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NAPLEX > Infectious Diseases and Immunizations > Flashcards

Infectious Diseases and Immunizations Flashcards

1
Q

Common pathogens for select sites: CNS/meningitis, mouth, upper and lower respiratory, endocarditis, SST, bones, and urinary tract

A

CNS/meningitis: Strep pneumo, Neisseria meningitidis, H. flu, Group B strep, E. coli (younger), Listeria (older)
Mouth: peptostreptococcus, Prevotella, strep groups, anaerobic Gram-negative rods
Upper respiratory: strep pyogenes, strep pneumo, H. flu, Moraxella catarrhalis
Lower respiratory: Community: Strep pneumo, H. flu, enteric Gram-negative, Legionella, Mycoplasma, Chlamydophila.
Hospital: Staph, pseudomonas, acinetobacter, strep pneumo, enteric Gram-negative rods (ESBL)
Endocarditis: Staph, aureus and epidermidis, strep, and enterococci
Abdominal: Enteric Gram-negative rods, enterococci, sttrep, Bacteroides
SST: Staph, strep, Pasteurella multocida
Bones: Staph and strep, Neisseria gonorrhoeae
Urinary tract: E. coli, Proteus, Klebsiella, staph saprophyticus, enterococci

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2
Q

Pathogen Gram staining and shapes

A

Atypicals: Chlamydia, Legionella, Mycoplasma pneumoniae, Mycobacterium tuberculosis
Gram-positive: Purple
Anaerobes; peptostreptococcus, Propionibacterium acnes, C. diff, Clostridium
Rods; Listeria monocytogenes, Corynebacterium
Cocci in clusters; Staphylococcus
Cocci in pairs/chains; Streptococcus, Enterococcus
Gram-negative: Pink
Anaerobes; Bacteroides fragilis, Prevotella
Rods; Pseudomonas aeruginosa, H. flu, Providencia
Enteric rods; Proteus mirabilis, E. coli, Klebsiella, Serratia, Enterobacter, Citrobacter
Cocci; Neisseria
Coccobacilli; Acinetobacter baumannii, Bordetella pertussis, Moraxella catarrhalis
Spirochetes; H. pylori, Campylobacter, Treponema, Borrelia, Leptospira

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3
Q

Commonly resistant pathogens

A

Kill Each And Every Strong Pathogen
Klebsiella pneumoniae (ESBL, CRE)
Escherichia coli (ESBL, CRE)
Acinetobacter baumannii
Enterococcus faecalis/faecium (VRE)
Staphylococcus aureus (MRSA)
Pseudomonas aeruginosa

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4
Q

Pharmacokinetics/dynamics of antibiotics: hydrophilic vs lipophilic

A

Hydrophilic agents:
Small Vd (less tissue penetration), really eliminated, low intracellular concentration (less active against atypical), and poor bioavailability (not 1:1)
Beta-lactams, aminoglycosides, vancomycin, daptomycin, polymyxins
Lipophilic agents:
Larger Vd (more tissue penetration), hepatically cleared, high intracellular concentration (active against atypical), good bioavailability (IV:PO is 1:1)
Quinolones, macrolides, rifampin, linezolid, tetracyclines

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5
Q

Classification of antibiotics and MOA

A

Cell wall inhibitors: bacteriocidal
Beta-lactams, monobactams, vancomycin, dalbavancin, telavancin, oritavancin
Cell membrane inhibitors: bacteriocidal
Polymyxins, daptomycin, telavancin, oritavancin
DNA/RNA inhibitors: bacteriocidal
Quinolones, metronidazole, tinidazole, rifampin
Protein synthesis inhibitors: bacteriostatic
Aminoglycosides (only bacteriocidal), macrolides, tetracyclines, clindamycin, linezolid, tedizolid, quinupristin/dalfopristin
Folic acid synthesis inhibitors: bacteriostatic
Bactrim, dapsone

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6
Q

Penicillins

A

Generally Gram-positive, however not active against MRSA
BBW: Penicillin G benzathine should never be used IV due to cardiac arrest
SE: seizures with accumulation, GI upset, diarrhea, rash (SJS/TENS), allergic reaction, anaphylaxis, hemolytic anemia (positive Coomb’s test)
CI: Type 1 reaction, CrCl <30
Monitor renal function
Natural penicillins: Gram-positive strep, enterococci, and anaerobes, not staph, no Gram-negative
Penicillin VK PO, penicillin G aqueous IV, penicillin G benzathine (Bicillin L-A) IM
Antistaphylococcal: Gram-positive strep, preferred for MSSA, no renal adjustments
Dicloxacillin PO, Nafcillin IV/IM (vesicant; use hyaluronidase), oxacillin IV
Aminopenicillins: Gram-positive strep, enterococci, anaerobes, Gram-negative H. flu, Neisseria, Proteus, and E. coli
Aminopenicillins with beta-lactamase inhibitors: added activity to MSSA and Gram-negative anaerobes
Amoxicillin PO, amoxicillin/clavulanate (Augmentin) PO (14:1 ratio), Ampicillin PO (rarely used d/t bioavailability) IV/IM, ampicillin/sulbactam (Unasyn) IV (dilute in NS only)
Extended-spectrum: Gram-positive strep, MSSA, enterococci, anaerobes, Gram-negative HNPEK, CAPES, and Pseudomonas
Piperacillin/tazobactam (Zosyn) IV over 4 hours (has 65mg Na per 1g pip)
Interactions: Probenecid increases levels, penicillins increase methotrexate, and warfarin (except nafcillin and dicloxacillin, which reduces warfarin)

