Exam 2- bacteria all up in my... Flashcards
1
Q
Bacteria resistant mechanisms: (7)
A
- genetic material from external sources
- mutational events –> DNA replication
- enzymatic inactivation (penicillins)
- ribosomal protection
- elimination of antibiotic target
- decrease cell wall permeability (vancomycin, doptamicin)
- effluc pumps (cipro_
2
Q
examples of mutations:
A
- up- regulate chromosomal B-lactamases
- up-regulate multi-drug efflux
- decrease permeability of membranes
- alterations in DNA gyrase
3
Q
Acquisition of DNA elements (plasmid)
A
- beta-lactamases
- aminoglycosides
4
Q
Gram + Aerobes Cocci examples
A
-clusters (staphylococci)
-pairs (s. pneumonia)
-chains (S. pyogenses, enteroccous
(these account for majority of infections)
5
Q
Gram + Aerobes Bacilli examples
A
-bacillus sp., corynebacterium sp., listeria monocyt. & nocardia
6
Q
what drugs are used for methicillin resistant staphylococci? (3)
A
VLD: vanco, linelozid, daptomycin
7
Q
what does SPACE stand for? (HARD to treat)
A
-S. marcescens, P. aerginosa, A. baumanni, Citobacter Enterobacter
8
Q
drug(s) to treat S.marcescens
A
-ceftriaxone & cefepime (IV)
9
Q
drug(s) to treat P.aerginosa
A
cefepime (tobramycin/cipro as alts)
10
Q
drug(s) to treat A. baumanni
A
cefepime (ceftaroline - 5th gen)
11
Q
drug(s) to treat Citrobacter
A
cefepime (ceftarolin- 5th gen)
12
Q
drug(s) to treat Enterobacter
A
cefepime (ceftarolin - 5th gen)
13
Q
What does PEKHEM stand for? (easier to treat)
A
Proteus marabilis, E. coli, Klebsiella, H. influnezae, Enterobecterialis, M. cutarrhalis
14
Q
drug(s) to treat Proteus marabilis
A
cephalexin, cefazolin
15
Q
drug(s) to treat E. coli
A
cefazolin (gentamicin as alt)
16
Q
drug(s) to treat Klebsiella
A
cefazolin
17
Q
drug(s) to treat H. influenzae
A
cefoxitin, cefector & cefotetan
18
Q
drug(s) to treat Enterobecteriallis
A
cefoxitin, cefector & cefotetan
19
Q
drug(s) to treat M. cutarrhalis
A
cefriaxone
20
Q
Above diaphragm anaerobes
A
- peptococcus, peptostreptococcus, prevetolla, vienolla
- -> treat with clinda
21
Q
Below diaphragm anaerobes
A
- C. perfringes, B. fragilis, fusobacterium
- -> treat with clinda or metronidazole
22
Q
drug(s) to treat Gram + cocci
A
1- penillin, ampicillin
2- macrolide (azithro), cefazolin
23
Q
drug(s) to treat MSSA
A
1- cefazolin
2-macrolide (azithro), clindamycin
24
Q
drug(s) to treat MRSA
A
1- vanco
2-linezolid
25
drug(s) to treat enterococcus
1- ampicillin + genta
| 2- vanco + genta
26
drug(s) to treat gram - bacilli
1- ceftraixone
| 2- genta
27
%T>MIC (drugs, pattern, dosing goal)
- penicillins, cephalosporins, carbapemens, macrolides
- time dependent killing & minimal persistent effects
- inc dose, prolonged/contentious infusion, shorter dosing interval
28
Cmax: MIC & AUC:MIC (drugs, pattern, dosing goal)
- aminoglycosides, quinolines
- concentration dependent & prolonged effects
- extended interval dosing & maximize safe dose
29
AUC:MIC (drugs, pattern, dosing goal)
- vancomycin, azithromycin & tetracycline
| - time-dependent & prolonged/persistant effects
30
what are disease related changes to drug pkpd?
1- pH (more ionized = more hydrophilic)
2-organ blood flow
**3- "fluid shifts --> change in Vd
4- changes in albumin
31
Sepsis & changes in population pharmacokinetics (Vd & CL)
- low CL & low volume of D = HIIGH concentration
| - high CL & high volume of D = LOW concentration
32
what changes can we except in the critically ill? (in terms of PKPD)
- decrease in cardiac output = reduced CL
- increase in capillary "leakiness" = increase Vd
- acute kidney injury = hyper filtration = increase CL
- chronic kidney injury = reduced renal clearance
33
Antibiotics WITHOUT renal dose adjustment
```
( CCOMMAND DE TitLe)
Ceftriaxone
Clindamycin
Oxacillin
Metronidazole
Moxifloxacin
Azithromycin
Nafcillin
Doxycycline
Dalfopristin
Erythromycin
Tigecycline
Linezolid
```
34
Drugs that have rapid development of resistance?
