3: Treatment of Gram Negative Infections, Anaerobic Infections, and STDs

What are the first line drugs of choice for uncomplicated cystitis

#1 Bactrim BID x 3 days

Nitrofurantoin 100 mg BID x 5 days

Trimethroprim 100 mg BID x 3 days

Fosfomycin 3 gm packet mixed in water x 1 dose

TMP-SMX DS is only used for uncomplicated cystitis if local resistance rates are <

20%

What are the second line drugs of choice for uncomplicated cystitis

B lactam for 3-7 days (*esp in pregnancy)

What characterizes complicated cystitis

symptoms >7 days

abn anatomy

hx of renal stones, DM, pregnancy, presence of catheter

What is the treatment for pyelonephritis

For those with high fever and flank pain, usually admit for IV Abx and once afebrile for 2 days, transition to oral

What are the drugs of choice for pyelonephritis

Ciprofloxacin 500 mg BID x 7d

Levofloxacin x 5d

TMP-SMX DS BID x14 days (if pathogen susceptible)

What IV drug can you use for pyelonephritis

Ceftriaxone followed by 7-14 days of oral abx

What characterizes a complicated UTI

Occur in patients with indwelling urinary catheters or anatomic or functional abnormalities of the urinary tract - more likely caused by antibiotic-resistant Gram negative bacilli

What are the pathogens that cause complicated UTI's most often

S. aureus

Enterococci

What is the treatment for complicated UTIs

Ciprofloxacin or levofloxacin, can be used to treat such infections in outpatients

In hospitalized patients, we can treat complicated UTIs with

Cefepime, Ceftriaxone, Fluoroquinolone, OR Piperacillin PLUS ticarcillin

What characterizes a "chronic UTI"

>3 episodes of cystitis in a year

What is the treatment for chronic UTIs

low, once daily dose of TMP-SMX for 6M-1Y

What are the alternatives to Bactrim for chronic UTI prophylaxis

TMP alone if intolerant to SMX

Fluoroquinolones if bacteria resistance to TMP-SMX

NiNitrotrofurantoin

What side effects often occur with Nitrofurantoin

nausea more common so you must take with food

Nitrofurantoin is active against _____ in urine unlike other agents

enterococcus

_______ provide symptomatic relief of pain, urgency, burning, and frequency associated with lower urinary tract mucosal inflammation from infection

urinary analgesics

What are the 2 urinary analgesics we should know

Phenazopyridine (pyridium) 200 mg PO TID and Flavoxate 100-200 mg PO TID-QID

Phenazopyridine (Pyridium) causes what strange side effect

colors urine and clothes red-orange (available OTC)

Flavoxate (Urispas) causes ______ adverse effects

anticholinergic

Pathogens causing acute prostatitis are usually similar to those causing _____. What are the pathogens?

UTIs

E. coli, Proteus spp. and Klebsiella spp

How long is the therapy for acute prostatitis

4 weeks

What is the drug of choice for acute prostatitis

TMP-SMX

What is the drug of choice for acute prostatitis when bacteria are not sensitive to TMP-SMX

Fluoroquinolones (gram - bacteria)

_____ is a common cause of recurrent UTI in men

Chronic prostatitis

Chronic prostatitis inflammation is less than acute prostatitis. Would you give the same abx as for acute? How long?

Yes, use the same abx as for acute but must give for 6-12 weeks

What antibiotic would you use for chronic prostatitis

TMP-SMX first

Then fluoroquinolones

What are the typical gram negative bacteria that cause intra-abdominal infections

•Esherichia coli

•Klebsiella spp

•Proteus spp

•Also Pseudomonas aeruginosa if hospital-acquired

What type of bacteria typically causes intrabd infections

gram negative

What is the gram-positive bacteria that causes intra-abdominal infections

Enterococcus

_______ bacteria typically is what causes intra-abdominal abscess formation and outnumber gram-negative bacteria by ______ in the colon

Anaerobic

1000:1

What is a single agent with gram-positive/negative and anaerobic coverage (including enterococcus)

Piperacillin-tazobactam (Zosyn)

