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AHN 577 > Infectious Disease > Flashcards

Infectious Disease Flashcards

(143 cards)

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1
Q

Volume of distribution

A

Drug must reach the sites of infection at adequate concentrations

Factors: Lipid solubility, tissue penetration, blood flow to tissues, pH, plasma protein binding

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2
Q

Tetracyclines have…

A

Great distribution to the tissue, do not stay in the blood stream. Not good to treat blood stream infections

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3
Q

Metabolism

A

Most are metabolized in the liver

CYP450: Macrolides, rifampin, sulfonamides…

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4
Q

Elimination

A

Renal and non renal

Some drugs: Vancomycin, zosyn need different dosing based on GFR

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5
Q

Absorption

A

Many routes of intake

IM, inhalation, IV, PO, Intraperitoneal, Intrathecal

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6
Q

Agents that are active against the cell wall…

A

B-lactams, Vancomycin, Daptomycin, Telavancin, Azoles

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7
Q

Antibiotics that are protein synthesis inhibitors…

A

Tetracyclines (3oS)
Macrolides, clindamycin, chloramphenicol, synercid (5oS)
Fluoroquinolones (DNA girasse, Topoisomerase)
Rifamycins (RNA polymerase)
Linezolid (Other ribosomal agents)

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8
Q

Antibiotics that are cationic detergents that dissolve the cell wall…

A

Polymyxins

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9
Q

Antibiotics that inhibit free radical formation…

A

Metronidazole

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10
Q

Antimicrobial resistance

A

Drug enzymatic inactivation
Altered target site
Decreased permeability of antibiotic into cell

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11
Q

What is bacteriostatic?

A

Inhibits growth and replications

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12
Q

What is bactericidal?

A

Cause bacterial cell death

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13
Q

MIC?

A

Minimum Inhibitory Concentration (for bacteriostatic)

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14
Q

MBC?

A

Minimum Bactericidal Concentration

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15
Q

Concentration dependent antibiotics..

A

Peak matters, time above the MIC doesn’t matter.

Aminoglycosides, Daptomycin, Flouroquinolones

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16
Q

Time dependent killing

A

More time above MIC, the better they kill. Peak doesn’t matter.

B-Lactams
Linezolid

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17
Q

A combination of concentration and time dependent killing

A

Vancomycin, Macrolides, Tetracyclines, azoles

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18
Q

B-Lactam antibiotics properties

A

Inhibit cell wall synthesis
Bactericidal
Time-dependent killing

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19
Q

B-Lactam antibiotics

A

Penicillins
Cephalosporins
Carbapenems
Monobactams

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20
Q

Penicillin antimicrobial spectrum

A

Gram positive
Primarily Streptococci

Gram negative, very few
Neisseria Meningitidis

Drug of choice for:
Actinomyces (found in mouth)
Syphillis (T. Pallidum)`

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21
Q

“Anti-staphylococcal” penicillins

A 
Methicillin
Oxacillin
Nafcillin
Dicloxacillin
Cloxacillin

Mostly for MSSA
Soft tissue/skin infections

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22
Q

Gram negative rods SPACE bugs…

A 
S-Serratia, Klebsiella, Enterococcus
P-Proteus vulgaris or Pseudomonas
A-Acromobacter or Acinetobacter
C-Citrobacter
E-Enterrobacter
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23
Q

