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Therapeutics P3 Spring > Exam 4 lecture 1 > Flashcards

Exam 4 lecture 1 Flashcards

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1
Q

What are the definitions of intraperitoneal and retroperitoneal organs? What are the organs?

A

Intraperitoneal- Completely covered with Visceral peritoneum
- Stomach
- 1st part Duodenum
-Jejunum
-Ileum
-Transverse colon
-Sigmoid colon
-Liver
-spleen

Retroperitoneal- partially covered with peritoneum
-Kidneys
-Ureters
-Suprarenal glands
-Rectum

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2
Q

Name the types of intra abdominal infections

A
  1. Diverticulitis (+/- perforation/abscess)
  2. Appendicitis (+/- rupture)
  3. Cholecystitis
  4. Intra abdominal abscess
  5. Peritoneal dialysis related peritonitis
  6. Spontaneous bacterial peritonitis
  7. Necrotizing pancreatitis
  8. Cholangitis
  9. Cholecystitis
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3
Q

What is primary peritionitis? Diseases?

A
  1. peritoneal dialysis related peritonitis
  2. Spontaneous bacterial peritonitis
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4
Q

What are the secondary peritonitis

A

diverticulitis
appendicitis
Cholecystitis
Cholangitis
Necrotizing pancreatitis
Intra abdominal abscess

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5
Q

Define uncomplicated and complicated infection

A

Uncomplicated infection
- Confined within visceral structure (gall bladder, liver, spleen, kidneys)
- does not extend into peritoneum

Complicated infection
-extends beyond a single organ into peritoneal space and associated with peritonitis

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6
Q

WHo is at highest risk for SBP (spontaneous bacterial contamination)? Most common monomicrobial? Source of contamination?

A

No obvious source for contamination

patient at highest risk- Hepatic failure and ascites- alcoholic cirrhosis

E coli is most common monomicrobial

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7
Q

Clinical presentation of SBP

A

-Abdominal pain
-N/V/D
-Fevers, chills\reduced/absent bowel sounds
-altered mental status/encephalopathy (especially in pts with alcoholic cirrhosis)

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8
Q

What is needed for diagnosis of SBP

A

S/s of infection
Ascitic fluid analysis

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9
Q

What lab results do we look at for ascitic fluid analysis of SBP (What number suggests)

A

TNC x Bands/neutrophils bdy fluid= ANC
absolute neutrophil count > 250 is SBP

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10
Q

What are the recommended empiric treatment options of SBP

A

Ceftriaxone**
Cefepime
Piperacillin/tazobactam
Meropenem

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11
Q

What to consider in tx of SBP if risk for MRSA present

A

Consider addition of Vancomycin, linezolid, daptomycin

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12
Q

What to use for anaerobic coverage for SBP

A

B lactam/ B lactamase inhibitor

Carbapenem

Metronidazole (ceftriaxone, cefepime)

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13
Q

SBP tx duration

A

5-7 days

14-21 days for peritonitis patients undergoing CAPD

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14
Q

What to use for secondary prophylaxis for SBP

A

TMP/SMX, PO QD or ciprofoxacin 500 mg PO QD

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15
Q

most common microorganisms for secondary intra abdominal infections

A

POLYMICROBIAL
aerobic (-)- E coli
Aerobic (+)- strep viridians
Anaerobic bacteria- bacteroides
Fungi- candida

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16
Q

What makes secondary intra abdominal infections so unique

A

Multiple organ systems affected
- GI tract- bowel paralysis
- CV- fluid shifts
- Respiratory- hypoxemia
- Renal- decreased renal perfusion

bacterial synergy
- enterobacterales creates perfect envt for anaerobes
-anaerobes cause abscess and have several virulent factors

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17
Q

s/s of secondary intrabadominal infections

A

-abdominal pain and distention
- N/V
-Fevers +/- chills
- loss of appetite
- Inability to pass flatus and/or feces

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18
Q

physical exam/ vital signs of secondary intra abdominal infections

A

Tachypnea, tachycardia
Hypotension
SIgnificant abdominal tenderness
Rigidity of abdominal wall
Reduced or absent bowel sound

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19
Q

What are the two pillars of intra abdominal infection tx

A

Source control
Antimicrobial therapy

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20
Q

What are examples of source control procedures? Why are they important?

A
  • Repair perforations
  • resection of ifected organs/tissue
  • Removal of foreign material
  • Drain purulent collections

Important to obtain cultures

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21
Q

What are the 3 main considerations for empiric antibiotic selection for secondary intra abdominal infection

A
  1. select agent or combination of agents with high likelihood to cover common organisms. (must look at local antibiogram)
  2. Consider if enterococci coverage is necessary
  3. consider if antifungal coverage is required
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22
Q

When are agents not recommended for intra abdominal infections?

A

agents not recommended if resistance rates exceed 10-20% for e coli

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23
Q

When is enterococci coverage not necessary for IAI?

A

(not necessary for mild- moderate severity of community acquired IAI.

