ID 2 Final: Guarascio Cumulative- All Treatments

Treatment of Endocarditis Caused by Streptococci-Native Valve

-"easiest" scenario is culture and susceptibilities shows that the bacteria is highly PCN susceptible (MIC ≤ ___ mcg/mL)

0.12

What is DOC for Native Valve Endocarditis Caused by Streptococci that is highly PCN susceptible?

penicillin G

Treatment of Endocarditis Caused by Streptococci that is highly PCN susceptible

-DOC is penicillin G, but another choice is ___

ceftriaxone

What should you use for Native Valve Endocarditis Caused by Streptococci that is highly PCN susceptible if patient has a severe beta-lactam allergy?

vancomycin

Treatment of Endocarditis Caused by Streptococci-Native Valve

-If MIC is ___-___ mcg/mL, it is PCN resistant

0.12-0.5

What should you use Treatment of Native Valve Endocarditis Caused by Streptococci that is PCN resistant?

penicillin G, gentamicin

What should you use for Native Valve Endocarditis Caused by Streptococci that is PCN resistant if patient has a severe beta-lactam allergy?

vancomycin

Treatment of Endocarditis Caused by Streptococci-Native Valve

-If MIC is >0.5 mcg/mL, it is highly PCN resistant, so you treat it as if it is enterococcal (still ___ __ + ___, but higher doses/durations)

penicillin G, gentamicin

Treatment of Endocarditis Caused by Streptococci-Prosthetic Valve

-think that you add ___ regardless of MIC values if prosthetic valve

gentamicin

What should you give for Treatment of Endocarditis Caused by Streptococci-Prosthetic Valve?

penicillin G or ceftriaxone AND gentamicin

What should you give for Treatment of Endocarditis Caused by Staphylococci-Native Valve if MSSA?

nafcillin/oxacillin, or cefazolin

What should you give for Treatment of Endocarditis Caused by Staphylococci-Native Valve if MRSA?

vancomycin

Treatment of Endocarditis Caused by Staphylococci-Native Valve

-if MRSA and vancomycin MIC is high (≥ 2), alternative options include ___ and ___

daptomycin, ceftaroline

Treatment of Endocarditis Caused by Staphylococci-Prosthetic Valve

-start thinking you need ___ drugs (add rifampin for biofilm, add gentamicin for synergy)

3

What should you give for Treatment of Endocarditis Caused by Staphylococci-Prosthetic Valve if MSSA?

nafcillin/oxacillin AND rifampin AND gentamicin

What should you give for Treatment of Endocarditis Caused by Staphylococci-Prosthetic Valve if MRSA/beta lactam allergy?

vancomycin AND rifampin AND gentamicin

Endocarditis Caused by Enterococci

-we always give ___ (usually with an aminoglycoside)

synergy

Endocarditis Caused by Enterococci

-meds alone are usually not enough to treat

-often ___ is the treatment of choice

surgery

What should you give for Treatment of Endocarditis Caused by Enterococci-Native or Prosthetic Valve?

ampicillin or penicillin G AND gentamicin

Treatment of Endocarditis Caused by Enterococci-Native or Prosthetic Valve

-If gentamicin resistant, use ___

streptomycin

Treatment of Endocarditis Caused by Enterococci-Native or Prosthetic Valve

-another option is ____ AND ____

-Cephalosporins do not cover enterococcus, so this doesn't immediately make sense. But we use one here bc they make the ampicillin work better (idiopathic synergy)

ampicillin, ceftriaxone

Treatment of Endocarditis Caused by Enterococci-Native or Prosthetic Valve

-if PCN/ampicillin resistant or pt has a beta-lactam allergy, use ____ AND ___

vancomycin, gentamicin

Treatment of Endocarditis Caused by Enterococci-Native or Prosthetic Valve

-if Vancomycin resistent enterococci (VRE), use ___ or ____

daptomycin, linezolid

For uncomplicated S. aureus bacteremia:

-treat for ___ weeks

2

For complicated S. aureus bacteremia:

-treat for ___ weeks

4

Treatment of Active TB

-in the initial phase, we need 4 drugs (RIPE), which are ___, ___, ___, and ___

rifampin, isoniazid, pyrazinamide, ethambutol

Treatment of Active TB

-use ALL 4 drugs for ___ ___

8 weeks

for RIPE therapy, we ___ out the dose

max

Treatment of Active TB

-Use all 4 drugs for 8 weeks (2 months)

-Next, based on drug susceptibilities, reduce to 2 or 3 agents, which typically are ____ and ____

isoniazid, rifampin

Treatment of Active TB

-Use all 4 drugs for 8 weeks (2 months)

-Next, based on drug susceptibilities, reduce to 2 or 3 agents, which typically are isoniazid and rifampin for the remaining ____ months of therapy

4

Treatment of Active TB

-minimum total duration of therapy is ___ ____ of combination therapy

(all 4 drugs for 2 months) + (4 months of therapy based on susceptibilities)

6 months

Treatment of Active TB

-Adjunct therapy is ____, which should be given to prevent isoniazid-associated neuropathy

pyridoxine

Treatment of Active TB

-Patients should be placed in negative-pressure room until:

