Naplex: Infectious Disease II: Bacterial Infections

What are the two common organisms on the surface of the skin?

Staphylococci and Streptococci

What two antibiotics are used commonly used prior to surgery (pre-operative) and when are they given?

beta-lactam: Cefazolin or Cefuroxime -- 60 minute before incision

If patient has a beta-lactam allergy, what other two antibiotics can be used prior to surgery and when are they given?

Quinolone or Vancomycin or Clindamycin -- 120 minute before incision

How many hours to discontinue the antibiotics in surgery?

24 hours

what abx are used in cardiac, orthopedic, and vascular surgeries? + alt s

what abx are used in GI surgeries?

What antibiotics are used in Hip fracture repairs/total joint replacements?

Cefazolin

What is meningitis?

inflammation of the meninges that cover the brain and spinal cord

What are the symptoms of meningitis?

headache, fever, nuchal rigidity (stiff neck) and altered mental status

Other symptoms: chills, vomiting, seizures, rash and photophobia

How is meningitis diagnosed?

lumbar puncture

What are common bacterias in Meningitis?

Streptococcus pneumoniae

Neisseria meningitidis

Haemophilus influenzae

(Listeria monocytogenese in neonate, >50, immunocomp'd)

Antibiotics duration for N. meningitidis and H. influenzae meningitis?

7 days

Not underlined

Antibiotics duration for S. pneumoniae meningitis?

10 - 14 days

Antibiotics duration for Listeria monocytogenes meningitis?

21 days

Not underlined

Why is dexamethasone given prior to the Antibiotic in meningitis>

To help prevent neurological complications (EG. hearing loss)

What steroid can be given in meningitis treatment to prevent neurological compications?

Dexamethasone 15 -- 20 minutes prior or with first antibiotic dose

What drug is given for Listeria coverage in meningitis?

Ampicilliin

Empiric treatment for bacterial meningitis in Age < 1 month (neonates)?

Ampicillin (for Listeria coverage) + Cefotaxime (no ceftriaxone) or gentamicin

do not use ceftriaxone!!

Empiric treatment for bacterial meningitis in Ages 1 month to 50 years

Ceftriaxone or cefotaxime + Vancomycin

Empiric treatment for bacterial meningitis in ages > 50 or Immunocompromised patients

Ampicillin (for Listeria) + Ceftriaxone or cefotaxime + Vancomycin

What are symptoms of acute otitis media?

bulging tympanic (eardrum), otorrhea (middle ear effusion/fluid), otalgia (ear pain), tugging or rubbing ears, fever and crying

What is an option for non-severe acute otitis media?

Observation without antibioitics for 48 - 72 hours

know when not to observe

when should you NOT observe (when are abx required) in AOM in kids?

know when not to observe

When should you try observation for AOM in children age 6 -- 23 months?

Try for 2 - 3 days if symptoms are non severe (mild otalgia < 48 hours or temperature < 102.2 * F and symptom in one ear only

When should you try observation for AOM in children age > 2 years?

Try for 2 - 3 days if symptoms are non severe (mild otalgia < 48 hours or temperature < 102.2 * F and symptom in one or both ears

What is First line treatment for Acute Otitis Media in?

Amoxicillin 90 mg/kg/day in 2 divided doses or

Amoxicillin/clavulanate 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses

How should amox/clauv be dosed (ratio) for AOM? why?

14:1

minimizes toxicity and diarrhea

What is an alternate treatment for AOM if child has a mild penicillin allergy?

Cefdinir 14 mg/kg/day in 1 or 2 doses

Cefuroxime 30 mg/kg/day in 2 divided doses

Cefpodoxime 10 mg/kg/day in 2 divided doses

Ceftriazone 50 mg/kg IM/IV daily for 1 or 3 days

not underlined

What is recommended if child fails the first treatment for AOM?

ceftriaxone IM

Clinical presentation of the common cold

sneezing, runny nose, cough, mucus production, sore throat and mild (low-grade) fever

Generally clears up in a few days

tx: symptomatic, no abx/anti viral

Clinical presentation of influenza

sudden onset fever, chills, fatigue, body aches, dry cough, sore throat and headache

What is the criteria for anti-infective treatment in influenza?

< 48 hours since symptom onset, severe illness (hospitalized), symptoms plus risk factors for influenza complications

Prophylaxis (if high risk for influenza complications or during outbreak scenario)

Treatment options for influenza?

Oseltamivir x 5 days

Baloxavir marboxil x 1 dose

Zanamivir inhalation x 5 days

Peramivir (IV)x 1 dose

Common pathogens in pharyngitis?

Respiratory viruses

S. pyogenes

aka strep throat

Clinical presentation of pharyngitis?

"Strep throat" often presents with sore throat, swollen lymph nodes and white patches on the tonsils, fever, headache

no cough, runny nose, congestion

Criteria for anti-infective treatment for pharyngitis?

