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Micro Exam 3 > Pogue: Treatment of CNS and Respiratory Tract Infections > Flashcards

Pogue: Treatment of CNS and Respiratory Tract Infections Flashcards

1
Q

Bacterial Meningitis

General Treatment Considerations: (4)

A

o IV therapy at MAX dose
o Bactericidal drugs preferred
o BBB decreases amount of drug that gets to the site of action (to a variable degree, depending on the drug)
o Fast, appropriate therapy saves lives

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2
Q

Bacterial Meningitis
Antibiotic Penetration into CSF
Probably Sufficient Agents: (7)

A
  • 3rd/4th generation cephalosporins (as good as it gets)
  • Penicillin (not benzathine)
  • Apicillin
  • Vancomycin
  • TMP/SMX
  • FQs
  • Metronidazole
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3
Q

Bacterial Meningitis
Antibiotic Penetration into CSF
Probably Insufficient Agents: (3)

A
  • Tetracyclines
  • Aminiglycosides
  • Polymixins
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4
Q

Bacterial Meningitis
Treatment Broken Down by Age
<1 Month
Causative Agents: (4)

A
  • S.agalactiae (GBS)
  • E.coli
  • L.monocytogenes
  • Klebsiella
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5
Q

Bacterial Meningitis
Treatment Broken Down by Age
<1 Month
Empiric Therapy

Important Point:

A

Important Point: children less than 1 month old do NOT have an intact BBB (do not have to worry about selecting drugs that will penetrate well)

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6
Q 
Bacterial Meningitis
Treatment Broken Down by Age
<1 Month
Empiric Therapy
Possibilities: (2)
A
  • Ampicillin + gentamicin

- Ampicillin + cefotaxime (NOT CEFTRIAXONE, because of contraindication

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7
Q

Bacterial Meningitis
Treatment Broken Down by Age
1-23 Months
Causative Agents: (5)

A
  • S.pneumoniae
  • N.meningitidis
  • S.agalactiae
  • H.influenzae (maybe, depends on vaccination status)
  • E.coli
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8
Q

Bacterial Meningitis
Treatment Broken Down by Age
1-23 Months
Empiric Therapy:

A

Vancomycin + 3rd generation cephalosporin

  • Vancomycin added for S.pneumo that is slightly resistant (elevated MICs) to 3rd generation cephalosporins
  • While this is normally not an issue in other infections (recall= 3rd gens can overcome resistance by binding tighter to PBP), this IS an issue in CNS infections because of variable penetration of the BBB
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9
Q

Bacterial Meningitis
2-50 Years
Causative Agents: (3)

A
  • N.meningitidis
  • S.pneumoniae
  • H.influenzae (if unvaccinated)
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10
Q

Bacterial Meningitis
2-50 Years
Empiric Therapy:

A

Vancomcyin + 3rd generation cephalosphorin + dexamethasone

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11
Q 
Bacterial Meningitis
Dexamethasone: 
Given to decrease inflammation in:
Mortality benefit:
Important Point:
A

o Dexamethasone: IV steroid give 4 x a day for 4 days
• Given to decrease inflammation in subarachnoid space to decrease neurologic sequelae
• Mortality benefit thought to outweigh immunossupression
• Important Point: need to give PRIOR to first antibiotic dose; if already received, don’t give

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12
Q

Bacterial Meningitis
>50 Years
Causative Agents: (4)

A
  • S.pneumoniae
  • N.meningitidis
  • L.monogytogenes
  • Gram negatives
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13
Q

Bacterial Meningitis
>50 Years
Empiric Therapy:

A

Vancomycin + 3rd generation cephalosporin + ampicillin (for Listeria)

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14
Q

Listeria DOC:

Others: (3)

A

Ampicillin is DOC

Others:
• TMP/SMX
• Meropenem
• Gentamicin sometimes added as adjunct (despite penetration issues)

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15
Q

Bacterial Meningitis

Most common causative agents for most patients:

A

S.pneumo and N.meningitidis

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16
Q

S.pneumo and N.meningitidis

Treatment:

A
  • High dose 3rd generation cephalosporins (ceftriaxone)

* High dose vancomycin added to cover for ceftriaxone resistant S.pneumo

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17
Q

Extremes of age need _______ coverage:

A

o Extremes of age need Listeria coverage:

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18
Q

Listeria Treatment

A

High dose ampicillin

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19
Q

Avoid ______ in neonates

A

Avoid ceftriaxone in neonates

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20
Q

Duration of Treatment:

A

Duration of Treatment: between 7-21 days and vary by bug (generally 14-21)

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21
Q

Prophylaxis
N.meningitidis

Who:
DOC:
Others:

A

Who: treat household contacts and people exposed to oral secretions

DOC: ciprofloxacin 500 mg x 1 dose

Others:

  • Rifampin x 2 days
  • IM Ceftriaxone
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22
Q

Prophylaxis
H.influenzae

Who:
DOC:

A

Who: everyone in the household with unvaccinated children

DOC: rifampin

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23
Q

CNS Shunt Infections (Special Populations)

Causative Agents:
Mostly:
Others:
Note:

A

Causative Agents: most often skin bugs
• Mostly: coagulase negative staph
• Others: S.aureus, GNR, streptococci
• Note: staph species account for ~75% of infections

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24
Q

CNS Shunt Infections (Special Populations)

Treatment:

A

Gram stain for pathogen and start on broad spectrum antibiotics

  • Vancomycin + cefepime
  • Vancomycin + pip/tazo

May use intraventricular antibiotics as adjunctive therapy

Remove shunt if possible (gets rid of source of infection)

Once cultures come back, de-escalate therapy to target specific organism

25
CNS Shunt Infections (Special Populations) | Duration:
Duration: treat for 7-21 days then put shunt back in if possible
26
Fungal CNS Infections Cryptococcal Meningitis: Treatment:
Cryptococcal Meningitis: often seen in HIV patients Treatment: - Lipid Amphotericin B + Flucystine for 2 weeks THEN - Fluconazole 400mg PO once daily for 8 weeks
27
Fungal CNS Infections Blastomycoses and Histoplasmosis Treatment:
- Lipid Amphotericin B for 4-6 weeks THEN | - Oral azole (flu, itra, vori) for 12 months (long treatment because associated with relapse)
28
Fungal CNS Infections Coccidiomycoses Treatment:
Treatment: high dose fluconazole (although some clinicians will still use amphotericin B)
29
Acute Bronchitis Vast majority of cases are: Exceptions:
Vast majority of cases are viral: antibiotics will NOT help; in this case, symptomatic treatment is mainstay ``` Exceptions: • Bordetella pertussis • Influenza • Mycoplasma • Chlamydia ```
30
Acute Bronchitis Treatment Influenza: B.pertussis: Mycoplasma and Chlamydia:
Influenza: vaccination is key (minimal efficacy with antivirals) B.pertussis: • Standard: macrolides • Others: tetracyclines, TMP/SMX Mycoplasma and Chlamydia: addressed in next section
31
COPD EXACERBATION | Only some get antibiotics:
``` COPD EXACERBATION: • Only some get antibiotics: need to have 3 cardinal symptoms (only need 2/3 if one is increased purulence) o Increased dyspnea o Increased sputum volume o Increased sputum purulence ```
32
COPD Exacerbation | Common causative agents: (5)
``` o S.pneumo o H.influenzae o M.cattarhalis o Chlamydia pneumo o Mycoplasma pneumo ```
33
COPD Exacerbation Treatment Oral therapy for mild-moderate infection: (5)
``` Oral therapy for mild-moderate infection: • Amoxicillin (+/- clavulanic acid) • Doxycyclin • TMP/SMX • Macrolides • FQs ```
34
COPD Exacerbation Treatment IV therapy considered for: IV therapy: (3)
o IV therapy considered for patients with risk factors for poor outcome: co-morbidities, severe COPD, frequent exacerbations, recent antimicrobial use • Ampicillin/sulbactam • 2nd/3rd generation cephalosporins • FQs
35
COPD Exacerbation Treatment If risk factors for P.aeruginosa exist:
* Oral FQs (only cipro and levo; if oral therapy is indicated) * Many other options with IV therapy
36
COPD Exacerbation Treatment Duration:
Duration: correlates with clinical improvement, generally 3-7 days (can be very short
37
``` CAP Causative Agents (“the big 6”): ```
``` o S.pneumo o H.influenzae o M.cattarhalis o M.pneumo o C.pneumo o Legionella pneumophilia ```
38
CAP | Other Causative Agents:
o S.aureus (increasing incidence of CA-MRSA; needs to be considered in some cases) • Post-influenza infection (secondary staph infection) • Severe or necrotizing infections o Oral anaerobes (aspiration pneumonia)
39
CAP Outpatient Therapy If previously healthy and no risk for drug-resistant S.pneumo: (2)
