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Micro Exam 2 > Pogue: Antimicrobial Agents GI and GU > Flashcards

Pogue: Antimicrobial Agents GI and GU Flashcards

1
Q

Which of the following is FALSE regarding
rifampin
– A) drug interactions, lots of em!
– B) monitor LFTs
– C) used for native valve endocarditis
– D) never used as monotherapy for Gram (+)
infections

A

C) used for native valve endocarditis

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2
Q 
Which of the following would not be a
suitable option for CA‐MRSA coverage in
cellulitis
– A) doxycycline
– B) TMP/SMX
– C) amoxicillin/clavulanic acid
– D) linezolid
A

C) amoxicillin/clavulanic acid

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3
Q

Normal Enteric Flora

Aerobes vs anaerobes
Microbs: (3)
Most resistant anaerobe:

A

Mostly Anaerobes: Bacteroides, Clostridium, peptostreptococci

Bacteroides fragilis: most resistant anaerobe

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4
Q

Normal Enteric Flora

Treatment:
Which treatments are unreliable?

A

Treatment: B-lactam/B-lactamase inhibitors, cefoxitin and metronidazole

Note: clindamycin and FQs unreliable

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5
Q

Normal Enteric Flora

Why isn’t enterococcus covered?
Strep:
E.coli sensitivities:

A

Some Aerobes (~1%): E.coli Proteus, Klebsiella, enterococcus
Even though enterococcus is present, it is not necessary to cover for it
- Not very virulent
- Resistant to a lot of drugs and treating doesn’t really make a difference

Streptococcus is there, but all regimens used cover it well

E.coli Sensitivities: vary greatly by location (important to now the sensitivities where you are located)

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6
Q

Community Acquired: (3)

A

Susceptible Gram negative organisms

Anaerobes

Enterococcus (but again, not necessary to empirically cover)

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7
Q

Hospital Acquired/Recent Antimicrobial Exposure:

A
  • Pseudomonas aeruginosa
  • Candida spp.
  • Enterococcus spp.
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8
Q

Spontaneous (Primary) Bacterial Peritonitis is commonly seen in what type of patient?’

Progression from cirrhosis to SBP

A

Commonly seen in patients with impaired liver function

Cirrhosis → impaired albumin → ascites → bacterial translocation → SBP

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9
Q

Spontaneous (Primary) Bacterial Peritonitis

Causative Agents: (3)

A

E.coli
Streptococcus spp.
Klebsiella spp.

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10
Q

Spontaneous (Primary) Bacterial Peritonitis

Mainstay Treatment:

A

3rd generation cephalosporins: mainstay

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11
Q

Spontaneous (Primary) Bacterial Peritonitis

Other treatment options:
Duration:

A 
Other Options:
•	Ampicillin/gentamicin
•	B-lactam/B-lactamase inhibitors
•	TMP/SMX
•	FQs

Duration: 5-7 days

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12
Q

Spontaneous (Primary) Bacterial Peritonitis

Prophylaxis:

A

Prophylaxis: often done if there was a previous episode and patient is at high risk for recurrence
o TMP/SMX 5 days per week
o Ciprofloxacin once per week

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13
Q

Spontaneous (Primary) Bacterial Peritonitis

Antifungal therapy:
Exception:

A

Antifungal therapy (ie. candida spp.) is unnecessary if fungus is isolated

Exception: immunocompromised patient or recurrent infection

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14
Q

Ruptured Bowel/Cholangitis/Abescesses

Cause:

A

Cause: normal flora (B.fragilis, E.coli)

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15
Q

Ruptured Bowel/Cholangitis/Abescesses

Treatment
Community Acquired: (3)

A

1st/2nd/3rd generation cephalosporine + metronidazole (cover anaerobes)

Cephamycin (cefotetan or cefoxitin) alone since they cover anaerobes

FQ + metronidazole (depends on FQ resistance in the area)

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16
Q

Ruptured Bowel/Cholangitis/Abescesses

Treatment
Nosocomial: (4)
-Expand coverage to include what?

