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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
Shigella Treatment: (6) DOC:
- 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)
26
Shigella | Duration of Therapy:
o 3-5 days for most patients | o 7-10 days in immunocompromised
27
E.coli spp Treatment depends on: DOC: Treatment: (3) Duration of therapy:
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
28
Aeromonas Treatment: (2) DOC: Duration of Therapy:
Treatment: o Ciprofloxacin (FQs): generally the DOCs o TMP/SMX Duration of Therapy: 3 days
29
Vibrio cholera | Treatment: (4)
o Doxycycline: 300mg x 1 dose (one high dose) Other options: o Tetracycline or TMP/SMX (3 days) o FQ (single dose)
30
Giardia ``` Type of organism: Treatment: DOC: Potential alternative: SE of alternative: ```
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
31
Clostridium Difficile Treatment What is the first choice therapy for mild-moderate disease? Severe disease?
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
32
Clostridium Difficile Treatment Other possibilities: Duration:
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)
33
Hepatitis B is preventable with: | Post-exposure prophylaxis:
Preventable with vaccination Post-Exposure Prophylaxis: Vaccine + HBVIG (immunoglobulins to HBV)
34
C.dif Fidaxomicin MOA: Bacteriostatic or cidal? Compare to vancomycin
Inhibits RNA synthesis by inhibiting RNA polymerases Bactericidal Initial data showed equivalence to oral vanco with a decrease in recurrence rates
35
Hepatitis B Treatment: (2)
Treatment: difficult to treat Interferon-α Some HIV meds (lamivudine, adefovir)
36
Hepatitis B Interferon-α MOA:
- Interferon-α: o MOA: multifactorial and not always directly antiviral • Inhibits viral protein synthesis • Inhibits viral penetration or uncoating • Boosts host immune response
37
Interferon-α SEs: (5)
* Flu-like syndrome (on administration, will dissipate over time) * Thrombocytopenia * Granulocytopenia * Severe depression (some protocols automatically give anti-depressants with it) * Rash and alopecia
38
Interferon-α Formulations: Use:
Formulations: only SC or IM Use: main use is for HCV, but can sometimes be used for acute HBV
39
Hepatitis C Historical Highly-Toxic Treatment regimen:
Highly toxic treatment regimen: | - Interferon-α + ribavirin
40
Ribavirin MOA | SEs:
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
HCV Protease Inhibitors (New Therapy): (2) MOA:
HCV Protease Inhibitors (New Therapy): Telaprevir and Boceprevir MOA: inhibit HCV protease (essential for HCV replication)
42
Adverse Drug Effects of Telaprevir and Boceprevir: When were these drugs studied:
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
JT is a 6 y/o male who recently drank well  water and is now presenting with profuse,  watery diarrhea. Stool diagnostics show  V.cholera. How would you treat JT? –A) supporative care (hydration) alone as we do not routinely give abx for cholera – B) Doxycycline 300 mg x 1  – C) TMP/SMX 1 DS BID x 3 days – D) TMP/SMX 1 DS BID x 10 days
C) TMP/SMX 1 DS BID x 3 days
44
``` Your patient is started on ribavirin + interferon  for the treatment of HCV. Which of the  following is the LEAST important monitoring  parameter for therapy. – A) HCV viral load – B) renal function – C) LFTs – D) Psychiatric monitoring ```
C) LFTs
45
Which organism listed below is of LEAST  concern for simple community‐acquired intra‐ abdominal infections –A) E.coli –B) B.fragilis –C) P.aeruginosa –D) K.pneumoniae
C) P.aeruginosa
46
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
E) A and B
47
Cystitis Empirically target: May be:
Empirically target E.coli: DOC based on local susceptibility data May be other Gram negatives or enterococcus, but direct therapy at E.coli
48
Cystitis Treatment: 3 vs. 7 days:
3 days: TMP/SMX or FQs 7 days: B-lactams or nitrofurantoin - S.saprophyticus: also needs a 7 days course
49
Fosfomycin MOA: Spectrum of Activity:
MOA: inhibits enopyruvate transferase which inhibits cell wall synthesis Spectrum of Activity: many urinary Gram negative, including drug-resistant isolates
50
Fosfomycin Use: Dosing:
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
Complicated UTIs :
- Obstruction - Foreign body - Recent urological procedure - Renal transplant - Males - Pregnancy - Diabetes - Immunocompromised - Health-care associated
52
CA Pyelonephritis Cause: How does treatment vary?
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
CA Pyelonephritis Treatment: Oral Therapy: (3) What is not appropriate?
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
CA Pyelonephritis Treatment IV Options: (4)
``` IV Options: FQ Aminoglycosides 3rd generation cephalosporins Extended-spectrum B-lactams or carbapenems (not empirically) ```
55
CA Pyelonephritis Duration Uncomplicated: Majority of patients:
Uncomplicated: 7-10 days Majority of patients: 14 days
56
Healthcare Associated UTIs Need to cover for: Also need to cover:
Need to cover for resistant pathogens: Pseudomonas is the most notable Also need to cover for other Gram negatives
57
``` Healthcare Associated UTIs Empiric coverage (broad-spectrum): (7) ```
``` 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
What is a major cause of inappropriate antibiotic use?
