Module 6-12 Flashcards
(178 cards)
1
Q
TB first line agents for latent TB
A
Rifampin 10mg/kg/day x 4 months
2
Q
Active TB treatment (quadruple therapy)
A
Isoniazid (5mg/kg/day)
Rifampin 10mg/kg/day
Pyrazinamide 20-25mg/kg/day
Ethambutol 15-20 mg/kg/day
3
Q
What do you monitor while being on TB meds ?
A
LFTs (AST, ALT) ; fulminant liver failure could develop
If detected, withhold meds and consult TB specialist
4
Q
What meds / vitamins can you use to help with isoniazide
A
B6 (pyridoxine) 25mg/ day to prevent neuropathy especially in adults with poor nutrition, alcohol, substance use disorder, DM and kidney disease
5
Q
Acute bronchitis treatment
A
Mostly non pharm, 90% are viral
Non pharm
-avoid tobacco smoke
Increase humidity help reduce cough
Increase fluids/ prevent dehydration
Honey could help
Pharm
Antipyretic/
Antitussives (dextromethorphan) = robittusin, benylin, buckleys
-could provide short term relief
6
Q
Pneumonia - adults first line treatment (without comorbidities)
A
without Comorbidities:
Amoxillicin 1g TID x 7-14 days
7
Q
Second line without comorbidities (pneumonia)
A
Azithromycin 500mg first day then 250 mg x 4 days
Could use doxy or Clarithro too
8
Q
Pneumonia first line with comorbidities adults / what are the comorbidities
A
Comorbidities:
- hospitalized in past 3 months
- chronic heart, lung, liver or renal disease
- diabetes
- alcoholism
-malignancies
-Asplenia
-immunosuppression
-age >65
First line:
** think high dose amox**
Amox 1g TID x 7–14 days PLUS
Azithromycin 500 mg daily on first day then 250mg daily x 4 days
Can also choose if allergies to penicillin:
Cefuroxime 500mg BID x 7-14 days
PLUS azithro 500mg daily on first day then 250 mg daily x 4 days
9
Q
Suspected aspiration pneumonia , what is first line?
A
Amox/ clav 875 mg BID x 7-14 days
PNC allergy:
Clindamycin 300-450 mg QID x 7–14 days
10
Q
First line agents for children with pneumonia <3 mo
A
1mo-3mo - consult peds
11
Q
When do you consider hospitalization in children with pneumonia ?
A
Hospitalize if:
- <1 month of age
Toxic appearing
Oxygen requirement
Dehydration
Vomiting
No response to oral antibiotics
Microbial therapy
Immunocompromised
Hypotension
Evidence of empyema or lung abscess
12
Q
First line agent for those with pneumonia who live in LTC
A
Amox 1g TID x 5-8 days PLUS
Azithro 500mg daily then 250mg daily x4 days
Watch: duration is less
If PNC allergy
Cefuroxime 500mg BID x 5-8 days
PLUS azithro as above or Clarithromycin 500mg BID x5-8 days
13
Q
What to watch for with TB meds ?
A
Ethambutol
-check colour vision and visual acuity at baseline and qMonthly (ocular toxicity / rare at 15mg/kg/ day
Isoniazid
Asymptomatic increase in ALT and bilirubin / peripheral neuropathy
- taking vitamin B6 (pyridoxine) 25mg/ day to help prevent it
Pyrazinamide
Hepatotoxic/ rare with 2 month therapy
Rifampin
-GI upset, orange discolouration of body fluids
-best absorbed on empty stomach but can have with small amount of food if can’t tolerate
14
Q
Adults first line therapy for asthma in adults
A
Low- medium dose ICS and SABA prn
Flovent 125mcg/inhalation MDI 2 puffs BID
Ventolin 100mcq/ inhalation MDI 2 inhalations q4-6hr prn
Max 8 puffs/ day
15
Q
Escalation therapy for adults asthma
A
ICS/ LABA
Symbicort turbuhaler (budesonide 200mcg/ formeterol 6mcq) 2 inhalation BID
And same as above 1 inhaler of 200mcq budesonide prn
Max 8 inhalations daily
16
Q
In very severe cases of asthma
A
Consider steroid use, consider biologics
Dex 16 mg po daily x 2 days
Add ICS/ LABA/ LAMA
Advair 250mcg/50mcg MDI 1 puff BID
+
Spiriva respimat 2.5mcq 2 puffs inhaled daily
Only use LAMA with combo ICS/ LABA
17
Q
Children >6 yo asthma treatment
A
Start - ICS low dose
Flovent HFA 50mcq/ inhalation 2 puff BID
With SABA prn
Ventolin 100mcq/ inhalation 1 inhalation q4-6 hours prn. Increase to 2 inhalations as needed
Max 4 inhalations in 24 hours
18
Q
Children <6 yo with asthma
1-5
A
First line SABA prn only
Ventolin 100mcq MDI 1 inhalation PRN q4-6h
Then
ICS Low dose
Flovent 50mcq/ inhalation 1 puff BID for total 100mcq/day
If needs higher escalation
Refer to asthma clinic / specialist
19
Q
what is bronchiectasis
A
Increased cough ++
Increased sputum volume or change in viscosity
Increased sputum purulence with or without wheeze
Dyspnea
Hemoptysis
20
Q
How to treat bronchiectasis
A
Gold standard chest CT= diagnosis
TMP/SMX 1 DS tab BID x 14 days
Children: 5-10mg/kg/day divided BID (trimethoprim)
Amox/clav 875 mg BID x 14 days
Children Amox 40mg/kg/day divided TID x 14 days
21
Q
COPD treatment first line
A
Bronchodilator
SABA
Ventolin 100mcq/inhalation MDI 1-2 puffs q4h prn max 8 puffs/ day
AND
SAMA
Atrovent 20mcq/inhalation , 2-4 puffs q6-8h prn
Max 12 puffs/ day
22
Q
Step 2 COPD
A
Add LAMA + SABA prn
Spiriva respimat 2.5mcq/ inhalation, take 2 puffs (5mcq) inhalation once daily
Max 2 puffs / 24 hours
+ Ventolin
100mcq/inhalation 2 puffs q4h prn max 8 puffs/ day
23
Q
Step 3 COPD
A
add LABA to lama + SABA prn
Inspiolto respimat 2.5mcq olodatero/ 2.5 mcq tiotropium/ inhalation
1 inhalation once daily
Max 1 / day
24
Q
Step 4 COPD
A
Combined lama + LABA + ICS
Trelegy ellipta 100mcq fluticasone/ 25mcq vilanterol/ 62.5mcq umeclidinium 1 inhalation once daily
Max 1 inhalation per 24 hours
25
First line agent for mild / low risk acute COPD exacerbation/ what is mild
Chronic cough and sputum for at least 3 months for 2 consecutive years
Mild to moderate lung impairment >50%
<3 exacerbations/ year no cardiac disease
Good prognosis
Abx:
Amoxicillin 500mg TID x 5 days
Or
Doxy 100mg BID first day, then 100mg daily x 5 days ?
