ch 23 ID II bacterial infections (copy)

skin flora

staph and strep

perioperative antibiotics for cardiac or vascular surgery

cefazolin

cefuroxime

perioperative antibiotics for cardiac, vascular, or orthopedic surgery

BETA-LACTAM ALLERGY

clindamycin

vancomycin

perioperative antibiotics for orthopedic surgery

cefazolin

perioperative antibiotics for gastrointestinal surgery

cefazolin + metronidazole

cefotetan

cefoxitin

unasyn

perioperative antibiotics for gastrointestinal surgery

BETA-LACTAM ALLERGY

clindamycin/metronidazole + aminoglycoside or quinolone

in gastrointestinal surgeries, the prophylactic abx regimen needs to cover skin flora plus ________

gram negative and anaerobes

what bacteria is a gram positive cocci in chains?

GBS

what bacteria is a gram positive cocci in pairs?

s. pneumoniae

what bacteria is gram positive bacilli (rods)?

listeria

what bacteria is gram negative cocci in pairs?

neisseria meningitidis

what bacteria is gram negative coccobacilli?

h. influenzae

what bacteria is gram negative bacilli (rods)?

e. coli

most common bacterial causes of meningitis

neisseria meningitidis

strep pneumoniae

h. influenzae

what ages do we need to cover listeria for meningitis?

< 28 days

> 50 years

what is the purpose of adding ampicillin in certain meningitis regimens?

covers listeria

meningitis tx: < 28 days old

ampicillin + ceftazidime ± gentamicin

meningitis tx: 28 days - 50 years old

ceftriaxone + vancomycin

meningitis tx: > 50 years old

ampicillin + ceftriaxone + vancomycin

why can’t ceftriaxone (rocephin) be used in neonates (< 28 days)?

kernicterus and biliary sludging

tx duration for meningitis caused by n. meningitidis and h. influenzae

7 days

tx duration for meningitis caused by strep pneumoniae

10 - 14 days

tx duration for meningitis caused by listeria

≥ 21 days

what can be used to prevent neurological complications caused by meningitis?

IV dexamethasone with first abx dose

most acute otitis media is caused by viruses, but what are common bacterial causes?

s. pneumoniae

h. influenzae

moraxella catarrhalis

acute otitis media

which of the following pts can be observed for 2-3 days before starting abx?

a. < 6 months old

b. 6-23 months old, unilateral

c. 6-23 months old, bilateral

d. 6-23 months old, severe

e. ≥ 2 years old, unilateral

f. ≥ 2 years old, bilateral

g. ≥ 2 years old, severe

b. 6-23 months, unilateral

e. ≥ 2 years old, unilateral

f. ≥ 2 years old, bilateral

acute otitis media

which of the following pts should we start abx immediately?

a. < 6 months old

b. 6-23 months old, unilateral

c. 6-23 months old, bilateral

d. 6-23 months old, severe

e. ≥ 2 years old, unilateral

f. ≥ 2 years old, bilateral

g. ≥ 2 years old, severe

a. < 6 months old

c. 6-23 months old, bilateral

d. 6-23 months old, severe

g. ≥ 2 years old, severe

johnny is 3 years old experiencing bilateral acute otitis media. he has a temperature of 103º F. should he be observed for 2-3 days or start abx immediately?

he should start abx immediately since he has a FEVER

first-line tx for acute otitis media

amoxicillin 90 mg/kg/day

augmentin 90 mg/kg/day

acute otitis media

what abx should be used in children with mild penicillin allergy?

second or third gen cephalosporin

acute otitis media

abx options after initial tx failure

augmentin 90 mg/kg/day (if amox used initially)

ceftriaxone IM

what abx do we use for the common cold?

trick question!

none - resolves in a few days on its own

when do we treat the flu?

symptoms < 48 hours

severe illness

common bacterial cause of pharyngitis?

