Block 3 Flashcards by Markus M

Q

Difference between uncomplicated and complicated IAI?

A

Uncomplicated is contained in a single organ w/o anatomical disruptions

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Q

Primary
Secondary
Tertiary…peritonitis

Which one is polymicrobial?

A

Secondary

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Q

Primary
Secondary
Tertiary…peritonitis

Which one is associated w/ low virulence organisms in critically ill or immunocompromised patients?

A

Tertiary

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Q

Primary
Secondary
Tertiary…peritonitis

Which one infects peritoneal cavity w/o evident source in the abdomen?

A

Primary

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Q

Primary
Secondary
Tertiary…peritonitis

Which one spreads to another organ resulting in focal disease in the abdomen?

A

Secondary

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Q

Primary
Secondary
Tertiary…peritonitis

Which one is persistent/recurrent for at least 48hrs after proper management?

A

Tertiary

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Q

Primary
Secondary
Tertiary…peritonitis

Which one is monomicrobial?

A

Primary

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Q

Primary
Secondary
Tertiary…peritonitis

Which one consists of spontaneous bacterial peritonitis?

A

Primary

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Q

Primary vs Secondary Peritonitis

Which one accounts for 80-90% of IAI?

A

Secondary

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Q

Primary vs Secondary Peritonitis

Which one occurs in 10-30% alcoholic cirrhotic pt?

A

Primary

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Q

Primary vs Secondary Peritonitis

Which one occurs in peritoneal dialysis pt?

A

Primary, average 1 episode

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Q

What are the primary etiologies of IAI?

A

Peritoneal dialysis

Cirrhosis w/ ascites

Nephrotic syndrome

CNS shunt

Everything else is secondary

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Q

How does bacteria enter the body for primary peritonitis?

A

Blood stream or lymphatic system

Indwelling peritoneal dialysis catheter

Fallopian tubes

Everything else is secondary

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Q

Where are the microflora concentrated in the GI tract?

A

Distal ileum and colon

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Q

What are the most common bugs for IAI?

A

E. coli (#1)
Strep spp
Bacteroides

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Q

Primary vs Secondary peritonitis

Which one has mildly elevated WBC?

A

Primary

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Q

Primary vs Secondary peritonitis

Which one has decreased UOP?

A

Secondary

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Q

Primary vs Secondary peritonitis

Which one has has normal body temp initially then increases?

A

Secondary

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Q

Primary vs Secondary peritonitis

Which one has has cloudy dialysate fluid?

A

Primary

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Q

Primary vs Secondary peritonitis

Which one causes loss of appetite and abdominal tenderness

A

Primary

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Q

Primary vs Secondary peritonitis

Which one has hypotension?

A

Secondary

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Q

Primary vs Secondary peritonitis

Which one has abdominal pain and tachycardia?

A

Secondary

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Q

Primary peritonitis diagnosis fluid workup?

A

> 250 PMN/mm3 (ascitic)

> 100 WBC count in peritoneal dialysis

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Q

Cirrhotic ascites-SBP Tx?

A

Cefotaxime or ceftriaxone x 5 days

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Prophylaxis for cirrhotic ascites-SBP?

Cipro or Bactrim

Peritoneal dialysis Tx?

Vanco + 3rd gen ceph or amino via intraperitoneal route

Low risk CA-IAI Tx?

Cefotaxime or ceftriaxone + Flagyl Ertapenem Moxi or Cipro + Flagyl

High risk CA-IAI Tx?

Zosyn Cefepime or Ceftazidime + Flagyl Dori or imipenem or merrem Aztreonam + Vanco + Flagyl

Bugs to cover in HA-IAI?

E. faecalis, E. faecium, VR Enterococcus spp

What Rx cover E. faecalis HA-IAI?

Zosyn, imi+cilastin, addition of amp or vanco

What Rx cover E. faecium HA-IAI?

Vanco

What Rx cover VR enterococcus HA-IAI?

Dapto or Zyvox

What are the antifungal Tx options for IAI?

Candida? -fungin rx for critical pt and fluconazole for less critically ill pt Non Candida? -fungin only

What is considered Tx failure for IAI?

No clinical improvement in organ dysfunction 48 hr+ after source control Progressive organ dysfunction within 1-2 days after source control Persistent signs of inflammation 5-7 days after source control

Tx duration for IAI?

Bad source control = 5-7 days Good source control = 4 days Anything to do with bowel operations = 24 hrs

What are some PO options for IAI?

Augmentin, moxi, or cipro + flagyl

What should i know for biliary infections, hepatic abscess, pancreatitis, and diverticulitis?

