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DnD- ID > Therapeutics 1/2 > Flashcards

Therapeutics 1/2 Flashcards

1
Q

General

Fever

A
  • non-specific, may not be caused by an infection
  • 100.4 F (38C)
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2
Q

General

WBC

A
  • non-specific
  • can be drug induced
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3
Q

Lactate

A
  • marker for sepsis, impair tissue oxygenation
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4
Q

CRP and ESR

A
  • non-specific markers for inflammation
  • used for monitoring
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5
Q

Procalcitonin

A
  • more specific for “bacterial” infection
  • tool used to dc antibiotics
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6
Q

Severity of infection

A
  • hemodynamic changes
  • respiratory change
  • neurologic
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7
Q

Blood cultures

A
  • sterile technique
  • 2 sets at 2 different sites (one aerobic bottle, one anaerobic bottle)
  • incubated for 5-7 days
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8
Q

Sputum culture

A
  • swish water to remove food debris
  • expectorate into sterile container
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9
Q

Urine Cultures

A
  • UA, urine dipstick
  • catch mid stream void or straight catheterization
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10
Q

Gram stain (1st clue)

A
  • type of organism involved
  • pos/neg? shape?
  • amount of organism
  • types of cells present
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11
Q

Steptococcus
Enterococcus
Staph Aureus
Staph Epidermidis

A

Gram Positive
Cocci
Aerobes

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12
Q

Corynebacterium
Listeria

A

Gram positive
Aerobes
Bacilli

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13
Q

Peptococcus
Peptostreptococcus

A

Gram positive
Anaerobes
Cocci

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14
Q

Closterium

A

Gram Positive
Anaerobe
Bacilli

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15
Q

E.coli
Enterobacter
Klebsiella

A

Lactose-fermenting
Gram-negative
Aerobes
Bacilli

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16
Q

Pseudomonas Aeruginosa
Acinetobacter

A

Non-fermenting
Gram Negative
Aerobes
Bacilli

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17
Q

Bacterial class

  1. Neisseria
    - Meningitidis
    - gonorrhoeae
  2. Haemophilus Influenzae
A

Gram negative
Aerobe
Cocci

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18
Q

Bacteroides
Fusobacterium
Prevotella

A

Gram Negative
Anaerobes
Bacilli

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19
Q

Mycoplasma
Legionella
Chlamydophila

A

Atypical bacteria

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20
Q

Antibiogram

A
  • shows how often an abx has aactivity against organism
  • shown as percent susceptible
  • useful in deciding empiric therapy
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21
Q

Factors on deciding ABX

A
  • age
  • organ dysfunction
  • preganacy/lactation
  • genetic variation
  • concomitant disease
  • concomitant drugs
  • Tissue penetration
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22
Q

Time dependant kiliing
(T>MIC)

A
  • rate and extent of bacterial killing depends on the time the active drug concentration remains above the MIC
  • Beta-lactams
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23
Q

Concentration dependant Killing
(CMAX:MIC)

A
  • bacterial killing depends on antimicrobial concentration
  • Aminoglycosides, fluroquinolones
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24
Q

Prolonged infusion of B-lactams

A
  • maximize the duration the pathogen is exposed to b-lactam
  • beneficial to critially ill patients and pathogens with high MIC
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25
Q

Extended interval Aminoglycoside dosing

A
  • high dose once daily
  • decrease nephrotoxicity, ease of administering and monitoring
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26
Q

Combination antimicrobial therapy

A
  • widens the already broad spectrum
  • syngery
  • prevents resistance
  • disadvantages: superinfection, toxic, antagonistic effect, cost
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27
Q

IV to PO switch

A
  • Overal improvement
  • lack fever for 24 hrs
  • decreased WBC
  • functioning GI tract
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28
Q

Vanco vs gram negative
Cephalosporin vs enterococcus

A

Intrinsic resistance

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29
Q

Decreased permeability
Efflux pump
Drug inactivation/modification
Altered target site

