Exam 2 Flashcards
What is nociceptive pain?
Transient pain caused by damage to tissue. ( cutaneous tissue, bone, muscle, connective tissue)
- Typically response to NSAIDS or opioids
What is neuropathic pain
Spontaneous pain and hypersensitivity to pain associated with damage to the central nervous system
- often described as shooting or burning pain
What is malignant pain?
- pain resulting from cancer or AIDS
WHO 3 step ladder approach to pain management
- Mild pain (1-4/10) : nonopioid analgesics such as acetaminophen or NSAIDS
- Moderate pain (4-6/10) : weak opioids like codeine or tramadol in combo with nonopiod
- Severe pain (6-10/10) : strong opioid like morphine or oxycodone in combo with nonopiod
What is the mechanism of action for NSAIDS ?
- inhibits the COX enzyme which reduces prostaglandin synthesis.
- Indicated for pain and inflammation
What are precautions against NSAIDS?
- GI bleeding. All NSAIDs are ulcerogenic and induce GI bleeding due to activity against COX
- renal impairment
- cardiovascular risks
- platelet inhibition , sodium retention
Use NSAIDs in caution with patients …
- but reduced cardiac output because of sodium retention
- taking anti-hypertensive, warfarin, and lithium
Use NSAIDs in caution with patients …
- but reduced cardiac output because of sodium retention
- taking anti-hypertensive, warfarin, and lithium
What kind of pain are NSAIDs preferred for?
- mild to moderate
- rheumatoid arthritis
- Menstrual cramps
- post surgical pain
These are all mediated by prostaglandins
What is a ceiling effect for NSAIDs?
- increasing the dose may not provide significant additional benefits
- at ceiling doses, the cox enzyme activity sites becomes saturated with the nsaid . No free enzyme can bind to further substrates which produces a plateauing effect on the drugs efficacy
What is the mechanism of action of acetaminophen ( APAP)?
- reduces pain and fever by inhibiting press the gland and synthesis in the central nervous system by blocking cox enzyme
- ACETAMINOPHEN NOT FOR INFLAMMATION
Precautions with acetaminophen
- liver toxicity ( hepatotoxicity)
Precautions with acetaminophen
- liver toxicity ( hepatotoxicity)
What is the normal dosing for acetaminophen in adults?
- 4g (4,000mg) in adults
- 3 g (3,000mg) in elderly
What is the normal dosing for acetaminophen in adults?
- 4g (4,000mg) in adults
- 3 g (3,000mg) in elderly
- over-the-counter medication’s like cold meds also carry acetaminophen so if patient is taking Tylenol and cold medicine, they can get too much
What is an example of neuropathic pain?
Post hepatic neuralgia (PHN) : pain associated with acute hepatic neuralgia or an acute singles outbreak
Peripheral versus central neuropathic pain
- peripheral: HIV or chemo
- Central: central stroke pain, trigeminal neuralgia
What type of non-opiate medication’s? Would you use for a patient with neuropathic pain?
- peripheral: TCAS ( amitriptyline or notriptyline)
- SSRI or SNRI ( duloxetine or venlafaxine)
- central: clonidine or baclofen
What does adjuvants analgesics mean?
- medications that were not primarily designed for pain, relief, but can enhance analgesic effects or treat specific pain types.
Ex: antidepressants or anti-convulsants for neuropathic pain
What does adjuvants analgesics mean?
- medications that were not primarily designed for pain, relief, but can enhance analgesic effects or treat specific pain types.
Ex: antidepressants or anti-convulsants for neuropathic pain
When would Advent analgesics be appropriate?
- neuropathic pain
- chronic pain like fibromyalgia and diabetic neuropathy
- inflammatory pain, like rheumatoid arthritis and inflammatory bowel disease
Examples of adjuvants medication for a different diseases
- diabetic peripheral neuropathy (DPN) : gabapentin ( anti-convulsant). SNRI like duloxetine
- Post hepatic neuralgia (PHN): gabapentin and lidocaine patch
- Fibromyalgia : duloxetine, amitriptyline. Avoid amitriptyline in older adults
What is the mechanism of action for opioids?
