Week 1 Lectures: Limp, Asthma, Abx Flashcards
Main toxicity/side effect of
(a) Penicillins
(b) Augmentin
(c) Vancomycin
(d) Bactrum
Main toxicity
(a) Penicillin- anaphylaaxis in 1/1,000
(b) Augmentin- diarrhea
(c) Vancomycin- red man’s syndrome due to histamine release => need to slow down rate of infusion
(d) Bactrum side effect = bone marrow suppression
What does vanco coverage?
Vanco covers MRSA, staph, and Strep (all gram positive cocci)
Describe the two types of tx for asthma
Rescue:
- albuterol (short acting beta agonist)
- oral corticosteroid
Controllers
- inhaled corticosteroids
- leukotriene inhibitors (Montelukast)
What can amox be used in combination w/ for Enterococcal infxn coverage
Amox + aminoglycosides (ex: gentamicin) for enterococcal coverage
Which of the 3rd gen cephalosporins covers pseudomonas
Only one: Ceftazidime
NOT Cafotaxime or Ceftriaxone
Pt has AKI on Vancomycin, what are they switched to next?
(a) Why is this drug second line
Assuming Vanco is used for coverage of MRSA (ex: MRSA cellulitis/abscess)
-side effect of Vanco = AKI => switch to Linezolid
(a) Linezolid is second line b/c it’s so expensive
Indications for trimethoprim/sulfa
Bactrim
- outpatient MRSA coverage after transition off IV Vanco: cellulitis
- UTI b/c covers E. Coli
Which abx can cause eosinophilia?
Macrolides: erythromycin/azithromycin
Indication for Daptomycin
VRSE = Vanco resistant staph species
Juvenile Idiopathic Arthritis
a) Indication of ANA (+
(b) When is RF sent?
JIA
(a) ANA (+) predicts higher risk for anterior uveitis
(b) Send RF in older children w/ poly-arthritis
Why is bactrum a great drug?
Bactrum = TMP + SMX (both folic acid synthesis inhibitors) is great b/c it covers for MRSA and is oral => can be given outpatient
Features of septic arthritis
Septic arthritis
- refusal to bear weight
- febrile
- ill-appearing
- worse at night
- autonomic instability: tachy, tachypnic, resting position of the limb is w/ hip abducted
What to use in an acute asthma exacerbation where albuterol isn’t enough
Systemic (oral/IV) corticosteroids
Describe proposed pathophysiology of Henoch Schonlein Purpura
IgA vasculopathy
-IgA deposition
Supportive biopsy of affected organ (ex: skin, kidney) shows IgA deposition
Rash + limp + episodic severe belly pain + patches of purple raised skin over legs and but
HSP = Henoch Shonlein Purpura
-immunoglobulin A vasculitis (IgA deposition)
- rash = non-thrombocytopenic (normal platelet count) purpura
- limp b/c of arthralgia/arthritis = swollen ankle
- episodic severe belly pain- ileoileal intussusception
Common side effects of albuterol in children
Kids get very hyper/jumpy
-anxiety, palpitations, tremor, headache
CC: Limp + knee pain
-worse at night, ill-appearing, febrile to 104, carried into the ER
Septic arthritis
- unable to weight bear => carried in
- knee pain due to referred hip pain
Define SIRS
Autonomic instability + elevated white count
SIRS = systemic inflammatory response syndrome
First line tx for mild persistent asthma
Mild persistent asthma tx
test answer = low dose inhaled corticosteroid
-real life: often try leukotriene inhibitor (montelukast) first b/c simple small QD chewable
+ SABA PRN (for all asthmatics)
First line tx for intermittent asthma
Intermittent asthma: tx w/ SABA (albuterol) for symptom control
Petechiae + Limp
Leukemia
Dangerous side effects of albuterol
Sudden death: 2 causes
- cardiac: arrhythmia
- airway plug: build up of underlying mucous/inflammation
Which abx do we give to GBS (+) moms who are allergic to Penicilin
Azithromycin (Macrolide)
-wouldn’t give Amox b/c that’s a type of Penicillin!!
Cefepime
(a) Coverage
(b) What doesn’t it cover?
(c) Main indication
Cefepime = 4th gen cephalosporin
(a) G(+) activity of 1st gens + G(-) activity of 2nd gens = the big guns!!!
(b) BUT no anaerobe or MRSA coverage
(c) Indication = fever in neutropenic pt
2 Oral abx for C. dif
Oral Vancomycin OR metronidazole (Flagyl)
Do asthma pts have to stay on controllers for their entire life?