A

Acquired resistance due to inappropriate abx use

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30
Q

MRSA
Methicillin-resistant S. Aureus

A
  • altered site: PBP2 –> PBP2a
  • resistant to meth, oxa, naf
    Drug of choice: vancomycin
    Alternative: dapto, linezolid, ceftaroline
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31
Q

VRE
Vancomycin resistant Enterococcus

A
  • altered site: D-ala-D-Ala to D-ala-D-lactate
  • Drug of choice: dapto, linezolid
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32
Q

ESBL
Extended Spectrum Beta-lactamases

A
  • hydrolyze b-lactam ring
  • inactivated most b-lactams
  • drug of choice: Carbapenems
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33
Q

CRE
Carbapenem resistant enterobacterales

A
  • carbapenamases: inhibit all b-lactam + carbapenems
  • Drug of choice: tailored to susceptibility (polymyxin, drug + b-lactamase inhibitor)
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34
Q

UTI

A
  • presence of microorganism in the urinary tract that cannot be accounted for by contamination
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35
Q

Cystitis
Urethritis
Prostatis

A

Lower UTI

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36
Q

Pyelonephritis

A

Upper UTI

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37
Q

Uncomplicated UTI

A
  • lack structural or functional abnormalities of the urinary tract interfering with the normal flow of urine
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38
Q

Complicated UTI

A
  • result of predisposing lesion of the urinary tract
  • congenital, stones, obstruction, etc
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39
Q

Clinical presentation

  • Gross Hematuria
  • Dysuria
  • Frequent + urgent
  • nocturia
  • suprapubic heaviness
A

Lower UTI

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40
Q

Clinical presentation

  • Gross hematuria
  • flank pain
  • FEVER
  • NV
  • malaise
  • costovertebral angle tenderness
A

Upper UTI

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41
Q

Clinical presentation

  • altered mental status
  • change in eating habit
  • GI symptoms
A

Geriatric atypical UTI symptoms

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42
Q

Clinical presentation

  • No lower UTI symptoms
  • Flank pain
  • Fever
A

Indwelling catheter or neurologic disorder UTI atypical symptoms

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43
Q

Diagnosis

Gold standard

A

Positive UA with positive Urine culture in symptomatic patient

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44
Q

Urine Collection

A
  • midstream clean catch (preferred)
  • catheterication
  • suprapubic bladder aspiration
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45
Q
  • Bacteriuria
  • Pyuria
  • hematuria
  • proteinuria
  • Nitrite positive
  • Leukocyte esterase Positive
A

UA, microscopy, dipstick values

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46
Q

UA Pitfalls

A
  • only useful when in conjunction with sypmtoms
  • many factors, may not be related to infection
  • urine sample should be used within 20 mins
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47
Q

Broad Abx collaterial damage

A
  • selection of drug resistant organisms
  • unwanted development of MDRO
  • impact on gut flora
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48
Q

Increasing resistant of E. coli to fluroquinolones

A

Limit the use

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49
Q
  • History of MDRO
  • recent use of broad spectrum abx
  • health care exposure
  • traveling to areas with MDRO
A

Risk factors for DMRO (prior 3 months)

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50
Q

Empiric treatment for simple Cystitis
(1st line)

A
  • Nitrofurantoin
  • TMP/SMX
  • Fosfomycin
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51
Q

Nitrofurantoin Avoid in

A
  • avoid in pyleonephritis
  • avoid in CrCl <30ml/min
  • avoid in 1st trimester
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52
Q

TMP/SMX Avoid in

A
  • avoid if resistance prevalance is greater than 20%
  • Avoid if used 3 months prior
  • Avoid in 1st and 3rd trimester
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53
Q

Fosfomycin Avoid in

A
  • avoid in pylonephritis
  • Expensive
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54
Q

Empiric Simple Cystitis
(2nd line)

A
  • Fluroquinolones
  • B-lactams (avoid ampi and amox)
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55
Q