- binds to opioid receptors (mu receptors)in central nervous system, which alters pain, perception and response .
- binds to mu receptors and central nervous system, which leads to decrease transmission of pain signals. Has an effect on reward pathways because it leads to a feeling of euphoria which reinforces behaviors associated with opioid use
What are the adverse effects of opioids?
- respiratory depression
- constipation, sedation, drowsiness, physical dependence
What prophylactic measures should you take with opioids?
- Laxatives for constipation
What is the medication to reverse respiratory depression with opioids?
- Naloxone
What if a patient has an anaphylactic allergy to an opioid? What are the other medication options?
- non-opioid analgesic like acetaminophen or NSAID
- adjuvants and OG like anti-convulsants, TCAs, or lidocaine
What is equianalgesic dose?
- doses of different drugs that provide approximate equal analgesic effects
- comparing doses of different opioids based on their potency
- Doses of different medication’s that are expected to produce comparable pain or relief when used in patients who have developed tolerance to one drug and need to switch to another
What is incomplete cross tolerance?
-When patient who has developed tolerance to one opioid may not exhibit, the same level of tolerance to another opioid because different opioids may act on different receptors
What is opioid rotation?
- switching from one opioid to another to achieve better pain control or manage adverse effects. Reasons could be in adequate pain, relief or intolerable side effects or patient preference
What are examples of NSAIDs?
NSAIDS THINK NSAIK
Naproxen
Salicylate acid (aspirin)
Acetylsalicylic acid ( aspirin
Ibuprofen and Indomethacin
Ketorlac (Tordol)
What disorders are contraindicated for NSAIDs?
- Peptic ulcer disease or any other bleeding disorder
What disorders are contraindicated for NSAIDs?
- Peptic ulcer disease or any other bleeding disorder
All NSAID except what’s increase cardiovascular risk
Aspirin
What is an example of a NSAID cox 2 inhibitor?
Celebrex ( celecoxib)
- good for osteoarthritis or rheumatoid arthritis
- side effects is increased risk for a thrombosis which can lead to a stroke
When is Celebrex contraindicated
- if a patient is allergic to aspirin, NSAID, or sulfonamides
- Celebrex can cause increased cardiovascular risk
What is aspirin good for?
- aspirin is an NSAID so it’s good for pain, inflammation, and fever
Is also good for preventing myocardial infarction and patients who are at risk
What are side effects of aspirin?
Tinnitus (ringing in ears)
GI upset and rash ( like all other NSAIDS)
When is aspirin contraindicated
- peptic ulcer disease
- Children with fever (Reyes syndrome)
Should you ever take two NSAIDs together?
NO!!
Are NSAID safe for asthma?
-No!!
- patients with asthma or nasal polyps should use acetaminophen instead
How long do migraines last?
4-72 hrs
What are some symptoms of migraines?
- photosensitivity, sound sensitivity, nausea and vomiting, throbbing pain
- Unilateral pain
What is the difference between migraines and cluster headaches?
- cluster headaches= no throbbing
What are cluster headaches?
- Unilateral non-throbbing pain typically around the eye or a temporal
What is the medication of choice for cluster headaches?
- Verapamil
How long do cluster headaches last?
- 30 min- 2 hrs
What are some food triggers for headache?
- tyramine( aged cheese, wine, organ meats)
- Citrus foods, bananas, avocado, raisins , chocolate
What medication are triggers for headache?
- Indomethacin, nifedipine, nitrates
- estrogen or oral contraceptives
- Menstrual cycles
What are headache, red flags? ( need urgent medical evaluation)
- New onset and/or severe headache( thunderclap headache - could be subarachnoid hemorrhoids)
- systemic signs like fever, weight loss and accelerated hypertension
- Facial neurologic symptoms like weakness and numbness
- patients with cancer or HIV
Treatment of acute migraine
NSAIDS like aspirin
Acetaminophen
Combination products containing caffeine with or without an opioid
When should triptans be used for migraine treatments?