A
  • Cefepime/metronidazole
  • Piperacillin/tazobactam
  • Carbapenem
  • FQ/metronidazole

Expand coverage to include Pseudomonas

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17
Q

Acute Cholecystitis

Infectious?
Inflamed?
When to treat?

A

Not often an infectious condition: although it is inflammatory

Treat only if infection is suspected: same causative organisms

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18
Q

Intra-abdominal Infections

Duration of Treatment:
Continue until when?

A

No hard-fast rule: generally 4-7 days

Continue until resolution of clinical signs/symptoms:
o Normalization of temperature
o WBC decrease
o GI function return

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19
Q

Infectious Diarrhea

What is the most important treatment?
When do you perform clinical evaluation? Antimicrobial therapy?

A

REHYDRATION: most important treatment

Perform clinical evaluation including fecal studies: when appropriate

Antimicrobial therapy when appropriate:
o Traveler’s diarrhea, Shigella, Campylobacter, C.difficile
o ALWAYS second line behind rehydration (electrolyte abnormalities can be fatal)

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20
Q

Infectious Diarrhea

Anti-motility agents:
Vaccinate:

A

Avoid anti-motility agents in certain disease states: will only exacerbate the problem
o Blood diarrhea
o Shiga-toxin producing E.coli
o C.difficile

Vaccinate when appropriate: cholera, typhoid etc.

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21
Q

Infectious Diarrhea
Pediatric Patients

Soft Contraindications:
Alternatives:

A

Soft Contraindications: tetracyclines and FQs (should be avoided if possible)

Alternatives: TMP/SMX, penicillins, cephalosporins

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22
Q

Salmonella

When is treatment recommended?

A

• Salmonella:

- Treatment not always recommended: only for severe disease, extreme ages, certain co-morbidities

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23
Q

Salmonella

Treatments: (5)
DOC:

A 
Treatment: 
o	Ciprofloxacin (FQs): generally the DOCs
o	Ampicillin/amoxicillin
o	TMP/SMX (if susceptible)
o	3rd generation cephalosporins 
o	Azithromycin
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24
Q

Salmonella
Duration of Therapy

Normal:
Immunocompromised:

A

Duration of Therapy:
o 5-7 days for most patients
o 14 days (or longer) for immunocompromised or relapsing disease

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25
Q

Shigella

Treatment: (6)
DOC:

A
  • FQs (norfloxacin, levofloxacin, ciprofloxacin): generally the DOCs
  • Amoxicillin/ampicillin
  • TMP/SMX
  • 3rd generation cephalosporins
  • Azithromycin
  • Naldixic acid (a quinolone but not an FQ; may also be used for Gram negative UTIs)
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26
Q

Shigella

Duration of Therapy:

A

o 3-5 days for most patients

o 7-10 days in immunocompromised

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27
Q

E.coli spp

Treatment depends on:
DOC:
Treatment: (3)
Duration of therapy:

A

Treatment: choice of agent depends a lot on local susceptibility pattern
o FQs: generally the DOCs
o TMP/SMX
o Cephalosporins

Duration of Therapy: 3 days

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28
Q

Aeromonas

Treatment: (2)
DOC:
Duration of Therapy:

A

Treatment:
o Ciprofloxacin (FQs): generally the DOCs
o TMP/SMX

Duration of Therapy: 3 days

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29
Q

Vibrio cholera

Treatment: (4)

A

o Doxycycline: 300mg x 1 dose (one high dose)

Other options:
o Tetracycline or TMP/SMX (3 days)
o FQ (single dose)

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30
Q

Giardia

Type of organism:
Treatment:
DOC:
Potential alternative:
SE of alternative:
A

PARASITE: therefore, antimicrobials like FQ will have no effect

Treatment:
Metronidazole: drug of choice (7-10 days)
Nitazoxanide: being studied as potential alternative if metronidazole cannot be tolerated
- Also being studied as an alternative for C.difficile

Nitazoxanide SE: diarrhea

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31
Q

Clostridium Difficile
Treatment

What is the first choice therapy for mild-moderate disease?
Severe disease?

