Final Questions Flashcards
For SIRS, what does it need at least two or more of?
Temp > 38C or < 36C. HR > 90. RR > 20 or PaCO2 < 32 mmHg. WBC > 12,000 or < 4,000, or > 10% immature bands
What are the goals of initial resuscitation of hypoperfusion (first 6h) for sepsis/septic shock?
**MAP: > 65. CVP: 8-12. Urine output > 0.5 ml/kg/hr. Central venous oxygen saturation > 65
When giving hypoperfusion in sepsis/septic shock, when should you reduce the fluid administration rate?
If cardiac filling pressures increase w/o concurrent hemodynamic improvement
When are vasopressors used for severe sepsis/septic shock?
Only given after the patient fails to respond to fluid therapy. They are used to achieve a minimal perfusion pressure and maintain adequate flow. Goal MAP > 65
What are the two best vasopressor choices for septic shock?
Norepinephrine (1st) or Dopamine. These are both good at increasing MAP
Which corticosteroid is the best choice for septic shock when patient fails both fluid therapy AND pressor therapy?
Hydrocortisone IV < 300mg/day
What is a general assessment of meningitis CSF vs. normal CSF?
Higher pressure. Lower glucose (b/c of decreased oxygenation). Protein higher (b/c of edema). WBCs are high (b/c of infection)
What is the main type of bacteria causing meningitis in < 2 months of age?
GBS
What are the common causes of meningitis in patients 2-23 months of age?
Strep. pneumoniae. Some GBS and N. meningitidis
What are the common causes of meningitis in patients 2-34 years of age?
About the same between S. pneumoniae and N. meningitidis
What are the common causes of meningitis in patients 35+ years of age?
Primarily S. pneumoniae
Which antibiotics do not need inflammation to penetrate into CSF?
Rifampin, INH, Pyrazinamide (RIP). Metronidazole, Linezolid, Bactrim (MLB). Before choosing treatment, always check to see if there is inflammation or not
When treating empirically for meningitis in age < 1 month (covering GBS, E. coli, Listeria, Klebsiella), what are some choices?
Ampicillin + Gentamycin. OR. Ampicillin + Cefotaxime
When treating empirically for meningitis in patients 1-23 months, what are your primary choices?
Vancomycin + Cefotaxime/Ceftriaxone
When treating empirically for meningitis in patients 2-50 years, what are your primary choices?
Vancomycin + Cefotaxime/Ceftriaxone
When treating empirically for meningitis in patients 50+ years, what are your primary choices?
Vancomycin + Cefotaxime/Ceftriaxone +/- Ampicillin
What is the definitive therapy for meningitis caused by Strep pneumoniae?
If susceptible: Pen G or Ampicillin. Cefotaxime/Ceftriaxone. Vanco + Cefotaxime/Ceftriaxone. 10-14 days
What is the definitive therapy for meningitis caused by N. meningitidis?
Cefotaxime/Ceftriaxone. 7-10 days
What is the definitive therapy for meningitis caused by H. influenzae?
Cefotaxime/Ceftriaxone. 7-10 days
What is the definitive therapy for meningitis caused by GBS?
Pen G or Ampicillin +/- Aminoglycoside. 14-21 days
What is the o Abx prophylaxis (for family members, dorm-mates who are around an infected person) for meningitis?
Rifampin x2 days. Cipro x1 dose. Ceftriaxone x1 dose
What is the role of Dexamethasone as adjunctive therapy in meningitis treatment?
When you kill bacteria, all the junk inside the bacteria gets released and your immune system mounts a response to this and causes more inflammation. In the case of meningitis, this will cause more swelling/edema which is really bad. Therefore, give dexamethasone (steroid) to prevent this secondary response
How is Dexamethasone dosed in meningitis treatment?
Adults: 10mg Q6h x4 days. Kids: 0.15-0.25 mg/kg Q6h x2-4 days
What is Latent TB like?
