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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
Q

CNS Shunt Infections (Special Populations)

Duration:

A

Duration: treat for 7-21 days then put shunt back in if possible

26
Q

Fungal CNS Infections

Cryptococcal Meningitis:
Treatment:

A

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
Q

Fungal CNS Infections
Blastomycoses and Histoplasmosis
Treatment:

A
  • Lipid Amphotericin B for 4-6 weeks THEN

- Oral azole (flu, itra, vori) for 12 months (long treatment because associated with relapse)

28
Q

Fungal CNS Infections
Coccidiomycoses
Treatment:

A

Treatment: high dose fluconazole (although some clinicians will still use amphotericin B)

29
Q

Acute Bronchitis
Vast majority of cases are:
Exceptions:

A

Vast majority of cases are viral: antibiotics will NOT help; in this case, symptomatic treatment is mainstay

Exceptions:
•	Bordetella pertussis
•	Influenza
•	Mycoplasma
•	Chlamydia
30
Q

Acute Bronchitis
Treatment

Influenza:
B.pertussis:
Mycoplasma and Chlamydia:

A

Influenza: vaccination is key (minimal efficacy with antivirals)

B.pertussis:
• Standard: macrolides
• Others: tetracyclines, TMP/SMX

Mycoplasma and Chlamydia: addressed in next section

31
Q

COPD EXACERBATION

Only some get antibiotics:

A 
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
Q

COPD Exacerbation

Common causative agents: (5)

A 
o	S.pneumo
o	H.influenzae
o	M.cattarhalis
o	Chlamydia pneumo
o	Mycoplasma pneumo
33
Q

COPD Exacerbation
Treatment
Oral therapy for mild-moderate infection: (5)

A 
Oral therapy for mild-moderate infection:
•	Amoxicillin (+/- clavulanic acid)
•	Doxycyclin
•	TMP/SMX
•	Macrolides
•	FQs
34
Q

COPD Exacerbation
Treatment
IV therapy considered for:
IV therapy: (3)

A

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
Q

COPD Exacerbation
Treatment
If risk factors for P.aeruginosa exist:

A
  • Oral FQs (only cipro and levo; if oral therapy is indicated)
  • Many other options with IV therapy
36
Q

COPD Exacerbation
Treatment
Duration:

A

Duration: correlates with clinical improvement, generally 3-7 days (can be very short

37
Q 
CAP
Causative Agents (“the big 6”):
A 
o	S.pneumo
o	H.influenzae
o	M.cattarhalis
o	M.pneumo
o	C.pneumo
o	Legionella pneumophilia
38
Q

CAP

Other Causative Agents:

A

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
Q

CAP
Outpatient Therapy
If previously healthy and no risk for drug-resistant S.pneumo: (2)

A
  • Macrolide (azithro)

* Doxycycline

40
Q

CAP
Outpatient Therapy
If presence of co-morbidities, Immunosuppression or recent antibiotic exposures:
In areas of high macrolide resistance:

A

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
Q

CAP
Inpatient Therapy
Non-ICU:

A
  • 3rd generation cephalosporin + macrolide/doxycycline

* Respiratory FQ (moxi or levo)

42
Q

CAP
Inpatient Therapy
ICU:

A

o ICU: IV therapy is necessary
• 3rd generation cephalosporin + macrolide (no doxy substitution)
• Add vancomycin if concern for MRSA

43
Q

Aspiration Pneumonia

Need to cover for:

A

Aspiration Pneumonia:

o Need to cover for oral anaerobes: recall that metronidazole is NOT good at this (but clindamycin is)

44
Q

Aspiration Pneumonia

Outpatient: (3)

A

• Clindamycin
• Amox/clav
• Moxifloxacine
.

45
Q

Aspiration Pneumonia

Inpatient: (3)

A

• Amp/sulbactam
• Clindamycin
• Moxifloxacin
.

46
Q

Aspiration Pneumonia

Duration of Therapy:

A 
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
Q

HAP/HCAP/VAP

Basics:

A

o All caused by the same agents
o Start treatment broadly (appropriate empiric therapy saves lives)
o Obtain cultures to de-escalate therapy

48
Q

HAP/HCAP/VAP

Causative Agents:

A 
o	P.aerugiosa**
o	S.aureus (MRSA)**
o	E.coli
o	K.pneumoniae
o	Enterobacter spp.
o	Serratia
o	A.baumannii
49
Q

HAP/HCAP/VAP
Empiric Therapy
3 drug combination:

A
  • 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
Q

HAP/HCAP/VAP

Note on Acinetobacter baumannii:

A

Resistant to most Abx: if it is prevalent where you are, your empiric regimen may be different

51
Q

HAP/HCAP/VAP

Duration of Therapy:

A

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
Q

HAP/HCAP/VAP
De-escalation once cultures come back
If not MRSA:

A

Ditch the Gram (+) coverage (get rid of vanco/linezolid)

53
Q

HAP/HCAP/VAP
Do I keep patient on both G (-) drugs?
Important point:

A

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
Q

Strenotropomonas maltophilia

DOC:
Others:

A

Strenotropomonas maltophilia: sometimes seen in hospital setting as cause of nosocomial pneumonia

DOC: TMP/SMX

Others:
• Ticarcillin/clavulanic acid
• Moxifloxacin
• Tigecycline

55
Q

Cystic Fibrosis Patients

Have extremely high metabolism rate for antimicrobials:

A

Have extremely high metabolism rate for antimicrobials: doses often exceed what we generally consider max doses

56
Q

Cystic Fibrosis Patients

Aerosolized antibiotics:

A

Aerosolized antibiotics: directly inhaled; goal is often suppression of organism (not eradication), and aerosolized Abx have been shown to be useful for this

57
Q

Cystic Fibrosis Patients

Odd organisms may be seen:

A

Odd organisms may be seen: due to the high number of antibiotics they receive
• Burkholderia cepacia

58
Q

Influenza

Vaccination:
Treatment:

A

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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