A

Treatment: Discontinue exacerbating causes:

  • Broad spectrum antibiotics
  • Acid-suppressive agents

Oral Metronidazole: DOC for mild-moderate disease

Oral Vancomycin: becoming increasingly popular for the treatment of severe disease

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32
Q

Clostridium Difficile
Treatment

Other possibilities:
Duration:

A

Other Possibilities:
o Nitazonoxanide and rifaxamin as adjuncts (recurring/relapsing disease)
o Fidaxomicin recently FDA approved;

Duration: 10-14 days for first instance (complicated after that)

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33
Q

Hepatitis B is preventable with:

Post-exposure prophylaxis:

A

Preventable with vaccination

Post-Exposure Prophylaxis: Vaccine + HBVIG (immunoglobulins to HBV)

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34
Q

C.dif
Fidaxomicin

MOA:
Bacteriostatic or cidal?
Compare to vancomycin

A

Inhibits RNA synthesis by inhibiting RNA polymerases

Bactericidal

Initial data showed equivalence to oral vanco with a decrease in recurrence rates

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35
Q

Hepatitis B Treatment: (2)

A

Treatment: difficult to treat

Interferon-α
Some HIV meds (lamivudine, adefovir)

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36
Q

Hepatitis B
Interferon-α

MOA:

A
  • Interferon-α:
    o MOA: multifactorial and not always directly antiviral
    • Inhibits viral protein synthesis
    • Inhibits viral penetration or uncoating
    • Boosts host immune response
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37
Q

Interferon-α

SEs: (5)

A
  • Flu-like syndrome (on administration, will dissipate over time)
  • Thrombocytopenia
  • Granulocytopenia
  • Severe depression (some protocols automatically give anti-depressants with it)
  • Rash and alopecia
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38
Q

Interferon-α

Formulations:
Use:

A

Formulations: only SC or IM

Use: main use is for HCV, but can sometimes be used for acute HBV

39
Q

Hepatitis C

Historical Highly-Toxic Treatment regimen:

A

Highly toxic treatment regimen:

- Interferon-α + ribavirin

40
Q

Ribavirin MOA

SEs:

A

MOA: inhibition of viral RNA synthesis (mimics guanine)

Side Effects:
o Hemolytic anemia (need to monitor hematocrit and Hb; may need to dose adjust)
o Avoid in renal insufficiency

41
Q

HCV Protease Inhibitors (New Therapy): (2)

MOA:

A

HCV Protease Inhibitors (New Therapy): Telaprevir and Boceprevir

MOA: inhibit HCV protease (essential for HCV replication)

42
Q

Adverse Drug Effects of Telaprevir and Boceprevir:

When were these drugs studied:

A

Telaprevir:
• Rash
• Anemia

Boceprevir:
•	Anemia
•	Headache
•	Taste disturbances
•	CYP3A4/5 inhibitor and metabolite

Only studied as an add on to IFN/ribavirin: increases activity but shortens duration of treatment

43
Q

JTisa6y/omalewhorecentlydrankwell
waterandisnowpresentingwithprofuse,
waterydiarrhea.Stooldiagnosticsshow
V.cholera.HowwouldyoutreatJT?
–A)supporativecare(hydration)aloneaswedonot routinelygiveabxforcholera
– B)Doxycycline300mgx1
– C)TMP/SMX1DSBIDx3days
– D)TMP/SMX1DSBIDx10days

A

C) TMP/SMX 1 DS BID x 3 days

44
Q 
Yourpatientisstartedonribavirin+interferon 
forthetreatmentofHCV.Whichofthe 
followingistheLEASTimportantmonitoring 
parameterfortherapy. 
– A)HCVviralload 
– B)renalfunction 
– C)LFTs 
– D)Psychiatricmonitoring
A