Positive rapid antigen diagnostic test (tonsil swab) or positive S. pyogenes culture

Treatment options for pharyngitis

penicillin VK, amoxicillin or cephalosporin (1st/2nd gen),

if for beta-lactam allergy: clarithromycin, azithromycin, clindamycin

Treat for 10 days, except with azithromycin (5 days)

Common pathogens for sinusitis

Respiratory viruses, S. pneumoniae, H. influenzae and M. catarrhalis;

Staphylococci, anaerobes and gram-negative rods can be present in chronic sinusitis

Clinical presentation of sinusitis

nasal congestion, purulent nasal discharge, facial/ear/dental pain or pressure, headache, fever and fatigue

Criteria for anti-infective treatment for sinusitis

> 10 days of symptoms

or

> 3 days of severe symptoms (fever > 102*F, face pain, purulent nasal discharge)

or

Worsening symptoms after initial improvement

Treatment options for sinusitis

First line-- Amoxicillin/clavulanate

Second line- oral 2nd/3rd gen cephalosporing + clindamycin, doxycycline or a respiratory quinolone (levofloxacin, moxifloxacin)

what are symptoms of acute bronchitis?

treatment?

non productive cough for 1-3 weeks

chest xray normal, usually virus

abx NOT rec'd -> supportive care

What bacteria cause whooping cough?

Bordetella pertussis

What antibiotic is used for Bordetella pertussis bronchitis?

Macrolide (azithromycin, clarithromycin) or SMX/TMP

What type of bronchitis often requires an antibiotic?

Acute bacterial exacerbation of chronic bronchitis (ABECB) aka copd exacerbation

What requirements must be met for Acute bacterial exacerbation of chronic bronchitis (ABECB) for antibiotic treatment? (COPD exacerbation)

↑ dyspnea, ↑ sputum volume and ↑ sputum purulence

↑ sputum purulence + 1 additional symptom

Mechanically ventilated

any of the following

Preferred antibiotics for ABECB?

Amoxicillin/Clavulanate, azithromycin, doxycycline, or respiratory quinolone (moxi, levo)

Common symptoms of pneumonia?

fever, cough with purulent sputum, chest pain, rales (cracling noises in the lungs, tachypnea (increased respiratory rate) and decreased breath sounds

What is the gold standard diagnosis for pneumonia?

Chest x-ray and showing "infiltrates", "opacities" or "consolidations" to indicate pneumonia

Common bacteria that cause community acquired pneumonia?

S.pneumoniae, H. influenzae, M. pneumoniae and possibly C.pneumoniae

What is the treatment duration for CAP?

5 - 7 days

What comorbities require broader coverage in pneumonia?

Comorbidities like chronic heart, lung, liver or renal disease; diabetes; alcoholism; malignancy or asplenia

What risks require coverage for Pseudomonas or MRSA in pneumonia?

Prior respiratory infection of either patogen or hospitilazation with receipt of parenteral antibiotics in the past 90 days

Treatment recommendation for outpatient CAP in patients with no comorbidities?

Amoxicillin high dose (1 gram TID), or

Doxycycline, or

Macrolide (azithromycin or clarithromycin) if resistance is < 25 %

Treatment recommendation for outpatient CAP in patients with comorbidities?

Beta lactam + macrolide or doxycycline (amoxicillin/clavulanate or cephalosporin (e.g., cefpodozime, cefuroxime) plus macrolide or doxycyline

or

Respiratory quinolone monotherapy (moxifloxacin, gemifloxacin or levofloxacin)

Drug specific risks when evaluating CAP therapy

macrolides

doxy

fqs

all: allergies

macorlides (eg. azith): qt prolong, drug interactions (clarith mainly)

doxy: good for risk of qt prolon pts. dont use in preg, breastfeeding

fqs: szs, qt prolong, tendonitis, cardiovascular, peripheral neuropathy, avoid also in preg

What are treatment options for Non-severe Inpatient CAP (gem med unit)?

Beta-lactam + macrolide or doxycycline (beta-lactams: ceftriaxone, ceftaroline or ampicillin/sulbactam)

or respiratory quinolone monotherapy

What are treatment options for Severe (ICU) Inpatient CAP?

Beta lactam + macrolide or

Beta lactam + respiratory quinolone

do not use quinolone monotherapy!!in

RP is a 46 year old female who presents to the urgent care clinic with shortness of breath productive cough and a temperature of 100.8. A chest X ray reveals a left lower lobe infiltrate. Her path metal history includes back pain and schizophrenia. She has a penicillin allergy (hives). Her scheduled medications include GEODON 40, Trazodone 50.

Which empiric antibiotic regimen should RP receive for cap?

No comorbidities (heart,lung, liver, renal dx, dm, alcohol use) - not at risk so s.pneumo - > healthy category

pencillin allergy -> avoid amoxicillin

macrolides can prolong wt -> avoid d/t use of geodon, trazodone (both can qt prolong)

which leaves doxycyline as the correct choice

inpatient CAP treatment:

risk factors for mrsa

pseudomonas

if hopsitalization and use of IV abx in past 90 days

MRSA: add vanc or linezolid

pseudomonas: add pip/tazo, cefepime, meropenem

if hopsitalization, use of parenteral abx in past 90 days: cover both mrsa and pseudomonas

What is hospital acquired pneumonia (HAP)?

pneumonia occurring 48 hours or longer after hospital admission

What is ventilator associated pneumonia (VAP)?

pneumonia that occurs at least 48 hours after the start of mechanical ventilation

Common pathogens in HAP and VAP

Nosocomial pathogens (increase risk for MRSA and MDR pathogens including P.aeruginosa, Acinetobacter, Enterobacter, E. coli and Klebsiella

What should not be used done when picking Pseudomonas treatment in HAP/VAP?