Doesn’t feel sick. Not contagious. Needs LTBI treatment + PPD test
What is Active TB like?
Feels sick. Infectious. Needs antibiotic treatment. PPD not always positive
What can cause a false positive PPD test?
Currently active TB. Old. Decreased serum protein. SubQ injection instead of intradermal. On corticosteroids
What is the first line treatment of LTBI?
INH x9 months QD or 2x/week. Can also do a 6 month option
When is a TB patient no longer considered infectious?
ALL 3 must be met: 1) 3 consecutive negative smears, separated by 8-24 hrs. 2) Standard TB treatment for at least 2 weeks. 3) Clinical improvement
What is the usual dosing of Isoniazid (INH) like for TB?
Daily: 300mg. 2x/week or 3x/week: 900mg
What is the usual dosing of Rifampin (RIF) like for TB?
Daily, 2x/week, 3x/week are all: 600mg
Which RIPE therapy does NOT need dose adjustment in CrCl < 30?
RIF and INH
Which RIPE therapy does NOT need dose adjustment in hepatic failure?
EMB
What are some ADRs to look out for with RIF?
Orange discolor of body fluids. Hepatitis (increased w/ INH combo). Flu-like symptoms
What are some ADRs to look out for with INH?
Increased ALT/AST. Peripheral neuropathy. Lupus-like syndrome. Caution: monoamine/tyramine poisoning
What are some ADRs to look out for with PZA?
Photosensitivity. Urecemia. Non-gouty polyarthralgia
What are some ADRs to look out for with EMB?
Optic neuritis
Which RIPE therapy needs to be taken on an empty stomach?
RIF (take w/ full glass of water) and INH
Which RIPE therapy needs to be taken with food?
PZE and EMB
Which RIPE therapy is avoided in children < 15 years?
Ethambutol (EMB) - visual acuity test is hard to perform
Which RIPE therapy is avoided in pregnancy/breastfeeding individuals?
NO Pyrazinamide (PZA), only R/I/E
What are the risk factors for C. difficile disease?
Antibiotic exposure. Advanced age (5x higher > 65 years). Hospitalization or LTC. Acid-suppressing agents. GI surgery or GI procedures
Which antibiotics cause C. diff disease more frequently?
B-lactams, CEPHs (2nd/3rd gen). Clindamycin, Macrolides, FQs, TCN
How is Mild-Moderate CDI classified?
Non-bloody, water diarrhea (5-10 stools/day). Fever, abdominal cramp. WBC < 15,000. SCr < 1.5x premorbid level
How is Severe CDI classified?
Blood in stool, profuse watery diarrhea (> 10 stools/day). High fever (102-104F), severe abdominal pain and tenderness. WBC > 15,000. SCr > 1.5x premorbid level
What is the treatment for Mild-Moderate CDI?
Metronidazole 500mg PO TID x10-14 days
What is the treatment for Severe CDI?
Vancomycin 125mg PO QID x10-14 days
What is the treatment for Severe/Complicated (hypotension or shock, ileus, megacolon) CDI?
Vancomycin 500mg PO QID + Metronidazole 500mg IV Q8h
What are the antibiotic choices for 1st recurrence of CDI?
Either Metronidazole or Vancomycin
What are the antibiotic choices for 2+ recurrence of CDI?
Pulse or taper Vancomycin. Metronidazole is discouraged (risk of peripheral neuropathy d/t cumulative neurotoxicity)
How is Vancomycin tapered in recurrent CDI?
125mg PO BID x7 days, then QD x7 days, then Q2-3 days x2-8 weeks
How is Vancomycin pulsed in recurrent CDI?
125, 250, or 500mg Q3 days x4-6 weeks
What type of Microbiology is often found in Primary Peritonitis?
Mostly monomicrobial: E. coli, Klebsiella, Streptococcus (GAS, S. pneum). Anaerobes are RARE
What is used for diagnosis of Primary Peritonitis?
