Cumulative Study Flashcards
(93 cards)
1
Q
WHICH ORGANISMS
cause
AOM
A
1 = STREPTOCOCCUS PNEUMONIAE
- *VIRUS = MOST COMMON**
- advocate to VACCINATE –> Influenze & Pneumococcal*
Moraxella Catarrhalis + HaemoPhilus Influenza
- Staphylococcus Aureus*
- rare but need for CLINDA for this*
2
Q
When to consider:
OBSERVATION
A
Based on:
Age & Severity
Healthy Children:
6mo - 2y/o w/ non-severe illness & unilateral involvement
or
> 2 y/o** w/ **non-severe** illness & **no otorrhea (ear discharge)
Observation is:
Defer AB therapy for 48-72 hours
Schedule an RE-Evalulation // Communication
SNAP –> don’t fill RX until DR. conformation
3
Q
2nd Line Treatment
For
SEVERE AOM
BILATERAL infection / OTORRHEA
Fever > 39*C (102.2*F)
A
- *CEFTRIAXONE**
- *IM QD x 3 days**
or
Cefdinir
QD - BID
Cefuroxime
BID
4
Q
1st Line Treatment
For
NON-SEVERE AOM
Mild Symptoms / Unilateral Infxn / No Otorrhea
Fever < 39* (102.2F)
A
AMOXICILLIN** @ **80-90 mg/kg/day BID
HIGH DOSE –> needs to reach MIDDLE EAR
OR
OBSERVATION
defer AB for 48-72 hours
if observed & failed after 48-72 hours –> AMOX 80-90
5
Q
Treatment if PCN allergy
For
NON-SEVERE AOM
Mild Symptoms / Unilateral Infxn / No Otorrhea
Fever < 39* (102.2F)
A
Cefuroxime - BID
or
Cefdinir - QD or BID
6
Q
3rd Line Treatment
For
NON-SEVERE AOM
Mild Symptoms / Unilateral Infxn / No Otorrhea
Fever < 39* (102.2F)
A
After Failing AMOXICILLIN +/- Observation:
&
Failing AUGMENTIN:
CEFTRIAXONE - IM QD F3D
- *CLINDAMYCIN**
- may need ADDITIONALLY to cover* H.Influenzae
TYMPANOCENTESIS
TUBE to withdraw fluid or pus from middle ear
7
Q
1st Line Treatment
For
SEVERE AOM
BILATERAL infection / OTORRHEA
Fever > 39*C (102.2*F)
A
AUGMENTIN** @ **80-90 mg/kg/day BID
8
Q
When to Suggest < 10 day therapy
for
AOM
A
7 DAY THERAPY for:
2-5 y/ow/mild-Moderate AOM
- *5-7 Day Therapy** for:
- *>** 6y/o
9
Q
Outpatient CAP Treatment
No recent AB therapy
<90 days
A
MACROLIDE** or **DOXYCYCLINE
-
ZPAK (500mg x1day -> 250mg x4days)
- 5 days, stays INSIDE cellls
-
Azithromycin XR Suspension 2gm
- one dose
-
Clarithromycin 250-500mg BID or XR 1gm daily
- no renal adjustment
- GI upset / Ototoxicity / 3A4 inhibitor
-
DOXYCYCLINE 100mg q12h
- 7-14 days
- no renal adjustment
- Teeth discoloration / GI Upset
- antacids / magnesium / iron / calcium
10
Q
INPATIENT CAP Treatment
NON-ICU
A
B-LACTAM
cefuroxime / ceftriaxone / ertepenem / amp-sulbactam
+
MACROLIDE** or **DOXYCYLINE** or **RESPIRATORY FLUOROQUINOLONE
levofloxacin / moxifloxacin
11
Q
INPATIENT CAP Treatment
ICU + PCN ALLERGY
A
RESPIRATORY FLUOROQUINOLONE
Levofloxacin + Moxifloxacin
+
AZTREONAM
1-2gm IVPB q8
instead of B-Lactam (ceftriaxone etc.)
