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NAPLEX 2022 > Infectious Diseases II: Bacterial Infections > Flashcards

Infectious Diseases II: Bacterial Infections Flashcards

1
Q

Perioperative Antibiotic Prophylaxis

Bug and Drug of Choice, Alternatives

A

Bug: Staphylococci and Streptococci

——Drugs——–
DOC: Cefazolin*** or Cefuroxime
Alt: Vancomycin or Clindamycin
- used when a beta-lactam allergy or risk of MRSA

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2
Q

Time of Perioperative Antibiotics

pg. 376

A

—-Pre-operative (prior to surgery)—-
DOC: 60 min before Alt: 120 min before

—-Intra-operative (during surgery)—-
Additional doses may be administered if surgery is >3-4
hours or there is major blood loss

—-Post-operative (after surgery)—-
ABX not usually needed; if used, discontinue within 24 hours

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3
Q

Surgery prophylaxis DOC & bug coverage

A

DOC: Cefazolin (1st gen ceph) - MRSA and Streptococci

Alt: Clindamycin if pt has a beta-lactam allergy or Vancomycin (MRSA colonization or risk instead of Clindamycin)

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4
Q

Colorectal surgery prophylaxis DOC vs alternatives & bug coverage

A

DOC: Cefotetan, cefoxitin, ampicillin/sulbactam (Unasyn), ertapenem, OR metronidazole PLUS cefazolin or ceftriaxone

Alt: Clindamycin PLUS (aminoglycoside, quinolone or aztreonam), OR metronidazole PLUS (aminoglycoside or quinolone)

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5
Q

Classic symptoms of meningitis

A

Fever
Headache
Stiff neck
Altered mental status

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6
Q

Meningitis Diagnosis & Bugs

A

Dx: Lumbar puncture

Bugs: S. pneumoniae, N. meningitidis, H. influenzae, Listeria

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7
Q

Acute Bacterial Meningitis Treatment (Community-Acquired)

ABX durations are pathogen-dependent

A

7 days for N. meningitidis and H. influenzae
10-14 days for S. pneumoniae
<21 days for Listeria monocytogenes

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8
Q

Meningitis: Empiric Treatment

A

Empiric antibiotic selection depends of age & RFs
Aggressive (high) doses are used to penetrate the CNS

——–Age < 1 month (neonates)——–
Ampicillin (Listeria) PLUS cefotaxime (no ceftriaxone) OR gentamicin

  • ——-Age 1 month to 50 years———
  • Ceftriaxone or cefotaxime PLUS vancomycin

——–Age > 50 years or immunocompromised———–
Ampicillin (Listeria) PLUS Ceftriaxone or Cefotaxime PLUS Vancomycin

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9
Q

Meningitis: Empiric Treatment but the adult has a severe penicillin allergy

A

Treat with a Quinolone (moxifloxacin) PLUS vancomycin +/- Bactrim (listeria coverage)

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10
Q

S/SX of AOM

A

Bulging tympanic (eardrum) membranes
Otorrhea (middle ear effusion/fluid)
Otalgia (ear pain)
Tugging/rubbing of ears

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11
Q

AOM Treatment in Kids: When to consider observation

A

Systemic drugs: Pain (APAP or Ibu)

Observation for 48-72 hours - non-severe AOM
-mild otalgia < 48 hours or temp <102.2F (39)

AND

Age 6-23 months: sx in one ear only
Age > 2 years: sx in one or both ears

**if sx do not improve, or worsen, use ABX

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12
Q

AOM Antibiotic Treatment

A

High-dose amoxicillin or amoxicillin/clavulanate (Augmentin)

**least amount of clavulanate - decrease risk of diarrhea

H-D covers S. pneumoniae

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13
Q

What is the ratio of amoxicillin to clavulanate? What’s the brand?

A

14:1 - Augmentin ES 600

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14
Q

American Academy of Pediatrics (AAP) guidelines recommended what drug class for non-severe penicillin allergy?