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7
Q

Cephalosporins

A

Generally not active against enterococcus or atypicals
Warnings: cross-reactive with penicillin allergies, cefotetan can increase the risk of bleeding and disulfiram reaction with alcohol d/t NMTT side chain
SE: seizures with accumulation, GI upset, diarrhea, rash (SJS/TEN), allergic reaction, anaphylaxis, hemolytic anemia (positive Coomb’s test)
CI: hyperbilirubinemia neonates d/t kernicterus if neonates are <28d, do not use with Ca-containing products
Monitor renal function
First generation: Gram-positive cocci, Gram-negative PEK; Proteus, E.coli, Klebsiella
Cephalexin (Keflex) PO (250-500mg q6-12H), cefazolin IV/IM, cefadroxil PO
Second generation: MSSA, S. pneumo, H. flu, Neisseria, Proteus, E. coli, and Klebsiella, cefotetan and cefoxitin adds Gram-negative anaerobes
Cefuroxime PO/IV/IM, cefotetan IV/IM, cefoxitin IV/IM, cefaclor PO, cefprozil PO
Third generation: Resistant strep, MSSA, Gram-positive anaerobes, and resistant HNPEK, ceftazidime covers Pseudomonas, but not Gram-positives
Cefdinir PO, ceftriaxone IV/IM (no renal adjustments), cefotaxime IV/IM, cefixime PO/chewable, cefpodoxime PO, ceftazidime IV/IM
Fourth generation: similar to ceftriaxone, add HNPEK, CAPES, and Pseudomonas
Cefepime IV/IM
Fifth generation: similar to ceftriaxone, add broad Gram-positive and MRSA
Ceftaroline fosamil (Teflaro) IV
Combinations: adds MDR Gram-negative rods
Ceftazidime/avibactam (Avycaz) IV (active against CRE), ceftolozane/tazobactam (Zerbaxa) IV
Sixth/other: Uses iron transport system. Active against E. coli, Klebsiella, Proteus, and Pseudomonas in complicated urinary infection
Cefiderocol (Fetroja) IV
Interactions: Ceftriaxone produces precipitates with Ca, acid reducers decrease cefuroxime, cefpodoxime, and cefdinir bioavailability

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8
Q

Carbapenems

A

Very broad spectrum reserved for MDR Gram-negative infections, however active against Gram-positive, anaerobic, and ESBL. No activity against atypical, MRSA, VRE, C. diff, and Stenotrophomonas
Warnings: do not use in PCN allergies, seizure risk
CI: Anaphylaxis to PCN
SE: Diarrhea
Monitor renal function
Doripenem IV
Imipenem/cilastin IV, imipenem/cilastin/relebactam (Recarbrio) IV (cilastin prevents degradation)
Meropenem IV, meropenem/vaborbactam (Vabomere)
Ertapenem (Invanz) IV/IM (Lack of Pseudomonas, acinetobacter, and enterococcus, stable in NS only)
Interactions: Decreases valproate, can decrease seizure threshold

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9
Q

Monobactams

A

Generally covers Gram-negative including Pseudomonas and CAPES, no activity against anaerobes or Gram-positives. Used in PCN allergy.
SE: similar to PCN
Aztreonam (Azactam)

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10
Q

Aminoglycosides

A

Active against Gram-negative including Pseudomonas, not used as monotherapy, used with synergy for Gram-positive
BBW: nephrotoxicity, ototoxicity, neuromuscular blockade, teratogenic
Warnings: caution in renal impairment, esp. elderly, and nephrotoxic drugs (amphotericin B, cisplatin, polymyxins, cyclosporine, loops, NSAID, contrast, tacrolimus, vancomycin)
SE: nephrotoxicity (acute tubular necrosis), ototoxicity (high pitch and balance)
Monitor renal function and drug levels
Gentamicin IV/IM/opth/top, tobramycin IV/IM/opth/inh, amikacin IV/IM, streptomycin IM, plazomicin IV (reserved for MDR Gram-negative UTI’s)
Dosing: traditional based on peak and trough, extended interval uses the nomogram with random level. Gentamicin and tobramycin traditional dosing: 1-2.5mg/kg/dose, extended dosing: 4-7mg/kg/dose
Peak and trough levels are based on drug and indication: gentamicin for synergy is 3-4mcg/mL pk, and <1 tr. Gentamicin in Gram-negative and tobramycin should be 5-10 pk and <2 tr. Amikacin is 20-30 pk and <5 tr.
Renal clearance determines interval: CrCl >60 is q8H
Underweight uses total body weight, overweight uses adjusted, and regular uses IDB.