GAS (strep pyogenes)

aka strep throat

abx tx for pharyngitis

penicillin VK

amoxicillin

when do we treat acute sinusitus?

≥ 10 days of persistent symptoms

≥ 3 days of severe symptoms (fever, face pain, purulent nasal discharge)

abx for acute sinusitus

augmentin

pt has cough lasting 1-3 weeks with wheezing

pt previously had an upper respiratory tract virus

chest x-ray was normal

what do they have and how do we treat?

acute bronchitis

NO ABX

-supportive care only

_________ is acute bronchitis caused by bordetella pertussis

pertussis aka whooping cough

how do we treat pertussis?

macrolides (azithromycin, clarithromycin)

3 cardinal symptoms of COPD exacerbation

1. incr. dyspnea

2. incr. sputum volume

3. incr. sputum purulence

common bacterial causes of acute COPD exacerbations

H. influenzae

M. catarrhalis

S. pneumoniae

who should get abx for acute COPD exacerbations?

-all 3 cardinal sx present

-incr. sputum purulence + 1 additional sx

-mechanically ventilated

preferred abx for acute COPD exacerbation

augmentin

bacterial causes of CAP

• s. pneumoniae

• h. influenzae

• atypicals

  • mycoplasma pneumoniae

pneumonia sx

SOB

fever

cough with purulent sputum

rales

tachypnea

gold standard diagnostic test for pneumonia

chest X-ray

-infiltrates

-opacities

-consolidations

duration of tx for CAP

5-7 days

outpatient CAP assessment and tx… what do we need to look for first?

comorbidities - classify as healthy or high risk

-chronic heart, lung, liver, or renal disease; DM; alcohol use disorder; malignancy; asplenia

pt presents with CAP and no comorbidities, what are the tx options?

amoxicillin

doxycycline

macrolide (pneumococcal resistance < 25%)

pt presents with CAP and comorbidities, what are the tx options?

1. beta-lactam + macrolide or doxy

   1. BL: augmentin or cephalosporin

2. respiratory FQ monotherapy

respiratory fluoroquinolones

levofloxacin

moxifloxacin

inpatient CAP tx: non-severe

1. beta-lactam + macrolide or doxy

   1. BL: ceftriaxone, unasyn

2. respiratory FQ monotherapy

inpatient CAP tx: severe (ICU)

1. beta-lactam + macrolide

2. beta-lactam + respiratory FQ

MRSA coverage for CAP

vanco

linezolid

pseudomonas coverage for CAP

zosyn

cefepime

meropenem (aztreonam)

when a pt has CAP, when do we need to cover MRSA and pseudomonas?

hospitalization and use of IV abx in past 90 days

nosocomial pathogens common in HAP or VAP

MRSA

MDR gram- rods

-pseudomonas

HAP/VAP initial BASIC empiric tx

abx covers pseudomonas and MSSA

-cefepime

-zosyn

-levofloxacin

HAP/VAP when to add MRSA coverage

-IV abx use in past 90 days

-MRSA prevalence in hospital unit > 20% or unknown

-prior MRSA infection

-positive MRSA nasal swab

when do we double cover pseudomonas in HAP/VAP?

-IV abx use in past 90 days

-prevalence of gram- resistance in hospital unit > 10%

-hospitalized ≥ 5 days prior to onset of VAP

abx that cover pseudomonas

• beta-lactams

  • zosyn

  • cefepime

  • ceftazidime

  • imipenem/cilastatin

  • meropenem

• FQs

  • levofloxacin

  • ciprofloxacin

• aztreonam

• aminoglycosides

  • tobramycin

how do you diagnose latent TB?

tuberculin skin test (TST/PPD) or IGRA blood test

what test for latent TB is preferred in pts with a history of bacille calmette-guerin (BCG) vaccination?

IGRA

pt with HIV/immunosuppressed gets a TB skin test done (latent)

what would be a positive result?

≥ 5 mm induration

pt is a resident/employee of “high-risk” congregate settings

what would be a positive TB skin test result (latent)?