Controllers are just that, just controllers (not a cure) => only work while the pt is on them
-work to prevent fibrosis/scaring
Indication for PenG
Syphilis
-b/c most strep is now resistant
Which abx causes Red Man Syndrome?
(a) What is Red Man Syndrome?
(b) How do we prevent this
Red Man Syndrome = chills, fever, phlebitis (venous inflammation), ototoxicity, nephrotoxicity
-due to Vanco b/c of the way Vanco is made that it causes histamine release throughout the body
(a) Histamine release during infusion =>
(b) Have to really spread out Vanco doses, infuse slowly to prevent Red Man Syndrome
Juvenile Idiopathic Arthritis
(a) gender
(b) asymmetric or symmetrical?
(c) acute or gradual onset?
(d) constitutional symptoms?
Juvenile Idiopathic Arthritis
(a) F > M
(b) symmetrical
(c) gradual onset- usually indolent until infection precipitates dramatic increase in symptoms
(d) Constitutional symptoms (fever etc) usually not present
Why don’t you want to keep asthmatics on chronic oral corticosteroids?
Side effects of steroids
- weight gain (moon face)
- immunosuppression
- growth suppression (so super bad for kids!!)
- aseptic necrosis of femoral head + osteonecrosis
- suppressed HPA => knock out the adrenal gland’s response to stress
Define SIRS: 2 out of 4 criteria
SIRS = presence of 2+
-temp > 38.5 or
What would you add to Cefepime to cover for
(a) MRSA
(b) anerobes
Add to Cefepime to cover
(a) MRSA = add Vanco
(b) Anerobes- add Flagil
Define asthma
Chronic inflammatory disease of the lungs
Aminoglycosides
Give examples
(a) reversible toxicity
(b) irreversible toxicity
Aminoglycosides = Gentamycin, Tobramycin
(a) Reversible toxicity = renal
(b) Irreversible toxicity = ototoxicity
Abx coverage for GBS Sepsis in newborn
First line = Ampicillin
Second line = Cephalosporin- Cefotaxime (NOT Ceftriaxone in newborns b/c of biliary sludging)
Why is septic arthritis a medical emergency
Can see permanent joint damage in just 24-48 hours
Why albuterol shouldn’t be used as controller?
Tolerance- beta2 receptor downregulation
Not treating the underlying cause
- risk of sudden death: arrhythmia, airway plug (inflammation, mucus builds up and plugs airway)
- SE of albuterol: anxiety, palpitations, tremor, headache, very hyper kid
Physical exam findings of septic arthritis
(a) specific physical exam maneuver
- Can’t palpate b/c of intense guarding and pain
- swollen hip
(a) painful FABER test: flexed, ab-ducted, externally rotated (frog legged position)
Most common systemic vasculitis of childhood
(a) Second most common childhood vasculitis
Henoch Schonlein Purpura
-immunoglobulin A vasculitis
(a) Second most common childhood vasculitis = Kawasaki (fever syndrome)
How is asthma severity classified?
NIH classifies asthma severity by frequency of symptoms
Symptoms no more than 2 days/week w/ 2 or fewer nighttime awakenings/month = Intermittent asthma
Then symptoms > 2 days/week = Persistent
Mild Persistent = symptoms > 2 days/week but not daily
-nighttime awakening 1-4x/month
Moderate Persistent = symptoms daily, nighttime awakening > 1/week but not nightly
Severe Persistent = symptoms throughout the day, often every night
Side effects of cephalosporins
- diarrhea
- C. diff risk
- possible thrombocytopenia and neutrocytopenia b/c can affect bone marrow
Which gen cephalosporins are great for sinus infections
2nd gen cephalosporins have great coverage of skin (staph) and respiratory flora (H. flu, moraxella catarrhalis, E. Coli, Klebsiella) => good for sinus infections
-also better CNS penetration than 1st gen
2 methods by which children can use albuterol inhaler
Spacer: takes just one minute
Nebulizer: takes about 15 minutes
What is chromolyn?
(a) Why is it second line in asthma tx?
Cromolyn = mast cell stabilizer- prevents release of inflammatory chemicals (ex: histamine) from mast cells
(a) However, second line to montelukast b/c it has to be inhaled (not oral) 3-4 x/day
- while montelukast (singulair) is a nice tasty small chewable tablet once a day)
Which cephalosporin needs to be avoided in children under 1 moa?
