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DOOS3 > ID questions-Ashley -Table 1 > Flashcards

ID questions-Ashley -Table 1 Flashcards

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1
Q

What medication do you never give for pulmonary infections?

A

Daptomycin- the surfactant deactivates it. Otherwise, a great gram + coverage

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2
Q

What ABX do you not want to use for pylonephritis, but has great coverage for cystitis?

A

Nitrofurantoin, It doesn’t penetrate the renal peranychema well.

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3
Q

What abx do you not want to use in sterile site infections?

A

Bacteroistatic abx need a host’s functioning immune system , so don’t use tetracyclines, macrolides(-mycin, clindamycin), or linezolid

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4
Q

what is considered a fever?

A

100.4 or higher

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5
Q

What are considered sterile sites?

A

blood, joints, CSF, intra-abdominal cavity outside lumen of guts, urine

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6
Q

There are two types of dosing regimens for maximizing pharmacologic therapies…what where they?

A

Concentration dependent(FQs, aminoglycosides(-micin) vs. time above MIC dependent(beta-lactams)

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7
Q

What FQ doesn’t cover pseudomonas?

A

Moxifloxacin

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8
Q

What is justin’s first line for pylonephritis?

A

Ceftriaxone (rocephin)- he also assumes that you would always tx inpt

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9
Q

When should you use carbapenems as DOC?

A

ESBL infections in any sterile site and fever of unknown origin

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10
Q

When should you treat asymptomatic bacteruria?

A

if pt is pregnant, neutropenic, or has an upcoming urologic surgical procedure

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11
Q

How can you r/o drug fever out of your ddx?

A

calculate pulse rate that should correspond to fever. ex.Fever of 103F, ((3-1)x10) +100=120bpm is normal response. if pulse rate is at that rate than know it’s not drug fever.

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12
Q

What are the anti-pseudomonal agents?

A

3°G Cef taz idime (taz taz taz taz)
4°G Cefepime, Antipseudomonal penicillins(pipercillin/tazo and ticarcillin/clav)
Aminoglycosides (synergy with beta-lactams)
Aztreonam (pseudomonal sepsis)
Fluoroquinolones: Ciproflocacin, levofloxacin Carbapenems: imipenem/cilistatin and meropenem

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13
Q

What is justin’s first line for acute cystitis?

A

Cefurozime(BID x 5 days), but nitrox5, bactrimx3D, and ciprox3 days are all options too.

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14
Q

What is SIRS criteria?

A

Systemic inflammatory response syndrome: temp>38 or 20, HR>90bpm, WBC>12k or 10%bands

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15
Q

3 or more organisms indicate what in a urine culture?

A

contamination, don’t treat foo!

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16
Q

What makes an infection “healthcare associated”?

A

hospitalized 2 or more days in past 90days, lives in nursing home or extended care facility, home infucion therapy, dyalysis, home wound care, immunosupressive dz and/or therapy, urologic instrument placement

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17
Q

What bug is a catalase negative staphylococci?

A

Staph. epidermidis- colonized our skin, non-pathogenic

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18
Q

What bugs are catalase positive? and the significance?

A

SPACE organisms: Staphylococcus aureus, Pseudomonas, aspergillus, candida, enterobacter. Catalase positive bacteria/fungi can produce enzymes that produce O2 gasses that are damaging= more virulence

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19
Q

What bug is coagulase +? and the significance?

A

Staph aureus, catalase+ also. Coagulase positive means that the bacteria can form a clot in blood stream that can be a hiding vessel for the pathogen=more virulence

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20
Q

What only beta lactam covers MRSA?

A

Ceftaroline=5th gen cephalosporin, Vancomycin is drug of choice

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21
Q

Are there community acquired versions of MRSA?

A

Yes, and they are more susceptible to clindamycin and doxycycline.

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22
Q

What is group A strep?

A

Streptococcus pyogenes, it is catalase negative, beta-hemolytic, - it is a common human pathogen - especially cellulitis

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23
Q

What are the DOC for non-purulent skin and soft tissue infections?

A

1st generation cephalosporins(cefazolin, cefalexin), these include coverage for GAS and MSSA

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24
Q

Do you treat DM cellulitis the same as a DM foot ulcer?

