ID 2 - disease states (NAPLEX)

Perioperative ABX for cardiac/vascular, or orthopedic surgery **

Cefazolin 1g 60 min prior

ALT: clindamycin or vancomycin

Perioperative ABX for GI surgery ***

Cefazolin+flagyl, cefotetan, cefoxitin, or unasyn

In what patients should listeria be covered in meningitis? (3)

Neonates

>50 yo

Immunocompromised

Meningitis TX (all 3 groups)

<1 month:

Ampicillin (listeria) + ceftazidime/cefepime +/- gentamicin

1 month-50 years:

Ceftraixone 2 g + vancomycin

>50 years or immunocompromised:

Ampicillin + ceftriaxone 2g + vancomycin

Why, when, and what dose is dexamethasone given in meningitis?

Prevent neurological outcomes like hearing loss

15-20 minutes before or at the SAME time as first ABX dose

Dose: 0.15mg/kg q6h IV

Can you use ceftriaxone for meningits in neonates?

NO - can cause biliary sludging and kernicterus

What is AOM?

Acute otitis media - upper respiratory tract infection most common in children

AOM SXS (5)

Bulging tympanic (eardrum)

Otorrhea (middle ear fluid)

Otalgia (ear pain)

Fever

Tugging/rubbing ears

Most common bugs with AOM (3)

Strep pneumo

H influenzae

Moraxella catarrhalis

When is AOM observation indicated? **know (study gal)

can observe for 48-72 hours if:

Otalgia <48 hours, no otorrhea, temp <102.2 AND:

• Age 6-23 months: sx only in one ear

• Age >2: sx in one or both ears

If sx worsen or no improvement can start ABX

AOM antibiotic TX + duration * know all :(

Amoxicillin 90 mg/kg/day or Augmentin 90 mg/kg/day

Alternative: CTX, cefdinir, etc.

Duration 10 days if <2 yo

TX failure if no improvement after 2-3 days:

Ceftriaxone 50 mg/kg IM QD x 3 days

Pharyngitis (strep throat) bug (1)

Strep pyogenes (Group A strep)

Pharyngitis (strep throat) diagnosis & TX (1+1)

Rapid antigen test (tonsil swab)

Penicillin or amoxicillin

Acute sinusitis criteria for TX (2)

≥10 days of persistent symptoms OR

≥3 days of severe symptoms (face pain, nasal discharge, temp >102)

Acute sinusitis TX (1)

Augmentin

COPD exacerbation TX options (3) + duration

Augmentin

Azithromycin

Doxycycline

5-7 days

TB bug (1)

Myobacterium tuberculosis (aerobic, non-spore forming bacillus)

What is the difference between latent vs active TB?

Latent: has infection but no symptoms

Active: highly contagious, cough, hempotysis, fever, etc

What isolation is recommended for TB?

Single negative pressure room + respirator mask (N95)

TB diagnosis tests (2)

TST (TB Skin Test) - skin test

IGRA (Interferon gamma release assay) - blood test

LATENT TB TX (4) ** know all :(

1. INH + rifapentine once weekly x 12 weeks by directly observed therapy (dont use in pregnant pts due to unknown effects with rifapentine)

2. INH + rifampin QD x 3m (can use in preg)

3. Rifampin QD x 4m (can use in preg)

4. INH 300 mg QD x 6-9m (can use in preg and preferred in HIV positive)

What does the CXR show in a pt with active TB?

consolidation or cavitation (empty space)

ACTIVE TB TX (intensive vs. continuation phases) *

INTENSIVE PHASE:

Rifampin + isoniazid + pyrazinamide + ethambutol (RIPE)

QD or 5x week by DOT x2 MONTHS.

CONTINUATION PHASE:

Isoniazid + rifampin

QD or 5x week by DOT x4 MONTHS

Rifampin adverse effects (4)

Orange-red discoloration of body secretions

anemia (+coombs test)

increased LFT's

flu-like syndrome

Rifampin DDI (3)

CYP3A4 inducer decreasing concentration of:

Protease inhibitors

Warfarin (dec INR)

Oral contraceptives (dec efficacy)

Dont use any blood thinners

Isoniazid BW (1)

Severe and fatal hepatitis

Isoniazid adverse effects (4)

peripheral neuropathy

increased LFT's

drug induced lupus erythematosus

anemia (+coombs test)

What vitamin is taken with isoniazid & what dose?

Pyridoxine (vit B6) 25-50mg daily

In what patients is pyrazinamide contraindicated in? (1)

GOUT due to increased uric acid

What drug causes vision damage & requires baseline & monthly vision tests?

Ethambutol for TB

Ethambutol adverse effects (4)

Optic neuritis (dose dependent)

Increased LFT's

Confusion

Hallucinations

Bugs causing IE (3)

staph, strep, enterocci

Gentamicin for IE peak & trough goals

Peak 3-4

trough <1

IE TX duration

4-6 weeks of IV ABX

Why might rifampin be added in IE?