Do not use two beta-lactams together

HAP/VAP treatment:

all pts

risk for mrsa

risk for pseudomonas

abx for pseudomonas/mssa

-cefepime, pip/tazo, levofloxacin (BL allergy)

mrsa: add vanc or linezolid

Pseudomonas: use two abx (not two beta lactams)

-BLs (piptazo, cefepime, ceftazidime, merrem)

-levo/ciprofloxacin

-aztreonam

-aminoglycosides (tobramycin,gentamicin)

What bacteria causes tuberculosis?

Mycobacterium tuberculosis

What are the symptoms in latent tuberculosis?

TB is latent so patient lacks symptoms

What are symptoms of active TB?

cough/hemoptysis

purulent sputum

fever/night sweats

unintentional weight loss

How is TB spread?

transmitted by aerolized droplets

How is latent TB diagnosed?

tuberculin skin test or PPD test

What is a PPD test?

purified protein derivative is injected intradermally and then the area is inspected for induration 48 -- 72 hours later

What can cause a false positive TB test?

If the patient received a BCG vaccine

in which populations is > 5 mm induration a positive result?

Close contacts of recent TB cases

Significant immunosuppression (e.g., HIV, taking transplant medications)

in which populations is > 10 mm induration a positive result?

Recent immigrants

IV drug users

Moderate immunosuppression

Residents/employees of "high risk" congregate settings (e.g., prison inmates, healthcare workers)

in which populations is > 15mm induration a positive result?

Patients that have no risk factors

What is preferred for Latent TB treatment?

Short regimens (3 or 4 months) are preferred for Latent TB due to higher completion rates and less hepatotoxicity risk

which medications are treatment for latent TB? + duration of therapy

Which latent TB treatment should NOT be used in pregnancy?

inh + rifapentine

what should be added to treatment in latent tb patient is taking and INH regimen?

add vit b6 to reduce risk for peripheral neuropathy

which duration of treatment regimen is preferred in latent tb?

shorter (3-4 months) decreases risk for hepatotoxicity and increases completion rates

which latent TB treatment is preferred in HIV+ pts taking art?

INH qd for 6-9 months

What is a preferred treatment for Laten TB in pregnant patients?

INH for 9 months

How is active TB diagnosed?

postive TST and confirmed with AFB stain in the lab

What therapy is used for initial phase of active TB?w

RIPE therapy- (rifampin, isoniazid, pyrazinamide and ethambutol) for 2 months

What is the continuation phase for Active TB treatment?

2 drugs (commonly rifampin and isoniazid for 4 months)

What are side effects of Rifampin?

↑ LFTs, hemolytic anemia (detected with a positive Coombs test), flu-like syndrome, GI upset, rash pruritus

Orange-red discoloration of body secretions (sputum, urine, sweat, tears, teeth); can stain contact lenses, clothing and bedsheets

what is the issue with using rifampin in treatment of TB?

many drug interactionsv-> can use rifabutin (eg. pt using protease inh)

What is used to prevent peripheral neuropathy in Isoniazid?

Pyridoxine (vitamin b6) 25 - 50 mg

Boxed warning for isoniazid

severe and fatal hepatitis

Side effects of Isoniazid (INH)?

↑ LFTs, drug-induced lupus erythematosus (DILE), hemolytic anemia (detected with a positive Coombs test), agranulocytosis, aplastic anemia, hyperglycemia, headache, GI upset, pancreatitis, severe skin reactions (SJS/DRESS), optic neuritis

What are contraindications for Pyrazinamide?

Acute gout, severe hepatic damage

side effects of pyrazinamide

↑ LFTs, hyperuricemia/gout, GI upset, malaise, arthralgias, myalgias, rash

Side effects for Ethambutol (Myambutol)?

↑ LFTs, optic neuritis (dose related), ↓ visual acuity, partial loss of vision/blind spot and/or color blindness (usually reversible), rash, headache, confusion, hallucinations, N/V

Why does Rifampin have many drug interactions?

It is a potent inducer of CYP450,1A2, 2C8, 2C9, 2C19, 3A4 and P-glycoprotein

Rifampin can decrease the effects of?

Protease Inhibitors

Warfarin

Oral Contraceptives

Don't use with apixaban, rivaroxaban, edoxaban, or dabigatran

RIPE key safety features (side effects)

What is endocarditis?

inflammation of the inner lining of the heart and valves

Who is at greater risk for endocarditis?

Patients who have prosthetic heart valves, chronic IV access, IV drug abuse or frequent and chronic healthcare exposure

The common organisms in endocarditis are?

Staphylocci, Streptococci and Enterococci

What drug is added for synergy in endocariditis?

Gentamicin is added when infection is more difficult to eradicate