Exam 5 Lecture 8 Flashcards
candidiasis risk factors
broad spectrum antibiotics
PN
Neutropenia (ANC<500)
Receipt of immunosuppressive agents
Surgery
Intrabdominal perforation
candida tx
Echinocandin
- micafungin (back up to flucanozole in not susceptible to flucanozole)
caspofungin
Anidulafungin
Once we know species, use flucanozole (albicans, tropicalis etc)
candidiasis signs
Fever
Tachycardia
Tachypnea
Chills
Hypotension
How long to treat candidemia
14 days after 1st negative blood culture
What things do we need before we narrow candida tx to oral therapy
-Need susceptibilities
- Patients needs to be clinically stable
- Negative repeat blood cultures
- Been in appropriate therapy for 48 hrs
- Chose the most narrow agent (ideally flucanozole)
How often to repear blood cultures for candidemia tx
48 hrs
candidemia tx in neutropenic pts
Echino candins
- caspofungin
-Micafungin
-Anidulafungin
AMPHOTEREFCIN B 3-5 mg/kg/day
choose one
What is flucanozole preferred in
C albicans
C parapsilosis
C tropicalis
C lustainae
What is voriconazole preferred in
Krusei
WHat are echinocandins preferred in?
C glabrata
C krusei
C lustainae
C auris
Histoplasmosis clinical presentation
fevers, chills, fatigue, weightloss (big one), night sweats (big one), hepatosplenomegaly, cough, chest pain, dyspnea
CNS histoplasmosis sx- fever, headache, seizure, mental status changes
Histo tx of acute pulmonary histo asymptomatic/mild immunocompetent host
No therapy
Mild/moderate disease with symptoms of histo tx in immunocompetent host
Itraconazole 200 mg TID x 3 days , 200 mg BID for 6-12 wks
Mod- severe disease of histoplasmosis tx in immunocompetent patients
Lipid amphoterecin B 3-5 mg/kg/day x 1 week, then itraconazole 200 mg TID x 3 days followed by 200 mg BID for 12 wks
Histoplasmosis tx in immunocompromised hist
amphoterecin 3-5 mg/kg/day x 1-2 wks then itra 200 mg TID x 3 days followed by 200 mg BID for at least 12 months
coccidioidomycosis tx of primary pulmonary disease
Most recover without therapy
coccidiodomycosis treatment of primary respiratory infection when to treat
Large inocul, severe infection or concurrent risk factors (HIV, organ transplant, pregnancy, or high dose corticosteroids)
How to treat primary respiratory infection? duration
Flucanozole 400-800 mg PO/IV daily
3-6 months
symptomatic chronic cavitary pneumonia treatment? duration
flucanozole 400-800 for 12 months
Diffuse pneumonia with bilateral or military infiltrate occidioides tx
Amphoterecin B treated for 12 months
Causative pathogens for cryptococcus? Where do we see each one
C neoformans- immunocompromised host
C gaattii- immunocompetent host
What infection plays a major role in host defence against cryptococcus
Cell mediated immunity
difference we see in cryptococcus patients with and without HIV
patients with HIV have less sx due to reduced immune system
Most common presentation in cryptococcus
Meningitis
How is cryptococcus diagnosed
Lumbar puncture
cryptococcal meningitis tx of Non HIV infected, non transplant host
Induction- Amphoterecin + flucytosine 4 wks
Consolidation- flucanozole 400-800 mg PO daily x 8 wks
Maintenance- Flucanozole 200-400 PO daily 6-12 months
Alternative cryptococcal meningitis tx in order
Ampho +flucytosine
Ampho + Flucanozole
Flucytosine + Flucanozole
High dose flucanozole
Amphoterecin alone
Aspergillosis tx and duration
Voriconazole
for 6-12 wks
Aspergillosis prophylaxis
Posaconazole
Antibiotic characteristics that influence CSF/CNS penetration
Lipid solubility- Lipid soluble drugs penetrate
Ionixation- unionized drugs penetrate
Protein binding- Only free drug
Molecular weight- Low MW penetrate
Degree of meningeal inflamation- some drugs penetrate into CSF with inflammation
Name drugs that need meningeal inflammation to achiever CSF concentrations
Penicillins
Some cephalosporins
Aztrenam
Meropenem
Collistin
Vancomycin
Therapeutic antibiotics that do NOT achieve therapeutic concentrations with or without meningeal inflammation
Macrolides
Aminoglycosides
B lactamases
Clindamycin
Tetracyclines
Echinocandins
How do bacteria gain access to CSF in meningitisq
Hematogenous ( through bloodstream)- common
Direct inoculatoon (skull fracture etc)
cliunical signs and wx of meningitis
Brudzinski and kernig sign in adults
Bulging fontanel in children
Meningococcal rash
diagnosis of bacterial meningitis
CSF 3 tubes via lumbar (microbiology, hematology and chemistry)
When should antibiotics be given in bacterial meningitis
Should be given after LP and not before
For bacterial meningitis, what do CSF labs look like
WBC>1000-5000
Differential >80% neutrophils
Proten >150
Glucose <50
empiric antibiotics of neonates, infants, children and adults, older adults >50
Neonates- ampicillin + ceftriaxone/cefepime or ampicillin + Aminoglycoside
infants (1-23 months) and children- adults (2-50)- vanc + Ceftriaxone
> 50- Vanc + Ceftriaxone + Ampicillin
What does ceftriaxone do in neonates
Causes billiary sludging
if pt with bacterial meningitis has streptococcus spp and is sensitive to pen, intermediate/resistant to pen, cephalosporin resistant
Sensitive to pen- penicillin or amp
PCN intermediate/resistant- ceftriaxone
Cephalosporin resistant- vanc
What to use for bacterial meningitis for reduction in neurologic sequale
Steroids before antibiotic
Bacterial meningitis MSSA, MRSA tx
MSSA- nafcillin
MRSA- vanc
bacterial meningitis with listeria monocytogenes tx
Ampicillin/gentamycin
H influenzae bacterial meningitis tx
B lactamase negative- ampicillin
B lactamase positive- Ceftriaxone
Bacterial meningitis tx with enterobacteriae (E coli etc)
Ceftriaxone
Cefepime
Neropenem
Bacterial meningitis with N meningitidis tx
Pen or ceftriaxone
Bacterial meningitis with S pneumoniae tx
Pen susceptoble- pen G or amp
Pen Resistant- vanc + Ceftriaxone
When does dexamethasone decrease mortality and unfavorable outcome in adults with bacterial meningitis
only with S pneumo
CSFinterpretation of fungal meningitis
WBC- 10-500
Differential- >50% lymphs
Protein- 40-150
Glucose- <30-70
Treatment of fungal meningitis
induction- Ampho + Flucytosine for 2 wks
COnsolidation- Flucanozole 400-800 8 wks
Maintenance- flucanozole 200-400 mg 12 months (atleast 12 months AND CD4 > 200 cells/ml AND suppression of viral load on ART
For patients living with HIV/AIDS, when should ART be initiated for cryptococcus patients
Not until 5 wks after initiation of tx for cryptococcal meningitis due to IRIS risk
Viral meningitis often characterized by
Altered mental status
CSF interpretation of viral meningitis
WBC- 5-300
Differential- 50% lymphs
protein- 30-150
Glucose- <40-70
