[07.19] Drugs for Hepatobiliary Infections, Cholethiasis, Pancreatitis, and Variceal Bleeding V2.1.pdf

Fever and right upper quadrant (RUQ) pain

What two clinical symptoms are commonly shared between hepatic abscesses and gallbladder problems?

Hepatitis

In which condition is jaundice more frequently observed than in a liver abscess?

Obstructive jaundice

An elevation in alkaline phosphatase levels typically signifies which condition?

Gas bubbles within the liver

What specific finding on a plain film X-ray is indicative of a liver abscess?

Homogeneous

How is normal liver parenchyma expected to appear during an ultrasound examination?

Presence of a cavity

What is the primary characteristic of a liver abscess seen on an ultrasound?

Biliary tract

Approximately 50% of liver abscesses originate from infections in which anatomical system?

Hepatic artery

Through which vessel do bacteria from other parts of the body travel to form a liver abscess during bacteremia?

Portal vein

Infections from the abdominal area, such as diverticulitis, reach the liver via which vessel?

Solitary

Approximately 50% of patients with a liver abscess present with how many lesions?

Right hepatic lobe (75%)

Which lobe of the liver is most commonly affected by abscesses?

Right shoulder

Diaphragmatic irritation from a liver abscess may refer pain to which specific body part?

Pyogenic (80%)

What is the most common type of liver abscess based on origin?

Fungal

Which type of liver abscess is seen in less than 10% of cases, primarily in immunocompromised patients?

S. aureus and Streptococcus sp.

What are the two most common Gram-positive bacteria that cause liver abscesses in pediatric patients?

Klebsiella spp. and Enterobacteriaceae

What are the most frequent Gram-negative pathogens causing pyogenic liver abscesses in adults?

Salmonella

Which non-lactose fermenting Gram-negative rod is associated with liver abscesses?

100%

What is the estimated mortality rate for pyogenic liver abscesses (PLA) if left untreated?

5–30%

What is the mortality range for pyogenic liver abscesses when treatment is administered?

3rd generation cephalosporin and metronidazole

What is the recommended initial empiric antibiotic regimen for a suspected pyogenic liver abscess?

Unilocular abscess less than 3 cm

In which specific scenario of PLA is treatment with antibiotics alone considered sufficient?

Drainage or aspiration

What procedure is required, along with antibiotics, for a pyogenic liver abscess larger than 3 cm?

Surgery

What is the recommended management for a large, multilocular, or inaccessible liver abscess?

Abscesses larger than 5 cm or complex/ruptured abscesses

When is surgical drainage preferred over percutaneous needle aspiration?

Ampicillin-Sulbactam or Piperacillin-Tazobactam

Besides Ceftriaxone, what are two penicillin-based empiric options for pediatric pyogenic liver abscess?

Metronidazole

Which drug is added to a regimen specifically to provide coverage for anaerobic organisms?

Fluoroquinolones

Which class of bactericidal antibiotics should NOT be administered to pediatric patients?

Vancomycin, Fluoroquinolones, Penicillins, Aminoglycosides, and Metronidazole

What are the five drug classes listed as bactericidal (Very Finely Proficient At Murder)?

Erythromycin, Clindamycin, Sulfamethoxazole, Trimethoprim, Tetracycline, and Chloramphenicol

What are the six drug classes listed as bacteriostatic (ECSTaTiC)?

Pseudomembranous colitis and skin rashes

What are two specific adverse effects associated with Ampicillin use?

Seizures

Patients with renal failure taking Ampicillin or Carbapenems are at an increased risk for which condition?

Acute kidney injury

What is the potential risk of combining Piperacillin-Tazobactam with Vancomycin?

P. aeruginosa

Piperacillin is an anti-pseudomonal penicillin that provides greater Gram-negative coverage for which specific organism?

Ceftriaxone

Which 3rd generation cephalosporin may cause bile sludge in patients with jaundice or cirrhosis?

Inhibits peptidoglycan cross-linking

What is the mechanism of action of 3rd generation cephalosporins?

Ertapenem

Which carbapenem is appropriate for monotherapy in patients at high risk for resistant Gram-negative rods?

Imipenem/Cilastatin

Which carbapenem is reserved specifically for seriously ill patients?

Blocks DNA synthesis via inhibition of DNA gyrase and topoisomerase IV

What is the mechanism of action of Fluoroquinolones?

Tendonitis and Neurotoxicity

What are two adverse effects uniquely associated with Fluoroquinolones?

14–42 days

What is the typical total duration for the treatment of a liver abscess?

Takes a minimum of 2 weeks for drugs to penetrate the granuloma

Why is the duration of treatment for liver abscesses often prolonged?

Fecal-oral route

What is the transmission route for amoeba ingestion in the Philippines?

Lungs, liver, and brain

Besides the colon, in which three organs can amoeba produce extraintestinal abscesses?

Echinococcus granulosus

What parasitic cause of liver cysts is typically asymptomatic but treated with Albendazole or Mebendazole?

Albendazole

What is the drug of choice (DOC) and surgical adjunct for hydatid cysts caused by Echinococcus?

Metronidazole

What is the drug of choice for extraluminal and hepatic amebiasis?

Nitro group is reduced by anaerobic bacteria/protozoans to form unstable, cytotoxic intermediates

What is the mechanism of action of Metronidazole?

Metallic taste and stomatitis (inflammation of the tongue)

What are two characteristic adverse effects of Metronidazole?

Tinidazole

Which amebicide has a higher half-life and a simpler 3–5 day dosing regimen compared to Metronidazole?

Tioconazole

In the product Gynomax, Tinidazole is combined with which other drug for vaginal infections?

