860 d exam 1!!!!

Skin normal flora

coagulase negative staph, corynebacterium, cutibacteria, viridans streptococci, bacillus

oral flora

streptococci, anaerobes

stomach flora

low microbial activity due to acid; h. pylori can live its environment

acid suppression meds may increase bacteria growth

duodenum to jejunum flora

gram negative nodes and anaerobic activity

colon flora

gram positive, gram negative, anaerobes

4 diseases associated with colonic flora

IBS/IBD

altered flora

C. diff

gram negative bacteremia

4 major glucose and lactose fermenting gram negative rods

e. coli

citrobacter

klebsiella

enterobacter

4 major glucose and lactose non fermenting gram negative rods

pseudomonas

acinetobacter

stenotrophomonas

burkholderia

which gram negative rod bacteria is oxidase positive

pseudomonas

major phylia that makes up the majority of gut and oral microbiota

firmicutes, bacteroides, proteobacteria, actinobacteria

firmicutes

staph, strep

proteobacteria

e. coli, haemophilus, klebsiella, citrobacter, enterobacter

bacteroidetes

bacteroides, prevotella

actinobacteria

actinomyces, cornyebacterium

vagina normal flora

lactobacillus

dysbiosis = candida vaginitis, bacterial vaginosis

common skin contamination bacteria

CoNS, such as staphylococcus epidermis, cornyebacterium

true skin infections until proven otherwise

staph. aureus/lugdenensis, gram negative bacteria/enterobacterales, candida, pseudomonas, bacteroides, GAS/strep. pyogenes, GBS/strep. agalitae, strep. pneumoniae

t/f: asymptomatic bacteruria is common and does not require treatment

TRUE

outpatient options for community MRSA /purulent SSTIs

bactrim, Clindamycin(needs D-test), oxazolidinones(linezolid, tedizolid), tetracyclines (doxycycline, minocycline, omadacycline), delafloxacin (**only flouroquinolone approved for MRSA**)

nonpurulent SSTIs (streptococci) treatment options

penicillin VK, amoxicillin, dicloxacillin, cephalexin, clindamycin

which penicillin is penicillinase resistant?

dicloxacillin

mild impetigo (MRSA, MSSA, GAS/strep. pyogenes) treatment

mupirocin, 5-7 daysdiclox

severe impetigo treatment

dicloxacillin, cephalexin

if MRSA is a concern: bactrim, doxycycline, clindamycin

5-7 days

which cephalasporins have activity against MRSA

5th generation cephalasporins

ceftaroline, ceftobiprole

t/f: folliculitis and small furuncles usually does need oral antibiotic treatment

FALSE; can resolve on its own, use a warm compress, or mupirocin may be used

main treatment for large carbuncle or furuncle

incision and drainage

cellulitis involves which portions of the skin?

dermis, subQ

when to hospitalize a patient with cellulitis?

severe infection = fever/chills, mental status changes, shock, dramatic infection

common bacteria found in dog/cat bites

pasturella sp., anaerobes

when is antibiotics indicated for bite wounds?

immunocompromised

asplenia

wounds to hands, face, or genitals

deep wounds close to bones

advanced liver disease

preferred antibiotic for bite prophylaxis

Augmentin, 3-5 days

preferred IV antibiotic for severe bites

ampicillin/sulbactam

uncomplicated UTI

lower urinary tract infection, confined to bladder, men or women, no systemic infections

complicated UTI

infection that spreads beyond the bladder, upper urinary infection, systemic symptoms

examples if complicated UTIs

pylonephritis

catheter associated UTI

prostasis

recurrent UTIs

2 separate episodes or acute bacterial cystitis and associated symptoms within 6 months

prostasis

inflammed prostate gland due to reflux of infected urine into the gland ; common in older men, caused by e. coli

t/f: prostasis is easy to treat since antibiotics can easily get to the prostate

FALSE

treatment for prostasis

flurouquinolones or bactrim (caution with bactrim in AZ)

acute: 2-4 weeks

chronic; 6-12 weeks

t/f: bacteria in the urine or abnormal urine cultures does not automatically mean a UTI diagnosis