A

NOOOOOOO! Justin emphasized this a lot at the conclusion of SSTI lecture. cellulitis is still staph or strep. DM foot ulcers are often

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25
How long should you wait for improvement of a SSTI before switching to another drug regimen?
24-48hrs even up to 72 hours for poor healers. Cidal agents will make these lesions appear worse initially d/t lysis of the strep/staph bacteria.
26
What are obese ppl difficult to treat with for cellulitis?
Venous insufficiency and venous stasis
27
Pt comes in who has had a cough for 2 weeks. You diagnose them with bronchitis and treat with what?
Supportive care! bronchitis can last up to 3 weeks and is viral in most cases.
28
For this class do you ever cover for MRSA in CAP?
Not for this test. In reality there are post viral pneumonia infections that can cause staph aureus colonization, but we wont be addressing that here.
29
What organism is responsible for 2/3rds of deaths d/t CAP?
Strep pneumoniae, always cover for in in your treatment!
30
What is the neutrophil cut off for a left shift?
anything >70%
31
While treating a CAP pt with potential atypical pathogens, what do you want to add to your strep meds such as cefurozime or augmentin(amoc/clav)?
Azithromycin, amox/clav and cefuroxime do not cover.
32
What fluroquinolone is not considered to be have respiratory coverage and is therefore and exception to other the other FQ that are used as monotherapy in treating pna?
Ciprofloxacin doesn’t cover s.pneumo good anymore. don’t use in pna. can use levofloxacin and moxifloxacin though.
33
Why do you switch to using ceftriaxone for treating inpatient CAP versus in outpatient you used cefuroxime?
Ceftriaxone is available IV and PO so good for inpt and stepdowns. Cefuroxime is only PO.
34
How long does it take for your pna pt’s CXR looks better?
4 weeks for 80% of patients even though they may be feeling better within 3-5 days
35
You’re pt is on IV tx for pna, when can you step this pt down to po?
-fever and wbc normalized/ hemodynamically stable/ pulse ox>90%/ tolerating po diet/ functioning GI/
36
If it is day 3 and your UNM pt qualifies for HCAP,HAP, VAP what are you treating with?
Zosyn(pipe/tazo) and vancomycin- there are “early onset
37
What is the basic recipe for treating HCAP, HAP, VAP?
Beta lactam backbone cefepime, meropenem, zosyn) PLUS MRSA coverage(vancomycin(cidal) or linezolid(static))- ppl double covered for pseudomonas in other regions, only do it pt is neutropenic or “knocking on deaths door stop” in NM.
38
What antibiotics cover B.Frag
Ampicillin/sulbactam, pipercillin/tazo, all carbapenems
39
We know some dosing for HCAP/HAP/VAP treatments: cefepime?, meropenem? pipercillin/tazobactam, vancomycin
Meropenem 1g IV Q8H, cefepime 1-2g IVQ8-12H, pipercillin/tazo 4.5g IVQ6H, Vancomycin 15mg/KgIVQ12H——-assuming good renal and hepatic function
40
How long should you treat HAP/HCAP/VAP?
7 days, unless the organims are Peudomonas aeruginosa, staph, acinetobacter = 14 day regimen
41
What are you treating for aspiration pneumonia and for how long? Which ones can be swapped out from IV to PO?
Anaerobes and Strep= unasyn(amp/sub), ceftriaxone+metronidazole, amox/clav,—- Unasyn(IV)—>Augmentin(amox/clav)((PO))
42
Primary peritonitis is caused by what 3 routes?
Hematogenous, lymphogenous, translocaiton of organisms through gut wall/vagina/tubes ——apparently these are controversial and Justin wants us to know about them
43
What medications should you not use during intraabdominal infections?
Cefotetan and clindamycin d/t B.Frag resistance
44
Of the FQ which one has anaerobic coverage?
Moxifloxacin, but resistance is showing in treatments for intra-abdominal infections - this is part of why moxifloxacin is not seen in severe intra-ab. infections. only used in mild-mod
45
What is the treatment progression from Community Intraab infection non-severe, comm IAI severe, HCA non-severe, HCA severe?
BROAD(+-anaerobes, aerobes):ex. ceftriaxone+metronidazole—>Broad+nosocomial+(maybe enterococci): pipercillin/tazo—> Broad+noso+enterococci+(maybe candida):Pipercilin/tazo+vancomycin
46
What ABX will cover all enterococci sp including fecium and fecalis?
Vancomycin, pip/tazo wont cover all potential virulent enterococci sp.
47
How long do you have until you must have abx onboard for a septic versus non-septic pt with IAI?
1Hr versus 8Hr
48
You're pt is sick from IAI in the small intestine. When you get his cultures back it results e.coli that is suseptible to ciprofloxacin. You where treating him empirically with Cirpofloxacin and metroniadazole, do you step down therapy?