WBC > 500 (best single predictor). Lactate > 25. pH > 7.4. Gram stain for organisms often negative
What is first line therapy for Primary Peritonitis?
2nd or 3rd gen CEPHs: Cefoxitin, Cefotetan, Cefuroxime, Cefotaxime, Ceftriaxone. Can add Clindamycin or Metronidazole if suspect anaerobes
What can be given to patients with Primary Peritonitis who have a PCN and CEPH allergy?
Vancomycin + Aztreonam
What type of microbiology is often found in Secondary Peritonitis?
Polymicrobial: PEK (E. coli most common) and B. fragilis (most common anaerobe)
What is done for the diagnosis of Secondary Peritonitis?
Exploratory laporatomy. Needle aspiration. Imaging studies. Blood cultures
What is the general outline of Secondary Peritonitis treatment?
Surgery (necessary to correct underlying pathology). Antibiotic selection based on severity and if its community-acquired (narrow spectrum, monotherapy) or heath-care associated (more resistant bacteria, possible multidrug treatment)
What are the treatment options for Secondary Peritonitis?
3rd gen CEPH + Metronidazole. OR. Ertapenem. OR. Zosyn +/- Aminoglycoside
What are the treatment options for Secondary Peritonitis for patients w/ PCN and CEPH allergy?
Aztreonam + Metronidazole
For IAI, what antibiotics with B. fragilis coverage do you NOT want to use?
Cefotetan/Cefoxitin, Clindamycin (NOT recommended d/t increased rates of resistance w/ B. fragilis)
For IAI, when do you need Enterococci coverage?
NEED for HCA-IAI, particularly in patients with: Postop infection, received prior CEPH therapy, Immunocompromised, Have valvular heart disease. NOT routinely needed for CA-IAI
What is the choice for empiric therapy if HCA-IAI when you want to cover for Enterococci?
Ampicillin. Zosyn. Vancomycin
What is the first line treatment for Chlamydia?
Azithromycin 1g PO x1 dose. OR. Doxycyline 100mg PO BID x7 days
What is the first line treatment for Gonorrhea?
Ceftriaxone 250mg IM x1 dose + Azithromycin 1g PO x1 dose or Doxycycline 100mg PO BID x7 days. Azithro or Doxy added d/t needing Chlamydia coverage as well
What is the treatment for Gonorrhea when the patient has a CEPH allergy?
Azithromycin 2g PO once + test of cure in 1 week
What is the first line treatment for Trichomonas vaginalis?
Metronidazole 2g PO x1 dose. OR. Tinidazole 2g PO x1 dose
What are the alternative regimens for Trichomonas Vaginalis?
Metronidazole 500mg BID x7 days. Pregnant: Metronidazole 2g PO x1 dose
What is the first line treatment for Bacterial Vaginosis?
Metronidazole 500mg BID x7 days. OR. Tinidazole 2g PO BID x2 days or 1g PO QD x5 days. Metronidazole gel 0.75%, 5g intravaginally QD x5 days. OR. Clindamycin cream 2%, 5g intravaginally QHS x7 days (not during 3rd trimester)
What is the recommended treatment for Syphilis?
Penicillin G (Bicillin LA, NOT CR) 2.4 million units IM
What is the treatment for Syphilis when the patient has a PCN allergy?
Doxycycline 100mg BID x14 days. OR. Ceftriaxone 1g IM/IV QD x8-10 days. OR. Azithromycin 2g PO single dose
What is the patient-applied treatment for HPV?
Podofilox 0.5% solution or gel. OR. Imiquimod 5% cream
What is the provider-administered treatment for HPV?
Cryotherapy. Podophyllin resin 10-25%. Trichloroacetic or Bichloroacetic acid 80-90%. Surgical removal
Which bacterial STD is mostly symptomatic in females?
Chlamydia. Trichomonas. Bacterial Vaginosis
Which bacterial STD is mostly symptomatic in males?
Gonorrhea
Which bacterial STD has a fishy odor?
