Infections and antibiotics Flashcards
How do you treat gonorrhea
Ceftriaxone 500mg IM x1 dose
Ceftriaxone 1000mg IM x1 dose if kg >150
Post exposure Doxy can be used for pts at increased risk of Gonorrhea/syphilis
How do you treat chlamydia
Doxycycline 100mg PO BID x7 days
Pregnant:
Azithromycin 1g PO x1 day
Amoxicillin 500mg TID x7 days
How do you treat endometritis/ PID
Outpatient:
Ceftriaxone 500mg (1g if >150kg) IM
PLUS
Doxycycline 100mg BID x14 days
PLUS
Metronidazole 500mg BID x14 days
Inpatient:
Ceftriaxone 1g IV q 24hrs
PLUS
Doxycycline 100mg PO/IV BID
PLUS
Metronidazole 500mg PO/IV BID
OR
Cefoxitin 2g IV q6 hrs
OR
Cefotetan 2g IV BID
PLUS
Doxycycline 100mg PO/IV BID
Then transition to flagyl and doxy for 14 days PO
How do you treat BV
Metronidazole 500mg PO BID x7 days
OR
Clindamycin 2% cream 5g per vagina qHS x7 days
OR
Metronidazole gel 0.75% 5g per vagina qHS x5 days
How do you treat UTI (cystitis)
Trimethoprim + Sulfamethoxazole 100/800mg BID x3 days
OR
Nitrofurantoin 100mg BID x7 days
OR
Fosfomycin 3g PO x1
Give quinolones only if no other alternatives
How do you treat pyelonephritis
Ceftiaxone 1g IV x1 then PO meds for 7 days
Outpatient:
Ciprofloxacin 500mg PO BID x7 days
Add meds if quinolone resistance >10%
How do you treat syphilis
Primary, secondary and early latent:
Benzathine penicillin 2.4mU IM x1
Late latent, unknown:
Benzathine PCN 2.4mU IM q weekly x3 if prior negative status not confirmed
How do you diagnose PID
Sexually active woman with risk of STDs and pelvic low abdominal pain and no other cause or tenderness of cervix, uterus, or adnexa
Additional criteria:
- Temp >101
- mucopurulent discharge
- WBC on saline prep
- Elevated ESR
- Elevated CRP
- +GC/Cl
What are the criteria for inpatient tx of PID
Surgical emergency not excluded
TOA
Pregnancy
No response to oral therapy/ failed outpatient therapy
Acute peritoneal signs, N/V, high fever
Noncompliance or intolerance of tx
What are options for HIV prevention (PreP)
Pre-exposure ppx
Emtricitabine 300mg/ Tenofovir 200mg Daily
- Comprehensive prevention strategy:
- Consistent daily use
- safe sex precautions
- STD screening
- Regular HIV testing - Testing prior to initiation
- HIV negative documented
- Defer initiation if concerns for acute HIV infection
- Hep B neg
- Hep B vaccine offered
- Creatinine clearance >60 - HIV testing q 3months
What are the risks or PreP
If HIV positive during use, resistance to tx
Hep B positive– acute flare, hepatic injury
Lactic acidosis
Severe hepatomegaly/steatosis
What is PEP
Postexposure ppx for HIV
How does syphilis present
Caused by treponema palladium
- contagious during 1st and 2nd stage and in 1st year of latent stage
Primary: 9-90 days
- painless chancre
Secondary: 6wks to 6mo
- Condylomata lata, maculopapular rash, lymphadenopathy
Latent stage: follows untreated 2nd stage and can last 2-20 years (early latent <1yr, late latent >1yr)
- not infections sexually but can transmit to fetus
Tertiary:
- Gumma, cardiac lesions, tabes dorsalis, Argyll-Robinson pupil
What are causes of false positive RPR
Autoimmune disease or positive ANA
History of malaria
History of smallpox or varicella
HIV
Pregnancy
Mycoplasma pneumonia
Elderly
IV drug use
Monitoring of syphilis treatment
Non-specific tests typically return to zero
- 4-fold titer decline at 3 months
- 8-fold titer decline at 6 months
- Baseline/nonreactive at 12 months
Specific tests typically remain positive for life
