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: have disease 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 :(

INH + rifapentine weekly for 12 weeks - no pregnancy

INH + rifampin daily for 3 months

Rifampin daily for 4 months

INH 300mg daily for 6-9 months - preferred HIV

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

consolidation or cavitation (empty space)

ACTIVE TB TX (intensive vs. continuation phases) *

Intensive:

Rifampin + isoniazid + pyrazinamide + ethambutol (RIPE)

daily or 5x a week for 2 MONTHS.

Continuation:

rifampin + isoniazid

daily or 5x week for 4 MONTHS

Rifampin adverse effects (4)

Orange-red discoloration of body secretions

increased LFTs

anemia (+coombs test)

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 LFTs

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 - increases uric acid levels

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

Ethambutol for TB

Ethambutol adverse effects (4)

Optic neuritis (dose dependent)

Increased LFTs

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?

can treat organisms in a biofilm that can develop esp on prosthetic valves

IE dental ppx (1+2)

amoxicillin 2g once 30-60 mins before procedure

Allergy: azithromycin 500 or doxycycline 100

Used in patients needed a root canal with select cardiac conditions

SBP ascitic fluid with ≥____ PMNS

250

SBP TX vs PPX

TX: Ceftriaxone for 5-7 days

PPX: bactrim or cipro

SSTI systemic signs (3)

Temp >100.4

HR >90

WBC >12000 or <4000

SSTI mild vs mod vs severe

Mild: no systemic sx

Moderate: systemic sx

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

What SSTI causes honey covered crusts?

Impetigo

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)

Vanco, dapto, linezolid

Necrotizing fascitis TX

Surgical debridement

Vanco 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 100mg BID x 5 days

Bactrim dosing UTI

SMX/TMP DS 1 tab BID x3 days

UTI bugs (5)

EPKSE

E coli

Proteus

Klebsiella

Strep

Enterocci

Phenazopyridine indication

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

Phenazopyridine dosing

200mg TID x2 days (max)

Take with 8oz of water and food to decrease GI upset

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 cramping

Fever

Elevated WBC

Drug causes of C Diff

PPI

ABX

CDI TX ***

first episode:

FDX 200 BID x10 days

vanco 125 QID x10 days

second episode:

above + prolonged pulse/taper of vanco

third or subsequent episodes:

above

or vanco followed by rifaximin 400 TID x20 days

Fecal microbota

Fulminant (hypotension, shock, toxic megacolon)

vanco 500 PO/NG/PR QID + flagyl 500 mg IV q8hr

DoxyPEP for STI's

Doxycycline 200mg ONCE within 72 hrs of sexual activity

Men sex with men, hx of >1 STI

Syphilis TX *

Primary, sec, early latent:

Bicillin LA 2.4 million units IM x 1 dose

Allergy: doxycycline x14 days

Tertiary or late latent:

Bicillin LA 2.4 million units IM weekly x 3 weeks

Allergy: doxycycline x28 days

what is syphilis penicillin desensitization?

For pregnant patients with an allergy to PCN who cant take doxy or a patient who would have poor adherence

Confirm allergy with a skin test!

What are you thinking if a treponemal test is positive?

Syphilis

Neurosyphilis TX

Pen G aqueous IV for 10-14 days

Gonorrhea TX

<150kg: CTX 500mg IM x1

>150kg: CTX 1g IM x1

Chlamydia TX

Doxycycline 100mg BID x7 days

Pregnant: azithromycin 1g once

bacterial vaginosis TX (2)

Metronidazole 500mg BID x7 days

Metronidazole 0.75% gel x5 days

bacterial vaginosis symptoms (3)

Discharge (grey, white, clear)

Fishy odor

pH >7.5

trichomoniasis TX

Metronidazole 500mg BID x7 days

Men: metronidazole 2g once

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

TRUE

Genital warts TX

Imiquimod cream

Vaginal candidasis TX

fluconazole 150mg once

Rock mountain spotted fever TX

Doxycycline

DOC even in peds

lyme disease TX

doxycycline

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 - can be used in HAP if combined with a gram positive ABX like vanco

most common bacteria in meningitis

neisseria meningitidis

strep pneumo

h influenzae

CAP bacteria

strep pneumo
h influenzae
mycoplasma pneumoniae

CAP duration of treatment

5-7 days

CAP empiric regimen in health patients:

amoxicillin high dose

doxycycline

macrolide (if resistance <25%)

CAP empiric treatment in high risk individuals:

beta-lactam + macrolide or doxycycline

respiratory quinolone monotherapy (moxi or levo)

comorbidities in CAP (5)

chronic heart, lung, liver, or renal disease

DM

AUD

malignancy

asplenia

non-severe inpatient CAP treatment

beta lactam + macrolide or doxycycline

respiratory quinolone monotherapy

preferred beta lactam: ceftriaxone or unasyn

severe CAP inpatient treatment

beta lactam + macrolide
beta lactam + respiratory quinolone

Never quinolone monotherapy

Psuedomonas and/or MRSA (risk factors): ABX

MRSA (prior isolation or positive nasal swab): vanco or linezolid

Pseudomonas (prior isolation): Zosyn, cefepime, meropenem

what to do if a patient was hospitalized and on parenteral antibiotics in the last 90 days?

regimen should cover MRSA and Pseudomonas

HAP pseudomonas and MSSA ABX (3)

cefepime

zosyn

levofloxacin

HAP MRSA ABX

vanco or linezolid

ABX for Pseudomonas if risk for MDR gram-negative pathogens

ABX use in last 90 days, >10% hospital prevalence, hospitalized >5 days

Zosyn + cipro + vanco

cefepime + gent + linezolid

Pseudomonas ABX (4)

beta lactams: Zosyn, cefepime, ceftazidime, imipenem/cilastatin, meropenem

levo or cipro

aztreonam

aminoglycosides

acute cystitis treatment

nitrofurantoin 100mg BID x5

SMX/TMP DS BID x3

fosfomycin 3g x1 dose

acute pyelonephritis treatment

local quinolone resistance <10%:

cipro or levo

local quinolone resistance >10%

CTX, ertapenem, aminoglycoside IV/IM x1 then quinolone

what should be used in acute pyelonephritis is ESBL-producing organism suspected?

carbapenem