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p2 year > rti, uti, c diff, immunizations, hiv > Flashcards

rti, uti, c diff, immunizations, hiv Flashcards

1
Q

pharmaceutical care outcomes

A
  • cure disease
  • eliminate/reduce symptoms
  • arrest or slow disease progression
  • prevent a disease –> immunization goal!!
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2
Q

story behind the first vaccine

A

smallpox vaccine
- milkmaids not get it bc had cowpox
- 1798

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3
Q

live attenuated vaccines

A
  • MMR: measles, mumps, rubella
  • varicella
  • influenza (LAIV)
  • polio (OPV)
  • rotavirus
  • zoster (ZVL)
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4
Q

toxoid vaccines

A
  • diphtheria
  • tetanus
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5
Q

inactivated vaccines

A
  • hepatitis A
  • influenza (IIV)
  • pertussis
  • polio (IPV)
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6
Q

inactivated/recombinant vaccines

A
  • hepatitis B
  • HPV
  • zoster (RZV)
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7
Q

conjugated/polysaccharide vaccines

A
  • Hib
  • meningococcal
  • pneumococcal
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8
Q

mRNA vaccines

A
  • COVID Pfizer
  • COVID Moderna
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9
Q

adenovirus vaccines

A
  • COVID Janssen J and J
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10
Q

herd immunity consideration

A
  • protect individual person immunized AND other members of the community

high vaccination rates are necessary to:
- dec likelihood of disease outbreak
- protect people who cannot be vaccinated (medical issues, too young, incomplete immune response to vaccines)

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11
Q

how long do you separate two inactivated vaccines

A

any interval

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12
Q

how long do you separate a live and an inactivated vaccine

A

any interval

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13
Q

how long do you separate two live vaccines

A

simultaneously OR 28 days minimum

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14
Q

how long before a minimum vaccine dosing interval does it not count and you need to repeat dose?

A

5 days or more

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15
Q

what do you do if an immunization dose interval has lapsed?

A

dose as normal, no start over

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16
Q

if no record of a vaccine…

A

redose as if didn’t get it

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17
Q

when to avoid/postpone immunizations

A
  • mod-severe illness (hospital)
  • type i hypersensitivity (anaphylaxis) to vaccine or components
  • LIVE: immunodeficient diseases/treatments –> congenital immunodeficiency, malignancy, symptomatic HIV, radiation, chemo, prednisone
  • pregnancy
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18
Q

pregnancy vaccine considerations

A

live: CONTRADINICATED
inactivated: okay, potentially wait for second trimester
recommended vaccines: flu, Tdap, COVID

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19
Q

conditions that are NOT CIs to vaccination

A
  • mild acute illness (low fever, …)
  • recent infection exposure
  • current antibiotics
  • breastfeeding
  • mild-mod local vaccine reactions
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20
Q

COVID-19 general recommendation

A

all people 6 months and older

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21
Q

patient is on chemo or radiation, when can you live vaccinate?

A

2 weeks before
OR
3 months after

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22
Q

systemic corticosteroid defintion

A

2 or more mg/kg/day OR 20 or more mg/day prednisone for 14 or more days

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23
Q

when can you vaccinate during systemic glucocorticoid therapy ?

A
  • topical or local injections
  • physiological maintenance therapy
  • low-mod dose daily or every other day
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24
Q

patient took high dose prednisone daily or every other for less than 14 days, when live vaccinate?

A

when stop
OR
2 weeks after

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25
Q

patient took high dose prednisone daily or every other for more than 14 days, when live vaccinate?

A

1 month or more

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26
Q

patient got live vaccine, how long until IVIG?

A

14 days or more
if can’t wait –> redose vaccine

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27
Q

patient got IVIG, how long until live vaccine?

A

3 months or more

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28
Q

patient got live vaccine, how long until PPD?

A

simultaneously
OR
4-6 weeks

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29
Q

patient got live vaccine, how long until anti-viral agents?

A

14 days

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30
Q

inactivated vaccine AEs

A
  • injection site reactions, with or without fever
  • inflammatory response to antigen
  • swelling, redness, pain
  • SQ has MORE AEs than IM
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31
Q

live attenuated vaccine AEs

A
  • mild form form of natural illness
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32
Q

general vaccine AEs

A
  • tired, fatigue
  • hypersensitivity reaction
  • vasovagal syncope
  • sterile abscesses
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33
Q

vaccine storage

A

cold chain!!
manufacturer –> wholesaler –> pharmacy

most vaccines: 2-8 C (fridge)
COVID –> freezer
light sensitive –> MMR, zoster

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34
Q

which vaccines can/do you give SQ?