12
Q
INPATIENT CAP Treatment
ICU
A
B-LACTAM
cefuroxime / ceftriaxone / ertepenem / amp-sulbactam
ceftriaxone could be dosed 1gm IVPB q12
+
MACROLIDE** or **RESPIRATORY FLUOROQUINOLONE
levofloxacin / moxifloxacin, same doses
13
Q
Common Organisms (6)
CAP
A
“SMH - MILC”
SMH = Same as AOM
STREPtococcus PNEUMoniae
M. Catarrhalis
H. Influenzae
Legionella + Influenza
Mycoplasma + Chlamydophilia
14
Q
Outpatient CAP Treatment
Recent AB therapy (90days) or Comorbid Conditions
Chronic: Liver / Heart / Renal / Lung Disease
Diabetes / Malignancy
Diabetes / Asplenia / IMS disease-drugs
A
RESPIRATORY FLUOROQUINOLONE
Levofloxacin / Moxifloxacin / Gemifloxacin
OR
MACROLIDE + B-LACTAM
Zpak or Clarithromycin
Augmentin / Amoxicillin / Cefuroxime / Cefpodoxime
15
Q
- *CURB-65**
- *PNEUMONIA TREATMENT**
Score:
0-1 = Outpatient
2 = Inpatient
> 3 = ICU
A
20 - 30/60/90
Confusion
Uremia = BUN > 20mg/dl
Respiratory Rate > 30
Blood Pressure < 90/60 mmHg
Age > 65
16
Q
CAP Treatment
Length of Therapy
A
7-14 Days total
except for zpak (5days) / levofloxacin (750mg 5days)
Legionella = 7-10 days
17
Q
When to COVER MRSA?
HAP
A
Risk factor for MDR
ABx <90 days / >5day hospitalization
VAP - Septic Shock / ARDS / Acute renal replacement therapy
Unit where patient is residing has:
>10% incidence of MRSA
Prevelence of MRSA NOT KNOWN
and/or
patient is INTUBATED
and/or
SEPTIC SHOCK
18
Q
HAP Treatment if
MSSA ISOLATED
A
2-N-O-C
Nafcillin
2gm IVPB q4h
Oxacillin
2gm IVPB q4h
Cefazolin
2gm q8h
19
Q
What HAP drug has DRUG INTERACTIONS?
& What drugs?
A
LINEZOLID
600mg q12h for MRSA Coverage
SSRI’s - Fluoxetine
TCA’s / Venlafaxine
Mirtazapine
TRAZADONE
20
Q
HAP TREATMENT
2 DRUGS
for
Pseudomonas or Resistant Gram-NEG-
SECOND DRUG
A
“CCBM + FAP”
Antipseudomonal Fluoroquinolone
- *Levofloxacin** - 750mg IVPB qd
- *Ciprofloxacin** - 400mg IVPB q8h
- *AminoGlycoside**
- *Gentamicin / Tobramycin / Amikacin**
- *Polymixin**
- *Colistin** - 5mg/kg x1dose -> 2.5mg/kg IVPB q12h
- *Polymixin B -** 2.5-3mg/kg/day IVPB in TDD
21
Q
HAP TREATMENT if
NO MRSA RISK FACTORS / No factors for Resistance
A
Empirically Cover with MONOTHERAPY“CLIP-M”
Cefepime
Levofloxacin
Imipenem
Piperacillin-Tazobactam
Meropenem
22
Q
When to use
2 DRUGS
for
Pseudomonas or Resistant Gram-NEG-
A
Risk Factor for MDR
ABx <90 days / >5day hospitalization
VAP - Septic Shock / ARDS / Acute renal replacement therapy
Unit where patient is residing has a:
>10% incidence of RESISTANCE to the ANTBIOTIC
that is being considered for monotherapy
Prevelance is NOT KNOWN & INTUBATED
Or
patient has structural lung disease –> ↑risk of G- infxns
CYSTIC FIBROSIS**or**BRONCHIECTASIS
23
Q
Risk Factors for
MULTI DRUG RESISTANT PATHOGENS
HAP
A
<90 day Antimicrobial Therapy
> 5 days of Hospitalization
Septic Shock @ time of VAP
ARDS preceding VAP
Acute Renal Replacement Therapy prior to VAP
24
Q
HAP TREATMENT
2 DRUGS
for
Pseudomonas or Resistant Gram-NEG-
FIRST DRUG
A
“CCBM + FAP”
Antipseudomonal Cephalosporin
- *CEFtazadime** - 2gm IVPB q8h
- *CEFipime** - 2gm IVPB q8h
Antipseudomonal Carbapenem
- *Imipenem** - 500mg IVPB q6h
- *Meropenem** - 1gm IVPB q8h
- *B-Lactam_/_B-lactamase inhibitor**
- *Piperacillin / Tazobactam** - 4.5gm IVPB q6h
- *Monobactam**
- *Aztreonam** - 2gm IVPB q8h
25
**Which TB Drug based on Target?**
INHIBIT:
**_Mycolic Acid Synthesis_** - C60-90 alpha alkyl
&
target **_inhA_** = **long chain NAD-dependent _enoyl-ACP reductase_**
*INH covalently attaches to nicotinamide ring of NADH@ side of hydride exhange*
* *_ISONIAZID_** = **INH**
* *ETHIONAMIDE = ETH**
**_*Hepatotoxicity***_ & _***PERIPHERAL NEURITIS*_** --\> **give B6**
Both are:
**_Bacterial-Activated Prodrugs_**
**Isoniazid** is activated by **_Catalase Peroxidase_ = _katG_**
**Ethionamide** is activated by **_Monooxygenase_ = _etA_**
26
**Which TB Drug based on Target?**
binds to:
**beta-subunit** **_rpoB_** of **RNA polymerase**
changes conformation -\> *prevents binding of nucleotides & inhibits initiation of transcription*
**_RIFAMYCINS_**
**HEPATITIS + RED URINE**
***_INDUCTION OF CYP450 ENZYMES_*** --\> ↓**Half-Life of:**
**steroids / anticoagulants / macrolides / imidazoles
Protease inhibitors / NNRTIs**
**Rifampin**
* *Rifabutin**
* less p450 activation --\> recommended for HIV/TB co-infection*
* *Rifapentine**
* LONG HALF LIFE --\> can be dosed WEEKLY in continuation phase*
27
**Which TB Drug based on Target?**
only active in vitro at **low pH \<6**
Requires:
**_pncA_**
to generate the active agent = **pyrazinoic acid**
**Sterilizing Activity**
treatment 9mo --\> 6mo
**_PYRAZINAMIDE_**
**Significant _HEPATOTOXICITY_**
↑**ALT ↑AST**
*MOA IS UNCERTAIN*
TB-SPECIFIC DRUG:
**TB has *_deficient efflux_*** **compared to some naturally resistant mycobacteria**
28
**Which TB Drug based on Target?**
inhibits:
**_ARABINOSYL TRANSFERASE_**
affecting the synthesis of:
**arabinogalactan & lipoarabinomannan in cell wall**
**_ETHAMBUTOL_**
***OPTIC NEURITIS***
visual acuity --\> red-green differentiation
29
**Isoniazid Resistance**
PERIPHERAL NEURITIS --\> GIVE B6
HEPATOTOXICITY
65% in
* *_katG_** = activating enzyme
* *Missense** or **Large deletions** in **catalase peroxidase**
20% in
* *_inhA_** = final target
* *mutations in NADH binding site**
30
**Rifamycin Resistance**
HEPATITIS + RED URINE
P450 INDUCER
**Single AA substitutions in hotspot in:
_rpoB_**
RNA polymerase subunit
31
**Ethambutol Resistance**
*OPTIC NEURITIS*
*very low resistance*
**OVERexpression of:
_embA**_+_**embB**_+_**embC_**
32
* *Rifabutin Uses**
* in comparison to RIFAMPIN*
* **_LESS ACTIVATION OF P450_***
* rifampin --\> strong p450 INDUCER*
Rifamycin of choice for:
**_HIV/TB Co-infection_** when using **protease inhibitors**
Active vs some:
**_Rifampin-resistant strains of M. TB_**
use for:
**_M.AVIUM_** - **intracellulare infection**
33
* *Rifapentine Uses**
* in comparison to RIFAMPIN*
* *_LONGER HALF LIFE_**
* *intermittent dosing** --\> **2x a week for initial phase**
**_ONCE A WEEK_** in **Continuation phase**
*_not active against Rifampin-resistant strains of M. TB_*
34
**_DiarylQuinoline = Bedaquiline_**
## Footnote
**Uses for TB**
Targets: **ATP-SYNTHASE**
**5 month half life --\> single dose**
highly potent vs:
***_NON-REPLICATING M.TB_*** = **LATENT TB**
**_FDA approved for MDR-TB_** when **no other options available**
Adr:
**Prolonged QT Interval** + **Hepatotoxicities**
35
**Treatment for:**
**_STAPH Aureus_**
Coagulase-Negative Staphylococci
**_PVE_**
(Prosthetic)
**_*No resistance* / Susceptible Strains_**
**PVE STAPH = 3 DRUGS** + **\>6 week treatment**
**_Nafcillin**_ or _**Oxacillin_**
**12g** per 24h
**_\>_ 6 WEEKS**
++++
