rti, uti, c diff, immunizations, hiv Flashcards
pharmaceutical care outcomes
- cure disease
- eliminate/reduce symptoms
- arrest or slow disease progression
- prevent a disease –> immunization goal!!
story behind the first vaccine
smallpox vaccine
- milkmaids not get it bc had cowpox
- 1798
live attenuated vaccines
- MMR: measles, mumps, rubella
- varicella
- influenza (LAIV)
- polio (OPV)
- rotavirus
- zoster (ZVL)
toxoid vaccines
- diphtheria
- tetanus
inactivated vaccines
- hepatitis A
- influenza (IIV)
- pertussis
- polio (IPV)
inactivated/recombinant vaccines
- hepatitis B
- HPV
- zoster (RZV)
conjugated/polysaccharide vaccines
- Hib
- meningococcal
- pneumococcal
mRNA vaccines
- COVID Pfizer
- COVID Moderna
adenovirus vaccines
- COVID Janssen J and J
herd immunity consideration
- protect individual person immunized AND other members of the community
high vaccination rates are necessary to:
- dec likelihood of disease outbreak
- protect people who cannot be vaccinated (medical issues, too young, incomplete immune response to vaccines)
how long do you separate two inactivated vaccines
any interval
how long do you separate a live and an inactivated vaccine
any interval
how long do you separate two live vaccines
simultaneously OR 28 days minimum
how long before a minimum vaccine dosing interval does it not count and you need to repeat dose?
5 days or more
what do you do if an immunization dose interval has lapsed?
dose as normal, no start over
if no record of a vaccine…
redose as if didn’t get it
when to avoid/postpone immunizations
- mod-severe illness (hospital)
- type i hypersensitivity (anaphylaxis) to vaccine or components
- LIVE: immunodeficient diseases/treatments –> congenital immunodeficiency, malignancy, symptomatic HIV, radiation, chemo, prednisone
- pregnancy
pregnancy vaccine considerations
live: CONTRADINICATED
inactivated: okay, potentially wait for second trimester
recommended vaccines: flu, Tdap, COVID
conditions that are NOT CIs to vaccination
- mild acute illness (low fever, …)
- recent infection exposure
- current antibiotics
- breastfeeding
- mild-mod local vaccine reactions
COVID-19 general recommendation
all people 6 months and older
patient is on chemo or radiation, when can you live vaccinate?
2 weeks before
OR
3 months after
systemic corticosteroid defintion
2 or more mg/kg/day OR 20 or more mg/day prednisone for 14 or more days
when can you vaccinate during systemic glucocorticoid therapy ?
- topical or local injections
- physiological maintenance therapy
- low-mod dose daily or every other day
patient took high dose prednisone daily or every other for less than 14 days, when live vaccinate?
when stop
OR
2 weeks after
patient took high dose prednisone daily or every other for more than 14 days, when live vaccinate?
1 month or more
patient got live vaccine, how long until IVIG?
14 days or more
if can’t wait –> redose vaccine
patient got IVIG, how long until live vaccine?
3 months or more
patient got live vaccine, how long until PPD?
simultaneously
OR
4-6 weeks
patient got live vaccine, how long until anti-viral agents?
14 days
inactivated vaccine AEs
- injection site reactions, with or without fever
- inflammatory response to antigen
- swelling, redness, pain
- SQ has MORE AEs than IM
live attenuated vaccine AEs
- mild form form of natural illness
general vaccine AEs
- tired, fatigue
- hypersensitivity reaction
- vasovagal syncope
- sterile abscesses
vaccine storage
cold chain!!
manufacturer –> wholesaler –> pharmacy
most vaccines: 2-8 C (fridge)
COVID –> freezer
light sensitive –> MMR, zoster
which vaccines can/do you give SQ?
- herpes zoster
- MMR
- MPSV-4
- PPV
- poliovirus trivalent inactivated
who is at the highest risk for COVID-19 hospitalization?
