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Therapeutics III > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Strep throat risk factors

A 
Children and teens
Spread by saliva and nasal secretions
2-5 day incubation period
Rapid transmission in schools, institutions, crowded places
Winter and spring
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2
Q

How long are you contagious with strep throat?

A

Untreated- 1 week

Treated- 24 hours

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3
Q

S/S strep throat

A

Fever, lymphadenopathy, tonsillar exudates, absence of cough

Fatigue, weakness

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4
Q

labs for strep throat

A

Rapid antigen detection test (RADT) and throat culture recommended
If RADT positive- initiate therapy
If RADT negative- may hold therapy or not

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5
Q

Streptococcal pharyngitis rationale for treatment

A

Can lead to further complications- acute rheumatic fever and poststreptococcal glomerulonephritis
Treatment within 9 days effectively prevents complications

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6
Q

Bacterial pharyngitis 1st line treatment

A

Penicillin or amoxicillin

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7
Q

Bacterial pharyngitis alternative treatment

A

Use in penicillin allergy

1st gen cephalosporin, clindamycin, macrolides

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8
Q

Bacterial pharyngitis treatment duration

A

10 days oral therapy

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9
Q

Acute Otitis Media risk factors

A 
Pediatrics (eustachian tube angle)
Age <2 
Boys > girls
Day care
Season (winter)
recent viral illness
Siblings
Frequent pacifier use
Breastfed <6 months
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10
Q

Acute otitis media S/S

A

Sudden onset fever, crying, irritability, anorexia, restlessness, otalgia, otorrhea, red/bulging TMs without movement

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11
Q

Acute otitis media labs

A

Usually none

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12
Q

AOM presentation

A

Otalgia (ear pain) and behavioral changes

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13
Q

AOM Common causes

A

mainly caused by virus
If bacterial- S. pneumonia, H. influenzae, M catarrhalis
(gram positive and negative aerobes)

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14
Q

Risk factors for amoxicillin-resistance

A

Child care center
Abx use in last 30 days
Age <2 years old

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15
Q

AOM- delayed therapy

A

Not recommended if the patient is <6 months old, 6-24 months with severe symptoms or definitive diagnosis, >2 years with both severe symptoms and a definitive diagnosis

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16
Q

AOM non-antimicrobial treatment

A

Pain management- acetaminophen or NSAIDs
Otic drops with anesthetic
Decongestants and antihistamines are not recommended
Pediatric dosing!

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17
Q

AOM 1st line antimicrobial therapy

A

Amoxicillin

Augmentin if severe infection, amoxicillin failure, or suspected beta-lactamase producing orgamism

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18
Q

AOM 2nd line treatment

A

2nd gen cephalosporins (cefdinir)
Macrolides
Clindamycin

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19
Q

AOM treatment duration

A

10 days in children < 2

5-7 days in children > 6 with mild-moderate symptoms

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20
Q

Rhinosinusitis causes

A

Most commonly viral

Bacterial causes same as AOM

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21
Q

Rhinosinusitis 1st line antimicrobial therapy

A

Augmentin

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22
Q

Rhinosinusitis 2nd line therapy

A

Non-hospitalized- doxycycline, respiratory fluoroquinolone)

Hospitalized- ampicillin/sulbactam, resp. fluoroquinolone, IV 3rd gen ceph

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23
Q

CAP

A

Infection present at hospital admission

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24
Q

HAP

A

Pneumonia occurring typically >48 hours after hospital admission

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25
Q

VAP

A

Pneumonia occurring typically >48 hours after endotracheal intubation

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26
Q

Common causes of outpatient CAP

A 
Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Respiratory viruses
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27
Q

CAP diagnosis

A

Clinical features- cough, fever, sputum production, pleuretic chest pain
Chest x-ray- acute infiltrate

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28
Q

How do you decide to admit a CAP patient?

