STIS AND IMMUNOCOMPROMISED HOST Flashcards by Briana Tutor

Treatment of uncomplicated gonococcal infections of the cervix, urethra, and rectum

ceftriaxone 500 mg IM x1 (<150 kg)
ceftriaxone 1 g IM x 1 (>150 kg)
if chlamydia infection is not excluded - + doxycycline 100 mg PO BID x 7 days
if chlamydia infection is not excluded and pregnant - + azithromycin 1 g x 1
alternative if ceftriaxone not available:
gentamicin IM x1 + azithromycin 2 g PO x 1
cefixime 800 mg PO x 1
-if chlamydia infection not excluded and treating with cefixime -> + doxycycline 100 mg PO BID x7 (azithromycin 1 g PO x 1 if pregnant)

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Treatment of uncomplicated gonococcal infections of the pharynx

ceftriaxone 500 mg IM x 1 (<150 kg)
ceftriaxone 1 g IM x 1 (>150 kg)
if chlamydia co-infection is identified - doxycycline 100 mg PO BID x 7 days (azithromycin 1 g PO x 1 if pregnant)
test-of-cure recommended 7-14 days after initial treatment, regardless of treatment regimen

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Treatment of syphilis: primary and secondary syphilis

benzathine Pen G 2.4 million units IM x 1

2. if allergic: doxy or tetracycline x 14 days

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Treatment of syphilis: early latent syphilis

benzathine Pen G 2.4 million units IM x 1 dose

2. pen-allergic: doxy or tetracycline x 28 days

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Treatment of syphilis: late latent or latent syphilis of unknown duration

benzathine Pen G 2.4 million units IM once weekly x 3 weeks
if pen-allergic: doxy or tetracycline x 28 days

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Treatment of syphilis: tertiary syphilis

benzathine Pen G 2.4 million units IM once weekly x 3 weeks
if pen allergic doxy or tetracycline x 4 weeks

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treatment of syphilis: Neurosyphilis

aqueous crystalline Pen G 304 million IV q4H x 10-14 days
alternative: procaine Pen G IM QD + probenecid PO QID x 10-14 days
may administer benzathine Pen G IM weekly for 3 weeks after completion of IV therapy
pen-allergic: ceftriaxone 2 g IM or IV daily x 10-14 days

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Treatment of syphilis: HIV

Primary and secondary syph: benzathine pen g IM x 1
early latent, late latent or syphilis of unknown duration:
- early latent: benzathine pen G IM x 1
- late latent or unknown: benzathine pen G IM once weekly x 3 weeks
neurosyphilis: same as non-HIV infected patient

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treatment of syphilis: pregnancy

penicillin is the only agent that reliably protects and treats the fetus; if pen allergic -> skin testing -> desensitization -> treat with penicillin regimen appropriate for their stage of infection

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Jarisch-Herxheimer reaction

acute febrile reaction characterized by flu-like symptoms, HA, fever, chills, malaise, arthralgia, myalgia, tachycardia, peripheral vasodilation
begins 2-4 hours after initiating therapy; may last 12-24 hours
do not confuse with penicillin allergy
more common in patients with early-stage syphilis (increased bacterial load)
treat with antipyretics

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Treatment of chlamydia

doxycycline 100 mg PO BID x 7 days

-alternative regimen: levofloxacin 500 mg PO q24h for 7 days

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treatment of chlamydia: pregnancy

azithromycin 1 gram PO x 1

-alternative amoxicillin 500 mg PO TID x 7 days

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Treatment of genital herpes: first clinical episode

acyclovir 400 mg PO TID
Famciclovir 250 mg PO TID
Valacyclovir 1 g PO BID

treat for 7-10 days

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Treatment of genital herpes: regimens for episodic recurrent infections

acyclovir 800 mg PO BID for 5 days or 800 mg PO TID for 2 days
Famciclovir 125 mg PO BID for 5 days or 1 gram PO BID for 1 day
Valacyclovir 500 mg PO BID for 3 days or 1 gram PO QD for 5 days

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treatment of genital herpes: regimens for daily suppressive therapy

acyclovir 400 mg PO BID
Famciclovir 250 mg PO BID
Valcyclovir 500 mg PO QD or 1 gram PO QD

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Treatment of genital herpes: severe disease

acyclovir 5-10 mg/kg/dose IV q8h for 2-7 days or until clinical improvement is observed followed by oral therapy to complete at least 10 days

Treatment of genital herpes: HIV

1. episodic infection: 
Acyclovir 400 mg PO TID
Famciclovir 500 mg PO BID
Valacyclovir 1 g PO BID
2. daily suppressive therapy: 
Acyclovir 400-800 mg PO BID or TID
Famciclovir 500 mg PO BID
Valacyclovir 500 mg PO BID

