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Therapeutics > Gastrointestinal Infections > Flashcards

Gastrointestinal Infections Flashcards

1
Q

define primary peritnotis

A

Spontaneous bacteria peritonitis SBP
infection of the ascitic fluid in the peritoneal cavity without an evident source of infection. Can be from a manifestation of chronic impairment of liver function or just an infection

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2
Q

what are some risk factors for primary peritonitis?

A 
ascites
cirrhosis
liver disease
portal hypertension
increased permeability of intestinal mucosal barrier
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3
Q

which organisms usually cause primary peritonitis?

A

Gram negative bacilli
E. Coli
Klebsiella

Gram Positive cocine
streptoccocus
enterococcus

*ususally monomicrobial and anaerobes are rare

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4
Q

what are the signs and symptoms of primary peritonitis?

A 
Fever*
Abdominal pain*
nausea/vomiting
diarrhea
rebound tenderness
decreased or absent bowel sounds
increased WBC
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5
Q

what three methods are used to diagnose primary peritonitis?

A
  1. imaging
  2. paracentesis:a. inc WBC: PMN> 250/mm3 b. gram stain of organism
  3. cultures: blood/ascitic acid culture
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6
Q

what agents can be used to treat primary peritonitis?

A
  1. 3rd gen cephalosporins: ceftriaxone, cefotaxime
  2. fluoroquinolones: levofloxacin, norfloxacin
  3. aminoglycosides + [ampicillin or penicillin] : gentamycin/tobramycin
  4. [vancomycin or clindamycin] + [ciprofloxacin or aztreonam or aminoglycoside]
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7
Q

what are the advantages of ceftriaxone or cefotaxime for primary peritonitis? disadvantages?

A 
\+broad spectrum
\+single agent
\+well tolerated
-No enterococcus coverage
-resistance
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8
Q

what are the side effects of 3rd generation cephalosporins?

A 
diarrhea-5%
vomiting-5%
rash-rare
hypersensitivity reaction-rare
pseudomembranous colitis-rare
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9
Q

what are the advantages of levofloxacin norfloxacin for primary peritonitis? disadvantages?

A 
\+broad spectrum
\+available po and IV
-resistance? 
-could exacerbate myasthenia gravis
-tendon rupture/inflammation increased risk with concurrent corticosteriouds, organ transplant recipients and patients >60
-diarrhea/nausea
-dizziness/headahce
-Qtprolongation
-seizure
-no divalent cations
-no enterococcus coverage
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10
Q

what are the advantages of amino glycoside plus [ampicillin or penicillin]?

A 
\+broad spectrum
\+bacteriocidal combo for enterococcus
-AMG requres close drg monitoring
-neuro/ototoxic -irrevirsible
-nephrotoxic
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11
Q

what are the adverse effects of vancomycin?

A

N/V
red man syndrome
rash/pruritis

Serious:
ototoxicity, nephrotoxicity, neutropenia, throbocytopenia, anaphylaxis

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12
Q

what are the adverse effects of clindamycin?

A 
Rash
GI symptoms
Serious:
pseudomembranous enterocolitis
increased LFTs
BBW: clostridium dificille diarrhea
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13
Q

how long should you see improvement with peritonitis antibiotics?what is the duration of therapy?

A

48 hours
10-14 days
5 days if patient responds well, discharging or insurance issues

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14
Q

when should you consider SBP prophylaxis for patients?

A
  1. Cirrhosis with and prior SBP
  2. ascitic fluid protein concentration <1g/dL
  3. cirrhosis with gastrointestinal bleed (+/- ascites)
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15
Q

how should you treat each of those patients that need SBP prophylaxis?

A
  1. indefinite or until transplantation or resolution of ascites: norfloxacin or TMP/SMX or ciproflox
  2. give following only during hospitalization: norfloxacin or TMP/SMX or ciproflox
  3. use primary peritonitis treatment for 7 days
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16
Q

what are the SBP prophylaxis doses of norfloxacin, TMP/SMX and Cipro?

A

norfloxacin 400mg po q24h
TMP/SMX
Cipro

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17
Q

what defines secondary peritonitis?

A 
contamination of peritoneal cavity by intestinal contents due to: 
Gi performation
malignancy
trauma
diverticulitis/ appendicitis
bowel obstruction/ strangulation
mesenteric vascular obstruction
pancreatitis
surgical contamination
complication of peritoneal dyalisis
ruptured abscess
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18
Q

what defines an intraabodminal abscess?