TRUE: symptoms need to be present as well, no abx are needed w/o symptoms

what 3 indicences do we treat asymptomatic bacteruria?

pregnancy

immunocompromised

recieving a urinary procedure

s/s of lower UTI/uncomplicated

dysuria

urgency

frequency

nocturne

suprapubic heaviness

s/s of upper UTI/complicated

fever

flank pain

CVA tenderness

malaise

t/f: UTIs are usually caused by a single organism

true

what are the two virulence factors that make E.Coli the main UTI causing organism?

fimbriae →hair like structures

adhesions → attach to host cell receptors

UTI causing bacteria

e. coli (90%)

staph. saprophyticus

enterococcus

other enterobacteriales (klebsiella, proteus)

pseudomonas (rare)

if using cranberry for prevention, how many PACs are needed?

36

t/f: methenamine hippurate is a good option for preventing rUTIs

true; the urine should be acidic (pH<5.5)

does fosfomycin cover staph. saprophyticus?

no

sulpenem etzadroxil-probenecid

newer agent reserved for abx resistance

e. coli porins

ompC, ompF

large and non-selective

pseudomonas porin

ompD

carbapenem channel, fewer portions compared to e. coli, more selective

2 common resistance mechanisms for gram positive bacteria

mutation in target (PBP mutations)

beta lactamases (staphlococcus)

3 common resistance mechanisms for gram negative bacteria

porins

efflux transporters

beta lactamases (most common)

4 common resistance mechanisms for beta lactams

altered binding to PBP (gram pos.)

production of beta lactamases (more common in gram neg)

abx efflux

altered permeability/porin loss

class A, C, D beta-lactamases

serine is in active site

class B beta lactamases

metallo, zinc is in active site

considered carbapenemases

HECK YES

enterobacterales with a risk of inducible ampC beta-lactamase production

Hafnia, enterobacterales cloacae, citrobacter fruendii, klebiella, yersinia

class D beta lactamase (OXA)

hydrolyzes oxacillian

what is the goal of making different generations of Cephalosporins?

more hydrophillic → better navigation through porins in gram negative bacteria

t/f: cephalosporins are active against enterococcus

false; penicillins are (except e. faecium)

what abx can be used for carbapenem resistant acinetobacter baumanii (CRAB)

sulbactam/durlobactam

2 resistance markers for carbapenemases

NDM-1

KPC-1

important beta lactamase in staph. aureus(MSSA)

class A, blaZ

mec-A gene

MRSA, PBP2a

van-A gene

synthesizes d-ala-d-lac, an alternative substrate for peptidoglycan synthesis = vancomycin resistance

AmpC

hydrolyzes 3GC →resistnat to beta lactams and 1,2,3 gen. cephalasporins

pharmacodynamic monitoring for beta lactams

time/MIC (susceptibility)

pharmacodynamic monitoring for aminoglycosides and sometimes fluouroquinolones

peak/MIC

pharmacodynamic monitoring for most other bacteria, like vancomycin

AUC/MIC

PAE

post antibiotic effects

when the abx is removed, the bacteria does not immediately start growing again; needs to recover before it starts growing again

acute tracheobronchitis clinical presentation

cough (productive or nonproductive)

low grade fever

preceded by cold symptoms

wheezing, coarse breathing

acute bronchitis treatment

hydration, smoking cessation

antitussives - dextromethorphan, codeine

bronchodilators

corticosteroids if they have asthma or copd

what must be done in conjunction with symptoms to rule out acute bronchitis caused more commonly by viruses?

chest x ray

3 typical bacteria that cause pneumonia

strep. pneumoniae

haemophilus pneumoniae

moraxella catarrhalis

3 atypical organisms that cause pneumonia

chlamydia pneumoniae

mycoplasma pneumoniae

legionella

clinical presentation of pneumonia

cough

fever/chills

pleuritic chest pain

dyspnea

rales/crackles when breathing

when to hospitalize CAP?