A
  • herpes zoster
  • MMR
  • MPSV-4
  • PPV
  • poliovirus trivalent inactivated
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35
Q

who is at the highest risk for COVID-19 hospitalization?

A
  • increases with age
    65 years and older highest risk
  • non-hispanic american indian, alaska native
  • non-hispanic black, latino
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36
Q

who is at highest risk for covid-19 mortality?

A

older than 65 years (even though small proportion of this age get it)

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37
Q

COVID-19 primary mode of transmission?

A
  • respiratory droplet exposure when in close contact –> inhaled or deposited on mucous membranes (nose/mouth)
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38
Q

COVID-19 clinical presentation

A
  • incubation period: 2-14 days (usually 6) – time between infected and symptoms
  • s/s: fever, cough, fatigue, HA, loss taste or smell
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39
Q

severe COVID-19 disease more common in/risk factors:

A
  • obesity
  • DM
  • asthma/chronic lung disease
  • immunosuppression
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40
Q

COVID-19 vaccine efficacy

A

95%

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41
Q

COVID vaccine AEs

A
  • local reactions
  • fever, chills, HA, muscle pain –> mild systemic

most serious: myocarditis!!!! (inflammation of middle layer of heart) –> highest in 12-24 yr old males

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42
Q

which COVID dose has most side effects?

A

most: 2nd dose
booster
least: 1st dose

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43
Q

antigenic drift

A

INFLUENZA

gradual protein changes, occur yearly
- impacts type A and B
- bc of mutation, substitutions, deletions, adaptation to human antibodies

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44
Q

antigenic shift

A

INFLUENZA

HUGE protein changes
- ONLY impacts type A
- changes in hemagglutinin (H) or neuraminidase (N)
- causes epidemics/pandemics
- ex: spanish flu (H1N1), avian flu (H5N1)

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45
Q

do you delay immunization patient is 65 years old and wants a flu shot but you do not have high dose?

A

NO –> can get normal dose

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46
Q

influenza vaccine efficacy

A
  • onset: 2 weeks
  • efficacy: 47%
    **depends on accuracy of forecast of circulating strain
  • dec risk of hospitalization, pneumonia, death
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47
Q

how often is the influenza vaccine updated

A

yearly

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48
Q

IIV AEs

A

local reactions

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49
Q

LAIV AEs

A

**rhinorrhea bc IN!!!

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50
Q

IIV precautions and CIs

A

precautions:
- GBS (group b strep) within 6 weeks of previous vaccine

CI:
- allergy to vaccine
**EGG ALLERGY NO LONFER CI!

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51
Q

LAIV precautions and CIs

A

precautions:
- asthma and older than 5 years
- conditions that inc risk of influenza related complications
- mod-severe illlness

CI:
- younger than 2 years, 50 years or older
- preganacy
- immunosuppression
- children 2-4 years with asthma or hx of wheezing
- children/adolescent receiving ASA
- CSF leaks
- asplenia
**EGG ALLERGY NO LONGER CI

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52
Q

a patient comes in with an egg allergy and requests a influenza vaccine, what can you give them?

A

IIV, HD-IIV, LAIV, …
NO LONGER A CI !!!

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53
Q

age range for IIV4

A

6 months or older

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54
Q

age range for RIV4

A

18 years or older

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55
Q

age range for LAIV4

A

2 years to 49 years

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56
Q

pneumococcos cause

A

streptococcus pneumonia –> 90 serotypes
- bacterial cause of acute otitis media, pneumonia, bacteremia, meningitis –> higher death rates

mortality from these conditions inc in elderly!!

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57
Q

pneumococcus efficacy

A

around 70%

efficacy of newer vaccines similar to the older ones!

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58
Q

penumococcus vaccination rates

A

around 60% in 65 years and older
- more in white than black or hispanic

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59
Q

PCV15 AEs

A
  • injection site pain
  • fatigue
  • myalgia
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60
Q

PCV20 AEs

A
  • injection site pain
  • muscle pain
  • fatigue
  • HA
  • joint pain
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61
Q

pneumococcal CIs

A
  • allergy
  • pregnancy
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62
Q

how long between pneumococcal doses?

