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Infections and antibiotics Flashcards

1
Q

What is the treatment for gonorrhea/chlamydia?

A

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

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2
Q

What is the treatment for PID

A

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

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3
Q

What is the treatment for BV?

A

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

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4
Q

What is the treatment for cystitis?

A

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

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5
Q

What is the treatment for pyelonephritis?
What is PCN allergy?

A

CTX 1g IV q24 then PO meds for 7d

alternatives: cefepime 1g BID
Amp + gent: amp 2g q5, gent 5mg/kg q24
Aztreonam if beta-lactam allergy: 1g BID

Outpatient: ciprofloxacin 500mg BID x7d

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6
Q

What is the criteria for diagnosis of PID?
Criteria for inpatient treatment?

A

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.
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7
Q

What is tuberculosis diagnosis?

A

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.

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8
Q

What is tuberculosis treatment?

A

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.

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9
Q

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

A

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

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10
Q

How do you counsel patients about RSV vaccine?

A

basic hand hygiene.

Vaccination between 32w0d-36w6d 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. Reduces the number of vaccines the infant receives at birth

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11
Q

What is sepsis in pregnancy?

A

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.

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12
Q

What is workup and management of sepsis in pregnancy?

A

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.

Workup:
-CBC w/ diff,
- CMP
- serum lactate
- coagulation studies
- ABG
- peripheral blood smear/Blood cultures
- UCx

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

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13
Q

What is organ damage caused by sepsis?

A

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.

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14
Q

What are most common sources of infection in sepsis (OB and non-OB)?

What are OB risks?

A

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

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

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15
Q

What is differential diagnosis for pregnancy w/ respiratory illness?

A

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.

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16
Q

What is expedited partner therapy?

A

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
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17
Q

What are recommendations for gonorrhea tx?

A

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

18
Q

What is management of HSV in pregnancy?

A

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.

19
Q

What is treatment of HSV in pregnancy?

A

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)
20
Q

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

A

Diagnostic criteria: need 2 of 3
- fever
- pain/tendernes
- purulent drainage

Gent dosing: 1.5 mg/kg q24 covers gram negatives
Clinda dosing: 900mg q8 covers anaerobes
Can add Amp if GBS pos (and not getting better after 48hr) 2g IV q6 bc clinda can be resistant to GBS pos.

21
Q

What are causes of watery diarrhea?

A

Infectious (norovirus, C.diff-fluoquinolones, gastroenteritis, listeria, Giardia, food poisoning), laxatives.

22
Q

What foods are high risk for contamination with listeria?
What are the symptoms?

A

Unpasteurized cheese, deli meats, smoked seafood, exposure to raw sewage

Fever, N/V, diarrhea, abdominal cramping, myalgias.

23
Q

How do you confirm the diagnosis of listeria?

What is management?

A

Blood cultures. Treat with IV ampicillin x 2 weeks. If PCN allergic? Bactrim.

Can cause fetal loss, PTL. if pt is asymptomatic, don’t treat. If some sx but no fever, don’t treat!!

24
Q

What are clinical findings of Parvo in pregnancy?

US findings?

Ddx?

A

Self-limiting. Slapped cheek rash, joint pain, fever, mild URI sx.
- causes fetal anemia, HF, hydros
- vertical transmission rate 25%

Hydrops

IgG and IgM but pCR more sensitive (on amniotic fluid).
- If IgM pos, need serial weekly US + MCAD for 8 wks to eval for fetal anemia/hydrops. IF hydros -> PUBS +IUT

Tx: PUBS looking for anemia and possible IUT
- weekly US for 2 months post-exposure

25
Q

What is clinical picture of Zika in pregnancy?
US findings?
What is diagnosis?
Treatment?

A

Mosquito born illness, also transmitted from sex. Fever, maculopapular rash, pleuritis, myalgias

Microcephay, intracranial calcifications

** IgG and IgM, PCR test 3 times during pregnancy**

none. If exposed to Zika, wait 2 months until try to conceive.

26
Q

What is clinical picture of listeria?

How to counsel patient if she hears about listeria outbreak?

Ddx/tx?

A

F, n/V, abdominal pain. Can cause fetal loss, PTL.

overall risk of exposure is low. If asymptomatic, observe for 2 months. If mild sx with NO fever: can manage as asymptomatic or send cultures and only tx if positive. IF febrile, BCx and treat.

Blood Cx. Tx=IV ampicilin x 2 weeks. If PCN allergic, trimethoprim-sulfamethoxazole.

27
Q

Which viruses are DNA viruses?

A

Hep B, HSV, HPV

28
Q

Which viruses are RNA viruses?

A

HAV, HCV, HDV, HIV

29
Q

Clinical manifestations of hepatitis?
How is acute hepatitis managed in pregnancy?
Vertical transmission of HBV without HBV/IG?