* Macrolide (azithro) | * Doxycycline
40
CAP Outpatient Therapy If presence of co-morbidities, Immunosuppression or recent antibiotic exposures: In areas of high macrolide resistance:
If presence of co-morbidities, Immunosuppression or recent antibiotic exposures: at risk for more drug resistant forms of S.pneumo • B-lactam + macrolide • B-lactam + doxyclcine • High dose amoxicillin (+/- clavulanic acid) • High dose 2nd/3rd generation cephalosporins o Some areas have high macrolide resistance: avoid using them in these areas
41
CAP Inpatient Therapy Non-ICU:
* 3rd generation cephalosporin + macrolide/doxycycline | * Respiratory FQ (moxi or levo)
42
CAP Inpatient Therapy ICU:
o ICU: IV therapy is necessary • 3rd generation cephalosporin + macrolide (no doxy substitution) • Add vancomycin if concern for MRSA
43
Aspiration Pneumonia | Need to cover for:
Aspiration Pneumonia: | o Need to cover for oral anaerobes: recall that metronidazole is NOT good at this (but clindamycin is)
44
Aspiration Pneumonia | Outpatient: (3)
• Clindamycin • Amox/clav • Moxifloxacine .
45
Aspiration Pneumonia | Inpatient: (3)
• Amp/sulbactam • Clindamycin • Moxifloxacin .
46
Aspiration Pneumonia | Duration of Therapy:
``` o Minimum of 5 days o Once past 5 days, discontinue if: • Afebrile for 48-72 hours • No more than one CAP related sign of instability: ➢ Fever ➢ Leukocytosis ➢ Heart rate ➢ Respiratory rate ```
47
HAP/HCAP/VAP | Basics:
o All caused by the same agents o Start treatment broadly (appropriate empiric therapy saves lives) o Obtain cultures to de-escalate therapy
48
HAP/HCAP/VAP | Causative Agents:
``` o P.aerugiosa** o S.aureus (MRSA)** o E.coli o K.pneumoniae o Enterobacter spp. o Serratia o A.baumannii ```
49
HAP/HCAP/VAP Empiric Therapy 3 drug combination:
* Anti-pseudomonal B-lactam: cefepime, ceftazadime, pip/tazo, meropenem, doripenem, imipenem, aztreonam PLUS * Anti-pseudomonal FQ of AMG: cipro, levo, gentamicin, tobramicin, amikacin PLUS * MRSA agent: vancomycin or linezolid
50
HAP/HCAP/VAP | Note on Acinetobacter baumannii:
Resistant to most Abx: if it is prevalent where you are, your empiric regimen may be different
51
HAP/HCAP/VAP | Duration of Therapy:
New Guidelines: • 7-8 day course if infection is caused by agent other than pseudoomas or acinetobacter • 14 days if caused by pseudomonas or acinetobacter .
52
HAP/HCAP/VAP De-escalation once cultures come back If not MRSA:
Ditch the Gram (+) coverage (get rid of vanco/linezolid)
53
HAP/HCAP/VAP Do I keep patient on both G (-) drugs? Important point:
Generally, streamline down to ONE drug: most narrow spectrum agent possible Possible exception is pseudomonas: - In vitro synergy has been shown (although not shown in patients) - Resistance development common Important point: some doctors WILL use 2 agents for pseudomonas, but there has never been any data to show this is effective (just use one!)
54
Strenotropomonas maltophilia DOC: Others:
Strenotropomonas maltophilia: sometimes seen in hospital setting as cause of nosocomial pneumonia DOC: TMP/SMX Others: • Ticarcillin/clavulanic acid • Moxifloxacin • Tigecycline
55
Cystic Fibrosis Patients | Have extremely high metabolism rate for antimicrobials:
Have extremely high metabolism rate for antimicrobials: doses often exceed what we generally consider max doses
56
Cystic Fibrosis Patients | Aerosolized antibiotics:
Aerosolized antibiotics: directly inhaled; goal is often suppression of organism (not eradication), and aerosolized Abx have been shown to be useful for this
57
Cystic Fibrosis Patients | Odd organisms may be seen:
Odd organisms may be seen: due to the high number of antibiotics they receive • Burkholderia cepacia
58
Influenza Vaccination: Treatment:
Vaccination: key to preventing acquisition/transmission Treatment: only modestly effective o Few agents o High resistance o Must start treatment early in disease course o Will only decrease duration and severity o Severely ill patients will often get longer courses of antivirals

Micro Exam 3 (11 decks)

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