A

1 year

8 weeks or more IF:
- immunocompromised
- cochlear implant
- CSF leak

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63
Q

diphtheria cause

A
  • corynebacterium diphtheriae –> toxin
  • most common in incompletely immunized patients –> 20-60%
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64
Q

tetanus cause

A
  • clostridium tetani –> toxin binds CNS
  • muscle rigidity, muscle spasms, lock-jaw
  • most common in non-vaccinated people –> 40-85% susceptibe
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65
Q

tetanus risk factors

A
  • puncture wounds
  • IV drug use
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66
Q

pertussis cause

A
  • bordetella pertussis
  • WHOOPING COUGH
  • 50% hospitalized in infants
  • apnea, seizures, pneumonia, encephalopathy
  • 3-5 year cycle of inc incidence
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67
Q

whooping cough

A
  • very contagious!!!!!
  • takes 12 weeks to resolve
  • week 1-2: cold-like
  • week 3-10: paroxysmal cough
  • week 11-12: cough lessens
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68
Q

how often Tdap?

A

every 10 years
every pregnancy

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69
Q

how often tetanus vaccine if at risk?

A

every 5 years

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70
Q

how often tetanus vaccine if injury

A

1 year after last dose

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71
Q

T,D,P vaccine AEs

A
  • local: redness, swelling, pain
  • fever

**the local reactions are more likely in older, therefore use vaccines with lower doses

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72
Q

T,D,P vaccine precautions and CIs

A

precautions:
- arthus hypersensitivity reactions
- unstable neurologic problem/seizures

CIs
- allergy
- Hx of encephalopathy within 7 days of pertussis vaccine

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73
Q

shingles cause

A
  • herpes zoster virus –> shingles
  • unilateral pain
  • opportunistic infection –> older or immunocompromised at risk
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74
Q

zoster efficacy

A

97% –> dec with age!!
- prevents postherpetic neuralgia

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75
Q

zoster AEs

A
  • injection site reaction: pain, erythema, swelling
  • allergic reaction (rare)
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76
Q

zoster precautions and CIs

A

CI
- allergic reaction Hx to vaccine
- pregnancy –> delay!!!

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77
Q

how to treat rabies

A

1) wound clean
2) human rabies IG: site and IM x1
3) rabies vaccine X4: day of exposure, day 3, day 7, day 14

usually only 19 years or older

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78
Q

rabies vaccine AEs

A
  • mild local reactions (pain, redness, swelling, itchy)
  • HA, N, abdominal pain, dizzy
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79
Q

rabies IG AEs

A
  • local pain
  • low grade level
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80
Q

can rabies vaccine be used in pregnancy

A

yes

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81
Q

do we treat rabies for domesticated animals that are up to date on vaccines?

A

no –> probably only wound clean

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82
Q

HIV prevalance

A

high in the US –> NYS number 7

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83
Q

AIDS definitions

A

CD4 count < 200
AIDS defining illnesses

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84
Q

AIDS defining illnesses

A
  • candidiasis
  • cryptococcosis
  • CMV
  • herpes simplex
  • kaposi sarcoma (cancer)
  • lymphomas (cancer)
  • mycobacterium infections
  • pneumonia

in general
- opportunistic infections
- neoplasms
- CNS involvement
- dermatologic manifestations
- hematologic abnormalities
- nephropathy

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85
Q

HIV patho things

A

**CD4 cells
- tropism: virus specifically targets one tissue (CD4 cells)
- blood and body fluid transmission

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86
Q

why are only 50% of people with HIV retained in care and experiencing viral supression? (cascade of treatment)

A

***social determinants of health –> knowledge, perceptions, beliefs

  • side effects
  • dosing regimen complex
  • NOT bc of cost –> access through government
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87
Q

two big markers in HIV

A

CD4 count
viral load

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88
Q

5 goals of ART (anti-retroviral treatment)

A
  • maximum and durable viral suppression (viral load undetectable)
  • restoration and preservation of immune function (CD4 count) (bc low CD4 –> AIDS –> infections –> death)
  • improved quality of life
  • reduced HIV-related opportunistic infections (OIs)
  • reduced morbidity and mortality
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89
Q

first line ART for most patients

A

INSTI + 2 NRTI
- Biktarvy – bictegravir + emtricitabine + tenofovir alafenamide
- Triumeq – dolutegravir + abacavir + lamivudine

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90
Q

integrase inhibitor AEs

A

generally mild
- GI distress
- CNS disturbance
- rash (less with bictegravir)
- false elevation in Cr
- weight gain!!!

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91
Q

INSTI DDI

A
  • cations (acid reducers) –> antacids
  • metformin
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92
Q

tenofovir AEs

A

NRTI

  • salicylates
  • nephrotoxic drugs
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93
Q

which INSTIs have high barrier to resistance –> favorable!

A

bictegravir
dolutegravir

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94
Q

which INSTIs come as STR?

A

bictegravir
dolutegravir

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95
Q

which INSTI is preferred in all trimesters of pregnancy?

A

dolutegravir

96
Q

which ART needs HLA-B*5701 monitoring?

