Q

poverty and infectious disease

A

poverty is a cycle!!
poverty –> low income –> poor sanitation and healthcare –> INFECTIOUS DISEASE –> dec work/productivity –> low income –> ….

97
Q

other impacts on poverty and infectious disease

A
  • variations in political/gov infrastructure
  • variations in economic, social, cultural factors
  • who controls government and makes health policy
  • war, conflict, natural disasters
  • climate differences –> insect vectors, intermediate hosts, weather patterns
98
Q

infectious disease considerations

A
  • resistance
  • vaccine hesitancy
  • diarrheal and respiratory illness
  • global influenza pandemic
  • “big four”: HIV, malaria, hep C< TB
  • neglected tropical infections
  • high threat pathogens
99
Q

top 10 infectious diseases

A

0.5) COVID
1) HIV/AIDS
2) ebola
3) SARS
4) malaria
5) anthrax
6) cholera
7) bubonic plague
8) influenza
9) typhoid fever
10) small pox

100
Q

malaria organism

A

plasmodium parasites
most common: P falciparum

101
Q

malaria transmission

A

mosquitos

102
Q

malaria disease impacts

A

infects RBCs

103
Q

malaria s/s

A

mild: flu like
severe: organ failure –> hemoglobinuria (hemorrhaging)

104
Q

how fast do you want to treat malaria?

A

within 24-48 hours, can progress quickly

105
Q

uncomplicated P. falciparum malaria first line

A

artemether + lumefantrine
- IM or PO
- fewer AE

106
Q

second line uncomplicated malaria

A

artesunate + amodiaquine
- IV or PO
- caution: hepatic and renal impairments
- more AE: GI, QT, …

107
Q

duration and dosage form

A

mild –> po
severe –> iv
3 days

108
Q

when do covid symptoms appear

A

5-6 days after infection

109
Q

which is the most common covid presentation

A

mild-moderate

110
Q

why did covid spread rapidly?

A

superspreaders
asymptomatic spread
mild spread

111
Q

disease course of covid

A

stage 1: early infection
- all viral response phase
- mild s/s
- mild clinical s/s

stage 2: respiratory phase
- viral response dec
- host inflammatory response inc
- SOB, hypoxia
- abnormal chest imaging

stage 3: hyperinflammation phase
- all host inflammatory reponse
- SIRS, shocks, ARDS, sepsis
- inc inflammation markers –> IL-6, BNP, CRP, D-dimer

112
Q

what is ARDS

A

acute respiratory distress syndrome
- stage 3 of covid (hyperinflammatory)
- so much fluid in lungs that there is little gas exchange
- need to be in ICU

113
Q

covid complications/risk factors

A

*these cause mortality, not really the virus itself
- CV –.> inc MI
- DM –> inc DKA, inc ARDS
- hepatobiliary
- GI
- renal – inc AKI
- neurologic
- thyrotoxicosis
- muscultocutaneous –> rash
- hematologic –> lymphopenia, thrombocytopenia (low platelets)

114
Q

covid variants

A

1) original
2) delta variant
- inc tranmissability
- dec vaccine efficacy
- inc disease severity
3) omicron
- inc inc transmissability
- dec dec vaccine efficacy
- many subvariants
*major today are subvariants of omicron

**need to consider the predominant variant at the time of publications!!!

115
Q

neutralizing monoclonal antibodies

A
  • pre-exposure and symptomatic
  • not FDA approved
  • bind to binding site therefore prevent entry into host cells
  • NOT ACTIVE AGAINST OMICRON – DO NOT USE
116
Q

paxlovid generic, dose, duration

A

nirmatrelvir/ritonavir
300mg/100mg –renal impaired–> 150mg/100mg
5 days ONLY NO MORE

117
Q

nirmatrelvir/ritonavir indication

A

outpatient, high risk (atleast 1 risk factor), 12+, positive test, within 5 days of symptoms onset

118
Q

paxlovid ddi

A

CYP 3A4 inducer –> many
bc ritonavir

119
Q

molnupiravir dose, duration

A

800mg po q12h
- no renal/hepatic dose adjust
5 days ONLY

120
Q

molnupiravir ddis

A

few
high barrier to resistance

121
Q

molnupiravir CI

A

PREGNANCY AND BREASTFEEDING

122
Q

molnupiravir indication

A

outpatient
mild-mod illness
high risk (1 or more risk factors)
18+
not pregnant/breastfeeding
within 5 days of symptoms
positive test