-___ negative sputum smears

-___ weeks of therapy

3, 2

Treatment Principles for Resistant TB infection

-no standard regimen

-once susceptibility is available, use 2+ drugs that patient has not previously received

-important= NEVER add a ___ drug to a failing regimen (avoid ___) because it will become resistant

single, monotherapy

Treatment Principles for CDI

-1st line is oral ___ and ___

vancomycin, fidaxomyxin

Treatment Principles for CDI

-treat for __-__ days regardless of follow-up laboratory testing results (even if bacteria is still there)

10-14

How to Treat Initial CDI Episode

-give ___ or ___ for 10 days

vancomycin, fidaxomicin

How to Treat First CDI Recurrence

-think we should "do something ____" than what we did to treat the first episode

different

How to Treat First CDI Recurrence

-there are 3 different options for treatment, choose something different than how the first episode was treated:

1. fidaxomycin

2. vancomycin in ____ regimen

3. vancomycin in ___/___ dose regimen

standard, taper/pulse

How to Treat Second or Subsequent CDI Recurrence

-exhaust 3 options:

1. fidaxomycin

2. vancomycin taper/pulse dose

3. vancomycin standard regimen followed by ____ for 20 days

rifaximen

How to Treat Second or Subsequent CDI Recurrence

-exhaust first 3 options (fidaxomycin, vancomycin taper/pulse, vancomycin standard followed by rifaximen)

-alternative is ___ ___ transplantation

fecal microbiota

How to Treat Fulminant CDI (shock)

-Oral____ at a higher dose

and

-IV _____ (to penetrate GI)

vancomycin, metronidazole

Traveler's Diarrhea

-Mild cases are self-limiting, use ___ ___ therapy

oral rehydration

Traveler's Diarrhea

-Moderate-Severe cases, use ___ or ____

ciprofloxacin, azithromycin

Azithromycin may be a better choice for traveler's diarrhea if patient contracted disease in ___ (bc quinolone resistance there)

asia

Traveler's Diarrhea

-Alternative treatment is ____ (noninvasive E. Coli strands in Mexico, Latin America, Africa)

rifaximin

Neurosurgery, Cardiothoracic, Vascular, Orthopedic, and Gastroduodenal surgeries: just give ____

cefazolin

For head and neck surgery, we usually just give ____. Due to the possibility of contact with the esophagus, we may add on _____ (but this is controversial)

cefazolin, metronidazole

For a hysterectomy (removal of uterus), we have 4 choices:

1) ______

2) _____ (anaerobic coverage, cephamycin)

3) _____(anaerobic coverage, cephamycin)

4) ____/_____ (anaerobic coverage)

cefazolin, cefoxitin, cefotetan, ampicillin/sulbactam

For a colorectal surgery we have 4 choices:

1) ______(anaerobic coverage)

2) _____ (anaerobic coverage, cephamycin)

3) _____(anaerobic coverage, cephamycin)

4) ____/_____ (anaerobic coverage)

ertapenum, cefoxitin, cefotetan, ampicillin/sulbactam

If someone has a a severe anaphylactic allergy to penicillins, just know in general we can use ___ or ___ as alternatives surgical prophylaxis (but these do not work as well)

clindamycin, vancomycin

If someone has a a severe anaphylactic allergy to penicillins and is undergoing colorectal surgery, we can use ____ (+ AG) or ____ (+FQ)

clindamycin, metronidazole

Vancomycin in surgical prophylaxis should only be considered when:

-patient has severe beta-lactam ____ (angioedema, bronchospasm, anaphylaxis)

-patient colonized by ___

-high rate of post-operative wound infections caused by ___ at institution

allergy, MRSA, MRSA

Primary Peritonitis Treatment:

-if peritoneal dialysis, use ___ (if MRSA) or ____/___ (if MSSA)

vancomycin, cefazolin/nafcillin

Secondary/Tertiary Peritonitis Non-Pharm Treatment:

-treatment of choice: ____ intervention !! (ie ___ control)

surgical, source

Secondary/Tertiary Peritonitis Pharm Treatment for Mild/Moderate:

-need to cover traditional Gm- and anaerobes

-most common treatment is ___ + ____

-also could use ertapenem, tigecycline, moxifloxacin, cefoxitin, or cipro+metronidazole if allergy

ceftriaxone, metronidazole

Secondary/Tertiary Peritonitis Pharm Treatment for High Risk

-monotherapy options are ___/___ or ____ (except ertapenem)

piperacillin/tazobactam, carbapenem

Secondary/Tertiary Peritonitis Pharm Treatment for High Risk

-combination option is ______ (or cipro/levo) + _____

cefepime, metronidazole

Treatment Course

Important: Continue antimicrobial therapy for __-___ days AFTER source control (ie after surgery occurs, even if antibiotics started prior to surgery)

5-7

Antifungal Activity

-Echinocandins is DOC for ___-___ ___ (particularly C. glabrata and C. krusei)

non-albicans candida

Antifungal Activity

-Fluconazole is DOC for ___ ____ (the most common!)

