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Flashcards in Ch_5 - Infectious Disease Deck (143):
1

Below what temp is NOT a fever?

<38*C (100.4*F) is NOT a fever

2

T/F Persistent fever is more dangerous than a single elevation

True

3

Normal Rectal Temp can be __*C (__*F) (higher/lower) than oral temp

Normal Rectal Temp can be 0.5*C (~1*F) HIGER than oral temp

4

Fever + Hypotension/Tachycardia = ?

SIRS (danger)

5

Fever + Hypotension/Tachycardia + acidosis + confusion = ?

Likely Sepsis (worse danger)

6

Fever + Hypotension/Tachycardia + acidosis + confusion + AKI + lung failure = ??

Severe Sepsis (death is knocking)

7

Do not send a culture (except blood culture) without what?

evidence of infection

8

If a sputum culture grows Staph in a patient with pneumonia, what are the reasons for growing the Staph in the sputum culture?

1. Contaminant from sloppy sample collection
2. Colonization of mouth
3. Colonization from endotracheal or tracheostomy tube.
4. Possible PNA

9

If patient gets sepsis (fever + hypotension/tachycardia + confusion or metabolic acidosis, what should the patient get?

FLUIDS! -- 500-1000 mL of NS
Blood cultures
and IV Antibiotics STAT!

10

Everyone with Unexplained fever needs (3)

Blood cultures (2 sets from different sites)
CXR
U/A

"Blood, lungs, and Urine"

11

If a patient presents with an obvious skin infection from cellulitis causing fever, does the pt need a UA?

No

12

Which cultures should you not do because they are useless or could be dangerous?

1. No UCx unless UA shows WBCs
2. No sputum Cx without a new infiltrate on CXR and pt produces no sputum.
3. Do not swab a skin ulcer and send for Cx. Any ulcer will grow something, and they may not have caused the infection.

13

When NOT to do a Urine culture?

When UA shows no evidence of infection (eg, WBCs)

14

When not to do a sputum cx?

If there's no infiltrate on CXR and pt doesn't produce sputum

15

Should skin ulcer surfaces be swabbed and sent for culture?

No

16

What are the possible adverse consequences of unnecessary cultures?

1. prolonged hospital stay
2. giving antibiotics that have no benefits (but can harm)
3. C. diff colitis diarrhea
4. Resistant organisms

17

T/F Wound or Urine "colonization" should be treated with antibiotics

False, should not!

18

an elevated WBC count (leukocytosis) should be evaluated the same way as ???

Fever

19

A pt presents with an elevated white count. Now what?

1) look for/ask about a clear cause of infection (Urine, lung, skin are MC)
2) 2 blood Cx, UA, CXR
3) No UCx unless WBCs are in UA
4) No sputum Cx unless new infiltrate on CXR and sputum is produced

20

What about "pan-culture"

Don't do it! The only thing you need for fever/high WBC is a blood culture (2). Do UCx only if UA is + for WBCs and no sputum culture unless indicated.

21

Urine culture done and shows E. coli and/or fungi. Now what?

if there's no evidence of infection (eg, no WBCs on U/A) then don't treat (exception is pregnant women).

22

E. coli growing from urine w/o WBCs or dysuria can be from?

1. Colonization of Foley
2. Contamination on urine collection
3. "Clean catch" urine can be very hard to obtain in bedbound pts, esp women, demented.

23

blood cx can be contaminated with _____ from inadequate prep

skin bacteria (flora)

24

If blood cx grows an organism you have to make sure it's...?

...a true infection and not a contaminant.

25

If blood cx grows an organism you have to make sure it's a true infection and not a contaminant. How can one tell whether it's a true infection (or limit the result to be of a contaminant?)

if same organism is grown from multiple sites (thus, taking at least 2 blood cx from MULTIPLE sites is key!)

26

the only routine culture in a febrile patient is...

a blood culture.

27

When should you suspect sepsis?

1. Fever + hypotension + tachycardia
2. Metabolic acidosis (pH < 7.2) w/ low HCO3
3. Incr anion gap
4. Resp alkalosis (compens) PCO2 <35
5. high/low WBC (less important than acidosis and hypotension)

28

What should you order for a pt with sepsis?

blood cx
UA
CXR
Abx NOW! -- don't wait for lab results (can't wait 1-2 days for blood cx results if pt is septic.

29

in addition to sepsis signs, what sx/sy would make you believe a pt is in severe sepsis?

organ dysfunction -- renal, hepatic, CNS disturbance

30

Treatment of sepsis is ..

empiric (prior to culture results)

31

Is there one single treatment for all sepsis?