A

Cephalosporin

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15
Q

Treatment duration with oral medications

A

10 days for children < 2 years
7 days for age 2-5 years
5-7 days for age > 6 years

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16
Q

AOM: Antibiotic Treatment

A

——-First-Line Treatment———
Amoxicillin 80-90 mg/kg/day in 2 divided doses
OR
Amoxicillin/clavulanate 90 mg/kg/day
OR
Ceftriaxone IM (if vomiting or unable to tolerate PO)

——-Alternative Treatment———-
Cefdinir 14 mg/kg/d in 1-2 divided doses
Cefuroxime 30mg/kd/d in 2 divided doses

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17
Q

Compare and Contrast - Clinical Presentation

Common cold
Influenza
Pharyngitis
Sinusitis

pg. 379

A

———Clinical Presentation———–
C: sneezing, runny nose, cough
I: sudden onset fever, chills, fatigue, body aches
P: sore throat, swollen lymph nodes, white patches on tonsils
S: nasal congestion, facial/ear/dental pain, headache

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18
Q

Compare and Contrast - Criteria for Anti-Infective Treatment

Common cold
Influenza
Pharyngitis
Sinusitis

pg. 379

A

———Criteria for Anti-Infective Treatment—–

C: none
I: < 48 hours since sx onset
P: rapid antigen diagnostic test
S: > 10 days of sx OR > 3 days of severe sx (temp >102*F)

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19
Q

Compare and Contrast - Treatment Options

Common cold
Influenza
Pharyngitis
Sinusitis

pg. 379

A

C: OTC products
I: Oseltamivir x 5 days | Baloxavir x 1 dose | Zanamivir inhalation
P: Penicillin, amoxicillin
Sinusitis:
1st line - Augmentin
2nd line - PO 2nd/3rd gen ceph PLUS clindamycin, doxycycline or resp. FQ

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20
Q

Lower Respiratory Tract Infections - Bronchitis

Symptoms
Cause
Diagnosis
Treatment of Choice

A

Bronchitis

Symptoms: cough
Cause: RSV or bacteria (Bordetella pertussis ‘whooping cough’)
Diagnosis: chest x-ray
Treatment of Choice: supportive care (fluids, otc meds. abx not recommended “exception is Bordetella - macrolide or bactrim) “

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21
Q

COPD patient with Acute Bacterial Exacerbation of Chronic Bronchitis

A
  1. Supportive treatment (O2, short-acting inhaled
    bronchodilators, IV/PO steroids)
  2. ABX for 5-7 days if any one of the following are met:
    - increase dyspnea, incr. sputum volume and incr. sputum purulence
    - mechanically ventilated
  3. Preferred ABX
    - Augmentin**
    - Azithromycin
    - Doxycycline
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22
Q

Community-Acquired Pneumonia

Symptoms
Diagnosis
Common pathogens
Treatment of Choice & Duration

A

Community-Acquired Pneumonia

Sx: cough, purulent sputum, rales, tachypnea (incr. RR)
Dx: Chest X-ray
Bugs: S. pneumonia, H. influenzae, M. pneumoniae “walking pneumonia”
DOC: Respiratory FQs x 5-7 days

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23
Q

Outpatient CAP Treatment Stepwise Approach

A

Step 1: look for comorbidities (chronic heart, lung, liver, kidney disease, DM, alcoholism, malignancy or asplenia)

Step 2: check for MRSA or Pseudomonas

Step 3: Category 1 vs Category 2

Step 4: Choose DOC within category (look for allergies/DDIs)

