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
2
Q
How long are you contagious with strep throat?
A
Untreated- 1 week
Treated- 24 hours
3
Q
S/S strep throat
A
Fever, lymphadenopathy, tonsillar exudates, absence of cough
Fatigue, weakness
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
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
6
Q
Bacterial pharyngitis 1st line treatment
A
Penicillin or amoxicillin
7
Q
Bacterial pharyngitis alternative treatment
A
Use in penicillin allergy
1st gen cephalosporin, clindamycin, macrolides
8
Q
Bacterial pharyngitis treatment duration
A
10 days oral therapy
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
10
Q
Acute otitis media S/S
A
Sudden onset fever, crying, irritability, anorexia, restlessness, otalgia, otorrhea, red/bulging TMs without movement
11
Q
Acute otitis media labs
A
Usually none
12
Q
AOM presentation
A
Otalgia (ear pain) and behavioral changes
13
Q
AOM Common causes
A
mainly caused by virus
If bacterial- S. pneumonia, H. influenzae, M catarrhalis
(gram positive and negative aerobes)
14
Q
Risk factors for amoxicillin-resistance
A
Child care center
Abx use in last 30 days
Age <2 years old
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
16
Q
AOM non-antimicrobial treatment
A
Pain management- acetaminophen or NSAIDs
Otic drops with anesthetic
Decongestants and antihistamines are not recommended
Pediatric dosing!
17
Q
AOM 1st line antimicrobial therapy
A
Amoxicillin
Augmentin if severe infection, amoxicillin failure, or suspected beta-lactamase producing orgamism
18
Q
AOM 2nd line treatment
A
2nd gen cephalosporins (cefdinir)
Macrolides
Clindamycin
19
Q
AOM treatment duration
A
10 days in children < 2
5-7 days in children > 6 with mild-moderate symptoms
20
Q
Rhinosinusitis causes
A
Most commonly viral
Bacterial causes same as AOM
21
Q
Rhinosinusitis 1st line antimicrobial therapy
A
Augmentin
22
Q
Rhinosinusitis 2nd line therapy
A
Non-hospitalized- doxycycline, respiratory fluoroquinolone)
Hospitalized- ampicillin/sulbactam, resp. fluoroquinolone, IV 3rd gen ceph
23
Q
CAP
A
Infection present at hospital admission
24
Q
HAP
A
Pneumonia occurring typically >48 hours after hospital admission
25
VAP
Pneumonia occurring typically >48 hours after endotracheal intubation
26
Common causes of outpatient CAP
```
Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Respiratory viruses
```
27
CAP diagnosis
Clinical features- cough, fever, sputum production, pleuretic chest pain
Chest x-ray- acute infiltrate
28
How do you decide to admit a CAP patient?
Pneumonia Severity Index (PSI) or CURB-65
| Does not decide ICU need
29
How to determine ICU need for CAP?
Admit if 1 major criteria (septic shock with need for vasopressors or resp failure requiring mechanical ventilation)
3 minor criteria
30
CAP treatment outpatient no comorbidities
Amoxicillin or doxycycline or macrolide
31
CAP treatment outpatient with risk factors
Combo Augmentin or cephalosporin AND macrolide or doxycycline
OR
monotherapy with resp. fluoroquinolones
32
CAP treatment inpatient
Nonsevere- beta lactam + macrolide or resp. fluoroquinolone
| Severe- Beta lactam + fluoroquinolone
33
Important changes in CAP from previous guidelines
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
34
CAP duration of Abx
based upon clinical stability ( resolution of vitals, ability to eat, normal mentation)
No less than 5 days
35
Pneumonia
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
36
Ventilator associated pneumonia
Most common ICU-acquired infection
| Risk increases as duration of mechanical ventilation increases
37
Are HAP and VAP mutually exclusive?
Yes
38
Pneumonia diagnosis
Presence of a new or progressive radiographic infiltrate PLUS at least 2 of the following:
Fever >38C
2.) Leukocytosis or leukopenia
3.) purulent secretions
39
Trachial aspirates
Grow more organisms than invasive cultures
| Negative cultures have a strong negative predictive value
40
Specimen collection for pneumonia likelihood for contamination
Lung biopsy> broncoscopy> Non-broncoscopy> endotracheal aspirates
41
HAP/VAP empiric coverage
Need coverage for S. aureus, P. aureginosa, and other gram negative bacilli
If MRSA coverage is needed- vanc or linezolid
42
Gram + with MRSA activity
Vanc or linezolid
43
Gram - with Antipseudomonal activity
Piperacillin-tazobactam, cefepime, ceftazidime, carbapenems, aztreonam, fluoroquinolones, aminoglycosides, polymyxins
44
HAP/VAP definitive therapy
MRSA_ vanc or linezolid
| P. aeruginosa- recommend definitive therapy, recocmmend monotherapy if septic shock not present
45
HAP/VAP duration
7 days course
| Use procalcitonin plus clinical criteria to determine treatment d/c
46
S/S of TD
Malaise, anorexia, cramps followed by sudden onset of diarrhea
47
TD cause
20-50% develop during 1st week of travel
| Cause: contaminated food or water. GI tract isnt used to food.