A 
collection of necrotic tissue, bacteria, leukocytes that form over a period of days to years. it prevents the spread of infections. Usually complications of primary or secondary peritonitis:
appendicitis/diverticulitis
trauma
biliary tract lesion
abodominal surgery
perforated perptic ulcer
IBD
pancreatitis
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19
Q

if you have an intraabdominal infection in the stomach, what are the likely organisms?

A

streptococcus and lactobacillus

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20
Q

if you have an intraabdominal infection in the upper intestine, what are the likely organisms?

A

streptococcus
PEK
lactobacillus

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21
Q

if you have an intraabdominal infection in the distal ileum, what are the likely organisms?

A

streptococcus
EK
bacteroides
clostridium

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22
Q

what are the most likely organisms that will cause an intra abdominal infection?(secondary peritonitis)

A

Aerobic: PEK Ecoli* most likely
Anerobic: B. Fragilis*, fusobacterium spp, Clostridium spp

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23
Q

what are the signs and symptoms of Secondary peritonitis?

A 
abdominal pain/tenderness/distenion
fever or hypothermia
decreased or absent bowel sounds
tachycardia
increased WBC (+left shift)
decreased mental status
hypotension
anorexia/nausea/vomiting
24
Q

how d other diagnose the IAI?

A
  1. ultrasound
  2. computerized tomography
  3. needle aspiration of peritoneal cavity
  4. blood cultures
  5. exploratory laparotomy
25
Q

which medications are NOT recommended to cover B.Fragilis?

A

cefotetan
clindamycin
ceftizoxime

26
Q

which medications have good coverage of B. Fragilis?

A 
metronidazole
ampicillin/sulbactam
ticarcillin/clavulanic
pip/tazo
tigecycline
moxi
cefoxitin
27
Q

what constitutes a high risk patient for secondary peritonitis?

A 
advanced age >70 yo
degree of peritoneal involvement
diffuse peritonitis
presence of malignancy
low albumin level 
comorbidity and agree of organ dysfunction 
delay in initial intervention >24 hours
APACHE II score > 15
poor nutritional status
28
Q

how do you treat patients that have mild to moderate infections (i.e Not high risk)?

A 
Chose one option ALL Intravenous
1. cefoxitin 2g q6h
2. ertapenem 1g q24h
3. moxi 400mg q24h
4. tigecycline 100mg x 1, 50mg q12h
5. ticarcillin/clav 3.1g q6h
Combine Metronid 500mg q8h with:
6. cefazolin 1-2g q8h
7. cefuroxime 1.5g q8h
8. ceftriaxone 1g q24h
9. cefotaxime 1g q8h
10. cipro 400mg q12h
11. levo 750mg qw24h
29
Q

who should be covered for enterococcus spp?

A
  1. enterococcus is recovered form culture
  2. predominant organism on culture is enterococcus and patient not responding to antibiotics
  3. post op infection, previous abc selecting for enterococcus, immunocompromised, valvular heart dx, prosthetic intravascular material
30
Q

which medications cover enterococcus?

A
  1. piperacillin/tazo
  2. dori/imi/meropenem
  3. tigecycline
  4. ampicillin
  5. ampicillin/tazobactam
  6. vancomycin
31
Q

which medications can you use for high risk secondary peritonitis?

A
  1. impenem cilastin 500mg-1g IV q6-8h
  2. meropenem 500mg-1g IV q6-8h
  3. doripenem 500mg IV q8h
  4. piperacillin/tazobactm 3.375g IV q6h
    Combine metronidazole 500mg iV q8h
  5. cefepime 1-2g IV q8h
  6. ceftazidime 1-2g VI q8h
  7. cipro 400mg IV q12h
  8. levo 750mg IV q24h
32
Q

what are the risk factors for MRSA?

A
  1. chronic dialysis within 30 days
  2. IV drug use
  3. history of MRSA infection
  4. immunosuppressed
  5. recent broad spectrum antimicrobial tx with minimal improvement (past 90 days)
33
Q

which agents should you use for IAI if patient is penicillin allergic?

A

aztreonam +metronidazole + vancomycin

34
Q

who should get anti fungal therapy for IAIs?