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24
Q

Outpatient CAP Treatment Stepwise Approach

Category 1

A

No comorbidities

Amoxicillin H-D 1g TID 
OR 
Doxycycline 
OR 
Macrolide (Azithromycin or clarithromycin)
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25
Outpatient CAP Treatment Stepwise Approach Category 2
Beta-lactam PLUS macrolide OR doxycycline - augmentin OR cephalosporin (cefpodoxime, cefuroxime) PLUS - macrolide OR doxycycline Respiratory quinolone monotherapy - moxifloxacin, gemifloxacin, levofloxacin
26
Inpatient CAP treatment for nonsevere (non-ICU care)
Beta-lactam PLUS macrolide OR doxycycline - preferred beta-lactams (Ceftriaxone, cefotaxime, ceftaroline or Unasyn) Respiratory quinolone monotherapy - moxifloxacin, gemifloxacin, levofloxacin
27
Inpatient CAP treatment for severe (ICU care)
Beta-lactam PLUS macrolide Beta-lactam PLUS respiratory quinolones (do NOT use FQ monotherapy)
28
Risk factors for Pseudomonas and/or MRSA in Inpatient CAP treatment:
MRSA: add coverage with Vancomycin or Linezolid Pseudomonas: add coverage with zosyn, cefepime, meropenem or aztreonam
29
Hospital-acquired pneumonia (HAP) has an onset of
onset > 48 hours after hospital admission
30
Ventricular-associated pneumonia (VAP) occurs
> 48 hours after the start of mechanical ventilation
31
Common pathogens in HAP and VAP
Nosocomial pathogens Risk for MRSA and MDR Gram-negative rods, including Pseudomonas
32
HAP/VAP: Selecting an Empiric Regimen All patients need an antibiotic for Pseudomonas and MSSA regimen:
cefepime | piperacillin/tazobactam (Zosyn)
33
HAP/VAP: Selecting an Empiric Regimen If patient is at risk for MRSA what drugs are added?
Vancomycin or Linezolid - cefepime PLUS vancomycin - meropenem PLUS linezolid
34
HAP/VAP: Selecting an Empiric Regimen What 2 antibiotics are used in Pseudomonas if risk for MDR pathogens?
-piperacillin/tazobactam PLUS ciprofloxacin PLUS vancomycin -cefepime PLUS gentamicin PLUS linezolid
35
Identify the risks for MRSA or MDR pathogens
1. Positive MRSA nasal swab (indicates MRSA colonization) 2. High prevalence (>10%) of pathogen resistance to any single agent noted in hospital unit 3. IV antibiotic use within the past 90 days
36
Antibiotics for Pseudomonas (**do NOT use 2 beta-lactams together**)
``` piperacillin/tazobactam cefepime, ceftazidime, or ceftolozane/tazobactam (Zerbaxa) levofloxacin or ciprofloxacin imipenem/cilastatin or meropenem aztreonam tobramycin, gentamicin or amikacin colistimethate or polymyxin B ```
37
Antibiotics for MRSA
vancomycin | linezolid
38
How is active pulmonary TB spread?
transmitted aerosolized droplets (i.e., sneezing, coughing & talking) **Highly contagious**
39
Clinical presentation of active pulmonary TB
cough/hemoptysis (coughing up blood) fever night sweats Hospitalized patients require isolation in a single negative-pressure room
40
Diagnosis of TB
Latent disease: TB skin test (PDD) | - intradermal injection, analyzed after 48-72 hours
41
Diagnosis of Latent TB: Criteria for Positive TB Skin Test Results
≥ 5 mm induration = significant immunosuppression ≥ 10 mm induration = high-risk congregate settings (healthcare workers) ≥ 15 mm induration = patients with no risk factors
42
Latent TB Treatment duration
Shorter regimens (3-4 mo) preferred** due to higher completion rates and less risk of hepatotoxicity
43
Preferred Latent TB Regimens - Drugs/Duration
1. INH and Rifapentine - weekly x 12 weeks via directly observed therapy (DOT) 'adherence' **do not use this regimen in pregnancy** 2. Rifampin x 4 months (preferred in children of all ages & HIV-negative adults) 3. Isoniazid w/ rifampin x 3 months (use in adults, children & HIV +)
44
Alternate Latent TB Regimens - Drugs/Duration
1. INH x 6-9 months (alternate for HIV -/+ adults/children) **INH x 9 months in pregnancy (Tx of choice)**
45
Active TB Diagnosis
A positive TST and confirmed with an acid-fast bacilli (AFB) statin
46
Active TB Treatment
2 phases (intensive and continuation) Intensive "RIPE x 2 months" Continuation phase x 4 months (2 drugs: rifampin & isoniazid)
47
RIPE Drugs
rifampin (RIF) isoniazid (INH) pyrazinamide (PZA) ethambutol Duration: 8 weeks (2 mo)
48
Rifampin - Safety/SE/Monitoring
