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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
Extended interval Aminoglycoside dosing
- high dose once daily - decrease nephrotoxicity, ease of administering and monitoring
26
Combination antimicrobial therapy
- widens the already broad spectrum - syngery - prevents resistance - disadvantages: superinfection, toxic, antagonistic effect, cost
27
IV to PO switch
- Overal improvement - lack fever for 24 hrs - decreased WBC - functioning GI tract
28
Vanco vs gram negative Cephalosporin vs enterococcus
Intrinsic resistance
29
Decreased permeability Efflux pump Drug inactivation/modification Altered target site
Acquired resistance due to inappropriate abx use
30
MRSA Methicillin-resistant S. Aureus
- altered site: PBP2 --> PBP2a - resistant to meth, oxa, naf Drug of choice: vancomycin Alternative: dapto, linezolid, ceftaroline
31
VRE Vancomycin resistant Enterococcus
- altered site: D-ala-D-Ala to D-ala-D-lactate - Drug of choice: dapto, linezolid
32
ESBL Extended Spectrum Beta-lactamases
- hydrolyze b-lactam ring - inactivated most b-lactams - drug of choice: Carbapenems
33
CRE Carbapenem resistant enterobacterales
- carbapenamases: inhibit all b-lactam + carbapenems - Drug of choice: tailored to susceptibility (polymyxin, drug + b-lactamase inhibitor)
34
UTI
- presence of microorganism in the urinary tract that cannot be accounted for by contamination
35
Cystitis Urethritis Prostatis
Lower UTI
36
Pyelonephritis
Upper UTI
37
Uncomplicated UTI
- lack structural or functional abnormalities of the urinary tract interfering with the normal flow of urine
38
Complicated UTI
- result of predisposing lesion of the urinary tract - congenital, stones, obstruction, etc
39
# Clinical presentation - Gross Hematuria - Dysuria - Frequent + urgent - nocturia - suprapubic heaviness
Lower UTI
40
# Clinical presentation - Gross hematuria - flank pain - FEVER - NV - malaise - costovertebral angle tenderness
Upper UTI
41
# Clinical presentation - altered mental status - change in eating habit - GI symptoms
Geriatric atypical UTI symptoms
42
# Clinical presentation - No lower UTI symptoms - Flank pain - Fever
Indwelling catheter or neurologic disorder UTI atypical symptoms
43
# Diagnosis Gold standard
Positive UA with positive Urine culture in **symptomatic patient**
44
Urine Collection
- midstream clean catch (preferred) - catheterication - suprapubic bladder aspiration
45
- Bacteriuria - Pyuria - hematuria - proteinuria - Nitrite positive - Leukocyte esterase Positive
UA, microscopy, dipstick values
46
UA Pitfalls
- only useful when in conjunction with sypmtoms - many factors, may not be related to infection - urine sample should be used within 20 mins
47
Broad Abx collaterial damage
- selection of drug resistant organisms - unwanted development of MDRO - impact on gut flora
48
Increasing resistant of E. coli to fluroquinolones
Limit the use
49
- History of MDRO - recent use of broad spectrum abx - health care exposure - traveling to areas with MDRO
Risk factors for DMRO (prior 3 months)
50
Empiric treatment for simple Cystitis (1st line)
- Nitrofurantoin - TMP/SMX - Fosfomycin
51
Nitrofurantoin Avoid in
- avoid in pyleonephritis - avoid in CrCl <30ml/min - avoid in 1st trimester
52
TMP/SMX Avoid in
- avoid if resistance prevalance is greater than 20% - Avoid if used 3 months prior - Avoid in 1st and 3rd trimester
53
Fosfomycin Avoid in
- avoid in pylonephritis - Expensive
54
Empiric Simple Cystitis (2nd line)
- Fluroquinolones - B-lactams (avoid ampi and amox)
55
Empiric Pyelonephritis Outpatient (1st line)
