ID**** Flashcards
Gram + cluster species
-MSSA
-MRSA
Gram + Pairs & Chains
-strep. pneumoniae
-strep. pyogenes
-entroccus (VRE)
Gram + Rods
- listeria
-monocytogens
-corynebacterium spp
Gram + Anaerobes
-peptostreptococcus
-propionibacterium acnes
-clostridioides difficile
-clostridium spp.
Gram - cocci
neisseria spp
Gram - rods, colonizing the gut
-proteus mirabilis
-E. coli
-Klebsiella
-serratia
-enterobacter cloacoe
-citrobacter
Gram - rods, that do not colonize gut
-pseudomonas aergunosa
-haemophilus influenzae
-providencia
Gram - Anaerobes
-bacteroides fragilis
-prevotella spp
Gram - Coccobacilli
-acinetobacter baumannil
-bordertella pertussis
-moraxella catarrhalis
Gram - curved or spiral shaped rods
-H. pylori
-Campylobacter
-treponema
-Barrelia
-Leptospira
Common Resistant Pathogens
Kill Each and Every Strong Pathogen
-klebsiella pneumoniae
-escherichia coli
-acinetobacter baumannii
-enterococcus faecalis/faecium
-staphylococcus aureus
-pseudomonas aerginosa
Natural Penicillins: Pen V, Pen G
-covers gram + cocci, gram + anaerobes (in mouth)
PO: pen V, IV/IM: pen G,
Aminopenicillins: amoxicillin, ampicillin
-covers gram + cocci, gram + anaerobes (in mouth)
-adds on gram - coverage (HNPEK)
-PO amoxicillin, IV ampicillin
Aminopenicillin + Beta-lactamase Inhibitors: amoxicillin/clavulanate, ampicilin/sulbactam
-covers gram + cocci, gram + anaerobes (in mouth)
- gram - coverage (HNPEK)
-adds MSSA, more resistant strains of HNPEK, gram - anaerobes (B. fragilis)
- PO augmentin, IV unasyn
Extended-spectrum + beta-lactamase inhibitor: piperacillin/tazobactam
-covers gram + cocci, gram + anaerobes (in mouth)
- gram - coverage (HNPEK)
-MSSA, more resistant strains of HNPEK, gram - anaerobes (B. fragilis)
-adds CAPES, + pseudomonas
-IV only
Anti-staphylococcal: nafcillin, oxacillin
-covers MSSA and streptococci only!
-both IV
PO: dicloxacillin
Penicillin class trends
-all cover enterococcus (except antistaphylococcal penicillins)
-do NOT cover atypicals (penicillin are cell wall active agents and atypical dont have cell walls) or MRSA
-do not use with beta lactam allergies or risk of seizures
outpt/PO penicillin usage: Penicillin VK
-strep throat
-mild skin infections
outpt/PO penicillin usage: Amoxicillin (Moxatag)
-acute otitis media (90 mg/kg/day)
-infective endocarditis ppx before dental procedures ( 2 g po x1 30-60 mins before)
-H. pylori tx
outpt/PO penicillin usage: Amoxicillin/Clavulanate (Augmentin)
-acute otitis media (90 mg/kg/day)
-bacterial sinusitis
–> use lowest dose of clavulanate to dec diarrhea
outpt/PO penicillin usage: Doxioxacillin
-covers MSSA and streptococci only
-does not need renal adjustment
Inpatient/parenteral use of Penicillins: Pen G (Bicillin-L-A)
-drug of choice for syphilis (2.4 mil units IM x1)
–>**never use IV = death
Inpatient/parenteral use of Penicillins: Piperacillin/Tazobactam (Zosyn)
-only one active against pseudomonas
-extended infusion (4 hrs) can be used to maximize T > MIC
Inpatient/parenteral use of Penicillins: Nafcillin and Oxacillin
-covers MSSA and streptococci only
-does not need renal adjustment
1st gen cephalosporins
-IV: cefazolin
-PO cephalexin (Keflex)
–> cover staphylococci, streptococci, PEK, mouth anaerobes
2nd generation cephalosporins
-IV/PO/IM: cefuroxime (Ceftin)
–> better gram - activity (HNPEK),
-Cefotetan and Cefoxitine have anaerobic activity (B. fragilis)
3rd generation cephalosporins
Group 1:
-IV Ceftriaxone
-PO Cefdinir
–> less staphylococci coverage but better streptococci coverage
Group 2:
-IV ceftazidime, ceftazidime/avibactam
–> pseudomonas
4th generation Cephalosporins
IV cefepime