- increases with age
65 years and older highest risk - non-hispanic american indian, alaska native
- non-hispanic black, latino
who is at highest risk for covid-19 mortality?
older than 65 years (even though small proportion of this age get it)
COVID-19 primary mode of transmission?
- respiratory droplet exposure when in close contact –> inhaled or deposited on mucous membranes (nose/mouth)
COVID-19 clinical presentation
- incubation period: 2-14 days (usually 6) – time between infected and symptoms
- s/s: fever, cough, fatigue, HA, loss taste or smell
severe COVID-19 disease more common in/risk factors:
- obesity
- DM
- asthma/chronic lung disease
- immunosuppression
COVID-19 vaccine efficacy
95%
COVID vaccine AEs
- local reactions
- fever, chills, HA, muscle pain –> mild systemic
most serious: myocarditis!!!! (inflammation of middle layer of heart) –> highest in 12-24 yr old males
which COVID dose has most side effects?
most: 2nd dose
booster
least: 1st dose
antigenic drift
INFLUENZA
gradual protein changes, occur yearly
- impacts type A and B
- bc of mutation, substitutions, deletions, adaptation to human antibodies
antigenic shift
INFLUENZA
HUGE protein changes
- ONLY impacts type A
- changes in hemagglutinin (H) or neuraminidase (N)
- causes epidemics/pandemics
- ex: spanish flu (H1N1), avian flu (H5N1)
do you delay immunization patient is 65 years old and wants a flu shot but you do not have high dose?
NO –> can get normal dose
influenza vaccine efficacy
- onset: 2 weeks
- efficacy: 47%
**depends on accuracy of forecast of circulating strain - dec risk of hospitalization, pneumonia, death
how often is the influenza vaccine updated
yearly
IIV AEs
local reactions
LAIV AEs
**rhinorrhea bc IN!!!
IIV precautions and CIs
precautions:
- GBS (group b strep) within 6 weeks of previous vaccine
CI:
- allergy to vaccine
**EGG ALLERGY NO LONFER CI!
LAIV precautions and CIs
precautions:
- asthma and older than 5 years
- conditions that inc risk of influenza related complications
- mod-severe illlness
CI:
- younger than 2 years, 50 years or older
- preganacy
- immunosuppression
- children 2-4 years with asthma or hx of wheezing
- children/adolescent receiving ASA
- CSF leaks
- asplenia
**EGG ALLERGY NO LONGER CI
a patient comes in with an egg allergy and requests a influenza vaccine, what can you give them?
IIV, HD-IIV, LAIV, …
NO LONGER A CI !!!
age range for IIV4
6 months or older
age range for RIV4
18 years or older
age range for LAIV4
2 years to 49 years
pneumococcos cause
streptococcus pneumonia –> 90 serotypes
- bacterial cause of acute otitis media, pneumonia, bacteremia, meningitis –> higher death rates
mortality from these conditions inc in elderly!!
pneumococcus efficacy
around 70%
efficacy of newer vaccines similar to the older ones!
penumococcus vaccination rates
around 60% in 65 years and older
- more in white than black or hispanic
PCV15 AEs
- injection site pain
- fatigue
- myalgia
PCV20 AEs
- injection site pain
- muscle pain
- fatigue
- HA
- joint pain
pneumococcal CIs
- allergy
- pregnancy
how long between pneumococcal doses?
1 year
8 weeks or more IF:
- immunocompromised
- cochlear implant
- CSF leak
diphtheria cause
- corynebacterium diphtheriae –> toxin
- most common in incompletely immunized patients –> 20-60%
tetanus cause
- clostridium tetani –> toxin binds CNS
- muscle rigidity, muscle spasms, lock-jaw
- most common in non-vaccinated people –> 40-85% susceptibe
tetanus risk factors
- puncture wounds
- IV drug use
pertussis cause
- bordetella pertussis
- WHOOPING COUGH
- 50% hospitalized in infants
- apnea, seizures, pneumonia, encephalopathy
- 3-5 year cycle of inc incidence
whooping cough
- very contagious!!!!!