Or
TMP/ SMX 1 DS tab BID x 5 days
2nd line
Cefuroxime 500mg BID x 7-14 days
Or
Azithro 500mg on first day then 250 mg daily x 4 days
26
Complicated high risk acute COPD infection / what is it
Poor underlying lung function (<50%)
Has significant cardiac disease (CHF, HF, isxhemia)
> 4 exacerbations/ year
Needs oxygen supplementation, chronic use of steroids or abx in last 3 months
First line
Amox/ clav 875 mg BID x 7 days
Second line
Levofloxacin 500mg once daily x 7 days
27
COPD/ chance of Pseudomonas infection what antibiotics ?
Poor underlying lung function <35%
Multiple RF including frequent exacerbations, chronic steroid use
First line
Ciprofloxacin 500mg BID x ?
28
Vasovagal episode what is it ?
Occurs with upright posture held for >30 seconds with exposure to emotional stress, pain or medical settings
29
What’s the Nonpharm way to treat vasovagal episodes
Encourage dietary salt (3-5g/ day)
Fluid up to 2.5L / day in the absence of HTN and HF
Recognize premonitory symptoms (diaphoresis, sense of warmth, flushing, nausea, abdo discomfort, vision loss)
Teach: squatting or crossing legs with contraception if standing, vigorous hand clenching (<40)
30
Pharm for vasovagal syncope
Unnecessary if infrequent who have premonitory symptoms ******
First line:
Fludrocortisone 0.2mg daily (can be tried if simple salt ineffective)
Second line
Midodrine 2.5-5mg TID q4h PO (not after 1700)
Paroxetine SSRI
31
What is orthostatic hypotension?
Drop in systolic >20mmHg systolic or >10mmHg when assuming upright position
32
Orthostatic hypotension Nonpharm interventions
Remove many hypotensive and volume depleting drugs as possible
Increase salt and fluid intake if no CI
Avoid hemodynamic stress such as getting up quickly, eating large meals, being in warm environments or hot Baths and activities involving heavy exertion
33
First line for orthostatic hypotension pharm
Fludrocortisone 0.2mg daily
(It increases blood volume and promotes water and sodium retention)
Second line
Midodrine =limited evidence to support this use
Nonselective BB
(Propranolol, timolol, nadolol)
- small trial may be helpful (use only if >40 years
34
Infective endocarditis : inflammation of heart caused by bacteria or fungal infection of the heart valves or inner lining of endocardium. Could lead to life threatening complications // what are the risk factors
Risk factors
congenital heart diseaS
IVDU
HIV pt/ organ transplant patient
Heart valve replacement or have pacemaker
35
When should you use prophylaxis antibiotics for infective endocarditis
Cardiac:
Prosthetic heart valves or materials used for cardiac repair
Previous bacterial endocarditis
Unrepaired cyanotic congenital heart disease
Dental
- any manipulation of gums
Respiratory
- tonsillectomy, adenoidectomy, surgical operations involving resp mucosa, bronchoscopy
Skin
Infected skin or msk
GI/GU
Not recommended
First line agent
Amox 2g one time 30-60 min prior
Peds: 50mg/kg/dose
PNC a clindamycin 600mg 30-60 min prior
Peds: 20mg/kg
36
First line for the dental / resp
Amox 2g given 30-60 min prior to procedure
Children: 50mg/kg
37
What do you prescribe for infective endocarditis if penicillin allergy?
Clindamycin 600mg given 30-60 min prior to procedure
Children 20mg/kg
38
TIA/stroke prevention for atherosclerosis and cardiogenic reasons
In most cases antithrombotic treatment should be continued long term, especially in older individuals with atherosclerosis and vascular risk factors
Antiplatelet therapy includes
First line - ASA 81mg
If can’t tolerate asa then can do clopidogrel 75mg daily
In nonvalvular atrial fib / not routinely administered with Asa unless cardiac indication. Would do:
Dabigatran 150mg BID
Apixaban 5mg BID
Edoxaban 60mg daily
Rivaroxaban 20mg daily
39
Heart failure <40% what is the therapy?
1. ARNI (entresto 24mg/26mg BID to start then increase to 49mg/51mg BID then increase to 97mg/ 103mg BID
2. Beta blocker
Bisoprolol 10mg daily (target) start at 1.25 mg daily
3. MRA
Spironolactone 25-50mg (target)
Or
Eplerenone 50mg daily (target)
4. SGLTi
Dapagliflozin 10mg daily = only for HFrEF
Empagliflozin (jardiance 10mg daily) = use this one ; for all types of HF
If NYHA 1-4 (ambulating) and has LVEF <35% refer to cardio for CRT/ ICD
If NYHA 3-4 and not walking = palliative, referral for mechanical circulatory support/ transplant
40
What are all the heart failure ?
What is
HFrEF?
