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You're Passing the Exam Sis... This Isn't an Option > Infectious Diseases > Flashcards

Infectious Diseases Flashcards

Recognize common organisms + groups of organisms Focus on resistant organisms and drugs that treat them Remember spectrum of activity for antimicrobial classes Practice assessing patient profiles for the exam

1
Q

Communicable disease VS. non communicable

A

contagious, spread from person to person

Non-communicable disease: heart disease, stroke, HTN, DM

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2
Q

Hospital acquired infections are usually involving _______ _________ __________ organisms

A

multidrug resistant (MDR)

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3
Q

In order to diagnose a true infection, we need _________ & ______ in addition to positive culture

A

signs and symptoms

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4
Q

(Lipophilic? or Hydrophilic?) antibiotics are able to penetrate tissue better and resolve infections

A

lipophilic

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5
Q

The way a drug is cleared can determine the efficacy it has - ex: non renally cleared drugs may not reach adequate drug concentrations in the urine if that’s the target (UTI)

A

that’s it thats all

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6
Q

What patient characteristics can impact treatment choices

A

age, body weight, renal function, hepatic function, allergies, recent antibiotic use, pregnancy, immune function, comorbid conditions, vaccination status, environmental exposure, colonization with resistant bacteria

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7
Q

Common bacteria for CNS/Meningitis

A

Strep. pneumoniae
Neisseria meningitis
H. Influenzae
Group B Strep/ Ecoli (young pts)
Listeria (young/old)

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8
Q

Common bacteria that cause Upper Respiratory Infections

A

Strep. pyogenes
Strep. pnuemoniae
H. influenzae
Morexalla Catarrhalis

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9
Q

Common bacteria that cause Heart infections/Endocarditis

A

Staph. Aureus (including MRSA)
Staph. Epidermidus
Streptococci
Enterococci

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10
Q

Common bacteria that cause skin/ soft tissue infections

A

Staph. aureus
Staph. epidermidus
Strep. pyogenes
Pasteurella multocida
(+/- aerobic/anaerobic gram negative rods (GNR) in diabetes)

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11
Q

Common bacteria that cause bone/joint infections

A

Staph. aureus
Staph epidermidus
N. gonorrheae
Streptococci
GNR only in specific situations

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12
Q

Common bacteria that cause infections in the mouth

A

Mouth flora (peptostreptococcus)
Anaerobic GNR (prevotella, others)
Viridans group streptococci

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13
Q

Common bacteria that cause community acquired lower respiratory infections

A

Strep pneumoniae
Haemophilus influenzae
Atypicals: Legionella, Mycoplasma, Chlamydophilia
Enteric GNR in alcoholics

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14
Q

Common bacteria that cause hospital acquired lower respiratory infections

A

Staph aureus (including MRSA)
Pseudomonas aeruginosa
Acinetobacter baumannii
Enteric GNR (including ESBL, MDR)
Strep pneumoniae

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15
Q

Common bacteria that cause intra-abdominal infections

A

Enteric Gram Negative Rods
Enterococci/Strepcocci
Bacteroides Species

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16
Q

Common bacteria that cause Urinary Tract Infections

A

E Coli
Proteus
Klebsiella
Staph. Saprophyticus
Enterococci

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17
Q

Gram negative organisms

A

Thin cell wall, pink or reddish color from safranin counterstain

peptidoglycan is thin

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18
Q

Gram positive organisms

A

Thick cell wall, dark purple or blueish from the crystal violet stain

Peptidoglycan is thick

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19
Q

Atypical organisms

A

(ex: legionella, mycoplasma, chlamydia, mycobacterium tuberculosis) they don’t have a cell wall and don’t stain well.

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20
Q

Types of gram positive bacteria morphology under a microscope

A

Positive = Purple

Cocci (types: clusters, pairs (diplococci), and chains)
Bacilli aka rods
Anaerobes aka spores

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21
Q

Types of cluster (cocci) bacteria (Gram positive)

A

staphylococcus spp. (including MRSA, MSSA)

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22
Q

Types of pair & chain (cocci) bacteria (Gram positive)

A

strep. pneumoniae (diplococci = pair)
streptococcus spp.
enterococcus spp. (including VRE)

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23
Q

Types of rod (baccili) bacteria (gram positive)

A

Listeria monocytogenes
corynebacterium spp.

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24
Q

Types of gram positive anaerobes

A

Peptostreptococcus ( mouth flora)
Propionibacterium acnes
Clostridioides difficile
Clostridium spp.

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25
Q

Gram negative bacteria (pink) morphology includes

A

Cocci
Rods (that either colonize in the gut or don’t or curved/or spiral shaped)
Anaerobes
Coccobaccili (rod pairs /oval shaped)

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26
Q

Types of cocci (gram negative)

A

Neisseria spp.

