Infections and antibiotics

Question 1

What is the treatment for gonorrhea/chlamydia?

Answer 1

ceftriaxone IM 500mg for co-infection
Doxycycline 100mg BID x7d for chlamydia (not pregnant)
Azithromycin 1mg PO or amoxicillin 500mg TID x 7d for chlamydia (pregnant)

Question 2

What is the treatment for PID

Answer 2

Outpatient: ceftriaxone IM 500mg + doxycycline 100mg BID x14d + flagyl (metronidazole) 400mg BID x14d

Inpatient: ceftiraxone 1g IV q24 + doxy 100mg PO/IV BID + flagyl 500mg PO/IV q12
OR
cefoxitin 2g IV q6
OR
cefotetan 2g IV q12 + doxy 100 BID and transition all to 14d total oral doxy + flagyl

Question 3

What is the treatment for BV?

Answer 3

Clindamycin 2% cream 5g x 7d
OR flagyl 500mg BID x7d
OR flagyl 0.75% gel intravaginal x5d

Question 4

What is the treatment for cystitis?

Answer 4

Bactrim (trimethoprim + sulfamethoxazole) 100/80mg BID x3d (preferred)
OR
Macrobid (Nitrofurantoin) 100mg BID x7d
OR
Fosfomycin 3g PO x1

Question 5

What is the treatment for pyelonephritis?

Answer 5

CTX 1g IV q24 then PO meds for 7d

Outpatient: ciprofloxacin 500mg BID x7d

Question 6

What is the criteria for diagnosis of pID?

Answer 6

low abdominal/pelivc pain in sexually active and no other obvious causes OR one of following 3 major criteria:
- adnexal tenderness, uterine tenderness, CMT

supporting evidence: fever, mucopurulent discharge, WBC on saline wet prep, +GC/CT, elev CRP/ESR, WBC >10, gram + diplococci on gram stain.

specific for ddx: EMB confirming endometritis, TVUS/MRI w/ thickened fluid filled tubes and TOA, laparoscopy w/ confirmed findings of PID

• criteria for inpatient PID: cannot r/o surgical emergency, pregnantt, no clinical response to oral abx.

Question 7

What is tuberculosis diagnosis?

Answer 7

PPD - administered intradermally. Wait 48hr to interpret. positive induration >10mm

IGRA blood test: detects immune response to TB bacteria

CXR: apical cavitation, hilar LAD

EMB: Longhand giant cells. mycobacterium tuberculosis on culture.

Question 8

What is tuberculosis treatment?

Answer 8

6-9 months
Isoniazid: 5mg/kg/d
Rifampin (interferes w/ OCP): 10mg/kg/day
Ethambutol (if isoniazid resistance): 15 mg/kg/day
Supplement w/ B6 to reduce risk of neurotoxicity.

2 phases tx: 4 drugs for 2 months then 2-3 drugs for 2-7 months.

Test for TB if clinical suspicion: F, night sweats, weight loss, cough. Get CXR and 3 sputum samples for culture, AFB stain.

Question 9

How many kids <5 are hospitalized each year for RSV?

Answer 9

60-80K. What treatments? Supportive (O2, IVF, intubation in severe cases)

Question 10

How do you counsel patients about RSV vaccine?

Answer 10

asic hand hygiene. Vaccination between 32-36wks btw Sep and Jan, prevents infection in newborns. Risk severe infection in newborn reduced by 80%. If decides against it, infant will need monoclonal Ab. If gets it, won’t need monoclonal Ab. vaccine must be given 14d prior to birth.

Question 11

What is sepsis in pregnancy?

Answer 11

2nd leading cause of maternal deaths.
life threatening organ dysfunction 2/2 dysregulated response to infection
- septic shock: subset w/ circulatory dysfunction. persistent hypotension requiring vasopressors to maintain MAP>65 and lactate >2 despite fluid resuscitation.

Question 12

What is workup and management of sepsis in pregnancy?

Answer 12

quick SOFA score: systolic BP <100, RR>22, AMS. If 2+ present, risk of sepsis.

ddx: infectious and non-infectious (DKA, adrenal crisis, cardiomyopathy, anaphylaxis) causes. Get CBC w/ diff, CMP, serum lactate, coagulation studies, ABG, peripheral blood smear/Blood cultures, sputum cx, urine.

tx: IVF (1-2L IV crystalloid-LR), strict I/O, norepi=1st line vasopressor. use vTE prophylaxis, insulin prn.

Question 13

What is organ damage caused by sepsis?

Answer 13

CNS: AMS
Cards: hypotension from vasodilation/3rd spacing, myocardial dysfunction
Pulm: ARDS
GI: paralytic ileus
Hepatic: hepatic failure
GU: oliguria or AKI
Heme: DIC or thrombocytopenia
Endocrine: adrenal dysfunction, incr insulin resistance.

Question 14

What are sources of infection in sepsis?

Answer 14

Obstetric: septic AB, chorio, endometritis, wound infection
NOn-OB: UTI, pneumonia, appendicitis, UTI, GI

most common cause antepartum=GU (peel). Intrapartum, GU and respiratory. Most frequent organisms: E. coli and GBS/group A strep.
- incr risk PTD, prolonged recovery, stillbirth and maternal death.

Question 15

What is differential diagnosis for pregnancy w/ respiratory illness?

Answer 15

Differential: influenza, covid, RSV, allergies, URI
Flu vaccine should be given by end of October

How do you counsel pt about influenza vaccine
Quadrivalent: 2 strains of influenza A and 2 strains of influenza B
Given for all age 6 months or older
Flu season: Oct to May
Can you receive antiviral treatment for both flu and covid infection at same time?
Yes. Tamiflu and Paxlovid should be taken together.

Question 16

What is expedited partner therapy?

Answer 16

GC/CT, trich
- preferable for partner to have complete STI evaluation but if not possible, EPT okay.

• provide abx to patient AND partner at time of visit. written instructions for STI testing, medical evaluation places.
• test of Cure for patient not indicated, retest for re-infection in 3 months

Question 17

What are recommendations for gonorrhea tx?

Answer 17

ceftiraxone: 500mg IM if <150kg or 1000mg if <150kg
- stopped CTX/azithro bc decreased susceptibility of GC to azithro

Question 18

What is management of HSV in pregnancy?

Answer 18

75% w/ HSV will have recurrence in pregnancy.
primary outbreak at delivery=40-80% risk transmission.

Neonatal HSV: disseminated, CNS, and skin/eye/mouth. occurs w/ primary infection in 1st tri (can cause chorioretinitis, microcephaly, skin lesions).

ddx: PCR>culture. type-specific abx testing.

Question 19

What is treatment of HSV in pregnancy?

Answer 19

antivirals inhibit DNA replication. reduce viral shedding and persistence of lesions.

• suppression at 36w to decr risk outbreak at delivery, reduce risk CS.

1. Acyclovir (most studied)
   - primary: 400 TID x 7-10d
   - recurrent: 400 TID x 5d
   - suppression: 400 TID daily
2. Valacyclovir: greater bioavailability=reduced dose frequency.
   - primary: 1000mg BID x 7-10d
   - recurrent: 500mg BID x 3d
   - suppression: 500mg BID daily
3. Famciclovir (no data in pregnancy)

Question 20

What is the treatment for endometritis? What do the antibiotics cover?

Answer 20

Gent dosing: 5 mg/kg q24 covers gram negatives
Clinda dosing: 900mg q8 covers anaerobes
Can add Amp if GBS pos 2g IV q6 bc clinda can be resistant to GBS pos.