HFpEF
HFrEF= LVEF <40%
HFpEF= LVEF >50%
41
NYHA classes ?
NYHA class 1= no symptoms
NYHA class 2= symptoms with ordinary activities
NYHA class 3= symptoms with < ordinary activity
NYHA class 4= symptoms at rest or minimal activity
42
What’s the treatment for HFpEF?
No strong census on treatment / manage risk factors like HTN, DM, AF
Could start jardiance 10mg daily
And could consider
ACEI or ARB or ARNI
MRA
Beta blocker
Use diuretic for congestion
43
A fib and a flutter ; what is the CHADS-65
C-CHF =1
H- HTN =1
A- age > 75=1
D- DM =1
S-stroke/ TIA =2
AGE >65= OAC
Chads >1 and < 65= OAC
CHADS 0 and <65 with Cad or VPD= antiplatelets
CHads 0 and <65 = nothing
44
What are OAC meds?
Rivaroxaban (xarelto) 20mg OD
Apixaban (eliquis) 5mg BID
45
What is step one of Afib and a flutter management ?
Review modifying risk factors like DM, HTN, alcohol, smoking, obesity, physical inactivity, sleep apnea, hyperthyroidism, dyslipidemia
46
Step 2 of afib and flutter management
Review thromboembolic risk with chads 65 score
And review has bled criteria ( bleeding risk)
H- HTN = 1
A- abnormal renal or lft = 1
S- stroke if hemorrhagic 2pt= 1
B-bleeding (hospitalization, transfusion)=1
L-labile INR =1
E- elderly >65 =1
D- drugs (nsaids/Asa) or alcohol (>8drinks/week) = 1 point each
> 3= high risk of bleeding / frequent reassessment of OAC
47
Step 3 of afib and a flutter management
Assess benefits vs risk
Stroke typically outweighs bleeding risk
Manage arrhythmia (rate vs rhythm control)
48
Long term rate control meds for AFib and Aflutter >40% LVEF
>40% LVEF
Start with beta blocker
Bisoprolol 2.5-10mg daily
Or can do CCB
Dilitiazem 120-480 mg daily
If inadequate HR control
Add either the CCB or digoxin
Digoxin is 0.125-0.25 mg po daily
If an adequate HR control after that, consider rhythm control / refer to cardiologist
49
Long term rate control for LVEF <40%
For afib and a flutter
Start with beta blocker
Bisoprolol 2.5-10 mg once daily
If inadequate hR control
Add digoxin
0.125-0.25 mg po daily
If inadequate HR control then refer to cardiologist for rhythm control
Always evaluate CHADS 65 score if we need to add anthrombolitics
50
Long term rate control for HTN or reactive airway disease for afib and aflutter
Non CCB
Dilitazem 120-480 mg daily
51
Long term rate and rhythm control for CAD
Beta blocker
Bisoprolol 2.5-10mg daily
52
Asymptomatic nonsustaineVT what is it ? Do you treat asymptomatic?
Consists of no sustained episodes 3-10 beats. Often discovered on ECG. In the absence of structural heart disease, there is a very low risk of significant cardiac event
In the presence of heart disease, especially left ventricular dysfunction, asymptomatic VT may indicate future risk of serious sustained VF/ VF
In the absence of no heart disease and normal QTc = no treatment
If QTc is prolonged -fix underlying cause (hypokalemia, drug induced)
53
Symptomatic VT/VF include palpitations, dyspnea, chest discomfort, presyncope, loss of consciousness or cardiac arrest -send to emerge
54
Sustained VT >30 seconds =requires immediate ER
55
Nonsustained VT <30seconds treatment
Unless symptomatic it requires treatment only in the likelihood of subsequent sustained VT or cardiac arrest is high LVEF <35% or associated marked QT prolongation
Syncope
-consider prolonged ECG
Palpitations
-beta blocker if exercise induced
-Amiodarone if structural heart disease is present
56
4 meds have been shown to reduce cardiovascular risk in post MI which are they?
Beta blocker
Bisoprolol 2.5-10 mg daily
Or
Metoprolol 100mg BID (best evidence here)
Start at 12.5 mg and double dose Q2weeks
ACEI
Altace (ramipril) 2.5-10 mg once daily target is 10mg
Start 2.5 mg x1 week then 5mg x 3 weeks then 10mg OD
Statins - high intensity
Atorvastatin 40-80 mg OD
May start high dose and see if tolerates
Anti platelet
ASA 81 mg daily
57
What are lifestyle modifications in post MI
Diet
Lifestyle changes
Exercise
Smoking cessation
58
What is stable angina?
Chest pain that lasts a few min and occurs in a pattern such as during exercise or stress
Usually caused by atherosclerosis
59
Nonpharm approaches to stable angina
Aggressive lifestyle changes
Regular aerobic exerixaw
Healthy eating
Physical activity
Avoid processed food containing trans fat
Quit smoking
Moderate alcohol consumption
If this fails
May need coronary bypass surgery
60
Pharm approaches to stable angina
Anti ischemic tx
SL NTG tab 0.3mg or 0.6mg Q5min prn
X1 if discomfort persist after 1 dose seek emerge
Continue for total of 3 doses until ambulance arrives
First line (long term prophylaxis)
Beta blocker or CCB
Metro pro lol 12.5mg -100 mg BID
Or
DHP CCB
Dilitiazem XC 120-360 daily
With SL NTG prn
Second line is
BB + LA- NTG
Long acting NTG
0.2mg/hr Nitroglycerin patch ; onset 2hrs , duration; until removed
0800-2000
61
Unstable angina what is it?
Pain can be stronger or last longer than stable angina and does not follow a pattern;; this is a medical emergency
62
What do you do if unstable angina?
Stat
Nitrate 0.3-0.6mg q5min x 3 doses
While waiting for ambulance
63
What is prinzmetal chest pain?
