ID Illness + Drug Regimen

Question 1

Non-Colorectal Surgery Prophylaxis

Answer 1

• Cefazolin
• B-lactam allergy? Clindamycin or Vanco
• Infuse 60 minutes before cut
• If using vanco or quinolone: infuse 120 mins before surgery
• D/C w/in 24 hours of surgery ending

Question 2

Colorectal/Abdominal Space Surgery Prophylaxis

Answer 2

• Cefotetan
• Cefoxitin
• Unasyn
• Ertapenem

OR

• Metronidazole + Cefazolin OR Ceftriaxone
• *Note: no pseudomonas coverage; isn’t needed**

Question 3

Meningitis Treat Durations

Answer 3

• N. meningitidis and H. influenzae - 7 days
• S. pneumoniae - 10-14 days
• Listeria Monocytogenes - at least 21 days

Question 4

Meningitis Treatments

Answer 4

• Dexamethasone can be given prior/with first abx dose
• Patient < 1 mo: Ampicillin (Listeria) + Cefotaxime or Gentamicin (CI: Ceftriaxone, biliary sludging)
• Age 1 mo - 50 years: Ceftriaxone or Cefotaxime + Vanco
• > 50 years or immunocompromised - Ampicillin (Listeria) + Ceftriaxone or Cefotaxime + Vanco
• *Ampicillin covers Listeria; add for neonates, immunocompromised, and adults >50 yo**

Question 5

Acute Otitis Media Treatments

Answer 5

• High-dose amoxicillin (80-90 mg/kg/day) or Augmentin (90 mg/kg/day)
• Non-severe penicillin allergy? Cephalosporin (IM or IV)
• Observation: 48-72 hours with mild sxs (most are viral inf.); 6-23 months: one ear; 24+ months: one/both ears
• *Use lowest dose of clavulanate to reduce diarrhea risk**

Question 6

Acute Otitis Media Durations

Answer 6

• 10 days for kids <2 year old
• 7 days for kids 2-5 yo
• 5-7 days for kids >= 6 yo

Question 7

Pharyngitis Treatment

Answer 7

• Strep throat: white patches on throat, sore throat
• Need positive rapid antigen test
• Penicillin or amoxicillin first line

Question 8

Sinusitis Treatment

Answer 8

• Drainage, pain/pressure on face
• Augmentin - 1st line
• 2nd line - cephalosporin (2nd or 3rd gen) + clinda/doxy OR resp. quinolone
• Need to wait 10 days of sxs for abx unless severe sxs (face pain, purulent discharge x3 days)

Question 9

Bronchitis

Answer 9

• Rule out pneumonia: chest x-ray doesn’t show infiltrates
• COPD Exacerbation IF mech. ventilation or purulent discharge + additional sxs: Augmentin (Alt: Azithromycin or doxycycline)
• Whooping Cough cause: azithromycin or clarithromycin or Bactrim

Question 10

Outpatient CAP

Answer 10

• Treat 5-7 days
• Category 1 (no comorbidities) - Amoxicillin high-dose (1g TID) OR Doxy OR Macrolide (if resistance < 25%)
• Category 2 (Comorbidities) - Beta-lactam (Augmentin or cephalosporin) + Macrolide/Doxy OR resp. quinolone alone
• Comorbidities: chronic heart/lung/kidney disease, DM, alcoholism, cancer, asplenia

Question 11

Non-Severe Inpatient CAP

Answer 11

• Non-ICU
• Beta-lactam + Macrolide or Doxy OR resp. quinolone alone
• Beta-lactam: usually ceftriaxone or cefotaxime (3rd gen)

Question 12

Severe Inpatient CAP

Answer 12

• ICU

- Beta-lactam + Macrolide or resp. quinolone (not Monotherapy)