A

abacavir (NRTI)

97
Q

which INSTI increases metformin levels?

A

dolutegravir

98
Q

CIs for dolutegravir + lamivudine (Dovato) use

A
  • HIV-1 RNA > 500,000 (cannot use if severe)
  • HBV coinfection
  • no resistance results (only double therapy)
99
Q

INDICATION (need these!!!) for dolutegravir + lamivudine + abacavir (Triumeq) use

A

HLA-B*5701 NEGATIVE!

100
Q

INDICATION (need these) for rilpivirine + emtricitabine + tenofovir alafenamide/disoproxil fumarate (Odefsey, Complera) use

A
  • HIV-1 RNA < 100,000
  • CD4 > 200
101
Q

omeprazole DDI

A

dec rilpivirine concentration –> dolutegravir + rilpivirine (Juluca)

102
Q

pantoprazole DDI

A

dec rilpivirine concentration –> dolutegravir + rilpivirine (Juluca)

103
Q

Al/Mg or Ca antacids DDI

A

ALL INSTIs –> dec absorption/concentration

104
Q

in ART naive adults, which therapy is non-inferior to triple therapy with dolutegravir + Truvada (emtricitabine + tenofovir disoproxil fumarate)?

A

dual therapy Dovato (dolutegravir + lamivudine)
**also was no treatment emergent resistance !

GEMINI-1 and 2 trials

105
Q

preferred HIV regimens for pregnancy and trying to concieve

A

1st line: 2 NRTI (dual backbone) + INSTI/boosted PI
2nd line: 2 NRTI (dual backbone) + NNRTI

106
Q

HIV drugs to avoid in pregnancy bc of insufficient data

A
  • bictegravir
  • doravirine
  • ibalizumab
  • fostemsavir
107
Q

HIV drugs to avoid in pregnancy bc of PK concerns

A

usually any combo with cobicistat!!
- elvitegravir + cobi
- atazanavir + cobi
- darunavir + cobi

108
Q

pregnancy preferred NRTI backbone

A
  • lamivudine + abacavir
  • lamivudine + tenofovir disoproxil
  • emtricitabine + tenofovir disoproxil
109
Q

which tenofovir is favored in pregnancy?

A

tenofovir disoproxil fumarate!!

alafenamide –> can continue, no data to start

110
Q

INSTIs preferred in pregnancy

A
  • dolutegravir
  • raltegravir
111
Q

which HIV drug used to be worried about NTD in infants but new studies showed no issue anymore and is now a recommended agent?

A

raltegravir (INSTI)

112
Q

same day ART initiation benefits

A
  • inc patient retention to follow up
  • dec time to viral supression/inc viral suppression by 12 months
  • inc liklihood of initiation of ART within 90 days of Dx
113
Q

NNRTI AEs and DDI exclude which drug?

A

doravarine

114
Q

NNRTI AEs

A
  • liver toxicity
  • rash (6 weeks)
  • hyperglycemia
  • hyperlipidemia

efavirenz + rilpivirine –> neuropsychiatric effects!\

NOT APPLY TO DORAVIRINE

115
Q

NNRTI DDIs

A
  • efavrinez: CYP 3A4 inhibitor
  • rilpivirine: CYP 3A4 substrate
116
Q

which NNRITs are CYP 3A4 inhibitors

A
  • efavirenz
  • nevirapine
  • etravirine
117
Q

doravirine combination therapy and its BBW

A

Delstrigo: doravirine + lamivudine + tenofovir disoproxil fumarate

BBW: severe HBV (hepatitis B virus) acute exacerbation
- in patients who:
1) coinfected with HIV and HBV
2) discontinued lamivudine or tenofovir disoprox

118
Q

benefits of tenofovir alafenamide

A
  • less impact on markers of renal tubular dysfunction
  • superior after 144 weeks
119
Q

benefits of tenofovir disoporxil fumarate?

A
  • generics avaliable with other NSTIs (lamivudine, emtricitabine)
  • pregnancy preferred
  • no weight gain
120
Q

tenofovir preferred?

A

alafenamide probably due to less renal impacts, use disoproxil in certain situations

121
Q

abacavir pros vs cons

A

pros: first line combo with dolutegravir, not renal CL

cons: HLA-B*5701 testing needed for negative results (inc time, …), inc AEs (cardio)

122
Q

when to use boosted PIs

A
  • starting ART before have resistance data avaliable
  • if worried about resistance
123
Q

things to consider with boosted PIs

A
  • DDI – many
  • GI intolerance
  • HLD
  • CV risk with some
  • metabolic syndromes
124
Q

which HIV drugs cause false elevation of SrCr?