Unprovoked, usually chest pain at rest and rarely does not occur with exertion/ duration 5-15 min
Most likely coronary artery spasm
64
What is the management for prinzmetal chest pain
non DHP CCB + NTG
Dilitiazem XC 120-360mg daily
Avoid BB
And encourage smoking cessation
65
Dyspepsia - what is it?
Pain or discomfort in upper abdomen
Some nausea and vomiting, fullness, early satiety and bloating
Dyspepsia is the cardinal symptoms of peptic ulcer disease
66
General management Nonpharm
Moderation of problematic foodsC avoid ASA/ nsaids, eat small frequent meals
67
What are dyspepsia red flags
>60, vomiting, bleeding , anemia, unexplained weight loss, dysphagia
68
In the absence of red flags, and H pylori what is the treatment for dyspepsia
PPI x4-8 weeks
Pantoloc 40mg po daily
If dyspepsia symptoms resolveC consider stopping PPI with or without initiating a step down therapy with daily H2RA
Can use
Famotidine (Pepcid) 20mg OD
Or
Ranitidine (Zantac) 150mg BID
69
What if your client had H. Pylori what is the first line therapy
PPI BID
Pantaloc 40mg BID x 14 days
+
Amox 1g BID x 14 days
+
Metronidazole 500mg BID x 14 days
+
Clarithromycin 500mg BID x 14 days
Or
PPI BID
+
Bismuth subsalicylate 525 mg QID
+
Metronidazole 500mg QID
+
Tetracycline 500mg QID
70
What if after H. Pylori therapy has ongoing symptoms?
Treat with PPI x4-8 weeks
Pantoloc 40mg once daily
If dyspepsia symptoms resolve, consider stopping stopping PPI with or without step down therapy with daily h2ra
Famotidine 20mg po
Or
Ranitidine 150mg BID
71
How do you prevent peptic ulcer disease that is due from Asa or nsaid overuse ?
What’s the med of choice for treatment
Always r/o. H. Pylori
1. PPI
2. Sub NSAID for cox-2 inhibitor
3. Misoprostol 200mcq daily QID= mucosal protective agent
If nsaids or Asa cannot be discontinued just make sure that you add PPI die as long as patient is on Asa
72
What is the common side effect of PPI?
Diarrhea, abdominal
Pain , flatulence
73
What is the common symptom of H2RA?
Diarrhea, constipation, headache, fatigue, confusion (elderly and those with poor renal function), cardiac effects, rash
74
True or false:
Successful treatment of H. Pylori will result in ulcer healing and will prevent the development of recurrent PUD (in the absence of concomitant asa and nsaid use)
True
75
Nonpharm approaches for GERD
Weight loss (avoid late evening meals) 3hours before bed
Smoking cessation
Electing HOB
Modifying diet (avoid chocolate, caffeine, acidic citrus juice, large fatty meals )
Avoid lying down after meals
Avoid tight clothing
Avoid alcohol
76
Mild gerd treatment
Antacids
(Calcium carbonate) or H2RA (Famotidine and ranitidine
Famotidine 20-40mg BID
Ranitidine 150 mg BID
77
Moderate to severe gerd treatment
PPI
Pantoloc 40mg OD x 8 weeks
If not effective then
Increase Pantoloc 40mg BID
If good response the first time then taper tx
78
On demand PPI what is it
Taking antacid daily for 8 weeks then tapering it off. Being in remission for a few months and then it comes back and you start daily therapy again until resolves
79
Refractory gerd what is that
Refer to gastro/ no response to treatment needs further work up
80
True or false is sporadic PRN PPI helpful?
False - there’s no rapid onset you’re better off with H2RA
81
What are the best pregnancy meds for GERD
#1 calcium carbonate
#2 ranitidine is safe
#3 PPI (omeprazole) 20mg one daily
30 min before food ** crucial
82
Colic nonpharm
Carrying, rocking, akin to skin
Environment manipulation could help
Dietary manipulation (finish infant BF on one breast rather than switching sides)
Changing formula to hypoallergenic
Feeding up right position? Burp upright
83
Colic pharm options
Probiotics biogaia 5 drops daily
Sucrose 1ml 24% prn
(Simethicone) Ovol 0.5 ml - 1ml po each feed
Funnel oil
84
Hepatitis A ? Pharm?
Fecal oral route
Supportive tx
85
Hepatitis B pharm?
Percutaneous , sexual and perinatal transmission
No treatment , mainly supportive
If people with liver cirrhosis or liver failure already should be treated with either
1. Peginterferon Alfa
Or
2. Antivirals like
Tenofovir
Tenofovir alfenamide TAF #1
Entecavir
Tenofovir disproving fumarate TDF #1
Prevention = vaccine 3 series
tt
86
If newborns are born to hepatitis B mothers can you give them the vaccine when?
As soon as they are born you give the baby the vaccine and HBIg
87
Hepatitis C pharm and prevention
Tx is mainly supportive
In USA they have direct actin anti vitals we don’t
If becomes chronic >6 months with viral infections
Treatment is:
Find genotype
Genotype 1-6
(EPCLUSA) Sofosbuvir 400mg/ velpatasvir 100mg x12 weeks
(MAVIRET) Glecaprevir/ pibrentasvir x 8 weeks
All causes headache and fatigue
Monitor: CBC and LFTs
There is no vaccine
88
IBD Nonpharm crohns
Smoking cessation
Don’t limit food groups; adequate caloric intake is necessary
Surgery may be necessary to treat structures, abscesses and fistulas
Psychological therapy is promising
89
Mild flare up for crohns/ what is the treatment for colonic disease and ileal disease
Colonic - sulfasalazine 1-2g QID x 4-6 weeks
Peds - 40-70mg/kg/day divided QID (max 6g/day)
Ileal- budesonide 9mg daily x 8-16 weeks
Peds >8- 9mg daily
If not effective can escalate to prednisone
Prednisone 40-60 mg daily x 10–16 weeks
Peds - 1-2 mg/kg/day
Maintenance therapy:
AZA
6MP
Or methotrexate (if aza/ 6MP failure)
90
Moderate flare up crohns
Start on oral prednisone 40-60mg day for 10–16 weeks
If not effective then hospital
If effective continue with maintenance therapy again
91
What do you monitor for with CD
Hgb, iron indices, nutritional status, growth with peds, BMD (increased osteoporosis risk),
Think: lots of bleeding, risk of anemia.