No

32

How do you generally empirically treat sepsis?

Vancomycin + 1 of the following
1. Zosyn (pipercillin/tazobactam) or Timentin (Ticarcillin/Clavulanic acid)
2. Carbapenem (DIM - Doripenem, Imipenem, Meropenem)
3. Cefepime or Ceftazidime

33

How do you generally treat severe sepsis?

Tx of sepsis (eg, Vanc + Zosyn) + a second gram-negative agent:
1. FQ
2. Monobactam (Aztreonam)
3. Aminoglycoside (Gentamicin, Amikacin, Tobramycin)

34

Name the commonly used FQs [4]

1. Ciprofloxacin
2. Levofloxacin
3. Moxifloxacin
4. Gemifloxacin

35

T/F Ciprofloxacin covers pneumococcus

False

36

Name the group of Abx that cover Gram-neg rods

FQs, some Penicillins, Cephalosporins, AGs, Monobactem (Aztreonam) and Carbapenems

37

Which 2 penicillin agents cover gram-neg rods?

Pipercillin, Ticarcillin

38

What must the 2 penicillin agents be combined with to cover for gram-neg rods?

a beta-lactamase inhibitor
Pipercillin - tazobactam
Ticarcillin - Clavulonate

39

What are the 4 commonly used Cephalosporins against gram-neg rods?

Ceftriaxone
Cefotaxime
Cefepime
Ceftazidime

40

What is considered the #1 Cephalosporin agent against pneumococcus?

Ceftriaxone

41

What are the 3 common aminoglycosides (AGs) used against gram-neg rods?

GTA
Gentamicin, Tobramicin, Amikacin

42

Should aminoglycosides be used as single agents against gram-neg rods?

No!

43

What is the common monobactem that is used against gram-neg rods?

Aztreonam

44

Which beta-lactam does not have cross-reaction with penicillin?

Aztreonam

45

What are the 4 carbapenems commonly used against gram-neg rods?

DIME
Doripenem, Imipenem, Meropenem, Ertapenem

46

Which carbapenem does not cover Pseudomonas?

Ertapenem

47

Pt has PCN allergy (rash only), can Ceph's be used

yes

48

Staph and Strep commonly cause which diseases (organs)?

Bone/heart/skin/joint infections

49

What are the IV meds used against Staph aureus and Strep pyogenes?

IV Oxacillin, IV Nafcillin, IV Cefazolin (1st gen Ceph)

50

What are the Oral meds used against S. aureus and Strep pyogenes?

PO Dicloxacillin, PO Cephalexin

51

Oxacillin route of administration?

IV

52

Dicloxacillin route of administration?

PO

53

Nafcillin route of administration?

IV

54

Cefazolin route of administration?

IV

55

Cephalexin route of administration?

PO

56

What are the common gram-neg rods?

E.coli, Enterobacter, Pseudomonas, Citrobacter, Klebsiella, Proteus, Serratia, Morganella

57

Gram-neg rods often cause what diseases (organs)?

GI/UTI/Liver

58

Anaerobes often cause what diseases (organs)?

Abdominal/Lung, Abscesses

59

GI diseases 2/2 anaerobes are often tx w/ what meds?

Flagyl (Metronidazole)
Carbapenems
B-lactam/lactamase

60

Respiratory diseases 2/2 anaerobes are often tx w/ what meds?

Clindamycin
B-lactam/lactamase

61

Tigecycline covers ___ and ___

MRSA and G(-) rods

62

MRSA infection can be divided into 2 types...

Severe infections and minor localized infection

63

'Severe' MRSA = ??

Lung, Heart, CNS, Bacteremia

64

'Minor localized' MRSA = ??

Skin

65

Severe MRSA drug options

1. Vancomycin
2. Linezolid
3. Daptomycin
4. Tigecycline
5. Ceftaroline

66

Minor localized MRSA drug options

1. Bactrim (TMP/SMX)
2. Clindamycin
3. Doxycycline
4. Linezolid

67

Common dangerous adverse effect of Linezolid?

Thrombocytopenia

68

Common dangerous adverse effect of Daptomycin?

CPK elevation

69

T/F Daptomycin is not effective in the lungs

True

70

Which cephalosporin covers MRSA?

Ceftaroline

71

What are the 4 commonly used Beta-lactam/Beta-lactamase antibiotics?