–> broad spectrum: gram +, HNPEK, CAPES, pseudomonas
5th generation cephalosporins
IV ceftaroline (Teflaro)
-less staphylococci coverage but better streptococci coverage
HAS MRSA COVERAGE
Cephalosporin class trends
-no enterococcus coverage
-does not cover atypical
-do not use with beta-lactam allergy and risk of seizures
outpt/oral cephalosporins: 1st gen
–> Cephalexin (Keflex)
-strep throat, MSSA skin infections (Staph)
outpt/oral cephalosporins: 2nd generation
–> Cefuroxime
-acute otitis media, CAP, sinus infections
outpt/oral cephalosporins: 3rd generations
–> Cefdinir (Omnicef)
- CAP, sinus infections
Inpt/parenteral cephalosporin use: 1st gen
–> cefazolin
-surgical prophylaxis
Inpt/parenteral cephalosporin use: 2nd gen
–> Cefotetan, Cefoxitin
-anaerobic coverage (B. fragilis)
-surgical ppx (GI procedures)
–> Cefotetan
AE: can cause a disulfiram-like reaction w/ alcohol ingestion
Inpt/parenteral cephalosporin use: 3rd gen
–> Ceftriaxone and cefotaxime
-CAP, meningitis, SBP, pyelonephritix
–> ceftriaxone does not need renal adjustment
AE: do not use with neonates (0-28 do)
–> ceftazidime:
-pseudomonas
Inpt/parenteral cephalosporin use: 4th generation
–> Cefepime
-pseudomonas
Inpt/parenteral cephalosporin use: 5th generation
–> ceftaroline
-MRSA, CAP, skin and soft tissue infections
Carbapenems: Study tip
–> IV Meropenem
–> IV/IM Ertapenem (Invanz)
Class effects:
-cover ESBL orgs (e. coli, klebsiella)
-pseudomonas (exceot ertapenem)
-beta-lactam allergy and seizures (do not use)
–> All are IV (NS must be used for ertapenem)
DOES NOT COVER:
-atypical, VRE, MRSA
-Ertapenem does not cover PEA (pseudomonas, enterococcus, acinetobacter)
Common uses:
-polymicrobial infections (severe diabetic foot infection)
-empiric therapy when multi drug resistance are suspected
Exam Scenario: if you see a carbapenem as a choice (meropenem, ertapenem (Invanz)
-PCN allergy: do not choose carbs
-if culture is growing EBSL + (e. coli) - yes choose it!
-if the culture is growing pseudomonas: do not choose ertapenem
-PMH: seizures, epileptic drug- do not use
Monobactam: Aztreonam (Azactam)
-IV only
CAN BE USED IN PTS WITH BETA LACTAM/PEN ALLERGY
-covers gram -, including pseudomonas
Aminoglycosides facts
Gentamicin, tobramycin (trough < 2, draw 30 mins before 4th dose) , amikacin
Coverage:
-gram -, including Pseudomonas, synergy for gram + (staphylococci/Enterococci)
SEs:
-toxicities like nephroxicity, ototoxicity
-taking advantage of the concentration dependent killing –> give larger doses less frequently –> this gives the kidneys time to recover in between doses
Quinolones
–> ciprofloxicin, levofloxicin, moxifloxicin, ofloxacin
-concentration-dependent killing
BBW: tendon rupture, peripheral neuropathy, CNS effects (use last line)
Warnings: QT prolongation, hypo/hyprtglycemia, psychiatric disturbances, photosensitivity, avoid use in children
Interactions: chelation with divalent cations
Respiratory quinolones (My Good Lungs)
-active againse S. pneumoniae
Levofloxacin
Gemifloxicin
Moxifloxaxin (IV:PO = 1 to 1, not renally adjusted, do not use for UTIs)
Anti-pseudomonal quinolones
-levofloxacin ( IV:PO = 1 to 1)
-Ciprofloxacin
–> pseudomonas infections, UTI, intra-abdominal infections, travelers diarrhea
Quinolones profile review tips
-caution in pts with CVD, dec mg/k, use of other QT prolonging drugs
-avoid if seizure hx or suing an antiepliptic drug
-avoid in children
-watch for tendon rupture, neuropathy, CNS/psychiatric SEs
Macrolides
-Azithromycin (Zithromax)
-Clarithromycin (Biaxin)
-Erythromycin (EES)
Coverage:
-atypical pathogens (Legionella, chlamydia, Mycoplasma, Mycobacterium avium)
