EXAM FOUR COVERAGE Flashcards
1
Q
Otitis Media
A
Inflammation of the middle ear
Most Common Pathogens:
1. Strep pneumo
2. Haemophilus influ
3. Moraxella catarr
MILD: <39C and Otalgia
SEVERE: >39C and severe Otalgia
2
Q
Otitis Media Diagnosis
A
- New onset Otorrhea (ear drainage TM ruptured)
- Mod-Severe bulging of TM
- Mild bulging of TM + new onset otalgia/erythema
3
Q
Pain Management of Otitis Media
A
Should be given to ALL patients with otalgia
PO: IBU and APAP
4
Q
When is treatment indicated for Otitis Media?
A
- ALL with SEVERE illness or otorrhea
- <24 months with BILATERAL Mild illness
5
Q
When is observation rather than treatment an option for Otitis Media?
A
- ALL with UNILATERAL Mild illness
- > 24 months with BILATERAL Mild illness
6
Q
What are the major resistance mechanisms of organisms that cause Otitis Media?
A
- H. flu = beta lactamase
- M. cat = beta lactamase
- S. pneumo = PBP alterations
7
Q
What is FIRST line therapy for Otitis Media?
A
- HIGH dose Amoxicillin (dose alone overcomes PBP modifications)
- HIGH dose Augmentin
8
Q
What is the DOSE of First Line Therapy for Otitis Media?
A
45 mg/kg PO BID
9
Q
When should Augmentin be used over Amoxicillin for first line therapy?
A
- Amoxicillin was given in a previous month
- Concomitant conjunctivitis
- Always recommend ES formulation
10
Q
What are the therapy options for Otitis Media if the patient has a PCN allergy?
A
Cefdinir
11
Q
What is the duration of antibiotics in Otitis Media for <2 yrs?
A
MILD = 10 days
SEVERE = 10 days
12
Q
What is the duration of antibiotics in Otitis Media for 2-5 yrs?
A
MILD = 7 days
SEVERE = 10 days
13
Q
What is the duration of antibiotics in Otitis Media for >6 yrs?
A
MILD = 5 days
SEVERE = 10 days
14
Q
When dosing medication in Otitis Media for overweight children, ensure what?
A
The maximum or adult dose is NOT exceeded when prescribing
15
Q
Treatment Failure Algorithm for Otitis Media
A
- Amoxicillin fails = Start Augmentin
- Augmentin daily = start Ceftriaxone IM +/- Clindamycin PO
16
Q
Otitis Externa
A
Cellulitis of external canal
Swimmer’s Ear
Most Common Pathogens:
1. Staphylococcus aureus = most common
2. Pseudomonas aeruginosa = 2nd
17
Q
S/S of Otitis Externa
A
- Rapid onset
- Otalgia
- Pruritus
- Otorrhea
- White Mucus = acute bacteria
- Fluffy Color Changing Mucus = fungal
18
Q
Is fever seen in Otitis Externa?
A
NO, indicative of additional infection
19
Q
Treatment Options for Otitis Externa
A
Treatment of Choice = Antibiotic DROPS
Symptom Relief Add On = Steroid DROPS
20
Q
If a Perforated TM is present in Otitis Externa you must AVOID what?
A
AVOID
1. Neomycin = ototoxic
2. Acetic Acid = ototoxic
3. Cipro HC = NOT sterile
21
Q
What is used for pain relief in Otitis Externa?
A
- NSAIDs
AVOID topical pain relievers, it will coat the area where the antibiotics will be working
22
Q
When should PO antibiotics be used in Otitis Externa?
A
- Persistant OE
- Temp >38.3
- Immunocompromised patients
23
Q
What is the duration of treatment for Otitis Externa?
A
3 DAYS PAST symptom resolution
24
Q
Sinusitis
A
Inflammation of the sinuses
Most often viral
Bacterial Causes (less common):
1. S. pneumo
2. H. flu
3. M. catarr
25
What are the THREE Cardinal Symptoms of Sinusitis?