“Low resistance” GNR…

A

Aminopenicillins

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24
Q

Aminopenicillin antimicrobial spectrum…

A

Gram negative with “low resistance” enterobacteriacae
H. Influenzae

Food-derived:
Listeria (DOC)
Salmonella and Shigella

Gram +, Streptococci and enterococci

Better anaerobic coverage

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25
Extended spectrum penicillins
Carboxypenicillins (Ticarcillin) Ureidopenicillins (Piperacillin) Rarely used as single agents in US
26
Extended spectrum antimicrobial spectrum
Gram negative, increased activity including pseudomonas Gram Positive, overall less, but still effective Excellent anaerobic activity
27
B-Lactamase inhibitors
Clavulanic acid Sulbactam Taxobactam Not used as single agents in the US
28
Cross-reactivity with other B-Lactams
1st gen. cephalosporins 5-10% 2 & 3 gen. Cephalosporins 1-5% Carbapenems 1-5% Monobactams, rare
29
How many generations of Cephalosporins
5
30
The first generations have only... | and as you move to the 5th generations they become more...
Gram positive Gram negative also
31
Colonization is...
the presence and replication of micro organisms without tissue invasion and/or damage
32
Normal Flora of the nasopharynx
``` Streptococci Haemophilus Neisseria Mixed anaerobes Candida Actinomyces ```
33
Normal Flora of the Skin
``` Staphylococci Streptococci Corynebacteria Proprionibacteria Yeasts ```
34
Normal Flora of the upper bowel
Enterobacteriaceae Enterococci Candida
35
Normal Flora of the Lower bowel
Bacteroides Bifidobacteria Clostridium Peptostreptococci
36
Normal flora of the vagina
``` Lactobacilli Streptococci Corynebacteria Candida Actinomyces Mycoplasma hominid ```
37
Innate immune system of eyes
Lysozyme in tears kills gram positive bacteria
38
Innate immune system of the nose
Removal of particles by turbinates and humidification
39
Innate immune system of the upper airway
Mucus and cilia capture organisms and remove them
40
Innate immune system of the skin
physical barrier
41
Innate immune system of the stomach
Stomach acid kills ingested pathogens
42
innate immune system of the bowel
Competition and toxic products from intestinal flora
43
innate immune system of the bladder
Flushing action of urinary flow removes organisms
44
innate immune system of the vagina
Low vaginal pH from lactobacilli prevents colonization by pathogens
45
Innate immune system of the whole body
molecular and cellular defense Patter recognition molecule Neutrophils Macrophages
46
Infection is an invasive presence and replication of micro-organisms accompanied by...
Local cell injury/death Secretion of toxins Host immune response
47
Culture interpretation is dependent upon:
Complete clinical picture Method of collection Gram stain results Cellular evidence
48
Most likely cause of contamination...
Poor collection technique
49
Gram positive Cocci
Staphylococcus Streptococcus Enterococcus
50
Gram positive Rods
Corynebacterium Bacillus Listeria
51
Gram Negative Cocci
Neisseria | Moxorella catarrhalis
52
Gram negative rods
``` Enterobacteriaciae Normal gut flora Vibrio Shigella Salmonella Pseudomonas Hemophilus ```
53
Anaerobes
Gut flora Actinomyces Bacteriodes
54
Mycobacteria
TB
55
Fungi
Candida | Aspergillus
56
Viruses
Herpesvirus family Adenovirus Influenza Coxsackievirus
57
Rickettsia
Rocky Mountain Spotted Fever
58
Parasites
Giardia Lamblia | Pneumocystis Jiroveci
59
Spirochetes
Treponema Pallidum
60
Principles of antimicrobial Coverage
The use of any antibiotic promotes resistance Broad spectrum is used- promotes resistance to both normal and pathogenic flora Narrow spectrum- confines resistance to fewer organisms
61
Therapeutic considerations of antimicrobial coverage
Identify whether infection is present | Choose the narrowest spectrum, least toxic, least invasive, and least expensive medication that is the most effective
62
Primary interventional concepts of antimicrobial coverage