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27
Q

Types of enteric rods (colonize the gut) (gram negative)

A

Proteus mirabilis, Escherichia coli, Klebsiella spp.
aka [PEK]

Serratia spp.
Enterobacter cloacae
Citrobacter spp.

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28
Q

Types of curved or spiral shaped rods (gram negative)

A

H pylori, campylobacter spp., treponema spp., borrelia spp., leptospira spp.

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29
Q

Types of rods that don’t colonize in the gut (gram negative)

A

pseudomonas aeruginosa
haemophilus influenzae
providencia spp.

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30
Q

types of coccobacilli (rod pairs /oval shaped) gram negative

A

Acinetobacter baumannii
Bordetella pertussis
Moraxella catarrhalis

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31
Q

Types of gram negative anaerobes

A

Bacterioides fragilis
Prevotella spp.

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32
Q

what is HNPEK

A

Haemophilus Influenzae
Neisseria
Proteus
E. coli
Klebsiella

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33
Q

what is CAPES

A

Citrobacter
Acinetobacter
Providencia
Enterobacter
Serratia

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34
Q

How is an antibiogram used

A

To determine the empiric therapies that can be used and help review resistance trends. Shows susceptibility patterns over a specific period (usually 1 yr) at an institution. The numbers show the percent susceptibility of each organism to the drugs

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35
Q

coccus, cocci, diplococci meaning

A

coccus - single
cocci - multiple
diplococci - pairs

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36
Q

What is an MIC

A

The minimum inhibitory concentration which is the lowest concentration with no bacterial growth

if the MIC is below the breakpoint, this means it is a good antibiotic to use!

We should never compare MIC’s between one antibiotic to another! Their values are specific to their minimum inhibitory concentration. We need to choose the MIC with the NARROWEST spectrum and (you have to know that part in your head, there’s no number associated with that)the one that is specifically best for the patient

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37
Q

What is the breakpoint

A

It is set by the clinical laboratory and standards institute and it is a standardized value for the concentration at which a particular bacteria was found to be susceptible to a particular drug

If the MIC is below the break point, it is susceptible, if it is one above the breakpoint, it’s intermediate, if it’s four above the breakpoint, its resistant

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38
Q

Synergy

A

Using two antibiotics to get a bigger benefit than just one antibiotic

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39
Q

sequence for choosing antibiotic therapy

A
  1. identify the organism through a culture
  2. check the susceptibility of the organism to different antibiotics
  3. determine with antibiotics have MIC’s below the break point
  4. determine which antibiotic has the narrowest spectrum and is the best for the specific patient (consider renal function, ability to penetrate specific area, drug interactions, dosage form, allergies, duration, adherence, inability to tolerate SE etc.)
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40
Q

How do we choose empiric treatment

A
  1. Think of the drugs that target the common organisms that infect the area where the current infection is.
  2. If there is a risk for MRSA, provide coverage
  3. Use the antibiogram and gram stain, if available, to narrow treatment selection

When the culture and susceptibility results come back in 24-72 hours, alwayssssss SET A TIME FRAME FOR THE ANTIBIOTICS! NEVER ALLOW THEM TO CONTINUE UNNECESSARILY

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41
Q

How should we monitor and assess the patients response to antibiotic treatment

A
  1. See their fever reduce and other vitals like O2 sat
  2. WBC trend
  3. Check notes for a reduction in the signs and symptoms of that particular infection
  4. Improved things like chest xrays, reduced markers of inflammation (procalcitonin, CRP, and ESR), repeat blood or CNS cultures - remember we DO NOT need to repeat sputum or urine cultures
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42
Q

E coli is resistant to vancomycin because

A

Vancomycin is too large to penetrate into Ecoli’s cell wall.

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43
Q

What is selection pressure

A

Another type of resistance.When an antibiotic kills off the bacteria that are susceptible to it, but it leaves behind the resistant bacteria and then they are able to multiply and become predominant which is a PROLEM!

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44
Q

Acquired vs. Intrinsic resistance

A

Intrinsic - the bacteria is naturally resistant to the antibiotic (ex: Ecoli and vancomycin because vancomycin is too large to penetrate the cell wall of ecoli)

Acquired - the bacterial DNA that has resistant genes is transferred from one species to another or picked up from dead fragments in the environment.