candida albicans

Antifungal Activity

-Fluconazole has ___ ___ susceptibility for C. glabrata (just means give high dose)

dose dependent

Antifungal Activity

-Itraconazole is DOC for step-down therapy from ___ or ____

histoplasma, blastomyces

Antifungal Activity

-Voriconazole is a DOC for ____

aspergillus

Antifungal Activity

-Posaconazole is used for ___

prophylaxis

Antifungal Activity

-we use amphotericin B when we have to bc poor tolerability, mainly DOC for ____ and ____/____

cryptococcus, histoplasma/blastomyces

Antifungal Activity

-so when patient has histoplasma/blastomyces, they are started on amphotericin B IV, then step down to ___ PO

Itraconazole

Dimorphic Fungi Treatment

-for severe disease, initially give ___ ___ for 1-2 weeks

amphotericin B

Dimorphic Fungi Treatment

-initially give amphotericin B for 1-2 weeks

-next give ____ if histo/blastomycosis or ____ if coccidiomycosis

itraconazole, fluconazole

Dimorphic Fungi Treatment

-duration of treatment is ___-___ months

3-6

Candidemia Treatment

-empiric 1st line is an _____

echinocandin

Candidemia Treatment

-if non-neutropenic and stable, patient can consider high dose ____

fluconazole

Candidemia Treatment

-change treatment after culture comes back

-typically a ___ ____ treatment course

2 week

Oropharyngeal candidasis → think ___ agents

Esophageal candidasis → think _____ agents

topical, systemic

Topical Agents

1) ____ troche for 7-14 days

2) _____ solution for 7 days

clotrimazole, nystatin

Systemic Agents

-for severe/unresponsive disease (esophageal component), give oral _____ for 7-14 days

fluconazole

Candida auris Treatment

-1st line is ____ (micafungin, caspofungin, anidulafungin)

-2nd line, unresponsive is ___ ___ ___

echinocandin, liposomal amphotericin B

What is the preferred treatment for cryptococcal meningitis?

-______ ___ + _____ for 2-4 weeks, then ____ for 8 weeks

amphotericin B, flucytosine, fluconazole

If treating an HIV patient with cryptococcal meningitis, continue fluconazole for at least ___ ___

12 months

Aspergillosis

-1st line = ____ (with a loading dose)

-2nd line = isavuconazonium, amphotericin B, echinocandins (not a focus)

voriconazole

does asymptomatic Vulvovaginal Candidiasis require treatment?

no

Vulvovaginal Candidiasis Treatment

-short course of therapy (__-__ days)

1-3

Vulvovaginal Candidiasis Treatment

-1 day treatment= ____ PO once (preferred), butoconazole, tioconazole

-3 day treatments = butoconazole, clotrimazole, miconazole, terconazole,

fluconazole

What 2 anti-fungals are preferred for vulvovaginal candidiasis in pregnancy?

clotrimazole, miconazole

recurrent vulvovaginal candidiasis = >__ episodes per year

4

For recurrent vulvovaginal candidiasis (>4 episodes a year), use fluconazole once weekly for ___ ___

6 months

Tinea Infections-Treatment

-tinea pedis requires treatment for how long?

2-4 weeks

Tinea Infections-Treatment

-tinea corporis/cruris requires treatment for how long?

2 weeks

Tinea Infections-Treatment

1) ____ for 1-4 weeks

2) ____ for 1-4 weeks

3) ____ for 2-4 weeks

4) _____ for 3-4 weeks

terbinafine, butenafine, clotrimazole, tolnaftate

Tinea Versicolor

-preferred topical treatment is ___ shampoo for 1-4 weeks (rinse off after 5-10 min of application)

ketoconazole

Tinea Versicolor

-preferred systemic treatment is ____ single dose

-also could use ___ or ___

ketoconazole, fluconazole, itraconazole

When giving ketoconazole orally, you must monitor for ____ and drug interactions (___)

hepatotoxicity, CYP3A4

Onychomycosis

-it is preferred to treat with oral therapy, either ___ or ___

terbinafine, itraconazole

Onychomycosis

-must treat for ___ ___ (amount of time needed for new toe nail to come in)

3 months

Onychomycosis

-can use topical agents, but only if <___% of nail involvement and requires ___ ___ of therapy

50, 48 weeks

Onychomycosis

-3 topical agents are ___, ___, and ____

elfinaconazole, ciclopirox, tavaborole

Lyme Disease Treatment- Early/EM alone

-treat for __-___ days

10-14

Lyme Disease Treatment- Early/EM alone

-___ 100mg PO q12h is preferred

-other options include ___ and ____

doxycycline, cefuroxime, amoxicillin

Lyme Disease Treatment- Late

-includes lyme meningitis (neuroborreliosis), lyme carditis, and late lyme arthritis

-treat for longer (____-___ days)

14-28

Lyme Disease Treatment- Late

-_____ is the initial IV agent recommended for meningitis and carditis

-(give IV until patient stable, then switch to oral doxycycline)

ceftriaxone