based on CURB 65: 2 points or more (each thing = 1 point)

• Confusion

• Uremia (urine nitrogen > 20)

• RR >30

• BP < 90/60

• > 65 y/o

when should you consider admitting CAP pt into ICU

CURB-65 score is 3 or more; pt needs ventilators or has septic shock

• confusion

• uremia (nitrogen >20)

• RR >30

• BP <90/60

• >65 y/o

t/f: glucocorticoids may decrease mortality for those with CAP in the ICU

true

antibiotics for outpatient CAP with no comorbities

amoxicillin

macrolides (azithromycin, clarithromycin)

Augmentin

respiratory flouroquinolone (levofloxacin, moxifloxacin)

duration: 7-14 days

antibiotics for outpatient CAP with comorbities

combo therapy:

Augmentin or cephalasporin (cefpodoxime, cefuroxime) AND macrolides or doxycycline

Monotherapy: respiratory fluorouquinolone (levo, moxi, gemifloxacin)

comorbidites for CAP

asplenia

alcoholism

chronic heart, lung, kidney, liver disease

diabetes

malignancy/cancer

MRSA/pseudomonas risk factors

prior history of positive isolation of either, or recent hospitalization + parenteral abx in the last 90 days

Cap admitted to hospital treatment

beta lactam (ceftriaxone, cefotaxime, augmentin, ampicillin-sulbactam) ± macrolides (zpak, clarithromycin)

respiratory fluoroquinolone

duration: at least 3 days

CAP treatment in ICU

beta lactam and macrolide

2nd line: beta lactam and respiratory fluoroquinolone

duration: depends on patient’s clinical stability

empirical therapy for hospitalized CAP w/ no MRSA or pseudomonas risk (group 1)

amp/sul or 3rd gen cephalosporin (ceftriaxone or cefotaxime) + macrolides or doxycycline

alternative: resp. fluoroquinolones

empirical therapy for hospitalized CAP w/ MRSA risk

group 1 + vanco or linezolid

atypical CAP coverage

macrolides, doxycycline, resp. FQ

empirical therapy for hospitalized CAP w/ pseudomonas risk

pip/tazo or cefepime or ceftazidime or imipenem or meropenem + macrolides or doxycycline or resp. FQ

empirical therapy for hospitalized CAP w/ MRSA and pseudomonas risk

pip/tazo or cefepime or ceftazidime or imipenem or meropenem + macrolides or doxycycline or resp. FQ + linezolid or vanco

clinical stability in hospitalized CAP pts

O2> 90

HR <100

RR <24

temp <100.9

criteria for switching pts from IV to PO

should be met for >/= 24 hours

t/f: hospitalized CAP pts need to be assessed for flu and pneumonia vaccine before being discharged if indicated

true

t/f: daptomycin can treat MRSA and pneumonia

FALSE; it gets inactivated in the lungs = no pneumonia treatment

most common causes of ARDS (acute respiratory distress syndrome)

pneumonia, sepsis

risk factors for HAP/VAP

intubation/mechanical ventilation

IV antibiotics in the last 90 days

long hospital duration

symptoms of HAP/VAP

fever

cough

leukocytosis or leukopenia

decline in oxygenation

purulent secretions

t/f: blood bacterial cultures should always be obtained twice for any patient with sepsis and/or possible infection before starting antibiotics

TRUE

t/f: moxifloxacin should be used in HAP/VAP

FALSE; moxifloxacin does not have pseudomonas coverage

empiric treatment of HAP with low mortality and MRSA risk (no IV antibiotics in last 90 days, MRSA/Staph spp. <20% )

CHOOSE 1

beta lactams: pip/tazo, cefepime, ceftazadime, imipenem, meropenem

fluoroquinolones: levofloxacin