A

Pneumonia Severity Index (PSI) or CURB-65

Does not decide ICU need

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29
Q

How to determine ICU need for CAP?

A

Admit if 1 major criteria (septic shock with need for vasopressors or resp failure requiring mechanical ventilation)
3 minor criteria

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30
Q

CAP treatment outpatient no comorbidities

A

Amoxicillin or doxycycline or macrolide

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31
Q

CAP treatment outpatient with risk factors

A

Combo Augmentin or cephalosporin AND macrolide or doxycycline
OR
monotherapy with resp. fluoroquinolones

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32
Q

CAP treatment inpatient

A

Nonsevere- beta lactam + macrolide or resp. fluoroquinolone

Severe- Beta lactam + fluoroquinolone

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33
Q

Important changes in CAP from previous guidelines

A

Amoxicillin now recommended
Macrolides are no longer 1st line
Cefuroxime no longer recommended
Recommends beta- lactam for antipseudomonal coverage
Anaerobe coverage not recommended for empiric

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34
Q

CAP duration of Abx

A

based upon clinical stability ( resolution of vitals, ability to eat, normal mentation)
No less than 5 days

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35
Q

Pneumonia

A

New lung infiltrate plus clinical evidence that the infiltrate is an infectious origin, which include the new onset of fever, purulent sputum, leukocytosis, and decline in oxygenation

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36
Q

Ventilator associated pneumonia

A

Most common ICU-acquired infection

Risk increases as duration of mechanical ventilation increases

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37
Q

Are HAP and VAP mutually exclusive?

A

Yes

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38
Q

Pneumonia diagnosis

A

Presence of a new or progressive radiographic infiltrate PLUS at least 2 of the following:
Fever >38C
2.) Leukocytosis or leukopenia
3.) purulent secretions

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39
Q

Trachial aspirates

A

Grow more organisms than invasive cultures

Negative cultures have a strong negative predictive value

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40
Q

Specimen collection for pneumonia likelihood for contamination

A

Lung biopsy> broncoscopy> Non-broncoscopy> endotracheal aspirates

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41
Q

HAP/VAP empiric coverage

A

Need coverage for S. aureus, P. aureginosa, and other gram negative bacilli
If MRSA coverage is needed- vanc or linezolid

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42
Q

Gram + with MRSA activity

A

Vanc or linezolid

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43
Q

Gram - with Antipseudomonal activity

A

Piperacillin-tazobactam, cefepime, ceftazidime, carbapenems, aztreonam, fluoroquinolones, aminoglycosides, polymyxins

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44
Q

HAP/VAP definitive therapy

A

MRSA_ vanc or linezolid

P. aeruginosa- recommend definitive therapy, recocmmend monotherapy if septic shock not present

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45
Q

HAP/VAP duration

A

7 days course

Use procalcitonin plus clinical criteria to determine treatment d/c

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46
Q

S/S of TD

A

Malaise, anorexia, cramps followed by sudden onset of diarrhea

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47
Q

TD cause

A

20-50% develop during 1st week of travel

Cause: contaminated food or water. GI tract isnt used to food.

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48
Q

What infectious agents are associated with TD?

A

Secretory (watery) diarrhea- ETEC (e.coli) and Vibrio (uncommon)
Inflammatory (bloody)- Shigella, salmonella, campylobacter, EHEC, EIEC

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49
Q

Severity of TD

A

Mild: 1-3 loose stools with cramping
Moderate- signs of dehydration, >4
Severe- presence of fever or blood in stools

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50
Q

Goals of therapy TD

A 
Avoid dehydration- ORT
Antiparistaltic agents (diphenoxylate, loperamide) only for mild, watery diarrhea
Avoid antiperistaltic agents in patients with high fever and bloody diarrhea
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51
Q

Management of TD

A

Fluids (bottled water)
Loperamide (preferred)
Bismuth subsalicylate
ABx (3 days) may reduce duration by 1-2 days with minimal risk