A
  1. recently received immunosuppressive therapy
  2. postoperative or recurrent gastrointestinal perforation or anastotmotic leakages
  3. perforation of gastric ulcer on acid suppression or malignancy
  4. fungi recovered form culture: usually c. albicans
35
Q

what is the c. albicans treatment?

A

fluconazole 12mg/kg (800mg) IV/Po x 1, 6mg/kg (400mg) q24h

36
Q

what if the patient is flucanazole-resistant?

A
  1. caspofungin 70mg x 1, 50mg IV q24h
  2. micafungin 100mg iv q24h
  3. anindulafungin 200mg x 1, 100mg IV q24h
37
Q

how long should antibiotic treatment be for secondary peritonitis?

A

4-7 days

38
Q

what are the oral treatment options for IAIs?

A
  1. moxifloxacin
  2. cipro/levofloxacin PLUS metronidazole
  3. oral cephalosporin plus metronidazole
  4. amox/clavulanate
39
Q

what is cholecystitis?

A

inflammation of the gall bladder

40
Q

what is cholangitis?

A

inflammation of biliary ductal system

41
Q

what pathogens are implicated in cholangitis?

A

aerobic gram N bacillli (enterobacteria)
anaerobes: b. fragilis
enteroccoccus (not always)

42
Q

what are the signs and symptoms of cholangitis?

A 
N/V
abdominal pain/ distension/tenderness
fever
increased LFTs, TBilirubin, alk phos, amylase, 
Increased WBC
Right upper quadrant pain
jaundice
43
Q

how do you treat mild to moderate community acquired acute cholecystits?

A

cefazolin
cefuoxime
ceftriaxone

44
Q

how do you treat sever community acquired acute cholecystits or acute cholangitis ?

A

use the high risk Community acquired IAI regimen

45
Q

how do you treat HCAI biliary infections

A

add vancomycin to above regimen

46
Q

how do you diagnose C. difficile?

A
  1. presence of symptoms like diarrhea
    2> a stoo test postivie for C. difficile toxins or toxigenic c. difficille or colonscopic findings demostrating pseudomembranous colitis
47
Q

what are some risk factors for acquiring CDAD?

A
  1. laxatives
  2. enemas
  3. GI tract manipulation
  4. gastric acis suppression: PPIs
  5. > 64 yo
  6. antibiotics exposure, clinda, ampicillin, cephalosporins, fluroquinolones
  7. poor antibody response
  8. chemotherapy
  9. severe underlying illnes
48
Q

what are the signs and symptoms of CDAD?

A 
sever diarrhea
fever 
lower abdominal pain/tenderness
N
malaise
leukocytosis
49
Q

what complications can occur with CDAD?

A 
dehydration
toxic megacolon
bower perforation 
renal failure
hypoalbuminemia
sepis
dead
50
Q

what constitutes mild to moderate CDAD?

A

diarrhea and abodminal cramping withougth systemic symptoms

WBC < 1.5 x premorbid level

51
Q

how do you treat mild to moderate CDAD?

A

metronidazole 500mg po q8h x 10-14 days

if worsening try vancomycin for severe CDAD

52
Q

what constitutes severe CDAD?

A 
abundant diarrhea
abodminal pain 
leukocytosis
fever or other systemic symptoms
WBC >15000 or SCr >1.5 x premorbid
53
Q

how to treat severe CDAD

A

vancomycin 125mg po q6h x 10-14 days

if hypotension, shock ileum or megacolon: can add IV metronidazole

54
Q

how to treat 2nd relapse of CDAD?

A

vanco taper

125mg q6h x 10-14 days, 125mg q12h x 7 days, 125mg q24 h x 7, 125mg q2-3days for 2-8 wks

55
Q

what is alternative tx for CDAD?

A

fidaxomicin 200mg po q12h
nitazoxanide 500mg po q12h (LAST EFFORT)
rifamicin 200-400mg po q8-12h
IVIG 150-400mg/kg IV q24hx x 1-3 doses

56
Q

what should CDAD patients avoid?

A

cholestyarmine colestipol cuz adverse effect of constipation and will decrease efficacy of vancomycin due to binding

57
Q

non pharm prevention of CDAD?

A 
strict hand hygeine
appropriate contact precauseions 
proper environmental contamination 
antimicorbial stwardship forumulary restrictions
prudent use of PPIs

Therapeutics (23 decks)

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