A

not sure, def stribild and genvoya

125
Q

indications for Stribild/Genvoya (elvitegravir + emtricitabine + tenofovir (either) + cobicistat

A
  • take with food (inc elvitegravir absorption)
  • CrCl > 70 to start, > 50 to continue

*expect SrCr elevations

126
Q

ritonavir and cobicistat DDIs

A
  • inhibit: 3A4, p-gp, 2D6
  • induce: 2C9
  • careful with: warfarin (monitor INR), DOACs (avoid)
127
Q

anticonvusant (carbamazepine, phenobarb, phenytoin) DDI with HIV

A
  • dolutegravir –> dec concentration
128
Q

which HIV drug are corticosteriods CIed with?

A

elvitegravir + cobicistat

**INHALED, TOPICAL, AND ORAL!!
topical hydrocortisone okay

129
Q

list of corticosteriods

A
  • betamethasone
  • budesonide
  • clobetasol
  • dexamethasone
  • fluticasone
  • hydrocortisone
  • methylprednisolone
  • prednisone
  • triamcinolone
130
Q

statin ART DDIs

A

boosted treatments (any with cobicistat or ritonavir) + lovastatin or simvastatin
- huge inc in statin concentratin

other statins at low doses or intensity –> suboptimal response

131
Q

BBW of any ART with emtricitabine + tenofovir (either)

A
  • lactic acidosis, severe hetapomegaly
  • HBV coinfection –> exacerbation if stop the drug

brand: Descovy, Truvada, Delstrigo

132
Q

which ART cause weight gain

A

pretty much all
- NNRTI < NRTI (?) < PR < INSTI

TAD < TAF

133
Q

do you change ART?

A

NO –> no benefit

only change if:
- AEs
- simplify regimen
- change administration
- pt change in indication/CI

134
Q

bacterial STI

A
  • gonorrhea
  • syphilis
135
Q

PrEP drugs

A
  • Descovy: emtricitabine + tenofovir alafenamide
  • Truvada: emtricitabine + tenofovir disoproxil fumarate
136
Q

three indication groups of PrEP

A
  • MSM
  • heterogeneous men and women
  • IV drug use
137
Q

PrEP clinical eligibilty

A
  • documented (-) HIV test
  • no s/s HIV
  • no CI medications
  • documented HBV infection/vaccine
  • normal renal function
138
Q

PrEP AEs

A
  • HA
  • abdominal pain
  • weight loss

very low

139
Q

adherence model

A

health belief model
- individual factors
- perceived benefits
- perceived susceptibility
- perceived threat of non-adherence
- liklihood to engage in adherence behavior
- cues to action
- self-efficacy for adherence

140
Q

adherence counseling

A
  • assess determinants
  • assess metrics
  • employ strategies
141
Q

how often do you assess PrEP

A
  • follow-up every 3 months: HIV test, adherence, behavioral risk reduction, AE assess, STI assess
  • testing after 3 months then every 6 months: renal function, bacterial STI
142
Q

URTIs

A
  • sinusitis (rhinosinusitis)
  • otitis media
  • pharyngitis
143
Q

sinusitis general s/s

A
  • inflammation
  • discharge
  • bilateral
144
Q

major nonspecific sinusitis symptoms

A
  • purulent anterior nasal discharge
  • purulent or discolored posterior nasal discharge
  • nasal congestion/obstruction
  • facial congestion or fullness
  • dec sense of smell
  • fever
145
Q

minor nonspecific sinusitis symptoms

A
  • HA
  • ear pain, pressure, fullness
  • halitosis, dental pain
  • cough
  • fatigue
146
Q

how to Dx sinusitis

A
  • no cultures
  • only clinically, s/s

**acute vs chronic

147
Q

common sinusitis pathogens

A

H influenzae
M catarrhalis
S pneumoniae

*therefore need gram + and - coverage

148
Q

amox/clav AE

A
  • diarrhea
  • rash
  • take with food so no GI upset
149
Q

sinusitis 1st line and durations

A

amox/clav

adults: 5-7 days
children: 10-14 days

150
Q

common pharyngitis pathogens

A

viral: rhinovirus
bacteria: group A strep (strep pyogenes)

151
Q

why do we treat pharyngitis (potential group A strep) if only a small percent bacterial?