**_Rifampin_**
**900mg** per 24 hours
**_\>_ 6 WEEKS**
+++
**_Gentamicin_**
**3mg/kg** per 24 hours
**2 WEEKS**
36
**Treatment for:**
**_STREP_**
Veridans / Gallolyticus / Abiotrophia / Granulicatella
**_NVE_**
(native valve endocarditis)
* *_PCN - Intermediate Resistance_**
* *MIC \> 0.12 , \<0.5**
* *_Penicillin G Sodium_**
* *24 million** units per 24 hours
* *4 WEEKS**
**++PLUS++**
* *_Gentamicin_**
* *3mg/kg** per 24 hours
* *2 WEEKS**
37
**Treatment for:**
**_STREP_**
Veridans / Gallolyticus / Abiotrophia / Granulicatella
**_NVE_**
(native valve endocarditis)
**_PCN ALLERGY_**
* *_Vancomycin_**
* *30mg/kg** per **24 hours** in 2divdoses
* *4 WEEKS**
for
**PVE --\> 6 Week treatment**
38
**Treatment for:**
**_STREP_**
Veridans / Gallolyticus / Abiotrophia / Granulicatella
**_NVE_**
(native valve endocarditis)
* *_PCN SENSITIVE_**
* *MIC \< 0.12**
* *_Penicillin G sodium_**
* *12-18** million units / **24** hours
* *4 WEEKS**
OR
**_Penicillin**_ + _**Gentamicin_**
same + **3mg/kg** / 24 hours
**2 WEEKS**
39
**Treatment for:**
**_STREP_**
Veridans / Gallolyticus / Abiotrophia / Granulicatella
**_PVE_**
(Proshetic Valve Endocarditis)
* *_PCN SENSITIVE_**
* *MIC \< 0.12**
* *_Penicillin G sodium_**
* *24 million** units for 24 hours
* *6 WEEKS**
with or without
* *_Gentamicin_**
* *3mg/kg** per 24 hours in 1 dose
* *2 WEEKS**
40
**Which patients should recieve
_PROPHYLAXIS_**
for
**Infective Endocarditis?**
**_Prosthetic Valve**_ OR _**Material_**
**_Previous IE_**
infective endocarditis
**_CONGENITAL HEART DISEASE_**
**palliative shunts / conduits**
**repaired** congenital heart defects
cardiac **TRANSPLANTATIOn recipients**
41
**Treatment for:**
**_STREP_**
Veridans / Gallolyticus / Abiotrophia / Granulicatella
**_PVE_**
(Proshetic Valve Endocarditis)
* *_PCN Resistant_**
* *MIC \> 0.12**
*Same as PCN resistant, but PLUS gentamicin is 6 WEEKS (not 2)*
* *_Penicillin G sodium_**
* *24 million** units for 24 hours
* *6 WEEKS**
++PLUS++
* *_Gentamicin_**
* *3mg/kg** per 24 hours in 1 Dose
* *6 WEEKS**
42
**Treatment for:**
**_STAPH Aureus_**
Coagulase-Negative Staphylococci
**_NVE_**
(Native Valve Endocarditis)
**_PCN ALLERGY_**
* *_Vancomycin_**
* *30mg/kg** QD
* *6 WEEKS**
43
**Treatment for:**
**_STAPH Aureus_**
Coagulase-Negative Staphylococci
**_NVE_**
(Native Valve Endocarditis)
***_No Resistance = Susceptible Strains_***
* *_Oxacillin**_ or _**Nafcillin_**
* *12g / 24h** in **4-6 dd**
* *6 WEEKS**
44
**Treatment for:**
**_STAPH Aureus_**
Coagulase-Negative Staphylococci
**_NVE_**
(Native Valve Endocarditis)
**_RESISTANT STRAINS_**
* *_Vancomycin_**
* *30mg/kg** per 24 hours in **2dd**
* *6 WEEKS**
same as PCN allergic
45
**Treatment for:**
**_STAPH Aureus_**
Coagulase-Negative Staphylococci
**_PVE_**
(Prosthetic)
**_RESISTANT STRAINS_**
* *PVE STAPH = 3 DRUGS** + **\>6 week treatment**
* Resistant --\> vanco instead of oxacillin*
**_VANCOMYCIN_**
**30mg/kg** per 24hr in **2dd**
**_\>_ 6 WEEKS**
++++
**_Rifampin_**
**900mg** per 24 hours
**_\>_ 6 WEEKS**
+++
**_Gentamicin_**
**3mg/kg** per 24 hours
**2 WEEKS**
46
**Treatment for:**
**_Enterococcuus_**
Coagulase-Negative Staphylococci
**_PVE**_ or _**NVE_**
(Prosthetic OR native)
**_RESISTANT STRAINS_**
to **PCN / Vancomycin / Gentamicin**
* *_LINEZOLID_**
* *600mg** IV or ORAL **q12 hr**