NO! Assume that there are anaerobes still there and keep the metro. Anaerobes are difficult to culture and often wont show up.
49
What is a recommended PO option for IAI?
Cefuroxime+ metronidazole, d/t improved E.coli coverage
50
What are the durations of therapy for IAI?
average 4-7 days, total range 3-10D- weeks(undrained abscess)- based on whether surgical intervention is done. - source control shortens abx therapy drastically
51
Treatment of acute pancreatitis was discussed briefly, what medcations penetrate the pancreas if abx are necessary?
Carbapenems, pip/tazoo, cipro +metro, ceftriaxone+metro,
52
On cbc with diff elevated neutrophils indicate what? Lymphocytes? Eosoniphils?
Bacterial. Viral. Allergic rxn and parasites.
53
Dexamethasone is given to whom? What is the dosing? when?
children>2mo. old w/ bacterial meningitis, adults with pneumococcal meningitis (Strep.pneumo)- 10mg dose or .015mg/kgQ6Hx2-4D- First dose given before or with first abx. -note: can use empirically, but pull as soon as you r/o strep.pneumo
54
When is the only time you give Ceftriazone twice a day to a pt?
Bacterial meningitis pt >1mo old. (dose 2g IVQ12H)
55
What is ampicillin covering for in bacterial meningitis txs? What populations?
Ampicillin covers Listeria monocytogenes found in pts50yo, alcoholics, pregnant pt, immunocompromised pts.
56
Does Moxifloxacin(avalox) cover pseudomonas?
Nah.Ciprofloxacin does though
57
What are the common agents for aseptic meningitis?
HSV2, Enterovirus(summer/fall), can be crypticococcal meningitis(amphoB and thia
58
Is acyclovir more effective for viral meningitis or encephalitis?
encephalitis(HSV1)
59
What are the durations of therapy for Bacterial meningitis?
1 week for Neisseria & H.influ, 2 weeks Strep pneumoniae, 3 weeks for strep.agalactiae(GBS), >3 weeks for Listeria monocytogens
60
Your boyfriend of 1 week came down with bacterial meningitis that is found to be N.mengitidis…What should you receive as prophylaxis?
Rifampin(600mg POQ12Hx2D-adult dose)- same if it is found to be H.infu(x4D)
61
There are vaccines for which bugs?
Pneumococcal(strep pneumo), HIB(H.influ), Meningococcal(N.meningiditis)
62
What is the difference between encephalitis versus meningitis?
Enceph: obtunded, visual/auditory impairments, super impaired cognition
63
What is the duration for encephalitis tx?
DOC: Acyclovir 10mg/kgIVQ8Hx14-21 days- Dosing should be based on IBW(ideal body wt) and adjusted renally
64
What side of the heart would a valve vegitation be worse?
Left side= d/t embolus to brain=higher mortality, surgery is most beneficial vs. Right sided= embolus to lungs and >85% cure rate, mostly no surgery needed
65
What is required for endocarditis to develope?
“Must have alteration in heart endothelium for bacterial adherence.”
66
What are the two types of endocarditis?
Acute infective endo: rapid onset, necrotizing, very virulent bugs(staph.aureus) —Subacute infective endo: less invasive, lower virulence, slow onset(strep viridans, strep bovis)——Overall, 70% are d/t gram + bugs(staph, strep, enterococcus)
67
What is Staph endocarditis associated with?
IV drug users, which sucks because tx is IV abx for 4-6 weeks and they often leave AMA.
68
What are the clinical presentations of endocarditis?
Fevers, more non-specific s/sx, some have heart mumurs, septic emboli can be visualized on CT, skin stuff(splinter hemorrhage,Petechiae, Osler’s nodes, Janeway lesions
69
How do diagnose endocarditis?
Hallmark is bacteremia(staph, strep or enterococcus), echocardiogram(TEE(most sensitive) or TTE(less sens))
70
What is the modified Duke Criteria?
Rules out or in endocarditis: Clinical criteria(2major criteria or 1major+3minor or 5 minor) or possible IE(1major+1minor or 3 minor)
71
What are the major criteria and minor criteria of DUKE criteria?
Major: positive blood cultures(Staph/strep/HACEK/enterocuccus) or positive imaging——Minor: predisposition, or heart condition or IDU/ fever>38C(100.4)/ vascular phenomenon(janeway)/ Immunological phenomena(osler’s, roth’s, rheumatoid factor, glomerularnephritis)/ Positive blood culture that is not a major
72
you have a 25 yo IVDU walk into clinic and you suspect IE what imaging do you do?
TTE(positive or poor quality) then TEE( to be sure
73
What is the treatment for IE?
high dose IV -cidal agent for 4-6 weeks from when the first blood culture comes back negative—(2, 4, 6 weeks) Streptococcus:PCN-G or PCN-G+gentimicin or CTX+gentimicin —Entercoccus: ampicillin(orPenG) + gentamicin(4w)/ Ampicillin(orPenG)+gentamicin(6W)
74
Why is there a +/- before Gentamicin added to staph IE?
considered optional d/t reduction in bacteremia by 1 day, but Justin warns against using gent in regimes with+/-.