A
  • labor burden on country, transmissible
  • improve symptoms
  • prevent transmission period to 24 hours instead of entire acute illness and one week after
  • avoid post-pharyngitis complications –> acute rheumatic fever (CHILDREN), pertionsillar abscess, cevical lyphandenitis, mastoiditis, glomerulonephritis
152
Q

major GAS pharyngitis presentation

A
  • sudden onset sore throat
  • scarlatiniform rash (cheeks)
  • tonsillopharyngeal inflammation (hemorraging nodes)
153
Q

pharyngitis Dx tests

A

adult: throat swab RADT
child: throat swab RADT, throat culture

154
Q

pharyngitis antibiotics

A

1st: penicillin VK, amoxicillin
2nd:
mild allergy –> cephalexin
severe allergy –> clindamycin, azithromycin (5 day duration)
noncompliance –> penicillin benzathine IM (x1)

duration: 10 days (unless indicated)

155
Q

common cause of otitis media

A

BACTERIAL
50/50: s. pneumoniae, h. influenzae

156
Q

otitis media signs and symptoms

A
  • fluid in middle ear
  • erythema/inflammation of tympanic membrane
  • ear pain, drainage
  • nonspecific: fever, lethargy, irritability –> tugging on ear
157
Q

acute otitis media Dx definition

A
  • middle ear effusion (fluid collection)
    AND ONE OF
  • mod-severe tympanic membrane bulging OR new onset otorrhea (ear drainage) that isn’t due to acute otitis externa
  • mild tympanic membrane bulging AND new onset ear pain within last 48 hours OR intense erythema of tympanic membrane
158
Q

in which patients do you treat otitis media?

A

6 mon - 12 yrs AND temp greater or equal to 102.2 F or mod-sev pain

6 mon - 23 mon AND nonsevere, bilateral AOM

159
Q

otitis media drugs

A

1st: amoxicillin
80-90 mg/kg/day divide into BID dosing

IF: Hx amox in last 30 days, recurrent not response to amox, purulent conjunctivitis
2nd: amox/clav

IF: penicillin allergy
3rd: cephalosporins

160
Q

pneumonia patho ish

A

aspirate pathogen into alveolar spaces –> inc immune recognition which inc fluid in alveoli –> dec space for oxygen diffusion

161
Q

penumonia s/s

A
  • sputum production
  • cough
  • fever
  • pleuritic (inhale/exhale) chest pain
162
Q

Dx pneumonia

A

SIRS
chest x-ray –> infiltrate (alveolar fluid): appears white hazy/streaky

163
Q

do you use cultures for pneumonia?

A

yes –> helpful in severe cases
- will be contaminated by oral normal flora, therefore look for significant big results
- GET BEFORE GIVE ANTIBIOTICS

164
Q

what is CURB-65 used for?

A

pneumonia
scoring system to determine in admit patient to hospital or not

165
Q

types of pneumonia defintions

A

CAP: no exposure to healthcare system
HAP: no pneumonia when admitted, developed 48 hours or more after admission ; OR ; got IV antibiotics within 90 days prior to admission
VAP: subset of HAP, pneumonia develops 48 hours or more after endotracheal ventilation

166
Q

CAP causes and characteristics of each

A

***s pneumoniae —> rust colored sputum
h influenzae, m catarrhalis –> comorbidities
anaerobes –> lose consciousness after OD
* CA-MRSA (communtiy aquired) –> after influenza, very severe admission

167
Q

causes of CAP and characteristics

A

*** s penumoniae –> rust colored sputum
H. influenzae, M. catarrhalis –> comorbidities
anaerobes –> loss of consiousness after OD
*CA-MRSA (community aquired) –> after influenza, severe presentation

168
Q

which atypical pathogen are we worries about with CAP, what do we do?

A

legionella pneumonphilia!!
- if severe presentation –> urinary test –> treat if positive
- fluoroqinolones, azithromycin

characteristics/risks: mild –> rapid progression, water exposure, male, smoker
symptoms: severe electrolyte changes (dec K and Na), diarrhea, confusion, LFT inc

169
Q

typical pneumonia presentations

A
  • abrupt
  • uilateral, well-defined infiltrate
  • significant fever, dyspnea
  • purulent sputum
  • pleuritic chest pain
170
Q

atypical pneumonia presentations

A
  • gradual
  • diffuse infiltrate
  • mild fever, dyspnea
  • dry cough
  • extrapulmonary symptoms: myalgia, GI
171
Q

what test for a patient with severe cap

A

urinary test for legionella

172
Q

what test for a patient with CAP ordered anti MRSA or pseudomonas

A

blood culture
sputum culture

173
Q

if treating CAP for legionella, what monitoring do you need?

A

QT prolongation –> azithro, fluoroquin cause it!!