Biliary infection; source control, use narrow therapy for CA mild-moderate severity Hepatic abscess; B-lactams, 3/4th gen + flagyl or FQ+Flagyl Pancreatitis; dont use unless you want to prevent resistance or decrease AE rxns Diverticulitis; ??

What is a C. diff infection?

≥3 unformed stools in 24hrs with either a positive c. diff toxin in stool test or detection of toxigenic c. diff or colonoscopic or histopathologic findings of pseudomembranous colitis

What is healthcare facility-onset CDI?

CDI, but lab identified ≥3 days after admission to facility

What is community-onset, healthcare faicility-associated CDI?

CDI that occurs within 28 days after discharge

What is community associated CDI?

Symptoms onset within 48hrs of admission to hospital or more than 12 weeks after discharge

C. diff organism info?

Exist in spore (resistant to heat, acid and Abx) and vegetative (active, toxin producing) form Produces two exotoxins: A+B A=inflammation leading to interstitial fluid secretions and mucosal injury B=10x more potent than A Spread by fecal-oral route

Which Rx class contribute to CDI?

Abx and PPI

Which Abx are very commonly associated with CDI?

``` Clinda Amp Amox Ceph FQ ```

GDH EIA NAAT Which one is just used as a screen and must be confirmed?

GDH

GDH EIA NAAT Which one cost the most?

NAAT

GDH EIA NAAT Which one cost the least?

GDH + EIA

GDH EIA NAAT Which one is used alone in acute diseae?

NAAT

GDH EIA NAAT Which one has false positives?

NAAT due to high sensitivity and specificity. Use EIA as a backup

GDH EIA NAAT Which one has high sensitivity, but low specificity?

GDH, EIA is the other way around

GDH EIA NAAT Which one measures C. diff nucleic acid?

NAAT

GDH EIA NAAT Which one measures C. diff common antigen?

GDH

GDH EIA NAAT Which one measures free toxins?

EIA

Can you get stool samples for C. diff on someone who takes laxatives?

Nope

Classification of CDI * Initial episode, non severe * Initial episode, severe * Initial episode, fulminant * First recurrence * Second/subsequent recurrence Hypotension

Fulminant

Classification of CDI * Initial episode, non severe * Initial episode, severe * Initial episode, fulminant * First recurrence * Second/subsequent recurrence WBC ≤15k AND SCr <1.5

Non-severe

Classification of CDI * Initial episode, non severe * Initial episode, severe * Initial episode, fulminant * First recurrence * Second/subsequent recurrence Shock

Fulminant

Classification of CDI * Initial episode, non severe * Initial episode, severe * Initial episode, fulminant * First recurrence * Second/subsequent recurrence WBC ≥15k OR SCr>1.5

Severe

Classification of CDI * Initial episode, non severe * Initial episode, severe * Initial episode, fulminant * First recurrence * Second/subsequent recurrence Reappearance of Sx and positive asay within 2-8wks after tx stopped

First recurrence

Classification of CDI * Initial episode, non severe * Initial episode, severe * Initial episode, fulminant * First recurrence * Second/subsequent recurrence Ileus or toxic megacolon

Fulminant

CDI Non severe Tx?

Vanc 125 PO QID Fidax 200 PO BID Flagyl 500 PO TID x10 days

CDI Severe Tx?

Vanc 125 PO QID Fidaxomicin 200 BID x10 days

CDI Fulminant Tx?

Vanc 500 PO or nasogastric QID Ileus? Do 500mg Vanco in 100mL NS q6h Present illeus, add flagyl 500mg IV q8h w/ oral or rectal vanc

CDI first recurrence Tx?

If flagyl was used, use vanco 125 PO QID If vanc was used, use fidaxomicin 200 BID x10days

CDI second or subsequent recurrence Tx?

Vanc 125 PO QID x 10days + Rifaximin 400 TID x20 days Fidaxo 200 PO x 10 days Fecal micro transplantation

Does flagyl require renal dose adjustments?

No

Oral vanco is only used for what?

CDI tx alone, poor oral absorption but concentrates well in the stool

Fidaxomicin MOA and age limit?

Inhibits RNA polymerase sigma subunit Must be 18+

Bezlotoxumab info?

Human monoclonal that binds to toxin B For 18+ For high risk of CDI recurrence, used in conjunction w/ ABx for CDI Not indicated to treat CDI

Should you use antiperistaltic agents for CDI?

Nope

Who is at highest risk for acute infectious diarrhea globally and in the US?

Globally = younger children <5yo US = elderly

Diarrhea vs dysentery definition

Diarrhea = loose or watery stool Dysentery = intestinal inflammation that leads to diarrhea w/ mucus or blood in feces

Water vs Dysentery Number per day

Water <10 Dysentery >10

Water vs Dysentery Occult blood and fecal PMNs

``` Water Occult blood (-) Fecal PMNs (Absent, few) ``` ``` Dysentery Occult blood (+) Fecal PMNs (Many) ```

Bugs found in watery diarrhea?