48
What infectious agents are associated with TD?
Secretory (watery) diarrhea- ETEC (e.coli) and Vibrio (uncommon)
Inflammatory (bloody)- Shigella, salmonella, campylobacter, EHEC, EIEC
49
Severity of TD
Mild: 1-3 loose stools with cramping
Moderate- signs of dehydration, >4
Severe- presence of fever or blood in stools
50
Goals of therapy TD
```
Avoid dehydration- ORT
Antiparistaltic agents (diphenoxylate, loperamide) only for mild, watery diarrhea
Avoid antiperistaltic agents in patients with high fever and bloody diarrhea
```
51
Management of TD
Fluids (bottled water)
Loperamide (preferred)
Bismuth subsalicylate
ABx (3 days) may reduce duration by 1-2 days with minimal risk
52
TD abx
Fluoroquinolones (Norfloxacin, ciprofloxacin, levofloxacin)
Rifaximin
Azithromycin
53
Rifaximin
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
54
Time course for TD
Sx usually resolve in a few days no treatment
| Not life threatening
55
TD prophylactic abx
Not recommended (resistance)
56
Salmonella- N/V
N/V within 72 hours followed by crampy abd pain, fever, d (bloody). More mucosal invasion (also from poultry, eggs, dairy)
57
E.coli
Abrupt onset watery diarrhea. Resolves in 24-48 hours
58
CDAD S/S
fever, hyperactive bowel sounds, guarding
Cramps, greenish diarrhea, abdominal tenderness
Labs: toxin +, WBC
59
Which abx are most likely to cause C.Diff?
```
Broad spectrum Abx
Amox+/- CA
Cephs
Clinda
FQs most frequent
```
60
If C.diff toxin had been negative, would this have ruled out CDAD?
No, the EIA sensitivity is only 75-99%
| NAAT is better
61
CDAD goals of therapy
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
62
Epidemiology of CDAD
500,000 cases in US yearly
Most likely in white women
"Urgent threat" list
63
Risk factors for CDAD
```
Age >64
CKD
IBD (crohns disease, ulcerative colitis)
Solid organ transplant
Exposure to abx
Chemo
```
64
CDAD presentation
Sudden, unexplained diarrhea
65
Nonsevere CDAD
WBC <15,000 cells/mL
| SCr >1.5mg/dL
66
Severe CDAD
WBC >150,000
| SCr >1.5
67
Fulminant CDAD
Hypotension, shock, ileus, megacolon
| Pt could die
68
Infection prevention control CDAD
```
Private room
Caution precautions
Hand hygiene- soap and water
Daily cleaning with ammonia product
Terminal cleaning with sporicidal agent
Antibiotic stewardship
```
69
Antimicrobial treatment of CDAD
Metronidazole no longer DOC. Should not be used in serious disease or retreatment.
Oral vanc 1st line- 10 days is standard of care
70
When do you consider fecal transplant for CDAD?
Multiple (>3) CDAD infections
| 95% effective
71
Patient followup CDAD
1st relapse- oral vanc or fidaxomicin
| Long term- oral vanc
72
Bezlotoxumab
For patients with recurrent CDAD infections
| Can cause cardiac failure
73
Blacklegged Tick
Transmits Lyme disease, anaplasmosis, babesiosis, and Powassan disease
74
Lone Star Tick
Transmits ehrlichiosis, tularemia, Southern-tick associated rash illness (STARI)
75
Dog tick
Transmits tularemia and rocky mounted spotted fever
76
Prevention of tick infections
Use EPA registered insect repellents containing DEET, picaridine, IR3535, oil and lemon eucalyptus, etc.
Treat clothing and gear with products containing permethrin
77
Lyme disease
Organism- Borrella spp.