- when analgesic are ineffective and for severe headaches
When should triptans be avoided for migraines?
- migraines associated with neurologic focalty
- history of previous stroke
- Uncontrolled hypertension
- unstable angina
- pregnancy
What other migraine medication should triptans not be used with together?
Ergotamine
What are typical symptoms of osteoarthritis?
- joints pain
- Stiffness
- decreased range of motion
- Symptoms worsen with activity and improve with rest
- Commonly affected weight-bearing joints, like knees, hips, and spine
What is osteoarthritis?
Degenerative joint disease that primarily affects the cartilage and underlying bone in joints. Most common type of arthritis and typically develops over time
Nonpharmacological treatment of osteoarthritis
- exercise, weight loss
Nonpharmacological treatment of osteoarthritis
- exercise, weight loss
What are pharmacological treatments for osteoarthritis?
- acetaminophen as first line/ initial therapy . For a mild to moderate osteoarthritis.
- NSAID for inflammation and pain. For moderate to severe pain or therapeutic failure of acetaminophen.
What are the difference between cox 1 and cox 2 inhibitors
- cox 1 inhibitors ( traditional NSAIDS ) have higher GI risk
- cox 2 inhibitors have less Gi toxicity but may increase cardiovascular risks ( celebrex is cox 2)
Who would benefit from a COXib?
COXib=cox 2= celebrex
- patience at a high risk of G.I. complications
When are opioids/tramadol used for osteoarthritis
Reserved for patients who are unresponsive to other therapies or when other therapies are contraindicated
Symptoms of a cluster headache
- nasal congestion
- Eyelid edema
- sweating
- Agitation and pacing
- Restlessness
- Sensation of fullness in the ear
Other red flags for headaches?
- cough - excretion- or valsalva triggered headache
- Pregnancy or postpartum state
- cancer or HIV
- Seizures
- New onset sudden and or severe pain
- Systemic signs like fever and weight loss and accelerated hypertension
- focal neurologic symptoms
What is the goal for treatment for osteoarthritis?
- Reduce pain and inflammation
- Treatment is not curative
NSAID versus acetaminophen for osteoarthritis
- osteoarthritis can occur with and without inflammation
What is osteoporosis?
Decreased bone density and increased risk of fractures
What are some risk factors for osteoporosis?
-Old age
Women
Family history
Low body weights or BMI
Smoking, excessive alcoholic consumption
Low calcium or vitamin D intake
Lack of physical activities
Medications: steroids, anticonvulsants, proton pump inhibitors, ssri
What are the recommended calcium and vitamin D amounts?
- calcium : 1000 mg a day. For women over 50 and men over 70: 1200 mg
- Vitamin D:
600-800
800-1000 IU daily for adults over 70
How do you interpret T scores?
Normal : -1.0 or higher
Osteopenia ( low bone mass): between -1.0-2.5
Osteoporosis : -2.5 or lower
What calcium supplement would be the best to give a patient with a history of reflux
- calcium carbonate
- calcium citrate ( would be the preferred choice. It is better tolerated, and people with sensitive stomachs.)
What is the use of bio phosphates for osteoporosis?
- they work by inhibiting bone resorption, which helps to maintain or increase bone mineral density, and reduce the risk of fractures
What are examples of biophosphonates?
- Alendronate ( Fosamax)
risedronate ( Actonel)
ibadronate ( Bonvia)
Biophosphonates : end in dronate
What are counseling points you should give to your patients when giving biphosphonates?
- oral: take on an empty stomach in the morning. Sit upright for at least 30 minutes after taking to minimize risk of esophageal reflux.
What are adverse effects of biophosphonates?