≥ 10 mm induration

pt has no risk factors and gets a TB skin test done (latent)

what would be a positive result?

≥ 15 mm induration

what sort of treatments (durations) are preferred in most adults for latent TB due to higher completion rates and less risk of hepatotoxicity?

shorter duration regimens

latent TB tx: INH and rifapentine

once weekly for 12 weeks

latent TB tx: INH with rifampin

daily for 3 months

latent TB tx: rifampin

daily for 4 months

latent TB tx: INH

daily for 6-9 months

what latent TB regimen is preferred in HIV-positive pts?

INH daily for 9 months

if a pt is pregnant, what latent TB tx can NOT be used?

rifapentine - fetal risk unknown

how do you diagnose active TB?

chest X-ray showing consolidation or cavitation

AFB smear of sputum sample

sputum culture or PCR for MTB (DEFINITIVE DIAGNOSIS)

active TB tx: intensive phase

RIPE for 2 months

rifampin

isoniazid

pyrazinamide

ethambutol

active TB tx: continuation phase

2 drugs for ≥ 4 months

rifampin

isoniazid

T/F all active TB tx drugs can increase LFTs

TRUE

all of RIPE incr. LFTs

ADRs of rifampin (rifadin)

orange-red discoloration of body fluids

hemolytic anemia

flu-like syndrome

ADRs of isoniazid

peripheral neuropathy

drug-induced lupus (DILE)

hemolytic anemia

what do we need to take with isoniazid and why?

pyridoxine (Vit. B6)

reduces peripheral neuropathy

CI and ADRs of pyrazinamide

CI: acute gout

ADRs: hyperuricemia/gout

ADRs of ethambutol

optic neuritis (think E = Eyes)

confusion

hallucinations

what should we do if rifampin and protease inhibitors are prescribed together?

substitute for rifabutin

what is the effect of rifampin on warfarin?

very large drop in INR

-incr. doses of warfarin required

what do we absolutely NOT want to use rifampin with?

apixaban

rivaroxaban

edoxaban

dabigatran

most common organisms that cause infective endocarditis

staph

strep

enterococci

when do we normally add an antibiotic (like gentamicin) for synergy when treating infective endocarditis?

more difficult to eradicate - prosthetic valve, resistant organisms

traditional dosing of aminoglycosides is used to target peak levels _______ and trough levels ______

peak levels: 3-4 mcg/mL

trough levels: < 1 mcg/mL

tx of infective endocarditis caused by viridans group strep

PCN or ceftriaxone (± gentamicin)

tx of infective endocarditis caused by staph (MSSA)

nafcillin or cefazolin or daptomycin

tx of infective endocarditis caused by staph (MSSA) and prosthetic valve

nafcillin or cefazolin + gentamicin and rifampin

tx of infective endocarditis caused by staph (MRSA)

vancomycin or daptomycin

tx of infective endocarditis caused by staph (MRSA) and prosthetic valve

vancomycin + gentamicin and rifampin

tx of infective endocarditis caused by enterococci (native and prosthetic valve)

PCN or ampicillin + gentamicin

ampicillin + high-dose ceftriaxone

pts at high risk for infective endocarditis (dental procedures)

dental work needed (manipulation of gingival tissue, periapical region, perforation of oral mucosa)

select cardiac conditions:

-prosthetic heart valve or artificial material repair

-hx of endocarditis

-heart transplant with abnormal heart valve function

-congenital heart defects

infective endocarditis dental prophylaxis regimens

amoxicillin 2 g PO

PCN allergy:

-azithromycin or clarithromycin 500 mg

-doxy 100 mg

when do you suspect SBP?

paracentesis reveals ≥ 250 cells/mm³ PMNs

empiric tx for SBP

ceftriaxone x5-7D

pt previously had an SBP episode and now require secondary prophylaxis

what are prophylaxis options?

bactrim

FQ