Transmission- blacklegged tick
Incubation period- 3-30 days
Geographic location- upper midwest and northeastern US
78
S/S lyme disease
Localized stage- erythema migrans rash: bulls eye pattern
Flu-like symptoms
Lymphadenopathy
Disseminated stage- rheumatologic, cardiac, neurologic, other
79
Lyme disease Tx
Doxycycline
Cefurooxime
Amoxicillin
10-21 days
80
Doxycycline in peds
Can cause permanent tooth discoloration
81
Post-treatment lyme disease syndrome
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
Rocky Mountain Spotted Fever
Organism- rickettsia species
Transmission- Dog tick, wood tick
Incubation- 2-14 days
Geographic location- NC, TN, MO, AR, OK
83
Rocky mountain spotted fever s/s
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
Rocky mountain spotted fever treatment
Doxycycline 5-7 days
85
Anaplasmosis
Organism- Anaplasma species
Transmission- Black-legged tick
Incubation -1-2 weeks
Geographic location- upper midwest and northeastern US
86
Anaplasmosis S/S
Fever, shaking, chills, HA, fatigue, myalgia, N/V/D, cough
| Severe illness- difficulty breathing, hemorrhage, renal failure, neurologic problems
87
Anaplasmosis tx
Doxycycline
| 10-14 days due to potential coinfection with lyme disease
88
Ehrlichiosis
Organism- Ehrlichia spp.
Transmission- Lone star tick
Incubation- 1-2 weeks
Geographic location- Southeaster/south central and eastern US
89
Ehrlichiosis
Flu like symptoms, confusion
| Severe- difficulty breathing, abnormal bleeding
90
Ehrlichiosis treatment
Doxycycline 5-7 days
91
Babesiosis
Organism- Babesia microti
Transmission- blacklegged tick
Incubation- 1-9 weeks
Geographic- northeast and upper midwest
92
Babesiosis s/s
Flu like gastrointestinal
Dark urine
Lab findings- decreased hematocrit, thrombocytopenia, elevated SCr and BUN, mildly elevated LFTs
93
Babesiosis tx
Atovaquine and azithromycin OR clindamycin and quinine
| 7-10 days
94
Tularemia
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
Tularemia s/s
Ulceroglandular, oculoglandular, oropharyngeal, pneumonic, typhoidal
Common s/s- fever, chills, HA, malaise, fatigue, myalgia
96
Tularemia tx
Aminoglycosides DOC
| Streptomycin or gentamycin minimum 10 days
97
Lab diagnosis for tick borne diseases
PCR analysis
Antibody tests
Can see babesia in whole blood smear
98
Mosquito borne illnesses
Zika, eastern equine encephalitis, malaria
99
Zika Virus
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
Zika virus s/s
Red eyes, joint muscle pain, fever, rash
101
Zika virus in pregnancy
Can cause microcephaly and other birth defects
102
How to prevent Zika virus?
Wear long sleeved shirts and long pants
Stay in places where windows/screens keep mosquitos separate
Use EPA registered insect repellants
Use condoms
103
Is there a vaccine for Zika virus?
No but many in development
104
Eastern equine encephalitis
Organism- alphavirus spp
Transmission- mosquito (aedes, coquillettidia, curlex)
Incubation- 4-10 days
Geographic location- eastern US
105
Eastern equine encephalitis s/s
fever, chills, malaise, arthralgia, myalgia
Encephalitic stage occurs abruptly- D/V, anorexia, cyanosis, convulsions, coma
Tx- supportive care
106
Malaria
Org- plasmodium spp
Transmission- anopheles mosquito
Incubation- 7-30 days
Geographic locations= areas close to equator
107
Malaria s/s
Uncomplicated- cold stage, hot stage, sweating stage
| Complicated- can result in end-organ damage
108
Malaria tx
Dependent on organism, area, sensitivity
| Prophylactic agents- atovaquine, chloroquine, doxy, mefloquine, primaquine, tefenoquine
109
Uncomplicated intra-abdominal infection
Intramural inflammation of GI tract
| Confied within tract
110
Complicated intra-abdominal infection
Infection beyond GI tract
111
Primary peritonitis
Peritonitis not related to other intra-abdominal abnormalities
Commonly referref to as ABP
Risk factors: cirrhosis and ascites
Usually mono-microbial
112
Secondary peritonitis
Peritonitis as a consequence of intra-abdominal process
Ruptured appendix or peptic ulcer
Polymicrobial
113
Tertiary peritonitis
Peritonitis that persists or recurs >48 hours after adequate treatment
114
Diagnosis of peritonitis
Clinical features
Physical exam- involuntary guarding of abdomen, distended and tender abdomen
Lab values- Leukocytosis (increased WBCs)
Signs of dehydration
115
Paracentesis
```
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
Primary peritonitis micro
Enteric gram negative and streptococcus spp.