- ## GI upset ( especially with oral) , musculoskeletal pain, headache
Alendronate
- used for post menopausal osteoporosis and pagets disease ( a bone disease. Rare form of breast cancer)
- mode of action: prevents bone resorption by inhibiting activity of osteoclasts ( usually osteoclasts break down bone take calcium from bone and put it in bloodstream. Alendronate helps keep calcium in the bone)
Side effect of Alendronate
- key: esophagitis ( inflammation of esophagus). Think Alan drones on and on about his esophagitis
- GI upset, muscle pain, visual disturbances
Teaching points for alendronate
- take on empty stomach in the morning with full glass of water
- sit up for 30 min! Don’t lay down, can result in esophagitis
- encourage calcium and vitamin D intake ( vitamin D needed for calcium absorption)
- weight bearing exercises
Selective Estrogen Receptor Modulator ( SERM) medication
Raloxifene
( look at name of med, fix backwards so think fix O = fix osteoporosis)
- used for post menopausal osteoporosis and can help reduce risk of breast cancer
- mode of action: binds to estrogen receptors which decrease bone resorption
- side effects : * increased risk for embolic events ( DVT, stroke, PE) * black box warning on this med for this reason
-hot flashes and leg cramps also common
Education: increase calcium and vitamin D intake and encourage weight bearing exercise
Selective Estrogen Receptor Modulator ( SERM) medication
Raloxifene
( look at name of med, fix backwards so think fix O = fix osteoporosis)
- used for post menopausal osteoporosis and can help reduce risk of breast cancer
- mode of action: binds to estrogen receptors which decrease bone resorption
- side effects : * increased risk for embolic events ( DVT, stroke, PE) * black box warning on this med for this reason
-hot flashes and leg cramps also common
Education: increase calcium and vitamin D intake and encourage weight bearing exercise
Hypocalcemic agent ( calcitonin)
- Calcitonin= think tone down calcium
-helps bring down calcium levels in the blood - used for post menopausal osteoporosis and for hypercalcemia
- inhibits the activity of osteoclasts
- side effects: GI upset. Nasal irritation and dryness if taking it intranasally
- teaching: calcium and vitamin D intake, weight bearing exercises.
Denosumab
For postmenopausal osteoporosis and hypercalcemia
Teriparatide
- medication for postmenopausal osteoporosis. Synthetic form of natural human parathyroid hormone
What is asymptomatic hyperuricemia?
Where serum urate concentration is elevated but there are no signs of crystal deposition like gout
May lead to gout overtime especially if there are other risk factors like obesity or alcohol consumption
What are secondary causes of hyperuricemia?
Purine rich foods ( organ meats, pork, beef, anchovies, alcohol, shellfish, soft drinks)
Alcohol consumption
Certain meds like diuretics
When should urate lowering therapy be instituted?
- in patients with recent gout attacks, tophi, or radiographic evidence of joint damage
- goal is to reduce uric acid levels below 6.0
What is the approach to therapy for acute gout attack?
1st line: NSAIDS ( ex Indomethacin), colchine, or oral corticosteroids
If GI ulcers - avoid NSAIDS
If diabetic- use caution with corticosteroids
If renal function- adjust colchine and NSAID dose
When to avoid colchicine?
Avoid in patients with hepatic impairment
When to avoid corticosteroids for gout
Uncontrollable diabetes or significant psychiatric conditions
When to avoid NSAIDS/ COXibs for gout
GI ulcers
renal impairment
cardiovascular disease
How does dosaging of colchicine differ when it used for acute attack vs prophylaxis?
Acute: initial dose of 1.2mg followed by 0.6mg one hour later ( max 1.8mg in an hour)
Prophylaxis: lower doses ( 0.6mg daily or every other day) to prevent recurrent attacks
When is prophylaxis for gout indicated?
When a patient has recurrent gout attacks( known as Gouty arthritis) which can lead to joint damage and chronic pain if it is not managed properly
Goal for prophylactic treatment is to reduce the frequency and severity of gout attacks by lowering uric acid levels over long-term
When is prophylaxis for gout indicated?