1. Purulent nasal discharge (green mucus)
2. Nasal congestion
3. Facial congestion
26
Bacterial Infection of Sinusitis
1. FEVER the ENTIRE time
2. Green mucus at the BEGINNING
3. Feel gross for more than 10 days
27
Viral Infection of Sinusitis
1. Fever for the first 48hrs ONLY
2. Mucus ALL the time
3. Peaks a day 6 and then better by day 10
28
What is Double Sickening in Sinusitis?
Starts viral but on day 6 gets worse = becomes a bacterial infection
29
What is first line treatment for Sinusitis?
Augmentin
30
What is the standard and high doses of Augmentin for Sinusitis?
Standard = 875/125 mg BID PREFERRED
High = 2000 mg BID
31
When should you use high dose Augmentin for Sinusitis?
1. Recent antibiotics
2. Age >65 yrs
3. Recent hospitalizations
4. Immunocompromised status
32
What are options for treatment in Sinusitis if the patient has a PCN allergy?
1. LEVOFLOXACIN
2. Maybe moxifloxacin
NEVER doxycycline
33
What are the Black Listed Agents when treating Sinusitis?
1. Macrolides
2. Bactrim
34
What is the duration of treatment for Sinusitis?
5-7 days
35
Pharyngitis
Viral 80%
Bacterial = GROUP A Strep (no resistance mechanisms)
Antibiotic therapy should work within 48 hrs
36
What is the TRIAD of symptoms for Pharyngitis?
1. Sore throat
2. Pharyngeal edema
3. Fever
(sudden onset)
37
What is the diagnosis for Pharyngitis?
Throat Swab - Rapid Antigen Detection Test - Culture
38
When can you give antibiotics in Pharyngitis?
Antibiotics ONLY with +RADT or Culture
39
What is the first line therapy for Pharyngitis?
Penicillin or Amoxicillin
Amoxicillin preferred due to QD dosing
40
What is the therapy in a Type 1 Allergy for Pharyngitis?
Clindamycin or Azithromycin
41
What is a Type 1 Allergy?
HIVES or ANAPHYLAXIS
42
What is the therapy in a NON-Type 1 Allergy for Pharyngitis?
Cefdinir
43
What antibiotics should be avoided in Pharyngitis?
1. Tetracyclines
2. Bactrim
3. Fluoroquinolones
44
Amoxicillin dosing for Otitis Media vs Sinusitis vs Pharyngitis
Otitis Media = BID
Sinusitis = BID
Pharyngitis = QD
45
Mycobacterim Tuberculosis
Doubles every 18 hrs, takes days to grow and get lab results
ACID FAST POSITIVE Rod Shaped Bacterium Bacilli
Large Lipid Content
NEEDS MORE THAN 1 DRUG TO TREAT
46
How does Tuberculosis spread?
1. COUGH
2. Sneezing
3. Shouting
4. Singing
DROPLETS LAST UP TO 30 MINS IN THE AIR
47
Where does Tuberculosis infect?
LUNGS/Pulmonary
48
Macrophages surround the TB infection forming a Granuloma, are Granulomas effective in fighting an ACTIVE TB Infection?
NO, TB continues to spread
Caeseating (necrotic) granuloma is formed by the inflammatory response
49
Are Granulomas effective in fighting a LATENT TB Infection?
YES, granuloma contains TB successfully
NOT infectious or contagious
50
When can Latent TB Infections be reactivated?
1. Infection
2. Immunosuppression
3. Immunocompromised
51
S/S of ACTIVE TB Infection
1. Cough lasting more than 3 WEEKS
2. Loss of appetite
3. Night sweats
4. Weight loss >30 LBS
52
What population of patients do NOT receive the Mantoux TB Skin Test?
1. Infants
2. Pregnant Women
3. HIV
4. TB Vaccinated
53
If the TB Skin Test is positive, what must be done next?
OFT-GIT or TSPOT TB BLOOD test and if positive, patient must go through additional testing of...
CHEST X RAY
54
Chest X-Rays determine what?