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52
Q

TD abx

A

Fluoroquinolones (Norfloxacin, ciprofloxacin, levofloxacin)
Rifaximin
Azithromycin

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53
Q

Rifaximin

A

Nonsystemic analog of rifampin
MOA- Binds to bacterial DNA dependent RNA polymerase (blocks transcription)
Used for TD (only ETEC), IBS, hepatic encephalopathy
>12 yo
Do not use in bloody, inflammatory diarrhea

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54
Q

Time course for TD

A

Sx usually resolve in a few days no treatment

Not life threatening

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55
Q

TD prophylactic abx

A

Not recommended (resistance)

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56
Q

Salmonella- N/V

A

N/V within 72 hours followed by crampy abd pain, fever, d (bloody). More mucosal invasion (also from poultry, eggs, dairy)

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57
Q

E.coli

A

Abrupt onset watery diarrhea. Resolves in 24-48 hours

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58
Q

CDAD S/S

A

fever, hyperactive bowel sounds, guarding
Cramps, greenish diarrhea, abdominal tenderness
Labs: toxin +, WBC

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59
Q

Which abx are most likely to cause C.Diff?

A 
Broad spectrum Abx
Amox+/- CA
Cephs
Clinda
FQs most frequent
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60
Q

If C.diff toxin had been negative, would this have ruled out CDAD?

A

No, the EIA sensitivity is only 75-99%

NAAT is better

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61
Q

CDAD goals of therapy

A

D/c inciting agents
Decrease Sx, supporting care
Restore normal GI flora
Correct imbalances
Do NOT give anti-peristaltic
Eradicate organism and prevent progression
Strict infection control practices to limit spread

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62
Q

Epidemiology of CDAD

A

500,000 cases in US yearly
Most likely in white women
“Urgent threat” list

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63
Q

Risk factors for CDAD

A 
Age >64
CKD
IBD (crohns disease, ulcerative colitis)
Solid organ transplant
Exposure to abx
Chemo
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64
Q

CDAD presentation

A

Sudden, unexplained diarrhea

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65
Q

Nonsevere CDAD

A

WBC <15,000 cells/mL

SCr >1.5mg/dL

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66
Q

Severe CDAD

A

WBC >150,000

SCr >1.5

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67
Q

Fulminant CDAD

A

Hypotension, shock, ileus, megacolon

Pt could die

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68
Q

Infection prevention control CDAD

A 
Private room
Caution precautions
Hand hygiene- soap and water
Daily cleaning with ammonia product
Terminal cleaning with sporicidal agent
Antibiotic stewardship
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69
Q

Antimicrobial treatment of CDAD

A

Metronidazole no longer DOC. Should not be used in serious disease or retreatment.
Oral vanc 1st line- 10 days is standard of care

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70
Q

When do you consider fecal transplant for CDAD?

A

Multiple (>3) CDAD infections

95% effective

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71
Q

Patient followup CDAD

A

1st relapse- oral vanc or fidaxomicin

Long term- oral vanc

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72
Q

Bezlotoxumab

A

For patients with recurrent CDAD infections

Can cause cardiac failure

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73
Q

Blacklegged Tick

A

Transmits Lyme disease, anaplasmosis, babesiosis, and Powassan disease

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74
Q

Lone Star Tick

A

Transmits ehrlichiosis, tularemia, Southern-tick associated rash illness (STARI)

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75
Q

Dog tick

A

Transmits tularemia and rocky mounted spotted fever

76
Q

Prevention of tick infections

A

Use EPA registered insect repellents containing DEET, picaridine, IR3535, oil and lemon eucalyptus, etc.
Treat clothing and gear with products containing permethrin

77
Q

Lyme disease

A

Organism- Borrella spp.
Transmission- blacklegged tick
Incubation period- 3-30 days
Geographic location- upper midwest and northeastern US