- rifampin
- clindamycin
- quinolines
35
pk/pd target for vancomycin?
AUC:MIC ratio > 400 (set it up and solve for x)
36
AUC:MIC is dependent on"
- the daily dose a pt receives
- the patient-specific clearance
- the bacterial-specific MIC
37
How do we determine the patient-specific clearance?
- trough (worst)
- calculation of AUC using peaks & trough (meh)
- Bayesian estimation (BEST!)
38
Purulent SSTIs
- caused by staph aureus
| - painful, fluctuant, red, nodules, often topped with pustules, rims of erythematous swelling (localized)
39
Mild, moderate & severe purulent SSTIs:
mild: no signs of infection
moderate: with systemic signs of infection
severe: failed I&D + oral antibiotics, septic or immunocompromised pts
40
what is the treatment criteria of purulent SSTIs?
-DRAIN THAT SHIT!
-gram stain & culture if I&D performed
+ abx IF pt has systemic signs of infection (moderate & severe), is immunocompromised or doesn't respond to I&D
(5-10 day duration)
41
SIRS criteria
- temp > 38 or <36
- tachypnea (>24)
- tachycardia (>90)
- WBC >12k, < 4k
42
When do we want to treat empirically for MRSA?
hx of multiple/recent hospitalizations, antimicrobial use, previous documented MRSA
43
MRSA tx for purulent SSTI use (Oral & IV)
Oral: BACTRIM (doxycycline, Linezolid)
IV: VANCO (daptomycin, ceftaroline, dalbavencin/ortavincin --> if pt has a hx of vanco intolerence)
44
MSSA tx for purulent SSTI use (oral & IV)
Oral: dicloxicillin, cephalexin, clindamycin
IV: (if they cant do oral): ampicillin/sulbactam, naficillin/oxacillin, cefazolin or clindamycin
(move from IV to PO)
45
Non-purulent SSTI signs:
Cellulitis/Erysiplelas
- red, warm, swollen & painful
- Caused by STREPTOCOCCUS (groups B)--> some severe by S. aureus
46
Non-purulent SSTI risk factors
-dry skin, fragile skin, obesity, previous skin trauma, previous cellulitis, edema from venous insufficiency, tinea pedis (athletes foot)
47
Treatment guidelines for non-purulent SSTIs
-ANTIBIOTICS! do not drain!
48
how to treat mild non-purulent SSTIs & duration
```
-ORAL- 5 days, as long as pt responds
#1s- amoxicillin & cephalexin
-pen V, amox/clav
(b-lactam allergies: clindamycin)
( bactrim & doxy: can be used but meh)
```
49
how to treat moderate ( 1 systemic sign of infection) non-purulent SSTI & duration
IV (in hospital 10-14 days) IV --> PO
-#1s: cefazolin & ceftriaxone
-pen G (reserve tho)
(severe pen allergies: clinda & vanco, linezolid, daptomycin)
50
how to treat severe (2 + systemic signs of infection) non-purulent SSTI
--> emergency surgery! empiric: vanco + piper/tazo
IV (in hospital 10-14 days) IV --> PO
-#1s: cefazolin & ceftriaxone
-pen G (reserve tho)
(severe pen allergies: clinda & vanco, linezolid, daptomycin)
51
Objective signs of necrotizing fasciitis
- severe systemic symptoms: fevered, altered mental state
| - fast temporal progression - see the severe tissue destruction happen in ~24-48 hrs
52
Subjective signs of necrotizing fasciitis
-pain out of proportion
53
Physical exam when it comes to necrotizing fasciitis
- edema & tenderness beyond the redness
- "wooden-hard" induration of subq tissue
- crepitus: can hear crackling sound under skin
- skin necrosis: death to tissues
- imaging may show gas in soft tissues, edema along fascia
- DONT WAIT- OPERATE!
