Disease States and Treatments Test 3 Flashcards
What are the most common risk factors for infective endocarditis?
Prosthetic valve and previous endocarditis
What are the most common causes of endocarditis and the adherence mechanisms of each?
Staph= glycocalyx Strep= dextran
What are the most common risk factors for a Staph endocarditis?
1st year of prosthetic valve, IV drug users
What are the most common risk factors for endocarditis caused by Enterococci?
genitourinary or obstetric procedures
What are the most common risk factors for gram negative endocarditis?
IV drugs users, prosthetic valves, cirrhosis
Peripheral stigmata
Seen in endocarditis
Osler nodes, splinter hemorrhages, petechiae, Janeway lesions, Roth spots, clubbing
“FROM JANE”
Clinical criteria for diagnosing endocarditis?
- 2 “major” criteria= (+)ECG + persistent bacteremia w/IE pathogens
- 1”major” and 3 “minor” criteria= persistent bacteremia OR (+) echo + fever, eye hemorrhages, + Osler nodes
- 5 “minor” criteria
Treatment for highly susceptible and relatively resistant Strep endocarditis
Highly susceptible:
Native valve: PCN G (12-18M)
Prosthetic: PCN G (24M)+ Mandatory 2 week gentamicin
Relatively resistant: PCN G + 2 week gentamicin
Tx for highly resistant Strep and susc. enterococci endocarditis
ampicillin + 4-8 weeks of gentamicin
Tx for endocarditis
LOOK AT TABLE IN NOTES
First line therapy for acute otitis media
HIGH-DOSE amoxicillin (90 mg/kg/day) x 5-10 days
**If that doesn’t work w/in 48-72 hours –> HIGH DOSE amox/clav (Augmentin)
First line therapy for acute sinusitis
Standard dose amox-clav
Drugs of choice in acute pharyngitis (Strep throat)
penicillin OR amoxicillin x 10 days
PCN allergy: azithromycin x 5 days
First line for acute bronchitis
USUALLY SELF LIMITING
If sx >1 week –> azithro/clarithromycin, doxy, or FQ
Place of care based on PSI score
0-70= outpatient
71-90= outpatient or brief inpatient stay
91 - >130= inpatient
CURB-65 criteria
Confusion, Urea 30, SBP, Age >65
0-1= outpatient
3-5= inpatient (4-5 can be ICU)
First line outpatient therapy for CAP
Previously healthy: macrolide
Recent abx thx or cormorbid conditions: Resp FQ
Suspected aspiration: amox/clav
Flu w/ the CAP: oral BL or resp FQ
First line inpatient therapy for CAP
Medical ward: Resp FQ
First line inpatient ICU therapy for CAP
Need to cover MRSA!
BL+ Azithro OR Resp FQ
Need to cover pseudomonas? Antipseudomonal BL + Resp FQ
Allergy to penicillins? Aztreonam
Gold standard for diagnosis of HCAP
lung biopsy (however generally reserved for pediatric or immunosuppressed pts)
Risk factors for MDR pathogens
Abx w/in 90 days, current hospitalization >5 days, high abx resistance in community, immunosuppression, RISK FACTORS FOR HCAP
Risk factors for HCAP
Hospital stay >2 days w/in the last 90 days, nursing home, home infusion tx, chronic dialysis, home wound care, family w/MDR pathogen
“early onset” pneumo
<5 days after admission; need to cover Strep pneumo, H. flu, MSSA, and PEcK
“late onset” pneumo
> 5 days after admission; need to cover all early onset pathogens PLUS MRSA, pseudomonas
First line tx for early onset HCAP with no risk factors for MDR pathogens
ampicillin/sulbactam, ceftriaxone, FQ, ertapenem
First line tx for late onset HCAP with risk factors for MDR pathogens
MRSA COVERAGE + ANTIPSEUDOMONAL BL + ANTIPSEUDOMONAL AG OR FQ
MRSA coverage is always vanc or linezolid
What is the most common portal of entry for osteomyelitis?
Contiguous (47%) or vascular insufficiency (34%)
Lab and Radiologic tests for osteomyelitis
inc WBC, inc ESR/CRP
Need blood culture, blood culture, and joint aspiration to get diagnosis (superficial cultures are NOT reliable)
MRI and bone scan can detect changes very early
First line treatment in hematogenous osteomyelitis
Children/ Sickle Cell pts: nafcillin + cefotaxime OR ceftriaxone
Adults: nafcillin
IV users: vancomycin + anti-pseudomonal
First line treatment in contiguous osteomyelitis/ vascular insufficiency
pip/tazo, cefepime + metronidazole (+ Vanc for MRSA) x AT LEAST 4-6 weeks
Non-pharm therapy for osteomyelitis
surgical debridement, hyperbaric oxygen therapy
What is the most common kind of infectious arthritis?