CD pt are at increase risk of cancer, osteoporosis, anemia, nutritional deficiencies, depression, infection and thrombotic events
Avoid: NSAIDs, smoking = makes it worse
Need to do colonoscopy / start screening within 8 years of diagnosis and do colonoscopy q1-3 years
92
What does a flare UC look like? What’s the treatment for mild -moderate flare up
Increase rectal bleeding, abdo cramps with + defecation
Mild to moderate flare up
5-ASA ( mesalamine)
2g suppository daily
(Can do topical or combo)
Peds >2: 30-50 mg/kg/day divided QID
If not effective then
Budesonide MMX 9 mg daily x8 weeks
Peds same dosing for >8
If ineffective then corticosteroids
Prednisone 40-60 mg day
Peds 1-2mg/kg/day
If ineffective hospital
Maintenance is:
Oral or topical 5-ASA + AZA or biological if 5-ASA ineffective
93
Who is offered prophylaxis antibiotics for travellers diarrhea?
Only used if pt is at risk of complications of diarrheal illness
94
What are prophylaxis antibiotics used for travellers diarrhea
Ciprofloxacin 500mg daily, take on first day of vacation and 1-2 days after returning home. Max 3 weeks
95
Non pharm approaches to travellers diarrhea
Boil it cook it or forget it
Drink only boiled bottle or can drinks
Alcohol drinks don’t sterilize ice
Eat fruit only if washed with clean water
Avoid salads and other vegetables
Avoid street vendors unless cooked warm
96
Acute cystitis treatment in pregnancy / which is CI?
Amoxicillin 500mg TID x 7 days
Or
Cephalexin 500mg QID x 7 days
CI = nitrofuranfoin Macrobid 100mg BID x 5 days /// CI in 36-42 weeks
TMP/SMX and trimethoprim = CI in early pregnancy and last 6 weeks
97
UTI children what is first line
TMP/SMX trimethoprim 5-10mg/kg/day divided Q12h x 7-14 days
98
Second line for uti children
Amox 40mg/kg/day divided TID x7 days
Or
Cephalexin 50mg/kg/day divided QID x 7 days
99
UTI LTC , what is first line therapy
What is the criteria for initiating antibiotics without a catheter and with a catheter
Without a catheter:
-Pyuria or fever
+ one of the following
Frequency, urgency, suprapubic pain, gross hematuria, CVA tenderness, urinary incontinence
With a catheter:
Presence of one: CVA tenderness, rigors with or without identified cause or new onset of delirium
Culture before abx therapy
#1 TMP/ SMX 1 DS tab BID x 7 days
Nitrofurantoin macrobid 100mg BID x 7 days
Amoxicillin 500mg TID x 7 days
If febrile or has more severe systemic symptoms, therapy is 10-14 days
100
Complicated UTI first line therapy
What constitutes complicated
Male, immunocompromised, structural abnormalities of urinary tract (obstructive, catheter, spinal cord injury)
Obtain culture before abx therapy
First line
TMP/ SMX 1DS tab BID x 7-10 days
Nitrofuranfoin macrobid 100mg BID x 7 days
Second line
Amox/clav 875 mg BID x 7 days
101
Pyelonophritis first line treatment
Pre treatment culture required
TMP/SMX 1 DS tab BID x 10-14 days
Norfloxaxin 400mg BID x 10-14 days
Second line:
Amox/clav 875 mg BID x 10-14 days
102
First line for preschool kids (3mo-5 years)
3mo-5yo- Amox 80mg/kg/day divided TID x7-10 days
If beta lactam allergy
Azithromycin 10mg/kg/ day on first day then 5mg/kg/day x 4 days
**** safety and effectiveness have not been shown with azithro and clarithro in <6 months****
103
First line for school age (5 year - 18)
5-18 years:
Azithro 10mg/ kg/ day on first day then 5mg/kg/ day x 4 days
Max -1.5 g/ 5 days
Or
Clarithromycin 15mg/kg/day divided BID x 7-10 days
104
Dyslipidemias , primary intervention what is it ?
Prevent first CVD event
Screening all men and women >40, those with a family history and post menopausal
Discussion needs to be had for >75, FRS >10-19%
Men and women with low HDL, impaired fasting glucose, smoker, HTN, high waist circumference and if any of there levels look like this:
LDL >3.5
Non hDL >4.3
ApoB >1.2
105
What’s your first line for primary prevention?
Start medium intensity statin
Atorvastatin 10-20 mg
Rosuvastatin 5-10mg
106
What are statin related conditions ?
Atherosclerosis, CVD, CKD, DM
LDL >5, apo B >1.45, non HDL >5.8
107
Mild to moderate C diff treatment first line for adults and children
Wbc <15
SCr <1.5 from baseline
Metronidazole 500mg TID x 10-14 days
15-30mg/kg/day divided TID x 10-14 days
If no response by day 5 of treatment, change agent to
Vancomycin Oral 125 mg QID x 10-14 days
40mg/kg/day divided QID x 10-14 days
108
What adjunct can you give with c diff for treatment ?