123
Q

order of therapies for outpatient, mild-mod illness, high risk, not on supplemental o2

A

1st: nirmatrelvir/ritonavir
2nd: remdesivir
3rd: molnupiravir –> only if no other options

124
Q

therapies for outpatient, mild-mod illness, no supplemental o2, not high risk

A

symptoms management ONLY

125
Q

remdesivir dosage form, dose, duration

A

IV ONLY
200mg IV LD –> 100mg IV qd
- caution GFR < 30!!
5 days

126
Q

remdesivir AEs

A

well tolerated overall
- inc LFT
- phlebitis
- extremity pain

127
Q

remdesivir indication

A

don’t need all:
outpatient OR inpatient, mild-mod disease, no oxygen, high risk, little oxygen
- only use in severe if no other option (severe = O2sat < 94%)

1) hospitalized, no o2, high risk
2) hospitalized, some o2

128
Q

remdesivir CI

A

GFR < 30 maybe

on ventilation
on ECMO

129
Q

is remdesivir FDA approved?

A

YES

130
Q

remdesivir benefit

A

dec time to clinical recovery
NO mortality benefit

broad antiviral activity

131
Q

corticosteroid drug, dose, duration, route

A

dexamethasone
6 mg qd
IV or PO
10 days or until discharge

132
Q

dexamethasone indication

A

hospitalized (all!)

133
Q

IL-6 antagonists

A

sarilumab –> not fda approved
tocilizumab –> FDA APPROVED

134
Q

tocilizumab dose, route, duration

A

IV
8mg/kg (max 800mg)
x1 (over 1hr)

135
Q

tocilizumab AE

A

inc LFT
neutropenia, thrombocytopenia
general infection
SERIOUS INFECTIONS
- TB, bacterial, fungal, bowel preforation
**NEED TO SCREEN TB AND INFECTION RISK BASELINE!

136
Q

tocilizumab indication

A

1) hospitalized, need o2/vent/ecmo, getting dexamethasone
2) hospitalized, severe/progressive, inc inflammatory markers (CRP > 75)

1) hospitalized, o2, rapidly inc o2 demand, systemic inflammation
2) hospitalized, need HFNC o2 or NIV
3) hospitalized, need vent or ecmo

137
Q

tocilizumab regimen

A

ALWAYS WITH SYSTEMIC GLUCOCORTICOIDS (they are the standard)

138
Q

baricitinib dose, duration, route

A

PO
4mg qd
14 days or until discharge

139
Q

baricitinib AE

A

infection
thrombosis

CAUTION: current infection, with IL-6 tocilizumab bc of immunosuppression risk

140
Q

baricitinib indication

A

1) hospitalized, severe, need o2/vent
2) hospitalized, need o2/vent/ecmo/niv
3) hospitalized, need o2, rapidly inc o2 need, systemic inflammation
4) hospitalized, need nfnc or niv
5) hospitalized, need vent/ecmo

141
Q

baricitinib regimen

A

with dexamethasone

FDA approved

142
Q

first line hospitalized, need o2/vent/ecmo/niv

A

dexamethasone + IV tocilizumab / PO baricitinib

143
Q

is it SOC to give antibiotics for covid

A

NO
- bacterial coinfection with COVID is uncommon

144
Q

is it SOC to give therapeutic anticoagulation in covid

A

covid: inc time to clot, but have some disseminated clots –> concern over bleed risk

if hospitalized, on supplemental o2, d-dimer > 4xULN (aka > 2000), no ICU: THERAPEUTIC heparin

all else (less severe and more severe): PROPHYLATIC heparin

145
Q

definition of high risk

A

**pretty much everyone, especially in hospital
- cancer
- CKD
- chronic lung
- chronic liver
- CF
- DM
- diability
- heart issue –> HF, CAD
- HIV
- mental health
- dementia
- obese
- immunodeficiency
- pregnant
- smoking
- SOT
- TB

146
Q

what is not included in the risk factors for high risk

A
  • asthma
  • HTN
147
Q

which COVID-19 therapies are FDA approved

A
  • remdesivir
  • tocilizumab
  • baricitinib

p2 year (9 decks)

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