Exam 2: HAI & Antibiotics Flashcards
(97 cards)
1
Q
What are hospital acquired infections? (nosocomial)
A
infections that happen in the hospital - they were not present and not incubating at the time of admission
S2
2
Q
____ in ____ hospital patients develop a nosocomial infection
A
1 in 31 pts
S3
3
Q
What are sources of hospital-acquired infections?
A
- CVL sepsis
- UTI 13%
- Surgical ste infection 22%
- Hospital acquired PNA 22%
- Vent associated PNA (long term vent)
- C-diff 12%
S4
4
Q
Risk factors in developing a HAI?
A
- Patient’s immune status
- Infection control practices
- Prevalence of certain pathogens in community
- Older age
- Longer hospital stays
- Multiple chronic illnesses
- Mechanical ventilatory support
- Critical care unit stays
S5
5
Q
How is the infection transmitted?
A
- direct contact with healthcare workers
- Contaminated environments
- Extraluminal migration
what the HEC
S6
6
Q
What are examples of contaminated environments that increase susceptibility to HAI’s?
A
- Inguinal
- Perineal
- Axilla
Gloves dont prevent contamination
S6
7
Q
What H&P symptoms suggest a pre-existing infection? (common sense)
A
- Subjective fever
- Chills
- Night sweats
- Altered mental status
- Productive cough
- Shortness of breath
- Rebound tenderness
- Suprapubic pain
- Dysuria
- CVA tenderness (costovertebral tenderness)
- Vital Signs (HoTN, tachypnea, low sats, tachycardia)
S7
8
Q
Labs that you can get to look for the evidence of organ dysfunction (duh)
A
Lactic acid
Prothrombin time
BUN/Creatinine
Elevated WBC
Hypo/hyperglycemia
Cultures
S9
9
Q
What bacteria are your skin flora?
A
Coagulase-negative staphylococci
Lecture
10
Q
Surgical site infections typically occur within ___ days of surgery.
A
30
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11
Q
What are the categories for surgical site infection?
A
- Superficial = skin & SC
- Deep = fascia & muscle
- Organ/Space
S12
12
Q
Signs of a Surgical Site infection
A
Redness
Delayed healing
Fever
Pain
Warmth
Swelling
Drainage of pus (abscess)
S13
13
Q
What are the three most common types of bacteria associated with surgical site infections?
A
- Staphylococcus
- Streptococcus
- Pseudomonas
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14
Q
How would a Clean wound be described?
A
Clean: not inflamed or contaminated and does not involve internal organs
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15
Q
How would a Clean-contaminated wound be described?
A
Clean-Contaminated: no outward signs of infection but does involve internal organs
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16
Q
How would a contaminated wound be described?
A
Contaminated: involves internal organ infection along with spillage of contents into surrounding tissue
i.e. ruptured appendix
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17
Q
How would a dirty wound be described?
A
Dirty: known infection at the time of surgery
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18
Q
What are risks factors for SSI?
A
- > 2hr surgery
- Comorbidities (smoker, DM, cancer, obese, immunocompromised etc)
- Elderly
- Emergency surgery
- Abdominal surgery
ACEE’S
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19
Q
Potentially ___% of SSI’s are preventable.
A
50%
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20
Q
What is a category 1A recommendation?
A
1A = Strongly recommended; moderate to high quality of evidence
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21
Q
What is a category 1B recommendation?
A
1B = Strongly recommended; low quality evidence
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22
Q
What is a category 1C recommendation?
A
1C = Strong recommendation based on state/federal regulation
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23
Q
What is a category II recommendation?
A
Weak recommendation
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24
Q
What exclusions were there to the Guideline for Prevention of SSI’s?
A
- SSI not a reported outcome
- All patients w/ “dirty procedures”
- No dental or oral health procedures
- Procedure did not have primary closure
- Study included wound protectors post-incision
They eliminated studies where interventions were already in place that woulld skew the results
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25
What are the recommendations for parenteral antibiotics?
1B - Administer only when indicated
1B - Time so that agent is active on tissue incision
| S20
26
What are the recommendations for non-parenteral antibiotics?