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45
Q

Describe enzyme inactivation and some examples

A

the bacteria naturally has enzymes that break down an important component of the antibiotic and reduces its effectiveness and enhances it’s resistance

Bacteria that produce beta lactamases break down beta lactams (ex: penicillins, cephalosporins, etc.) before they can reach their site of activity. We can use beta lactamase inhibitors like clavulanate, sulbactam, tazobactam, avibactam to prevent the enzymes from impacting the drug performance

ESBL’s - extended spectrum beta lactamases: enzymes that can break down all penicillins and most cephalosporins- very hard to kill and cause serious infections even with beta lactamase inhibitors. We typically use carbapenems or cephalosporin/beta lactamase inhibitor combinations

Carbapenem resistant enterobacteriacecae (CRE) are MDR gram negative organisms like Klebsiella and ecoli that produce enzymes like carbapenemases that break down penicillins and most cephalosporins and carbapenems. We use combinations of high intensity, toxic, and expensive drugs like polymixins, avibactam, and ceftazadime to kill these bacteria — this would be an advanced case of needing an ID pharmacist/antibimicrobial stewardship team to help with.

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46
Q

What are some common resistant pathogens and how are they resistant

A

“Kill each and every strong pathogen”

Klebsiella pneumoniae - ESBL, CRE
Escherichia coli - ESBL, CRE
Acinetobaceter
Enterococcus faecalis, Enterococcus faecium (VRE)
Staphylococcus aureus (MRSA)
Pseudomonas Aeruginosa

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47
Q

How does a C. Difficile infection occur

A

Clostridioides Diff. spores are present in normal gut flora, but it’s when the good healthy GI flora are killed off that resistant organisms have a chance to grow, become activated, and produce toxins. C diff does this and causes inflammation to the GI mucosa and causes a super infection. All antibiotics have a risk of causing this but especially broad spec. penicillins, cephalosporins, quinolones carbapenems, and BLACK BOX WARNING: CLINDAMYCIN not because it’s the worst offender but because it was the first offender to be identified but quinolones and broad spec. have more problems with this

Symptoms can be - mild: diarrhea, abdominal cramping severe: pseudomembranous colitis which can require a colectomy or be fatal. C diff infections continue to be difficult to treat

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48
Q

What does an anti-microbial stewardship program too

A

-Improve pt safety and outcomes
curb resistance to drugs
improve cost efficacy

Interventions ex:
- monitoring PK of aminoglycosides and vancomycin
- using clinical decision support software to help identify pathogens and reduce time to starting therapy
- pre-authorization of select antimicrobials (some antibiotics can’t be ordered unless antimicrobial steward team is consulted)
- prospective audit and feedback to prescribers of selected antibiotic
- timely transitions from IV to PO

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49
Q

Generally what types of antibiotics are bacteriocidal

A

The cell wall/membrane inhibitors, DNA/RNA inhibitors, aminoglycosides are bacteriocidal (kill bacteria)

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50
Q

Generally, what types of antibiotics are bacteriostatic ( inhibit bacterial growth)

A

Most protein and folic acid synthesis inhibitors

Example of synergy can be accomplished if we are able to pair one of these drugs with a cell wall/membrane inhibitor in order to allow the drug to even get inside the cell)

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51
Q

Which antibiotics are folic acid synthesis inhibitors

A

Sulfonamides
Trimethoprim (often combined with sulfamethoxazole overcome resistance)
Dapsone

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52
Q

Which antibiotics are cell wall inhibitors

A

Beta lactams (penicillins, cephalosporins, carbapenems)
Monobactams (aztreonam)
Vancomycin, dalbavancin, televancin, oritavancin

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53
Q

Which antibiotics are protein synthesis inhibitors

A

Aminoglycosides
Macrolides
Tetracyclines
Clindamycin
Linezolid, tedizolid
Quinupristin/Dalflopristin

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54
Q

Which antibiotics are cell membrane inhibitors

A

Polymixins
Daptomycin
Telavancin
Oritavancin

55
Q

Which antibiotics are DNA/RNA inhibitors

A

Quinolones (DNA gyrase, topoisomerase IV, metronidazole, tinidazole, rifampin)

56
Q

What are examples of hydrophillic agents

A

Beta-lactams
Aminoglycosides
Vancomycin (glycopeptides)
Daptomycin
Polymixins

57
Q

What are four key characteristics of hydrophilic agents and why is it important to remember and contrast with lipophilic

A
  • Small VD and low intracellular concentrations = poor tissue penetration and not active against intracellular pathogens
  • Renally excreted - must consider dose adjustments to avoid drug accumulation SE like nephrotoxicity and seizures
  • Increased clearance and/or distribution in sepsis so we need to use loading doses and higher doses
  • Poor /moderate bioavailability (ability to reach circulation/serum concentrations), so it’s usually not used orally unless you need it to reach a specific area (ex: oral vanc for c diff) , or the IV: PO ratio is not 1:1
58
Q

What are four key characteristics of lipophilic drugs and contrast with hydrophilic