Most common organisms- e.coli, klebsiella pneumonia, streptococcus pneumonia
Anaerobes are usually NOT involved
117
Empiric therapy for intra-abdominal infections
3rd gen cephalosporins- ceftriaxone, cefotaxime
Fluoroquinolones- levofloxacin, moxifloxacin
Broad spectrum penicillins- augmentin, pip-tazo
Carbapenems
Duration 4-7 days
118
SBP secondary prophylaxis
Norfloxacin 400mg QD
Bactrim DS once daily for 5days/week
Cipro 750mg weekly
Until resolution of ascites, transplant, or death
119
Complicated intra abdominal infections (cIAIs)
Need to cover anaerobes and gram negatives
120
Anaerobic coverage
```
Beta lactam/beta lactamase inhibitors
Cefoxitin and cefotetan
Carbapenems
Clindamycin
Metronidazole
Moxifloxacin
Tigecycline/eravacycline/omadacycline
Chloramphenicol
```
121
Pseudomonas coverage
```
Pip/Tazo
Ceftazidime, cefepime, cefiderocol, ceftolozane/tazo, ceftizidime/ tazo
Carbapenem (not erta)
Aztreonam
Cipro/ levo
Aminoglycosides
Polymixin B, Colistin
```
122
Hospital associated or severe intra abdominal infections
You want an agent that covers for pseudomonas and maybe MRSA
| MDR organisms
123
Intra abdominal infection mild-moderate single therapy
```
Ampicillin/ sulbactam
Augmentin
Cefoxitine
Ertapenem
Moxifloxaxin
```
124
Intra-abdominal infection CA severe or hospital associated
Pip/Tazo
Imipenem/cilastatin
Meropenem
Doripenem
125
IA infection mild-moderate abx tx combo
cefazolin, cefuroxime, ceftriazone PLUS metronidazole
| Cipro, Levo PLUS metronidazole
126
IA community acquired severe or HA Tx combo
Ceftazidime, cefepime PLUS metronidazole
Cipro, levo PLUS metronidazole
Gentamicin, tobramycin, amiKacin PLUS metronidazole
127
Mild to moderate CA cIAI not recommended
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
Severe cIAIs
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
Duration of therapy cIAIs
Source control
| 4-7 days unless inadequate source control
130
SSI
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
Superficial Incisional SSI
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
Deep incisional SSI
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
Organ/Space SSI
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
Pathogenesis
Microbiome, intraoperative contamination, foreign bodies, , intrinsic risks (obesity, smoking, etc.)
Surgery itself
135
Endogenous risk factors
age, glucose control, obesity, smoking cessation, immunosuppressive therapy, nutrition status, remote sites of infection, pre-operative hospitalization
136
Exogenous risk factors
```
Surgeon hand washing
Foreign bodies
Abdominal drains
Operative hypothermia
OR ventilation
OR traffic
Cleaning OR rooms
```
137
Prehospital surgical interventions
```
Chlorhexidine bathing
Smoking cessation
Glucose control
MRSA screenings
Bowel prep
Antimicrobial prophylaxis
```
138
Class I (clean)
Dont have entry into a site that contains a high flora
Minimum risk
No abx
139
Class II (clean contaminated)
Respiratory, alimentary, genital, and urinary tracts are entered.
In controlled conditions
Prophylactic abx
140
Class III (contaminated)
Any of the above but not in a controlled environment
Trauma patients
Gun shot wound
Prophylactic abx
141
Class IV (dirty)
Existing clinical infections
| Tx abx
142
Abx for surgery, what type?
```
IV- ideal
Oral- some data to support
Topical- controversial
Cephalosporins mainly used
Vancomycin not routine
```
143
Timing of abx for surgery
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
When to redose abx for SSI
When 1-2 half lives have passed
145
How long abx for surgery?
D/C within 24 hours after surgery
146
What is infective endocarditis?
Infection of the heart valves
Bacterial, fungi, and atypicals
Acute and sometimes fatal
uncommon, not rare
147
Who gets infective endocarditis?