75
How do you treat staphylococcus endocarditis?
Staph:Nafcillinx6W or prosthetic staph: nafcilin6W+rifampin6W+gentamicin2W , if there is PCN allergy use Cefazolin or vancomycin. Don’t add vancomycin(15-20 troughs) and gentamicin together though.
76
Enterocuccus fecium versus enterococcus fecalis: which one is more resistant?
E. Fecalis(sounds like feces)
77
Why add ampicillin and ceftriazone for E.Faecalis IE?
Synergism and alternative: Ceftiaxone can hit some binding sites of bacteria wall. This gives you a way to avoid gentimicin in IE tx- But stick with gent for test
78
What is an upcoming drug that can be used for MRSA or MSSA IE?
Daptomycin: it is cidal- concentration dependent- potent drug- some enterococcus coverage(VRE)
79
Why might you get a negative culture endocarditis?
HACEK organisms or started abx prior to culture - FYI the tx is horrible for this because you cover for everything!
80
What is the standard tx for someone with latent TB? And how is this diagnosed?
INH (+B6) daily for 6-9 mo, PPD 5mm or greater in HIV, 10mm or greater for high risk contact or foreigners with negative chest xray. or positive quantiferon gold serum test
81
If you have reactivated or active TB what is your first line tx?
Isoniazid, rifampin, pyrazinamide, ethambutol x4 mo, then reassess and follow with 4-7 additional months based on progress.
82
What are the standard tests done for ppl with active or reactivated TB?
CXR—>Acid fast(AFB) staining and culture of sputum to confirm definitively—> Xpert MTB/RIF assay to detext TB and rifampin resistance(fast test, everything else takes weeks)
83
What is bad about the second line tx for active/reactived tb?
Low degree of efficacy and higher SE profiles- this will probably impair adherence and lengthen treatment duration.
84
You find a large non-tender supraclavicular lymph node on your pt. It turns out that it is TB, but they have no lung infiltrates. Should you fear for subsequent transmission?
No, if the TB is not pulmonary then they aren’t infectious. Extra-pulm manifestations of TB occur once the mycobacteria has disseminated into the blood stream.
85
What are some other common sites that TB can manifest?
Skin(lupus vulgaris, erythema somthing), meninges(TB meningitis), GU(autonephrectomy-EW!), Pericardium(pericarditis), Bone(40% to spine=POTTS dz), Eye(scleritis, conjunctivitis), reproductive system(infertitlity), hepatic(rare), Lymph node(post-cervical, supraclavicular)
86
Why do we treat latent TB?
90% prevention in conversion to active. Tubercles still house live infection. If immune system weakens than tubercle could burst.
87
Is TB a notifiable disease?
Definately!
88
Pulmonary TB typically appears as a focal cavitary concentrated in the upper lobe, but what are some other radiographic appearances are there?
CXR: lobar pneumonia, Pleural disease, Miliary b/l infiltrates, appears like lung abscess—(aerobic bacteria so likes upper lung most)
89
What is a Ghon complex?
Tubercle(walled off infection) that has calcified. They are often visible on CXR
90
What latent TB populations do you worry about reactivation happening?
Old ppl, CA, immunosupressive drug uses, HIV infections, ppl using anti-TNF drugs(infliximab-tx.crohns/UC/RA)
91
Are latent TB ppl infectious?
No, they nave no disease, not sick, not infectious.
92
How long can someone live for with untreated active TB?
Usually die within 2 years
93
What are some clinical symptoms that could lead you to believe that someone has active chonic TB?
night sweats, wt loss, fever, chest pains, coughing up blood, cough, anorexia, extrapulmonary symptoms
94
What is the offending organism of TB and what else does it cause?
Mycobacterium tuberculosis, Leprosy - this bacteria is known for forming granulomas
95
What are the at risk groups for TB?
healthcare worker, HIV infected, foreigners,
96
When did the TB drugs first come onto market?
1940’s-1960’s
97
What is the specific tx of the RIPE drugs in active TB?
all 4 drugs for first 2mo—>only Isoniazid and rifampin for last 4 mo. (Only use pyrazinamide for 2mo and don’t use in preganancy)
98
What is Pott’s syndrome?
degradation of spinal vertebra, often appearing as a gibbus(acute angulation of spine), aka. TB osteomyelitis, TB drugs will eradicate this.
99
What is the PPD test? and what is a positive result?
sub-dermal injection of tuberculin proteins- screening for asymptomatic individuals who are in or will be in an at-risk condition- Positive is >=10mm, if in at risk groups >=5mm is positive this is d/t an expected reduced tb antibody response that you would see on this type of exam.

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