Acyclovir resistant HSV treatment

foscarnet 40-80 mg/kg/dose IV q8h

cidofovir 5 mg/kg/kg IV once weekly

Suppressive therapy in pregnant women with recurrent genital herpes

start at 36 weeks gestation
acyclovir 400 mg PO TID
Valacyclovir 500 mg PO BID

Treatment of trichomoniasis

women: metronidazole 500 mg BID x 7 days
men: metronidazole 2 g PO x 1
alternatives: tinidazole 2 g PO x 1

retest all sexually active women <3 months of initial treatment
allergy to metronidazole -> desensitization
avoid alcohol with metronidazole (24 hours) and tinidazole (72 hours)
HIV positive: metronidazole 500 mg PO BID x 7 days

Etiologic agents of PID

N. gonorrhoeae
C. trachomatis
vaginal flora (anaerobes, gardnerella vaginalis, gram (-) bacilli, S. alagactiae)
mycoplasma hominis, mycoplasma genitalium
ureaplasma urealyticum

PID treatment

ceftriaxone 1 g IV Q24H + Doxycycline 100 mg IV or PO q12h + Metronidazole IV or PO q12h
Cefotetan 2 g q12h OR cefoxitin 2 g IV q6H + doxycycline 100 mg IV or PO q12h
alternative parenteral regimen:
- unasyn 3 g IV q6h + doxycycline 100 mg IV/PO q12h
- clindamycin 900 mg IV q8h + gentamicin
IM/Oral based: ceftriaxone IM x 1 + doxycycline PO AND metrodinazole PO q12h x 14 days

Absolute neutrophil count (ANC)

ANC = WBC x (% polys + % bands)

Common pathogens in immunocompromised host infections

bacteria: S. aureus, S. epidermidis, streptococci, enterococci, E. coli, K. pneumoniae, psuedomonas
fungi: candida, aspergillus, zygomycetes (mucor, rhizopus)
viruses: HSV

Defects in T-lymphocyte and macrophage function (cell-mediated immunity)

- result in reduced ability of the host to defend against intracellular pathogens - common pathogens: 1. bacteria: listeria, nocardia, legionella, mycobacteria 2. fungi: C. neoformans, candida, histoplasma capsulatum 3. viruses: CMV, VZV, HSV 4. fungi: pneumocystis jiroveci

defects in B-cell function (humoral immunity)

-common bacterial pathogens (encapsulated) - S. pnuemoniae, H. influenzae, N. meningitidis

bacteremic episodes in cancer patients are due to___

gram (+) cocci

primary risk factor for aspergillus spps infections

prolonged neutropenia

Low risk: anticipated neutropenia <7 days, clinically stable, no medical comorbidities, and outpatient fever onset

1. outpatient: oral FQ + augmentin | 2. inpatient: zosyn, antipseudomonal carbapenem (not erta), cefepime, ceftazidime

high risk: anticipated neutropenia > 7 days, clinically unstable, any medical comorbidities, HSCT, or inpatient at fever onset

1. zosyn, antipseudomonal carbapenem (not erta), cefepime, ceftazidime -add vancomycin for cellulitis, pneumonia, severe sepsis or shock, gram + bacteremia, suspected IV catheter infection - for septic shock, gram - bacteremia, or pneumonia: add aminoglycoside or antipseudomonal FQ (cipro, levo)

Management of antimicrobial therapy after initiation of empiric therapy for an immunocompromised host

1. re-evaluate the clinical status of the patient after 48-72 hours of empiric antimicrobial therapy 2. addition or modification to the initial regimen may be required, especially in patients with ANC <500/mm3 for > 1 week - if MRSA - consider addition of van, linezolid, or dapto - if VRE - consider early addition of linezolid or dapto - if ESBL producer- consider early use of a carbapenem - if KPC producer- consider ceftazidime/avibactam =, meropenem/vaborbactam, imipenem/cilstatin/relebactam

Antifungal therapy for immunocompromised hosts

1. begin empiric therapy in neutropenic patients who remain febrile with undocumented infection after 4-7 days of broad-spectrum antibiotics (if duration of neutropenia is expected to be >7 days) 2. antifungal treatment options: - amphotericin B or liposomal amphotericin - azoles: fluconazole, itraconazole, voriconazole, isavuconazole, posaconazole - echinocandins 4. continue antifungal therapy for 2 weeks in the absence of signs and symptoms of active fungal disease

The most important determinant of patient outcomes in immunocompromised hosts

resolution of neutropenia

Prophylaxis of Infections in neutropenic cancer patients

1. reverse isolation with strict adherence to infection control guidelines 2. laminar airflow rooms to reduce the risk of airborne pathogens 3. FQ prophylaxis should be considered in moderate to high-risk patients with expected prolonged and profound neutropenia (ANC <100/mm3 for >7 days) - cipro or levo. If pt develops breakthrough infection during FQ prophylaxis, avoid FQ-based empiric antibiotic regimen 4. antifungal prophylaxis: azoles (fluconazole, itraconazole, voriconazole, posaconazole), echinocandins (capsofungin and micafungin) 5. bactrim reduces risk for P. jiroveci pneumonia 6. anti-viral prophylaxis: acyclovir for HSV, annual influenza vaccine with inactivated vaccine, varicella vaccine