Exam 3: Respiratory, UTI, C Diff, Vaccines Flashcards
What are some clinical presentations of sinusitis?
Purulent anterior nasal discharge, purulent posterior nasal discharge, nasal congestion/obstruction, facial fullness, decreased smell, fever
RARE: severe HA, ear pain/fullness, halitosis, dental pain, cough, fatigue
Sinusitis is mostly viral/bacterial
Viral
How do you treat sinusitis?
USE NON-Rx FIRST (ie. Netti pot)
Viral sinusitis: decongestants, irrigation, mucolytics
Bacterial sinusitis: NO decongestants or antihistamines
Corticosteroids: intranasal for allergic rhinitis
When are antibiotics used for sinusitis?
Persistent symptoms (>10 days) without improvement
Severe symptoms (>3 - 4 days) at the start of the illness
- Fever > 102F
- Purulent nasal discharge
- Facial pain
Worsening symptoms after a typical URI (viral, ~5 days) = double sickening!
What is the best antibiotic for sinusitis?
Amoxicillin/clavulanate (combo amoxicillin + beta lactamase inhibitor)
What are some side effects of amoxicillin/clavulanate? (2)
Diarrhea
Rash
Other than amoxicillin/clav, what options are there to treat sinusitis?
Fluoroquinolones (costly, more resistance)
Clindamycin + cefpodoxime/cefuroxime
Doxycycline (underrated!)
TMP/SMX or macrolides (questionable efficacy)
What is the duration of antibiotics for sinusitis in adults? In kids?
Adults: 5-7 days
Kids: 10-14 days
What duration indicates CHRONIC sinusitis?
Symptoms persist for 12+ weeks
Not infectious
Take cultures!
What TWO bugs are most covered by amoxicillin/clav?
S. Pneumoniae
H. Influenzae
What is the most common virus to cause viral pharyngitis?
What is the most common bacteria to cause bacterial pharyngitis?
Virus = rhinovirus
Bacteria = Group A strep
Name some clinical symptoms that indicate bacterial pharyngitis?
5-15 years old
Sudden sore throat
Fever
Headache
Tonsillary inflammation
Tender lymph nodes (cervical adenitis)
Palate petechiae
Season (winter/early spring)
History of exposure
Pink rash
What are some post-pharyngitis complications?
Acute rheumatic fever
Peritonsillar abscess
Cervical lymphadenitis
Mastoiditis
Glomerulonephritis
What are the drugs of choice for treating pharyngitis? (2)
What is the duration of treatment?
Penicillin VK or Amoxicillin
(Narrow spectrum of activity, well-tolerated, inexpensive)
10 days
Patient AJ comes into the clinic presenting with pharyngitis. AJ has a severe penicillin allergy. What treatments could you give them?
Clindamycin x 10 days
Azithromycin x 5 days
What is the mild penicillin allergic alternative for pharyngitis?
Cephalexin x 10 days PO
Which otitis media patients should DEFINITELY be treated with antibiotics?
6 months - 12 years old with MODERATE to SEVERE pain OR fever >= 102.2
6 - 24 months with non-severe bilateral acute OM
What is the first line for otitis media treatment? What is the second line and when do we use it?
Amoxicillin 80-90 mg/kg per day / 2
If 30 days amox and unresponsive OR purulent conjunctivitis:
Amox/clav
What is CURB-65? When do we use it?
To assess pneumonia severity
Confusion
Uremia (BUN 20+)
Respiratory rate 30+
Blood pressure (SBP<90 or DBP<60)
65 or over
0-1 = outpatient
2 = inpatient general floor
3+ = ICU
What bugs cause CAP?
S. Pneumoniae
H. Influenzae
Legionella
What treatments can we use if a patient w/ outpatient CAP is otherwise healthy?
PO Amoxicillin
PO Doxycycline
PO Macrolides (azithro/clarithro)
(ADAC)
What comorbidities can complicate outpatient CAP?
Age < 2 or >65
Beta - lactam within prior 3 mo.
Alcohol abuse
Immunosuppression
Exposure to daycare
Cancer
Chronic respiratory disease
What treatments are available for outpatient CAP if a patient has comorbidities?
**Amox/clav OR
**cephalosporin + Macrolides (azithro/clarithro)
Respiratory quinolones (levo/moxi)
What do we use to treat non-severe inpatient CAP?