- takes 12 weeks to resolve
- week 1-2: cold-like
- week 3-10: paroxysmal cough
- week 11-12: cough lessens
how often Tdap?
every 10 years
every pregnancy
how often tetanus vaccine if at risk?
every 5 years
how often tetanus vaccine if injury
1 year after last dose
T,D,P vaccine AEs
- local: redness, swelling, pain
- fever
**the local reactions are more likely in older, therefore use vaccines with lower doses
T,D,P vaccine precautions and CIs
precautions:
- arthus hypersensitivity reactions
- unstable neurologic problem/seizures
CIs
- allergy
- Hx of encephalopathy within 7 days of pertussis vaccine
shingles cause
- herpes zoster virus –> shingles
- unilateral pain
- opportunistic infection –> older or immunocompromised at risk
zoster efficacy
97% –> dec with age!!
- prevents postherpetic neuralgia
zoster AEs
- injection site reaction: pain, erythema, swelling
- allergic reaction (rare)
zoster precautions and CIs
CI
- allergic reaction Hx to vaccine
- pregnancy –> delay!!!
how to treat rabies
1) wound clean
2) human rabies IG: site and IM x1
3) rabies vaccine X4: day of exposure, day 3, day 7, day 14
usually only 19 years or older
rabies vaccine AEs
- mild local reactions (pain, redness, swelling, itchy)
- HA, N, abdominal pain, dizzy
rabies IG AEs
- local pain
- low grade level
can rabies vaccine be used in pregnancy
yes
do we treat rabies for domesticated animals that are up to date on vaccines?
no –> probably only wound clean
HIV prevalance
high in the US –> NYS number 7
AIDS definitions
CD4 count < 200
AIDS defining illnesses
AIDS defining illnesses
- candidiasis
- cryptococcosis
- CMV
- herpes simplex
- kaposi sarcoma (cancer)
- lymphomas (cancer)
- mycobacterium infections
- pneumonia
in general
- opportunistic infections
- neoplasms
- CNS involvement
- dermatologic manifestations
- hematologic abnormalities
- nephropathy
HIV patho things
**CD4 cells
- tropism: virus specifically targets one tissue (CD4 cells)
- blood and body fluid transmission
why are only 50% of people with HIV retained in care and experiencing viral supression? (cascade of treatment)
***social determinants of health –> knowledge, perceptions, beliefs
- side effects
- dosing regimen complex
- NOT bc of cost –> access through government
two big markers in HIV
CD4 count
viral load
5 goals of ART (anti-retroviral treatment)
- maximum and durable viral suppression (viral load undetectable)
- restoration and preservation of immune function (CD4 count) (bc low CD4 –> AIDS –> infections –> death)
- improved quality of life
- reduced HIV-related opportunistic infections (OIs)
- reduced morbidity and mortality
first line ART for most patients
INSTI + 2 NRTI
- Biktarvy – bictegravir + emtricitabine + tenofovir alafenamide
- Triumeq – dolutegravir + abacavir + lamivudine
integrase inhibitor AEs
generally mild
- GI distress
- CNS disturbance
- rash (less with bictegravir)
- false elevation in Cr
- weight gain!!!
INSTI DDI
- cations (acid reducers) –> antacids
- metformin
tenofovir AEs
NRTI
- salicylates
- nephrotoxic drugs
which INSTIs have high barrier to resistance –> favorable!
bictegravir
dolutegravir
which INSTIs come as STR?
bictegravir
dolutegravir
which INSTI is preferred in all trimesters of pregnancy?
dolutegravir
which ART needs HLA-B*5701 monitoring?
abacavir (NRTI)
which INSTI increases metformin levels?
dolutegravir
CIs for dolutegravir + lamivudine (Dovato) use
- HIV-1 RNA > 500,000 (cannot use if severe)
- HBV coinfection
- no resistance results (only double therapy)
INDICATION (need these!!!) for dolutegravir + lamivudine + abacavir (Triumeq) use
HLA-B*5701 NEGATIVE!