174
Q

how to treat viral CAP

A

supportive care
no antibiotics beyond first 24 hours

175
Q

how to treat outpatient CAP

A

healthy:
1st: amoxicillin
2nd: doxycycline or macrolide if allergy

comorbidities:
1st: amox/clav + macrolide
cefpodox + macrolide
2nd: fluoroquinolone

176
Q

comorbidity definition for outpatient CAP

A
  • under 2 yrs or over 65 yrs
  • immunosuppression
  • cancer
  • beta lactam in last 90 days
  • alcohol abuse
  • daycare
  • chronic respiratory disease
177
Q

CAP duration

A

5-7 days
afebrile for 48-72 hr

178
Q

inpatient bacterial CAP requirements

A
  • respiratory complications
  • systemic inflammation (fever, leukocytosis)
  • comorbidities
179
Q

inpatient CAP non-severe treat

A

1st: IV beta-lactam + macrolide
2nd: fluoroquinolone

180
Q

inpatient CAP severe treat

A

start:
IV beta lactam + macrolide
IV beta lactam + fluoroquinolone

if…
MRSA –> ceftaroline, vanco…
pseudomonas –> pip/tazo, carbapenem
legionella –> make sure have azithro or fluoroquin

181
Q

VAP contamination

A
  • healthcare worker hands
  • ventilator circuit
  • biofilm of endotracheal tube
182
Q

VAP cause

A

gram negative

183
Q

HAP testing

A

do non-invasive cultures –> sputum or endotracheal aspiration

only do invasive biopsy/BAL if serious

184
Q

criteria to cover MRSA and pseudonomas for HAP/VAP

A

one of following
- started 5 days or more after admission
- risk for MDR

185
Q

risks for MDR pathogen

A
  • antibiotics in past 90 days
  • immunosuppression
  • colonization of MDR
  • recent hospitalization
  • chronic care
186
Q

HAP/VAP treat no MDR risk

A
  • ampicillin/sulbact
  • cipro, moxi
  • ceftriazone
  • ertapenema
187
Q

HAP/VAP treat with MDR risk

A

anti-MRSA + anti-pseudomonal

MRSA
- vancomycin
- linezolid

pseudomonal:
- pip/tazo
- cefepime
- cipro, levo
- carbapenems (not ert)
…

188
Q

HAP/VAP duration

A

7 days

189
Q

risk factors for UTI

A
  • healthy premenopausal women (no risk)
  • sexual behavior, contraceptive devices
  • pregnancy
  • male
  • badly controlled DM
  • short term urinary tract catheter
  • asymptomatic bacteriuria
  • long term urinary catheter
190
Q

upper UTI

A
  • pyelonephritis
    kidneys
    more serious
191
Q

lower UTI

A
  • cystitis
    bladder
    less serious
192
Q

cysitits s/s and tests

A
  • dysuria
  • frequency/urgency
  • hematuria
  • urinalysis
  • urine gram stain and culture
193
Q

pyelonephritis s/s and tests

A
  • all of cystitis (hematuria, dysuria, frequency/urgency)
  • CVA tenderness / flank pain
  • fever
  • chills
  • N/V
  • urinalysis
  • urine culture and stain
  • CBC
  • blood culture
194
Q

uncomplicated UTI definition and cause

A
  • normal urinary tract, normal removal of bacteria with voiding
  • e coli
195
Q

complicated UTI definition and cause

A
  • abnormality that prevents removal of bacteria with voiding
  • clinical def:
    catheter
    recurrence
    highly resistant
    SIRS/sepsis
    immunosupression
  • e coli + gram negative (pseudomonas)
  • s aureus + s epi
  • candida (yeast)
196
Q

urinalysis results

A

tell if infection
- pyuria: > 10 WBC/mm3 , > 5-10 WBC/hpf
- nitrites
- leukocyte esterase
- WBC casts

197
Q

urine culture and stain

A

tell what the pathogen is

198
Q

significant bacteriuria (asymptomatic UTI)

A

traditional: > 10^5 cfu/mL
women: > 10^2 cfu/mL
men: > 10^3 cfu/mL

199
Q

clinical UTI definition

A

significant bacteriuria
+
pyuria (pus)
+
s/s infection

200
Q

woman, not pregnant, cystitis treatment

A

nitrofurantoin X 5 days
TMP/SMX X 3 days

201
Q

woman, not pregnant, pyelonephritis, outpatient

A

TMP/SMX x 14 days

202
Q

woman, not pregnant, pyelonephritis, inpatient

A

IV*
extended spectrum cephalosporin (cefepime, ceftaroline, …)
penicillin + aminoglycoside

10-14 days

203
Q

when do you treat asymptomatic bacteriuria?