When a patient has recurrent gout attacks( known as Gouty arthritis) which can lead to joint damage and chronic pain if it is not managed properly
Goal for prophylactic treatment is to reduce the frequency and severity of gout attacks by lowering uric acid levels over long-term
Xanthine Oxidase Inhibitors
Prophylactic treatment for gout
Ex : allopurinol, febuxostat
-Mechanisms of action: inhibits xanthine oxidase enzyme which reduces production of urine acid levels
- First like agents for lowering uric acid levels and preventing gout attacks
- Typically started after the acute flare has resolved to prevent subsequent attacks
Uricosurics
Prophylactic medication for gout
Ex: probenecid, lesinurad
Mechanism of action: increases renal excretion of uric acid by inhibiting its reabsorption in the kidney tubes
Indication: when xanthine oxidase inhibitors are contraindicated or not tolerated. Or with patients with under excretion of uric acid
Started after acute symptoms have resolved
Colchicine
Mechanism: inhibits inflammatory response to urate crystals in joints
Indication: used for both acute treatment of gout attacks, and for prophylaxis against future attacks during initiation of other therapies
Can be started simultaneously with other prophylactic agents during the acute attack phase to prevent flares triggered by initiating urate lowering lowering therapies
Colchine
- can help reduce the pain and inflammation in acute gout attack by interfering with the white blood cells initiation of the inflammatory response in the body
Side effects of colchicine
- GI upset
- thrombocytopenia ( low platelet level)
Patient teaching for colchicine
- increase fluid intake
-NO GRAPEFRUIT JUICE WHILE TAKING COLCHICINE
Colchine = looks like cool chicken = pecks gouty toe
Uricosuric ( probenecid)
For chronic gout
- inhibits renal reabsorption of uric acid. Helps improve excretion of uric acid
Side effects : GI upset, renal calculi ( kidney stones)
Encourage fluid intake to prevent kidney stones
Monitor uric acid levels and renal function
Xanthine oxidase inhibitor
Allopurinol
Think allopurinol= purify= get rid of all uric acid
Chronic gout
Mechanism: inhibit uric acid production
Side effects: GI upset, rash, hepatic toxicity, nephrotoxicity
Fluid intake, monitor liver and renal functions
Takes 2-6 weeks to see improvement in symptoms
How long does it take to see improvement of symptoms from allopurinol?
2-6 weeks
If a patient had GERD and taking a PPI and needed calcium supplements, which one would be recommended?
Calcium citrate because it’s not dependent on PH or acid for absorption
Side effects of calcium supplements
Increased risk of constipation , diarrhea, or abdominal pain
Higher risk of kidney stones
Side effects of calcium supplements
Increased risk of constipation , diarrhea, or abdominal pain
Higher risk of kidney stones
When should urate lowering therapies be initiated for gout?
2 or more gout attacks a year
Radiographic evidence
At least one subcutaneous tophus
(At least one of these)
What is the first line for a gout prophylactics?
- xanthine oxidase inhibitor ( allopurinol)
- uricosuric agents ( probenecid)
Alendronate teaching
- take on empty stomach in the morning with full glass of water ( other beverages can reduce the absorption of med)
- sit upright for 30 min after taking to prevent esophagitis
What level is considered to be hyperuricemia?
Above 7 mg/ dl
What happens when uric acid levels exceed 7 mg/dl?
Body fluids ( luke synonival joints) become saturated ——> uric acid then precipitates——> urate crystals form ——> gout
If a patient has an allergy to morphine, what would you prescribe and not prescribe?
- alternatives: hydromorphine ( Dilaudid), fentanyl, oxycodone, codeine
NOT prescribe : meperidine, methadone,
How do triptans work? What are side effects of them?
Bind to serotonin receptors on blood vessels and nerve endings in the brain- this leads to vasoconstriction and inhibition of inflammatory release
Side effects : chest tightness or pressure, flushing, dizziness, drowsiness, nauseas. Contraindicated in patients with uncontrolled hypertension, ischemic heart disease, or hx of stroke
What medications cause hyperuricemia?
- diuretics ( thiazides)
- immune suppression
-low dose aspirin - chemo drugs
What meds are uricosuric ( help reduce uric acid levels)?