Asymptomatic Bacteriuria
59
Asymptomatic Bacteriuria Only treat some cases:
Only treat some cases: pregnancy, neonates, urinary tract instrumentation/surgery/obstruction, renal transplant
60
Candiduria Almost always represents: Discontinue: (2)
Almost always represents colonization instead of active infection: therefore, almost never needs treatment Discontinue Foley: if possible Discontinue unnecessary antibiotics
61
Chancroid Cause: Infection: (2)
Cause: Haemophilus ducreyi Infection: Painful ulcers Possible co-infection with HSV or syphilis
62
Chancroid Treatment aimed at: Treatment: (4) DOC:
``` 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
Chancroid Treatment of sex partners:
Treat sex partners regardless of whether or not they have symptoms present: if they had sexual contact within 10 days of partners symptoms.
64
Genital Herpes Duration:
Chronic viral infection: lasts for entire life
65
Genital Herpes | Treatment of First Clinical Episode: (3)
Acyclovir (3-5 times per day; 7-10 days) Valacyclovir (offers BID dosing) Famciclovir
66
Genital Herpes Treatment of Recurrent Infections Suppressive Therapy:
Suppressive Therapy: reduces frequency in patients with frequent episodes (greater than 6 per year); many will have no outbreaks at all
67
Genital Herpes Treatment of Recurrent Infections: (2) Episodic Regimens:
Valacyclovir: once daily; most often used Acyclovir/Famciclovir: twice daily Episodic Regimens: Acyclovir: 5 day course (standard of care)
68
``` Genital Herpes Disseminated Infection (Severe Disease) ``` Manifestations:
Manifestations: pneumonitis, hepatitis, meningitis, encephalitis
69
``` Genital Herpes Disseminated Infection (Severe Disease) ``` Treatment: Follow With:
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
Syphilis | Cause:
T.pallidum
71
Syphilis Primary Infection: Secondary Infection: Tertiary Infection: Latent Infection:
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
Syphilis Treatment: Benzathine penicillin use: (2)
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
Syphilis Penicillin Allergy: Other agents used: (4)
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
Syphilis Treatment Latent syphilis: Tertiary Syphilis:
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
Syphilis Treatment Neurosyphilis When can CNS involvement occur? Dosing: Drug:
Neurosyphilis: CNS involvement that can occur at ANY stage Requires MAX DOSE IV therapy Aqueous crystalline penicillin G (10-14 days)
76
Syphilis Treatment Neurosyphilis What if compliance is an issue? If penicillin allergy:
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
Jarisch-Herxheimer Reaction When is it seen? Symptoms: Cause:
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
Jarisch-Herxheimer Reaction Duration: Treatment:
Duration: can last 1-2 days Treatment: anti-inflammatory drugs
79
Chlamydia | Treatment: (4)
Azithromycin (1g PO x 1 dose) Doxycyline (100mg PO x 7 days) Erythromycin FQs
80
Chlamydia Sex partner referral; How long should the patient abstain from sex?
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
Gonorrhea | Results of Uncomplicated Gonococcal Infection: (2)
Causes: cervicitis, urethritis
82
Gonorrhea Treatment: (3) What is no longer recommended?
Ceftriaxone 250mg IM x 1 dose (DOC) Cefixime 400mg PO x 1 dose Spectinomycin FQs no longer recommended (resistance)
83
Gonorrhea Disseminated Gonococcal Infection (DGI) Manifestations:
Manifestations: septic arthritis, endocarditis, meningitis.
84
Gonorrhea Disseminated Gonococcal Infection (DGI) Treatment: Duration: Note:
Treatment: MAX DOSE IV 3rd generation cephalosporins (ceftriaxone 1g q24h) Duration: based on infected site Note: **ALWAYS TREAT FOR CHLAMYDIA UNLESS RULED OUT**
85
Trichomoniasis Treatment: (1) What are the alternatives? (2)
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
Vaginosis 3 main categories:
Bacterial: anaerobic organisms like Gardenella vaginalis Trichomoniasis: Candidiasis: C.albicans
87
Vaginosis Treatment of bacterial and trichomoniasis:
Bacterial: anaerobic organisms like Gardenella vaginalis - Metronidazole (7 days) - Clindamycin (alternative) Trichomoniasis: same as above
88
Vaginosis Treatment of Candidiasis
Candidiasis: C.albicans - Fluconazole x 1 dose - Variety of topicals
89
Pelvic Inflammatory Disease Causative Agents: When do you treat sexual partners:
N.gonorrhea, C.trachomatis, some Gram negatives, anaerobes, and possibly some strep Treat if concern for neisseria or chlamydia
90
Pelvic Inflammatory Disease Empiric Recommendations (IV): (4)
Cephamycin (cefotetan or cefoxitin) + doxycycline Clindamycin + gentamicin FQ + metronidazole Ampicillin/sulbactam + doxycycline
91
Pelvic Inflammatory Disease Oral Therapy Used for: Drugs: (3) Duration:
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
Epididymitis Causative Organisms: From anal intercourse:
Causative Organisms: C.trachomatis, N.gonorrhea Anal intercourse: E.coli, Pseudomonas
93
Epididymitis Treatment: (3) DOC: For enteric organisms: When do you treat sexual partners?
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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