54
Clinical settings that are often associated with NF
- abdominal trauma/surgery
- decubitus ulcers
- IVDU- injection sites
- spread from genital site
55
Broad spectrum (MRSA, gram -, gram + and anerobes) for NF
- vanco + piper/tazobac
- vanco + carbapenem (mero, imi, dori)
- vanco + cefepime + metro/clinda
- vanco _ cipro + metro/clinda
- -> clinda 900mg IV sometimes added too
56
Streptococcus tx in NF
pen G + clinda
57
MRSA tx in NF
vanco
58
MSSA tx in NF
oxacillin/nafcillin or cefazolin
59
Clostridium tx in NF
clinda + pen G
60
Treatment of Bite wounds
ampicillin/sulbactam (IV) or Amox/clauv (PO)
| -alts: 2nd/3rd gen cephalosporins + metronidazole or levoflox + metronidazole (when allergy to amox)
61
Classical findings of diabetic foot infection
-redness, warmth, swelling, pain, purulent drainage
62
Secondary findings of diabetic foot infection
-non-purulent secretions, discolored granulation of tissues & foul odor
63
The foot in diabetic foot infection
-hammer toes, bunions, calluses & charcot foot
64
The wound in diabetic foot infection
- depth & tissues involved, requires debridement of necrotic tissues, looking for abscesses, sinus tract, foreign bodies, prone to bone infection
- -Xray for all- MRI if bone disease is suspected
65
Mild criteria for diabetic foot infection & tx
erythema .5-2 cm, PO 1-2 weeks
MSSA (strep)- cephalexin, amox/clav (clindamycin)
MRSA: TMP/SMX, doxycycline
66
Moderate & severe criteria for diabetic foot infection & tx
MOD(1-3 weeks): erythema >2 cm or involving structures deeper than the skin
SEV (3-4 weeks): local infection with 2+ SIRS
-MSSA, strep, gram - anaerobes: 1- AMP/SULB, 2-cefoxitin, 3-moxifloxacin (ceftriaxone + metronidizole, cipro + clinda, ertapenem)
MRSA: vanco
Pseudomonas: piper/tazo, cefepime
everything: vanco+ pipera/tazo
67
Risk factors for for diabetic foot infection (MRSA & Pseudomonas)
MRSA: hx of MRSA, high local prevalaence, recent antimicrobial use & severe infection
Pseudomonas: warm climate, FREQUENT exposure to water, high local prevalence and recent antimicrobial use
68
Pseudomonas tx in diabetic foot infection
piper/tazo, cefepime
69
Risk factors for UTIs
- no known reason
- pregnancy, male gender, badly controlled diabetes
- renal insufficiency
- short-term urinary tract catheter, asymptomatic bacteriuria
- long term urinary tract catheter treatment
70
Uncomplicated UTI
- normal urinary tract
- normal voiding function dispenses bacteria
- -> e. coli, staph saprophyticus
71
Complicated UTI (risk factors & implications)
-congenital or acquired abnormality that prevents normal dispensing of bacteria from the urinary tract
Risk factors: lack of response to tx, severity of illness, commorbidities, origin of pt
Clinical implications: recurrence, SIRS/sepsis, antimicrobial resistance, immunosuppression, catheters
72
Cystitis (bladder) symptoms
-dysuria
-frequency/urgency
-hematuria
Diagnose with UA & urine gram stain & culture
73
Pyelonephritis (kidney) symptoms
-dysuria, frequency/urgency, hematuria
-CVA tenderness
-fever, chills
Diagnose with UA, urine gram stain & culture, CBC or blood culture
74
Important things to look for in a UA
- WBC (0-5)
- RBC (0-5)
- leukocytes easterase (-)
- nitrates (-)
- protein (-)
- bacteria (-)
75
3 thresholds of significant bacteriuria
- traditional: >10^5
men: >10^3
women: > 10^2
76
clinical urinary tract infection
-significant bacteriuria PLUS pyuria (pus) & signs/symptoms of infection
77
when do we treat UTIs?
* *do not treat asymptomatic!
| exceptions: pregnancy, prior to invasive urinary tract procedures or prior to renal transplantation
78
how to treat women with acute, uncomplicated cystitis (3)
1- nitrofurantoin 100mg BID x5d
2- Bactrim 160/800 BID x3
3- fosfomycin 3mg PO single dose
79
Nitrofurantoin
-use for gram -, e. coli, Klebsiella
-CI with CrCL <60
AEs: GI, neuropathy, pulmonary toxicity & hepatoxicity
80
Treatment for subclinical pyelonephritis
-pt appears to have uncomplicated cystitis
-suspected with failure of single or multi-dose regimen
at risk: diabetics, immunocompromised, h/o cystitis, pyelonephritis
81
acute pyelonephritis out patient tx
1- ciprofloxacin 500mg bid x7d
2-once daily quinolone: ciprofloxacin 1000mg ER x7, levofloxacin 750mg x5d
3-*bactrim bid x14d
4-oral beta lactam (less effective)
82
severe pyelonephritis tx in hospital
-symptoms of upper tract infection + marked systemic response,
1) quinolone IV (cipro)
2) aminoglycosides (gentamicin) +/- ampicillin
3)** cephalosporin or penicillin +/- gentamicin
duration 10-14 days
83
UTIs in pregnancy treatment
1) *amox/clauv x 7 days
2)* cephalexin x3-7 days
3) amoxicilin x 7days (only if sensitivity is known)
(nitrofurantoin x7 & bactrim x3- avoid in last trimester or close to delivery)
84
what 2 drugs do you want to avoid in UTI if a pt is close to delivery?