Avoid ceftriaxone in children under 1 moa- use Cefotaxime (also a 3rd gen cephalosporin) instead
Which abx does ortho love
Clindamycin (in its own class)
-b/c achieves high levels in bone
Most common bug for osteomyelitis
Staphhhhhh (usually MSSA)
Common pathway by which triggers cause asthma
Mast cell degranulation releasing: histamine, cytokines, leukotrienes
Release of these 3 inflammatory mediators => inflammation of lung parenchyma
Differentiate the coverage of 3 types of penicillins
(a) Natural penicillins
(b) Aminopenicillins
(c) Nafcillin
3 types of penicillin
(a) Penicillin- covers strep and E. Coli
(b) Ampicillin (PO) and Amoxicillin (IV) cover
(c) Very narrow spectrum = Nafcillin and Oxacillin- resistant to penicillinase (beta-lactamase) produced by Staph aureus => can treat MSSA
- works for MSSA and Strep, NOT MRSA
CC: limp
- right knee warm, swollen, LROM w/ atrophy of thigh
- ^ same for left ankle
- no fever, play is ok, lasting months
Juvenile Idiopathic Arthritis (JIA)
-arthritis in 4+ joints
Tetrad of Henoch Schonlein Purpura and the clinical manifestations they cause
HSP
(1) Abdominal pain- mild (N/V/D) to severe (GI hemorrhage, ileoileal intussecption)
(2) Palpable purpura w/o thrombocytopenia or coagulopathy
- purpura w/ normal platelet count
(3) Arthralgia and/or arthritis
- can present w/ limp or limb/joint pain
(4) Renal disease- IgA deposition glomerulonephritis
- can cause pedal edema
MRSA
(a) Resistant to what
(b) Sensitive to what
MRSA
(a) Resistant to penicillins (and amox) and beta-lactams (including all generation cephalosporins, aztreonma, meropenem, sulbactam)
(b) Sensitive to vancomycin (inhibits cell wall synthesis) and Linezolid (inhibits protein synthesis)
Empiric abx coverage for bacterial meningitis in neonate
Ampicillin + Cefotaxime
Ampicillin: covers GBS and LIsteria
Cefotaxime covers E. Coli
Fever + vomiting in a baby
Think UTI
What are 5 common asthma triggers
- allergens- dust, pets, mold, rodents
- environmental irritants- cigarette smoke, pollution, any noxious smell
- exercise
- weather- change in temperature/pressure
- URI (most common!)
1st line outpt treat for pneumonia in 5-15 yo pt
Most likely mycoplasma: first line Azithromycin (macrolide)
When untreated, distinguish how often each of the 4 severity classifications of asthmatics use their rescue inhaler
Frequency of SABA use
-2 or less days/week = intermittent
- > 2 days/week but not daily = mild persistent
- daily = moderate persistent
- several times per day = severe persistent
First line tx for severe persistent asthma
Severe persistent asthma tx = high dose inhaled corticosteroids
Any adjunct:
- Montelukast
- LABA
- SABA for PRN
Which beta lactamase inhibitor combinations are
(a) PO
(b) IV
Beta lactamase inhibitor combinations
(a) Only Augmentin (Amox + Clavulanate) is PO
(b) Unasyn, Timentin, and Zosyn are all IV
But aren’t inhaled corticosteroids still just steroids…?
3 ways by which inhaled corticosteroids could get into the bloodstream
B/c inhaled are targeted (and not just systemic and hoping for some to get to the lungs) those dose is MUCH lower
- to avoid absorption directly into buccal mucosa pts are told to rinse out mouth/drink water after taking it
- to avoid a little bit from getting digested if swallowed, all are 99% biodegradable so the bit that gets to the stomach gets degraded before absorbed into circulation thru liver
- lung tissue: can’t avoid getting washed away into pulm circulation but dose is so low => no bone defects
Lab findings of septic arthritis
- Leukocytosis (elevated whites) w/ left shift
- elevated CRP (associated w/ inflammation)
Common side effects of penicillins
Hives (hypersensitivity rxn), diarrhea (especially amp/amox), neutropenia (in PenG and Nafcillin)
First line tx for moderate persistent asthma
Moderate persistent asthma tx = moderate dose inhaled corticosteroid
Adjuncts:
- Montelukast
- long acting beta-agonist
- SABA for PRN (all asthmatics)
Indications for beta lactamase inhibitor combination
- MSSA
- Strep
- E. coli
- GNR
- Psuedomonas (for Timentin and Zosyn, NOT Augmentin and Unasyn)
- Anaerobes
What measurement can be used to chart/track an asthmatics lung fxn?
FEV1 = forced expiratory volume in one second
How may 2 significant asthmatic episodes w/in 6 months affect one’s treatment?
2 significant episodes (ex: need prednisone course in hospital) in 6 mo bumps up the classification of severity above daily symptoms
First line tx for osteomyelitis
Osteomyelitis
First line = Nafcillin- great staph coverage (MSSA)
What is theophylline?
(a) Why is it second line in asthma tx?