Any 4 fold increase means treatment failure
Follow up titers at 6, 12, 24 months. Test for HIV
Jarisch-Herxheimer reaction:
Acute febrile reaction
Occurs in primary and early latent phase
Presents: fever, headache, arthralgia, myalgias, increased rash
Onset at 4-6 hrs post treatment
Duration 24 hrs
Release of treponema endotoxins
Not a penicillin allergy
May cause PTL and fetal distress
Differential of vulvar ulcer
HSV
Syphilis
Chancroid
Lymphogranuloma venerum
Granuloma inguinale
Bechet’s
Vulvar carcinoma
How do you treat a Bartholin’s gland abscess
treat with incision and drainage followed by a word catheter
Recurrence: marsupialization
Excise or biopsy in pts >40 to rule out adenocarcinoma
Cultures recommended due to MRSA
What is the most common pathogen in bartholin’s cyst
E. coli
Should also test for GC/Cl (NAAT)
When do you prescribe antibiotics for Bartholin’s cyst
Recurrent abscess
Extensive surrounding cellulitis
Pregnant
Immunocompromised
Risk of MRSA
Culture +MRSA
Signs of systemic disease
What is the normal pH of the vagina
4.5
What tests are available for vaginitis screening
pH, 10% KOH, wet prep with NS, commercial tests
What are the diagnostics of BV:
pH >4.5
Microscopy: clue cells (20% of epithelial cells)
Positive whiff test
What are the diagnostics of candidiasis
pH 4.0-4.5
Microscopy: candida (with KOH wet mount– budding yeast, psuedohyphae, hyphae)
Negative whiff test
What is a normal pH and microscopy
pH 4.0-4.5
Microscopy: lactobacillus, absent white cells
Whiff test negative
What are diagnostics of trich
pH 5.0- 6.0
Microscopy: motile trichomonads
Whiff test positive or negative
What is a uncomplicated yeast infection and what is the tx
Infrequent/sporadic episodes
Mild-mod symptoms
C. albicans
Non-immunocompromised
Tx with vaginal azole or oral fluconazole
What is a complicated yeast infection and what is the tx
Recurrent (4 or more episodes/yr)
Severe symptoms
Non-albicans yeast (suspected or proven)
DM, immunocompromised (HIV, steroids, debilitated)
Tx: yeast specification necessary
Non albicans: 600mg boric acid x14 days qHS
Severe: topical intravaginal azoles for 10-14 days or 3 doses of 150mg fluconazole q 3 days
Recurrent: fluconazole 150mg PO q 3 days x3, then suppressive therapy with 150mg fluconazole PO weekly x6 months OR topical clotrimazole 500mg weekly for 6 months
What are Amsel’s criteria
Diagnosis of BV (3 of 4)
- pH >4.5
- positive amine test (whiff test)
- Homogenous thin discharge coats vaginal walls
- 20% clue cells (vaginal epithelial cells studded with bacteria)
- Multiple POC tests and NAATs
What are the risks of BV
- PTL/PPROM
- PID
- post procedural GYN infections
- STI acquisition
TX: oral or vaginal metronidazole or clindamycin
What is the tx of recurrent BV
3 documented infections in 1 year
- After 7-14 days of initial therapy , twice weekly metronidazole gel for 6 months
How do you diagnose trichomonads
NAAT testing preferred
Trish on wet mount
Increased pH
Tx: flagyl 500mg BID x7 days
Retest in 3 months
How do you diagnose Tuberculosis
PPD: administered intradermally
- eval 48 hrs later, if >10mm abnormal
IGRAs (interferon gamma release assay)
- Blood test for dx of latent TB
CXR:
- Apical cavitation
- Hilar adenopathy
Endometrial bx
- Longhand giant cells on histology
- Mycobacterium tuberculosis on culture
What is the tx of TB
Isoniazid
Rifampin
Ethambutol (if isoniazid resistance)
Supplement with Vit B6 to reduce risk of neurotoxicity with isoniazid