78
Q

S/S lyme disease

A

Localized stage- erythema migrans rash: bulls eye pattern
Flu-like symptoms
Lymphadenopathy
Disseminated stage- rheumatologic, cardiac, neurologic, other

79
Q

Lyme disease Tx

A

Doxycycline
Cefurooxime
Amoxicillin
10-21 days

80
Q

Doxycycline in peds

A

Can cause permanent tooth discoloration

81
Q

Post-treatment lyme disease syndrome

A

Most cases of lyme disease resolve 2-4 weeks after abx treatment
Some patients can experience symptoms for more than 6 months after treatment
No proven treatment

82
Q

Rocky Mountain Spotted Fever

A

Organism- rickettsia species
Transmission- Dog tick, wood tick
Incubation- 2-14 days
Geographic location- NC, TN, MO, AR, OK

83
Q

Rocky mountain spotted fever s/s

A

Early stage- flulike symptoms
late stage- spotted rash, stomach pain, myalgia, lack of appetite
Long term consequences- persistent infections, amputation, hearing loss, paralysis, mental disability

84
Q

Rocky mountain spotted fever treatment

A

Doxycycline 5-7 days

85
Q

Anaplasmosis

A

Organism- Anaplasma species
Transmission- Black-legged tick
Incubation -1-2 weeks
Geographic location- upper midwest and northeastern US

86
Q

Anaplasmosis S/S

A

Fever, shaking, chills, HA, fatigue, myalgia, N/V/D, cough

Severe illness- difficulty breathing, hemorrhage, renal failure, neurologic problems

87
Q

Anaplasmosis tx

A

Doxycycline

10-14 days due to potential coinfection with lyme disease

88
Q

Ehrlichiosis

A

Organism- Ehrlichia spp.
Transmission- Lone star tick
Incubation- 1-2 weeks
Geographic location- Southeaster/south central and eastern US

89
Q

Ehrlichiosis

A

Flu like symptoms, confusion

Severe- difficulty breathing, abnormal bleeding

90
Q

Ehrlichiosis treatment

A

Doxycycline 5-7 days

91
Q

Babesiosis

A

Organism- Babesia microti
Transmission- blacklegged tick
Incubation- 1-9 weeks
Geographic- northeast and upper midwest

92
Q

Babesiosis s/s

A

Flu like gastrointestinal
Dark urine
Lab findings- decreased hematocrit, thrombocytopenia, elevated SCr and BUN, mildly elevated LFTs

93
Q

Babesiosis tx

A

Atovaquine and azithromycin OR clindamycin and quinine

7-10 days

94
Q

Tularemia

A

Organism- Francisella tularensis
Transmission- blacklegged tick, dog tick, lone star tick
Incubation period- 3-5 days
Geographic location- all continental states
AKA “Rabbit fever”
Concern that F/ tularensis could be developed into a biologic weapon

95
Q

Tularemia s/s

A

Ulceroglandular, oculoglandular, oropharyngeal, pneumonic, typhoidal
Common s/s- fever, chills, HA, malaise, fatigue, myalgia

96
Q

Tularemia tx

A

Aminoglycosides DOC

Streptomycin or gentamycin minimum 10 days

97
Q

Lab diagnosis for tick borne diseases

A

PCR analysis
Antibody tests
Can see babesia in whole blood smear

98
Q

Mosquito borne illnesses

A

Zika, eastern equine encephalitis, malaria

99
Q

Zika Virus

A

Transmitted- Aedes mosquito bites (found in US), sexual contact, from pregnant women to fetus, possibly through blood transfusions (unconfirmed)
Geographic location- No reports in US since 2018, no current outbreaks worldwide, precautions should be taken when traveling to countries in N and S america and africa

100
Q

Zika virus s/s

A

Red eyes, joint muscle pain, fever, rash

101
Q

Zika virus in pregnancy

A

Can cause microcephaly and other birth defects

102
Q

How to prevent Zika virus?