INDICATION (need these) for rilpivirine + emtricitabine + tenofovir alafenamide/disoproxil fumarate (Odefsey, Complera) use
- HIV-1 RNA < 100,000
- CD4 > 200
omeprazole DDI
dec rilpivirine concentration –> dolutegravir + rilpivirine (Juluca)
pantoprazole DDI
dec rilpivirine concentration –> dolutegravir + rilpivirine (Juluca)
Al/Mg or Ca antacids DDI
ALL INSTIs –> dec absorption/concentration
in ART naive adults, which therapy is non-inferior to triple therapy with dolutegravir + Truvada (emtricitabine + tenofovir disoproxil fumarate)?
dual therapy Dovato (dolutegravir + lamivudine)
**also was no treatment emergent resistance !
GEMINI-1 and 2 trials
preferred HIV regimens for pregnancy and trying to concieve
1st line: 2 NRTI (dual backbone) + INSTI/boosted PI
2nd line: 2 NRTI (dual backbone) + NNRTI
HIV drugs to avoid in pregnancy bc of insufficient data
- bictegravir
- doravirine
- ibalizumab
- fostemsavir
HIV drugs to avoid in pregnancy bc of PK concerns
usually any combo with cobicistat!!
- elvitegravir + cobi
- atazanavir + cobi
- darunavir + cobi
pregnancy preferred NRTI backbone
- lamivudine + abacavir
- lamivudine + tenofovir disoproxil
- emtricitabine + tenofovir disoproxil
which tenofovir is favored in pregnancy?
tenofovir disoproxil fumarate!!
alafenamide –> can continue, no data to start
INSTIs preferred in pregnancy
- dolutegravir
- raltegravir
which HIV drug used to be worried about NTD in infants but new studies showed no issue anymore and is now a recommended agent?
raltegravir (INSTI)
same day ART initiation benefits
- inc patient retention to follow up
- dec time to viral supression/inc viral suppression by 12 months
- inc liklihood of initiation of ART within 90 days of Dx
NNRTI AEs and DDI exclude which drug?
doravarine
NNRTI AEs
- liver toxicity
- rash (6 weeks)
- hyperglycemia
- hyperlipidemia
efavirenz + rilpivirine –> neuropsychiatric effects!\
NOT APPLY TO DORAVIRINE
NNRTI DDIs
- efavrinez: CYP 3A4 inhibitor
- rilpivirine: CYP 3A4 substrate
which NNRITs are CYP 3A4 inhibitors
- efavirenz
- nevirapine
- etravirine
doravirine combination therapy and its BBW
Delstrigo: doravirine + lamivudine + tenofovir disoproxil fumarate
BBW: severe HBV (hepatitis B virus) acute exacerbation
- in patients who:
1) coinfected with HIV and HBV
2) discontinued lamivudine or tenofovir disoprox
benefits of tenofovir alafenamide
- less impact on markers of renal tubular dysfunction
- superior after 144 weeks
benefits of tenofovir disoporxil fumarate?
- generics avaliable with other NSTIs (lamivudine, emtricitabine)
- pregnancy preferred
- no weight gain
tenofovir preferred?
alafenamide probably due to less renal impacts, use disoproxil in certain situations
abacavir pros vs cons
pros: first line combo with dolutegravir, not renal CL
cons: HLA-B*5701 testing needed for negative results (inc time, …), inc AEs (cardio)
when to use boosted PIs
- starting ART before have resistance data avaliable
- if worried about resistance
things to consider with boosted PIs
- DDI – many
- GI intolerance
- HLD
- CV risk with some
- metabolic syndromes
which HIV drugs cause false elevation of SrCr?
not sure, def stribild and genvoya
indications for Stribild/Genvoya (elvitegravir + emtricitabine + tenofovir (either) + cobicistat
- take with food (inc elvitegravir absorption)
- CrCl > 70 to start, > 50 to continue
*expect SrCr elevations
ritonavir and cobicistat DDIs
- inhibit: 3A4, p-gp, 2D6
- induce: 2C9
- careful with: warfarin (monitor INR), DOACs (avoid)
anticonvusant (carbamazepine, phenobarb, phenytoin) DDI with HIV
- dolutegravir –> dec concentration
which HIV drug are corticosteriods CIed with?