If TB Infection is Active or Latent
55
TB Infection Treatment Options
R: Rifampin
I: Isoniazid
P: Pyrazinamide
E: Ethambutol
56
Treatment goals of TB Infections
Active: treat to cure
Latent: treat to stop progression
57
Rifampin TB
Inducer of Everything
Take on an EMPTY stomach
AE:
1. Red/Orange discoloration
2. Can discolor contacts
3. Elevated AST/ALT
Monitor: LFTs
58
What are the alternatives to Rifampin in TB?
Rifapentine and Rifabutin
Rifapentine = less frequent dosing intervals
59
Isoniazid-Isonicotinic Hydralazine INH
Inhibits mycelia acid and nucleic acid synthesis
Take on an EMPTY stomach
AE: peripheral neuropathy
Monitor: LFTs, peripheral neuropathy, optic neuritis
MUST TAKE 25 MG OF PYRIDOXINE B6 QD with INH for prevention of peripheral neuropathy
60
What are the drug interaction concerns with INH?
1. Slow Acetylators: higher INH concentration = white/jewish
2. Fast Acetylators: low INH concentration (need higher dose) = Inuit and Japanese
3. Strong CYP 2C10 and 2D6 inhibitors
61
Pyrazinamide PZA
Inhibits cell enzyme and cell membrane function leading to cell death
Take without regard to food
AE: HYPERURICEMIA, elevated LFTs
Monitor: LFTs, uric acid, renal function
Renally excreted AVOID in CrCl <30
62
Ethambutol EMB
Disrupts synthesis of arabinogalactan component of cell wall
Take without regard to food
AE: Optic neuritis
Renally excreted AVOID in CrCl <30
63
Latent TB Treatment Options
Adherence is the MOST IMPORTANT factor
1. INH + Rifapentine Once WEEKLY x 3 months
2. Rifampin QD x 4 months
64
INH + Rifapentine Once Weekly x 3 Months
1. Safe for HIV patients
2. Shorter
3. MUST ADD B6
4. High pull burden
5. Syncope/Hypotension
65
Rifampin QD x 4 months
1. Safe for ALL ages
2. 2 caps QD
3. No studies in HIV patients
4. Lots of drug interactions
66
What is the checklist BEFORE treatment for ACTIVE TB infection?
1. Culture and sensitivities
2. Baseline labs
3. Identify potential drug interactions
4. HIV test
67
What is the checklist DURING treatment for ACTIVE TB infection?
1. Monthly sputum culture
2. Adherence
3. Periodic CBC, CMP, and eye exam
4. DDI
5. Check for neuropathy
68
What is the Intensive Treatment in ACTIVE TB infection?
Empiric Treatment
START RIPE: QD for 8 WEEKS
Stop Ethambutol if M. tuberculosis is susceptible to other medications
69
What is the Continuation Phase Treatment in ACTIVE TB infection?
INH + Rifampin QD for 18 WEEKS
Can INCREASE continuation phase to 30 WEEKS if signs of relapse are present
70
If Optic Neuritis occurs, what must be done?
1. DC EMB
2. Consider DC INH
71
If a Rash occurs during TB infection, assess for involvement of mucous membranes and what must be done?
No mucous involvement = Antihistamine Treatment
YES to FEVER or MUCOUS Membrane Involvement = DC ALL THERAPY, INPATIETNT, Re-Introduce therapy with sequential order
72
Intensive Phase ACTIVE TB Interruption Protocol
Lapse < 14 days in duration = continue treatment, ALL doses MUST be completed within 3 months
Lapse >14 days in duration = RESTART treatment from beginning
73
Continuation Phase ACTIVE TB Interruption Protocol
1. Received >80% & AFB NEG = further therapy not necessary
2. Received >80% & AFB POS = continue treatment, ALL doses MUST be completed
3. Received <80% & lapse <3 months = continue therapy until completed
4. Received <80% and lapse >3 months = RESTART therapy from BEGINNING AKA INTENSIVE PHASE FIRST followed by continuation phase
74
Bronchitis
Inflammation of large airways of the tracheobronchial tree
75
Acute Bronchitis
1. Self Limiting
2. Viral Infections
76
Chronic Bronchitis
Defined by CHRONIC COUGH with SPUTUM production lasting > 3 CONSECUTIVE MONTHS for at least 2 YEARS
1. Associated with COPD
2. Bacterial Infections
-Mycoplasma pneumoniae (atypical)
-Strep pneumo
-H. flu
-M. catarr
77
S/S of Bronchitis
1. COUGH is the hallmark symptom of ACUTE bronchitis
2. EARLY and persists for 3 weeks
78
Treatment of Acute Bronchitis
Provide Comfort
Supportive Care
-Antitussives
-Analgesics/Antipyretics
-Antihistamines
79
What is NOT indicated in Acute Bronchitis and can lead to harm?