Empiric Pyelonephritis Outpatient
(1st line)

A
  • If prevalence less than 10%: cipro
  • if prevalence more than 10%: Ceftriaxone or Gentamycin/tobramycin
  • If susceptible: TMP/SMX
  • Initial Long-acting IV abx + B-lactam(less effective)
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56
Q

FDA warning

Quinolone in simple UTI

A
  • servere side effects
  • risk outweigh benefits
  • should only be used if no other option
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57
Q

Empiric Pyelonephritis Hospital

A
  • Not critically ill/ obstruction:
  • Ceftriaxone (ES cephalo)
  • Genta/Tobramycin (Aminoglyc)
  • Carbapenem (for ESBL)
  • If critically ill + obstruction:
  • Broad sepc anti-psuedo
  • ESBL coverage
  • MRSA coverage
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58
Q

Recurrent UTI

A
  • more than 2 w/i 6 months or 3 w/i 1 year
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59
Q

Relapse Infection

A
  • repeat infection with the same initial organism
  • within 2 weeks of initial infection
  • due to unsuccessful tx or resistance
60
Q

Reinfection

A
  • caused by different organism than initial
  • treat as new infection
61
Q

Manage Recurrent UTI

A
  • treat as separate occuring infection
  • self-administer therapy
  • postcoital therapy
  • continuous low dow prophylaxis
62
Q

Asymptomatic bacteriuria

A

Do not treat unless:
- pregnant
- undergoing urological intervention
- recent renal transplant

63
Q

Asymptomatic bacteriuria Tx

A
  • Pregnant: 4-7 days
  • Procedure: 1 or 2 dose, 30-60 min before procedure
64
Q

Decrease adherence of bacteria to bladder epithelial cells

A

Cranberry

65
Q
  • regulate genitourinary bacteria
  • keeps normal vaginal pH
A

Lactobacillus

66
Q

Urinary analgesic

Phenazopyridine

A
  • no Abx activity
  • limit to 2-3 days for symptomativ relief
  • used in combo with abx
67
Q
  • inflammation of prostate gland and surround tissue
  • commonly by gram negative bacteria (e.coli)
  • occasionally by STDs
A

Prostatitis

68
Q

Clinical presentation

  • Sudden fever
  • genitourinary tenderness
  • urinary symptons
  • constitutional symptoms
A

Prostatitis

69
Q

Clinical presentation

  • Acute: swollen, tender, tense, indurated gland
  • Chronic: boggy, indurated for at least 6 months
A

Prostatitis

70
Q

TX for Prostatitis

A
  • Quinolones or TMP/SMX
  • acute might need intial IV
  • Chronic: longer tx period/ surgery
  • acute: 2-4 weeks
  • chronic: 4-6 weeks
71
Q

SSTIs

A
  • may involve any or all layers of the skin, fascia, and muscle
  • can spread from the intial site and lead to severe complications
  • Gram positive if above the waist
  • Gram neg and pos if below the waist
72
Q

Nosocomial Pathogen

A
  • pseudomonas
  • MRSA
73
Q
  • folliculitis
  • furuncle
  • carbuncle
  • abscess
A

Purulent SSTI

74
Q
  • Impetigo
  • erysepilas
  • cellulitis
  • necrotizing fasciitis
A

Non-purulent SSTI

75
Q
  • adjacent furuncles combined to form a single inflamed area
  • form deep masses, can drain into multiple sinus tracts
A

Carbuncle

76
Q
  • collection of pus within the dermis and deeper skin tissue
A

Abcsess

77
Q

Management

Furuncle, carbuncle, abscess

A
  • mild: I&D
  • Moderate: I&D, C&S, Emperic PO abx against MRSA
  • Severe: I&D,C&D, Empiric IV abx against MRSA