Rheumatic heart disease
Congenital heart disease
IV drug use
148
Infective endocarditis and IV drug use
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
Pathophysiology of IE
Endothelial surface of the heart is damaged
Platelet and fibrin deposition occurs on abnormal surfaces
Bacteremia
150
IE s/s
Nonspecific subacute presentation
Fevers, chills, weakness, dyspnea, night sweats, weight loss, fever, heart murmur, emboli, skin abnormalities, persistant bacteremia
151
Clinical features IE
Fever most common sign
Murmur common
Interval between index bacteremia and onset of sxs is about <2 weeks
152
IE clinical features and complications
Systemic emboli, neurological sequelae, ,CHF, renal insufficiency
153
Duke criteria
Diangosis of IE
| Definitive- 2 major criteria, 1 major and 3 minor, 5 minor
154
Risk factors for IE
Preexisting cardiac valvular abnormalities
Previous endocarditis
Heart diesase
Chronic IV access
Diabetes
Healthcare related exposure
Bacteremia with streptococci, staphylococci, enterococci
155
Orgs that cause IE
Staphylococci
Streptococci
Enterococci
Gram + most common!
156
General principles for IE
Confirm organism within 3-4 sets of blood cultures
Treatment tailored to organism
High dose, bactericidal abx
Treatment duration usually 2-6 weeks
157
IE abx
Treatment tailored to etiologic agent
Important to get MIC/MBC relationship for each causative organism
High serum concentration necessary to penetrate avascular vegetation
158
Treatment of native valve IE
```
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
Treatment of native valve IE enterococcus
Ampicillin or penicillin G plus gentamicin
OR amplicillin plus ceftriaxone if renal failure or resistant to gent
OR
Dapto or linezolid
160
Prosthetic valve endocarditis (PVE) treatment
MSSA- nafcillin/oxacillin + rifampin for 6 weeks PLUS gent for 2 weeks
MRSA- vanc+ rifampin for 6 weeks PLUS gentamicin for 2 weeks
161
Meningitis
Inflammation of the membranes surrounding the brain and spinal cord.
Can be caused by bacteria, viruses, or fungi
Clinical consequences- neurologic sequelae
162
meningitis etiology
Nasopharyngeal colonization often occurs first
Streptococcus pneumo, neisseria meningititis
Listeria in extremes of ages
HSV 1 or 2 most commonly treatable viral cause
163
Meningitis presentation
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
Initial antimicrobial management of meningitis
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
Empiric abx coverage after neurosurgery or penetrating head trauma
Vanc plus cefepime/ceftazidime/meropenem
166
What is used to cover Listeria?
Ampicillin
167
Therapeutic levels in presence of inflammation
Penicillins ,beta lactams, vancomycin, daptomycin, carbapenems, acyclovir, quinolones
168
Poor penetration even with inflammation
Aminoglycosides
1st and 2nd gen cephalosporins
Itraconazole
Do not use with meningitis
169
Recommended duration of treatment for meningitis
S. pneumonia- 10-14 days
N. meningitidis, H. influenzae- 7-10 days
Anything else- 21 days
170
Corticosteroids for bacterial meningitis
Dexamethasone is preferred
Must be given with or before 1st dose of abx
Not recommended for viral meningitis
Controversial
171
Abx prophylaxis for meningitis
Rifampin, ciprofloxacin, ceftriaxone
172
Sepsis 3: Septic Shock
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
Septic shock pathophysiology
Vasodilation
Decreased preload
Impaired cardiac output
174
Septic shock therapeutic goals
```
Restore effective tissue perfusion
Therapy selection dependent on source of dysfunction
Fluids- increase preload
Vasopressors- increase vascular tone
Inotropes- increase CO
```
175
Initial resuscitation goals sepsis
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
Initial resuscitation goals sepsis
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
Sepsis fluid therapy
Crystalloids (NS/LR)
No HES use
Albumin can be used when patients require substantial amounts of crystalloids
178
Sepsis diagnosis
Appropriate cultures before antimicrobial therapy (w/in 45 minutes)
2 or more sets (aerobic and anaerobic) of blood cultures should be obtained
179
Sepsis antimicrobial therapy initial
Iv abx WITHIN 1 HOUR
| broad spectrum, at least 2 abx
180
Abx therapy for sepsis
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
Sepsis therapy duration
Typically 7-10 days
182
Vasoactive agents sepsis
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
Corticosteroid recommendations for sepsis
IV hydrocortisone if adequate fluid resuscitation and vasopressor therapy and still not responding
184
Glucose control in sepsis
Commence insulin when two consecutive blood glucose levels are >180mg/dL
Check glucose every 1-2 hours
185
Anticoagulation in sepsis
VTE prophylaxis- UFH or LMWH
186
sepsis stress ulcer prophylaxis
Given to patients with risk factors for GI bleeding