Binds to the 40S ribosomal subunit of the amoeba

What is the mechanism of action of Emetine and Dehydroemetine?

Cardiotoxicity (arrhythmias, heart failure)

Why is Emetine considered a treatment of last resort?

Metronidazole, Emetine, and Tinidazole

Which three drugs make up the "MEET" mnemonic for extraintestinal amebicides?

Kills free-floating trophozoites but not those lodged in tissues

What is the specific target of luminal amebicides?

Diloxanide furoate, Iodoquinol, and Paromomycin

Which three drugs make up the "DIP" mnemonic for luminal amebicides?

Diloxanide furoate

What is the drug of choice for asymptomatic luminal infections and cyst passers in the Philippines?

Iodoquinol

Which luminal amebicide is 90% retained in the intestine but is contraindicated in patients with thyroid disease or iodine sensitivity?

Optic neuritis and optic atrophy

What are two serious adverse effects of Iodoquinol?

Paromomycin

What is the drug of choice for luminal amebiasis in the USA?

Aminoglycoside that inhibits the 30S ribosomal subunit

What is the classification and mechanism of action of Paromomycin?

Age >55 years, Abscess >5 cm, or failure of medical therapy for 7 days

What are three predictors for the need for percutaneous aspiration of a liver abscess?

Binds to ergosterol, forming a pore and causing loss of potassium

What is the mechanism of action of Amphotericin B?

Amphotericin B

Which antifungal is not absorbed orally and has poor CNS penetration?

Inhibits ergosterol biosynthesis by inhibiting CYP P450

What is the mechanism of action of Fluconazole?

Fluconazole

Which antifungal has good CSF penetration and is used if an abscess involves the brain?

Charcot’s Triad

The presence of jaundice, RUQ pain, and fever indicates which condition?

Reynold’s Pentad

What term refers to Charcot’s triad plus hypotension and confusion?

Acute Suppurative Cholangitis

The presence of pus in the biliary ducts and Reynold's pentad signifies which condition?

Prevent surgical site infections (SSIs) and intrahepatic abscess formation

What are the two primary goals of antimicrobial therapy in acute cholangitis?

Biliary penetration

What drug property is critical when selecting an antimicrobial for biliary tract infections?

Flomoxef

Which 2nd generation oxacephem is used for biliary infections and has a significant post-antibiotic effect?

Respiratory depression

What unique adverse effect of Flomoxef requires monitoring during IV administration?

Pazufloxacin

Which fluoroquinolone is indicated for peritonitis and has two-fold greater activity against Enterobacteriaceae than other quinolones?

Interferes with penicillin-binding protein (PBP) activity

What is the mechanism of action of the 4th generation cephalosporin Cefozopran?

Acute acalculous cholecystitis

What condition presents as gallbladder infection without stones, often in severely ill patients?

Piperacillin-Tazobactam, Ampicillin-Sulbactam, or 3rd gen Cephalosporins

What are the preferred antibiotic regimens for acute acalculous cholecystitis in the Philippines?

Grade 1 (Mild)

Which Tokyo Guideline grade for cholecystitis involves no organ dysfunction?

Grade 2 (Moderate)

Which Tokyo Guideline grade is defined by WBC >18,000, a palpable mass, or duration >72 hours?

Grade 3 (Severe)

Which Tokyo Guideline grade involves cardiovascular, neurologic, or renal dysfunction?

Ertapenem

According to the 2018 Tokyo Guidelines, which carbapenem is used for Grade 1 and 2 community-acquired biliary infections?

Cefepime

What is the drug of choice for healthcare-associated biliary infections and Grade 3 infections?

4 to 7 days

What is the recommended treatment duration for Grade III severe cholangitis?

Upper abdominal pain that pierces through to the back

What is the characteristic clinical description of pain in acute pancreatitis?

Binge alcohol consumption

Which social activity is most commonly associated with a preceding acute pancreatitis attack?

Cullen’s sign

What is the term for periumbilical discoloration in severe necrotizing pancreatitis?

Grey-Turner sign

What is the term for reddish discoloration in the flanks?

Fluid resuscitation and nutritional support

What is the mainstay of treatment for all patients with acute pancreatitis?

Suspected pancreatic necrosis (gas in necrosis, persistent fever)

When are antibiotics indicated for acute pancreatitis?

Piperacillin-Tazobactam or Meropenem IV

What is the first-line antibiotic treatment for acute pancreatitis with suspected necrosis?

Ciprofloxacin or Levofloxacin plus Metronidazole

What is the second-line antibiotic treatment for acute pancreatitis?

Female, Fertile, Fat, Forty

What are the "4 Fs" representing the incidence of cholelithiasis?

Micelles

Bile acids solubilize lipids and fatty acids by forming what structures?

Ursodeoxycholic acid (UDCA)

Which tertiary bile acid comprises around 5% of circulating bile acids and is used for stone dissolution?

Radiolucent stones less than 10 mm

Medical dissolution therapy is considered in patients with a functional gallbladder and which type of stones?

6 months to 2 years

How long does it typically take to achieve complete gallstone dissolution with medical therapy?

30–50%

What is the risk of gallstone recurrence within 3–5 years after stopping medical dissolution therapy?

Reduces hepatic cholesterol secretion

What is the primary mechanism of action of Ursodeoxycholic acid?

Primary Biliary Cirrhosis

Ursodeoxycholic acid is the first-line treatment for which autoimmune biliary disease?

Obeticholic acid

Which synthetic derivative of chenodeoxycholic acid is a ligand for the nuclear farnesoid X receptor?

Severe pruritus

What is the most common adverse effect of Obeticholic acid seen in 25% of patients?