Probiotics prophylaxis in adults and children result in a reduction of c. Diff associated diarrhea
109
When do you question c diff ? What increases your risk of Cdiff
Recent antibiotics in last 3 months; especially clindamycin, extended spectrum cephalosporin or fluoroquinolone
Risk factor:
PPI = increases risk factor for C diff in last 14 days
S/s: up to 2 weeks from antibiotic therapy or > 6 weeks after antibiotic therapy
Watery diarrhea without blood
Abdo cramps/ pain
Fever
Nausea
Malaise
Anorexia
Dehydration
Note: alcohol and antiseptic are ineffective against c.diff
110
Severe c. Diff infection treatment
WBC > 15
SCr >1.5 from baseline
Oral Vanco 125mg orally QID for 10-14 days
Children 40mg/kg/day orally divided QID x 10-14 days
111
Constipation first line in the absence of red flags
3 Fs
Fluid 2L
Fibre 25g
Fitness
Fibre ** non pharm
112
Adequate fibre intake ? Yes what’s next ?
Trial an osmotic laxative 17g PEG 3350
113
Inadequate fibre intake ? Yes
Bulk forming agent (metamucil
114
First line for constipation in children?
Non pharm always 3 Fs
If not effective
For decompaction:
Peg 3350 1-1.5g/kg/day x 3 days
If not effective
Try lactulose
If not effective
Stimulant
Last - enema
For maintenance:
Peg 3350 0.4-1g/kg/day
+ rescue stimulant prn
115
First line for pregnancy, older adults and chronic constipatikn?
All non pharm
3 Fs
If ineffective bulk forming first 3.4-6.8g daily
If ineffective
Osmotic lax (peg 3350)
Or add
Stimulant (sennoside)
116
First line for opioid induced constipation?
Stimulant laxative (sennoside) (if no BM x 3 days)
Add osmotic lax if ineffective
117
Mild to moderate travellers diarrhea (3 movements / day no blood or fever
Loperamide 4mg stat and 2mg after each loose stool
Max 16mg/day
Or pepto bismol 2 tabs repeat q30min prn (max 8 doses/ day)
118
What can you do to prevent travellers diarrhea ?
Pepto bismol 2 Tabs QID with meals
119
Side effect of bismuth
Black tongue, dark stools
Do not use this in peds with influenza or chickenpox due to risk of developing Reye’s syndrome or allergic to Asa
Do not use in second half of pregnancy
120
Moderate travellers diarrhea 3-5 movements per day/ no blood or fever
To severe with blood or fever
Ciprofloxacin 500mg BID x 3 days
Save Azithromycin 500mg daily for 1-3 days
- for people who travel to thailand, India, Nepal, Indonesia (TINI)
- agent of choice for pediatrics
10mg/kg/day x 3 days
- agent of choice for pregnancy
consider cefixime 400mg single dose for pediatrics if macrobid Contraindicated
121
What agent should you avoid in high fever or blood in travellers diarrhea ?
Loperamide
Unless traveller has poor access to toilet you shouldn’t use
122
Prophylaxis antibiotic for travellers diarrhea ?
Ciprofloxacin 500mg daily , take on the day you arrive and 2 days after you come back for a total of 3 weeks
Only for those pt at risk of complications of diarrhea illness (frail elderly)
(Watch dosing changes with treatment)
123
Motion sickness Nonpharm and pharm treatment
Nonpharm
-avoid large meals within 3 hours of travel
-avoid smoking
-avoid alcohol and disagreeable doors
-avoid visual stimuli that worsens
Cognitive therapy
Avoid rapid head movements
Pharm
Antihistamine (gravol or Benadryl)
Second line
Scopolamine patch 1.5 mg
(Caution in elderly) strong anti- Ach
Non drug related: sea band may be effective
124
Gastroenteritis nausea and vomiting first line
Hydration
Then either diphenhydramine (Benadryl) or dimenhydrinate (gravol)
Gravol 25-100mg q4h-6h po
Benadryl 25-50mg TID-QID
Side effects l:
sedation, dry mouth, constipation, urinary retention, blurred vision
125
Nausea/vomiting in pregnancy mild first line approach
Mild <1 hour of nausea, <2 instances of vomiting / day
Nonpharm:
- eat small, frequent meals
-eat bland foods
-avoid spicy fattt and strong smelling food
-take frequent naps
-shorten work day if possible
-practice p6 acupuncture
Pharm
Ginger tabs 250mg
Pyridoxine B6 25mg q8h po
126
Moderate to severe nausea in pregnancy first line
Same interventions as mild but add a first line agent:
- gravol (diphenhydrinate) 25-40mg q4-6h prn
-Benadryl 25mg q4-6h or 50mg q6-8h prn
Second line
Add
Chlorpromazine
Metoclopramine
Prochloperazine
Last resort and severe cases
Can do zafron
127
What is the most ideal balanced electrolyte solution for kids? When mild and moderately dehydrated
Sodium: 45-75 mmol/L
Potassium: 20 mmol/L
Glucose: 20-24 g/L
128
Management for mild and moderate dehydration in kids?