7-14 days

78
Q
  • doxycycline
  • TMP/SMX
A

for moderate purulent SSTI

79
Q
  • Vancomycin
  • daptomycin
  • linezolid
  • ceftaroline
A

for severe purulent SSTI

80
Q
  • superficial skin infection (child)
  • starts from minor trauma
  • contagious
A

Impetigo

81
Q
  • most common
  • cause by strep or S. aureus
  • small, fluid filled vesicles- golden yellow crust
A

Non-bullous Impetigo

82
Q
  • caused by toxin producing s. aureus
  • vesicles, clear yellow fluid, thin, light brown crust (enlarged lymph nodes)
A

Bullous impetigo

83
Q

Management of impetigo

Treatment

A
  • Mild: topical mupirocin BID
  • On face/ multiple lesion: oral abx for 7 day
  • MSSA: diclox, cephalexin
  • MRSA: clindamycin, doxy. TMP/SMX
84
Q
  • superficial layers + lymphatics
  • associated with group A strep (s. pyogenes)
  • Penicilin drug of choice
A

Erysipelas

85
Q

Clinical presentation

  • red continous, indurated, edamatous area
  • spreads peripherally
  • constitutional discomfort
A

Erysipelas

86
Q

Erysipelas

Treatment

A

Mild-mod: Procaine Penicillin IM
Severe: Penicillin G IV
Switch to PO with overall improvement

87
Q
  • starts from epidermic/dermis and spreads through superficial fascia into lymphatic tissue and bloodstream
  • usually caused by group A strep and S. aureus
  • may lead to abscess
A
  • cellulitis
88
Q

Clinical presentation

  • erythema, edema of skin
  • warm and painful
  • lesions non-elevated, poorly defined margins
A

Cellulitis

89
Q

Empiric Mild to mod cellulitis

A

Purulent: TMP/SMX, doxy
Nonpurulent: Betalactams (pen, cephalexin, diclox)
can consider cephalosporins ($$$)

90
Q

Empiric for Severe cellulitis

A

Purulent: vanco, dapto, linezolid, ceftaroline, tela
can consider dalbavancin, oritavancin ($$$)

Nonpurulent: moderate: MSSA+Strep = cefazolin/ceftriaxone

MRSA: Vanco
Immunocompromised: Vanco + pip/tazo

91
Q
  • progrssive destruction of superfascia + subq fat
  • 20-50% mortality
A

Necrotizing fasciitis

92
Q

Type 1,2, 3 Necrotizing fasciitis

A
  1. occurs after surgery/trauma, anaerobes, stept, entero
  2. with underlying disease, group A strep, rapid
  3. gas gangrene, clostridium perfringes, advances rapidly
93
Q

Clinical presentation

  • consitutional discomfort
  • hot, swollen, red
  • shiny, tender, painful
  • diffuse sweating of the area followed by bullae filled with clear fluid
  • can evolve to gangrene
A

necrotising fasciitis

94
Q

Management

Necrotizing fasciitis

A
  • surgical debridement
  • blood+deep tissue culture
  • Empiric (MRSA,Pseudo, ana): Vanco+pip/tazo
  • definitive: Group A - Pen+clinda
95
Q
  • infection of the bone marrow and surrounding bone associated
  • All ages, any bone
A

Osteomyelitis

96
Q

Causes of Osteomyelitis

A
  • hematogenous spread (bloodstream, <16yo)
  • contiguous spread (direct infection from adjacent tissue, >50yo)
  • s.aureus
97
Q

Management

Osteomyelitis

A
  • debridement
  • Abx (IV, High dose)
    4-6 weeks
    delay in stable patients until cultures
98
Q

TX Empiric Osteomyelitis

MSSA

A
  • Naf/Oxa
  • cefazolin
99
Q

TX Empiric Osteomyelitis

MRSA

A
  • vanco
  • dapto
  • linezolids
100
Q

TX Empiric Osteomyelitis

Gram-neg (pseudo)