1. Bronchodilators
2. Inhaled/Systemic Steroids
3. Antibiotics
80
Treatment of Chronic Bronchitis
Reduce Severity and Symptoms
Pharmacotherapy
-Vaccines
-Antibiotics
Nonpharmacotherapy
-Smoking cessation
81
What antibiotics can be used for Strep. pneumo causation of chronic bronchitis?
1. High Dose Amoxicillin
2. Doxycycline
3. Respiratory FQ
82
What antibiotics can be used for H. flu and M. catarr causation of chronic bronchitis?
1. Augmentin
2. Respiratory FQ
83
What antibiotics can be used for Mycoplasma pneumo and Chlamydophila pneumo causation of chronic bronchitis?
1. Macrolides (Azithromycin)
2. Tetracyclines (Doxycycline)
3. Lefamulin
4. Respiratory FQ
84
Influenza
Cause: single-stranded RNA virus
Transmitted through inhalation of respiratory droplets or direct contact with virus contaminated surface
85
Antigenic Drift
Point mutations resulting in small changes
EPIDEMICS
86
Antigenic Shift
Novel virus created from reassortment of 2 previous strains
PANDEMIC
87
Incubation and Infectious Periods of Influenza
Incubation = 1-7 days
Infectious = 1 day before to 7 days after symptom onset
88
What are the HIGH RISK targeted groups that are TREATED for influenza regardless of time since symptom onset?
1. Hospitalized with flu
2. Outpatient with severe or progressive illness
3. Immunocompromised
4. Children <2 yrs
5. Adults >65 yrs
6. Pregnant Women (or within 2 wks postpartum)
89
When do you treat other patients that do not fall into the high risk category for influenza?
Treat ONLY if symptom onset within 48 HOURS of presentation
90
What are the 3 antiviral classes used for influenza?
1. Neuraminidase inhibitors
2. Endonuclease inhibitors
3. Adamantanes
91
List the drugs that are classified as Neuraminidase Inhibitors?
1. Oseltamivir/Tamiflu
2. Zanamirvir/Relenza
3. Peramivir/Rapivab
92
List the drugs that are classified as Endonuclease Inhibitors?
1. Baloxavir/Xofluza
93
List the drugs that are classed as Adamantanes?
1. Amantadine/Rimantadine aka AVOID DO NOT USE
94
Oseltamivir
Capsule/Suspension
95
Zanamivir
Inhalation
96
Zanamivir
Inhalation
97
Peramivir
IV Solution
98
Baloxavir
Tablet, WEIGHT BASED SINGLE ORAL DOSE
99
Community Acquired Pneumonia CAP
Pneumonia developing in the outpatient setting or <48 hrs after hospital admission
100
Hospital Acquired Pneumonia HAP
Pneumonia developing in hospitalized patients >48 hrs after admission
101
Ventilator Associated Pneumonia VAP
Pneumonia developing >48 hrs after endotracheal intubation
102
What are the COMMON Causative Organisms for CAPs?
1. Viral
2. Strep pneumo
3. H. flu
4. M. catarr
5. Mycoplasma pneumo
6. Chlamydophila pneumo
7. Legionella species
103
When should MRSA and Pseudomonas Coverage be considered for CAPs?