-H. influenzae
-S. pneumoniae
Common uses of macrolides
-CAP, strep throat
–> Azithromycin: COPD exacerbation, pertussis, chlamydia (in prego pts), ppx for mycrobacterium avium complex, severe travelers diarrhea
- z pack: 500 mg (2 350 mg on day 1), then 250 mg x 4 days
–> Clarithromycin: H. pylori tx
–> Erythromycin: inc gastric motility, used in gasteroparesis
Macrolide safety issues
-QT prolongation: caution in CVD, dec Mg/K, use other QT prolonging drugs
-drug interactions: clarith/erthyo: CI with simvastatin and lovastatin
Tetracyclines agents & coverage
-Doxycycline (Vibramycin)
-Minocycline (minocin, Solodyn)
-Tetracycline
Coverage:
-S. aureus (including CA-MRSA)
-H. influenzae, Moxraella, atypicals +/- S. pneumo
-Rickettsiae
-H. pylori
-VRE
Common uses of tetracyclines
-CA-MRSA skin infections, acne (doxy and mino)
-Doxycycline: tick-borne illness (lymes, rocky mountain spotted fever), chlamydia, CAP, COPD exacerbation, bacterial sinusitis, VRE, UTI
-Tetracycline: H. pylori
Safety issues with tetracyclines
-avoid use in children < 8 y/o, pregnancy and breast feeding
-photosensitivity
-interactions w/ divalent cations
-IV:PO = 1 to 1 (doxy, mino)
-mino: DILE
Sulfonamides: sulfamethoxazole/trimethoprim (Bactrim)
-dosed based on TMP component
-treat uncomplicated UTI: 1 DS tab PO BID x 3 days
-do not use if sulfa allergy, pregnant or breastfeeding
Warnings: skin reactions (SJS/TEN), G6PD deficiency
SE: photosensitivity, in K, hemolytic anemia (positive Coombs test), crystalluria
SMX/TMP (bactrim) uses and SEs
Common uses:
-CA-MRSA infections
-UTI
-Pneumocystis pneumonia
5:1 Ration SMX/TMP: *dosing
-SS tab = 80 mg
-DS tab = 160 mg
Sulfa allergy:
-rash/hives are common
-can causes severe skin reactions
–> can inc INR when used with Warfarin (bactrim is 2C9 inhibitor
Abx for gram + infections: Vancomycin
Coverage:
-MRSA
-streptococci
-Enterococci
-C. diff (only time to use PO, 125 mg QID x10d)
Dosing:
-IV: 15-20 mg/kg q8-12 h using TBW (adjust in renal failure)
–>monitor SCr and avoid other nephrotoxic or ototoxic drugs (furosemide, aminoglycosides, cisplatin)
Key points about vancomycin
-1st line for MRSA infections (pneumonia, meningitis, bacteremia, some skin infections)
-target through for severe infections: 15-20 mcg/ml
-red man syndrome with rapid infusions
-PO only for c.diff infections (125 mg QID x 10d)
-ototoxicity, nephrotoxicity
**MIC > 2 = do not use
Lipoglycopeptides: Telacancin, oritavancin, dalbavancin
Coverage:
-MRSA
-streptococci
-Enterococci
-approved fro skin infections (telavancin approved fro HAP/VAP)
-can all cause red man syndrome
–> orit and dalb are single dose regimens
BBW: fetal risk, nephrotoxicty, inc mortality
CI: concurrent use of IV UFH
Warnings: inc aPTT/PT/INR
Abx for gram +: Daptomycin (Cubicin)
-coverage:
-MRSA
-streptococci
-Enterococc
-VRE
–> approved for SSTIs, bloodstream infections/endocarditis
Warnings: myopathy and rhabdomyolysis, falsely inc PT/INR
-compatible with NS and LR only
*do not use for pneumonia (surfactant in the lungs)
-monitor CPK weekly
Oxazolidonones: Linezolid (Zyvox), Tedizolid
Covers:
-MRSA
-streptococci
-Enterococc
-VRE
IV:PO = 1:1
CI: no MAOi within 14 days
Warnings: duration related myelosuppression - thrombocytopenia , optic neuropathy
–> Serotonin syndrome: caution! avoid tyramine- containing foods (ages, pickled)
Quinupristin/Dalfopristin (synercid(
Covers: MRSA, VRE (E. faecium only)
Indications: skin/soft tissue infection
Poorly tolerated: arthralgias/myalgias, infusion reactions, hyperbilirubinrmia- only give via central line
*compatible with D5W only!