C) LFTs

45
Q

WhichorganismlistedbelowisofLEAST
concernforsimplecommunity‐acquiredintra‐
abdominalinfections
–A)E.coli
–B)B.fragilis
–C)P.aeruginosa
–D)K.pneumoniae

A

C) P.aeruginosa

46
Q

HR is being treated with doxycycline for cholera. What piece of advice would you give him regarding adverse reactions?
–A) Avoid the sun if possible
–B) Avoid taking with multi‐vitamins
–C) We will need to monitor labs in order to see if you have kidney injury from the drug
–D) All of the above
–E) A and B

A

E) A and B

47
Q

Cystitis

Empirically target:
May be:

A

Empirically target E.coli: DOC based on local susceptibility data

May be other Gram negatives or enterococcus, but direct therapy at E.coli

48
Q

Cystitis

Treatment:
3 vs. 7 days:

A

3 days: TMP/SMX or FQs
7 days: B-lactams or nitrofurantoin
- S.saprophyticus: also needs a 7 days course

49
Q

Fosfomycin

MOA:
Spectrum of Activity:

A

MOA: inhibits enopyruvate transferase which inhibits cell wall synthesis

Spectrum of Activity: many urinary Gram negative, including drug-resistant isolates

50
Q

Fosfomycin

Use:
Dosing:

A

Use: only for UTIs; safe to use in pregnancy

Dosing:

  • 3g x 1 dose for cystitis (maintains high concentration in urine for 48 hours)
  • 3g every 3 days in complicated UTIs
51
Q

Complicated UTIs :

A
  • Obstruction
  • Foreign body
  • Recent urological procedure
  • Renal transplant
  • Males
  • Pregnancy
  • Diabetes
  • Immunocompromised
  • Health-care associated
52
Q

CA Pyelonephritis

Cause:
How does treatment vary?

A

Cause: E.coli and other Gram negatives

Note: same cause, but treatment will be different because you need a drug to penetrate the tissue

53
Q

CA Pyelonephritis

Treatment:
Oral Therapy: (3)
What is not appropriate?

A

Treatment: target therapy against isolated pathogens

Oral Options:
FQ
3rd generation cephalosporins 
TMP/SMX (rarely used)
Nitrofurantoin NOT appropriate (tissue concentrations not good enough)
54
Q

CA Pyelonephritis
Treatment

IV Options: (4)

A 
IV Options:
FQ
Aminoglycosides
3rd generation cephalosporins 
Extended-spectrum B-lactams or carbapenems (not empirically)
55
Q

CA Pyelonephritis
Duration

Uncomplicated:
Majority of patients:

A

Uncomplicated: 7-10 days

Majority of patients: 14 days

56
Q

Healthcare Associated UTIs
Need to cover for:
Also need to cover:

A

Need to cover for resistant pathogens: Pseudomonas is the most notable

Also need to cover for other Gram negatives

57
Q 
Healthcare Associated UTIs
Empiric coverage (broad-spectrum): (7)
A 
o	Cefepime
o	Ceftazadime
o	Pip/Tazo
o	Ciprofloxacin or levofloxacin
o	Group 2 carbapenems
o	Amnioglycosides
o	Some add vancomycin (to cover for MRSA; but not warranted because S.aureus rarely plays a role)
58
Q

What is a major cause of inappropriate antibiotic use?

A

Asymptomatic Bacteriuria

59
Q

Asymptomatic Bacteriuria

Only treat some cases:

A

Only treat some cases: pregnancy, neonates, urinary tract instrumentation/surgery/obstruction, renal transplant

60
Q

Candiduria

Almost always represents:
Discontinue: (2)

A

Almost always represents colonization instead of active infection: therefore, almost never needs treatment

Discontinue Foley: if possible
Discontinue unnecessary antibiotics

61
Q

Chancroid

Cause:
Infection: (2)

A

Cause: Haemophilus ducreyi

Infection:
Painful ulcers
Possible co-infection with HSV or syphilis

62
Q

Chancroid

Treatment aimed at:
Treatment: (4)
DOC:

A 
Treatment: aimed at curing infection, resolving symptoms, and preventing transmission 
o	Azithromycin 1g x 1 dose (PO) = DOC
o	Ceftriaxone (1 dose IM)
o	Ciprofloxacin 500mg BID for 3 days
o	Topical erythromycin TID for 3 days
63
Q

Chancroid

Treatment of sex partners:

A

Treat sex partners regardless of whether or not they have symptoms present: if they had sexual contact within 10 days of partners symptoms.