-fenofibrate
- losartan
What gout meds to avoid in patients with renal failure
Colchicine and NSAIDS
Dosaging for colchicine
1mg followed by 0.5mg after 1 hr
Difference between OA and RA
-OA: osteoarthritis- degenerative joint disease. Occurs due to wear and tear of cartilage over time
- RA: rheumatoid arthritis- autoimmune disease where immune system attacks the synovium joint lining
Treatment for gout
NSAIDS, colchicine, corticosteroids
Does asymptomatic hyperuricemia require treatment?
No
Does asymptomatic hyperuricemia require treatment?
No
What is a gram stain
Lab technique used to classify bacteria into 2 broad categories: gram positive and gram negative
What are normal floras in the body?
Staphylococcus epidermis
Streptococcus pneumonia
Staphylococcus aureus
What are the typical pathogenic organisms at the sites of infection?
Staphylococcus aureus
Streptococcus pyogenes
Haemophulus influenza
Describe : resistance, susceptibility, pathogenicity, virulence, MIC, empirical
- Resistance: ability of bacteria to withstand antibiotic treatment
- susceptibility: vulnerability of bacteria to antibiotic action
- pathogenicity: ability of bacteria to cause disease
- virulence: degree of pathogenicity
- MIC ( minimum inhibitory concentration) : lowest concentration of antibiotic inhibiting bacterial growth
- empirical : treatment based on experience rather than specific diagnosis
What are LRTIs?
Lower Respiratory Tract Infections
Preventative strategies: vaccination, hand hygiene, stop smoking
Etiologies: common bugs including streptococcus pneumonia, haemophilius influenza, and mycoplasma pneumonia
What organism causes different types of pneumonia
Streptococcus pneumoniae (CAP)
Haemophilius influenzae ( in smokers)
Mycoplasma pneumoniae ( atypical)
Treatment for community acquired pneumonia (CAP)
- healthy adults without comorbidities:
Amoxicillin 1g TID or
Doxycycline 100mg BID or
A macrolide ( azithromycin, clarithromycin)
Pt with comorbidities:
Combo therapy
Amoxicillin with macrolide ( azithromycin)
Itchiness and rash with opioids
Are side effects, NOT allergy!!
If truly allergic: tramadol or fentanyl can be used. Treat with epi and steroids initially then discontinue opioid
Prophylaxis treatment for migraines
Beta blockers ( if not contraindicated )
Low dose TCAs ( amitriptyline, venlafaxine)
Anticonvulsants ( topiramate, valporic acid, depakote)
What class of migraine prophylactic should be avoided in asthma
Beta blockers
Treatment for CAP
1st line: macrolides ( azithromycin)
Alternatives: amoxicillin, fluroqunilones only in specific circumstances or if there is resistance to first line agents
Recommended duration 5-7 days
What are URTIs?
Upper Respiratory Tract Infections
Ex : Acute Rhinosinusitis ( ARBS), acute Ottis media ( AOM)
Preventative strategies: hand hygiene, avoid close contact with infected individuals
Risk factors: crowded living conditions, immunocompromised state
What are risk factors for otitis media? ( OM)
Children
Exposure to tobacco smoke
Daycare attendance
What are risk factors for acute bacterial rhinosinustis? (ARBS)
Persistent upper respiratory symptoms, facial pain, purulent nasal discharge
Common bugs like streptococcus pneumonia, haemophillis infuenzae
What are risk factors for acute bacterial rhinosinustis? (ARBS)
Persistent upper respiratory symptoms, facial pain, purulent nasal discharge
Common bugs like streptococcus pneumonia, haemophillis infuenzae
Treatment for uncomplicated acute otitis media (AOM)
- observation without antibiotics if mild
- use of amoxicillin or amoxicillin- clavulante for moderate to severe cases
Treatment for acute bacterial rhinosinustis (ARBS)
Observation initially for mild cases
Antibiotics ( amoxicillin, doxycycline) for persistent symptoms
Antibiotics for treatment of acute Ottis media
Amoxicillin
Amoxicillin- clavulante