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11
Q

Quinolones/Fluroquinolones

A

Concentration-dep activity against both Gram and atypicals, and is last line for sinusitis, bronchitis, and uncomplicated UTI
BBW: tendon inflammation or rupture, peripheral neuropathy, seizures
Warnings: QT prolongation (highest is moxi), glycemic changes, psychiatric changes, avoid in children and pregnancy, photosensitivity
CI: cipro with tizanidine
SE: the usual
Ciprofloxacin (Cipro) PO/IV; with dexamethasone ear drops (Ciprodex); oral suspension cannot go into tubing
Levofloxacin PO/IV, Moxifloxacin IV/PO (no renal adjustments, not for UTI), delafloxacin PO/IV, gatifloxacin opth, ofloxacin (Ocuflox) PO/opth
Respiratory coverage of S. penumo; levo/moxi
Pseudomonas; levo/cipro
Anaerobic; moxi
MRSA; dela
Interactions: polyvalent cations d/t chelation, phosphate binders (separate by 2 hours, or 6 with Sevelamer), QT prolonging drugs (azoles, antipsychotics, methadone, macrolides), probenecid and NSAID’s increase levels, quinolones increase warfarin, sulfonylurea, and cipro d/t 1A2 increases caffeine, theophylline, and tizanidine

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12
Q

Macrolides

A

Covers atypicals (Legionella, chlamydia, Mycoplasma, Mycobacterium, H. flu), esp in community respiratory illness, and chlamydia. High resistance in S. pneumo, H. flu, chlamydia, and Moraxella
Warnings: QT prolongation (erythromycin is highest), hepatotoxicity, clarithromycin in CAD
CI: lovastatin and simvastatin in clarithromycin or erythromycin
SE: GI upset
Azithromycin (Zithromax, Z-pak) PO/IV (better G-), clarithromycin PO (better G+), erythromycin (E.E.S., Ery-Tab, Erythrocin) PO/IV
Interactions: E and C are substrates of 3A4, used caution in Eliquis, colchicine, Xarelto, theophylline, and warfarin. Azith has less SE. All have caution in QT prolongation

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13
Q

Tetracyclines

A

Covers many Gram-positive including staph, strep, enterococci, and Propionibacterium, Gram-negative including H. flu, Moraxella, atypicals, and unique pathogens including Rickettsiae, anthrax, syphilis.
Warnings: limit use in children <8yo and pregnancy, photosensitivity, and minocycline can cause DILE (lupus)
For doxy an mino, IV:PO is 1:1
Doxycycline (Vibramycin) PO/IV(no renal adjustment, sit upright for 30min after admin), minocycline (Minocin, Solodyn) IV/PO, eravacycline IV (only for abdominal infections), omadacycline IM/PO, sarecycline PO (only for acne), tetracycline PO
Interactions: polyvalent cations, sucralfate, bismuth, bile acid resins, dairy, multivitamins, and lanthanum Fosrenal can decrease drug

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14
Q

Sulfonamides

A

Active against MSSA/MRSA, and broad Gram-negative (H. flu, Proteus, E. coli, Klebsiella, Enterobacter, Shigella, Salmonella, and stenotrophomonas), oppurtunistic infections (Nocardia, PJP, toxoplasmosis). No activity agaisnt Pseudomonas, eneterococci, atypicals, anaerobes, S. penumo, or strep.
Warnings: Skin reactions SJS/TEN/TTP, hemolytic anemia (positive Coomb’s test) caused by immune system or G6PD deficiency, teratogenic
CI: sulfa allergy, anemia, <2mos
SE: photosensitivity, hyperkalemia, crystalluria, false high SCr
Sulfamethoxazole/trimethoprim (Bactrim) ratio 5:1, dose based on TMP
SS: 400/80mg PJP ppx daily
DS: 800/160mg UTI BID or ppx daily
Severe infections: 10-20mg/kg/day
Interactions: 2C8 and 2C9 inhibition; increases warfarin and INR, enhances MTX, diminished by leucovorin, hyperkalemia esp with ACEI/ARB or renal impairment.

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15
Q

Glycopeptide

A

Only covers Gram-positive including MRSA, strep, enterococci, and C. diff (oral only)
Warnings: ototoxicity, nephrotoxicity, PO is not systemically absorbed, Red Man Syndrome if infused too fast (1g/hr)
Monitor renal function, drug levels, AUC/MIC ratio or trough; serious infection AUC is 400-600, trough 15-20mcg/mL
Vancomycin (Vancocin) IV 15-20mg/kg q8-12H (total body weight), or PO 125mg QID x 10 days
CrCl 20-50 extend interval QD
Generally first-line for MRSA, unless MIC >2
Interactions: nephrotoxicity and ototoxicity are compounded

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16
Q

Lipoglycopeptides

A

Concentration-dep against Gram-positive bacteria (similar to vanco)
BBW: teratogenic, nephrotoxicity (increased mortality)
Warnings: infusion reaction with rapid admin, falsely raise aPTT/PT/INR without increased bleeding risk (orit/tela), QT prolongation (tela), 3X ULN ALT (dalb)
CI: Oritavancin; do not use IV UFH for 5 days due to aPTT abnormalities
Telavancin IV (SSTI), oritavancin IV (one dose over 3 hours), dalbavancin IV (single dose over 30 min)
Interactions: Decompensated HF, QT prolongation

