infectious diseases, part 2 Flashcards
Tx for acute bacterial skin and skin structure infections, outpatient
Cephalexin
- great for MSSA and strep (Not MRSA)
- dosed 4x a day: compliance issue
- cannot use in PCN allergy pts
Tetracyclines (doxycycline, minocycyline)
Bactrim
Clindamycin - use as last nine b/c of C. diff
Linezolid
- IV and PO, very $$
- toxicities if used longer than 2 weeks
- reserved for resistant MRSA
Dalbavancin or Oritavancin
- one injection , one time dose
- very long 1/2 life, similar to vanco
- useful for non-compliant pts
Tx for acute bacterial skin and skin structure infections , inpatient
pharm agents for inpatient (wanna cover for MRSA): Vancomycin Linezolid Ceftaroline Daptomycin
acute uncomplicated cystitis
usually casued by E. coli (75-95% of cases)
urgency, increased frequency, dysuria, suprapubic pain or tenderness
diagnostics! get UA first, then urine culture
only get urine culture if UA is abnormal
urine culture may show bacteria but if the patient is asymptomatic, shouldn’t treat
Antifungals
tx disease causing yeast and molds
common classes
- Polyenes
- Triazoles
- Echinocandins
Common pathogens: Candida and aspergillus
triazoles spectrum of activity
————————————————->
increasing spectrum of activity
fluconazole itraconazole voriconazole posaconazole isavuconazole
fluconazole is the least broad
candida glubra is 30% resistant to fluconazole
URI tx
avoid antibiotics, treat symptoms nasal discharge - antihistamine nasal congestion - decogenstant / saline sore throat - lozenges headache etc - acetaminophen
Isavuconzole (Cresemba)
BIG GUN
available IV and PO
metabolized primarily by liver
very broad spectrum of activity including yeast and mold
URI work up
bacterial versus viral
fever
rapid throat swab - rule out strep
nasal viral swab - rule out flu
CURB-65
CONFUSION BUN > 20 RR > 30 BP systolic < 90 or diastolic < 60 Age > 65
one point for each
0-1 –> outpatient
2 - discretion / either short inpatient or supervised out
3 - inpatient
4-5 - inpatient / icu
when to tx a URI with antibiotics
strep throat
-amoxicillin or augmentin
otitis externa
otitis media with pus draining
worsening URI
community acquired pneumonia diagnosis
fever tachypnea cough sputum production confusion fatigue CXR showing infiltrate
Other agents for UTI
Bactrim - not in pregnancy
Fluroquinolones (Levofloxacin, Ciprofloxacin)
use in allergic or severe/refractory case
DO NOT USE MOXIFLOXACIN FOR UTI
Beta-lactams (definitive therapy)
amoxicillin clauvanate (Augmentin)
oral cephalosporins ie cefpodoxime (Vantin)
Fluconazole (Diflucan)
Excellent oral bioavailability
Good distribution in CSF, vitreous, urine
Renal elimination -adjust dose in renal failure
Think: C. albicans injections - thrush, UTI, blood
empiric therapy
no culture data to guide antibiotic selection
takes into account common pathogens
takes into account pt hx and local resistance
Fosfomycin (Monurol) PO
MOA: interferes with cell wall synthesis
broad spectrum , covering - and +
Reserved for refractory cases***
Given as a one time dose in uncomplicated disease
Many will complain of diarrhea, nausea.. sometimes dizziness
Patients develop resistance so only should use empirically once or twice, need to base it on cultures after that
treatment of CAP outpatient
first line: for outpatient, uncomplicated
Doxycycline or azithromycin
first line (oupatient, complicated)
same as above or
levofloxacin or moxifloxacin
complicated = patient has multiple comorbidities including COPD, diabetes, CHF, OR they have recent antibx use
tx about 5-7 days
indications for antifungal disease
invasive candidiasis
- mucocutaenous disease
- candiduria
- candidemia (4th most common blood stream infection)
- intra-abdominal infections
- meningitis
- endocarditis
invasive mold infections (lung, skin, sinus, CNS)
- aspergillosis
- other mold species
community acquired pneumonia
similar symptoms to structural lung disease and CHF exacerbations
in elderly, confusion may be only initial symptom
chest x-ray not always sensitive
Voriconazole (VFEND)
drug of choice for invasive pulmonary aspergillis
excellent distribution including CSF, and CNS BUT NOT URINE
iv and oral option - great bioavailability
requires monitoring, goal is 2 - 5.5 mcg/ml
side effects include visual disturbances and hallucinations!! can develop tolerance tho
Azole ADE / Monitoring
LFTs Renal Function QTc interval Drug Interactions GI Intolerance Agent Specific
Itraconazole (Sporonax)
less common -inotropic effects Contraindicated with class 3 and 4 heart failure metabolized extensively by liver requires monitoring of drug levels
treatment of acute uncomplicated cystitis
Fluoroquinolones no longer recommended as first line therapy - reserve for allergy / severe
Resistance is huge concern
typical duration is just 3-5 days
preferred agents: nitrofurantoin (Macrobid) Bactrim Fosfomycin Fluoroquinolones Beta-lactams (amoxicillin-clauvanate, cefpodoxime)
treatment of CAP inpatient
Ceftriaxone PLUS Azithromycin
(PCN allergy: levofloxacin or moxifloxacin)
concern for pseudomonas :
anti-pseudomonal agent + Levofloxacin
concern for MRSA: add vanco or linezolid
tx about 7-10 days
Nitrofurantoin (Macrobid) PO
MOA: works intracellularly to damage bacterial RNA and DNA
requires patients to have CrCl > 50
Requires minimum of 5 days treatment
Safe in pregnancy
Well tolerated
-diarrhea, hypersensitivity, rash, anemia (rare), peripheral neuropathy (rare, long term use)
Covers many gram-negative organims (E. coli)
also coveres Enterococcus, VRE
DO NOT USE IN COMPLICATED DISEASE
poor GU tissue concentrations
need to rule out upper GU involvement
Posaconazole (Noxafil)
expanded spectrum including rare molds
IV and po options
therapeutic drug monitroing
prophylaxis in neutropenic patients tx for AML
