PharmTher II - Ortho Infxn - Quizzam 3

1st

what generation of cephalosporins have the best staph coverage?

Osteomyelitis Tx Goals

-Resolution of infxn -> cure rates for acute osteomyelitis >80% when abx are given 4-6 wks AND Surg intervention occurs

-Prevention of long-term comp -> recurrent chronic infxn, amputation

Antimicrobial Therapy - Osteomyelitis Infxn

-empiric selection dictated by gram staining or probable infecting pathogens

-initial therapy should be given intravenously

-definitive therapy should be based on the identity/susceptibility of the bacteria ID'd in synovial fluid, blood, and/or ancillary cultures

Surgical Intervention - Osteomyelitis

-may include debridement, amputation, removal of prosthetic hardware

-prolonged antimicrobial therapy is usually required when surgical intervention is not an option or all infected tissue cannot be removed

intravenous

initial abx therapy should be given via what route?

Anti=staph agent AND 3rd/4th Gen Cephalosporin (no ceftriaxone)

what is the empiric antimicrobial therapy for a neonate with a hematogenous ortho infxn?

antistaph agent OR clindamycin

what is the empiric antimicrobial therapy for a pre-pubertal child with a hematogenous ortho infxn?

Antistaph agent AND 3rd/4th gen cephalosporin

what is the empiric antimicrobial therapy for an elderly person with a hematogenous ortho infxn?

Empiric Abx Therapy - Adults >50 w/ vascular insufficiency and contiguous ortho infxn

VANC AND

1) zosyn OR

2) imipenem/cilastatin, meropenem or doripenem OR

3) Cefepime or ceftazidime and clindamycin or metro

4) cipro or levo and clinda or metro

antistaph agent ONLY

what is the empiric abx therapy for a contiguous ortho infxn in an adult >50 y/o without vascular insufficiency?

clindamycin

what abx does NOT need to be adjusted in renal dysfunction?

3 multiple choice options

Nafcillin

which abx needs to be adjusted in patients with both hepatic and renal dysfunction?

3 multiple choice options

Linezolid

Which abx may contribute to the development of serotonin syndrome?

2 multiple choice options

Vancomycin

___________ should be used as the antistaphylococcal agent if the patient has risk factors for MRSA or if the prevalence of community acquired MRSA is high

MRSA RF

-central venous catheter in place

-other indwelling hardware

-known colonization with MRSA

-injection drug use

-recent (within 3 months) or current hospitalization >2 wks

-transfer from a nursing home or other subacute facility

linezolid or daptomycin

If the vancomycin MIC is >2mcg/mL against MRSA, consider an alternative agent such as what?

Linezolid

-worry about serotonin syndrome

-may occur with SSRIs/SNRIs, TCAs, triptans, meperidine, tramadol, buspirone

-should not be used concurrently with ^meds unless closely monitored

oral therapy

following 1-2 weeks of IV therapy, a switch to ______________ may be considered in patients with good adherence and outpatient follow-up

Oral Agent Characteristics - ortho infxns

-high bioavailability

-good bone penetration

-long half-life

Oral Therapy Abx - Ortho Infxn

-FQs -> cipro, levov, moxi

-Clindamycin

-Linezolid

-Bactrim

4-6 weeks

what is the duration of abx therapy for acute osteomyelitis?

4-6 weeks

what is the duration of abx therapy for chronic osteomyelitis?

major surgical intervention

in chronic osteomyelitis patients who have undergone surgical intervention, the total length of therapy should be counted after the last _______________.

resolved

abx therapy for osteomyelitis should be continued until the infection has _______________

Successful Osteomyelitis Tx

considered successful if all clinical s/s are resolved and all lab tests have returned to normal following therapy

Follow Up Eval

-patient compliance

-significant DI

-appropriate dosage to achieve therapeutic concentrations

-development of antimicrobial resistance

-need for additional imaging

-diagnostic reevaluation

1 year (q3-6 months)

due to high rates of relapse, osteomyelitis patients should have medical follow-up for at least ____________.

Septic Arthritis - Goal of Therapy

1) resolution of infxn

2) prevention of long-term sequelae -> risk of long-term comp increased

Long-term Comp Risks - Septic Arthritis

-symptoms >7 days before abx admin

-hip joint involvement

-infection due to gram neg rod

Septic Arthritis Management

1) prompt joint drainage

2) antimicrobial therapy

intravenous abx

initial therapy for septic arthritis should be with _______________; intra-articular abx are NOT recommended

false

T or F: intra articular abx are recommended for management of septic arthritis.

Gram positive Nongonococcal Cocci Tx

-vancomycin dosed to achieve a goal trough of 15-20 mg/dL

Gram negative Nongonococcal Rods - Tx

-ceftazidime, cefepime, zosyn, imipenem-cilastatin, meropenem, doripenem

-significant PCN/Ceph allergy -> aztreonam, cipro, levo

vanc PLUS gram neg agent

what should the abx treatment be for a gram stain negative septic arthritis?

MSSA

if culture yields ___________, therapy should be narrowed to an anti-staph PCN or a 1st gen cephalosporin

carbapenem

for patients with a previous history of an ESBL infxn or colonization, a ___________ is preferred over other B-lactam antimicrobials

Nongonococcal Septic Arthritis - Management

-IV abx x 2wks, followed by oral therapy for a minimum of 2 additional weeks

-longer courses of IV abx may be necessary to treat pathogens such as pseudomonas

-A 4wk course of IV abx is recommended in pts with documented bacteremia and secondary S. aureus arthritis

10-14 days

what is the total duration of therapy for gonococcal septic arthritis?

Ceftriaxone

what is the preferred abx therapy for gram negative cocci (gonococcal)?

cefotaxime

what is the alternative to ceftriaxone for gram neg cocci (gonococcal) septic arthritis?

FQ

what abx should you NOT used d/t high rates of resistance in gonococcal septic arthritis?

cefixime 400 mg BID

what oral abx can you convert to for gonococcal septic arthritis once clinical improvement occurs?

Non-gonococcal

given, this gram stain, is it gonococcal or not gonococcal?

-gram negative rods

Vancomycin

which of the following is NOT 1st line treatment in gram negative rods?

2 multiple choice options

Gonococcal

Given the gram stain, is it gonococcal or not gonococcal?

-gram negative cocci

ceftriaxone

what is the preferred treatment for gram negative cocci?

non-gonococcal

given the gram stain, is it gonococcal or not gonococcal?

-gram positive cocci

Vancomycin

What is the 1st line treatment for gram positive cocci?

3 multiple choice options

15-20 mg/L

what is the goal trough level of vancomycin in treating gram-positive cocci?

3 multiple choice options