* *_\>_** **6 Weeks**
**OR**
* *_DAPTOMYCIN_**
* *10-12 mg/kg per dose**
* *_\>_** **6 Weeks**
47
**Treatment for:**
**_Enterococcuus_**
Coagulase-Negative Staphylococci
**_PVE**_ or _**NVE_**
(Prosthetic OR native)
***_NO RESISTANCE_***
to **PCN / Vancomycin / Gentamicin**
* *_AMPICILLIN_**
* *2g** every **4hrs**
* *4-6 WEEKS**
for PCN allergy:
**Vancomycin + Gentamycin**
48
**Treatment for:**
**_FUNGI_**
Infective Endocarditis
* *_Amphotericin B_** **+/- _Flucytosine_**
* treatment duration is UNKNOWN*
## Footnote
**_REQUIRES VALVE REPLACEMENT_**
49
**Treatment for:**
**_GRAM NEGATIVE BACILLI_**
Infective Endocarditis
* *_B-Lactam**_ + _**AminoGlycoside_**
* *6 WEEKS**
## Footnote
**_REQUIRES VALVE REPLACEMENT_**
50
**Treatment for:**
**_HACEK_**
Haemophilus / Aggregatibacter / Cardiobacterium / Eikenella-Kingella
Responsible for 5-10% of community aquired NVE
* *_CEFTRIAXONE_**
* *2g** per **24hours** IV or IM **1 dose**
## Footnote
**4 WEEKS**
51
**Indications for
_LONG-TERM CATHETERS_**
**PICC**
**Port-a-cath**
**Groshong = CLosed end**
**Hickman = open end**
* Lack of short term peripheral venous access (e.g, **IV drug users**)
* Infusion of hyperosmolar solutions (e.g., **TPNs**)
* Infusion of vessicant/ irritant drugs (e.g., certain **chemotherapy**)
* Long-term IV therapy (e.g., **treatment of endocarditis**)
* Infusion of intermittent drug therapy (e.g., chemotherapy)
* Use of continuous ambulatory drug pumps (e.g., TPN)
* Patient, physician or nursing preference
* Geographic location (e.g., lives out in the country)
52
**_Bacterial ETIOLOGY_**
of
**CR-BSI**
**_Coagulase Negative STAPHylococcus_**
**All Gram Negative Bacteria**
**Enterococci = STAPH.Areus**
**Candida**
53
**CR-BSI TREATMENT:**
**_STAPHYLOCOCCUS AUREUS_**
***no resistance***
* *_Nafcillin_** or **_Oxacillin_**
* *1-2 gm IVPB q4-6hr**
## Footnote
**2-6 WEEKS**
**_REMOVE LINE_**
54
**CR-BSI TREATMENT:**
**_ENTEROCOCCI_**
&
**VRE
(Vanco Resistant Enterococci)**
*same as Coagulase Negative STAPH*
**_VANCOMYCIN_**
**15mg/kg q12h
AB LOCK
10 - 14 day treatment**
**_for isolated VRE - PULL LINE_**
**_Daptomycin_** - **6mg/kg/day**
OR
**_Linezolid_** - **600mg q12h**
55
**CR-BSI TREATMENT:**
**_GRAM NEGATIVE BACILLI_**
**Piperacillin/Tazobactam**
**Ceftazidime** or **Cefipime**
**Imipenem** or **Meropenem**
+/- **aminoglycoside**
**_7-14 days_**
***_REMOVE THE CATHETER_***
56
**CR-BSI TREATMENT:**
**_STAPHYLOCOCCUS AUREUS_**
**RESISTANCE**
Methicillin Resistant Strains
* *_Vancomycin_**
* *15mg/kg q12**
OR
* *_Daptomycin_**
* *6-8mg/kg**
**2-6 WEEKS
_REMOVE LINE_**
57
**TREATMENT FOR:**
* *_SEVERE / MODERATE PURULENT ABSSSI_**
* *Cutaneous / Furuncle / Carbuncle**
**SYSTEMICALLY ILL**
Elevated HR / RR / TEMP / WBC
**IMMUNOCOMPROMISED**
**Multiple Abscesses - Extreme Age**
***Lack of RESPONSE to I&D***
**_INCISION & DRAINAGE_**
+
**_EMPIRIC ABx --\> MRSA_**
**Vancomycin / Daptomycin / Linezolid / Doxy / Bactrim**
+
**Check Cultures --\> _DEFINED Rx_**
MSSA Possible --\> Nafcillin / Cefazolin / Clindamycin
58
* *_Erysipelas & Cellulitis_**
* **NON-purulent ABSSSI***
**_CAUSED BY WHAT ORGANISM(s)?_**
Primarily caused by:
**STREPtococcus SPP.**
**_B-HEMOLYTIC GROUP A_**
(**S. Pyogenes)**
Groups: **B-C-F-G**
## Footnote
***_rarely Staph Aureus_***
59
* *_CUTANEOUS ABSCESS_**