1. Previous respiratory isolation of either organism
OR
2. Recent <90 days hospitalization AND receipt of IV antibiotics
104
Outpatient CAPs Treatment
1. NO Comorbidities = AMOXICILLIN, if PCN allergy use Doxycycline
2. Comorbidites = AUGMENTIN or CEPHALOSPORIN + Macrolide or Doxycycline
-Cephalosporin: Cefpodoxime or Cefuroxime
-AVOID Doxycycline if patient has QT problem
-Allergy = use FQs LEVO or MOXI
105
Inpatient CAPs Treatment
1. Non-Severe = IV Beta Lactam + Macrolide or Resp FQ
2. Severe = IV Beta Lactam + Macrolide or IV Beta Lactam + Resp FQ
-Beta Lactase: Unasyn/Cefotaxime/Ceftriaxone/Ceftaroline
ADD ON if MRSA or Pseudomonas
MRSA = Vanc or Linezolid
Pseduo = Zosyn, Cefepime, Ceftazidime, Imipenem, Meropenem, or Aztreonam
106
Duration of Therapy for CAPs
NO LESS than 5 DAYS
If treating MRSA/Pseudomonas add on duration >7 DAYS
107
List 3 Prediction Rules in determine location of care for CAPs
1. CURB-65
2. Pneumonia Severity Index PSI
3. IDSA/ATS Criteria for Severe CAP
108
CURB65 and PSI
Both are utilized to determine Inpatient vs Outpatient preference
Guidelines prefer PSI
109
IDSA/ATS
Determine if patient should be placed in ICU for Severe CAP
110
Do you use Procalcitonin in CAPs?
NO, not to be used
111
What are the Causative Organisms for HAP and VAP?
1. Enteric Gram Neg: Klebsiella/E.coli
2. Pseudomonas
3. Acinetobacter, Stentrophomonas
4. Staph Aureus
112
Empiric Therapy for HAP/VAP, no matter what these have to be covered empirically
1. Staph Aureus MSSA
2. Pseudomonas
3. Gram Neg Bacilli
113
You should always cover MSSA in HAP, but when should you recommend MRSA Coverage?
1. MDR Risk Factor
2. High mortality risk
3. Unit prevalence of MRSA >20%
114
You should always cover MSSA in HAP, but when should you recommend PSA Coverage?
1. MDR Risk Factor
2. High mortality risk
3. Structural lung disease
DOUBLE COVER = 2 drugs from different classes
115
Empiric Therapy for HAP/VAP
NO MRSA/MDR =
1. Zosyn or
2. Cefepime or
3. Levofloxacin or
4. Imipenem/Meropenem
MRSA but NO MDR =
1. Zosyn or
2. Cefepime/Ceftazidime or
3. Cipro/Levofloxacin or
4. Imipenem/Meropenem or
5. Aztreonam
PLUS VANC or LINEZOLID
DOUBLE COVERAGE NOT NEEDED
116
Empiric Therapy for MDR HAP/VAP (PSA Double Cover)
1. Zosyn or Cefepime/Ceftazidime or Imipenem/Meropenem or Aztreonam
2. Ciprofloxacin/Levofloxacin or Amikacin/Gentamicin/Tobramycin or Colistin
One from option 1 and One from option 2 for DOUBLE PSA COVERAGE
IF MRSA present with MDR RISK FACOR ADD ON:
3. Vancomycin or Linezolid
117
Duration of Therapy for HAP/VAP
Uncomplicated = 7 days
118
What are the two major classes of UTIs?
1. Cystitis = Lower UTI
2. Pyelonephritis = Upper UTI
119
What is the most common pathogen to cause UTIs?
E.coli
120
What are the S/S of Cystitis?
1. Urgency
2. Frequency
3. Dysuria
4. Suprapubic
5. Heaviness
121
What are the S/S of Pyelonephritis?
1. FLANK PAIN
2. FEVER
3. Malaise
4. HA
5. Nausea
6. Vomiting
7. Lethargy
122
Urinalysis Components
Leukocyte Esterase = BEST Predictor
Nitrates = appears with gram neg bacteria
123
Urine Cultures are the GOLD Standard but what are the specific indications when it should be used?