1B - no antibiotic ointment on incision
***Dry incisions are better.***
| S21
27
What recommendations are there for antibiotic irrigation and prosthetic soaking in antibiotic solution?
**No recommendations** on prosthetic soaking in abx solution or abx irrigation
*Dr M says you will still see abx irrigation but it wont hurt anythign*
| S21
28
What are the 1A recommendation levels for glycemic control?
- Perioperative control of glucose
- Target glucose < 200 mg/dL (both intraop and postop)
| S22
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What is the recommendation level for A1C targets?
No recommendation for A1C target
Just acute control of BG.
| S22
30
Maintaining perioperative normothermia is a ___ recommendation.
1A
No rec for strategies to maintain normothermia - just use what you have to maintain temp)
| S23
31
What is the 1A recommendation for oxygenation in GETA patients?
* No recommendation for increased FiO2 in normally functioning patients
* Only increase the FiO2 with...
* intraoperatively with GETA (i.e. not necessary in Preop with a normal pt)
* Neuraxial anesthesia
* Postoperatively by mask or nasal cannula
* No trials r/t percentage/duration/delivery method
*Recommendation is losing credibility as a way to prevent SSI's - contradictory (Dr. Schaffer's research)*.
| S24
32
What are the recommendations for antiseptic prophylaxis?
1A - Intraoperative skin prep w/ alcohol-based antiseptic.
1B - Shower or bathe w/ soap/antiseptic the night before surgery.
II - Consider intraoperative Iodine irrigation.
* No benefit intra-peritoneally,
* No benefit with iodine imbedded adhesive drapes
* No benefit soaking prosthetic devices
| S25
33
What is the recommendation for blood transfusion?
1B - Do not withhold necessary blood transfusions as a means to prevent SSI.
| S26
34
Should systemic corticosteroids be utilized in a patient with joint arthroplasty?
Uncertain. Infection is most common indication for TKA revision however.
| S27
35
What does MIC stand for?
Minimum Inhibitory Concentration
36
What is the goal for preoperative prophylaxis?
* Adequate bactericidal concentration in serum and tissues when incision is made…
* MIC: Minimum inhibitory concentration within tissues
* Based on evidence
* Given by anesthesia
| S29
## Footnote
**ancef is 15 min prior to incision - if given an hour before, must redose
**most antibiotics need to be completed within 15 minutes of surgery and intiated under an hour. This is 45 minutes of "working time"
37
What are the 6 general principles of preoperative antibiotic prophylaxis?
1. Should be active against *common* SSI pathogens
2. Proven efficacy by clinical trials
3. MIC must be achieved
4. Shortest possible effective course
5. New ABX reserved for resistant infections
6. If possible, use oldest/cheapest ABX
Active Ethyl Must Shortlist New Old-people
| S30
38
ABX should be initiated within ____ hour of incision.
1 hour (30 min even better)
| S31
39
____ and ____ can be initiated within 2 hours of incision.
Vancomycin and Fluoroquinolones (like Cipro)
| S31
40
Status of abx prior to trouniquet use?
ABX must be completely infused prior to tourniquet use
* may hold abx for cultures
| S31
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Re-dosing of antibiotics is permissible after what conditions?
- 2 ABX half-lives
- Excessive blood loss
- Following Cardiac bypass
- Prolonged procedures (usually 2-4 hours in OR)
Phil Follows Blood Too (2 but yea...)
| S32
42
What drugs are β-lactam based?
- Penicillins
- Cephalosporins
- Carbapenems
| S33
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What are the 5 major common surgical antibiotics?
- β-lactams
- Vancomycin
- Aminoglycosides (gentamycin)
- Fluoroquinolones (cipro)
- Metronidazole (flagyl)
| S33
44
How do Penicillin β-lactam antibiotics work?
Inhibition of bacterial cell wall synthesis
| S34
45
Resistance to Penicillin β-lactam antibiotics is based on what?
β-lactamase enzyme on outer surface of cytoplasmic membrane
| S34
46
Penicillin β-lactams are the drug of choice for what pathogens?