1. Unasyn (Ampicillin/Sulbactam)
2. Augmentin (Amoxacillin/Clavulonate)
3. Zosyn (Piperacillin/Tazobactam)
4. Timentin (Ticarcillin/Clavulonate)

72

What is the generic name for Unasyn?

Ampicillin/Sulbactam

73

What is the generic name for Augmentin?

Amoxacillin/clavulanate

74

What is the generic name for Zosyn?

Piperacillin/Tazobactam

75

What is the generic name for Timentin?

Ticarcillin/Clavulante

76

The beta-lactam/beta-lactamase meds all cover what?

1. Streptococcus
2. Anaerobes
3. Most gram-(-) rods
--Piperacillin and Ticarcillin also cover Pseudomonas

77

What does the beta-lactamase inhibitor do? Why add it to the beta-lactam?

Adds Staph coverage
Expands gram-neg rod coverage

78

Which Abx are safe in pregos?

1. Penicillins (ALL of them)
2. Cephs (ALL)
3. Aztreonam
4. Carbapenems
5. Nitrofurantoin (eg, UTI)
6. Metronidazole
7. Azithromycin

79

Flagyl + EtOH -->??

Disulfuram-like reaction --> Nausea + Vomiting

80

Flagyl adverse effects?

Metal taste
CNS disturbance

81

Imipenem adverse effect?

Seizures

82

Quinolones adverse effects?

1. Bone/tendon growth abnormality
2. Avoid in pregnancy/children
3. Rare QT prolongation

83

All UTIs present with?

Dysuria

84

What is dysuria?

"F U Bitch"
Frequency
Urgency
Burning

85

What is urinary frequency?

urge to urinate often, without much urine coming out

86

what question can you ask to assess for urinary urgency?

"When you feel you have to go, do you feel you have to RUN to the bathroom?"

87

Frequency vs Polyuria

Frequency = going often, may or may not pee a lot
Polyuria = increased volume of urine (eg, DM, DI)

88

What clinical presentation do you expect in a pt with Cystitis?

look for Dysuria (FUB) + Suprapubic/bladder pain + Afebrile + UA > 5-10 WBCs

89

Patient presents with dysuria, suprapubic pain + U/A 6 WBCs. T* 37.3*C. Next best step in therapy?

start treatment with Abx (Nitrofurantoin, Fosfomycin, or Bactrim). Do not wait for results of urine culture.

90

What are the drugs to use for Cystitis?

Nitrofurantoin
Fosfomycin
Bactrim

91

What dose of Nitrofurantoin may you use to tx Cystitis?

Nitro 100 mg BID x 5 days

92

What dose of Fosfomycin may you use to tx Cystitis?

Fosfo 3 g single dose

93

What dose of Bactrim (TMP/SMX) may you use to tx Cystitis?

Bactrim DS 1 bid x 3 days

DS = double strength

94

What would you do if the cystitis is "complicated"?

extend *length* of Abx

95

Who is treated longer for cystitis, males or females?

Males b/c of longer UT and likely anatomical defect.

96

Male presents with UTI. Next step after empiric treatment?

Renal/Urinary tract imaging with U/S or CT.

97

Complicated UTIs need at least how many days of therapy?

7 days.

98

What is usually the case when a patient has a complicated UTI?

obstruction or foreign body 2/2
1. stone
2. stricture
3. tumor, obstruction, neurogenic bladder
4. Pregnancy
5. catheters
6. diabetes

99

what is the clinical presentation of Pyelonephritis?

Dysuria + UA w/ WBC (more than in cystitis)
1. Flank or CVA tenderness and pain
2. FEVER!!!
3. More "sick" than cystitis

100

What do you need to do diagnostically in someone with dysuria + WBC on UA + CVA tenderness + fever?

Get U/S or CT to determine CAUSE of UTI.

eg, to look for stone, stricture, obstruction

101

If patient gets recurrent UTIs, what may be the underlying cause?

anatomic problem causing the pyelo that is not detected on US or CT.

102

Outpatient Tx of Pyelo?

PO Ciprofloxacin 750 mg bid for 10-14 days.

103

What is the clinical significance b/w PO and IV Cipro

PO Cipro at higher dose (750 mg bid) has a similar "area under the curve" as IV cipro (ie, bioavailability).

104

Inpt tx of pyelo?

Ceftriaxone 1 g q 24 hours
Ciprofloxacin
Ampicillin and Gentamicin
Meropenem, b-l/b-lase (severe, complicated cases)

105

If a pt has a resistant organism causing pyelonephritis, what can they develop?

