Treatment of CNS and Respiratory Infections

Question 1

What antibiotics typically don’t reach sufficient levels in the CSF?

Answer 1

the 30S inhibitors -> tetracyclines / aminoglycosides, + polymyxins

Question 2

What is the empiric coverage we use for meningitis in patients <1 month?

Answer 2

Ampicillin + gentamicin or cefotaxime (3rd generation not ceftriaxone)

Gentamicin is okay because patient has no BBB

Question 3

What is the empiric coverage for meningitis in patients 1-23 months of age and why?

Answer 3

Vancomycin + 3rd generation cephalosporin

Use vancomycin for possibility of mildly elevated MICs of Streptococcus pneumoniae which would not allow killing by cephalosporin in CSF

Question 4

What is the only difference between treating adults under 50 and children for CNS infection?

Answer 4

Adults get Dexamethasone prior to first antibiotic dose

Question 5

What is the purpose of giving dexamethasone?

Answer 5

It is a steroid to decrease inflammation in subarachnoid space and thus decrease neurological sequelae

Question 6

What must be added onto the antibiotic regimen for adults >50 and why?

Answer 6

ampicillin, for listeria coverage

So regimen is:
ampicillin + vancomycin + ceftriaxone

Question 7

What can be used against Listeria if patient is allergic to ampicillin?

Answer 7

TMP/SMX

Question 8

Who gets prophylaxis for meningitis caused by N. meningitis and H. influenzae and what is it?

Answer 8

N. meningitis - anyone exposed to oral secretions and household contacts - Ciprofloxacin 500 mg or rifampin

H. influenzae - everyone in a household with unvaccinated children (might spread to them) - Rifampin

Question 9

What is the most common causative pathogen in CSF shunt infections, and what is the recommended empiric treatment?

Answer 9

Usually coag-negative staph (from skin)

Recommended broad therapy: Vancomycin + cefepime or ceftazidime

Question 10

What is the basic treatment for all fungal CNS infections minus Coccidio?

Answer 10

Lipid Amphotericin B + flucytosine for all
Blasto and Histo longer therapy, and longer oral therapy

Recommend switching to oral azole therapy after a few weeks

Question 11

What is the recommended therapy for only Coccidio CNS infection?

Answer 11

High dose fluconazole

Question 12

Typically acute bronchitis is not treated. What are the exceptions? What is used to treat?

Answer 12

Mycoplasmal, chlamydial, or B. pertussis

All use Macrolides with second line doxycycline

Question 13

During a COPD exacerbation, who gets antibiotics?

Answer 13

Only those with increased sputum purulence

Question 14

What are the most common bugs for COPD exacerbation?

Answer 14

S. pneumoniae, H. influenzae, M. catarrhalis (typical pathogens)

With some Chlamydia or mycoplasma

Question 15

What is the first-line treatment for COPD exacerbation?

Answer 15

Doxycycline, with second-line amoxicillin/clavulanic acid

Question 16

Who gets IV therapy for COPD exacerbations and what is it?

Answer 16

Those at high risk for poor outcome -> frequent exacerbations, comorbidities, and Abx use

It is ampicillin/sulbactum (basically IV augmentin)

Question 17

How long are COPD exacerbations treated?

Answer 17

3-7 days

Question 18

What are the only times you treat for sinusitis, since it is usually viral?

Answer 18

When signs / symptoms are persistent >10 days, with no improvement, or the symptoms are severe with purulent discharge / facial pain at least 3-4 days

Question 19

What is the therapy for sinusitis?

Answer 19

Same as outpatient COPD: amox/clav or Doxycycline

Question 20

What are “the big 6” of Community-Acquired pneumonia?

Answer 20

1. Streptococcus pneumoniae
2. Hemophilus influenzae
3. Moraxella cattarhalis
4. Mycoplasma pneumoniae
5. Chlamydia pneumoniae
6. Legionella pneumophilia

Question 21

What is given to healthy CA-pneumonia and high risk CA-pneumonia in outpatient therapy?

Answer 21

Previously healthy: azithromycin or doxycycline

High risk: beta-lactam + azithromycin or doxycycline

Question 22

For inpatient non-ICU CAP, what is the treatment?

Answer 22

Azithromycin or doxy + 3rd generation ceph, or respiratory fluoroquinolone

Question 23

For inpatient ICU CAP, what is the treatment?

Answer 23

Same drugs, but IV is necessary. Can add Vancomycin if concern for MRSA

Question 24

What is the treatment of choice for outpatient aspiration pneumonia?

Answer 24

Amoxicillin/clavulanic acid (good gram negative / anaerobe coverage)

Question 25

What is the treatment of choice for inpatient aspiration pneumonia?

Answer 25

Ampicillin / sulbactam (IV version of augmentin)

Question 26

What dictates the duration of therapy for community-acquired pneumonia?

Answer 26

Minimum of 5 days, must be afebrile for 48-72 hours, and no more than one “sign of instability”

1. Fever, leukocytosis, tachycardia, tachypnea

Question 27

What is the empiric therapy for HAP/HCAP/VAP?

Answer 27

1. Antipseudomonal beta-lactam
\+
2. Antipseudomonal FQ or aminoglycoside
\+
3. MRSA coverage: Vancomycin or linezolid

Question 28

What organism throws a wrench in your HAP/HCAP/VAP plans?

Answer 28

Acinetobacter baumanii -> resistant to many drugs

Typically you need tigecycline or polymyxins since it is gram negative

Question 29

What is the duration of therapy recommended for HAP bugs?

Answer 29

7 days, assuming initial response to drugs and no pseudomonas

Question 30

What should be done if the HAP is not MRSA? What should be done with pseudomonas?

Answer 30

Immediately discontinue vancomycin

Also de-escalate the anti-pseudomonal drugs to narrowest one possible

Question 31

How should you treat Stenotrophomonas maltophilia pneumonia?

Answer 31

TMP/SMX is the drug of choice

Question 32

Why do we give CF patients high dose antibiotics and often aerosolized antibiotics?

Answer 32

High dose - they metabolize the drugs super fast

Aerosolized - just want to suppress the infection, we aren’t gonna stop it entirely