A
  • cipro
  • levo
  • cefepime
  • pip/tazo
101
Q

TX Empiric Osteomyelitis

Anaerobes

A
  • metronidazole
102
Q

define

Bacterial meningitis

A
  • inflammation of meninges surrounding brain and spinal cord due to bacterial invasion to the CNS
  • about 20% of survivors experience neurological disabilities
  • Hematogenous spread
  • contiguous spread (area close to brain)
  • direct inoculation (head trauma)
103
Q

Clinical Presentaion

ABRUPT
- fever, nuchal rigidity, altered mental status #
- constitutional discomfort
- seizures
- septic shock rash
- apnea
- bulging fontanelle (infants)
- refusal to eat

A

Bacterial Meningitis

104
Q

lumbar puncture

CSF analysis

A
  • purulent, cloudy
  • elevated opening pressure
  • high WBC
  • Neutrophil (pre-dominance)
  • elevated protein
  • low glucose
  • decrease blood glucose ratio
105
Q

Lab values for Meningitis

A
  • left shift
  • leukopenia (severe)
  • thrombocytopenia
  • positive blood culture
  • positive CSF analysis and CSF culture
106
Q

factors

Strept meningitis

A
  • s. pneumonia
  • > 2 months of age
  • secondary infection resulting from primary (ear, sinus)
  • or other predisposing factors
107
Q

Group B strep meningitis

A
  • Strep agalactiae
  • neonates
  • vertical transmission from pregnant women to fetus (GI, genitourinary)
  • intrapartum antimicrobial prophylaxis may decrease incidence
108
Q

Meningococcal Meningitis

A
  • N. meningitidis
  • the presence of petechia rash
  • contagious (pharyngeal secretion, droplets)
  • Predisposing factors: HIV, deficiencies, smoking
109
Q

H. Influenzae Type B Meningitis

A
  • not common due to worldwide vaccination
  • associated with ear infection, paranasal sinus infection, or CSF leakage
110
Q

Listeria monocytogenes meningitis

A
  • affects: neonate, alcoholics, immunocompromised, elderly
  • Food born transmission pathogen
111
Q

Gram negative meningitis

A
  • uncommon, but nosocomial
  • UTI, associated with higher risk of gam-neg meningitis in adults
112
Q

Meningitis Pathogen

Neonates

A
  • group B strep
  • enteric gram-ng
  • listeria
113
Q

Meningitis Pathogen

Infants

A
  • strep. pneumo
  • N. meningitidis
  • H. influenza
  • group b strep
114
Q

Meningitis Pathogen

child + adult

A
  • N. meningitidis
  • s. pneumo
115
Q

Meningitis Pathogen

Geriatrics

A
  • S. pneumo
  • N. meningitidis
  • Listeria
  • enteric gram neg
116
Q

Management

Bacterial meningitis

A
  • death if not treated
  • empiric abx within 1 hr
    high dose, IV, CNS penetration
  • supportive car (fluids, electrolytes)
  • dexamethasone
117
Q

Empiric Bacterial Meningitis

Neonates

A
  • ampicillin + cefotaxime
  • ampicillin + aminoglycosides
118
Q

Empiric Bacterial Meningitis

Infant

A
  • Vancomycin + 3rg gen cephalosporin ( ceftriaxone or cefotaxime)
119
Q

Empiric Bacterial Meningitis

Child + adult

A
  • Vancomycin + 3rg gen cephalosporin ( ceftriaxone or cefotaxime)
120
Q

Empiric Bacterial Meningitis

Geriatric

A
  • Vancomycin + 3rg gen cephalosporin ( ceftriaxone or cefotaxime) + ampicillin
121
Q

Empiric Bacterial Meningitis

Closed head trauma

A
  • Vanco + 3rg gen (ceftriaxone/cefotaxime)
122
Q

Empiric Bacterial Meningitis

  • Penetrating head trauma
  • neurosurgery
  • CSF shunt
A

Vanco + (cefepime/ceftazidime) or Meropenem

123
Q

Dexamethasone

A
  • adjunct therapy for bacterial mengitis
  • immunomodulate inflammation
  • decrease neurologic complications
124
Q

Dexamethasone recommendation

A

Infant and children: H influenzae, pneumococcal
Adult: pneumococcal
* give before or with 1st dose of abx
* dc if other pathogens are identified

125
Q

Meningococcal Meningitis Chemoprophylaxis

A
  • ideally within 24 hrs
  • cipro, rifampin, ceftriaxone
126
Q

Endocarditis

A
  • inflammation of the endocardium, membrane lining the chambers of the heart and covering the cups of the valves
  • infection of the heart valves
127
Q

1.