A
  • High VD and high intracellular concentrations = great tissue penetration and active against intracellular pathogens
  • Hepatically excreted - must consider dose drug interactions and hepatotoxicity
  • Normal clearance and/or distribution in sepsis so we can use normal doses/no adjustments needed
  • Great bioavailability (ability to reach circulation/serum concentrations) IV: PO ratio is 1:1
59
Q

What are examples of lipophilic agents

A

Quinolones
Macrolides
Rifampin
Linezolid
Tetracyclines

60
Q

What is the difference between concentration dependent killing and time dependent killing and example drugs

A

Conc. dependent drugs are given in larger doses with longer time intervals in between so our goal with these is to see high peak (killing) and low troughs (toxicity). Cmax: MIC
- Aminoglycosides, quinolones, daptomycin
another ex of conc. dependent is AUC:MIC and it’s used in a similar way where we try to maximize the pts exposure to the drug over time.

Time > MIC – Time dependent killings drugs are given in more frequent time interval or each dose can have a longer administration/infusion time so that the concentration can be maximized above the MIC. So we can do extended or continuous infusions or shorter dosing intervals to try to maintain the drug level above the MIC for most of the dosing interval
- Beta lactams (penicillins, cephalosporins, and carbapenems)

61
Q

Describe AUC: MIC (exposure/concentration dependent) and mention the drugs that rely on it.

A

goal is to increase the bacterias exposure to the drug over time using variable dosing strategies

EX: Vancomycin, macrolides, tetracyclines, polymixins

62
Q

What categories of abx are beta lactams

A

penicillins, cephalosporins, carbapenems

63
Q

beta lactam abx MOA/description

A

All of them have a beta lactam ring

They bind to penicillin binding proteins (normally would help build peptidoglycan in cell wall) and inhibit the cell wall synthesis.

64
Q

True or false: penicillins are able to cover MRSA and atypical organisms

A

False. Penicillins do not cover MRSA or atypical organisms

65
Q

Which penicillins are “natural” and what are their doses/forms

A

Penicillin V Potassium PO (tablet or susp.)
125- 500 mg Q6 -12 hrs on empty stomach

Penicillin G Aqueous IV
2-4 million units Q4-6 H

**Penicillin G Benzathine (Bicillin L-A) or Pen G Benzathine +Pen G Procaine (Bicillin C-R) INTRAMUSCULAR ONLY !!
1.2-2.4 million units one time (freq. varies)
- Pen G Benzathine is only IM never IV because it can cause cardiorespiratory arrest and death!

66
Q

Which penicillins are anti-staphylococcus & what are their doses/forms and important points

A

Dicloxacillin (capsule)
PO: 125-500 MILLIGRAMS Q6H

Nafcillin (inj.)
IV/IM: 1-2 grams Q4-6H
- This is a vesicant and extravasation can occur (leaky vessels), so we should use cold packs and hyaluronidase injections

Oxacillin (inj.)
IV: 250-2,000 MILLIGRAMS Q4-6H

These are preferred for MSSA soft tissue, bone & joint, endocarditis and blood stream infections
- These DON’T need renal dose adjustments

67
Q

Which the aminopenicillins and what are their doses/forms and important counseling points for each

A

** Amoxicillin (PO - chew, tab., susp., caps.)
varied dosing, 24h ER tab is one daily
- this is rarely used bc PO has poor bioavailability!!
- CI: if CrCl< 30 ml/min, NEVER use XR amox, or XR forms augmentin or the 875 mg dose of augmentin

** Amoxicillin/Clavulanate (Augmentin, Augmentin ES-600) - (PO: tab, chew, susp.)
varied dosing, XR tablet Q12H with food
- use a 14:1 ratio of amox/clav to reduce diarrhea caused by clauv
- CI: NEVER use Augmentin or Unasyn if history of cholestatic jaundice or hepatic dysfunction assoc. with prev. use.
- CI: if CrCl< 30 ml/min, NEVER use XR amox, or XR forms augmentin or the 875 mg dose of augmentin

**Ampicillin (Inj. - IV/IM & PO - capsule, susp.)
PO - 250 - 500 MG Q6H on empty stomach 1 hr before or 2 hrs after a meal
IV/IM 1-2 GRAMS Q4-6H
- must be diluted in NS ONLY

**Ampicillin/sulbactam (Unasyn) - Inj.
IV/IM 1.5-3 GRAMS Q6H
- must be diluted in NS ONLY
- CI: NEVER use Augmentin or Unasyn if history of cholestatic jaundice or hepatic dysfunction assoc. with prev. use.

68
Q

Which penicillin is extended spectrum and what is important to know about sodium content

A

Piperacillin/Tazobactam (Zosyn) - Inj.