- 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)
56
# FDA warning Quinolone in simple UTI
- servere side effects - risk outweigh benefits - should only be used if no other option
57
Empiric Pyelonephritis Hospital
- 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
58
Recurrent UTI
- more than 2 w/i 6 months or 3 w/i 1 year
59
Relapse Infection
- repeat infection with the same initial organism - within 2 weeks of initial infection - due to unsuccessful tx or resistance
60
Reinfection
- caused by different organism than initial - treat as new infection
61
# [](http://) Manage Recurrent UTI
- treat as separate occuring infection - self-administer therapy - postcoital therapy - continuous low dow prophylaxis
62
Asymptomatic bacteriuria
Do not treat unless: - pregnant - undergoing urological intervention - recent renal transplant
63
Asymptomatic bacteriuria Tx
- Pregnant: 4-7 days - Procedure: 1 or 2 dose, 30-60 min before procedure
64
Decrease adherence of bacteria to bladder epithelial cells
Cranberry
65
- regulate genitourinary bacteria - keeps normal vaginal pH
Lactobacillus
66
# Urinary analgesic Phenazopyridine
- no Abx activity - limit to 2-3 days for symptomativ relief - used in combo with abx
67
- inflammation of prostate gland and surround tissue - commonly by gram negative bacteria (e.coli) - occasionally by STDs
Prostatitis
68
# Clinical presentation - Sudden fever - genitourinary tenderness - urinary symptons - constitutional symptoms
Prostatitis
69
# Clinical presentation - **Acute**: swollen, tender, tense, indurated gland - **Chronic**: boggy, indurated for at least 6 months
Prostatitis
70
TX for Prostatitis
- Quinolones or TMP/SMX - acute might need intial IV - Chronic: longer tx period/ surgery - acute: 2-4 weeks - chronic: 4-6 weeks
71
SSTIs
- 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
Nosocomial Pathogen
- pseudomonas - MRSA
73
- folliculitis - furuncle - carbuncle - abscess
Purulent SSTI
74
- Impetigo - erysepilas - cellulitis - necrotizing fasciitis
Non-purulent SSTI
75
- adjacent furuncles combined to form a single inflamed area - form deep masses, can drain into multiple sinus tracts
Carbuncle
76
- collection of pus within the dermis and deeper skin tissue
Abcsess
77
# Management Furuncle, carbuncle, abscess
- 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
- doxycycline - TMP/SMX
for moderate purulent SSTI
79
- Vancomycin - daptomycin - linezolid - ceftaroline
for severe purulent SSTI
80
- superficial skin infection (child) - starts from minor trauma - contagious
Impetigo
81
- most common - cause by strep or S. aureus - small, fluid filled vesicles- golden yellow crust
Non-bullous Impetigo
82
- caused by toxin producing s. aureus - vesicles, clear yellow fluid, thin, light brown crust (enlarged lymph nodes)
Bullous impetigo
83
# Management of impetigo Treatment
- Mild: topical mupirocin BID - On face/ multiple lesion: oral abx for 7 day - MSSA: diclox, cephalexin - MRSA: clindamycin, doxy. TMP/SMX
84
- superficial layers + lymphatics - associated with group A strep (s. pyogenes) - Penicilin drug of choice
Erysipelas
85
# Clinical presentation - red continous, indurated, edamatous area - spreads peripherally - constitutional discomfort
Erysipelas
86
# Erysipelas Treatment
Mild-mod: Procaine Penicillin IM Severe: Penicillin G IV Switch to PO with overall improvement
87
- 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
- cellulitis
88
# Clinical presentation - erythema, edema of skin - warm and painful - lesions non-elevated, poorly defined margins
Cellulitis