A

Wear long sleeved shirts and long pants
Stay in places where windows/screens keep mosquitos separate
Use EPA registered insect repellants
Use condoms

103
Q

Is there a vaccine for Zika virus?

A

No but many in development

104
Q

Eastern equine encephalitis

A

Organism- alphavirus spp
Transmission- mosquito (aedes, coquillettidia, curlex)
Incubation- 4-10 days
Geographic location- eastern US

105
Q

Eastern equine encephalitis s/s

A

fever, chills, malaise, arthralgia, myalgia
Encephalitic stage occurs abruptly- D/V, anorexia, cyanosis, convulsions, coma
Tx- supportive care

106
Q

Malaria

A

Org- plasmodium spp
Transmission- anopheles mosquito
Incubation- 7-30 days
Geographic locations= areas close to equator

107
Q

Malaria s/s

A

Uncomplicated- cold stage, hot stage, sweating stage

Complicated- can result in end-organ damage

108
Q

Malaria tx

A

Dependent on organism, area, sensitivity

Prophylactic agents- atovaquine, chloroquine, doxy, mefloquine, primaquine, tefenoquine

109
Q

Uncomplicated intra-abdominal infection

A

Intramural inflammation of GI tract

Confied within tract

110
Q

Complicated intra-abdominal infection

A

Infection beyond GI tract

111
Q

Primary peritonitis

A

Peritonitis not related to other intra-abdominal abnormalities
Commonly referref to as ABP
Risk factors: cirrhosis and ascites
Usually mono-microbial

112
Q

Secondary peritonitis

A

Peritonitis as a consequence of intra-abdominal process
Ruptured appendix or peptic ulcer
Polymicrobial

113
Q

Tertiary peritonitis

A

Peritonitis that persists or recurs >48 hours after adequate treatment

114
Q

Diagnosis of peritonitis

A

Clinical features
Physical exam- involuntary guarding of abdomen, distended and tender abdomen
Lab values- Leukocytosis (increased WBCs)
Signs of dehydration

115
Q

Paracentesis

A 
Drain peritoneal fluid and send for analysis
Serum-ascites albumin gradient >1.1= SBP
Protein <1g/dl= primary
>1g/dL= secondary
PMNs >250= primary
Glucose >50= primary 
Culture= 40% negative
116
Q

Primary peritonitis micro

A

Enteric gram negative and streptococcus spp.
Most common organisms- e.coli, klebsiella pneumonia, streptococcus pneumonia
Anaerobes are usually NOT involved

117
Q

Empiric therapy for intra-abdominal infections

A

3rd gen cephalosporins- ceftriaxone, cefotaxime
Fluoroquinolones- levofloxacin, moxifloxacin
Broad spectrum penicillins- augmentin, pip-tazo
Carbapenems

Duration 4-7 days

118
Q

SBP secondary prophylaxis

A

Norfloxacin 400mg QD
Bactrim DS once daily for 5days/week
Cipro 750mg weekly
Until resolution of ascites, transplant, or death

119
Q

Complicated intra abdominal infections (cIAIs)

A

Need to cover anaerobes and gram negatives

120
Q

Anaerobic coverage

A 
Beta lactam/beta lactamase inhibitors
Cefoxitin and cefotetan
Carbapenems
Clindamycin
Metronidazole
Moxifloxacin
Tigecycline/eravacycline/omadacycline
Chloramphenicol
121
Q

Pseudomonas coverage

A 
Pip/Tazo
Ceftazidime, cefepime, cefiderocol, ceftolozane/tazo, ceftizidime/ tazo
Carbapenem (not erta)
Aztreonam
Cipro/ levo
Aminoglycosides
Polymixin B, Colistin
122
Q