elvitegravir + cobicistat
**INHALED, TOPICAL, AND ORAL!!
topical hydrocortisone okay
list of corticosteriods
- betamethasone
- budesonide
- clobetasol
- dexamethasone
- fluticasone
- hydrocortisone
- methylprednisolone
- prednisone
- triamcinolone
statin ART DDIs
boosted treatments (any with cobicistat or ritonavir) + lovastatin or simvastatin
- huge inc in statin concentratin
other statins at low doses or intensity –> suboptimal response
BBW of any ART with emtricitabine + tenofovir (either)
- lactic acidosis, severe hetapomegaly
- HBV coinfection –> exacerbation if stop the drug
brand: Descovy, Truvada, Delstrigo
which ART cause weight gain
pretty much all
- NNRTI < NRTI (?) < PR < INSTI
TAD < TAF
do you change ART?
NO –> no benefit
only change if:
- AEs
- simplify regimen
- change administration
- pt change in indication/CI
bacterial STI
- gonorrhea
- syphilis
PrEP drugs
- Descovy: emtricitabine + tenofovir alafenamide
- Truvada: emtricitabine + tenofovir disoproxil fumarate
three indication groups of PrEP
- MSM
- heterogeneous men and women
- IV drug use
PrEP clinical eligibilty
- documented (-) HIV test
- no s/s HIV
- no CI medications
- documented HBV infection/vaccine
- normal renal function
PrEP AEs
- HA
- abdominal pain
- weight loss
very low
adherence model
health belief model
- individual factors
- perceived benefits
- perceived susceptibility
- perceived threat of non-adherence
- liklihood to engage in adherence behavior
- cues to action
- self-efficacy for adherence
adherence counseling
- assess determinants
- assess metrics
- employ strategies
how often do you assess PrEP
- follow-up every 3 months: HIV test, adherence, behavioral risk reduction, AE assess, STI assess
- testing after 3 months then every 6 months: renal function, bacterial STI
URTIs
- sinusitis (rhinosinusitis)
- otitis media
- pharyngitis
sinusitis general s/s
- inflammation
- discharge
- bilateral
major nonspecific sinusitis symptoms
- purulent anterior nasal discharge
- purulent or discolored posterior nasal discharge
- nasal congestion/obstruction
- facial congestion or fullness
- dec sense of smell
- fever
minor nonspecific sinusitis symptoms
- HA
- ear pain, pressure, fullness
- halitosis, dental pain
- cough
- fatigue
how to Dx sinusitis
- no cultures
- only clinically, s/s
**acute vs chronic
common sinusitis pathogens
H influenzae
M catarrhalis
S pneumoniae
*therefore need gram + and - coverage
amox/clav AE
- diarrhea
- rash
- take with food so no GI upset
sinusitis 1st line and durations
amox/clav
adults: 5-7 days
children: 10-14 days
common pharyngitis pathogens
viral: rhinovirus
bacteria: group A strep (strep pyogenes)
why do we treat pharyngitis (potential group A strep) if only a small percent bacterial?
- labor burden on country, transmissible
- improve symptoms
- prevent transmission period to 24 hours instead of entire acute illness and one week after
- avoid post-pharyngitis complications –> acute rheumatic fever (CHILDREN), pertionsillar abscess, cevical lyphandenitis, mastoiditis, glomerulonephritis
major GAS pharyngitis presentation
- sudden onset sore throat
- scarlatiniform rash (cheeks)
- tonsillopharyngeal inflammation (hemorraging nodes)
pharyngitis Dx tests
adult: throat swab RADT
child: throat swab RADT, throat culture
pharyngitis antibiotics
1st: penicillin VK, amoxicillin
2nd:
mild allergy –> cephalexin
severe allergy –> clindamycin, azithromycin (5 day duration)
noncompliance –> penicillin benzathine IM (x1)
duration: 10 days (unless indicated)
common cause of otitis media
BACTERIAL
50/50: s. pneumoniae, h. influenzae
otitis media signs and symptoms
- fluid in middle ear
- erythema/inflammation of tympanic membrane
- ear pain, drainage
- nonspecific: fever, lethargy, irritability –> tugging on ear
acute otitis media Dx definition
- middle ear effusion (fluid collection)
AND ONE OF - mod-severe tympanic membrane bulging OR new onset otorrhea (ear drainage) that isn’t due to acute otitis externa
- mild tympanic membrane bulging AND new onset ear pain within last 48 hours OR intense erythema of tympanic membrane
in which patients do you treat otitis media?