Tigecycline (Tygacil)
Covers: MRSA, VRE, gram -, anerobes, atypical
–> approved fro complicated SSTIs, intra-abdominal infections and CAP
BBW: increased risk of death, do NOT use for blood stream infections
-no activity against: pseudomonas, proteus, providencia
-solution should be yellow-orange in color
Polymyxins: Colistimethate sodium, polymyxin B
Covers: MDR gram - infections
Toxicities: nephrotoxicity, neurotoxicity
Chloramphenicol
-broad spectrum abx
-serious blood dycrasias
-gray syndrome (high serum levels, coma and die)
Clindamycin (Cleocin)
-covers: staphylococci, streptococci, and anaerobes
-no dose adjustment in renal impairment
BBW: C. diff
-positive induction test = resistance with clindamycin
Metronidazole (Flagyl)
-anaerobic and protozoal infections
-IV:PO = 1 to 1
CI: pregnancy, alcohol (dissulfiram reaction)
-metallic taste
0inc INR with warfarin
Fidaxomicin (Dificid)
-1st line tx or C. diff infections
PO only
Rifaximin
-e. coli
PO only
Uses: travelers diarrhea, prevention of hepatic encephalopathy, IBS with diarrhea
Urinary Agents: Fosfomycin
-single dose
covers: E. coli (include ESBL - producing organisms) E. faecalis (including VRE)
Urinary agents: Nitrofurantoin
drug of choice for uncomplicated UTI
-do not use if Crcl < 60
–> common dosing = macrobid 100 mg BID x 5d
Warnings: avoid G6PD deficiency, can cause hemolytic anemia (positive coombs test)
Counseling: take with food, can discolor urine (brown)
Mupirocin nasal (Bactroban)
-drug of choice when pt has MRSA colonization
-5 days of therapy, ointment
abx for CA-MRSA skin & soft tissue infections
-SMX/TMP (bactrim)
-doxyctcline
-minocycline
-clindamycin (D- test)
-Linezolid
abx for severe SSTI requiring IV tx or hospitalization
-vancomycin
-linezolid
-daptomycin
-ceftaroline
-telavancin
ABX for VRE (E. faecium)
-daptomycin
-linezolid
-tiglecycline
–> cystitis only: nitrofurantoin, fosfomycin, doxycycline
abx that cover psuedomonas aergoninosa
-pip/tazo
-cefepime
-ceftrazidime
-ceftozidime/avibactam
-ceftolozone/tazobactam
-ciprofloxicin
-levofloxacin
-aztreonam
-aminoglycosides
-colisitmethate
-polymixin B
abx for carbapenem-resistant gram - rode (CRE)
-caftazidine/avibactam
-colistimethate
-polymyxin B
abx for Bacteroides fragilis
-metronidazole
-cefotetan
-cefoxitin
-carbapenems
abx for C. diff infections
-vancomycin (PO)
-fidaxomicin
-metronidazole
abx for MRSA
-vancomycin
-linezolid
-daptomycin (not in pneumonia)
-ceftaroline
what abx require refrigeration after reconstitution
-pen VK
-ampicillin
-amoxicillin/clavulanate (Augmentin)
-cephalexin (Keflex)
which abx should NOT be refrigerated?
-cefdinir
-azithromycin
-doxycycline
-ciprofloxacin
-clindamycin
abx that DO NOT require renal dose adjustments
-antistaphylococcal penicillins (nafcillin, dicloxacilin, oxicillin)
-ceftriaxone
-clindamycin
-doxycycline
-macrolides (azithromycin, erthrymycin)
-metronidazole
-moxifloxacin
-linezolid
which abx needs light protection during admin?
-doxycycline
-micrafungin
which abx are only compatible with dextrose?
-quinupristine/dalfopristin
-bactrim
-amphotericon B
which abx are only compatible with Saline?