* *Purulent ABSSSI**
**_CAUSED BY WHAT ORGANISM(s)?_**
**Painful** - **Tender** - **Fluctuant Red Nodules**
Often surmounted by a:
**Pustule** & **Circumscribed by a rim of Erythema + Swelling**
Collection of
**PUS** within **dermis & deeper skin tissue**
Primarily caused by:
**_STAPH Aureus_**
Treatment:
**_Incision & Drainage_**
addition of Systemic ABx does NOT improve cure rates
*even in MRSA*
60
* *_CARBUNCLE_**
* *Purulent ABSSSI**
**_1st LINE TREATMENT_**
1st Line Treatment:
**_Incision & Drainage_**
*abx unnecessary unless SYSTEMIC S/Sx of infection*
61
* *_ERYSIPELAS & CELLULITIS_**
* **NON-Purulent ABSSSI***
**_1st LINE TREATMENT_**
1st Line Treatment:
**_ABx Therapy_** to cover:
**_GROUP A STREP**_ = _**B-HEMOLYTIC Group A_**
(**S. Pyogenes****)**
**PENICILLIN VK**
**CEPHALOSPORIN** / Ceftriaxone IV / Cefalozin IV
**CLINDAMYCIN**
**DICLOXACILLIN**
62
* *_NECROTIZING FASCIITIS_**
* **NON-Purulent ABSSSI***
**_1st LINE TREATMENT_**
**_SURGICAL INSPECTION**_ + _**DEBRIDEMENT_**
**ABx therapy until --\> *_no more debridement needed_***
clinically improved / afebrile for 48-72 hours / until they are better
_EMPIRIC THERAPY_
* *_Gram +POS+_** = **_STREP**_ / _**STAPH**_ (_**MRSA_**)
* *_VANCOMYCIN_** - Linezolid - Daptomycin
* *_Gram -Neg-_**
* *_PIP/TAZO_** - Carbapenem - Ceftriaxone
* *_PLUS METRONIDOZOLE_**
* **_If suspected GAS_***
* *Protein Synthesis Inhibitor**
63
* *_PURULENT ABSSSI_**
* *Cutaneous / Furuncle / Carbuncle**
## Footnote
**When would we use _ANTIBIOTICS?_**
* *_SYSTEMICALLY ILL_**
* *Elevated HR / RR / TEMP / WBC**
**_IMMUNOCOMPROMISED_**
**_Multiple Abscesses**_ - _**Extreme Age_**
**_*Lack of RESPONSE to* *I&D*_**
**ABx targetting MRSA**
**In ADDITION to I&D**
64
**Osteomylitis Treatment**
**DURATION**
&
**Special Considerations?**
minimum of
* *_\>_** **6 Weeks**
* consider IV --\> PO switch for NON-B-lactam ABs*
_EXCEPTION:_
**_\>_** **8 Weeks**
**_VERTEBRAL OSTEOMYELITIS_**
+
**_PARAvertebral ABSCESS**_ OR _**MRSA Infection_**
65
**Osteomylitis Treatment**
* *_Streptococcus spp._**
* pcn sensitive*
**PCN Allergy**
PCN Allergy:
**_VANCOMYCIN_**
Normal:
**_CeftriaXone_**
or
**_Penicillin G_**
66
**Osteomylitis Treatment**
* *_Streptococcus spp._**
* *PCN RESISTANT**
**1st Choice**
base on susceptibilities:
**_CeftriaXone_**
or
**_Vancomycin_**
67
**Osteomylitis Treatment**
Gram Negatives
* *_Enterobacteriaceae_**
* *E. Coli / K. Pneumoniae / Enterobacter / Citrobacter**
**1st Choice**
**_CefePIME_**
**_Ertapenem_**
Alternate for PCN allergy:
Ciprofloxacin
68
**Osteomylitis Treatment**
Gram Negatives
**_P. Aeruginosa_**
**1st Choice**
**_CefePIME_**
**_MEROpenem_**
Alternate for PCN allergy:
Ciprofloxacin
69
**Osteomylitis Treatment**
Gram Negatives
**_Salmonella Spp_**
**1st Choice**
**_CIPROFLOXACIN_**
**Salmonella = typically with SICKLE CELL**
Alternate:
CeftriaXone
70
**Diabetic Foot Infection Treatment**
**1st line Therapy**
**_SEVERE_**
IV ONLY
VERY BROAD:
MRSA / Streptococcus / Enterobaceteriae
Anaerobes / P.aeruginosa
**SEVERE = VCM ALL 3**
**_Vancomycin_**
**_Cefepime_**
**_Metronidazole_**
Moerate or Severe = **2-3 Weeks**
until infection has cleared
71
**Diabetic Foot Infection Treatment**
**_Moderate_**
MSSA + Streptococcus
Enterobacteriaceae + anaerobes
+