Observation without antibiotics Preventive/Prophylactic therapy- patients with artificial heart valve who need dental work Empiric therapy- what we use while we await cultures Specific therapy- tailored to the cultures
63
Meningitis common bacterial organisms
Strep Pneumonia Neisseria meningitidis Gram negative, group B strep more common in > 50 years
64
Meningitis common viral organisms
HSV EBV Varicella Zoster Coxsackievirus
65
Meningitis clinical manifestations
``` HA and fever AMS Nuchal rigidity Positive Kernig and Brudzinskis May also see photophobia and seizures ```
66
Kernigs sign
Hip flexion on supine patient, hamstrings contract and they are unable to extend their knees
67
Brudzinskis sign
Head flexion causes spontaneous hip and knee flexion
68
Meningitis diagnosis
CT scan CSF for gram stain, culture, AFB Blood cultures CT must be done before LP because you can cause herniation is symptoms are caused by space occupying lesion
69
Bacterial Meningitis LP
Leukocytes- 100-50000 PMN Protein- 100-500 Glucose- Low
70
Viral Meningitis LP
Leukocytes- less than 1000 MN Protein 50-200 Glucose normal or high
71
Viral encephalitis LP
Leukocytes- less than 1000 PMN early then MN Protein 50-200 Glucose- normal or high
72
TB meningitis LP
Leukocytes- 10-500 lymphocytes Protein- 100-500 Glucose Low < 40
73
Brain Abscess
Leukocytes- 10-200 lymphocytes Protein 100-500 Glucose Normal
74
Meningitis treatment | Antibiotics
Need bactericidal medication Drugs that readily cross the BBB Dexamethason prior to abs, then Q 6h Ceftriaxone + Vancomycin (18-50 y.o community acquired) Add ampicillin if > 50 Continue for 10-14 days
75
Meningitis treatment other
Avoid volume overload seizure precautions monitor for cerebral edema ID consult
76
If meningococcal meningitis is diagnosed
Prophylactic treatment is indicated for anyone with close contact College setting
77
Viral meningitis treatment
Self-limiting | Treatment directed towards the specific virus
78
Endocarditis risk factors
Native heart valve disease in those > 60 years Prosthetic heart valves IV drug Abuse (tricuspid valve) Bacteremia following dental (streptococci), pulmonary, urologic or lower GI procedures
79
Endocarditis common organisms
``` S. Aureus is the MOST COMMON!!! Streptococci Enterococci Coag negative staphylococci HACEK organisms (pg 1458 CMDT) Fungi ```
80
Endocarditis Clinical manifestations
``` Persistent fever- days to weeks Malaise Fatigue Anorexia Arthralgias/Myalgias ``` New or worsening murmur Petechiae, Osler (tender on pads fingers and toes)/janeway nodes (Contender erythematous macule on palms and feet), splinter hemorrhages Roth spots Splenomegaly
81
What are Osler nodes
Tender nodules on the pads of the fingers and toes
82
What are Janeway nodes?
Nontender erythematous macule on palms of the hands and soles of the feet
83
How to diagnose Endocarditis
BC x 3 at least an hour apart TTE & TEE CXR Modified Duke criteria
84
What is the modified duke criteria?
Clinical criteria 2 major, 1 major + 3 minor or 5 minor Major criteria Positive blood culture for characteristic organism or persistently positive Echocardiographic identification of a valve related mass or abscess New Valvular regurgitation ``` Minor criteria Predisposing heart lesion or IV drug Fever Vascular lesions Immunological phenomena Microbiologic evidence Echocardiographic findings consistent with but not diagnostic of endocarditis ```
85
Endocarditis treatment
Empiric treatment with Ceftriaxone and Vancomycin Then tailor therapy for culture ID and Cardiology consult Surgical intervention if treatment failure after 7-10 days or acute HF
86
Tailored treatment of endocarditis
Streptococci -PCN or Ceftriaxone Enterococci- PCN/Ampicillin and Gentamycin MSSA/MRSA- Nafcillin/Oxacillin or Cefazolin; Vancomycin/Daptomycin Coag negative staph (Prosthetic valves)- Vancomycin, Rifampin, Gentamycin HASEK- Ceftriaxone
87
Dental prophylaxis
Amoxicillin is preferred | Alternative for PCN allergy is Clindamycin, Cephalexin, Azithromycin
88
Endocarditis complications
Myocardial abscess Rhythm disturbances Embolization- septic emboli to brain, coronary arteries, spleen TV endocarditis- septic pulmonary emboli with IVDA