Perinephric abscess

106

T/F A pt with pyelonephritis will not improve after 5-7 days of treatment.

True, especially if they have a resistant organism causing a perinephric abscess

107

Pt with a perinephric abscess would show what on CT?

CT of kidneys will show a collection under the capsule.

108

What is required in the management of a perinephric abscess?

CT-guided biopsy/aspiration. Appropriate therapy has to be tailored to what is found in the culture.

109

How are skin infections diagnosed?

By physical exam (appearance). There's, generally, no specific diagnostic test.

110

Why are there, generally, no specific, useful diagnostic tests for skin infections?

Swab cultures are worse than useless and aspirations yield little.

111

How many skin infections cause bacteremia?

<5%.

112

What is cellulitis?

deep tissue infection in the subcutaneous tissues and dermis.

113

Is drainage common in cellulitis?

no

114

What is the MC organism that causes cellulitis?

S. aureus

115

What is another common cause of cellulitis?

Group A beta hemolytic Strep pyogenes (less common than S. aureus).

116

List the following skin infections from superficial to deep.
Erysipelas, Impetigo, Cellulitis

Superficial --> Deep

Impetigo --> Erysipelas --> Cellulitis

117

Bright red and warm/hot skin 'rash'
somewhat deep
culture shows GAS
Who am I?

Erysipelas

118

T/F Erysipelas is easier to determine by appearance

False

119

Superficial skin infection
"weeping, crusting, oozing lesion that may look like honey

Impetigo

120

IV treatment for skin infections (eg, cellulitis)

IV Oxacillin, Nafcillin
IV Cefazolin (Ancef)
IV Vancomycin if no response after 2-3 days or anaphylaxis to Penicillin

121

Dose of IV oxacillin or nafcillin for skin infection (eg, Cellulitis)

1-2 grams q 4 hrs

122

Dose of IV Cefazolin for skin infection

1-2 grams q 8 hrs

123

Dose of IV Vancomycin for skin infection

1 gram q 12 hours

124

Is Cefazolin safe when patient has rash allergy to penicillin?

yes

125

Topical meds for skin infection caused by staph or strep?

Mupirocin (Bactroban)
or
Retapamulin

126

What is muporocin used for?

It's a topical antibiotic used against staph/strep skin infections

127

What is Retapamulin used for?

It's a topical antibiotic used against staph/strep skin infections

128

Oral meds against staph/strep skin infections?

PO Dicloxacillin or Cloxacillin
PO Cephalexin (Keflex)
anti-MRSA (local) abx (Bactrim, Clindamycin, Doxycycline, Linezolid)

129

How much of dicloxacillin or cloxacillin should be used for staph/strep skin infections?

PO, 500 mg 4x/day

130

How much of cephalexin (Keflex) should be used for staph/strep skin infections?

PO, 500 mg 4x/day

131

Endocarditis - look for what in the patient?

fever
new murmur or change in a murmur

132

Risks of endocarditis

injection drug use
prosthetic valves

133

Rare manifestations of endocarditis

embolic events (splinter hemorrhage, Roth spots in eye, Janeway/Osler's in hands/feet).

134

T/F Persistent bacteremia may be a feature of endocarditis

true

135

patient is an IV drug user, fever, new murmur.
-MLDx?
-first best test?

Endocarditis
Blood cultures (3) to rule out ec.

136

What is a strong clinical indicator of endocarditis?

sustained or persistent bacteremia

137

patient is an IV drug user, fever, new murmur.
-MLDx?
-first best test?
-first test is +, next best diagnostic step?

-endocarditis
-blood cultures (+)*
-ECHO (TTE first)

*if suspicion for ec is high, start empiric Abx tx

138

When would you do a TEE for endocarditis?

If TTE is negative and there is persistent bacteremia.

TEE is 95% Sn and Sp.

139

What would you expect to see on ECHO for endocarditis?

vegetations
murmurs

140

When should treatment for endocarditis be started if suspicion is high?

as soon as 3 blood cx are obtained.

141

Empiric antibiotic therapy for endocarditis?

Vancomycin + Gentamicin

142

When should antibiotics be changed for endocarditis?

once blood cx grow and the specific organism and sensitivity is known, switch abx

143

Pt with suspected endocarditis has positive blood culture of an organism that is sensitive to PCN. The patient had been on vanc + gent. Next best step?

Switch from Vanc --> PCN b/c of more efficacy!