Trichomonas and Bacterial Vaginosis
Which bacteria causes Bacterial Vaginosis?
Polymicrobial, mostly Gardnerella vaginalis
Which bacteria causes Syphilis?
Trepnoema pallidum
What tests are the best to indicate UTI (positive result)?
Leukocyte Esterase (LE) and WBC > 5-10,000 are the best indicators
What are the first line treatment options for a UTI in pregnancy?
Nitrofurantoin 100mg PO BID x7 days. OR. B-Lactam (Augmentin) 500/125mg PO BID x7 days
What are the first line treatment options for an uncomplicated UTI?
Nitrofurantoin 100mg PO BID x5 days. TMP/SMX 160/800mg PO BID x3 days
Which antibiotics need to be avoided for UTI in pregnancy?
FQs and Tetracyclines d/t teratogenicity
What are some alternative treatments for uncomplicated UTIs?
Fosfomycin 3g PO x1 dose. B-Lactam (Cefopodoxime (3rd gen; 100mg PO BID) or Augmentin). FQ (Cipro 250mg PO BID x3 days)
What are the first line treatment options for a complicated Outpatient UTI?
Need antibiotic to get into urine AND blood. Bactrim +/- IV Ceftriaxone or IV AG x14 days. PO FQ +/- IV FQ or IV Ceftriaxone or IV AG x5-7 days
What are the treatment options for a complicated Inpatient UTI?
FQ 400mg Q12h. OR. 3rd/4th gen CEPH. OR. AG + Ampicillin 2g IV Q6h
For IE prophylaxis, what are the commonly used antibiotics?
Amoxicillin 2g PO 30-60 min prior to dental procedure
For IE prophylaxis, what antibiotics are used in patients unable to take oral medications?
Cefazolin 1g IM/IV or Ampicillin 2g IM/IV 30-60 minutes prior to dental procedure
For IE prophylaxis, what antibiotics are used when the patient is allergic to PCN?
Clindamycin 600mg PO/IV or Azithromycin 500mg 30-60 minutes prior to procedure
What is the primary therapy for SSTI?
Incision and drainage
When should an antibiotic be used for SSTI?
Progressing SSTI or if associated w/ cellulitis. Abscesses > 5cm. Signs and symptoms of systemic illness. Co-morbid conditions. Location where its hard to do I&D
What are the antibiotic treatment choices for outpatient treatment of MRSA?
Clindamycin 150-450mg PO Q8h. Bactrim 800/160mg 1-2 tabs Q12h. Doxycycline 100mg Q12h x10 days. Rifampin 300mg PO Q8h (in combo with one of the above). Linezolid 600mg Q12h
What is the first line empiric treatment for severe invasive SSTI?
Vancomycin (trough 15-20)
What other treatment options are there for severe invasive SSTI besides vancomycin?
Daptomycin 6mg/kg IV Q24h. Linezolid 600mg IV Q12h. Synercid 7.5mg/kg IV Q8h. The above + AMG or RIF for synergy
What are the treatment options for MRSA Pneumonia?
Vancomycin trough 15-20. NO Daptomycin or Tigecycline!
What are the treatment options for MRSA bloodstream infections?
Vancomycin, Linezolid, Daptomycin. NO Tigecycline. Usually 14 day course, can be 4-6 weeks in complicated cases
What are the treatment options for MRSA infections with possible endocarditis?
Vancomycin, Linezolid, Daptomycin. NO Tigecycline. Typical duration is 4-6 weeks
When is IV treatment for cellulitis preferred?
If lesion rapidly spreading. If systemic response prominent. Significant comorbidities
What medications are used for cellulitis caused by Strep or Staph aureus?
PO: Dicloxacillin or Cephalexin. IV: Oxacillin or Cefazolin
What medications are used for cellulitis caused by Strep or Staph aureus in a patient with B-lactam allergy?
Clindamycin, Erythromycin (not really)
What are the PO treatment options for cellulitis caused by CA-MRSA?