Hospital associated or severe intra abdominal infections

A

You want an agent that covers for pseudomonas and maybe MRSA

MDR organisms

123
Q

Intra abdominal infection mild-moderate single therapy

A 
Ampicillin/ sulbactam
Augmentin
Cefoxitine
Ertapenem
Moxifloxaxin
124
Q

Intra-abdominal infection CA severe or hospital associated

A

Pip/Tazo
Imipenem/cilastatin
Meropenem
Doripenem

125
Q

IA infection mild-moderate abx tx combo

A

cefazolin, cefuroxime, ceftriazone PLUS metronidazole

Cipro, Levo PLUS metronidazole

126
Q

IA community acquired severe or HA Tx combo

A

Ceftazidime, cefepime PLUS metronidazole
Cipro, levo PLUS metronidazole
Gentamicin, tobramycin, amiKacin PLUS metronidazole

127
Q

Mild to moderate CA cIAI not recommended

A

Do not treat for broad spectrum, pseudomonas
Ampicillin-sulbactam not recommended due to high resistance
Aminoglycosides (other drugs available)
Empiric coverage of enterococcus or antifungal

128
Q

Severe cIAIs

A

Avoid use of quinolone if E.coli resistance > 10%
If use Aztreonam + metronidazole, add agent to cover gram positive cocci
Empiric coverage of Enterocci recommended
Empiric coverage of MRSA NOT recommended

129
Q

Duration of therapy cIAIs

A

Source control

4-7 days unless inadequate source control

130
Q

SSI

A

Infection that occurs within 30 days after operation or 1 year after device implantation
Involves any of the following: Incision and/or deep soft tissue and/or any part of anatomy that was opened

131
Q

Superficial Incisional SSI

A

Purulent drainage
Organisms obtained from the superficial incision
At least one of the following: pain, localized sweating, erythema, heat
Incision deliberately opened
Diagnosed by surgeon

132
Q

Deep incisional SSI

A

Purulent drainage
Deep incision that spontaneous dehisces or is deliberately re-opened by the surgeon and is culture positive plus one of the following: fever, localized pain or tenderness
Abscess
Diagnosed by surgeon

133
Q

Organ/Space SSI

A

Purulent drainage from a drain in the space
Organism isolated from fluid/tissue
Abscess or other evidence of infection which is found on repeat surgery

134
Q

Pathogenesis

A

Microbiome, intraoperative contamination, foreign bodies, , intrinsic risks (obesity, smoking, etc.)
Surgery itself

135
Q

Endogenous risk factors

A

age, glucose control, obesity, smoking cessation, immunosuppressive therapy, nutrition status, remote sites of infection, pre-operative hospitalization

136
Q

Exogenous risk factors

A 
Surgeon hand washing
Foreign bodies
Abdominal drains
Operative hypothermia
OR ventilation 
OR traffic
Cleaning OR rooms
137
Q

Prehospital surgical interventions

A 
Chlorhexidine bathing
Smoking cessation
Glucose control
MRSA screenings
Bowel prep
Antimicrobial prophylaxis
138
Q

Class I (clean)

A

Dont have entry into a site that contains a high flora
Minimum risk
No abx

139
Q

Class II (clean contaminated)

A

Respiratory, alimentary, genital, and urinary tracts are entered.
In controlled conditions
Prophylactic abx

140
Q

Class III (contaminated)

A

Any of the above but not in a controlled environment
Trauma patients
Gun shot wound
Prophylactic abx

141
Q

Class IV (dirty)

A

Existing clinical infections

Tx abx

142
Q

Abx for surgery, what type?

A 
IV- ideal
Oral- some data to support
Topical- controversial
Cephalosporins mainly used
Vancomycin not routine
143
Q

Timing of abx for surgery

A

Within 60 minutes for short half-lives (cefazolin)
Within 120 minutes for longer administrations (fluoroquinolones/ vanc)
Increased risk of SSI when administered more than 120 minutes before procedure

144
Q

When to redose abx for SSI

A

When 1-2 half lives have passed

145
Q

How long abx for surgery?

A

D/C within 24 hours after surgery

146
Q

What is infective endocarditis?