89
CLABSI risk factors
Healthcare associated infection | Central lines placed in the femoral artery- 72%
90
CLABSI clinical manifestations
Fever Purulent drainage from the site No other readily available source
91
CLABSI common organisms
``` Coag negative staph (most common) MRSA E. Faecium Pseudomonas Acinetobacter Candida ```
92
CLABSI antibiotic empiric treatment
Ceftazidine or Cefepime plus Vancomycin
93
CLABSI management
ABX Remove lines Culture tip Blood cultures
94
Pneumonia Types
``` Community associated (CAP) Ventilator associated (VAP) Hospital associated (HAP) Healthcare associated (HCAP) ```
95
Pneumonia common organisms
CAP- S. Pneumonia (most common), Klebsiella, S. Aureus, H. Influenzae VAP/HAP/HCAP- MRSA (most common), P. Aeruginosa (often MDR), Acinetobacter, E. Coli, Enterobacter Atypical- M. Pneumonia, Legionella Viral
96
Pneumonia clinical manifestations
1. CAP- fever, cough, may have sputum or dyspnea, chills, diaphoresis, pleurisy, anorexia, HA, Fatigue, Myalgias 2. VAP/HAP/HCAP- the presence of a new infectious infiltrate on CXR with new onset fever, sputum production, leukocytosis, and reduced SaO2 3. PE findings- Tachypnea, ST, Crackles, or diminished breath sounds
97
Urinary antigen for S. pneumoniae and legionella pneumophilia-
reserved for severe cases of CAP in the ICU
98
CAP management | outpatient, healthy, no recent abx
a. Macrolide or doxycycline
99
CAP management outpatient with comorbid conditions
a. Resp. FQ (Levaquin) | b. PO beta lactam and macrolide
100
CAP management | Inpatient, nonicu
a. IV betalactam + macrolide | b. Resp. FQ (Levaquin)
101
CAP management | inpatient, ICU
a. IV beta lactam + macrolide | b. IV beta lactam + Resp FQ
102
HAP treatment
1. Use 2 drugs if (antipseudo + a Fluroquinalone or an aminoglycoside) a. prior IV abx last 90 days b. Structural lung disease c. Septic shock or MV need 2. AntiMRSA coverage is required if… a. Staph isolates b. Prior IV ABX last 90 days c. Septic shock or MV
103
HAP antipseudomonal treatment
1. Antipseudomonal beta lactam a. Zosyn b. Cefepime c. Meropenem d. Imipenem Plus 1 of the following: 2. Resp. FQ a. Levofloxacin b. Ciprofloxacin 3. AG a. Gentamycin b. Tobramycin c. Amikacin
104
HAP MRSA treatment
1. Antipseudomonal beta lactam a. Zosyn b. Cefepime c. Meropenem d. Imipenem Plus Add 1: Vancomycin Linezolid
105
VAP treatment
1. Antipseudomonal ABX needed if a. > 10% GNR resistance b. Structural lung disease c. Risk factors for MDR VAP 2. MRSA ABX needed if a. > 10-20% isolates MRSA b. Risk factors for MDR VAP
106
VAP antipseudomonal treatment
1. Antipseudomonal beta lactam a. Zosyn b. Cefepime c. Meropenem d. Imipenem Plus 1 of: a. FQ: Levo, Cipro b. AG: amikacin, gent. Tobra c. Polymyxin: Colistin
107
VAP MRSA treatment
1. Antipseudomonal beta lactam a. Zosyn b. Cefepime c. Meropenem d. Imipenem Plus 1 of: Vancomycin or Linezolid
108
Risk factors for MDR
Antimicrobial therapy in previous 90 days Current hospitalization of > 5 days Immunosuppressive disease and or therapy ``` Other: Previous hospitalization within last 90 days Resides in nursing home Home infusion therapy Chronic dialysis Home wound care Family members with MDR ```
109
Urinary tract infection risk factors
Indwelling catheters | females
110
UTI common organisms
- E. Coli, Klebsiella, Proteus miribilis + S. saprophytic, E. Faecalis, GB strep
111
Uncomplicated cystitis ABX
``` Nitrofurantoin Bactrim Fosfomycin Fluoroquinolones AMX Cefdinir, Cefaclor, Cefpodoxime ```
112
Uncomplicated pyelonephritis ABX
``` Fluoroquinolones Levofloxacin Ciprofloxacin Bactrim Aminoglycosides +/- ampicillin Cephalosporin or penicillin +/- ahminoglycosides Carbapenems ```
113
Complicated cystitis ABX
Fluoroquinolones Levofloxacin Ciprofloxacin Ampicillin or amoxicillin
114
Complicated pyelonephritis ABX
Fluoroquinolone plus cephalosporin or penicillin or carbapenem
115
Skin and soft tissue infections risk factors
Invasive devices Surgical procedures Debilitated skin integrity Diabetics
116
Skin and soft tissue infection clinical presentation