-ampicillin
-ampicillin/sulbactam
-ertapnem
-daptomycin
Preoperative ABX Prophylaxis: prior to surgery
-infused abx:
–> betalactams (cefazolin or cefuroxime) within 60 mins of first incision
–> quinolone or vancomycin are used, start infusion 120 mins before first incision
Preoperative ABX Prophylaxis: intra-operative
additional doses may be administered for longer surgeries:
- > 4 hrs or major blood loss
-frequency is based on abx 1/2 life
Preoperative ABX Prophylaxis: post operative
< 24 hr for most procedures
–> extending the duration does not have clinical benefit. can lead to:
-increased risk of AEs
-antimicrobial resistance
-C. diff infection
ABX Prophylaxis: cardiac, orthopedic and vascular surgeries
Organisms: staphylococci & streptococci
Preferred abx: Cefazolin or Cefuroxime
Beta lactam allergy: vancomycin (can add on if MRSA risk) or clindamycin
ABX Prophylaxis: Gastrointestinal Surgeries
Concerning orgs: staphlococci, streptococci, e. coli, Klebsiella, B. fregellias
Preferred abx:
-ampicillin/sulbactam
-cefoxitin
-cefotetan
-cephalosporin + metronidazole (adds on anaerobic activity)
Beta lactam allergy:
-metronidazole or clindamycin + fluoroquinolone or amino glycoside
Common pathogens that cause bacterial meningitis: gram +
-cocci chains: group B streptococcus
-cocci pairs: streptococcus pneumoniae
-Bacilli rods: Listeria monocytogenes
Common pathogens that cause bacterial meningitis: gram -
-cocci pairs: Neisseria meningitidis
-coccobacilli: Haemophilus influenzae
-bacilli rods: e. coli
Empiric tx of Community - acquired Bacterial Meningitis: tx principles
–> IV dexamethasone (0.15 mg/kq q6) to reduce neurologic complications just before or with 1st dose of abx (x 4 days, d/c if org is NOT s. pneumonia)
–> IV abx duration
-N. menigitidis and H. influenzae: 7 days
-S. pneumoniae: 10-14 days
-Listeria monocytogenes: at least 21 days
Empiric tx of Community - acquired Bacterial Meningitis: < 1 month (neonates)
–> e. coli, group B strep, listeria
-Ampicillin + ceftaximine or gentamicin
DO NOT USE ceftriaxone
Empiric tx of Community - acquired Bacterial Meningitis: 1 month - 50 y/o
1-23 month: S. pneumoniae, N. meningitidis, H. influenzae, E. coli, group B strep
2- 50 y/o: S. pneumoniae, N. meningitidis
-Ceftriaxone or cefotaxime + vancomycin
Empiric tx of Community - acquired Bacterial Meningitis: > 50 y/o or immunocompromised
-S. pneumoniae, N. meningitidis, listeria
-Ampicillin + ceftriaxone or cefotaxmine + vancomycin
Acute Otitis. Media tx
Bacteria: S. pneumonia, H. influenzae, M. catarrhalis
1st line:
–> Amoxicillin or Amoxicillin/clavulanate ( 90 mg/kg/day D BID)
Alt (mild penicillin allergy)”
–> Cefuroxime
–> Cefdinir
–> Cefpodoxime
–> Ceftriaxone IM x 1-3 days
Tx failure:
–> Amoxicillin/clavulante (if used amoxicillin first)
–> ceftriaxone IM x 3 days
duration 5-10 days (younger pts get longer tx)
Upper respiratory tract infections
-Common cold: OTC products
-Influenzae: Oseltamivir (Tamiflu), Baloxavir (Xofluza) if symptom onset < 48 hrs or inpatient/high risk
-Pharyngitis: + antigen test - Pen VK, amoxicillin (alts = macrolides, clindamycin)
-acute sinusitis: amoxicillin/clavulanate IF symptoms > 10 days, facial pain, purulent nasal drainage or temp > 102 for > 3 days, or worsening of symptoms
Bronchitis, Pertussis and COPD exacerbation tx
B: dextromethorphan, guaifenesin - abx not indicated
P: azithromycin, clarithromycin
COPD: O2, SABA, IV/PO steroids