1. Must be performed with pyelonephritis
2. +/- with acute cystitis
3. Reflex culture
124
Phenazopyridine/AZO
Pain Relief ONLY
1. Limit use to 2 DAYS ONLY
2. Red/Orange discoloration of urine
3. Take with food
125
Ibuprofen (UTI)
Can help with pain and fever
1. AVOID with kidney disease, increased risk of bleeding, and cardiac conditions
2. Take with food
126
APAP (UTI)
Can help with pain and fever
1. AVOID or reduce dose with liver disease
127
Nitrofurantoin/Macrobid
-Enterics, E. faecalis
AE: urine discoloration
High concentration in urine
CAUTION: CrCl <30
TAKE with FOOD
128
Bactrim
-Enterics, staph
AE: Rash, SJS, Pancytopenia, Hyperkalemia
TAKE with 8oz of WATER
129
Fosfomycin
-Enterics, Gram +
AE: HA/Diarrhea
High concentration in urine
Dose ADJUST CrCl <40
1 TIME DOSING
130
Fluoroquinolone: Ciprofloxacin and Levofloxacin UTI
-QT Prolongation
-Chelation with cations
Moxifloxacin is NOT used UTIs, does not have good concentrations in the bladder
131
Beta Lactam: Augmentin, Ceftriaxone, Cephalexin, Cefdinir, and Zosyn UTI
NOT FIRST LINE
132
Management of Cystitis Uncomplicated
AVOID FQ is possible
FIRST LINE:
1. Nitrofurantoin BID x 5 days
2. Bactrim BID x 3 days
3. Fosfomycin PO SINGLE dose
133
Management of Cystitis COMPLICATED
Empiric:
1. Cipro PO BID
2. Cipro IV
3. Levo PO QD
Duration 7-14 days
134
What makes a patient deemed COMPLICATED in UTIs?
1. Male
2. Pregnant Women
3. Structural Abnormalities
4. Immunocompromised
5. Catheters
6. Uncontrolled Diabetes
135
Management of Pyelonephritis Uncomplicated with LOCAL FQ resistance <10%
1. Cipro BID x 7 days
2. Levo QD x 5-7 days
136
Management of Pyelonephritis with LOCAL FQ resistance >10% ADD ON THERAPY for uncomplicated or complicated
1. Ceftriaxone 1 TIME DOSE
2. Aminoglycoside 1 TIME DOSE
137
Management of Pyelonephritis if Susceptible
1. Bactrim BID x 14 days + Ceftriaxone x 1 time
2. Beta Lactam x 10-14 days + Ceftriaxone x 1 time
138
Management of Pyelonephritis COMPLICATED
Empiric:
1. Cipro BID
2. Cipro IV
3. Levo QD
Severe Illness: INPATIENT
1. IV FQ or AG +/- Ampicillin
2. Zosyn, Cefepime, or Ceftazidime
DURATION = 14 DAYS
139
UTI Management in Pregnant Women
PREFERRED: Beta Lactams
1. Augmentin BID x 7 days
2. Cephalexin q6h x 7 days
3. Cefdinir BID
AVOID
-Nitrofurantoin in the last 30 days of pregnancy
-Bactrim overall
140
What is the diagnosis of Recurrent UTIs?
1. >2 POS cultures and symptomatic acute cystitis episodes in 6 months
2. >3 episodes in 1 year
141
Treatment of Fungal UTI
1. Fluconazole -- Preferred
2. Amphotericin B DEOXYCHOLATE
142
When are the TWO TIMES you ALWAYS treat Asymptomatic Bacteriuria?