64
Q

Genital Herpes

Duration:

A

Chronic viral infection: lasts for entire life

65
Q

Genital Herpes

Treatment of First Clinical Episode: (3)

A

Acyclovir (3-5 times per day; 7-10 days)
Valacyclovir (offers BID dosing)
Famciclovir

66
Q

Genital Herpes
Treatment of Recurrent Infections

Suppressive Therapy:

A

Suppressive Therapy: reduces frequency in patients with frequent episodes (greater than 6 per year); many will have no outbreaks at all

67
Q

Genital Herpes

Treatment of Recurrent Infections: (2)
Episodic Regimens:

A

Valacyclovir: once daily; most often used
Acyclovir/Famciclovir: twice daily

Episodic Regimens:
Acyclovir: 5 day course (standard of care)

68
Q 
Genital Herpes
Disseminated Infection (Severe Disease)

Manifestations:

A

Manifestations: pneumonitis, hepatitis, meningitis, encephalitis

69
Q 
Genital Herpes
Disseminated Infection (Severe Disease)

Treatment:
Follow With:

A

Treatment: IV acyclovir (5-10mg/kg q8h) for 2-7 days until clinical improvement

Follow With: oral therapy to complete 10 day course (minimum)

70
Q

Syphilis

Cause:

A

T.pallidum

71
Q

Syphilis

Primary Infection:
Secondary Infection:
Tertiary Infection:
Latent Infection:

A

Primary Infection: ulcer/chancre at infection site

Secondary Infection: skin rash, mucocutaneous lesions, lymphadenopathy

Tertiary Infection: cardiac/ophthalmic manifestations, auditory abnormalities

Latent Infection: lack clinical symptoms but positive serology

72
Q

Syphilis

Treatment:
Benzathine penicillin use: (2)

A

Penicillin: preferred agent for all stages (but use different formulations/dosage/duration for each)

Primary/Secondary Infection:
Benzathine penicillin (1 max IM injection)
-	Pediatrics: lower dose, but still 1 max IM injection
73
Q

Syphilis

Penicillin Allergy:
Other agents used: (4)

A

Penicillin Allergy: tough because there is limited data to support other agents

  • Doxycycline (14 days)
  • Ceftriaxone (1g for 8-10 days)
  • Azithromycin (2g x 1 dose)
  • Desensitization to penicillin
74
Q

Syphilis
Treatment

Latent syphilis:
Tertiary Syphilis:

A

Treat to avoid long-term complications
- 3 doses IM benzathine penicillin at 1 week intervals

Tertiary Syphilis: does NOT include neurosyphilis; same 3 dose regimen as latent

75
Q

Syphilis
Treatment
Neurosyphilis

When can CNS involvement occur?
Dosing:
Drug:

A

Neurosyphilis: CNS involvement that can occur at ANY stage

Requires MAX DOSE IV therapy

Aqueous crystalline penicillin G (10-14 days)

76
Q

Syphilis
Treatment
Neurosyphilis

What if compliance is an issue?
If penicillin allergy:

A

Can give IM dose of probenecid if compliance is an issue

If an allergy to penicillin exists, desensitize or possibly use high dose ceftriaxone

77
Q

Jarisch-Herxheimer Reaction

When is it seen?
Symptoms:
Cause:

A

Jarisch-Herxheimer Reaction: sometimes seen in patients soon after syphilis treatment has begun

Symptoms: headache, myalgias, fever, tachycardia

Cause: release of pyrogen from the spirochetes

78
Q

Jarisch-Herxheimer Reaction

Duration:
Treatment:

A

Duration: can last 1-2 days

Treatment: anti-inflammatory drugs

79
Q

Chlamydia

Treatment: (4)

A

Azithromycin (1g PO x 1 dose)
Doxycyline (100mg PO x 7 days)
Erythromycin
FQs

80
Q

Chlamydia

Sex partner referral;
How long should the patient abstain from sex?