–> abx if: inc dyspnea, sputum volume, sputum purulence or mechanically ventilated: amox/clav, azithromycin, doxycycline, resp. flouroquinolones for 5-7 days
TX of CAP: outpatient
Healthy w/ no comorbidities:
- Amoxicillin high dose ( 1 gram TID)
-Doxycycline
-Macrolide (azithro, clarithro if local resistance < 25%)
High - risk w/ comorbidities ( chronic heart, lung, liver or renal disease)
-Beta lactam (amox/clav or cephalosporin) + macrolide or doxycycline
-respiratory fluoroquinolone mono therapy (moxi or levo)
CAP tx: Inpatient
Non severe/non-ICU:
-beta lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam, ceftaroline) + macrolide or doxycycline
-respiratory fq monotherapy
Severe/ICU
-beta lactam + macrolide
-beta lactam + resp fq
HAP & VAP Empiric tx regimen
-at least 1 abx with both pseudomonas and MSSA: cefepime, pip/tazo, meropenem, levofloxacin
-MRSA risk (IV abx in the past 90 days, MRSA prevalent > 20%, prior MRSA infection or + MRSA nares): add vancomycin or linezolid
-MDR gram - or MRSA risk (IV abx in past 90 days, gram - resistance > 10%, hosp. > 5 days prior to vental.): use 1 abx for pseudomonas (ex: pip/tazo + cipo + vancomycon)
Treatment Regimens for Latent TB
-INH + rifapentine weekly x 12 weeks – observe pt, do not use with pregnancy (give B6)
-INH + rifampin daily x 3 months (give B6)
-Rifampin daily x 4 months
-Isoniazid daily x 6 or 9 months – for HIV pts, give B6
Treatment of Active TB
–> Initial intensive phase (2 months) with RIPE:
-Rifampin
-Isoniazid
-Pyrazinamide
-Ethambutol
–> continuation phase (> 4 months) with RI: (no evidence of resistance & repeat sputum cultures are neg)
-Rifampin
-Isoniazid
RIPE therapy for TB: key features
-monitor infection: sputum sample, symptoms and chest x-ray
-all RIPE drugs inc LFTs
–> Rifampin: orange bodily secretions, strong CYP450 inducer (can use rifabutin if DDIs), flu-like symptoms
–> Isoniazid: peripheral neuropathy: with with pyridoxine (vit B6) 25-50 mg PO daily, monitor for symptoms of DILE
–> Rifampin and Isoniazid: risk for hemolytic anemia
–> Pyrazinamide: inc uric acid - do not use with acute gout
–> Ethambutol: visual damage (requires baseline and monthly vision exams), confusion/hallucinations
Pathogen-directed treatment of Infective Endocarditis: Viridans streptococci
-Penicillin or Ceftraixone ( +/- Gentamicin)
Beta lactam allergy: Vancomycin
Pathogen-directed treatment of Infective Endocarditis: Staphylococci
-Methicillin-susceptible: Nafcillin or Cefazolin
-Methicillin-resistant: Vancomycin or daptomycin
-Prosthetic valve: add gentamicin & rifampin to above
Beta lactam allergy: Vancomycin
Pathogen-directed treatment of Infective Endocarditis: Enterocci
-Native & prosthetic valve: Penicillin or Ampicillin + Gentamicin or high dose ceftriaxone
-Vancomycin resistant: Linezolid or daptomycin
Beta lactam allergy: Vancomycin + gentamicin
Infective Endocarditis Prophylaxis
1st line: Amoxicillin 2 gram PO
If unable to take PO: Ampicillin 2 gram IV/IM or Cefazolin 1 gram IV/IM
Penicillin allergy: Azithromycin or Clarithromycin 500 mg PO or Doxycycline 100 mg PO
administer as a single dose 30-60 mins prior to the dental procedure
Spontanesous Bacterial Peritonitis tx
PMN > 250 cells/mm3
-1st line: ceftriaxone or cefotaxime
- critically ill or risk of MDR: pipercillin/taxobactam, meropenem
–> 5-7 day duration
SBP Prevention: (prior SBO or ascitic fluid protein < 1.5 + impaired renal/hepatic function
–> SMX/TMP or flouroquinolone (cipro) indefinite or until post-liver transplant