Rifampin can treat organisms in a biofilm which can develop esp on prosthetic valves

IE dental ppx (1+2)

amoxicillin 2 g PO once 30-60 mins before procedure

Allergy: azithromycin 500 or doxycycline 100

Used in patients needed like a root canal with select cardiac conditions

SBP ascitic fluid with ≥____ PMNS

250

SBP TX vs PPX

TX: Ceftriaxone x 5-7d

PPX: bactrim or cipro

SSTI systemic signs (3)

Temp >100.4

HR >90

WBC >12,000 or <4,000

SSTI mild vs mod vs severe

Mild: no systemic sxs

Moderate: systemic sxs

Severe: systemic sxs or fluid blister, hypotension, immunocompromised, failed ABX and I/D

What SSTI causes honey covered crusts?

Imeptigo

Impetigo TX

Localized lesions: topical mupirocin

Numerous lesions: Cephalexin PO

Furuncle TX

Bactrim or doxy

Non-purulent cellulitis TX (1)

Cephalexin

Abscess purulent TX (2)

Bactrim or doxy

Severe purulent SSTI TX options (3)

Vanc, dapto, linezolid

Necrotizing fascitis TX

Surgical debridement

Vanc or dapto + zosyn + clinda

Diabetic foot infection duration

No bone involvement: 2-4 weeks

OM: 4-6 weeks

Amputation: 2-5 days with no residual infection

Nitrofurantoin dosing UTI

Macrobid 100 mg PO BID x 5 days

Bactrim dosing UTI

SMX/TMP DS 1 tab PO BID x 3 days

UTI bugs (5)

E coli

Proteus

Klebsiella

Strep

Enterocci

Phenazopyridine indication

Helps with pain/burning with urination but does not treat infection

Phenazopyridine dosing

200 mg PO TID x 2 days (max)

Take with 8 oz of water with food to miniimze GI effects

Max duration of phenazopyridine

2 days

What medication can cause red-orange coloring?

Phenazopyridine (azo)

Diagnosis of asymptomatic bacturia

≥10^5 bacteria on UA

T/F: you should always treat asymptomatic bacteriuria in pregnancy

TRUE

Asymptomatic bacteruria TX

Augmentin or cephalexin

CDI symptoms (4)

≥3 watery stools per day

Abdominal cramps

Fever

Elevated WBC

Drug causes of C Diff

PPI's

ABX

CDI TX ***

1st episode:

• FDX 200 BID x 10d

• VAN 125 QID x 10d

2nd episode:

• above + prolonged pulse/taper of VAN

3rd or subsequent episodes:

• above

• or VAN followed by rifaximin 400 TID x 20d

• Fecal microbota

Fulminant (hyptension, shock, toxic megacolon)

• VAN 500 PO/NG/PR QID + flagyl 500 mg IV q8hr

DoxyPEP for STI's

Doxycycline 200 mg ONCE within 72 hrs of sexual activity

Men sex with men, hx of ≥1 STI

Syphilis TX *

Primary, sec, or early latent:

• Pen G (Bicillin L-A) 2.4 million units IM x 1

• Allergy: doxy x 14d

Teritary or late latent:

• Pen G (Bicillin L-A) 2.4 million units IM weekly x 3w

• Allergy: doxy x28d

what is syphilis penicillin desensitization?

• For pregnant patients who are allergic to PCN and can't take the alternative doxy due to fetal harm or a patient who would have poor adherance to doxy

• Confirm allergy with a skin test!

syphilis bug

treponema palidium spirochete

What are you thinking if a treponemal test is positive?

Syphilis

Neurosyphilis TX

Pen G aqueous IV x 10-14d

Gonorrhea TX

<150 kg: CTX 500 mg IM x 1

≥150 kg: CTX 1g IM x 1

Chlamydia TX

Doxy 100 mg BID x 7d

Pregnant: zithromax 1g x1

BV TX (2)

Metronidazole 500mg BID x 7d

Metronidazole 0.75% gel x5d

BV symptoms (3)

Discharge (grey, white, clear)

Fishy odor

pH >7.5

Trich TX

Metronidazole 500 mg BID x7d

- Males: 2g x1

T/F: CDC recommends flagyl for trich in all trimesters during pregnancy

TRUE even though per package insert it is contraindicated during first trimester

Genital warts TX

Imiquimod cream

Vaginal candidasis TX

fluconazole 150 mg PO x1

Rock mountain spotted fever TX

Doxy

- even in peds its the DOC

lyme disease TX

doxy

Azithromycin is not a preferred CAP OP in healthy pts without comorbidites if local pneumococcal resistance >____%

>25%

Can aztreonam be used as monotherapy in CAP?

NO - it can be used in HAP if combine with a gram + ABX like vanc

most common bacteria in meningitis

neisseria meningitidis
strep pneumo

haemophilus influenzae