A

Sex partners referred for evaluation if they had sexual contact within 60 days of symptoms

Should abstain from sex until treatment completed

Note: even though azithromycin given as 1 day course, treatment still 7 day course!

81
Q

Gonorrhea

Results of Uncomplicated Gonococcal Infection: (2)

A

Causes: cervicitis, urethritis

82
Q

Gonorrhea

Treatment: (3)
What is no longer recommended?

A

Ceftriaxone 250mg IM x 1 dose (DOC)
Cefixime 400mg PO x 1 dose
Spectinomycin

FQs no longer recommended (resistance)

83
Q

Gonorrhea
Disseminated Gonococcal Infection (DGI)

Manifestations:

A

Manifestations: septic arthritis, endocarditis, meningitis.

84
Q

Gonorrhea
Disseminated Gonococcal Infection (DGI)

Treatment:
Duration:
Note:

A

Treatment:
MAX DOSE IV 3rd generation cephalosporins (ceftriaxone 1g q24h)

Duration: based on infected site

Note: ALWAYS TREAT FOR CHLAMYDIA UNLESS RULED OUT

85
Q

Trichomoniasis

Treatment: (1)

What are the alternatives? (2)

A

Metronidazole or tinidazole (2g x 1 dose)

Metronidazole 500mg BID x 7 days (only if they cannot tolerate high dose)

Alternative: Clindamycin (possible use if allergy to metronidazole; not a lot of good data)

86
Q

Vaginosis

3 main categories:

A

Bacterial: anaerobic organisms like Gardenella vaginalis

Trichomoniasis:

Candidiasis: C.albicans

87
Q

Vaginosis

Treatment of bacterial and trichomoniasis:

A

Bacterial: anaerobic organisms like Gardenella vaginalis

  • Metronidazole (7 days)
  • Clindamycin (alternative)

Trichomoniasis: same as above

88
Q

Vaginosis

Treatment of Candidiasis

A

Candidiasis: C.albicans

  • Fluconazole x 1 dose
  • Variety of topicals
89
Q

Pelvic Inflammatory Disease

Causative Agents:

When do you treat sexual partners:

A

N.gonorrhea, C.trachomatis, some Gram negatives, anaerobes, and possibly some strep

Treat if concern for neisseria or chlamydia

90
Q

Pelvic Inflammatory Disease

Empiric Recommendations (IV): (4)

A

Cephamycin (cefotetan or cefoxitin) + doxycycline

Clindamycin + gentamicin

FQ + metronidazole

Ampicillin/sulbactam + doxycycline

91
Q

Pelvic Inflammatory Disease
Oral Therapy

Used for:
Drugs: (3)
Duration:

A

Used for mild-moderate disease after response to initial IV therapy

  • Ceftriaxone IM + doxycline (+ metronidazole)
  • FQ (+ metronidazole)
  • Amox/clav + doxycycline

Duration based on clinical scenario

92
Q

Epididymitis

Causative Organisms:
From anal intercourse:

A

Causative Organisms: C.trachomatis, N.gonorrhea

Anal intercourse: E.coli, Pseudomonas

93
Q

Epididymitis

Treatment: (3)
DOC:
For enteric organisms:

When do you treat sexual partners?

A

Ceftriaxone + Doxycycline (DOC)
FQ (for enteric organisms)
Ceftriaxone + Doxycycline + FQ (if all of the above are of concern)

Treat sex partners if C.trachomatis or N.gonorrhea are suspected

Micro Exam 2 (18 decks)

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