Hematogenous (seeding from systemic infection)
Clinical features of gonococcal and nongonococcal infectious arthritis
SEE CHART IN LECTURE
Treatment for infectious arthritis
Children/adults: nafcillin + cefotaxime OR ceftriaxone
Prosthetic joint, surgery, or IV users: vanc + antipseudomonal
Duration of treatment for infectious arthritis
Nongonococcal: 2-3 weeks
Gonococcal: 7-10 days
Types of Diarrhea
Acute: 14 days
Chronic: >4 weeks
Which types of E. coli are in watery diarrhea?
Enterotoxigenic and enteropathogenic
First line treatment for diarrhea
FLUID REPLACEMENT/ oral rehydration therapy
Examples of anti-motility agents
diphenoxylate, loperamide
DO NOT USE IN INFLAMMATORY DIARRHEA
Example of absorbent
Kaolin-pectin/aluminum hydroxide
When do you recommend antibiotics in diarrhea?
usually not indicated!
only for use in Shigella, Campylobacter, and Yersinia
Diagnosis of C. diff
stool culture and at least one toxin test (ELISA)
Treatment for initial infection of C.diff
Mild-Mod= metronidazole PO
Severe= vancomycin PO
Severe, complicated= vanc PO + metronidazole IV
Treatment for relapse of C. diff
1st relapse= same agent that you used on initial infection according to severity
>2nd relapse= vancomycin (taper)
Bismuth subsalicylate
use in traveler’s diarrhea
inhibit enterotoxin activity and prevent diarrhea
do not use for >3 weeks or in prego
Antimicrobials for traveler’s diarrhea
usually not needed
DOC is FQ (Cipro or Norfloxacin)
Main causative organism in Primary CAPD
S. aureus
Causative org in primary SBP
E. coli
Main causative org in secondary peritoneal disease
polymicrobial: E. coli, Bacteroides, and Candida can be seen
Source Control
Antibiotics alone are not enough to treat secondary intra-abdominal infections!! Need to drain infected foci, abscesses, and fluid collections and do surgical repair of damage (seldom used in primary infections)
Treatment of primary CAPD
Gram (+) coverage (cefazolin or vanc) + Gram (-) coverage (aminoglycoside, FQ)
Treatment of primary SBP
cefotaxime, ceftriaxone, FQ
Treatment of secondary intra-abdominal infections
CA, mild-mod risk: ticarcillin/clavulanate, cefoxitin, ertapenem, metronidazole + ceph
CA, high risk: pip/tazo, antipseudomonal carbapenems
Aminoglycosides PD
CONCENTRATION DEPENDENT
Peak conc 8-10X the MIC of the pathogen
beta-Lactams PD
TIME DEPENDENT
40-50% of the time >MIC
MIC Creep
MIC’s are rising for some org which makes it harder to meet target in some agents
Vancomycin PD
TIME DEPENDENT (troughs are assoc w/ efficacy) AUC/MIC >400
FQ PD
CONCENTRATION DEPENDENT
Gram (-)= AUC/MIC >125
Gram (+)= AUC/MIC >33.7
Loading Dose for Vancomycin
for pts with SEVERE illness
25-30 mg/kg IV x 1
Max 2000 mg (2 grams)
Maintenance Dose for Vancomycin
15-20 mg/kg/dose using ABW (max 2 gr)
Q8-12H based on renal function
SIRS Criteria (did I already put these on here? I can’t even remember anymore #pharmacyschoolprobs)
HR >90 RR >20 Temp >38 (>100.4) WBC >12,000 NEED > OR = 2 OF THE 4 CRITERIA
Sepsis
SIRS + infection
Severe sepsis
Sepsis + organ dysfunction or hypotension
Septic shock
Severe sepsis + hypotension that won’t come down even after fluid therapy and requires vasopressor
Common pathogens in sepsis
S. aureus, P. aeruginosa, Enterobacteriace
Gram (-) and fungi (yeast) have high mortality
What are the three things sepsis causes?
Coagulation, vasodilation, and capillary leak
Diagnosis of sepsis
do not delay abx administration due to cultures
minimum 2 blood cultures + 1 or more percutaneous blood cultures + one blood culture from each vascular access device
How do you treat hypotension in sepsis?
FLUID RESUSCITATION FIRST! If that doesn’t work, then vasopressors (norepinephrine). If that doesn’t work, then steroids