Bactrim, Doxycycline, Clindamycin
What are the IV treatment options for cellulitis caused by CA-MRSA?
Vancomcyin, Linezolid, Daptomycin, Tigecycline, Telavancin
What are the common causes of acute diabetic foot infections?
Typically monomicrobial: S. aureus, B-hemolytic strep (Groups A, B, C, G)
What are the common causes of chronic diabetic foot infections?
Obligate anaerobes. Pseud. aeruginosa. MRSA. VRE
What are the treatment options for Mild-Moderate diabetic foot infections?
Relatively narrow spectrum agent (cover aerobic GPC). Oral agent may be appropriate (especially with high bioavailability)
What are the treatment options for severe chronic diabetic foot infections?
Cover GPC (including MRSA), GNR, and anaerobes. Give parenteral therapy (IV)
What is look at for the sputum analysis for Pneumonia?
Squamous epithelial cells (reject sample if > 10). WBCs (> 25 reflects infection)
What treatment is used for Pneumonia Group 1 (low risk = outpatient)?
First line (Macrolide or Doxycycline). or Telithromycin
What treatment is used for Pneumonia Group 2 (moderate risk = outpatient)?
B-Lactam (oral or one time IV/IM ceftriaxone followed by oral) + Macrolide or Doxycycline
What treatment is used for Pneumonia Group 3a (moderate/inpatient, w/ cardiopulmonary)?
IV B-Lactam + IV Macrolide or Doxycycline. OR. IV anti-pneumococcal or FQ
What treatment is used for Pneumonia Group 3b (moderate/inpatient, w/o cardiopulmonary)?
IV Azithromycin alone (if macrolide intolerant, Doxycycline + B-lactam). OR. IV anti-pneumococcal or FQ
What treatment is used for Pneumonia Group 4a (severe/inpatient, unlikely Pseudomonas)?
IV B-Lactam (3rd or 4th gen CEPH) + IV Macrolide or IV FQ
What treatment is used for Pneumonia Group 4b (severe/inpatient, likely Psuedomonas)?
B-Lactam + AG/FQ + IV Macrolide
When is it ok to switch a patient from IV to PO when treating pneumonia?
Review patient after 3 days IV. When stable and taking orals. After afebrile x24h and improving. Functional GI tract. No nausea/vomiting. Mentally alert/minimize aspiration risk
What are the treatment choices for Legionella pneumophilia?
Azithromycin x3 weeks or IV Cipro x3 weeks
What are the treatment choices for Early HAP/VAP?
B-Lactam (3rd gen CEPH or Amp/Sulbactam)
What are the treatment options for Late HAP/VAP?
B-Lactam (Zosyn or Cefepime) +/- AG (P. aeruginosa suspicion) +/- Vancomycin (MRSA suspicion)
Once culture is back and bacteria causing pneumonia is identified as S. pneumo, what are your treatment options?
PCN-susceptible (PCN, 2nd gen CEPH, Macro, Doxy). PCN-resistant (Vanco, Levofloxacin, Linezolid, Imipenem)
Once culture is back and bacteria causing pneumonia is identified as H. influenzae, what are your treatment options?
B-lactamase negative (Amp 1-2g IV). B-lactamase positive (Cefuroxime, Bactrim IV, 3rd gen CEPH, Cipro)
Once culture is back and bacteria causing pneumonia is identified as PEK, what are your treatment options?
3rd gen CEPH. Cipro
Once culture is back and bacteria causing pneumonia is identified as Enterobacter, serratia, citrobacter, what are your treatment options?
Cipro or Bactrim or Imipenem
Once culture is back and bacteria causing pneumonia is identified as P. aeruginosa, what are your treatment options?
AG (tobra, gent). Zosyn 4.5g. Ceftazidime, Cefepime, Cipro
Once culture is back and bacteria causing pneumonia is identified as S. aureus, what are your treatment options?
MRSA (Vanco, Bactrim, NO Dapto). MSSA: Cefazolin, Oxacillin