SE: increase LFTs, hemolytic anemia (detected with a positive Coombs test), flu-like syndrome, orange-red discoloration (sputum, urine, sweat, tears, teeth), stain contacts & clothes DDI: -RIF is a potent inducer of CYP450 and P-glycoprotein - decrease concentration of PI, Warfarin (decr. INR), OC (decr. efficacy) - Do NOT use RIF w/ apixaban, rivaroxaban **Alternative to rifampin is rifabutin (less DDIs)**
49
Isoniazid - Safety/SE/Monitoring/Notes
Boxed Warning: hepatitis Warnings: Peripheral neuropathy Notes: Supplement with pyridoxine (Vit B6) 25-50 mg to decr. risk of peripheral neuropathy SE: increase LFTs, drug-induced lupus erythematosus (DILE), hemolytic anemia (+ Coombs test)
50
Pyrazinamide - Safety/SE/Monitoring/Notes
Contraindications: acute gout SE: increase LFTs, hyperuricemia/gout
51
Ethambutol - Safety/SE/Monitoring/Notes
SE: increase LFTs, optic neuritis (dose-related), confusion, hallucinations
52
RIPE Therapy for TB (Drug-Specific Key Points)
Monitor infection: sputum samples, sx, and chest x-ray All RIPE drugs: increase LFTs -----------Rifampin------------ orange bodily secretions strong CYP450 inducer (use rifabutin if CI) flu-like symptoms -----------Isoniazid------------ peripheral neuropathy; give w/ pyridoxine (Vit B6) 25-50 mg PO daily monitor for sx of DILE -----------RIF & INH----------- risk of hemolytic anemia (+ Coombs test) --------Pyrazinamide-------- increase uric acid - do not use with acute gout --------Ethambutol----------- visual damage (requires baseline & monthly vision exams) confusion/hallucinations
53
Infective endocarditis - Diagnosis & Common Pathogens
Dx: ECG & positive cultures Pathogens: Staphylococci, Streptococci & Enterococci
54
What drug is added for synergy effect in Infective Endocarditis? Monitoring?
Gentamicin Pathogens: active against Pseudomonas and enhances Gram-positive coverage with used as synergy Monitoring: peak levels 3-4 mcg/mL & troughs <1 mcg/mL
55
Preferred ABX Regimen in infective endocarditis treatment associated with which pathogen?
Viridans group Streptococci: PCN or ceftriaxone (+/- Gent) Staphylococci (MSSA): NAF or cefazolin (+ Gent & RIF 'if prosthetic valve') **use Vanc if beta-lactam allergy** Staphylococci (MRSA): Vancomycin (+ Gent & RIF 'if PV') Enterococci: Both native & prosthetic valve IE - PCN or ampicillin + gent OR ampicillin + high-dose ceftriaxone **beta-lactam allergy: Vanc + Gent** ^^ if VRE, use daptomycin or linezolid ^^
56
Infective endocarditis dental prophylaxis Adult Prophylaxis Regimen
PO: Amoxicillin 2 g 30-60 min b4 dental procedure **if can't do PO: Ampicillin 2g IM/IV OR Cefazolin 1 g IM/IV ^^ if allergic to PCN: Clindamycin 600 mg OR Azithromycin/Clarithromycin 500 mg **if can't do PO & PCN allergy: Clindamycin 600 mg IM/IV
57
Intra-abdominal infections DOC in spontaneous bacterial peritonitis (SBP) Pathogens for Primary & Secondary Peritonitis
DOC: Ceftriaxone x 5-7 days Prophylaxis for SBP: Bactrim or Cipro Primary Peritonitis: Streptococci, enteric Gram-negative (Proteus, E.coli, Kleb, or PEK) Secondary Peritonitis: "same" PLUS anaerobes (B. fragilis) - DOC: Flagyl
58
Intra-abdominal infections Define Cholecystitis vs Cholangitis
Cholecystitis: inflammation of the gallbladder Cholangitis: infection of the common bile duct
59
Skin & Soft Tissue - Clinical Presentation & Classifications
Mild: Superficial (impetigo, furuncles, carbuncles) Moderate: Non-purulent cellulitis Severe: Purulent/Abscesses Systemic Signs: - Temp > 100.4*F - HR > 90 BPM - WBC > 12000 < 4000 cells/mm^3
60
Outpatient Treatment of MSSA/MRSA & Streptococci SSTIs Impetigo
Honey-colored crusts DOC: mupirocin (Bactroban) **if numerous lesions, use PO abx for MSSA: Keflex
61
Outpatient Treatment of MSSA/MRSA & Streptococci SSTIs Folliculitis/furuncles/carbuncles
Follicles & Furuncles: warm compress Carbuncles require incision & drainage ((&D) * *if systemic signs, PO for MSSA: Keflex * *if unresponsive to initial treatment, change to CA-MRSA: Bactrim or Doxy
62
Mild Cellulitis (Non-purulent) SSTI
PO abx must be active againists Streptococci + MSSA DOC: Keflex Alt: Clindamycin
63
Mild-Moderate purulent SSTI
Commonly caused by CA-MRSA 1st-line: I&D **if systemic signs or multiple sites: I&D PLUS Bactrim or Doxy
64
Severe purulent SSTI Treatment
Cover MRSA + CA-MRSA Vancomycin (goal trough 10-15 mcg/mL) Daptomycin** Linezolid** **VRE coverage
65
Necrotizing fasciitis Treatment