6 mon - 12 yrs AND temp greater or equal to 102.2 F or mod-sev pain
6 mon - 23 mon AND nonsevere, bilateral AOM
otitis media drugs
1st: amoxicillin
80-90 mg/kg/day divide into BID dosing
IF: Hx amox in last 30 days, recurrent not response to amox, purulent conjunctivitis
2nd: amox/clav
IF: penicillin allergy
3rd: cephalosporins
pneumonia patho ish
aspirate pathogen into alveolar spaces –> inc immune recognition which inc fluid in alveoli –> dec space for oxygen diffusion
penumonia s/s
- sputum production
- cough
- fever
- pleuritic (inhale/exhale) chest pain
Dx pneumonia
SIRS
chest x-ray –> infiltrate (alveolar fluid): appears white hazy/streaky
do you use cultures for pneumonia?
yes –> helpful in severe cases
- will be contaminated by oral normal flora, therefore look for significant big results
- GET BEFORE GIVE ANTIBIOTICS
what is CURB-65 used for?
pneumonia
scoring system to determine in admit patient to hospital or not
types of pneumonia defintions
CAP: no exposure to healthcare system
HAP: no pneumonia when admitted, developed 48 hours or more after admission ; OR ; got IV antibiotics within 90 days prior to admission
VAP: subset of HAP, pneumonia develops 48 hours or more after endotracheal ventilation
CAP causes and characteristics of each
***s pneumoniae —> rust colored sputum
h influenzae, m catarrhalis –> comorbidities
anaerobes –> lose consciousness after OD
* CA-MRSA (communtiy aquired) –> after influenza, very severe admission
causes of CAP and characteristics
*** s penumoniae –> rust colored sputum
H. influenzae, M. catarrhalis –> comorbidities
anaerobes –> loss of consiousness after OD
*CA-MRSA (community aquired) –> after influenza, severe presentation
which atypical pathogen are we worries about with CAP, what do we do?
legionella pneumonphilia!!
- if severe presentation –> urinary test –> treat if positive
- fluoroqinolones, azithromycin
characteristics/risks: mild –> rapid progression, water exposure, male, smoker
symptoms: severe electrolyte changes (dec K and Na), diarrhea, confusion, LFT inc
typical pneumonia presentations
- abrupt
- uilateral, well-defined infiltrate
- significant fever, dyspnea
- purulent sputum
- pleuritic chest pain
atypical pneumonia presentations
- gradual
- diffuse infiltrate
- mild fever, dyspnea
- dry cough
- extrapulmonary symptoms: myalgia, GI
what test for a patient with severe cap
urinary test for legionella
what test for a patient with CAP ordered anti MRSA or pseudomonas
blood culture
sputum culture
if treating CAP for legionella, what monitoring do you need?