Acute IE

A
  • fulminating
  • high fever
  • systemic toxicity
  • S. aureus
  • death if untreated
128
Q

Subacute IE

A
  • indolent
  • viridans streptococci
  • pre-exisiting heart disease
129
Q

IE risk factors

A
  • Prosthetic valve
  • previous endocarditis
  • healthcare exposure
  • congenitial heart disease
130
Q

Clinical presentation

IE

A
  • fever
  • heart murmur
  • constitutional discomfort
  • malaise, night sweat
  • weight loss
131
Q

IE labratory values

A
  • # continuous bacteriemia
  • leukocytosis
  • anemia
  • thrombocytopenia
  • high ESR, CRP
  • Proteinuria, hematuria
132
Q

IE

Major Criteria

A
  • blood culture positive for IE
  • evidence of endocardial involvement
  • echocardiogram positive for IE
  • New valvular regurgitation
133
Q

IE

Minor Criteria

A
  • Predisposition (condition/IVDU)
  • fever
  • vascular phenomena
  • immunological phenomena (osler nodes, etc)
  • microbiological evidence
134
Q

Management

IE

A
  • Pharmalogical
  • Surgical (replacement)
    for: heart failure, large vegetations, persistent bacteremia
135
Q

IE bacteria

A
  • Viridans group strep
  • strep. gallolyticus
  • usually involving native valves
136
Q

Treatment all IV

Native Valve IE

A

Susceptible
1. Pen G, Ceftriaxone, Pen G + Genta, Ceftriaxone + Genta
2. Vancomycin
Relatively resistant
1. Pen G+ genta, Ceftriaxone + Genta (genta first 2 weeks)
Resistant = treat as enterococcal IE

137
Q

Treatment All IV

Prosthetic Valve IE

A

Susceptible
1. PenG, Ceftriaxone, Vanco
Relatively resistant
1. PenG + Genta, Ceftriaxone + Genta, Vanco
Resistant = treat as enterococcal IE

138
Q

Staphylococci Endocarditis

A
  • S. aureus (IVDU, catheters, valve surgery)
  • S. epi and S. aureus prominent in PVE
139
Q

Treatment IV

NVE - staphylococci

A

MSSA: Naf, oxa, cefazolin
MRSA: Vanco or dapto

140
Q

Treatment IV

PVE Staphylococci

A

MSSA: Naf/Oxa + rifampin + genta
MRSA: Vanco + rifampin + genta

141
Q

Enterococcal Endocarditis

A
  • e. faecalis, e. faecium
  • more resistant to therapy
  • combo therapy
142
Q

Enterococci Endocarditis TX

Pen and Genta susceptible

A
  • Ampi/PenG + Genta
  • Ampi + ceftriaxone
143
Q

Enterococci Endocarditis TX

Pen Sus, Genta resist

A
  • ampi + ceftriaxone
  • Ampi/ Pen G + streptomycin
144
Q

Enterococci Endocarditis TX

Penicillin Resist, Vanco and genta sus

A

Vanco + Genta

145
Q

Enterococci Endocarditis TX

Pen, Gent, Vanco resist

A
  • Linezolid
  • Daptomycin
146
Q

Prophylaxis in IE

A

For those: prosthetic valve, previous IE, cardiac transplant, heart disease, invasive dental procedures
- Amox PO single dose, 30-60 min before procedure
- allegic? = Clindamycin

DnD- ID (4 decks)

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