1. Pregnant Women
2. Urologic Surgical Procedures
143
Chlamydia
1. Atypical Organism
2. NAAT = most sensitive test
3. Often Asymptomatic
4. Most frequently reported STI
144
Chalmydia Treatment
1. Doxycycline x 7 days = first line
2. Azithromycin SINGLE DOSE = alternative
3. Levo x 7 days = alternative
145
Chalmydia Mangement
1. Refer sex partners 60 days of onset of symptoms or diagnosis
2. RE-TEST 3 MONTHS after completion of treatment
146
Gonorrhea
1. Gram Neg Diplococci
2. NAAT = most sensitive test
3. Second most reported bacterial communicable disease
147
Gonorrhea Treatment
First Line: Ceftriaxone, and if chlamydia has not been excluded add on Doxycycline x 7 days, if chlamydia was ruled out then do Ceftriaxone ALONE
Alternative: Gentamicin + Azithromycin (both as SINGLE doses)
148
Gonorrhea Management
1. Presumptively treat sex partners within the last 60 days
2. RE-TEST at 3 months after treatment
149
Syphilis
1. Slow Growing Spirochete
2. Titers
Primary syphilis = Single Chancre
Secondary syphilis = Skin Rash
Tertiary syphilis = Gummatous Lesions
Neurosyphilis = Altered Mental Status
150
Syphilis Treatment
Primary/Secondary syphilis = Penicillin G IM SINGLE dose
Tertiary syphilis = Penicillin G IM once weekly for 3 DOSES
Neurosyphilis = Penicillin IV x 10-14 days
151
Jarisch-Herxheimer Reaction
1. Occurs within 24 hrs after initiation of ANY syphilis treatment
2. NOT an allergic reaction to penicillin
3. Manage with ANTIPYRETICS
152
Penicillin Allergies in Syphilis
MUST USE PENICILLIN for Pregnant Women and Neurosphyilis even if there is a reported allergy
MUST desensitize patient and use penicillin treatment
PCN Allergy in Primary or Secondary Syphilis:
1. Doxycycline x 14 days
2. Tetracycline x 14 days
3. Ceftriaxone x 10 days
153
Syphilis Management
1. RE-TEST 6-12 months after treatment
2. Titer expect a 4-FOLD DECLINE (2 dilutional)
154
Genital HSV
1. HSV 1 = Oral
2. HSV 2 = Genital (highest among AA and lowest in asians)
-More severe in women
LIFE LONG INFECTION
Herpes Simplex Virus
155
Genital HSV Treatment
First Episode:
1. Acyclovir, Famciclovir, Valacyclovir
2. 7-10 days
3. NO topical therapy
Recurrent:
1. Foscarnet or Cidofovir
2. QD
Episodic:
1. Start therapy with 1 day of lesion onset
2. Acyclovir, Famciclovir, Valacyclovir
156
Trichmoniasis
1. Most prevalent NON Viral STI worldwide
2. Anaerobic Flagellated Protozoan Parasite
3. Wet mount microscopy
4. WOMEN RE-TEST 3 months after initial treatment, no re-testing in men
157
Trichmoniasis Treatment
1. Metronidazole PO x 7 days = preferred
2. Tinidazole PO SINGLE dose = alternative
158
Bacterial Vaginosis
1. NOT technically an STI
2. Reducing normal vaginal flora of lactobacillus and increased concentrations of anaerobic bacteria
3. Amsels Criteria
4. NO Follow Up
159
Amsels Diagnostic Criteria, requires at least 3 of the following:
1. Thin milk like consistency
2. Clue cells
3. pH of vaginal fluid >4.5
4. Fish odor of vaginal discharge before or after addition of 10% KOH
160
Bacterial Vaginosis Treatment
1. Metronidazole PO x 7 days
2. Metronidazole GEL INTRAvaginally x 5 days
3. Clinda CREAM INTRAvaginally x 7 days
161
Meningitis
Inflammation of subarachnoid space of CSF
-Bacterial
162
Encephalitis
Inflammation of the brain tissue
-Viral
163
Meningoencephalitis
Inflammation of both
164
Bacterial Meningitis
1. S. pneumo is the MOST common pathogen
2. Community Acquired: most common, infants, crowded conditions
3. Hospital Acquired: invasive or neurological trauma
165
Causative Organisms of Hospital Acquired Bacterial Meningitis
1. S. aureus
2. S. epidermis
3. Gram neg bacilli
166
What is the classic TRIAD of symptoms for bacterial meningitis?