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17
Q

Cyclic lipopeptide

A

Concentration-dep activity against Gram-positive including MRSA, and VRE
Warnings: myopathy and rhabdo, falsely elevate PT/INR without bleding risk
SE: increased CPK
Monitor CPK weekly
Daptomycin (Cubicin, Cubicin RF) IV (not for PNA)
Cubicin is compatibe with NS and LR (no dextrose), Cubicin RF compatible with NS after dilution with sterile water
Interactions: additive risk with statins

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18
Q

Oxazolidinones

A

Binds to 50S bacterial ribosome (inhibits translation and synthesis)
Activity against Gram-positive including MRSA and VRE
Warnings: myelosuppression if >14d, optic neuropathy if >28d, serotonin syndrome, hypoglycemia
CI: do not use within 2 weeks of an MAOI
SE: thrombocytopenia
Monitor CBC weekly
Linezolid (Zyvox) IV/PO (1:1 ratio, no renal adjustments)
Tedizolid IV/PO (1:1 ratio, no renal adjustments)
Interactions: avoid tyramine and serotonergic drugs d/t MAOI MOA, can exacerbate hypoglycemic episodes

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19
Q

Streptogramin

A

Binds the 50S bacterial ribosome (inhibits synthesis)
Active against Gram-positive including MRSA, and VRE, but not E. faecalis
SE: arthralgias, myalgias, infusion reactions, hyperbilirubinemia
Quinupristin/dalfopristin IV
Dilute in D5W only, administer centrally only

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20
Q

Glycylcycline

A

Binds to 30S bacterial ribosome (inhibits synthesis)
Broad spectrum against including VRE and MRSA, G+/G-, atypicals and anaerobes. Not active against Pseudomonas, Proteus, Providencia
BBW: increased risk for death (use is limited)
Warnings: structurally similar to tetracyclines; avoid in children <8yo
Tigecycline (Tygacil) IV (not for blood infections, solution is yellow-orange color)

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21
Q

Polymyxins

A

Active against MDR Gram-negative including Enterobacter, E. coli, Klebsiella, Pseudomonas. Not active against Proteus. Generally in combo with others
Colistimethate/colistin IM/IV/inh (mix immediately prior to use
Warning: dose-dep nephrotoxicity, neurotoxicity
Prodrug; assess dose carefully
Polymyin B IV
BBW: dose-dep nephrotoxicity, neurotoxicity d/t neuromuscular blockade (resp. paralysis)
1mg=10,000units
Interactions: nephrotoxicity is additive

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22
Q

Chloramphenicol

A

Reversibly binds 50S of bacterial ribosomes (inhibits synthesis)
Very broad spectrum
Warning: gray syndrome (circulation issues, cyanosis, acidosis, myocardial depression, coma)
Chloramphenicol IV

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23
Q

Lincosamide

A

Reversibly binds 50S of bacterial ribosomes (inhibits synthesis)
Active against Gram-positive including MRSA and anaerobes. Does not cover Gram-negative, or Enterococci
BBW: C. diff colitis infection
SE: N/V/D
Clindamycin (Cleocin) IV/PO (no renal adjustments)
Clindamycin topical (Clocin-T, Clindagel)
Induction D-test for S. aureus to determine erythromycin cross-resistance

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24
Q

Antibiotic/Antifungal class

A

Causes loss of helical DNA structure and strand breakage (inhibits synthesis)
CI: pregnancy 1st trimester, alcohol d/t disulfiram
SE: metallic taste
Metronidazole (Flagyl) PO/IV/top/vag (IV:PO is 1:1)
Active against protozoans, anaerobes, and is used for bacterial vaginosis, trichomoniasis, giardiasis, amebiases, and C. diff
Interactions: alcohol, 2C9 inhibition (increased INR)
Tinidazole PO
Active against protozoan giardiasis, amebiasis, trichomoniasis, and bacterial vaginosis
Secnidazole PO (single dose)
Active for bacterial vaginosis, trichomoniasis
SE: vulvovaginal candidiasis

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25
Q

Pleuromutilin

A

Binds to 50S ribosome (inhibits synthesis)
Used for CAP
Lefamulin IV/PO
Warnings: QT prolongation

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26
Q

Fidaxomicin

A

Used for C. diff
Fidaxomicin (Dificid) PO
Warnings: only for GI, not systemically absorbed

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27
Q

Rifaximin

A

Used for HE, C. diff, but no systemic absorption
Rifaximin (Xifaxan) PO; traveler’s diarrhea 200mg TID x 3 d, HE ppx 550mg BID, IBS-D 550mg TID x 14 d