Rapidly spreading area of erythema Culture the site if appropriate Can lead to sepsis Assess for necrotizing fasciitis if areas of necrosis appear
117
Skin and soft tissue infection common organisms of necrotizing fasciitis
V. Vulnificis S. Pyogenes Aeromonas Clostridiums
118
Skin and soft tissue infection ABX therapy for non purulent infections
Cellulitis - penicillin - ceftriaxone - cefazolin - clindamycin If severe: rule out nec fasc. vancomycin plus zosyn
119
Skin and soft tissue infection treatment
May require surgical debridement
120
Skin and soft tissue infection ABX therapy for purulent infections
Mild- just I&D Moderate- I&D plus C&S -Bactrim or doxycycline Once C&S: MRSA- Bactrim MSSA- Cephalexin or Dicloxacillin Severe- I&D plus C&S - Vancomycin - Daptomycin - Linezolid - Televancin - Ceftaroline ``` Once C&S: MSSA use: -Nafcillin -Cefazolin -Clindamycin ```
121
Defined ABX therapy for severe non purulent soft tissue infection
Streptococcus pyogenes- Penicillin plus clindamycin Clostridial sp. - penicillin plus clindamycin Vibrio vulnificus- Doxycycline plus ciprofloxacin Polymicrobial Vanco plus Zosyn
122
Clinical manifestations of necrotizing fascitis
``` Erythema Marked edema SEVERE tenderness Bullae formation Compartment syndrome Systemic symptoms- fever, septic shock ```
123
ABX coverage for nec. fasc
Vancomycin and Zosyn Doxycycline and Ceftazidime are essential with a high degree of suspicion for Vibrio vulnificus Surgical debridement is primary treatment
124
Surgical site infection risk factors
``` severity of illness type of surgery length of surgery comorbidities age steroids other infected sites ```
125
Surgical site infection clinical manifestations
Fever evidence of local infection- redness, drainage, poor healing (Culture drainage)
126
Surgical site infection treatment
Determined by gram stain and culture Treat for common skin flora in that area
127
Osteomyelitis risk factors
Diabetes and diabetic foot wounds | Injured bone that has lost vascularity- no longer accesses to blood borne defenses
128
Osteomyelitis common organisms
S. Aureus | Coag negative staphylococcus
129
Osteomyelitis management
Orthopedic referral MRI Culture of open site or surgical bone biopsy Drainage is the central concept of therapy- ABX are an adjunct may require many months of therapy
130
C. Diff colitis risk factors
Antibiotic use- primarily fluoroquinolone, clindamycin and cephalosporins Age > 65 Hospitalization Severe illness
131
C. Diff
Anaerobic gram + spore forming bacillus
132
C. Diff managment
Prevention of transmission is essential
133
C. Diff ABX
Metrondiazole Add vancomycin PO for severe disease 10-14 days
134
C. Diff clinical manifestations
``` Colitis with diarrhea Watery, foul smelling abdominal pain/crampin fever anorexia nausea malaise fever shock leukocytosis renal failure ```
135
C. Diff treatment
DC offending antibiotics GI/ID consult ABX Fecal transplants
136
Fever of unknown origin definition
Fever > 101 for at least 3 weeks | Definitive cause occult despite complete workup
137
FUO common etiologies
``` Infection malignancy autoimmune disease- 22% Drug induced Granulomatous disease Any inflammatory process- surgery, burns, trauma Factious fever ```
138
FUO treatment well appearing
``` Stop non essential meds CBC BMP LFT UA Radiographs as needed Observation ```
139
FUO treatment is appearing ill
``` Admit to hospital Stop non essential meds LFT hepatitis panel BC UA CSF culture CRP ```
140
FUO workup for suspected infectious cause
Cultures CSF studies CRP/ESR Empiric antibiotics
141
FUO workup for suspected oncologic cause
``` Uric acid Lactate dehydrogenase Ferritin Peripheral smear Chest radiograph Hold steroids ```
142
FUO workup for suspected autoimmune cause
``` Antinuclear antibody Rheumatoid factor C3, C4, CH50 Thyroid function CRP ESR Ferritin ```
143
FUO workup for suspected immunodeficiency causes
immunoglobulins lymphocyte markers consider antibody titers to known vaccinations HIV

AHN 577 (4 decks)

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