A

Infection of the heart valves
Bacterial, fungi, and atypicals
Acute and sometimes fatal
uncommon, not rare

147
Q

Who gets infective endocarditis?

A

Rheumatic heart disease
Congenital heart disease
IV drug use

148
Q

Infective endocarditis and IV drug use

A

S. aureus predominant organism
Increased frequency of gram negative infection such as P. aureginosa and fungal infections
High concordance of HIV positivity and IE

149
Q

Pathophysiology of IE

A

Endothelial surface of the heart is damaged
Platelet and fibrin deposition occurs on abnormal surfaces
Bacteremia

150
Q

IE s/s

A

Nonspecific subacute presentation
Fevers, chills, weakness, dyspnea, night sweats, weight loss, fever, heart murmur, emboli, skin abnormalities, persistant bacteremia

151
Q

Clinical features IE

A

Fever most common sign
Murmur common
Interval between index bacteremia and onset of sxs is about <2 weeks

152
Q

IE clinical features and complications

A

Systemic emboli, neurological sequelae, ,CHF, renal insufficiency

153
Q

Duke criteria

A

Diangosis of IE

Definitive- 2 major criteria, 1 major and 3 minor, 5 minor

154
Q

Risk factors for IE

A

Preexisting cardiac valvular abnormalities
Previous endocarditis
Heart diesase
Chronic IV access
Diabetes
Healthcare related exposure
Bacteremia with streptococci, staphylococci, enterococci

155
Q

Orgs that cause IE

A

Staphylococci
Streptococci
Enterococci
Gram + most common!

156
Q

General principles for IE

A

Confirm organism within 3-4 sets of blood cultures
Treatment tailored to organism
High dose, bactericidal abx
Treatment duration usually 2-6 weeks

157
Q

IE abx

A

Treatment tailored to etiologic agent
Important to get MIC/MBC relationship for each causative organism
High serum concentration necessary to penetrate avascular vegetation

158
Q

Treatment of native valve IE

A 
Highly penicillin-susceptible 
Pen G or ceftriaxone
Serious beta lactam allergy: vanc
Pen G or ceft Plus gentamicin for 1-2 weeks
If MSSA- nafcillin/oxacillin 
If MRSA- vanc, dapto
159
Q

Treatment of native valve IE enterococcus

A

Ampicillin or penicillin G plus gentamicin
OR amplicillin plus ceftriaxone if renal failure or resistant to gent
OR
Dapto or linezolid

160
Q

Prosthetic valve endocarditis (PVE) treatment

A

MSSA- nafcillin/oxacillin + rifampin for 6 weeks PLUS gent for 2 weeks
MRSA- vanc+ rifampin for 6 weeks PLUS gentamicin for 2 weeks

161
Q

Meningitis

A

Inflammation of the membranes surrounding the brain and spinal cord.
Can be caused by bacteria, viruses, or fungi
Clinical consequences- neurologic sequelae

162
Q

meningitis etiology

A

Nasopharyngeal colonization often occurs first
Streptococcus pneumo, neisseria meningititis
Listeria in extremes of ages
HSV 1 or 2 most commonly treatable viral cause

163
Q

Meningitis presentation

A

Almost all patients have 2 of the following:
nuchal rigidity, fever, HA, altered mental status
Cerebrospinal analysis: protein >50, glucose <45, WBC > 1000
Other: photophobia, seizure, vomiting, chills, brudinzkis sign, kernigs sign, skin lesions

164
Q

Initial antimicrobial management of meningitis

A

Blood and CSF drawn immediately, but do not delay abx
Empiric antibiotic therapy by age group
<1 month- ampicillin plus cefotaxime/aminoglycoside
1month-50 years- vanc plus ceftoxamine/ceftriaxone
>50 years- ampicillin plus vanc plus cefotaxime/ceftriaxone

Vanc is added to cover any strep pneumo that is resistant to 3rd gen ceph

165
Q

Empiric abx coverage after neurosurgery or penetrating head trauma

A

Vanc plus cefepime/ceftazidime/meropenem

166
Q

What is used to cover Listeria?