28
Q

Urinary agents

A

Fosfomycin: active against ESBL E. coli, E. faecalis, VRE
Uncomplicated UTI in females as a single dose
Nitrofurantoin (Macrobid)100mg BID x 5 d
Nitrofurantoin (Macrodantin) 100mg QID x3-7 d
DOC for uncomplicated UTI; covers E. coli, Klebsiella, Enterobacter, Staph, enterococcus, VRE
Warnings: hemolytic anemia in G6PD deficiency
CI: CrCl <60
SE: GI upset, brown urine discoloration
Counsel on GI upset (take wiht food), and urine discoloraiton

29
Q

Topical decolonization

A

Eliminates MRSA colonization
Mupirocin (Bactroban) 1/2 tube in each nostril BID x 5 d

30
Q

MSSA

A

Dicloxacillin, nafcillin, oxacillin
Cefazolin, cephalexin (1/2 gen cephalosporins)
Augmentin, Unasyn

31
Q

MRSA

A

Vancomycin, linezolid, daptomycin (not in PNA), ceftaroline
Community SSTI: Bactrim, doxycycline, minocycline, clindamycin

32
Q

VRE

A

Linezolid, daptomycin
E. faecalis; pen G, ampicillin
Cystitis; nitrofurantoin, fosfomycin, doxycycline

33
Q

Atypical organisms

A

Azithromycin, clarithromycin
Doxycycline, minocycline
Quinolones

34
Q

HNPEK

A

[Haemophilus, Neisseria, Proteus, E. coli, Klebsiella]
Beta-lactam/beta-lactamase inhibitors
Cephalosporins (except first gen)
Carbapenems, aminoglycosides, quinolone, Bactrim

35
Q

Pseudomonas aeruginosa

A

Zosyn, cefepime, ceftazidime (w/wout avibactam), ceftolozane/tazobactam, carbapenems (except ertapenem), cipro or levofloxacin, aztreonam, tobramycin, colistimethate, polymyxin B

36
Q

CAPES

A

[Citrobacter, Acinetobacter, Providencia, Enterobacter, Serratia]
Pip/tazo, cefepime, carbapenems, aminoglycosides, colistin, polymyxin B

37
Q

ESBL

A

Carbapenems, ceftazidime/avibactam, ceftolozane/tazobactam

38
Q

CRE

A

Ceftazidime/avibactam, colistin, polymyxin B, meropenem/vaborbactam, imipenem/cilastatin/relebactam

39
Q

Gram-negative anaerobes

A

Metronidazole, beta-lactam/beta-lactamase inhibitor, cefotetan, cefoxitin, carbapenems, moxifloxacin

40
Q

C. difficile

A

Oral vancomycin, fidaxomicin, metronidazole

41
Q

Storage requirements for antibiotics

A

Refrigeration required after reconstitution:
Penicillin VK, ampicillin, Augmentin
Others: cephalexin, cefadroxil, cefpodoxime, cefprozil, cefuroxime, cefaclor, vancomycin oral, valganciclovir
Do not refrigerate:
Cefdinir
Others: azithromycin, clarithromycin, doxycycline, ciprofloxacin, levofloxacin, clindamycin, linezolid, Bactrim, acyclovir, fluconazole, posaconazole, voriconazole, nystatin
IV: metronidazole, moxifloxacin, Bactrim, acyclovir

42
Q

Pharmacokinetics/dynamics of antibiotics: dose optimization

A

Concentration-dep killing
Aminoglycosides, quinolones, daptomycin
The goal is high peak, and low trough, by using large doses with long intervals
Time-dep killing
Beta-lactams
The goal is to maintain a level above the MIC by using shorter intervals, or infusions
Exposure-dep killing
Vancomycin, macrolides, tetracyclines, polymyxins
The goal is to have a general exposure over time using both concentration and time

43
Q

Key features of penicillins

A

Class effect: Avoid in a beta-lactam allergy, except in syphilis in pregnancy, and all increase seizure risk with accumulation
Outpatient/oral
Penicillin VK: 1st for strep throat, SSTI without abscesses
Amoxicillin: 1st for otitis media (peds 80-90mg/kg/d), DOC for dental ppx of endocarditis (2g), and used in H. pylori infection
Augmentin: 1st for otitis media (peds 90mg/kg/d), and sinusitis, the clavulanate causes diarrhea
Dicloxacillin: No renal adjustments, and only covers MSSA
Inpatient/parenteral
PenG: DOC for syphilis (2.4milU), never IV
Nafcillin/oxacillin: No renal adjustments, only MSSA
Zosyn: only one active against Pseudomonas, extended infusions are preferred

44
Q

Key features of cephalosporins

A

Class effect: Risk of seizures in accumulation, low risk for cross-reactivity
Outpatient/oral
Cephalexin: MSSA and strep
Cefuroxime: CAP, otitis media
Cefdinir: otitis media
Inpatient/parenteral
Cefazolin: surgical ppx
Cefotetan, cefoxitin: B. fragilis anaerobe coverage, GI surgical ppx, disulfiram reaction
Ceftriaxone, cefotaxime: CAP, meningitis, SBP, pyelonephritis, avoid in neonates <28d and no renal adjustments in ceftriaxone
Ceftazidime, cefepime: active against Pseudomonas
Combinations: MDR Gram-negative organisms
Ceftaroline: MRSA, CAP, SSTI