A

RUQ Abdominal pain, hepatomegaly, jaundice, N/V, fatigue, coagulopathy.

Supportive care.

40%. If HBeAg pos, 80-90%.

Risk of HIV transmission without treatment is 25%, <1% with treatment.

30
Q

Who should get tested for HCV?

A

All pregnant patients!

hIV or another hepatitis. IV drug use. Blood transfusion from donor who later tested positive. Long-term hemodialysis, chronic liver disease.

Risk of occupational exposure for physician to HBV, HIV. HBV 20-30%, HIV 0.3%.

31
Q

Pneumonia physical exam findings?

A

Decreased or bronchial breath sounds.
Crackles on auscultation of the affected regions of the lung.
Dullness on percussion

32
Q

For endometritis, why gent and clinda?

A

Gent for gram negatives, clinda for anaerobes.

– if no improvement in 24hrs, what do you do? Add ampicillin 2g q6 to broaden if GBS pos.

33
Q

What are recs for HIV in pregnancy?

A
  • screen w/ ELISA, confirmatory w/ Western blot.
  • if both pos, CD4, VL (HIV RNA PCR), CBC, LFTs.

check VL: IPV, 2–4 weeks after initiating (or changing) cART drug regimens; monthly until RNA levels are undetectable; and then at least every 3 months during pregnancy

  • if VL >1000, CS at 38 0/7 weeks of gestation to reduce the risk of mother-to-child transmission. IV zidovudine (ZDV), ideally 3 hours preoperatively as a 1-hour intravenous loading dose then continuous until delivery to achieve adequate levels of the drug in maternal and fetal blood.

if VL < 1000, avoid operative delivery, FSE, methergine in labor if using protease inhibitor.

34
Q

What is toxoplasmosis?

A

60% vertical tramission risk in 3rd trimester.
- highest severity in 1st trimester though

CLINICAL (all HEAD problems):
- intracranial calcifications
- chorioretinis
- HSM
- hearing loss
- low IQ

need serologies (IgM and IgG)

Tx: Spiramycin in 1st tri.
Pyrimethamine-sulfadiazine in 2nd tri

35
Q

What is CMV?

A

3% prevalence
30% vertical transmission, 30% of infected infants will due

CLINICAL
- chorioretinis
- HSM
- abdominal/liver calcifications
- FGR
- hydros

36
Q

What is varicella?

A

chickenpox
- pneumonia occurs in 20% pregnant woman. hIGH mortality! treat w/ IV acyclovir and iCU admission
- shingles=reactivation of latent virus.

FETAL EFFECTS
- SAB, IUFD
- congenital varicella: limb hypoplasia, microcephaly, cataracts, chorioretinis
- varicella embryopathy in 2nd trimester
- high mortality if maternal infection < 5d before delivery (Bc no passive transfer of IgG)

sx: fever, malaise, URI, rash.
dd: clinical, serologic testing IgG and IgM. PCR of vesicular fluid.
tx: Oral acyclovir 800mg 5x/day for 7d
- maternal tx DOES NOT prevent congenital varicella, only benefits mom.

Delay delivery for 1 week to allow passive transfer of IgG
- if can’t delay, give VZIG to neonate.

post-exposure ppx if non-immune: immune globulin or acyclovir.

after vaccines avoid pregnancy for 1 month!

37
Q

What is AIDS?

A

positive HIV with CD4 <200 OR 1+ opportunistic infections regardless of Cd4

screening for HIV: ELISA then confirmatory with Western blot.
- if both positive, need Cd4 count and viral load, Hep B and C testing, CBC, LFTs.

38
Q

What is the transmission rate for HIV?

What are deliver recs for HIV?

A

without zidovudine: 24%
with ZDV 8%
with ZDV and CD 2%
VL <1000, on HAART and no CD 1-2%

if unknown viral load, CD
if VL <1000, no CD. If > 1000, CD prior to labor or ROM at 38wks

intrapartum
- give IV ZDV 2mg/kg IV load then 1mg/kg/hr until delivery. if elective CD, need 3 hrs prior.
- avoid methergine with use of protease inhibitors.

39
Q

What is differential for diffuse rash in pregnancy?

A

scarlet fever, parvo, roseola, toxo, PUPPS, varicella

40
Q

how do you counsel HIV positive pt about reducing tramission?

A
  • use condoms
  • take hIV meds
  • partners should take PREP
  • annual screening for high risk behavior (multiple sexual partners and drug use)
  • serosorting and seropositioning (limit unprotected intercourse to other HIV pos and use se positions less likely to transmit hIV like oral sex, penile/vaginal vs. anal)

HIV pos can use all contraception methods if consider drug-drug interaction.

41
Q

What is prenatal treatment of HIV?

A

HAART
- 3 drugs from 2 different classes of meds (to decrease antiviral resistance).

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