IV: 3.375 g Q6H or 4.5 g Q 6-8 H

PROLONGED EXTENDED INFUSIONS:
3.375-4.5 g IV Q8H (each dose infused for 4 hrs)

There are 65 g Na per 1 g of Pip/Tazo

69
Q

What are general side effects and monitoring points for all penicillins

A

SE:
- seizures can occur if drugs accumulate when not correctly dosed in pts with renal dysfunction
- GI upset, diarrhea, rash (SJS/TEN/allergy/anaphylaxis, hemolytic anemia), renal failure, myelosuppression with prolonged use, increased LFTs

Monitoring:
renal function, symptoms of anaphylaxis with 1st dose , CBC, LFT’s with prolonged course

Interactions:
- Probenacid (gout drug) can increase the levels of beta lactams because it decreases renal excretion - sometimes this combo is used intentionally in severe infections!

  • Warfarin: beta lactams inhibit vitamin K dependent clotting factors which increases warfarins anticoagulation activity. (except naf/dicloxacillin- they actually do the opposite and decrease warfarins effectiveness)
  • Penicillins increase the serum concentration of methotrexate and can decrease the conc. of mycophenolate active metabolites due to impaired enterohepatic recirculation
70
Q

What do natural penicillins cover

A

Gram + cocci (strep, enterococci, but NOT staph) and Gram + anaerobes (mouth flora)

They do not cover gram -

71
Q

Antistaphylococcal penicillins cover…

A

Streptococci,
*** MSSA (enhanced coverage for)

NO activity against enterococcus, gram neg. pathogens and anaerobes, or MRSA

72
Q

What do aminopenicillins cover

A

Strep
Enterococci
Gram positive anaerobes (mouth flora)
With the addition of the amino group, it can cover. (HNPE) Haemophilis, Neisseria, Proteus, E coli - if combined with a beta lactamase inhibitor, it creates a broad spectrum of activity for the Klebsiella too (HNPEK) and
Gram negative anaerobes (B. fragilis)

73
Q

What do extended spectrum penicillins in combo with beta lactamase inhibitor (pip/tazo) cover

A

(very broad SOA)
Cover anything that aminopenicillins/beta lactamases cover with the addition of
Pseudomonas, CAPES (nosocomial bacteria)

74
Q

Generally, all penicillins cover _______ but they dont cover ______

A

generally cover enterobacter - except for the anti-staph penicillins

They never cover MRSA or atypicals (due to lack of cell wall)

75
Q

Always avoid penicillins in patients with

A
  1. ANY beta lactam allergy (penicillins, carbapenems, cephalosporins) - unless treating syphilis in pregnancy or in patients with poor compliance/follow up – in these cases we can desensitize patients and treat them with Pen G benzathine
  2. Seizure history or you notice they are on seizure medications AND renal dysfunction. Because any beta lactam is a hydrophillic drug and if it accumulates in the kidney this can cause seizures (not as common to get beta lactam related seizures)
76
Q

Which penicillins can be taken outpatient (PO)? for what indications and give doses if needed

A

Penicillin VK - K is for Potassium (first line for strep throat, non purulent skin infection without abscess, or tooth abscess)

Amoxicillin aka “amox- tag”
- First line treatment for acute otitis media (pediatric dose is 80-90 mg/kg/day max PO)
- Drug of choice for infective endocarditis prophylaxis before dental procedure or in patient with previous infection. 2g PO x once 30-60 minutes before procedure
- H pylori treatment as well.

Amoxicillin/Clavulanate (Augmentin)
- First line treatment for acute otitis media 80-90 mg/kg/day of amox. (make sure to do 14:1 ratio with clavulanate to ensure reduction in diarrhea
- Used to treat bacterial sinusitis

Dicloxacillin
- covers MSSA , not MRSA, no need to renally dose adjust

77
Q

Use of Pen G Benzathine (Bicillin L-A) and important points

A

Drug of choice for syphilis (2.4 million units IM x 1 for early stage infections, but if later stage, we sometimes give 1/week injection)
- this MUST be IM, NEVER IV because of the risk of death (it’s a lipid emulsion)

78
Q

Which penicillin should never be given IV because of it’s risk of death

A

Penicillin G Benzathine (Bicillin LA)

79
Q

Which important Penicillins are only Parenteral use

A

Pen G (IM ONLY, NEVER IV)
Nafcillin (IV/IM) /Oxacillin (IM)
Piperacillin/Tazobactam (Zosyn) - only one that covers psuedomonas and uses extended infusions to maximize the Time > MIC

80
Q

What are the first generation cephalosporins, their dosage forms and doses

A

Cefazolin IV/IM: 1-2 grams Q8H (equiv to keflex)
Cephalexin PO 250-500 mg Q6-12H (equiv to cefazolin)
Cefadroxil PO 1-2 grams Q12-24H