Gram + Bacterium (Cocci)
- Streptococci
- Meningococci
- Pneumococci
+ about PMS
| S34
47
β-lactams are good for which HAI's?
| Locations throughout body
skin, catheter, and upper respiratory infections
| S34
48
What four examples of penicillin based antibiotics were given?
- Penicillin G
- Methicillin
- Nafcillin
- Amoxicillin
| S34
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What are the common adverse reactions to penicillin β-lactams?
- Hypersensitivity (includes anaphylaxis at 0.05%)
- GI upset with large doses
- Vaginal Candidiasis
| S35
50
Cephalosporin - β-lactams are more stable against ____.
β-lactamases (broader spectrum)
| S36
51
MOA for cephalosporin-beta lactams
Beta-lactam rings bind to Penicillin-binding protein and inhibit the normal activity of the protein (can’t synthesize a bacterial cell wall)
| S36
52
Cephalosporin β-lactam antibiotics are the drug of choice for what?
- Surgical prophylaxis
- PCN allergy patients (except true anaphylaxis)
| S36
## Footnote
can give a test dose of ancef because 99.9% of the time these reactions aren't anaphylactic
53
Cefazolin is generation ____ with trade name(s) ____ and ____ and best at treating?
* 1st generation
* Ancef, Kefzol
* Does not penetrate BBB, Most gram + (staph and streptococci), **Cellulitis, abscesses, URI, UTI**
| S37
54
Cefuroxime is generation ____ with trade name(s) ____ and ____ and best at treating?
* 2nd generation
* ceffin, Zinacef
* Better gram – coverage
**H-influenzae pneumonia, UTI, otitis media**
| S37
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Cefoxitin is generation ____ with trade name(s) ____ and ____.
* 2nd generation
* Metoxin
| S37
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Cefotetan is generation ____ with trade name(s) ____ and ____ .
* 2nd generation
* Cefotan
| S37
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Cefotaxime is generation ____ with trade name(s) ____ and ____ and best at treating?
* 3rd generation
* Claforan
* Some cross BBB, Better gram – than before; treats resistance
**Meningitis**
| S37
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Ceftriaxone is generation ____ with trade name ____ and best at treating?
* 3rd generation
* Rocephin
* Gonorrhea
| S37
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Ceftazidime is generation ____ with trade name(s) ____.
* 3rd generation
* Fortaz
| S37
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Cefepime is generation ____ with trade name ____ and best at treating?
* 4th generation
* Maxipime
* Most resistant to hydrolysis by beta lactamases, Usually reserved for multi-resistant organisms
Penetrates BBB well
| S37
61
What cephalosporins do not penetrate the blood brain barrier?
Generation 1: Cefazolin
Generation 2: Cefuroxime, Cefoxitin, Cefotetan
Zol, Rox, Fox, Tetan
| S37
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What generation of cephalosporins penetrate the blood brain barrier well (the best)?
Generation 4: Cefepime (Maxipime)
*Most resistant to β-lactamase*.
*Reserved for multi-resistant organisms*.
| S37
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Adverse reactions to cephalosporins
Hypersensativity is uncommon
* rashes
* fever
* nephritis
* anaphylaxis
* potential production deficit of Vit K (be aware with clotting disorders)
| S38
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What drugs should be used if true anaphylaxis to penicillin exists?
Vancomycin or clindamycin
| S38
65
What drugs are a common cause of colitis?
3rd generation cephalosporins
| S38
66
Carbapenem β-lactams have good activity against ____ and ____.
Gram - rods (Pseudomonas Aeruginosa) and enterobacter
| S39
67
What β-lactam drug class has the broadest spectrum of activity and can inhibit the β-lactamase enzyme? MOA?
Carbapenems
* inhibit the beta-lactamase enzyme and binds to penicillin-binding protein
| S39
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What type of infections are carbapenems saved for?
Intra-abdominal, resistant UTIs, and pneumonia
*most penetrate BBB*
| S39
69
What examples of carbapenems were given?