45
Q

Key features of carbapenems

A

Class effect: All active against ESBL, do not use in PCN allergies, seizure risk
Does not cover: atypical, VRE, MRSA, C. diff, Stenotrophomonas (ertapenem: Pseudomonas, enterococcus, acinetobacter)
Common uses: polymicrobial (diabetic foot infections), empiric MDR’s, ESBL, resistant Pseudomonas or Acinetobacter
All are IV, ertapenem must be NS only

46
Q

Key features of aminogycosides

A

Class effect: Kill Gram-negative and Gram-positive with synergy, low resistance and cost. Concentration-dep killing and post-antibiotic effect
Risks: SE may be irreversible, and must always be monitored
Dosing: give larger doses less frequently

47
Q

Key features of quinolones

A

Commonly used for PNA, UTI, abdominal, traveler’ diarrhea
IV:PO is 1:1 for levo and moxi
Counsel; sun exposure, polyvalent cations, BG, tendon rupture, neuropathy, CNS or psychiatric SE
Clinical review; CVD, K, Mg, QT prolongation, avoid in children, pregnancy, and seizures
Respiratory: levo/moxi
Antipseudomonal: cipro/levo
Moxi: not for UTI, no renal adjustments

48
Q

Key features of macrolides

A

Commonly used in CAP, strep alternative,
Azithromycin: commonly dosed in Z-Pak for COPD, pertussis, chlamydia in pregnancy, MAC ppx, dysentery
Clarithromycin: H. pylori
Erythromycin: increases gastric motility, used for gastroparesis
Interactions: lovastatin and simvastatin are CI in C and E
Caution in CVD, low K, low Mg, and QT prolonging drugs (azoles, quinolones, methadone, antipsychotics)

49
Q

Key features of tetracyclines

A

Common uses:
Minocycline: CA-MRSA SSTI and acne
Doxycycline: DOC for tick illnesses, chlamydia, CAP, COPD, sinusitis, VRE, and UTI, CA-MRSA SSTI, and acne
Tetracycline: H. pylori
Do not use in pregnancy or children <8yo

50
Q

Key features of sulfonamides

A

Commonly used for CA-MRSA SSTI, UTI, PCP
Dose based on TMP in a 5:1 ratio SMX:TMP, usual dose is DS (800/160mg) BID
Commonly causes rash or hives, rarely severe skin reactions
If on warfarin, avoid due to high INR

51
Q

What drugs do not need renal adjustments

A

Antistaphylococcal penicillins, ceftriaxone, clindamycin, doxycycline, azithromycin, erythromycin, metronidazole, moxifloxacin, lineolid
Others: chloramphenicol, fidaxomicin, other tetracyclines, Synercid, rifaximin, rifampin, tedizolid, tigecycline, tinidazole, PO vanco

52
Q

Special requirements including food, PO:IV, light protection, and compatibility

A

Food: most take with food. Except: ampicillin, levofloxacin solution, pen VK, rifampin, isoniazid, itraconazole solution, voriconazole. Within 1 hour of food; amoxicillin ER
1:1 IV:PO: levofloxacin, moxifloxacin, doxycycline, minocycline, linezolid, tedizolid, metronidazole, Bactrim
Protect from light: doxycycline, metronidazole, pentamidine
Compatibility: Dextrose only; Synercid, Bactrim, amphotericin B, pentamidine. NS only; ampicillin, Unasyn, ertapenem, daptomycin RF. NS/LR only; daptomycin, caspofungin

53
Q

Key counseling points for antibiotics

A

All antibiotics: proper storage and administration is important. Shake suspensions well. Only treats bacterial infections. Complete the full course of therapy. Measure doses carefully. Do not use liquid or chewable if phenylketonuria is present. SE: rash, nausea, diarrhea.
Quinolones: can cause CNS effects, glycemic changes, peripheral neuropathy, photosensitivity, QT prolongation, tendinitis. Avoid in pregnancy and children. Lots of interactions d/t chelation.
Macrolides: Can cause GI upset, QT prolongation. Z-Pak is 2 tablets day 1, then 1 tablet for 4 days.
Tetracyclines: avoid in pregnancy and children <8yo, lots of interactions d/t chelation, can cause photosensitivity. Doxycycline must take with full glass of water and stay upright for 30min.
Bactrim: avoid in pregnancy and allergies, can cause photosensitivity and crystals in the urine.
Metronidazole: do not use alcohol, can cause metallic taste and nausea.
Nitrofurantoin: take with food, can cause brown urine and nausea.
Mupirocin nasal ointment: 1/2 tube per nostril, and squeeze nose for 1 minute to spread, wash hands after use, can cause burning or itching to the nose.

54
Q

Perioperative antibiotic prophylaxis

A

Pre-operative: generally 1 hour before, or 2 hours if quinolone or vancomycin.
Intra-operative: >4 hour surgeries or major blood loss, can be administered again
Post-operative: Not needed, discontinue within 24 hours
Cefazolin is preferred for MSSA. Clindamycin is an alternative to allergy to beta-lactams. In GI add metronidazole, cefotetan, cefoxitin, or Unasyn. Vancomycin for MRSA.