81
Q

What are the 2nd generation cephalosporins, their dosage forms, and their doses

A

Cefuroxime (Ceftin) PO,IM,IV 250-1500 mg Q8H -12H
Cefotetan (Cefotan) IV/IM 1-2 grams Q12H
Cefaclor PO 250-500 mg Q8H
Cefoxitin IV/IM 1-2 g Q6-8H
Cefprozil PO 250-500 mg Q12-24H

82
Q

What are the GROUP 1- 3rd generation cephalosporins, their doses, and their dosage forms

A

Cefdinir -old brand name was “omnicef”, but ppl still use that (PO equivalent of cextriaxone) PO 300 mg Q12H or 600 mg daily
Ceftriaxone IV/IM 1-2 grams Q12-24 hrs
Cefotaxime IV/IM 1-2 grams Q4-12 hrs
Cefditoren PO 200-400 mg Q12H with food
Cefixime (Suprax) PO: 400 mg divided Q12-24 H
Cefpodoxime PO: 100-400 mg Q12H
Ceftibuten: PO: 400 mg daily on an empty stomach

83
Q

What are the group 2 third generation cephalosporins and their combinations , dose, and dosage form

A

Ceftazidime (fortaz, tazicef) IV/IM 1-2 grams Q8-12 H
Ceftolozane

Psuedomonas coverage:
Ceftazidime/avibactam (Avycaz) - IV: 2.5 g Q8H
Ceftolozane/tazobactam (Zerbaxa) - IV: 1.5-3 g

84
Q

What is the 4th generation cephalosporin and what is it’s dosage form and strength

A

Cefepime IV/IM: 1-2 g Q 8-12 H

Covers pseudomonas

85
Q

What is the 5th generation cephalosporin and what is it’s dosage form and dose

A

Ceftaroline fosamil (Teflaro) IV: 600 mg Q12H
Covers MRSA

86
Q

What is the siderophore cephalosporin and what is it’s function

A

Cefidericol- it uses the iron transport system to enter gram negative cell wall.

Approved for complicated UTI/pyelonephritis and active against Enterobacter, Klebsiella, Proteus, (PEK) and Pseudomonas and E. coli

87
Q

What are some contraindications for Ceftriaxone

A

Hyperbilirubinemic neonates (causes biliary sludging kernicterus)

Concurrent use with calcium containing IV products in neonates < 28 days old

88
Q

Class effects of Carbapenems

A

all active against ESBL producing organisms
and pseudomonas (except ertapenem)

cannot be used with penicillin allergy

CNS adverse effects, confusion, seizure risk at high doses or failure to adjust dose in renal dysfx (check if they are on any seizure meds), or with use of imipenem cilastatin. they decrease the serum conc. of valproic acid and poor seizure control

all are IV, and ertapenem has to be diluted in normal saline

SE: diarrhea, rash, DRESS syndrome, bone marrow suppression with prolonged use, increased LFTs

all are hydrophillic, so they can accumulate in renal failure and cause seizure

MONITOR: renal function**,CBC, LFT, sx of anaphylaxis on first dose

89
Q

what do carbapenems not cover

A

Because they are cell wall acting agents, they don’t cover atypicals, VRE, MRSA, C diff, or stenotrophomonas

ErtAPenem doesnt cover EAP: pseudomonas, enterococcus, and acinetobacter

90
Q

common uses for carbapenems

A

polymicrobial infx (ex: sever diabetic foot infx)
empiric therapy when resistant organisms suspected
ESBL positive infections
Resistant pseudomonas or acinetobacter infx (except ertapenem)

91
Q

Types of carbapenems

A

doripenem - never use for any type of pneumonia

Imipenem/Cilastatin (primaxin) - old, combo to prevent drug degredation

Meropenem (meropenem/vaboractam = vabomere)
Ertapenem (Invanz) - dilute with stable NS only; common for Diabetic foot infx

92
Q

aztreonam

A

a monobactam

can be used in pts with beta lactam allergy

gram negative coverage including pseudomonas (no gram positive or anaerobic activity)

SE: similar to penicillins, including rash, N/V/D and increased LFTs

93
Q

beta lactams/aztreonam that cover MRSA

A

ceftaroline

94
Q

penicillin SOA

A

(+)
S. pneumoniae
Viridans group strep
Enterococcus (not VRE)
Gram positive anaerobes

no gram negative

95
Q

amoxicillins SOA

A

(+)
S. pneumoniae
Viridans strep.
Enterococcus (not VRE)
Gram pos. anaerobes

(-)
PE - no klebsiella
HNPE - no klebsiella

96
Q

Oxacillin + Nafcillin SOA

A

(+)

MSSA/ staph. aureus
S. pneumoniae
Viridians strep.
Enterococcus (not VRE)