IV beta-lactam (unasyn, ceftriaxone) + macrolide OR respiratory quinolone
What do we use to treat severe inpatient CAP?
IV beta-lactam + macrolide
IV beta-lactam + respiratory quinolone
Add anti-MRSA or anti-pseudomonal is shown in cultures
How long do we treat CAP?
Minimum 5 days, generally 7 days
______ culture and ________ sample should be ordered for all patients w/ anti-MRSA and anti-pseudomonal antibiotics ordered.
Blood culture and sputum samples
VAP occurs ___ hours or more after ventilator use
48 hrs
We use ____ antibiotics FIRST in HAP/VAP.
Empiric
When initiating HAP/VAP treatment, what are some indications to use broad-spectrum empiric therapy?
Late onset/risk factors for multi-drug resistant pathogens, prior antibiotic use, colonization, hospitalization, chronic care, immunosuppressive therapy
What 4 options are there for empiric HAP treatment initiation if NO MDR RISK?
Ceftriaxone
Respiratory quinolone (levo/moxi)
Unasyn
Ertapenem
What options are there for empiric HAP treatment initiation if MDR RISK?
Vancomycin
Patient JT presents with HAP; blood future shows (+) for pseudomonas. What antibiotics can be used? [7] How many of them can be used at once?
Only use ONE antipseudomonal at once
*Zosyn (pip/taz)
*Cefepime or Ceftazidime
Imipenem or Meropenem (reserved due to potency)
Aztreonam (reserved for alt. combos)
Cirpofloxacin (reserved for PO, renal risk)
Aminoglycosides (adjunctive, renal risk)
Polymixin B (renal risk, neurotoxicity, BM suppression, last line)
What is the duration of treatment for VAP and HAP?
7 days for both
Summarize outpatient and inpatient CAP 1st line treatments
OUT:
Healthy:
- Amoxicillin po OR
- doxycycline OR macrolide
Comorbid:
- amox/clav OR
- cephalosporin + macrolide (azithro/clarithro) OR
- respiratory quinolone
IN:
Non-severe
- IV beta-lactam + macrolide OR
- respiratory quinolone
Severe:
- IV beta-lactam + macrolide OR
- IV beta-lactam + respiratory quinolone
Differences between cystitis and pyelonephritis
Cystitis: dysuria, urgency, hematuria
Pyelonephritis: cystitis + CVA pain/tenderness, fever, chills, N/V
What are some LAB FINDINGS indicating UTI?
pH ~6.0
WBC > 50
RBC ~20
Leukocyte esterase (+)
Nitrite (+)
Bacteria (+ GNR)
What is the treatment for ACUTE UNCOMPLICATED cystitis (not pyelo)?
Nitrofurantoin po bid x 5 days
Bactrim po bid x 3 days
(Beta lactams, fosfomycin, quinolones)
What is the treatment for OUTPATIENT ACUTE PYELONEPHRITIS?
Bactrim po bid x 14 days
- ciprofloxacin 500 po bid x 7 days
- quinolone once
- IV beta-lactam then oral beta-lactam x 10-14 days (last line)
How do we change therapy for SEVERE acute pyelonephritis?
CHANGE TO IV!
Symptoms of upper tract also being infected + systemic response
What is the treatment for INPATIENT ACUTE PYELONEPHRITIS?
IV extended spectrum beta-lactam (cefoxitin or cefepime) +/- aminoglycoside x 10-14 days
- quinolone IV
- aminoglycoside +/- ampicillin
- carbapenem
In WHAT PATIENTS do we treat asymptomatic UTIs?
Pregnant
Prior to invasive urinary tract procedure
Prior to renal transplant
What treatments should we use for pregnant women with ASYMPTOMATIC UTIs?
Amox/clav x 7 days
Cephalexin x 3-7 days
- nitrofurantoin x 7 days (avoid if close to delivery)
- amoxicillin x 7 days
- Bactrim x 3 days (avoid in last trimester)
- IV beta-lactams (cefazolin, ceftriaxone)
What drugs are contraindicated for UTI treatment in pregnant women?
Quinolones
Doxycycline
What treatments are used for acute bacterial prostatitis in men? What is the duration?
Bactrim po bid
- quinolones
- gentamicin/ampicillin if infected by enterococcus
Duration: 2-4 weeks
What treatments are used for chronic bacterial prostatitis in men? What is the duration?