-nitro & bactrim
85
pyelonephritis in pregos (tx)
-IV b-lactams- ceftriaxone, cefazolin (switch to PO - 14days)
DO NOT USE: quinolones (cipro) , tetracyclines or sulfonamides
86
prevention of pyelonephritis in pregos with UTI
-monitor urine cultures, treat asymptomatic bacteriuria
87
Presentation of UTIs in males
rare: dysuria, frequency
| common in old men: dysuria, frequency, fever, lower abdominal pain
88
acute bacterial prostatitis (males) PE, labs
- prostate is tender & swollen
| labs: pyuria, bacteria
89
acute bacterial prostatitis tx
- 2-4 weeks
- *bactrim PO
- gentamicin/ampicillin (if enterococcus)
- quinilones (reserve)
90
chronic bacterial prostatitis tx
4-6 weeks
* bactrim PO
- quinilones
- suppressive therapy 1/2 the normal dose chronically
91
when to treat candiduria & drugs
- high risk pts or undergoing urologic procedures
- fluconazole 200mg x2weeks
- ampho B deoxycholate x1-7 days OR flucytosine x7-10d (glaberta only)
92
Mild water loss
- alert, restless
- increased thirst
- moist to slightly dry mucous membranes
- normal/slightly decreased urinary output
93
moderate water loss
- lethargic, restless
- low volume (low BP, high HR)
- dry mucus membrane
- delayed cap refill
- dark urine
94
severe water loss
-drowsy, limp, LOC
-bradycardia
-cyanotic
-skin "tenting"
-no urine production
EMERGENCY!
95
general risk factors for C.diff
- age >65
- GI surgery
- tube feeding
- immunocompromised
- length of stay in hospital
- ICU admission
- chemo
- antibiotics
96
lowest risk of C.diff
- aminoglycosides (gentamicin)
- vancomycin
- metronidazole
97
lower risk of C.diff
- erythromycin
- ampicillin/amox/pip-tazo
- tetracyclines
98
highest risk of C. diff
- clindamycin
- cephalosporins
- carbapenems
- quinolones
99
AB-associated diarrhea without colitis
~6 loose bms/day
- crampy lower abd/discomfort
- slight lower abdominal tenderness
100
AB-associated colitis w/o pseudomembranes
10+ loose bm/day, fecal laukocytes, occult blood
- Nausea, anorexia, fever, malaise, dehydration, leukocytosis
- abdominal distention, tenderness
101
pseudomembranous colitis
>10 loose bm/day, fecal leukocytes, occult blood
- Nausea, anorexia, fever, malaise, dehydration, electrolyte imbalance, leukocytosis
- marked abdominal tenderness, distention
102
toxic megacolon
- life- threatening complication of CDI, distention of colon,
- ileus: gut shuts down, no diarrhea
103
Clinical diagnosis of CDI
> 3 unformed stools in 24 hrs PLUS
- + stool test OR
- pseudomembranous colitis diagnosed by colonoscopy
104
golden standard for CDI testing
1-EIA detection of GHD
| 2- cell cytotoxicity assay or toxigenic culture as confirmation
105
CDI: initial, non-severe criteria & tx
-WBC < 15k AND Scr <1.5
-vanco 125mg QID x10
-fidaxomicin 200mg PO BID x10
(metronidazole 500mg PO TID x10)
106
CDI: initial, severe criteria & tx
- WBC > 15k OR Scr >1.5
- vanco 125mg PO QID x10
- fidaxomicin 200mg PO BID x10d
107
CDI: severe, complicated criteria & tx
- hypotension, shock, ileus, megacolon
| - vancomycin 5000mg PO or NG QID PLUS metronidazole 500mg IV Q8hr if ileus is present
108
second reoccurrence of CDI
- vanco tapered to vanco pulsed
| or: vacno 125mg QID x10 then rifaximin 400mg TID x20d