89
Empiric Mild to mod cellulitis
Purulent: TMP/SMX, doxy Nonpurulent: Betalactams (pen, cephalexin, diclox) can consider cephalosporins ($$$)
90
Empiric for Severe cellulitis
**Purulent:** vanco, dapto, linezolid, ceftaroline, tela can consider dalbavancin, oritavancin ($$$) **Nonpurulent: moderate:** MSSA+Strep = cefazolin/ceftriaxone **MRSA:** Vanco **Immunocompromised:** Vanco + pip/tazo
91
- progrssive destruction of superfascia + subq fat - 20-50% mortality
Necrotizing fasciitis
92
Type 1,2, 3 Necrotizing fasciitis
1. occurs after surgery/trauma, anaerobes, stept, entero 2. with underlying disease, group A strep, rapid 3. gas gangrene, clostridium perfringes, advances rapidly
93
# 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
necrotising fasciitis
94
# Management Necrotizing fasciitis
- surgical debridement - blood+deep tissue culture - Empiric (MRSA,Pseudo, ana): Vanco+pip/tazo - definitive: Group A - Pen+clinda
95
- infection of the bone marrow and surrounding bone associated - All ages, any bone
Osteomyelitis
96
Causes of Osteomyelitis
- hematogenous spread (bloodstream, <16yo) - contiguous spread (direct infection from adjacent tissue, >50yo) - s.aureus
97
# Management Osteomyelitis
- debridement - Abx (IV, High dose) 4-6 weeks delay in stable patients until cultures
98
# TX Empiric Osteomyelitis MSSA
- Naf/Oxa - cefazolin
99
# TX Empiric Osteomyelitis MRSA
- vanco - dapto - linezolids
100
# TX Empiric Osteomyelitis Gram-neg (pseudo)
- cipro - levo - cefepime - pip/tazo
101
# TX Empiric Osteomyelitis Anaerobes
- metronidazole
102
# define Bacterial meningitis
- 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
# Clinical Presentaion ABRUPT - fever, nuchal rigidity, altered mental status # - constitutional discomfort - seizures - septic shock rash - apnea - bulging fontanelle (infants) - refusal to eat
Bacterial Meningitis
104
# lumbar puncture CSF analysis
- purulent, cloudy - elevated opening pressure - high WBC - Neutrophil (pre-dominance) - elevated protein - low glucose - decrease blood glucose ratio
105
Lab values for Meningitis
- left shift - leukopenia (severe) - thrombocytopenia - positive blood culture - positive CSF analysis and CSF culture
106
# factors Strept meningitis
- s. pneumonia - > 2 months of age - secondary infection resulting from primary (ear, sinus) - or other predisposing factors
107
Group B strep meningitis
- Strep agalactiae - neonates - vertical transmission from pregnant women to fetus (GI, genitourinary) - intrapartum antimicrobial prophylaxis may decrease incidence
108
Meningococcal Meningitis
- N. meningitidis - the presence of petechia rash - contagious (pharyngeal secretion, droplets) - Predisposing factors: HIV, deficiencies, smoking
109
H. Influenzae Type B Meningitis
- not common due to worldwide vaccination - associated with ear infection, paranasal sinus infection, or CSF leakage
110
Listeria monocytogenes meningitis
- affects: neonate, alcoholics, immunocompromised, elderly - Food born transmission pathogen
111
Gram negative meningitis
- uncommon, but nosocomial - UTI, associated with higher risk of gam-neg meningitis in adults
112
# Meningitis Pathogen Neonates
- group B strep - enteric gram-ng - listeria
113
# Meningitis Pathogen Infants
- strep. pneumo - N. meningitidis - H. influenza - group b strep
114
# Meningitis Pathogen child + adult
- N. meningitidis - s. pneumo
115
# Meningitis Pathogen Geriatrics
- S. pneumo - N. meningitidis - Listeria - enteric gram neg
116