Impetigo Treatment
Pathogens: staph aureus, Group A strep
Topical: Mupirocin, retapamulin
Oral: Cephalexin, dicloxacillin
Folliculitis, fureneles + carbuncles tx
–> S aureus (MSSA, MRSA)
Oral: sulfazmethoxazile/trimethoprim, doxycycline
Cellulitis tx
Purulent (MSSA, MRSA): I&D PLUS SMX/TMP or doxycycline
Non-purulent: Dicloxacillin or cephalexin
-beta latam allergy: clindamycin
Severe: vancomycin, daptomicin, linezolid
Treatment of Necrotizing Fasciitis
urgent surgical debridement AND
-pip/tazo or meropenem + vancomycin or damptomycin + clindamycin
Empiric tx of Diabetic Foot Infection
No concern for Pseudomonas or MRSA:
-Ampicillin/sulbactam
-Ertapenem
-Moxifloxacin
-Metronidazole + Ceftriaxone
Concern for Pseudomonas:
-Pip/tazo
-Meropenem
-Metronidazole + cefepime, cipro or levo
Acute cystitis tx
-Nitrofurantoin 100 mg PO BID x 5 days (CI if crcl < 60)
-SMX/TMP DS 1 tab PO BID x3 days (CI in sulfa allergy)
-Fosfomycin 3 gram x 1 dose
Acute pyelonephritis tx
-systemic symptoms
Outpatient:
-Ciprofloxacin or levofloxacin
-Sulfamethoxazole/trimethoprim
Inpatient:
-Ceftriaxone
-Ciprofloxacin or Levofloxacin
Concerns for resistance: pip/tazo, carbapenem
Treatment of bacteremia in pregnancy
Preferred: (beta-lactams): cephalexin, amox/clavulanate
Alts (in cases of beta lactam allergy): Fosfomycin, nitrofurantoin, SMX/TMP
Treatment options for C. diff: Initial episode
-Fidaxomicin 200 mg PO BID
-Vancomycin 125 mg PO QID
–> only if above unavailable:
-metronidazole 500 mg PO TID
Duration = 10 days
Treatment options for C. difficile: recurrence & fulminant disease
-Fidaxomicin 200 mg PO BID
-Vancomycin PO + prolonged taper
–> 2+ recurrences
-Vancomycin PO + rifaximin x 20 days
-fecal microbiota transplant
Fulminant: (hypotension, shock)
-Vancomycin 500 mg PO/NG Q6h (or PR if ileus) PLUS IV metronidazole
Symptoms of common STIs
-Chlamydia: genital discharge or no symptoms
-Gonorrhea: genital discharge or no symptoms
-Genital warts: single ot multiple pink/skin-toned lesions
-Latent syphillis: asymptomatic
-Primary syphills: painless, smooth genital sores
Females only:
-bacterial vaginosis: vaginal d/c (clear, white or gray) that has a fishy odor and pH > 4.5
-Trichomoniasis: yellow/green, frothy vaginal d/c with pH > 4.5, soreness, pain with intercourse
Syphilis tx
-treponema pallidum
tests: VDRL, PRP test
–> Penicillin G benzathine (Bicillin LA) 2. 4 mill IM x1 (latent gets 3 doses)
-beta lactam allergy: doxycycline x 14 days
Penicillin desensitization for syphilis
desensitization is required in: neurosphylis, pregnancy and expected suboptimal adherence to doxycycline
-confirm the allergy with a skin test, temp desensitize with an approved protocol, then treat with IM Pen G benzathine (Bicillin LA)
Gonorrhea treatment
-N. gonorrhoeae
Males: urethral d/c, dysuria or asymptomatic
Females: commonly asymptomatic, vaginal prutitis & mucopurulent cervial d/c
–> vag swab or urine test
-Ceftriaxone 500 mg IM x1 (< 150 kg)
–> if chlamydia not excluded, add doxycycline
Chlamydia treatment
-Chlamydia trachomatis
-commonly asymptomatic
-nucleic acid swab
-Doxycycline 100 mg PO BID x 7 days
Pregnancy: Azithromycin 1 gram PO x 1 dose
Bacterial vaginosis treatment
-Gardnerella vaginalis
-off-white vag d/c, fishy odor, little or no pain
-Metronidazole 500 mg PO x 7 days
-Metronidazole 0.75% gel x 5 days
-Clindamycin 2% cream x 7 days
Trichomoniasis treatment
-Trichomoniasis vaginalis
-yellow/green, frothy d/c, foul odor, soreness and pain