97
Q

unasyn and augmentin SOA

A

(+)

Staph aureus/MSSA
S. pneumoniae
Viridans strep.
Enterococcus (not VRE)
gram positive anaerobes

(-)
PEK
HNPEK
Bacterioides fragilis

98
Q

Zosyn and carbapenem (except ertapenam) SOA

A

BROAD (+ and -)

they don’t cover atypicals or MRSA

ertapenam doesn’t cover PEA (psuedo, enterococcus, or acinetobacter), the rest of the carbapenems cover E fragilis type of enterococcus

99
Q

all gen ceph’s SOA (cephalexin, cefazolin)

A

(+)
S. aureaus (MSSA)
S pneumoniae
Viridans Strep.
gram positive anaerobes

(-)
PEK

additional coverages as we increase generations:
2nd generation cephalosporins can additionally cover HNPEK (-) and the only ones that coverbacterioides fragilis (cefuroxime, cefotetan, cefoxitin) cefotetan doesnt cover B fragilis

3rd generation cephs can additionally cover (-) CAPES, but don’t cover B fragilis. (cefotaxime, ceftriaxone).
Ceftazadime is different. it and aztreonam only covers gram negative (PEK, HNPEK, CAPES, psuedomonas)

4th gen (cefepime) covers all of the above except B fragilis (HNPEK, PEK, CAPES, pseudomonas, MSSA , Spneumoniae, V strep.

5th ceftaroline (+)*(MRSA; (-) covers no psuedomonas, doesnt cover providencia or acinetobacter

100
Q

cephs that cover pseudomonas

A

cefepime
ceftazadime
ceftolozane

101
Q

what do we need to make sure to give with the 5th gen ceph combos

A

ceftolozane/tazobactam
ceftazadime/avibactam

both should be given with metronidazole to ensure proper anaerobic coverage

these can help with MDR pseudomonas or MDR gram negative rods

102
Q

aminoglycosides

A

highly toxic to kidneys and ears. concentration dependent abx. not used as much. need monitoring and dose specific considerations. usually used empirically in combo with other things, not alone.

used mostly for gram negatives including pseudomonas. at lower doses can be used for gram positives (staph and enterococci)

traditional dosing (if renal fx is normal)- 1-2.5 mg/kg IV Q8H, monitor using peaks and troughs (draw trough 30 min before 4th dose and peak 30 min after end of 4th dose infusion (usually 1 hr) - trough is what causes toxicity, so we should monitor this < 2 mcg/mL we don’t want trough accumulation; peak should be 5-10 mcg/mL for gent/tobra

extended interval dosing - 4-7 mg/kg IV q24h, we monitor by drawing random level and using nomogram- shortest interval is 24 hrs for normal renal fx. this is better for the sake of toxicity because we can give larger doses less frequently and allows kidneys to rest, also lower cost

gentamicin, tobramycin, amikacin (most active against pseudomonas), streptomycin, plazomicin

103
Q

gentamicin and streptomycin can be used for synergy in combo with a beta lactam or vanc. to treat gram (+) infections like enteroccocal endocarditis

A
104
Q

streptomycin and amikacin can be used as second line agents for mycobacterium

A
105
Q

Boxed warnings and regular warnings and SE for Aminoglycosides

A

nephrotoxicity
ototoxicity
neuromuscular blockade and resp. paralysis
avoid with other neurotoxic/nephrotoxic drugs, CI in pregnancy cause teratogenic

regular warnings:
caution if impaired renal fx, in elderly, and in pts taking nephrotoxic drugs: ampB, cistplatin, polmixins, cyclosporine, loop diuretics, NSAIDS, radiocontrast dye, tacrolimus, vancomycin.** need to know this list!

SE: otoxocity, nephrotoxicity, vestibular toxicity (balance)

106
Q

what should we monitor in pts on Aminoglycosides

A

trough (<2 mcg/mL) and peak levels (5-10 mcg/ml)
renal function (urine output)

107
Q

Renal dose adjustments for patients on traditionally dosed aminoglycosides

A

crcl
at least 60 ml/min q8h
40-60 ml/min q12h
20-40 ml/min q24 hr
< 20 ml/min - use just one dose, then dose based on levels.

108
Q

use adjusted body weight when TBW > 120% of IBW. use IBW if normal weight, use ABW if ABW < IBW

A
109
Q

hospitals have protocols to guide dose adjustments for aminoglycosides based on the serum concentrations.

A
110
Q

drugs that decrease stomach acid can decrease the F of some cephalosporins

A

separate cefuroxime, cefpodoxime, cefdinir, and cefditoren from short acting antacids. Avoid H2RAs and PPIs

111
Q

Cephs that cover MRSA

A

ceftaroline

112
Q

contraindications of ceftriaxone

A

never use in hyperbilirubinemic neonates because it causes biliary sludging, and kernicterus

never use with calcium containing IV products in neonates less than 28 days old because of the precipitates it forms with calcium containing IV fluids.

