ID 2 - disease states

Perioperative ABX for cardiac/vascular, or orthopedic surgery **

• Cefazolin 1g 60 mins prior

• ALT: clindamycin or vancomycin

Perioperative ABX for GI surgery ***

• Cefazolin + flagyl (metronidazole), cefotetan, cefoxitin, or unasyn (ampicillin/sulbactam)

uworld, know all

In what patients should listeria be covered in meningitis? (3)

• Neonates

• >50 yo

• Immunocompromised

Meningitis TX (all 3 groups)

<1 month:

• Ampicillin (listeria)

• Cefepime or ceftazidime

• +/- gentamicin

1 month-50 years:

• Ceftriaxone + vancomycin

>50 years or immunocompromised:

• Ampicillin + ceftriaxone 2g + vancomycin

Why & when is dexamethasone given in meningitis?

• 15-20 min before or at the SAME time

• Prevent neurologic complications like hearing loss

Can you use ceftriaxone for meningits in neonates?

NO - can cause biliary sludging and kernicterus

What is AOM?

Acute otitis media is a upper respiratory tract infection most common in children

AOM SXS (5)

• Bulging tympanic (eardrum)

• Otorrhea (middle ear fluid)

• Otalgia (ear pain)

• Fever

• Tugging and rubbing on ears

Most common bugs with AOM (3)

• Strep pneumo

• H flu

• Moraxella catarrhalis

When is AOM observation indicated? **know (study gal)

Can try observation for 2-3 days if SXS are non-severe:

• Otalgia <48 hrs, no otorrhea, temp <102.2 AND:

• Age 6-23 months: SXS in 1 ear

• Age ≥2 yo: SXS in 1 or both ears

- If SXS dont improve, or worsen, can use ABX!!

AOM antibiotic TX + duration * know all :(

• Amoxicillin 90 mg/kg/day in 2 DD or Augmentin 90 mg/kg/day in 2 DD

• Alternative: CTX, cefdinir, etc.

• Duration 10 days if <2 yo

TX failure if done improve after 2-3 days:

• Ceftriaxone 50 mg/kg IM QD x 3 days

Pharyngitis (strep throat) bug (1)

Strep pyogenes (Group A strep)

Pharyngitis (strep throat) diagnosis & TX (1+1)

• Rapid antigen test (tonsil swab)

• Penicillin or amoxicillin

Acute sinusitis criteria for TX (2)

• ≥10 days of persistent symptoms OR

• ≥3 days of severe symptoms (face pain, nasal discharge, temp >102)

Acute sinusitis TX (1)

Augmentin`

COPD exacerbation TX options (3) + duration

• Augmentin

• Azithromycin

• Doxycyline

• 5-7 days

TB bug (1)

Myobacterium tuberculosis (aerobic, non-spore forming bacillus)

What is the difference between latent vs active TB?

• Latent: immune system contains the infection but the patient lacks symptoms and cannot spread the disease

• Active: highly contagious, cough, hempotysis, fever, etc

What isolation is recommended for TB?

Single negative pressure room + respirator mask (N95)

TB diagnosis tests (2)

• TST (Tuberculin Skin Test) - skin test

• IGRA (Interferon gamma release assay) - blood test

LATENT TB TX (4) ** know all :(

• INH + rifapentine once weekly x 12 weeks by directly observed therapy (dont use in pregnant)

• INH + rifampin QD x 3 months (can use in preg)

• Rifampin QD x 4 months (can use in preg)

• INH 300 mg QD x 6-9m (can use in preg and preferred in HIV positive)

ACTIVE TB TX (intensive vs. continuation phases) *

INTENSIVE PHASE:

• Rifampin + isoniazid + pyrazinamide + ethambutol (RIPE) QD or 5 x per week by directly observed therapy for 2 MONTHS.