QT prolongation –> azithro, fluoroquin cause it!!
how to treat viral CAP
supportive care
no antibiotics beyond first 24 hours
how to treat outpatient CAP
healthy:
1st: amoxicillin
2nd: doxycycline or macrolide if allergy
comorbidities:
1st: amox/clav + macrolide
cefpodox + macrolide
2nd: fluoroquinolone
comorbidity definition for outpatient CAP
- under 2 yrs or over 65 yrs
- immunosuppression
- cancer
- beta lactam in last 90 days
- alcohol abuse
- daycare
- chronic respiratory disease
CAP duration
5-7 days
afebrile for 48-72 hr
inpatient bacterial CAP requirements
- respiratory complications
- systemic inflammation (fever, leukocytosis)
- comorbidities
inpatient CAP non-severe treat
1st: IV beta-lactam + macrolide
2nd: fluoroquinolone
inpatient CAP severe treat
start:
IV beta lactam + macrolide
IV beta lactam + fluoroquinolone
if…
MRSA –> ceftaroline, vanco…
pseudomonas –> pip/tazo, carbapenem
legionella –> make sure have azithro or fluoroquin
VAP contamination
- healthcare worker hands
- ventilator circuit
- biofilm of endotracheal tube
VAP cause
gram negative
HAP testing
do non-invasive cultures –> sputum or endotracheal aspiration
only do invasive biopsy/BAL if serious
criteria to cover MRSA and pseudonomas for HAP/VAP
one of following
- started 5 days or more after admission
- risk for MDR
risks for MDR pathogen
- antibiotics in past 90 days
- immunosuppression
- colonization of MDR
- recent hospitalization
- chronic care
HAP/VAP treat no MDR risk
- ampicillin/sulbact
- cipro, moxi
- ceftriazone
- ertapenema
HAP/VAP treat with MDR risk
anti-MRSA + anti-pseudomonal
MRSA
- vancomycin
- linezolid
pseudomonal:
- pip/tazo
- cefepime
- cipro, levo
- carbapenems (not ert)
…
HAP/VAP duration
7 days
risk factors for UTI
- healthy premenopausal women (no risk)
- sexual behavior, contraceptive devices
- pregnancy
- male
- badly controlled DM
- short term urinary tract catheter
- asymptomatic bacteriuria
- long term urinary catheter
upper UTI
- pyelonephritis
kidneys
more serious
lower UTI
- cystitis
bladder
less serious
cysitits s/s and tests
- dysuria
- frequency/urgency
- hematuria
- urinalysis
- urine gram stain and culture
pyelonephritis s/s and tests
- all of cystitis (hematuria, dysuria, frequency/urgency)
- CVA tenderness / flank pain
- fever
- chills
- N/V
- urinalysis
- urine culture and stain
- CBC
- blood culture
uncomplicated UTI definition and cause
- normal urinary tract, normal removal of bacteria with voiding
- e coli
complicated UTI definition and cause
- abnormality that prevents removal of bacteria with voiding
- clinical def:
catheter
recurrence
highly resistant
SIRS/sepsis
immunosupression - e coli + gram negative (pseudomonas)
- s aureus + s epi
- candida (yeast)
urinalysis results
tell if infection
- pyuria: > 10 WBC/mm3 , > 5-10 WBC/hpf
- nitrites
- leukocyte esterase
- WBC casts
urine culture and stain
tell what the pathogen is
significant bacteriuria (asymptomatic UTI)
traditional: > 10^5 cfu/mL
women: > 10^2 cfu/mL
men: > 10^3 cfu/mL
clinical UTI definition
significant bacteriuria
+
pyuria (pus)
+
s/s infection
woman, not pregnant, cystitis treatment
nitrofurantoin X 5 days
TMP/SMX X 3 days
woman, not pregnant, pyelonephritis, outpatient
TMP/SMX x 14 days
woman, not pregnant, pyelonephritis, inpatient
IV*
extended spectrum cephalosporin (cefepime, ceftaroline, …)
penicillin + aminoglycoside
10-14 days
when do you treat asymptomatic bacteriuria?