# Management Bacterial meningitis
- death if not treated - empiric abx within 1 hr high dose, IV, CNS penetration - supportive car (fluids, electrolytes) - dexamethasone
117
# Empiric Bacterial Meningitis Neonates
- ampicillin + cefotaxime - ampicillin + aminoglycosides
118
# Empiric Bacterial Meningitis Infant
- Vancomycin + 3rg gen cephalosporin ( ceftriaxone or cefotaxime)
119
# Empiric Bacterial Meningitis Child + adult
- Vancomycin + 3rg gen cephalosporin ( ceftriaxone or cefotaxime)
120
# Empiric Bacterial Meningitis Geriatric
- Vancomycin + 3rg gen cephalosporin ( ceftriaxone or cefotaxime) + ampicillin
121
# Empiric Bacterial Meningitis Closed head trauma
- Vanco + 3rg gen (ceftriaxone/cefotaxime)
122
# Empiric Bacterial Meningitis - Penetrating head trauma - neurosurgery - CSF shunt
Vanco + (cefepime/ceftazidime) or Meropenem
123
Dexamethasone
- adjunct therapy for bacterial mengitis - immunomodulate inflammation - decrease neurologic complications
124
Dexamethasone recommendation
Infant and children: H influenzae, pneumococcal Adult: pneumococcal * give before or with 1st dose of abx * dc if other pathogens are identified
125
Meningococcal Meningitis Chemoprophylaxis
- ideally within 24 hrs - cipro, rifampin, ceftriaxone
126
Endocarditis
- inflammation of the endocardium, membrane lining the chambers of the heart and covering the cups of the valves - infection of the heart valves
127
# 1. Acute IE
- fulminating - high fever - systemic toxicity - S. aureus - death if untreated
128
Subacute IE
- indolent - viridans streptococci - pre-exisiting heart disease
129
IE risk factors
- Prosthetic valve - previous endocarditis - healthcare exposure - congenitial heart disease
130
# Clinical presentation IE
- fever - heart murmur - constitutional discomfort - malaise, night sweat - weight loss
131
IE labratory values
- #continuous bacteriemia - leukocytosis - anemia - thrombocytopenia - high ESR, CRP - Proteinuria, hematuria
132
# IE Major Criteria
- blood culture positive for IE - evidence of endocardial involvement - echocardiogram positive for IE - New valvular regurgitation
133
# IE Minor Criteria
- Predisposition (condition/IVDU) - fever - vascular phenomena - immunological phenomena (osler nodes, etc) - microbiological evidence
134
# Management IE
- Pharmalogical - Surgical (replacement) for: heart failure, large vegetations, persistent bacteremia
135
IE bacteria
- Viridans group strep - strep. gallolyticus - usually involving native valves
136
# Treatment all IV Native Valve IE
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
# Treatment All IV Prosthetic Valve IE
Susceptible 1. PenG, Ceftriaxone, Vanco Relatively resistant 1. PenG + Genta, Ceftriaxone + Genta, Vanco Resistant = treat as enterococcal IE
138
Staphylococci Endocarditis
- S. aureus (IVDU, catheters, valve surgery) - S. epi and S. aureus prominent in PVE
139
# Treatment IV NVE - staphylococci
MSSA: Naf, oxa, cefazolin MRSA: Vanco or dapto
140
# Treatment IV PVE Staphylococci
MSSA: Naf/Oxa + rifampin + genta MRSA: Vanco + rifampin + genta
141
Enterococcal Endocarditis
- e. faecalis, e. faecium - more resistant to therapy - combo therapy
142
# Enterococci Endocarditis TX Pen and Genta susceptible
- Ampi/PenG + Genta - Ampi + ceftriaxone
143
# Enterococci Endocarditis TX Pen Sus, Genta resist
- ampi + ceftriaxone - Ampi/ Pen G + streptomycin
144
# Enterococci Endocarditis TX Penicillin Resist, Vanco and genta sus
Vanco + Genta
145
# Enterococci Endocarditis TX Pen, Gent, Vanco resist
- Linezolid - Daptomycin
146
Prophylaxis in IE
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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