What is a single agent with gram-positive/negative and anaerobic coverage (not including enterococcus)

Doripenem

Doripenem is an imipenem derivative with longer _____

T 1/2

Doripenem is most resistant to ______ to _______

B-lactams to extended spectrum B lactamasese

What is a common anaerobic GI infection

Bacteroides fragilis (common bacterium in distal small bowel and colon)

What is a common anaerobic respiratory infection

Peptostreptococcus (can cause aspiration pneumonia from inhalation of upper GI bacterial flora)

What is a common anaerobic skin and soft tissue infection

C. perfringes (causative agent of gas gangrene)

What abx increase the risk for C. diff

clindamycin, tetracyclines and cephalosporins

For mild-moderate C. diff infection use

Oral metronidazole 500mg TID x 10-14 days (absorbed, but high concentrations reach colon)

For severe C. diff infection use

Oral vancomycin 125mg QID x 10-14 days (not absorbed, high concentrations in the colon)

For life threatening C. diff infection use

Oral vancomycin 500mg QID plus IV metronidazole 500mg TID x 10-14 days

What is the BEST agent for anaerobic infections

metronidazole

Metronidazole has excellent ____ penetration, esp CNS. It is rapidly bacterio____. It has local antiinflammatory activity in GI tract.

tissue

bacteriocidal

What are the other antibiotic agents to use for anaerobic infections

Clindamycin and Penicillin/B-lactamase inhibitor combos

What is used for Pseudomonas aeruginosa UTI

Cipro

What is used for Pseudomonas aeruginosa systemic infections

•Piperacillin/tazobactam +/- tobramycin

•Ceftazidime or cefepime +/- tobramycin

•Meropenem or doripenem +/- tobramycin

What is used for Pseudomonas aeruginosa pulmonary infections

•Same as above but add aminoglycoside

•Inhaled tobramycin also available for cystic fibrosis patients

Hospital acquired pneumonia is defined as

pneumonia that occurs 48 hrs or more after hosp admission or endotracheal intubation

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What are the two main treatments for Chlamydia

Azithromycin 1 gm x 1 dose or

Doxycycline 100mg PO bid x 7 days

What are alternative treatments for Chlamydia

•Erythromycin 500mg PO qid x 7 days

•Levofloxacin 500mg PO qd x 7 days

If you treat for gonorrhea, you don't even have to test for ____ because you are treating it anyways

chlamydia

What is the treatment for gonorrhea

Ceftriaxone 250 mg IM x 1 dose PLUS Azithromycin 1gm x 1 dose

OR Doxycycline 100mg BID x 7d

_______ or _____ are no longer recommended for gonorrhea due to high resistance rates

Fluoroquinolones or oral cephalosporins

PID is a polymicrobial infection possibly involving

Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobic bacteria, and gram negative bacteria

What is the outpatient treatment for PID

•Ceftriaxone 250 mg IM x 1 dose plus

•Doxycycline 100 mg bid x 14 days with or without

•Metronidazole 500 mg bid x 14 days

What is the intpatient treatment for PID

•Give IV until able to tolerate oral antibiotics

•Cefotetan 2 gm IV q12 hrs plus

•Doxycycline 100 mg IV q12 hrs

What are the pathogens causing nongonococcal urethritis

Ureaplasma urealyticum or Mycoplasma genitalium

What is the treatment for nongonococcal urethritis? what is the same as

Usually responds to azithromycin or doxycycline at same doses as for Chlamydia trachomatis

What is the treatment for trichomoniasis

Metronidazole 2 gm orally x 1 dose

What is the treatment for BV

•Metronidazole 500mg PO bid x 7 days

•Metronidazole gel 0.75% intravaginally qd x 5 days

What is the treatment for primary and secondary syphilis

Penicillin G benzathine 2.4 million units IM x 1 dose

What is the alternative for primary secondary syphilis if there is an allergy to penicillin

doxycycline 100 mg PO BID x 14 days

What is the treatment for tertiary syphillis

Penicillin G benzathine 2.4 million units IM weekly x 3 doses for tertiary infections

What is the treatment for neurosyphillis

High dose Penicillin G IV x 10-14 days