55
Q

Meningitis treatment

A

Empiric treatment generally for common bacteria
<1 month old: Ampicillin with cefotaxime or gentamicin. Do not use ceftriaxone; can cause biliary slugging and kernicterus.
1 month to 50 years: ceftriaxone or cefotaxime, and vancomycin (double Strep pneumo coverage)
>50yo: Ampicillin, with vancomycin, and ceftriaxone or cefotaxime.
Duration: Based on pathogen.
7 days: N. meningitidis, H. flu
10-14 days: Strep pneumo
21 days: Listeria
Add on dexamethasone for Strep pneumo for 4 days

56
Q

Upper respiratory tract infections

A

Acute otitis media
Observation: nonsevere, otalgia<48h, no otorrhea, <102.2F/39C, and 6-23mos old in one ear only.
Amoxicillin 90mg/kg/day BID or Augmentin with 6.4mg/kg/day BID. The preferred ratio is 14:1.
Alternatives include cefdinir, cefuroxime, cefpodoxime, or ceftriaxone.
Duration: 10 days for <2yo, 7 days for 2-5yo, and 5-7 days for >6yo.
Non-AOM: Common cold, and influenza are viruses. Pharyngitis is caused by Strep Group A, preferred treatment is penicillin or amoxicillin, an alternative is second-generation cephalosporins. Acute sinusitis is generally viral, but caused by strep pneumo, H. flu, and M. cat bacterias. >10 days persistence, or >3 days, treatment should be Augmentin.

57
Q

Lower respiratory tract infections

A

Acute bronchitis: cough lasting 1-3 weeks, systemic symptoms, chest tenderness, and wheezing. Bacterial causes are rare, antibiotics are not recommended.
Pertussis: Bordetella pertussis is the cause of whooping cough and should be treated with macrolides.
COPD exacerbations: 5-7 days of antibiotics if three cardinal symptoms are present (dyspnea, sputum volume, and sputum purulence). Preferred is Augmentin, azithromycin, doxycycline, or quinolone.
Pneumonia: Outpatient CAP; amoxicillin 1g TID, doxycycline, or azithromycin (under 25% resistant), or if high risk (with comorbidities) use amoxicillin with either doxy or azithro, or levo/moxi. Inpatient CAP; nonsevere can use beta-lactams (ceftriaxone, cefotaxime, ceftaroline, Unasyn) with azithro or doxy, or levo/moxi. Severe should use a beta-lactam with either azithro or levo/moxi. If at risk for MRSA use vancomycin. Risk for Pseudomonas add Zosyn, cefepime, or meropenem. HAP/VAP; always cover for Pseudomonas and MSSA, and add on another agent for MRSA or Pseudomonas in high risk.

58
Q

Tuberculosis treatment

A

Mycobacterium tuberculosis; aerobic non-spore forming bacillus. Latent is infected without symptoms. Active TB is highly contagious and must be in a negative pressure room.
TB tests: PPD for the skin (5, 10, or 15mm induration depending on risks) can be false-positive in BCG vaccine, IGRA blood test.
Latent TB: INH and rifapentine qwk x12wks except in pregnancy. INH with rifampin QD x 3mos. Rifampin 600mg QD x 4mos. INH 300mg QD x 6-9mos (preferred in HIV).
Active TB: The intensive phase is RIPE for 2 months, and the continuation phase is 2 drugs for 4 months.
R:rifampin; hemolytic anemia, LFT’s, orange-red discoloration. Potent inducers with lots of DI (PI’s, warfarin, birth control, DOAC’s) can sub rifabutin if too many DI.
I:isoniazid; boxed warning for severe hepatitis. SE: neuropathy (take B6), LFT’s, DILE, hemolytic anemia.
P:pyrazindamide; not continuous phase; CI in gout d/t uric acid increases.
E:ethambutol; not continuous phase; CI optic neuritis. SE: LFT’s, confusion, hallucinations.

59
Q

Endocarditis treatment

A

Empiric treatment is vancomycin with ceftriaxone. Gentamicin may be added for synergy. Generally, 4-6 weeks of IV antibiotics is needed.
Viridans group strep: penicillin or ceftriaxone.
MSSA: nafcillin or cefazolin [with both gentamicin and rifampin if its a prosthetic valve].
MRSA: vancomycin [with both gentamicin and rifampin if its a prosthetic valve].
Enterococci: penicillin, ampicillin with gentamicin, or ampicillin and ceftriaxone. VRE use daptomycin or linezolid.
All: use vancomycin if penicillin allergy.
Prophylaxis is for adults needing dental work with either an artificial heart valve, endocarditis hx, transplant with abnormal function, or genetic valve disease. Use Amox 2g 30-60min prior. Unable to tolerate orals use amp, cefazolin, or ceftriaxone. Unable to use pencillins use azithromycin or clarithromycin 500mg or doxycycline 100mg.