CONTINUATION PHASE:

• Isoniazid + rifampin QD or 5 x per week by directly observed therapy x 4 MONTHS

Rifampin adverse effects (4)

• Orange-red discoloration of body secretions

• Hemolytic anemia (+ coombs test)

• increased LFT's

• flu-like syndrome

Rifampin DDI (3)

CYP3A4 inducer decreasing conc of:

• Protease inhibitors

• Warfarin (dec INR)

• Oral contraceptives (decreases efficacy)

Do not use with DOACs

Isoniazid BW (1)

Severe and fatal hepatitis

Isoniazid adverse effects (4)

• peripheral neuropathy

• increased LFT's

• drug induced lupus erythematosus

• hemolytic anemia (+ coombs test)

What vitamin is taken with isoniazid & what dose?

Pyridoxine (vit B6) 25-50 mg PO QD

• Decrease INH associated peripheral neuropathy

In what patients is pyrazinamide contraindicated in? (1)

GOUT due to increased uric acid

What drug causes vision damage & requires baseline & monthly vision tests?

Ethambutol for TB

Ethambutol adverse effects (4)

• Optic neuritis (dose dependent)

• Increased LFT's

• Confusion

• Hallucinations

Bugs causing IE (3)

staphylococci, streptococci, enterococci

Gentamicin for IE peak & trough goals

Peak 3-4; trough <1

IE TX duration

4-6 weeks of IV ABX

Why might rifampin be added in IE?

Rifampin can treat organisms in a biofilm which can develop on prosthetic valves

IE dental ppx (1+2)

• Amoxicillin 2 g PO once 30-60 mins before procedure

• Allergy: azithromycin 500 or doxycycline 100

Used in patients needed like a root canal with select cardiac conditions

SBP ascitic fluid with ≥____ PMNS

250

SBP TX vs PPX

• TX: Ceftriaxone x 5-7d

• PPX: bactrim or cipro

SSTI systemic signs (3)

• Temp >100.4

• HR >90

• WBC >12,000 or <4,000

SSTI mild vs mod vs severe

• Mild: no systemic sxs

• Moderate: systemic sxs

• Severe: systemic sxs or fluid blister, hypotension, immunocompromised, failed ABX and I/D

What SSTI causes honey covered crusts?

Imeptigo

Impetigo TX

• Localized lesions: topical mupirocin

• Numerous lesions: Cephalexin PO

Furuncle TX

Bactrim or doxy

Non-purulent cellulitis TX (1)

Cephalexin

Abscess purulent TX (2)

• Bactrim or doxy

Severe purulent SSTI TX options (3)

Vanc, dapto, linezolid

Necrotizing fascitis TX

• Surgical debridement

• Vanc or dapto + zosyn + clinda

Diabetic foot infection duration

• No bone involvement: 2-4 weeks

• OM: 4-6 weeks

• Amputation: 2-5 days with no residual infection

Nitrofurantoin dosing UTI and CI

Macrobid 100 mg PO BID x 5 days

CrCl < 60

Bactrim dosing UTI

SMX/TMP DS 1 tab PO BID x 3 days

UTI bugs (5)

• E coli

• Proteus

• Klebsiella

• Strep

• Enterocci

Phenazopyridine indication

• Helps with pain/burning with urination but does not treat infection

Phenazopyridine dosing

200 mg PO TID x 2 days (max)

• Take with 8 oz of water with food to miniimze GI effects

Max duration of phenazopyridine

2 days

What medication can cause red-orange coloring?

Phenazopyridine (azo)

Diagnosis of asymptomatic bacturia

≥10^5 bacteria on UA

T/F: you should always treat asymptomatic bacteriuria in pregnancy

TRUE

Asymptomatic bacteruria TX

Augmentin or cephalexin

CDI symptoms (4)

• ≥3 watery stools per day

• Abdominal cramps

• Fever

• Elevated WBC

Drug causes of C Diff

• PPI's

• ABX

CDI TX ***

1st episode:

• FDX 200 BID x 10d

• VAN 125 QID x 10d

2nd episode:

• above + prolonged pulse/taper of VAN

3rd or subsequent episodes:

• above

• or VAN followed by rifaximin 400 TID x 20d

• Fecal microbota

Fulminant (hypertension, shock, toxic megacolon)

• VAN 500 mg PO/NG/PR QID + metronidazole 500 mg IV q8hr

DoxyPEP for STI's

• Doxycycline 200 mg ONCE within 72 hrs of sexual activity

• Men sex with men, hx of ≥1 STI

Syphilis TX

Primary, sec, or early latent:

• Pen G (Bicillin L-A) 2.4 million units IM x 1

• Allergy: doxy x 14d

Teritary or late latent:

• Pen G (Bicillin L-A) 2.4 million units IM weekly x 3w

• Allergy: doxy

what is syphilis penicillin desensitization?