1. ORS (mild is 50ml/kg; moderate is 100ml/kg)
2. Replace ongoing losses
3. then age appropriate diet after rehydration
129
Severe dehydration in kids ; what do you do
Send to emerge
>10% of body weight
Rapid HR
Decreased BP
Anuria
Dry mucous membranes
Very sunken fontanelle
Increases cap refill > 3s
130
Hypokalemia first line
Normal is 3.5-5
Mild =3-3.5 (oral KCl)
Moderate= 2.5-2.9 (oral KCl)
Severe = <2.5 (IV replacement)
Reduce or stop meds causing it (aminoglycosides, caffeine, corticosteroids, diuretics, insulin)
Check magnesium levels (hypomagnesemia causes low potassium)
Treat etiology
Pharm:
KCl salt 40-60 mmol/L divided 2-4 times daily (increases potassium 1-1.5mmol)
Potassium citrate (K-lyte) 40-60 mmol/L
If decrease in phosphate: potassium phosphate
Can add MRA if continues to have increase loses
Can consider adding Mg supplement / it’s crucial to replace magnesium to treat hypokalemia
131
What do you do for mild hyperkalemia
Normal 3.5-5
Mild = 5-6
- stop meds that are causing it (ACEI/ MRA, ARB,
- reduce potassium intake (potatoes, bananas, cantaloupe, avocado, spinach)
Continue to monitor renal function and K+ until <5 mmol/L
Lasix 40-250 mg PO/ IV (risk of volume depletion)
132
Moderate and severe hyperkalemia treatment n
Normal is 3.5-5
6.1- 6.5 mod
>6.5 severe
Sodium polystyrene sulfonate ( kayexalate) 15-60mg po (moderate)
Consider calcium gluconate + insulin and dextrose (CPS) = severe cases
133
HSV- genital adults
First line for first symptomatic episode
Acyclovir 400 mg TID x 5-7 days
Famciclovir 250 mg TID x5-7 days
Valacyclovir 500-1000mg BID x 5-7 days
**genital=7 letters = 7 days**
Initiate up to 7 days after onset ; best within 72 hours of onset of signs and symptoms for the most benefit
134
Acute recurrent HSV - genital
<6 episodes / year
Acyclovir 400mg TID x 5 days
Famciclovir 125 mg BID x 5 days
Valacyclovir 500mg BID x 3 days
Initiate therapy within 1 day of lesion onset or duration prodrome that precedes outbreaks is encouraged to ensure effective treatment of recurrent herpes
135
Chronic suppressive > 6 episodes/ year for HSV genitalia
Acyclovir 400mg BID 3-6 months
Valacyclovir 500mg daily (increase to 1000mg daily if > 9 episodes per year)
R/a therapy every 6-12 months since frequency of outbreaks diminished over time in many patients
136
Firs symptomatic episode of HSV genitalia while pregnant
Acyclovir 400mg TID x 5 days
137
Prior infection within previous year of HSV genitalia and you’re pregnant at 36 weeks. What’s your med
Acyclovir 400mg TID at 36 weeks prophylaxis
138
HSV genitalia peds first episode
If child is >3 months , suspect abuse
Acyclovir 80mg/kg/day divided QID 5-7 days
Initiative within 72 hours of signs and symptoms for the most benefit
139
Acute recurrence of genital herpes in peds treatment
Acyclovir 400mg TID x 5 days
140
Treatment of syphillis chancres
Painless ulcers usually single
Benzathine penicillin 2.4 million units IM
141
genital warts - 20% resolve spontaneously within 6 months, client wishes to do own therapy instead what are her options?
Imiquimod 3.75% cream, apply qHS x 8 weeks
Wash 6-10 hours after application with soap and water ***
Apply first so client knows how to use it
Or
Podofilox (podophyllotoxin) 0.5% solution
Apply BID in am and HS for 3 days, followed by no treatment for 4 days,
Repeat max 4 cycles
** avoid on cervix, anal canal, during pregnancy**
Or
Sinecatechins apply 0.5cm of ointment to each wart TID for up to 16 weeks. Do not wash off after use. (Easiest)
142
client actually changed their mind and wishes to go provider administered things for the wart
Cryotherapy (best for pregnancy)
143
Vaginal dryness first line
Could try non pharm: sexual stimulation
Pharm: vaginal lubricants (water based) like KY liquid/ astroglide or vaginal moisturizers (Polycarbophil and hyaluronic acid gels, they attach to vaginal epithelial and provide water and electrolytes
-apply Q3 days
Also hormone therapy, estrogen and progesterone reverse vaginal changes seen with menopause and relives symptoms
144
When to suspect toxic shock
Temp >38
Hypotension
Rash and subsequent desquamation in hands and feet
Involvement at least 3 of the following systems:
GI
MSK
MM
Kidney
Liver
Blood
CNS
If pt symptoms = fever, rash, vomiting, profuse diarrhea, dizziness and faintness ; signals TSS
145
Nonpharm for toxic shock
Use pads instead
change tampons 4-6 times/ day, never longer than 8 hours/ day
146
Pharm for TSS
Send to ER- it is fatal
147
Vulvovaginitis candidiasis first line treatment
S/s: itch, external dysuria, vaginal discharge, post coital dyspeurenia, up to 20% see asymptomatic
Fluconazole PO 150mg single dose
Clotrimazole 500mg tab intravaginally single tab
148
What if she has >4 recurrences / year of vaginal candidiasis
What is the treatment
Usually requires investigation for underlying cause and different therapeutic strategy
Treatment usually requires induction and 6 Mo of maintenance
Induction: fluconazole 150mg PO Q72 hours for 3 doses
Maintenance: fluconazole 150mg PO Qweekly x 6 months
149
What if she was pregnant and had a yeast infection ? What is the treatment
First line are topicals
Miconazole 2% cream one applicator full intravaginal daily x 7 days
150
First line for bacterial vaginosis
Metronidazole 500mg BID x 7 days
Or
Metronidazole 0.75% gel qhs intravaginally x 5 days
Or clindamycin 2% cream QHS x 7 days
151
Recurrent BV what is the treatment ?
Metronidazole 500mg BID x 10-14 days
152
What is first line for bacterial vaginosis for pregnant women
avoid oral metronidazole in first and second trimester and avoid clindamycin topical (increase risk of pseudomembranous colitis)
First :
1-2 trimester:
Topical Metronidazole 0.75% one applicatorfull (5g) vaginally qhs x 5 days
3 trimester:
Metronidazole 500 mg PO BID x 7 days
Need a test for cure ***
Male partners do not need treatment
BF - stop BF if metro or do topical
153
Trichomonias first line
S/s: profuse vaginal discharge, itch, post coital dyspareunia, dysuria, 10-50% asymptomatic
Metronidazole 2g single dose
Partners need to be treated
154
Asymptomatic pregnant person with Trichomonias - do you treat
No treatment needed
155
Symptomatic pregnant person first line treatment for trichomonias
Metronidazole 2g single dose ( any stage of pregnancy)
** this is contradictory in BV**
BV says 1-2 trimester : metronidazole gel
3 trimester: metronidazole po
156
Do you report Trichomonias to public health?
No you don’t need to.