- Ertapenem (Invanz)
- Meropenem (Merrem)
- Imipenem (Primaxin)
70
IM formulations of carbapenems contain ____.
Lidocaine
*Consider LA allergies prior to IM administration*.
| S40
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Carbapenems can decrease what medication by up to 90%?
What can this precipitate?
Valproic Acid (Depakote); and can precipitate seizures
| S40
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How does vancomycin work?
Inhibition of cell wall synthesis
| S41
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Vancomycin is active against ____ bacteria but is too large to penetrate ____ bacteria.
Active against gram +
too large for gram - bacteria
*Vanco only works if the bacteria is actively dividing*
| S41
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Vancomycin is most useful against what infections?
Blood stream MRSA
MRSA endocarditis
| S41
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What are the most common adverse reactions to vancomycin?
- Phlebitis at site
- Chills, fever
- Nephrotoxicity
- "Red man" syndrome from quick administration
| S42
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How do Aminoglycosides work?
Inhibition of ribosomal proteins and cause mRNA misreading
| S43
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Aminoglycosides have a ____ post-antibiotic effect.
prolonged (long 1/2 life)
| S43
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Aminoglycosides are ____ w/ β lactams or vancomycin.
Synergistic
*Especially useful for enterococcal endocarditis*.
| S43
## Footnote
Gentamycin example
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What are the adverse reactions associated with gentamycin?
- Ototoxicity
- Nephrotoxicity: (more than 5 days, elderly, renal insufficiency, high doses and with loop diuretics)
- Curare-like affect
| S44
80
Explain the curare-like effect of gentamycin (aminoglycoside).
Gentamycin can interfere with ACh receptors and potentiate effects of NMB drugs. (seen more with depolarizing NMB)
| S45
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What is the treatment for curare-like effects from gentamycin?
Ca⁺⁺
| Lecture
82
How do fluoroquinolones work?
Inhibit bacterial DNA synthesis
| S45
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Fluoroquinolones are best used for what type of bacteria? used on?
Gram - organisms:
- UTI
- Bacterial diarrhea
- Bone/joint infections
| S45
84
What examples are there of fluoroquinolones?
- Ciprofloxacin
- Levofloxacin
| S45
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What are the adverse reactions for fluoroquinolones?
- N/V/D
- QT interval prolongation
- Cartilage damage / Tendon rupture
| S46
## Footnote
Hint: fluroquinolones treat joint infections and diarrhea
86
What three factors will exacerbate cartilage damage and tendon rupture associated with fluoroquinolones?
- Renal insufficiency
- Concurrent steroids
- Advanced age
| S46
87
What type of antibiotic is metronidazole?
Antiprotozoal / Anaerobic antibacterial
| S47
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How does Metronidazole work?
Forms toxic byproducts that destabilize bacterial DNA.
| S47
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What is metronidazole (flagyl) indicated for?
- Intra-abdominal infections
- Vaginitis
- C-diff
| S47
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What drug should Flagyl not be combined with?
EtOH
Disulfiram-like effect induces hangover-like s/s (flushing, dizziness, HA, CP, abd pain)
| S48
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What are the adverse reactions associated with metronidazole?
- Nausea
- Peripheral neuropathy (w/ prolonged use)
- Disulfiram-like effect
| S48
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What is (essentially) the first line antibiotic for essentially all surgical prophylaxis?
Cefazolin (Ancef)
| S49
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What is the most common alternative to cefazolin for surgical prophylaxis?
Clindamycin (or vancomycin)
| S49
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What drug(s) increases the likelihood of nephrotoxicity when paired with aminoglycosides?
Loop Diuretics
| S44
95
With small intenstinal obstruction, what are the recommended antibiotics?
cefazolin + metronidazole, cefoxitin or cefotetan
| S49
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With Small intestine cocorectal surgery, what antibiotics are recommended?
Cefazolin +
metronidaxole, cefoxitin, cefotetan, ampicillin-sulbactam or ceftriaxone +
metronidazole or ertapenem
| S49
97
Adult dosing for cefazolin
* 1g /= 120kg
| S50