• For pregnant patients who are allergic to PCN and can't take the alternative doxy due to fetal harm or a patient who would have poor adherance to doxy

• Confirm allergy with a skin test!

syphilis bug

treponema palidium spirochete

What are you thinking if a treponemal test is positive?

Syphilis

Neurosyphilis TX

Pen G aqueous IV x 10-14d

Gonorrhea TX

• <150 kg: CTX 500 mg IM x 1

• ≥150 kg: CTX 1g IM x 1

If chlamydia not excluded add doxy

Chlamydia TX

• Doxy 100 mg BID x 7d

• Pregnant: zithromax 1g x1

BV TX (2)

• Metronidazole 500mg BID x 7d

• Metronidazole 0.75% gel x5d

BV symptoms (3)

• Discharge (grey, white, clear)

• Fishy odor

• pH >7.5

Trich TX

Metronidazole 500 mg BID x7d

- Males: 2g x1

T/F: CDC recommends flagyl for trich in all trimesters during pregnancy

TRUE even though per package insert it is contraindicated during first trimester

Genital warts TX

Imiquimod cream

Vaginal candidasis TX

fluconazole 150 mg PO x1

Rock mountain spotted fever TX

Doxy

- even in peds its the DOC

lyme disease TX

doxy

Azithromycin is not a preferred CAP OP in healthy pts without comorbidites if local pneumococcal resistance >____%

>25%

uworld

Can aztreonam be used as monotherapy in CAP?

NO - it can be used in HAP if combine with a gram + ABX like vanc

Why are cefazolin (1st gen) or cefuroxime (2nd gen) preferred for most surgeries

Prevent MSSA

Most common bacterial causes of menigitis

Neisseria meningitidis

Streptococcus pneuomoniae

When to infuse beta lactams for perioperative antibiotic prophylaxis

1 hr

When to infuse vancomycin and FQ for perioperative antibiotic prophylaxis

120 minutes

Perioperative antibiotic prophylaxis for cardiac or vascular or orthopedic procedure when pt has a beta lactam allergy

clindamycin or vancomycin

Common bacterial causes of CAP

-S. Pneumoniae

-H. Influenzae

-M. Pneumoniae (mycoplasma pneumoniae)

Outpatient CAP tx if healthy w/o comorbidies

amoxicillin or doxycycline or macrolide (azithromycin or clarithromycine)

Outpatient CAP tx if high risk with comorbidities

Beta lactam (Augmentin, or cephalosporin) + macrolide or doxycycline or respiratory FQ (levo or moxi)

Risks of macrolides

QT prolongation

Risks of doxycycline

Cannot use while pregnant or breast feeding

Risks of FQ

QT prolongation

Tendonitis

Peripheral neuropathy

Seizures

Cardiovascular

Cannot use while pregnant

In patient CAP non severe tx

beta lactam (Ceftriaxone or ampicillin/sulbactam) + macrolide or doxycycline

or

respiratory FQ

In patient CAP severe tx

Beta lactam + macrolide

or

Beta lactam + respiratory FQ

What to add when in patient risk for MRSA

vancomycin or linezolid

Beta lactams that cover pseudomonas aeruginosa

Piperacillin/tazobactam

cefepime

Meropenem

HAP

onset > 48 hrs after hospital admission

VAP

Onset > 48 hrs after mechanical vent

Common HAP VAP pathogens

nosocomial

MRSA

MDR gram negative

Pseudomonas aeruginosa

What do all HAP VAP pts need abx to cover

Pseudomonas and MSSA

HAP VAP abx that cover pseudomonas and MSSA

Cefepime

Piperacillin/tazobactam

Levofloxacin

HAP VAP tx to add if MRSA risk

vancomycin or linezolid

What do two abx need to cover in HAP VAP pts at risk for MDR gram negative pathogens

Pseudomonas