113
Q

Quinolones

A

concentration dependent killing (dosed twice daily). inhibit bacterial DNA topoisomerase 1 and 2

  • boxed warnings: DC immediately if tendon rupture/achilles tendon (esp. in pts on systemic steroids or organ trasnplant pts > 60 yrs; long lasting peripheral neuropathy, CNS effects (including seizures), use last line
  • warnings:
  • QT prolongation
  • hypo and hyperglycemia
  • psychiatric disturbances
  • photosensitivity
  • avoid use in children and anyone pregnant/breastfeeding because of musculoskeletal effects
  • avoid in pts with myasthinia gravis bc it can exacerbate muscle weakness
  • caution with CVD, decreased K+/Mg and with other QT prolonging drugs!! (ex: azoles, antipsychotics, macrolides, methadone, antifungals)
  • avoid in pts with seizure history or using antiepileptic drugs
  • monitor BG in pts with DM

interacts with divalent cations (iron, calcium, magnesium, etc.) separate from phosphate binders too

names: Cipro, levo, moxifloxacin, and gemifloxacin

can be used for travelers diarrhea, Intraabdominal ifnections and pseudomonas needs

114
Q

Respiratory quinolones

A

My Good Lungs (moxi, gemi, and levofloxacin)
they are active against S. pneumoniae in pneumonia and atypical bacteria

115
Q

Moxifloxacin (IV: PO 1:1) is the only quinolone that is not renally adjusted so it should never be used for UTIs

A
116
Q

Antipseudomonal quinolones

A

Levofloxacin IV:PO - 1:1
Ciprofloxacin

117
Q

Quinolones can increase effects of warfarin, increase effects of sulfonylureas, insulin, and other hypoglycemic drugs

A

Ciprofloxacin can increase caffeine, theophylline, and tizanidine levels by reducing metabolism

118
Q

Ciprofloxacin

A

brand: cipro, ciloxan eye drops, cetraxal, and otiprio ear drops (ear drops can come in combo with steroid)

IV and PO dosing interval varies w/ CrCl

Contraindicated with concurrent use of tizanidine

dont put the oil based suspension in a feeding tube because it adheres to tubing, but you can crush the immediate release tablet and mix with water. hold feedings 1 hour before and 2 hrs after dose.

119
Q

Levofloxacin (levaquin)

A

IV and PO. dose adjust if CrCL < 50 to Q48H or decrease dose

120
Q

Moxifloxacin (Avelox)

A

Moxeza and Vigamox eye drops

no renal dose adjustments required

QT prolongation risk is the highest

121
Q

cefotetan has a side chain (NMTT or 1-MTT) that can increase the risk of bleeding or cause a disulfuram like reaction

A

some cephalosporins can increase INR for pts on warfarin.

122
Q

monitoring with cephalosporins

A

renal function, signs of anaphylaxis with first dose, CBC, LFTs

123
Q

ceftriaxone requires no renal dose adjustment but it reaches CNS penetration at high doses

A

normal dose IV/IM 1-2 g Q12-24 H

124
Q

cefazolin and cephalexin are 1st gen cephs that are equivalents

A

cefazolin IV/IM 1-2 grams Q8H
cephalexin (Keflex) PO: 250-500 mg Q6-12 H

125
Q

if pt has penicillin allergy, for exam dont give them a cephalosporin unless

A

they are pediatric patients with acute otitis media and mild penicillin allergy

126
Q

Common use for cephalexin outpt (PO)

A

best drug for staph

MSSA skin infections, strep throat

127
Q

common use for cefuroxime outpt (PO)

A

acute otitis media
CAP

128
Q

common use for cefdinir outpt (PO)

A

acute otitis media

129
Q

Common use of cefazolin inpt

A

surgical prophylaxis

equivalent to keflex (cephalexin)

130
Q

common use of cefotetan and cefoxitin

A

anaerobic coverage ( B fragilis), GI surgical prophylaxis, cefotetan

131
Q

Common uses for ceftriaxone and cefotaxime

A

CAP
meningitis
spontaneous bacterial peritonitis
pyelonephritis

remember: ceftriaxone has no renal dose adjustment and we should never give it to neonates < 28 or pregnant women

132
Q

Common uses for ceftazadime and cefepime and ceftolozane

A

pseudomonas

133
Q

common uses for ceftolozane/tavibactam and ceftazidime/avibactam

A

MDR gram negative organisms (including pseudomonas)

134
Q

Common uses for ceftaroline

A

only beta lactam that is active against MRSA

CAP
skin and soft tissue infections

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