Vibrio cholerae Enterotoxigenic E. coli Rotavirus Norovirus

Bugs found in dysentery?

Shigella Salmonella EnteroHEMORRHAGIC E. coli C. diff

Water vs Dysentery Which one allows use of Abx?

Dysentery except if it EnteroHEMORRHAGIC E. coli (due to HUS)

Vibrio cholerae Enterotoxigenic E. coli Rotavirus Norovirus Infects children <5yo

Rotavirus

Vibrio cholerae Enterotoxigenic E. coli Rotavirus Norovirus Not really common in US

Vibrio

Vibrio cholerae Enterotoxigenic E. coli Rotavirus Norovirus Common cause of food and water associated outbreaks?

Enterotoxigenic E. coli

Vibrio cholerae Enterotoxigenic E. coli Rotavirus Norovirus Accounts for >90% of viral gastroenteritis amongst all age groups

Norovirus

Norovirus vs Rotavirus Peak time?

Noro = winter Rota = Oct - April

Norovirus vs Rotavirus Common Sx?

Noro = ab pain, myalgia Rota = fever, ab pain, lactose intolerance

What bug causes most foodborne illnesses?

Enterohemorrhagic E. coli

What bug causes the most nonviral gastroenteritis?

S. sonnei and S. flexneri

Which bug for watery diarrhea actually damages the epithelial lining?

Rotavirus, the other 3 just cause lots of water secretion

What is hemolytic-uremic syndrome?

A complication of EnteroHEMORRHAGIC E. coli Triad of conditions: Acute renal failure Thrombocytopenia Hemolytic anemia

What is Reiter syndrome?

Result of a shigella infection Joint pain, eye irritation, painful urination, maybe arthritis

DOC for pregnant women + water diarrhea?

Azithromycin

Common bugs that cause foodborne illnesses?

CCENNSS ``` Campylobacter Clostridium E. coli Norovirus Nontyphoidal salmonella Shigella Staph ```

Ancillary mgmt + diarrhea?

Anti-motility agents; give at 18+, only when adequately hyrdated, avoid in toxin producing bacteria (shigella or EHEC) or bloody diarrhea or fever Anti-emetics; given in ORS 4+yo Can give probiotics and oral zinc

Vibrio cholerae Enterotoxigenic E. coli Rotavirus Norovirus Supportive care is used when?

All of them

Vibrio cholerae Enterotoxigenic E. coli Rotavirus Norovirus Abx is used when?

Only in vibrio (doxy) or enterotoxigenic (cipro)

Shigella Salmonella EnteroHEMORRHAGIC E. coli Supportive care is used when?

All of them

Shigella Salmonella EnteroHEMORRHAGIC E. coli Abx is used when?

Only salmonella and shigella (cipro for both)

What is used to Tx C. botulinum?

Respiratory support + botulinum antitoxin

Clean Clean-contaminated Contaminated Dirty Doesnt need Abx

Clean

Clean Clean-contaminated Contaminated Dirty Therapeutic Abx indicated

Dirty

Clean Clean-contaminated Contaminated Dirty Open, fresh, accidental wounds

Contaminated

Clean Clean-contaminated Contaminated Dirty Operative wounds in controlled conditions

Clean-contaminated

Clean Clean-contaminated Contaminated Dirty Perforated viscera or clinical infection

Dirty

Clean Clean-contaminated Contaminated Dirty Major break in sterile technique

Contaminated

Clean Clean-contaminated Contaminated Dirty Gross spillage from GI tract

Contaminated

Clean Clean-contaminated Contaminated Dirty Nonpurulent inflammation is is encountered

Contaminated

Top bugs in surgery?

S. aureus + CoNS

Greatest risk of contamination in surgery?

Incision -> closure

Which surgical procedures require anaerobic coverage?

Appendicitis, small intestines, colorectal, urologic, or hand and neck Therefore dont choose Ancef

Cefazolin dosing + surgery?

2g 3g if ≥120kg

Gent dosing + surgery?

5mg/kg as a single dose

When should Abx be given for surgery?

1 hr before incision 2 for vanco + FQs

When should Abx be redosed during surgery?

If procedure exceeds two half-lives of Abx or Blood loss ≥1500mL

If bowel prep is used, what PO Abx can be given?

MEN Metro Erytho Neo Prophylaxis Abx will still be given like IV cefazolin or metro