1. FEVER
2. Nuchal Rigidity
3. Altered Mental Status
167
Petechial Rash is seen most common with?
Meningococcal meningitis -- Neisseria Meningitidis
168
What are the objective tests that should be performed prior to antimicrobial administration, for bacterial meningitis?
1. Lumbar Puncture BP
2. CT or MRI
3. Blood Cultures
169
What are the 5 FATORs that make an antimicrobial agent effective in penetrating in the CNS?
1. Dose = higher doses best
2. MW = lower molecular weight
3. Lipid Solubility = lipid soluble > water soluble
4. Protein Binding = free drug passes easier
5. Ionization = non-ionized able to diffuse
170
What 4 antibiotics require specific dosing alterations when used in the treatment of CNS infections?
1. Ceftriaxone
2. Meropenem
3. Vancomycin
4. Ampicillin
Need higher doses for better penetration in the setting of CNS infections
171
What is the empiric therapy of CNS infections for a patient less than 1 month old?
Ampicillin + Cefotaxime or Gentamicin
Continue 48-72 hrs until infectious process ruled out
172
What is the empiric therapy of CNS infections for a patient age 1 month to 50 yrs?
Vancomycin + Cefotaxime or Ceftriaxone
Continue 48-72 hrs until infectious process ruled out
173
What is the empiric therapy of CNS infections for a patient >50 yrs?
Vancomycin + Ampicillin + Cefotaxime or Ceftriaxone
Continue 48-72 hrs until infectious process ruled out
174
What is the definitive therapy for S. pneumo causation of CNS infections?
1. PCN Susceptible: PCN G or Ampicillin
2. PCN Intermediate: Ceftriaxone, Cefotaxime, Meropenem
3. PCN Resistant: Vanco + Cefotaxime or Ceftriaxone
175
What is the definitive therapy for GBS causation of CNS infections?
Ampicillin or Penicillin
176
What is the definitive therapy for Neisseria meningitis causation of CNS Infections?
PCN Susceptible: PCN G or Ampicillin
PCN Resistant: Cefotaxime or Ceftriaxone
177
What is the prophylatic therapy for Nesisseria meningitides?
Infants and Children = Rifampin q12h x 4 DOSES or Ceftriaxone x 1
Adults = Rifampin q12h x 4 DOSES or Ceftriaxone x 1 or Cipro
178
What is the defintive therapy for H. flu causation of CNS Infections?
B-Lactamase Neg: Ampicillin
B-Lactamase Pos: Cefotaxime or Ceftriaxone
179
What is the prophlyatic therapy for H. flu?
Rifampin x 4 DAYS
NOT recommended if FULLY VACCINATED
If not vaccinated, then vaccine should not be initiated
180
What is the defintiive therapy for Listeria monocytogenes causation of CNS infections?
Penicillin G or Ampicillin + Gentamicin
181
What is the definitive therapy for Gram Neg Bacteria (klebsiella, e.coli, s. marcescens, p. aeruginosa, salmonella) causation of CNS infections?
Pseudomonas: Cefepime or Ceftazidime + Aminoglycoside
Other Gram Neg: 3rd or 4th gen cephalosporin
182
When should Dexamethasone Q6h for 2-4 days be used to reduce inflammatory mediated sequelae in CNS Infections? Adjunct Therapy
1. Children 6 weeks and older with either pneumococcal or meningococcal meningitis
2. Adults with pneumococcal meningitis
183
What is empiric therapy for hospital acquired CNS infections?
VANC + Cefepime or Meropenem
AVOID Zosyn due to poor CNS penetration
184
What is definitive therapy for hospital acquired CNS Infections?
1. MSSA: Nafcillin, NOT cefazolin
2. MRSA: VANC, consider rifampin for biofilm penetration on hardware
3. Pseudomonas: Antipseudomonal B-Lactam; can add AG for extracerebral infections
185
What is definitive therapy for HSV Encephalitis?
IV Acyclovir
If resistant = Foscarnet