Question 13

Pseudomonas/MRSA Add-ons for CAP

Answer 13

• Vanco or Linezolid for MRSA risks

- Zosyn, meropenem, or aztreonam for pseudomonas risks

Question 14

HAP/VAP Treatment

Answer 14

• All need antibiotic for MSSA/Pseudomonas: Cefepime, Zosyn
• Add Linezolid or Vanco if MRSA risk
• Typically ends up being a 3-drug regimen if MDR risk (one of each above + Gentimicin or cipro for example)
• MRSA/MDR risk factors: IV abx in last 90 days, IV drug use, positive nasal swab, >10% prevalence of pathogen resistant

Question 15

Latent TB Regimens

Answer 15

• Confirmed by TST (also PPD)
• Preferred: Isoniazid + Rifampin daily for 3 months (okay in most pts, adults and kids)
• Alt: INH daily for 6 or 9 months (preferred in preggos and any HIV pts -less DDI)
• Alt: Rifampin daily for 4 months (INH resistant/intolerant)
• INH + Rifapentine once weekly for 12 weeks via DOT (NOT recommended kids/preggo/HIV)

Question 16

Active TB Regimen

Answer 16

• RIPE x 2 months (intensive phase)
• Continuation Phase: Rifampin and isoniazid usually for 4 months (extended to 7 mo if sputum culture still positive at 2 months)
• P: pyrazinamide and E: ethambutol

Question 17

Infective Endocarditis - Viridans Streptococci

Answer 17

• Diagnosis: echocardiogram and blood cultures
• Penicillin or Ceftriaxone +/- Gent
• B-lactam allergy? Use Vanco monotherapy

Question 18

Infective Endocarditis - MSSA

Answer 18

• Nafcillin or Cefazolin
• Replace with vanco if B-lactam allergy
• Add gent and vanco if prosthetic valve

Question 19

Infective Endocarditis - MRSA

Answer 19

• Vanco (MIC < 2; don’t use if >=2)
• Add gent and rifampin if prosthetic valve
• *With gent synergy lower trough goals (<1 mcg/mL)**

Question 20

Infective Endocarditis - Enterococci

Answer 20

• Penicillin or Ampicillin + gent or ampicillin + high-dose ceftriaxone
• B-lactam allergy? Vanco + gentamicin
• VRE? Use Daptomycin or Linezolid

Question 21

Infective Endocarditis Dental Prophylaxis

Answer 21

• Amoxicillin 2g 30-60 minutes before dental procedure

- Penicillin allergy? Clindamycin (600 mg), Azithromycin or Clarithromycin 500 mg

Question 22

Intraabdominal Infections (SBP)

Answer 22

• First-line: Ceftriaxone x 5-7 days
• Bactrim or Cipro for secondary prophylaxis of SBP
• Add metronidazole to cover anaerobes (secondary peritonitis, abscess, etc.)

Question 23

Impetigo

Answer 23

• Honey-covered crusts
• Mupirocin if mild
• Cephalexin if numerous lesions

Question 24

Folliculitis/Carbuncles

Answer 24

• Systemic signs? Cephalexin

- Alternatives: Bactrim or Doxycycline (cover CA-MRSA)

Question 25

Cellulitis

Answer 25

- Cephalexin | - Beta-lactam allergy? Clindamycin (MSSA and anaerobes)

Question 26

Abscess

Answer 26

- I&D - Systemic signs? Bactrim or Doxycycline (cover CA-MRSA) - Alt w/ systemic signs: Minocycline, Clindamycin

Question 27

Severe Purulent SSTI

Answer 27

Usually staph involvement: - Vancomycin - Linezolid - Daptomycin

Question 28

Necrotizing Faciitis

Answer 28

-Vanco + B-lactam (Zosyn, meropenem, etc.)

Question 29

Moderate-Severe Diabetic Foot Infections

Answer 29

Monotherapy - Unasyn - Zosyn - Carbapenem - Tigecycline Combo Therapy -Vanco + Ceftazidime, Cefepime, Zosyn, Aztreonam, or a carbapenem Treat 7-14 days (usually polymicrobial, broad spectrum!)