Ceftriaxone
Antibiotics for treatment of acute bacterial rhinosinusitis
Amoxicillin ( amoxicillin for 5-7 days is effective for most infections and is less expensive)
Doxycycline
Or respiratory fluoroquinolones ( levofloxacin)
Antibiotics for treatment of acute bacterial rhinosinusitis
Amoxicillin ( amoxicillin for 5-7 days is effective for most infections and is less expensive)
Doxycycline
Or respiratory fluoroquinolones ( levofloxacin)
What antibiotic to give it patient is allergic to penicillin or fluroquinolones (levofloxacin)
Doxycycline
Side effects of antibiotics in children
Rash, nausea, vomit
What antibiotics can actually cause infections
Fluoroquinolones
TMZ
What pathogen causes acute bacterial rhinosinusitis
Streptococcus pneumonia and H influenza
What non prescription meds are for common cold
Decongestant ( pseudoephedrine)
Antihistamine ( loratadine)
Analgesic ( acetaminophen)
Upper respiratory infection end in
Itis
Treating CAP in patients with comorbidities ( ex: COPD, diabetes, heart failure)
Beta lactam plus macrolide
Respiratory fluoroquinolones
Treating children with CAP
Amoxicillin for mild cases
Ceftriaxone plus macrolide ( azithromycin) for moderate to severe cases
What is aspiration pneumonia
When gastric contents or oropharyngeal secretions are aspirated into the lungs which leads to an infection
Treatment for aspiration pneumonia
Clindamycin
Amoxicillin- clavulante
Plus a macrolide
What causes acute bacterial rhinitis
A proceeding viral infection, like rhinovirus or influenza, damages the respiratory epithelium and disrupts normal sinus drainage, which allows bacteria to colonize and cause infection
What are the treatments for acute bacterial rhinitis?
Amoxicillin, amoxicillin- clavulante, and doxycycline our first line agents
If there is a penicillin allergy , fluoroquinolones or second generation cephalosporins
What is the treatment for otitis media?
In children, older than six months, who are otherwise healthy, observation without immediate antibiotic treatment
Analgesic like acetaminophen or NSAID to help with ear pain and reduce fever
Antibiotics are typically recommended for children under six or a severe symptoms or signs of systemic illness like high fever
Amoxicillin is the first line antibiotic
Common food / supplement interactions with fluoroquinolones
- Dairy products ( calcium containing foods): avoid milk, yogurt, cheese within 2 hrs before and 6 hrs after
- multivitamins ( calcium, magnesium, iron, zinc) : same with 2 hrs before and 6 hrs after
- antacids containing aluminum or magnesium
Common pathogens that can cause CAP
Streptococcus pneumonia ( most common cause)
Symptoms usually include sudden onset of fever, chills, productive cough, and pleuritic chest pain
Others: staphylococcus aureus, H influenza, mycoplasma pneumonia
In the outpatient setting, which antibiotics are recommended for the empiric treatment of CAP in adults
- healthy adults with no comorbidities:
Amoxicillin 1g TID
doxycycline 100mg BID
Macrolide
- outpatient adults with comorbidities
Combo therapies
Amoxicillin-clavulante 500mg /125mg TID
or
Amoxicillin- clavulante 875/125mg BID
OR
Cephalosporin (cefpodoxime 200mg bid) and macrolide ( azithromycin 500mg on first day then 250mg daily)
Or
Doxycycline 100mg BID
Or monotherapy ( respiratory fluoroquinolones like Levofloxacin)
In the inpatient setting, what antibiotics for CAP for adults without risk factors for MRSA and P aeruginosa
Combo therapy with a beta- lactam ( ampicillin + sulbactam), cefotaxime and a macrolide
What pathogen can cause cellulitis
Streptococci ( mainly group A)
What are risk factors for cellulitis?
- diabetes mellitus
- immunocomprimised states ( HIV/AIDS) -peripheral vascular disease
- injection drug use , skin trauma, obesity
- exposure to contaminated water or soil
What pathogens cause cellulitis?