Bactrim po bid
- quinolones (quite common for chronic!)
- suppressive therapy
Duration: 4-6 weeks
How do we treat infectious diarrhea?
Supportive care = rehydration + electrolytes
- mild/moderate = oral replacement
- severe = IV fluids
DON’T use antimotility
What are some risk factors for C. Diff?
ICU admission
Tube feeding
Acid suppressors
Length of stay
Immunocompromised
Chemotherapy
Antibiotics**
GI Surgery
Exposure
65 year or older
ITALIC AGE 65
What are some high risk antibiotics for causing C.Diff?
Clindamycin
Late-gen Cephalosporins
Carbapenems
Fluoroquinolones
What are some low risk antibiotics for causing C.Diff?
Vancomycin
Aminoglycosides
Metronidazole
What are the guidelines for non-severe, severe and fulminant C. Diff?
Non-severe = leukocytosis (WBC < 15k) AND SCr < 1.5
Severe = leukocytosis (WBC > 15k) OR SCr > 1.5
Fulminant = Hypotension/shock, ileus, megacolon
What are some NON-RX ways to manage C. Diff?
Avoid anti-motility agents
Rehydration and replenish electrolytes
D/C antibiotics if possible
What are the treatments for non-severe and severe C.Diff (same)? What is the treatment for fulminant?
Vancomycin 125 mg po QID x 10 days
Fidoxomicin 200 mg po BID x 10 days
Fulminant: vancomycin 500 mg po QID (+ metronidazole 500 mg IV for ileus)
Other than antibiotics, what treatment options are available for C. Diff?
Actoxumab/Bezlotoxumab (mAb)
Fecal Microbiota Transplantation (FMT)
What are some LIVE vaccines?
Measles/mumps/rubella
Varicella
LAIV
Polio
Rotavirus
ZVL (Zoster)
How many weeks apart should we space live vaccines if they aren’t given simultaneously?
28 days minimum interval
What vaccines are CONTRAINDICATED in pregnancy?
HPV
LAIV
MMR
Varicella
Zoster
What are some general vaccine interactions?
- chemotherapy = live vaccines should be given 2 weeks before or 3 months after
- High dose corticosteroids (20 mg/d prednisone x 14+ days) may cause inadequate response from inactivated vaccines
(If <14 days vaccinate right after D/C or wait 2 weeks. If >14 days, wait 1 month after D/C) - Do not administer IVIGs 14 days after live vaccines
- Live viruses suppress TB skin tests
When is flu season?
October to March/April
What causes the flu vaccine to change yearly?
Antigenic DRIFT (gradual)
Whereas antigenic SHIFT is drastic
For flu vaccines: ____ is recommended in ages >6 months. ____ is recommended in ages >18. ____ is recommended for healthy people ages 2 - 49.
IIV4
RIV4
LAIV4
Who should get the pneumococcal vaccine?
Age >65
Risk factors (ie. Sickle cell, Crohn’s, smoker)
PNEUMOCOCCAL Vaccine: ______ is for children. Otherwise adults can use ______ + _______ or only the _______.
Children = PCV13
PCV15 + PPSV23
OR
PCV20
PCV15 should be followed up by PPSV23 after ___ year(s), unless the patient is immunocompromised/cochlear implant/CSF leak, then may get PPSV23 after ________.
1 year
Immunocompromised = after 8 weeks
Tetanus should get boosted every __ years, every __ years if at risk and __ years after last dose in case of severe injury
10 years
5 years = at risk
1 year = severe injury
DTaP should be used up until age ____
7
What vaccines should pregnant women get?
IIV4 (IF FLU SEASON)
COVID if full regimen not complete
**TdaP (not Td!)
What is a major contraindication for the TdaP/DTaP vaccines?
History of encephalopathy within 7 days of pertussis vaccination
Who should receive the Zoster vaccine (RZV/Shingrix)? What is the course for this vaccine?
Age 50+, regardless of clinical history of herpes zoster or receipt of live herpes zoster vaccine (ZVL) [no longer available].
2 doses separated by 2 to 6 months
Patient RV is bitten by a groundhog with rabies. What is the post-exposure prophylaxis?
- Wound cleansing
- Human Rabies IG at site x1 PLUS IM x1 on day 0
- Rabies vaccine x 4 doses (day 0, 3, 7, 14)
(Already received prophylactic? Only receive vaccine regimen)