**_P. Aeruginosa Risk Factor_**
**MACERATED would** OR High Prevelence
_MODERATE + P.Aeruginosa Risk Factor (MACERATED)_
* *_PIP TAZO_**
* *2-3 Weeks**
Moderate Treatment:
_Amoxicillin / Clavulanate_
_Ampicillin / Sulbactam_
_Piperacillin / Tazobactam_
72
**Diabetic Foot Infection Treatment**
**1st line Therapy**
**_MILD_**
+
**_P. Aeruginosa Risk Factor_**
**MECERATED WOUND** OR **High Local P.Aeruginosa Prevelence**
_P. Aeruginosa Risk Factor = Macerated Wound_
**_CEPHELEXIN**_ + _**CIPROFLOXACIN_**
Mild = **1-2 Weeks**
*until the infection has cleared*
Normal Mild Treatment:
**_Cephalexin**_ OR _**Augmentin**_ OR _**Clindamycin_**
73
**WHEN to treat EMPIRICALLY** + **What Abx?**
for
**Osteomyelitis?**
*_typically NOT treating empirically_* --\> want **cultures first**
only if:
**_HEMODYNAMICALLY UNSTABLE_**
cover for:
**MRSA** / **Streptococci** / **Gram-NEG- bacilli**
**_VANCOMYCIN**_ + _**CEFEPIME_**
PCN ALLERGY:
*instead of cefepime* --\> **cipro** or **aztreonam**
74
**Osteomyelitis Treatment**
**_MSSA_**
Staphlococcus
**ALTERNATE CHOICE**
PCN Allergy:
**_VANCOMYCIN_**
Alt:
**_BACTRIM DS**_ + _**RIFAMPIN_**
**N-O-C**
**_Nafcillin**_ or _**Oxacillin_**
or
**_CefaZolin_**
75
**Osteomylitis Treatment**
* *_MRSA_**
* *_Coagulase Negative Staphylococcus_**
**ALTERNATE Choice**
**_DAPTOMYCIN_**
or
**_Bactrim DS**_ + _**RIFAMPIN_**
Normal:
**_VANCOMYCIN_**
76
**Osteomylitis Treatment**
**_When to add RIFAMPIN?_**
to regular treatment of:
**_MSSA_**
or
**_MRSA**_ + _**Coagulase NEG Staphylococci_**
**RIFAMPIN in COMBO**
*has synergistic activity against BIOFILMS*
for
**_PROSTHETIC JOINTS_**
or
**Alternative _PO THERAPY_**
77
**Osteomylitis Treatment**
**_Streptococcus spp._**
**1st Choice**
**_CeftriaXone_**
**_Penicillin G_**
PCN Allergy:
**Vancomycin**
78
**Osteomylitis Treatment**
Gram Negatives
* *_Enterobacteriaceae_**
* *E. Coli / K. Pneumoniae / Enterobacter / Citrobacter**
**PCN ALLERGY** or **PO Therapy**
Alternate for PCN allergy or PO therapy:
**_CIPROFLOXACIN_**
Normal:
**_CefePIME_** or **_Ertapenem_**
79
**Osteomylitis Treatment**
Gram Negatives
**_P. Aeruginosa_**
**PCN ALLERGY**
Alternate for PCN allergy:
**_CIPROFLOXACIN_**
Normal:
**_CefePIME_** or **_MEROpenem_**
80
**Osteomyelitis**:
**Which bacteria are considered**
**_Enterobacteriaceae?_**
**E. Coli**
**Kleb. Pneumoniae**
**Enterobacter**
**Citrobacter**
Treat with:
**_CefePIME_** or **_Ertapenem_**
Alternate for PCN allergy:
**Ciprofloxacin**
81
**Diabetic Foot Infection Treatment**
**1st line Therapy**
**_MILD_**
+
**_MRSA Risk Factor_**
**H/O MRSA Infxn** OR **High Local MRSA prevelence**
MRSA Risk Factor:
**_CEPHALEXIN**_ + _**BACTRIM_** (sulfa+trimeth)
Mild = **1-2 Weeks**
*until the infection has cleared*
Normal Mild Treatment:
**_Cephalexin**_ OR _**Augmentin**_ OR _**Clindamycin_**
82
**Diabetic Foot Infection Treatment**
**_Moderate_**
MSSA + Streptococcus
Enterobacteriaceae + anaerobes
+
**_MRSA Risk Factor_**
H/O MRSA infxn OR High MRSA Prevelence
_MODERATE + MRSA Risk Factor_
* *_AMPICILLIN/SULBACTAM**_ + _**VANCOMYCIN_**
* *2-3 Weeks**
Moderate Treatment:
_Amoxicillin / Clavulanate_
_Ampicillin / Sulbactam_
_Piperacillin / Tazobactam_
83
**What SITES have ANAEROBES?**
Bacteriodes / Clostridium / Peptostreptococcus
## Footnote
**Intra-Abdominal Infections**
**Anaerobes**
Bacteriodes / Clostridium / Peptostreptococcus