Strep A
Staph Aureus ( including mrsa)
Symptoms of cellulitis
- Red, swollen, tender skin that may feel warm to the touch
- edema and erythema
- fever, chills, malaise
What is the difference between MSSA and MRSA
- MSSA ( methicillin- sensitive staphylococcus aureus) : susceptible to antibiotics, less virulent, low mortality rates,
-MRSA ( methicillin resistant staphylococcus aureus) : resistant to many types of antibiotics, more virulent, high mortality rates. Requires use of alternative antibiotics
Treatment for MSSA vs MRSA
-MSSA: beta lactam antibiotics like cefazolin
- MRSA: antibiotics that are effective against resistant strains like vancomycin
What is uncomplicated UTI
Lower urinary tract infection ( cystitis) that occurs in an otherwise healthy individual with no functional abnormalities of the urinary tract
Causes: E. coli
Symptoms: dysuria, frequency, urgency, lower abdominal discomfort
Tx: short course antibiotics
What is complicated UTI?
UTI occurring in individuals with structural or functional abnormalities of the urinary tract that predisposes them to infection or make treatment more challenging
Risk factors: anatomical abnormalities ( urinary tract obstruction) , functional abnormalities ( urinary stents), underlying conditions ( diabetes mellitus, immuno suppression)
Symptoms: similar to uncomplicated UTI but can present with more severe symptoms
What is Pyelonephritis
Upper urinary tract infection involving the kidneys and renal pelvis
Symptoms: fever and chills , flank pain or back pain, nausea, vomiting, frequency, urgency
Can lead to septicemia ( bacteria in the bloodstream) and potentially life-threatening conditions if untreated
Tx: hospitalization for IV antibiotics ( fluoroquinolones, 3rd gen cephalosporin) followed by oral antibiotics
Other things that make a patient have complicated uti
Male
Childhood UTI
Diabetes
Failed antibiotic course
Pregnancy
Elderly
Symptoms of UTI in elderly patients
Altered mental status
Poor appetite
Incontinence
Lethargy
Confusion
Labs for UTI
Urinalysis : Pyuria ( WBC or pus in urine. Greater than 10)
Bacteriuria ( E. coli)
Presence of leukocyte esterase
Presence of nitrates
Labs for UTI
Urinalysis : Pyuria ( WBC or pus in urine. Greater than 10)
Bacteriuria ( E. coli)
Presence of leukocyte esterase
Presence of nitrates
Treatment for acute pyelonephritis
- oral fluoroquinolones as a 5-7 day regimen if local E. coli resistance is less than 10% plus one time dose of ciprofloxacin
If more than 10% : initial dose of Ceftriaxone 1gram IV plus oral fluoroquinolones
TMP/SMX as 2 week treatment if susceptibly is confirmed. If not confirmed- 1 gram ceftra IV plus TMP/SMX
How do you treat a pregnant patient who has a UTI
Nitrofurantoin is category B and is safe to use EXCEPT IN THE LAST 30 DAYS due to increased risk of neonatal jaundice
Cystitis
Infection of lower urinary tract. Caused by E. coli
MRSA VS MSSA
MSSA: strain of staphylococcus aureus that is susceptible to methicillin so that means antibiotics can effectively kill MSSA bacteria. More common in healthcare and community settings. Think of MSSA as angel
MRSA : resistant to methicillin so more difficult to treat because fewer antibiotics are effective against it. More common in healthcare settings. Think of MRSA as devil
What antibiotics for uti to avoid in pregnant patients
- fluoroquinolones ( ciprofloxaxin)
- tetracycline ( doxycycline)
- TMP/ SMX ( bactrim or septra)
Safe for pregnancy:
Penicillin ( amoxicillin)
Cephalosporin ( cephalexin)
Nitrofurantoin
Fosfomycin
MRSA antibiotics
Vancomycin
Daptomycin
Clindamycin
Ceftaroline
Linezolid
Nitrofurantoin
Used to treat cystitis caused by E. coli
Used as first line treatment for uncomplicated E. coli
TMP/ SMX- when is it used
Only can be given if E. coli resistance is less than 20% in area
Treatment for acute uncomplicated UTI
Nitrofurantoin, TMP/SMX, or fosfomycin for 3-5 days