Empiric therapy is broad: Vanc + beta-lactam Beta-lactam: piperacillin/tazobactam (Zosyn), imipenem/cilastatin or meropenem)
66
What are the aerobic Gram-positive pathogens?
S. aureus (MRSA) Group A Streptococcus Viridans group Streptococci S. epidermidis
67
What are the aerobic Gram-negative pathogens?
``` E. coli K. pneumoniae P. mirabilis Enterobacter cloacae Pseudomonas ```
68
What are the anaerobic Gram-positive pathogens?
Peptostreptococcus | Clostridium perfringens
69
What are the anaerobic Gram-negative pathogens?
Bacteroides fragilis and faecium
70
Urinary Tract Infection (UTI) Symptoms
``` -------Cystitis (Lower UTI)------- urgency and frequency (nocturia) dysuria suprapubic heaviness hematuria ----Pyelonephritis (Upper UTI)---- flank pain ----Vaginal Candida albicans "fungal infection"---- itchy ```
71
Uncomplicated UTIs occur in what population(s)?
non-pregnancy women
72
Complicated UTIs occur in what population(s)?
Males Patients with indwelling catheter Children
73
Does the presence of bacteria alone qualify to be diagnosis as a UTI?
No Urinalysis must confirm pyuria & bacteriuria **Exception: asymptomatic bacteriuria in pregnancy**
74
Drugs of Choice in Acute Uncomplicated Cystitis
Macrobid 100 mg PO BID x 5 days (CI: CrCl < 60 mL/min) OR Bactrim DS 1 tab PO BID x 3 days OR Fosfomycin 3 g x 1 dose
75
What are the drugs of choice in pregnancy with acute uncomplicated cystitis?
Keflex & Amoxicillin x 7 days **PCN allergy: Fosfomycin
76
Which quinolone is not used in UTIs?
Moxifloxacin **it's only available in retail as antibiotic eye/ear drops**
77
What is the class of choice in Complicated UTI if ESBL-producing bacteria is present?
Carbapenems
78
Phenazopyridine - Brand & Counseling Points
Brand: Pyridium or AZO CP: max 2 days, take with 8 oz of water or food to decr. GI upset, may cause red-orange coloring of urine; contact lense/clothes staining
79
Common pathogens of Travelers' Diarrhea
``` -----Bacterial------ E. coli Campylobacter jejuni Shigella Salmonella ``` Viral: Rotavirus
80
Travelers' Diarrhea Treatment
Azithromycin preferred treatment if fever, blood in stools, pregnant or pediatric Quinolones (1-3 days) or rifaximin (3 days) if bloody diarrhea is not present Antimotility agents: Loperamide (for symptomatic relief only)
81
Symptoms of C. difficile infection (CDI)
``` Abdominal cramps Profuse diarrhea (can be bloody) Fever ```
82
C. difficile guideline recommendations for treatment
- ---------1st episode (nonsevere or severe)------- - Vancomycin 125 mg PO QID x 10 days OR - Fidaxomicin 200 mg PO BID x 10 days * *if non-severe and above treatment not available - Metronidazole 500 mg PO TID x 10 days --------Fulminant/Complicated 1st episode-------Vancomycin 500 mg PO/NG/PR QID + Flagyl 500 mg IV Q8H - ------2nd episode "Recurrence"------------ - If MET used initially: Vanc 125 mg PO QID x 10 days - If VANC used initially: FDX 200 mg PO BID x 10 days - If VANC or FDX used initially: Vanc tapered and pulsed regimen** (125 mg QID x 10 days, BID x 1 week, daily x 1 week, then 125 mg Q2-3 days x 2-8 weeks) -------Subsequent Episodes----------- VANC taperer and pulsed regimen** OR VANC 125 mg PO QID x 10 days, then rifaximin 400 mg TID x 20 days OR FDX 200 mg PO BID x 10 days OR Fecal microbiota transplant
83
Syphilis (primary, secondary or early latent) Treatment of Choice, Dosing/Duration & Alternatives
DOC: Bicillin L-A Dosing/Duration: 2.4 million units IM x 1 Alternatives: Doxycycline If allergic to PCNs (desensitized and treat with Bicillin L-A) - HIV - Pregnancy
84
Syphilis (late latent or tertiary) Treatment of Choice & Dosing/Duration
DOC: Bicillin L-A Dosing/Duration: 2.4 million units IM x 3 weeks
85
Neurosyphilis and congenital syphilis DOC
Pen G
86
Gonorrhea DOC
Ceftriaxone < 150 kg: 500 mg IM x 1 > 150 kg: 1 g IM x 1 If Chlamydia has not been excluded: add Doxycycline
87
Chlamydia DOC
Doxycycline 100 mg PO BID x 7 days OR Azithromycin 1 g PO x 1
88
Bacterial Vaginosis DOC
Metronidazole PO or 0.75% gel
89
Trichomoniasis DOC
Metronidazole 2 g PO x 1 **CDC recommended Flagyl in all trimesters (even though MET is CI in 1st trimester)**
90
Genital Warts (HPV) DOC
Imiquimod cream
91
What is the drug of choice in rickettsial diseases?
DOC: Doxycycline **DOC esp. pediatrics**

NAPLEX 2022 (25 decks)

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