Question 30

Uncomplicated UTIs

Answer 30

- Nitrofurantoin 100 mg PO BID x 5 days (CI: CrCl <60) - Bactrim DS PO BID x 3 days (CI: sulfa allergy) - Fosfomycin 3g x 1 - Phenazopyridine for urine discomfort sxs relief (red/orange discoloration)

Question 31

Pregnancy + UTI

Answer 31

Treat even if asymptomatic!! - Cephalexin - Amoxicillin - Treat 3-7 days asxs, 7 days with sxs * *Avoid quinolones**

Question 32

Acute Pyelonephritis

Answer 32

Local Quinolone Resistance < 10% - Levofloxacin - Ciprofloxacin Local Quinolone Resistance > 10% - Ceftriaxone, ertapenem, or aminoglycoside then quinolone - Bactrim - B-lactam

Question 33

Complicated UTI

Answer 33

- Carbapenem if ESBL-producing bacteria present | - Otherwise similar treatment plan to acute pyelonephritis

Question 34

Syphillis

Answer 34

- Painless, smooth genital sore (chancre) - Primary/Early/Secondary: Bicillin-LA 2.4 million units once - Late/Tertiary: Bicillin-LA 2.4 million units Qweek x 3 weeks - Alt: Doxycycline - MUST desensitize preggo patients after confirming allergy skin test

Question 35

Gonorrhea

Answer 35

- No sxs/discharge - Ceftriaxone 500 mg IM x 1 (<150 kg) - Include Doxycycline if chlamydia hasn't been ruled out

Question 36

Chlamydia

Answer 36

- No sxs/discharge - Doxycycline - 100 mg PO BID x 7 days - Azithromycin - 1g PO x 1 (pref. for preggo)

Question 37

Bacterial Vaginosis/Trichamonas

Answer 37

- Vaginosis: discharge with fishy odor - Trichamonas: yellow-green "frothy" discharge, pain during intercourse (treat in any trimester) - Metronidazole (gel option for BV)

Question 38

Genital Warts

Answer 38

- HPV; genital warts | - Imiquimod cream

Question 39

Tamiflu

Answer 39

- Used for influenza tx if criteria met: - Sxs onset w/in 48 hours** - Complication risk - Severe illness - Prophylaxis (siblings, etc.)

Question 40

Meds to Cover Pseudomonas

Answer 40

- Zosyn** - Cefepime**, ceftazidime, ceftolozane/tazobactam - Levo or ciprofloxacin - Imipenem/cilastatin or meropenem** - Aztreonam** - Tobramycin, gentamicin, or amikacin - Polymixin

Question 41

RIPE Key Notes

Answer 41

- ALL can cause hepatotoxicity - Rifampin: discolors secretions orange - Rifampin: STRONG CYP P450 inducer, flu like sxs - INH: peripheral neuropathy (P used to reduce this risk, 25 mg) - RI: take on empty stomach, hemolytic anemia risks (Coombs!) - Ethambutol: vision damage, confusion/hallicination - Pyrazinamide: increases UA (gout attacks)

Question 42

SSTI Moderate Sxs

Answer 42

Systemic! - Fever > 100.4 F - HR > 90 - WBC > 12000 or < 4000

Question 43

SSTI Severe Classification

Answer 43

- Failed I&D - Purulent on oral abx - Deep infection - Immunocompromised

Question 44

Traveler's Diarrhea

Answer 44

- Loperamide for sxs relief - Preferred: azithromycin (good in preggo, kids, blood stool, fever) - Alt: rifaximin, levofloxacin, ciprofloxacin (inappropriate for above conditions)

Question 45

Rickettsial Disease

Answer 45

- Doxycycline - Use even in peds patients (benefits > risk) - Ex: Lyme disease (bullseye rash), typhus - Lyme confirmed by ELISA