ONLY IF
- pregnant
- before catheterization
- before renal transplant
UTI safe in pregnancy
amoxicillin/clav x 7 days
cephalexin x 3-7 days
IV beta-lactam (ceftriaxone, cefazolin) x 14 days total (change to po when can)
UTI avoid in pregnency
fluoroquinolones
tetracyclines (doxy, tetra)
sulfonamides in LAST TRIMESTER –> kernicterus, hyperbilirubinemia
goal of treating in pregnancy
prevent pyelonephritis –> pregnancy complications
male UTI cause
e coli
male UTI cystitis presentation
**elderly men
- dysuria
- frequency
- fever
- lower abdominal pain
male UTI pyelonephritis presentation
- similar to women
male acute UTI treatment
TMP/SMX DS BID
or
fluoroquinolone
- if enterococcus: ampicillin + gentamicin
2-4 weeks
male chronic UTI treat
TMP/SMX DS BID
or fluoroquinolone
4-6 weeks
increased prevalence of infectious diarrhea and c diff in…
water
tropics
seasonally
populations at risk for ID and c diff
- travelers, campers
- < 5 years, > 74 years
- military (travel, proximity)
- chronic care institutions
- immunocompromised
infectious diarrhea pathogens
- viral: rotavirus
- bacterial: c difficile
- parasitic: roundworms, tapeworms, …
mild water loss
< 5% body weight lost
- alert
- inc thirst
- normal urine output
moderate water loss
6-9% body weight loss
- lethargic, low BP, high HR, dry membranes, dark urine
severe water loss
> 10% body weight loss
- drowsy
- bradycardia
- skin tenting
- no urine
how to treat traveler’s diarrhea
- loperamide x 2days
if high risk
- TMP/SMX
- cipro
how to treat acute viral gastroenteritis
no antibiotic
how to treat food poisoning
no antibiotic
how to tret enterotoxic e coli
**major abdominal cramping
azithro
cipro
how to treat mild and mod dehydration
oral replacement therapy
how to treat severe dehydration
IV fluids – NS or LR
risk factors for c diff
1) patient specific
- > 65 yrs
- GI surgery
- tube feeding
- immunocompromised
2) facility specific
- longer hospital stay
- ICU
- exposure
3) medication related
- acid suppresors – PPI, h1 RA
- chemo
- antibiotics!!
number 1 risk factor for c diff
ANTIBIOTICS!!
highest risk antibiotics for c diff
clindamycin
cephalosporins 3rd and 4th gen
carbapenems
fluoroquinolone
**broadest spectum
c diff severity
non-severe:
- leukocytosis WBC < 15,000 cells/mL
AND
- SCr < 1.5 mg/dL
severe:
- leukocytosis WBC > 15,000 cells/mL
OR
- SCr > 1.5 mg/dL
fulminant:
- megacolon
- illeus
- hypotension, shock
types of c diff infections
1) carrier, colonized
- no diarrhea
2) AB-associated diarrhea, no colitis
- 6 loose bm/day
3) AB-associated colitis, no pseudomembranes
- 10+ loose bm/day
- occult blood
- fecal WBC
4) pseudomembranous colitis
- > 10 loose bm/day
- occult blood
- fecal WBC
c diff Dx
- > 3 unformed stools in last 24 hours
AND - (+) stool test for c diff or toxins OR pseudomembranous colitis seen on colonoscopy
do you repeat stool assays during treatment
no, stay (+) for 6 weeks
supportive c diff care
1) fluids, electrolytes
2) avoid anti-peristaltic –> loperamide, narcotics
3) stop offending antibiotic if possible
how to treat initial non-severe c diff
vancomycin 125mg po QID x 10 days
OR
fidaxomicin 200mg po BID x 10 days
could use
metronidazole 500mg po TID x 10days
how to treat initial severe c diff
vancomycin 125mg po QID x 10 days
OR
fidaxomicin 200mg po BID x 10 days
how to treat initial fulminant/severe, complicated c diff
vancomycin 500 mg po OR NGT QID
+ (if ileus)
metronidazole 500 mg IV q8h
how to treat first recurrent c diff
same
to treat second recurrent c diff
antibiotics
- vancomycin tapers
- vancomycin pulsed OR fidaxomicin
moAB
- actoxumab
- bezlotoxumab
*neutralize toxins
FMT (fecal microbiotic transplant)
- high efficacy
- within 24 hours
- from partner, housemate, family
how to prevent c diff infection
- hand hygiene
- contact precautions