**_Proximal + Distal Small Intestine_**
**_COLON_**
***_no anaerobes in BILIARY TRACT or STOMACH_***
84
**Spontaneous Bacterial Peritonitis = SBP**
**TREATMENT**
* *Streptococcus** + **Enterics** (E.Coli + Kleb)
* no anaerobes*
**_CEFTRIAXONE**_ or _**Cefotaxime_**
for the ENTERICs, strep is covered by most
**_5 DAYS_**
should have improvement within 24-48 hours
**_PROPHYLAXIS_**
typically for MOST SBP (until no longer in LIVER FAILURE)
**FQs** or **BACTRIM**
85
**_ABSCESSES_**
**TREATMENT**
**_SOURCE CONTROL_**
**DRAIN via Percutaneous Catherer or Surgery**
*unable to FULLY DRAIN? --\> duration could be **WEEKS**
based on the **IMAGING***
_Treatment is the same as CIAI_
**CEFTRIAXONE or Cefotaxime**
_Polymicrobial_
* *Enterics + Anaerobes**
* *Pseudomonas - if HIGH-severity or Healthcare-associated**
86
**_TREATMENT_**
_**Community-Acquired** **MILD-MODERATE**_
**_CIAI_**
Complicated ItraAbdominal Infection = Secondary Peritonitis
* *_CEFOXITIN_**
* *Enteric + Anaerobic** Activity
* **_Ertapenem_*** --\> only for **pt w/ ho ESBL**
or
**_METRONIDAZOLE**_ + _**CEFTRIAXONE**_ or _**Cefotaxime_**
87
**_ORGANISMS_**
* *_CIAI_**
* *Complicated ItraAbdominal Infection = Secondary Peritonitis**
Often _POLYmicrobial:_
* *_ENTERICS_**
* *E. Coli + Kleb**
* *_GI ANAEROBES_**
* *Bacteroides / Clostridium / Peptostreptococcus**
* **_PSEUDOMONAS_***
* *Mainly if HIGH-SEVERITY** or **HEALTHCARE-ASSOCIATED**
88
**_TREATMENT_**
**_HIGH-RISK / SEVERE Community-Aquired_**
**_CIAI_**
Complicated ItraAbdominal Infection = Secondary Peritonitis
**ICU PATIENT**
**Advanced Age / Comorbidities**
Immunocomprimised / Malignancy
**DELAY in initial intervention \>24 hours**
**Treatment is the SAME with Healthcare-Associated CIAI**
**_PIPERACILLIN / TAZOBACTAM_**
want to cover ALL
Enterics + Anaerobes + **PSEUDOMONAS**
**Carbapenems --\> reserved for ESBL**
89
**_TREATMENT_**
**_CHOLANGITIS_** + **_Biliary-Enteric Anastamosis_**
Infection/Inflammation of **bile ducts**
**_Enterics**_ + _**Enterococcus_**
With additional coverage for:
**_ANAEROBES**_ + _**PSEUDOMONAS_**
So treat with:
**_PIP/TAZO_**
or
**_CARBAPENEMS_**
*except ERTAPENEM*
ALSO:
**_SOURCE CONTROL_** --\> **_REMOVE GALL BLADDER_** or **_ERCP_**
90
**_TREATMENT_**
**Community Acquired, Mild/Moderate**
**_CHOLECYSTITIS_**
Infection/Inflammation of **gallbladder**
* does NOT need anaerobic activity*
* *Typically Sterile**
* *_Enterics**_ + _**Enterococcus_**
## Footnote
**_CEFTRIAXONE_**
91
**_TREATMENT_**
**Healthcare-Associated** or **High Severity Community-Acquired**
**_CHOLECYSTITIS_**
Infection/Inflammation of **gallbladder**
**_Enterics**_ + _**Enterococcus_**
With additional coverage for:
**_ANAEROBES**_ + _**PSEUDOMONAS_**
So treat with:
**_PIP/TAZO_**
or
**_CARBAPENEMS_**
*except ERTAPENEM*
ALSO:
**_SOURCE CONTROL_** --\> **_REMOVE GALL BLADDER_** or **_ERCP_**
92
**Treatment / Bacteria**
**_APPENDICITIS_**
_Polymicrobial_
**Enterics** + **Anaerobes** + **Streptococci**
**_ABx Choice is SAME as Community-Acquired CIAI_**
**_CEFOXITIN_**
Enterics + Anaerobic
OR
**_Ceftriaxone**_ + _**Metronidazole_**
93
**_Treatment DURATION_**
for
**Short-Corse Antimicrobial Therapy
Intrabdominal Infections**
_after **SOURCE CONTROL:**_
| (fix leak / aspirating abscess)
## Footnote
**_4 DAYS_**