157
Unknown lab result, man comes in with purulent penile discharge, severe dysuria, what is first line treatment
Recommended to treat both gonorrhea and chlamydia. Where lab results are not available and there is urethral discharge, treat for both.
If no urethral discharge is detected, defer antimicrobial treatment until results are available
Cefixime 800mg single dose
+
Azithromycin 1g single dose
All partners must be treated r
158
What if the guy had a penicillin allergy what is first line treatment for gonococcal urethritis
Ciprofloxacin 500mg single dose
+
Azithro 2g single dose
- azithro dosing increased /// idk why but watch that
Need a test of cure if Azithromycin of doxy is not used
Also if adherence is questioned
159
<9 yo comes in with a gonoccocal urethritis
Cefixime
8mg/ kg/ single dose
cefixime = 8 letters
+
Azithromycin
10mg/ kg single dose
Kids - need a test of cure 1-2 weeks after
160
Pregnancy with gonococcal urethritis
Cefixime 400-800mg single dose
Or
Ceftriaxone 250 mg IM
If chlamydia +
Need to add azithro 1g single dose
Test of cure is required for pregnant women 4-5 days after
161
Non-gonococcal urethritis first line treatment for >9 and <9 y
Report to PHU
>9y
Azithro 1g single dose
<9
Azithro 10mg/kg single dose
Test of cure is not routinely recommended unless alternate agent was used.
Test of cure is recommend if child is <14 years old
162
If chlamydia recurrence
Consider noncompliance
Tetracycline resistant
If deemed it was not noncompliance, retreat:
Metronidazole 2g single dose
+
Erythromycin 500mg QID x 7 days
163
Cervicitis what is it and what is first line treatment
Inflammation of the cervix with mucopurulent or purulent discharge
It does not occur in prepubertal girls; counterpart is prepubertal vaginitis
Cervicitis must be reported to PHU it is caused my chlamydia and gonorrhea
Defer treatment until microbio results are available in “at risk” patients including sexually active women, where no purulent cervical discharge are present
First line is
Cefixime 400-800mg single dose
+
Azithro 1g single dose
164
First line treatment for Cervicitis in pregnancy
Cefixime 400-800mg single dose
Or
Ceftriaxone 250 mg iM single dose
165
When to hospitalize for PID
P- pregnant
a- abscess (tubo-ovarian)
I- Ill (vomiting and fever)
L-lack of response to meds in 48-72 hours
+ nonadherent to meds
166
First line for PID / what are symptoms of PID
Report to PHU
Symptoms:
Lower abdo pain or recent onset, heavy menses, inter-menstrual or post coital bleeding, deep dyspareunia, vaginal discharge
First line
Cefixime 800mg single dose
+/-
METRONIDAZOLE 500mg BID x 14 days
(If women has adnexal mass formation, tubo-ovarian abscess, peritonitis, increased risk of anaerobes)
BV is often associated with PID so you’re killing it with metronidazole too
167
Epididymitis first line treatment for <35 year olds / what is it
Inflammation of the epididymitis manifested by acute onset of unilateral testicular pain and swelling often with tenderness of the epidymitis and vas deferans with occasional erythema and edema of overlying skin
If there is discharge = STI
R/0 other causes of testicular swelling
Important to r/a if no improvement within 3 days of antibiotics
If sex acquired, need to report to PHU and partners need to be treated
First line:
Cefixime 800mg single dose
+
Azithro 1g single dose
168
Epididymitis treatment for >35 years
Ciprofloxacin 500mg BID x 10-14 days
169
2 meds approved for PrEP/ who should be offered ?
IVDU
MSM
Transgendered women
Emtricitabine/ Tenofovir DF (truvada)
TDF
SE: headache , nausea , diarrhea, flatulence
BMD, decreases BMD and increases chance of osteoporosis
Renal: do not use if CrCl <60
Emtricitabine/ Tenofovir AF (descovy)
TAF
SE: weight gain, initial headache, nausea and diarrhea
Better for bones and renal health
Do not use if CrCl <30
170
Follow up for prep
What is it (renal, bone, STI, HIV and pregnancy)
Renal - baseline, Q1month from initiation and Q3 months
Bone - BMD not required unless osteoporosis fracture
STI- at baseline and Q3 months
HIV- at baseline and Q3 months
Pregnancy - at baseline and Q3 months
171
Goal of HIV therapy
To get HIV RNA copies <40 copies/ L
172
HIV therapy you need a combination of meds
Truvada (TDF) : CrCl >60
+
An integrase inhibitor (dolulegravir)
Or
Cobicistat + ritonavir-boosted protease inhibitors
Or
Non-nucleoside reverse transcriptase inhibitor (doravirine)
173
What happens if rebound plasma viral load >200 what does that mean ?
Implies treatment failure or non
adherence
If adherence is confirmed, drug resistance testing should be performed and CART should be selected on pt he and precious drug resistance results
174
HIV monitoring (viral load and CD4 count)
Plasma viral load Q 3-4 months
Can be changed to Q6months if on stable, antiretroviral with viral load <40 copies /mL and good adherence >1 year
Increased monitoring if symptomatic or diagnosed with AIDS
CD4 count Q3-4 months ; it is optional if viral load is <40 copies and CD4 > 250 cells for >1 year
175
What do you start if CD4 <200
Start prophylaxis for PJP with
TMP/ SMX 1 DS tab QID x 10 days
Then 1 DS tab MWF for maintenance until CD4 > 200 for >6 months
176
If CD4 cells <100 what do you start
Start toxoplasmosis prophylaxis if seropositive and not on TMP/SMX for PJP prophylaxis
If already on TMP/SMX you need to refer
177
Pneumonia first line in 3months- 5 years
Amox 80mg/kg/day divided TID x 7-10 days
Or
PNC allergy
Azithromycin 10mg/kg/day first day then 5mg/kg/day the next 4 days
178
First line agent for pneumonia in 5-18 year old
Azithromycin 10mg/kg/day on first day then 5mg/kg/day x 4 day