A

Ampicillin

167
Q

Therapeutic levels in presence of inflammation

A

Penicillins ,beta lactams, vancomycin, daptomycin, carbapenems, acyclovir, quinolones

168
Q

Poor penetration even with inflammation

A

Aminoglycosides
1st and 2nd gen cephalosporins
Itraconazole
Do not use with meningitis

169
Q

Recommended duration of treatment for meningitis

A

S. pneumonia- 10-14 days
N. meningitidis, H. influenzae- 7-10 days
Anything else- 21 days

170
Q

Corticosteroids for bacterial meningitis

A

Dexamethasone is preferred
Must be given with or before 1st dose of abx
Not recommended for viral meningitis
Controversial

171
Q

Abx prophylaxis for meningitis

A

Rifampin, ciprofloxacin, ceftriaxone

172
Q

Sepsis 3: Septic Shock

A

Subset of sepsis with underlying circulatory shock and cellular/metabolic abnormalities
Identified by a clinical construct of sepsis consisting of:
-Persistant hypotension requiring vasopressors to maintain MAP >65
Serum lactate > 2mmol/L despite adequate volume resuscitation

173
Q

Septic shock pathophysiology

A

Vasodilation
Decreased preload
Impaired cardiac output

174
Q

Septic shock therapeutic goals

A 
Restore effective tissue perfusion
Therapy selection dependent on source of dysfunction
Fluids- increase preload
Vasopressors- increase vascular tone
Inotropes- increase CO
175
Q

Initial resuscitation goals sepsis

A

Begin resuscitation and treatment IMMEDIATELY
Initial fluid challenge- 30mL/kg of crystalloids (NS/LR) within first 3 hours of presentation
Assess further fluid needs by using dynamic not static variables

176
Q

Initial resuscitation goals sepsis

A

Initial target MAP of 65mmHg in patients with septic shock requiring vasopressors
Target resuscitation to normalize lactate levels as a marker of tissue hypoperfusion

177
Q

Sepsis fluid therapy

A

Crystalloids (NS/LR)
No HES use
Albumin can be used when patients require substantial amounts of crystalloids

178
Q

Sepsis diagnosis

A

Appropriate cultures before antimicrobial therapy (w/in 45 minutes)
2 or more sets (aerobic and anaerobic) of blood cultures should be obtained

179
Q

Sepsis antimicrobial therapy initial

A

Iv abx WITHIN 1 HOUR

broad spectrum, at least 2 abx

180
Q

Abx therapy for sepsis

A

monotherapy- extended spectrum penicillin with or wihtout beta lactamase inhibitor
3rd or 4th gen cephalosporin
Carbapenem

Combo- beta lactam + aminoglycoside OR fluoroquinolone + anti-gram positive agent (vanc, linezolid, dapto)

181
Q

Sepsis therapy duration

A

Typically 7-10 days

182
Q

Vasoactive agents sepsis

A

Levophed is 1st line
Add either vasopressin or epinephrine with intent of raising MAP to target
Dopamine as alternative only- can stimulate arrhythmias
No lose dose dopamine (does NOT provide renal protection)
Dobutamine in patients with persistent hypoperfusion despite adequate fluid loading and vasopressor agent use

183
Q

Corticosteroid recommendations for sepsis

A

IV hydrocortisone if adequate fluid resuscitation and vasopressor therapy and still not responding

184
Q

Glucose control in sepsis

A

Commence insulin when two consecutive blood glucose levels are >180mg/dL
Check glucose every 1-2 hours

185
Q

Anticoagulation in sepsis

A

VTE prophylaxis- UFH or LMWH

186
Q

sepsis stress ulcer prophylaxis

A

Given to patients with risk factors for GI bleeding

Therapeutics III (7 decks)

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