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24
Q

When is enterococci coverage necessary for IAI

A

high severity IAI
hx of recent cephalosporin use
immunocompromised
biliary source of infection
hx of valvular heart disease
prosthetic intravascular material

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25
when can we consider antifungal coverage
only add if isolated in culture May consider if patient not improving on appropriate antibiotic therapy
26
empiric antibiotic regimen for community acquired mild-moderate secondary IAI
enterococci not covered - ceftriaxone -cefazolin - ciprofloxacin - levofloxacin cefoxitin - Ertapenem - Tigecycline
27
Empiric therapy for community qcquired high severity and healthare associated IAI
Piperacillin/tazobactam Meropenem Cefepime Ciprofloxacin Levofloxacin
28
secondary IAI candida albicans (fungi) tx? Non albican tx
Flucanozole use micafungin if treating candida species other than albicans on culture
29
Is ampicillin/sulbactam included in tx of IAI
no, e coli resistance is high for ampicillin/sulbactam
30
What is a note about IAI about anaerobic bacteria
Common to maintain anaerobic coverage even if culture does not isolate anaerobic bacteria
31
common oral antibiotic regimens for IAI for de escalation
Amox/clav (can be dosed TID) Cefpodoxime if possible confirm susceptbility Cephalexin Cefadroxil Ciprofloxacin Levofloxacin TMP/SMX
32
Tx duration for general tx, diverticulitis, appendicitis, cholecystitis, bowel injuries repaired within 12 hrs
general tx duration- 4-7 days after source control Diverticulitis- uncomplicated- no antibiotic, moderate/severe- 5-10 days appendicitis, cholecystitis and bowel injuries- 24 hrs
33
which organisms do not need to be covered empirically for appendicitis, e coli, enterococcus, bacteroides, s. aureus
S aureus
34
do ceftriaxone or metronidazole cover enterococcus?
no
35
What type of microbe is c diff
Gram positive spore forming Obligate anaerobic
36
two toxins procuded by c diff? What is the more virulent strain?
TcdA (inflammatory enterotoxinc) and TcdB (cytotoxin) BI/NAP1/027 (high severity and toxicity)
37
How is C diff transmitted from person to person
Fecal-oral route through spores
38
C diff risk factors
Antibiotic exposure Healthcare exposure age > 65 proximity to person with C diff Chemo GI surgery Immunosuppression use of antacids
39
what are the antibiotics with highest risk for C diff
fluoroquinolones clindamycin 3rd/4th gen cephalosporins (specifically ceftriaxone) carbapenems
40
pathogenesis of c diff
disruption of colonic microflora source and introduction of C diff to colon Multiplication of c diff colon becomes edematous
41
two primary symptoms of c diff
profuse, watery or mucoid green, foul smelling diarrhea abdominal pain
42
When to test for C diff? 3 testing methods for C diff?
When to test- 3 or more profuse, watery or mucoid green, foul smelling stools in 24 hrs 3 tests 1. nucleic acid amplification test (NAAT) alone 2. antigen test (GDH) + toxin A/B test 3. NAAT + toxin A/B test
43
is repeat testing for C diff recommended
no
44
s/s of different C diff classifications
Non severe- WBC< 15,000 Scr < 1.5 severe- WBC > 15,000 Scr > 1.5 Fulminant- hypotension or shock, toxic megacolon
45
What are the different C diff treatment options
Oral vancomycin (standard of care) Fidaxomixin (narrower spectrum) metronidazole- no longer 1st line
46
PK/PD of oral vanc
extremely poor oral absorption C diff only indication for oral vanc
47
doses of oral vanc
standard- vanc 125 mg PO Q6h fulminant- vanc 500 mg PO Q 6H
48
biggest barrier to fidaxomicin
4500 dollar cost of use
49
c diff infection treatment for initial episode non severe and initial episode severe
initial episode non severe- Fidaxomicin, vancomicin, metronidazole (only if other options unavailable/unfeasible) Initial episode severe- fidaxomicin vancomycin
50
would u recommend loperamide for c diff
no
51
general approach with recurrent c diff
change something, either drug or dosing regimen
52
What treatment options to use for first CDI recurrence (in order of preference)? Second or subsequent CDI recurrence
-Fidoxomicin 200 mg PO BID x 10 days -Vancomycin 125 mg PO Q6H x 10 days - Fidaxomicin 200 mg PO BID x 5 days, then 200 mg PO every other day x 20 days - Vanc tapered and pulsed Second recurrence- same drugs, just select different treatment
53
How to treat fulminant CDI? WHat if ileus present?
Vancomycin 500 mg PO Q6H + Metronidazole 500 mg IV Q 8H IF ILEUS PRESENT, consider adding vanc 500 mg rectally q6h
54
What are the 3 biggest risk factors for CDI recurrence
Age> or = 65 Immunocompromised host Severe CDI on presentation
55
What is FMT? Potential indications?
- administration of fecal material from a healthy person to restore a balanced gut microbiome - Utilized as both a treatment option and method to reduce reccurence Indication - 3 or more episodes of CDI - Poor response to initial antibiotic therapy for CDI
56
What is rebyota? Compare to other FMTs
Fecal microbiota suspension administered via rectal tube 24-72 hrs after tx completion
57
compare vowst to rebyota
Vowst us bacterual spore suspension (oral) 4 capsules PO x 3 days starting 2-4 days after tx completion
58
Compare bezlotoxumab to other drugs used after FMT
Benzlotoxumab is a monoclonal antibody targeting C diff toxin B to neutralize itseffect IV x 1 dose during CDI tx
59
what to be careful of when giving bezlotoxumab
Caution in pts with CHF (increased risk for mortality and CHF)
60
who should not receive probiotics
Bowel perforation patients patients in ICU
61
Do patient applications at 1 hour 24 mins on march 10 lecture

Therapeutics P3 Spring (33 decks)

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