Females: metronidazole 500 mg PO x 7 days
Males: metronidazole 2 g PO x1
Genital Wart treatment
-HPV strains 6 & 11
-lesions range from smooth, flattened papules to cauliflower-like growths
-Imiquimod cream (immune activator)
-Podofilox solution or gel (causes wart necrosis)
-prevention: Gardasil 9, barrier contraception
Lyme Disease tx
-Borrelia burgdorferi
-erythema migraines flu-like symptoms, can lead to disseminated disease & organ dysfunction, chronic disorders
PO doxycycline, amoxicillin, or cefuroxime
Severe cases: IV ceftriaxone
Rocky Mountain Spotted Fever treatment
-Rickettsia rickettsii
-fever, HA, muscle pain, erythematous petechial rash appears 3-5 days after initial symptoms
Adults and peds: Doxycycline 100 mg PO/IV BID x 5-7 days
Erlichiosis treatment
-caused by Ehrlichia chaffeensis
-endemic to southeastern and south central US
-symptoms: flu-like illness, confusion
-PO doxycycline
Amphotericin B
-conventional and lipid formulation
BBW: mixing dosing of diff formulations can result in cardiopulmonary arrest
SE: infusion related: fever, chills, HA, malaise, rigors, dec K, Mg, nephrotoxicity
–> premedicate with APAP/NSAIDs, diphenhydramine
use a filter
Flucytosine
-used in combo with amphotericin B for tz of invasive Cryptococcal (meningitis) or Candida infections
SE: myelosuppression
-oral only
Key issues with Azole antifungals
Class effects:
-inc LFTs, hypokalemia
-QT prolongation (except isavuconazonium)
-many drug interactions
Drug specific concerns:
-Fluconazole: requires renal dose adjustment
-Ketoconazole: hepatotoxicity (mainly used topically)
-Itraconazole: can cause HF - used for nail bed fungal infections
-Voriconazole: can cause visual changes and phototoxcity
-Posaconazole: take with food
IV Admin:
-IV to PO ratio is 1:1 for all azoles
Antifungal agents: Echinocandins
-Caspofungin (Cancidas)
-Micafungin (Mycamine)
–> for Candida species C. glabrata and C. krusei
-IV only, no adjustments for renal failure
Warning: histamine mediated symptoms
SE: inc LFTs, HA, hypotension
Treatment of Influenza
–> use within 48 hrs of symptoms or contact
Warning: neuropsychiatric symptoms
-Oseltamivir (Tamiflu):
tx: 75 mg PO BID x5 d
ppx: 75 mg PO qd x 10 d
GI SEs common- n/v
-Zanamivir (Relenza Dishkaler)
tx: 2 inhalations BID x 5d
ppx: 2 inhalations qd x 10d
CI: breathing problems, can cause bronchospasm
Treatment for Herpes Simplex and Varicella Zoster Viruses
-Acyclovir (Zovirax) (IV, PO, buccal, topical)
-Valacyclovir (Valtrex) (PO)
-Famciclovir (PO)
HSV encephalitis: IV acyclovir 10 mg/kg
Cytomalovirus treatment
-Granciclovir (IV)
-Valaganciclovir (Valcyte- PO)
BBW: myelosuppression, tx followed by maintenance/secondary ppx until immune system recovers
Primary ppx in pts with HIV
-Pneumocystis (PCP) : CD4 <200 or oral candidiasis
–> SMX/TMP DS qd (alts: Dapsone or Dapsone + pyrimethamine + leucovorin)
-Toxoplasma gondii encephalitis: CD4 < 100 w/ + toxoplasma IgG
–> SMX/TMP DS qd ( alts: Dapsone + pyrimethamine + leucovorin)
-Mycobacterium avium complex: CD4 < 50
–> Azithromycin 1200 mg per week (alt: clarithrymocin) + bactrim
Treatment of opportunistic infections (6 of them)
-Candidiasis: fluconazole
-Cryptococcal meningitis: Amphotericin B + flucytosine
-Cytomeglaovirus: Valganciclovir (PO) or Ganciclovir (IV)
-Mycobacterium avium: Clarithromycin/azithromycin + ethambutol
-Pneumocystis pneumonia: SMX/TMP +/- prednisone x 21 days
-Toxoplasma gondii encephalitis: Pyrimethamine + leucovorin + sulfadiazine