60
Q

Intra-abdominal infection treatment

A

Community-acquired should cover PEK, anaerobes, and streptococci using ertapenem, moxifloxacin, metronidazole with 3rd gen cephalosporin or quinolone.
High-risk patients should be covered for PEK, Pseudomonas, enterobacter, anaerobes, streptococci, and enterococci. Use carbapenems (except erta), Zosyn, or metronidazole with cefepime or ceftazidime.
SBP: if >250 PMN and is empirically covered with ceftriaxone 5-7days. Secondary ppx is always needed using Bactrim or quinolones.

61
Q

Skin and soft tissue infections

A

Impetigo [MSSA or strep pyrogenes]: honey-colored crusts around area usually on the face or hands. Generally topical with mupirocin. If needed use Keflex 500mg QID or dicloxacillin.
Folliculitis/furuncle/carbuncle [MRSA]: from hair follicles. Use I&D. If needed use Bactrim or doxycycline.
Cellulitis [strep or staph]: non-purulent. Use Keflex 500mg QID, dicloxacillin, or clindamycin for 5 days.
Abscess [MRSA]: purulent. Use Bactrim, doxycycline, minocycline, or clindamycin. Severe purulent infections should be covered with vancomycin, dapto, or linezolid for 7-14 days.
Necrotizing fasciitis [GAS, MRSA, G-, anaerobes]: life-threatening. I%D with empiric vancomycin or dapto, with Zosyn (or meropenem), and clindamycin.

62
Q

Diabetic foot infections

A

Generally polymicrobial. Duration is 1-2 weeks, unless it is osteomyelitis.
Aerobic G+; MSSA, MRSA, viridans strep, staph epi.
Aerobic G-; E. coli, Klebsiella pneumoniae, proteus mirabilis, Enterobacter cloacae, pseudomonas.
Anaerobic G+; peptostreptococcus, C. perfringens.
Anaerobic G-; B. fragilis.
MSSA coverage needed: Unasyn, Zosyn, carbapenems, moxifloxicin, metronidazole with either ceftriaxone, levofloxacin, cefepim, or ciprofloxacin.
MRSA coverage: Add vancomycin, dapto, or linezolid.

63
Q

Urinary tract infections

A

Acute uncomplicated cystitis: Macrobid 100mg BID x5d (CI if CrCl<60), or Bactrim DS BID x3d, or fosfomycin 3g x1D. In pregnancy, use amoxicilin, fosfomycin or Kelfex for 7 days. Alternatives include Augmentin, cipro, or levo (not moxi).
Acute pyelonephritis: levo or cipro unless resistance is >10%, then use ceftriaxone, ertapenem, or aminoglycoside, then transition to quinolone. Use carbapenem if ESBL.
Phenazopyridine (AZO) is an OTC pain reliever; 200mg PO TID x 2 days max with 8oz water and food. It may cause red-orange discoloration of fluids.
In pregnancy; beta-lactams are preferred. Cannot use nitro or Bactrim in 1st trimester, and no nitro in 3rd trimester. No quinolones.

64
Q

C. diff infection treatment

A

First episode: fidaxomicin 200mg PO BID x10d, vancomycin 250mg PO QID x10d, or metronidazole 500mg PO TID x 10d.
Second episode/first recurrence: fidaxomicin, or vancomycin taper (unless metronidazole was used, then no taper).
Subsequent episodes: standard fidaxomicin, vancomycin with pulse or taper, or vancmoycin followed by rifaximin 400mg TID x20d.
Fulminant disease (HoTN, shock, ileus, toxic megacolon): vancomycin 500mg QID with metronidazole 500mg IV q8h.

65
Q

Sexual transmitted infections

A

Chlamydia trachomatis (G-): doxycycline 100mg PO BID x 7 days. Pregnancy azithromycin 1g PO x1D. Alt; erythromycin, levofloxacin, (P) amoxicillin.
Neisseria gonorrhoeae (G- diplococci): ceftriaxone 500mg IM x1D (or 1g if >150kg). Alt; cefixime or gentamicin then azithromycin.
Bacterial vaginosis (Gardnerella vaginalis): metronidazole 500mg PO BID x7d, or applications intravaginally. Alt; clindamycin, tinidazole, or secnidazole.
Trichomonas vaginalis (protozoan): metronidazole 500mg PO BID x7d (males 2g PO x1D). Pregnancy: technically CI in 1st trimester, however CDC says treat anyway.
Genital warts (HPV 6, 11): imiquimod cream (Aldara, Zyclara).
Syphilis primary, secondary, or early latent (treponema pallidum, a spirochete): penicillin G benzathine 2.4mil U IM x1D (Bicillin L-A only). Alt; doxycycline 100mg PO BID x14d.
Syphilis tertiary or late latent >1yr: penicillin G benzathine 2.4mil U IM qwk x3wk (Bicillin L-A only). Alt; doxycycline x28d.
Neurosyphilis: Penicillin G aqueous crystalline 3-4mil U IV q4h x10-14d. No alt.
Penicillin desensitization:

66
Q

Tick-borne illness treatment

A

Its always Doxycycline

NAPLEX (20 decks)

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