Theophylline = phosphodiesterase inhibitor => raises intracellular cAMP to inhibit TNF-alpha and inhibit leukotriene synthesis
=> good anti-inflammatory
(a) Second line b/c very narrow therapeutic index
- used in adults w/ COPD
Workup (after abx coverage) for UTI in pt under 2 yoa
Check for anatomic anomaly that may have led to UTI => get renal ultrasound
- hydronephrosis
- abscess
- VUR = vesico-urethral reflex
Which abx are the
(a) big guns
(b) super huge big guns
Abx
(a) Big guns = Cefepime = 4th gen cephalosporin
- covers G(+) but MRSA, covers G(-), doesn’t cover anaerobes
(b) Super huge big guns = Imipenem and Meropenem: only given inpatient: broad spectrum against GNR, GPC (gram positive cocci) AND anaerobes
How are LABAs given to children?
(a) Efficacy of this method
LABAs given in combo w/ inhaled corticosteroids
ex: Symbicort and Advair
(a) LABAs act slowly => nice 12 hour curve of bronchodilation, but also have a synergistic effect when used as adjunct to inhaled corticosteroid
Why get abdominal ultrasound on kid w/ presenting w/ purpura + joint swelling + limp
Purpura, joint swelling, limp- think HSP (Henoch Schonlein Purpura)
-get abdominal US for possible ileal-ileal intussusception
Pallor + weight loss + limp + cervical lymphadenopathy
Acute lymphocytic leukemia
- MSK presentation is common
- pallor due to anemia
- also see petechiae b/c of thrombocytopenia
Meningitis buzzword
Lethargy
Z-pack
(a) Coverage
= Azithromycin (macrolide)
(a) Coverage
- atypical pneumonia: Chlamydia, Mycoplasma, Legionella
- pertussis
- GAS in penicillin allergic pts
Kid wakes up at night w/ MSK pain, alleviated w/ massage and is normal the next day on the playground
-normal physical exam
Benign growing pains
- nighttime wakening but no symptoms during the day
- normal physical exam
JIA
(a) one aggravating factor
(b) one alleviating factor
JIA
(a) Worse in the morning
(b) Better w/ NSAIDs
Describe the use of the following in pediatric asthmatics
(a) anti-histamines
(b) anti-cytokines
Pediatric asthma: targeting the 3 inflammatory factors released by degranulatied mast cells
(a) anti-histamines: not helpful
(b) anti-cytokines: helpful, in clinical trials
go to = anti-leukotriene
Main side effect of imipenem and meropenem
Renal failure- almost all pts who take imipenem and meropenem will go into AKI
Beta lactamase inhibitor combination
(a) Augmentin
(b) Unasyn
(c) Timentin
(d) Zosyn
Beta lactamase inhibitor combinations
(a) Augmentin (PO) = amoxicillin/calvulanate (PO
- amox = broad spectrum penicillin
- calvulanate = beta-lactamase inhibitor
(b) Unasyn (IV) = Ampicillin/sulbactam
(c) Timentin (IV) = ticarcillin/clavulanate
(d) Zosyn (IV) = Piperacillin/ tazobactam
What is Cephalexin (Keflex)?
(a) Indications
Cephalexin = first gen cephalosporin => good G(+) w/ poor G(-) coverage
(a) UTI (E. coli coverage) and soft tissue infxn (big indication = cellulitis)
Features of growing pain
(a) Physical exam findings
(b) Limp
(c) Day vs. night
Growing pains
Features present:
- nocturnal wakening
- lasts months
(a) Always normal physical exam w/ normal labs and imaging
(b) No limp
(c) Never have daytime symptoms, but have nocturnal wakening
- no joint welling
Differentiate ampicillin and amoxicillin
Same thing- both broad spectrum penicillins
-cover strep, E. coli, and GNR (salmonella, shigella, enterobacter = proteus)
But: ampicillin is PO and amoxicillin is IV
Beta lactam coverage of
(a) Strep
(b) E. coli
(c) Pseudomonas
(d) MRSA
Beta lactam coverage of
(a) Strep = penicillin
(b) E. coli = amoxicillin
(c) Pseudomonas = Zosyn- combination of Piperacillin (antipseudomonal penicillin) + Tazobactam (beta-lactamase inhibitor)
(d) MRSA- none! can’t use beta lactams against MRSA
Indications for Linezolid
Multi-drug resistant bacteria: VRE, MRSA
- PO and IV
- CRAZY EXPENSIVE $$$
Side effects of aminoglycosides
Gentamycin = aminoglycoside
- irreversible ototoxicity
- very narrow therapeutic index => need to measure peaks and troughs