A

ONLY IF
- pregnant
- before catheterization
- before renal transplant

204
Q

UTI safe in pregnancy

A

amoxicillin/clav x 7 days
cephalexin x 3-7 days

IV beta-lactam (ceftriaxone, cefazolin) x 14 days total (change to po when can)

205
Q

UTI avoid in pregnency

A

fluoroquinolones
tetracyclines (doxy, tetra)
sulfonamides in LAST TRIMESTER –> kernicterus, hyperbilirubinemia

206
Q

goal of treating in pregnancy

A

prevent pyelonephritis –> pregnancy complications

207
Q

male UTI cause

A

e coli

208
Q

male UTI cystitis presentation

A

**elderly men
- dysuria
- frequency
- fever
- lower abdominal pain

209
Q

male UTI pyelonephritis presentation

A
  • similar to women
210
Q

male acute UTI treatment

A

TMP/SMX DS BID
or
fluoroquinolone

  • if enterococcus: ampicillin + gentamicin

2-4 weeks

211
Q

male chronic UTI treat

A

TMP/SMX DS BID
or fluoroquinolone

4-6 weeks

212
Q

increased prevalence of infectious diarrhea and c diff in…

A

water
tropics
seasonally

213
Q

populations at risk for ID and c diff

A
  • travelers, campers
  • < 5 years, > 74 years
  • military (travel, proximity)
  • chronic care institutions
  • immunocompromised
214
Q

infectious diarrhea pathogens

A
  • viral: rotavirus
  • bacterial: c difficile
  • parasitic: roundworms, tapeworms, …
215
Q

mild water loss

A

< 5% body weight lost
- alert
- inc thirst
- normal urine output

216
Q

moderate water loss

A

6-9% body weight loss
- lethargic, low BP, high HR, dry membranes, dark urine

217
Q

severe water loss

A

> 10% body weight loss
- drowsy
- bradycardia
- skin tenting
- no urine

218
Q

how to treat traveler’s diarrhea

A
  • loperamide x 2days

if high risk
- TMP/SMX
- cipro

219
Q

how to treat acute viral gastroenteritis

A

no antibiotic

220
Q

how to treat food poisoning

A

no antibiotic

221
Q

how to tret enterotoxic e coli

A

**major abdominal cramping
azithro
cipro

222
Q

how to treat mild and mod dehydration

A

oral replacement therapy

223
Q

how to treat severe dehydration

A

IV fluids – NS or LR

224
Q

risk factors for c diff

A

1) patient specific
- > 65 yrs
- GI surgery
- tube feeding
- immunocompromised

2) facility specific
- longer hospital stay
- ICU
- exposure

3) medication related
- acid suppresors – PPI, h1 RA
- chemo
- antibiotics!!

225
Q

number 1 risk factor for c diff

A

ANTIBIOTICS!!

226
Q

highest risk antibiotics for c diff

A

clindamycin
cephalosporins 3rd and 4th gen
carbapenems
fluoroquinolone

**broadest spectum

227
Q

c diff severity

A

non-severe:
- leukocytosis WBC < 15,000 cells/mL
AND
- SCr < 1.5 mg/dL

severe:
- leukocytosis WBC > 15,000 cells/mL
OR
- SCr > 1.5 mg/dL

fulminant:
- megacolon
- illeus
- hypotension, shock

228
Q

types of c diff infections

A

1) carrier, colonized
- no diarrhea

2) AB-associated diarrhea, no colitis
- 6 loose bm/day

3) AB-associated colitis, no pseudomembranes
- 10+ loose bm/day
- occult blood
- fecal WBC

4) pseudomembranous colitis
- > 10 loose bm/day
- occult blood
- fecal WBC

229
Q

c diff Dx

A
  • > 3 unformed stools in last 24 hours
    AND
  • (+) stool test for c diff or toxins OR pseudomembranous colitis seen on colonoscopy
230
Q

do you repeat stool assays during treatment

A

no, stay (+) for 6 weeks

231
Q

supportive c diff care

A

1) fluids, electrolytes
2) avoid anti-peristaltic –> loperamide, narcotics
3) stop offending antibiotic if possible

232
Q

how to treat initial non-severe c diff

A

vancomycin 125mg po QID x 10 days
OR
fidaxomicin 200mg po BID x 10 days

could use
metronidazole 500mg po TID x 10days

233
Q

how to treat initial severe c diff

A

vancomycin 125mg po QID x 10 days
OR
fidaxomicin 200mg po BID x 10 days

234
Q

how to treat initial fulminant/severe, complicated c diff

A

vancomycin 500 mg po OR NGT QID
+ (if ileus)
metronidazole 500 mg IV q8h

235
Q

how to treat first recurrent c diff

A

same

236
Q

to treat second recurrent c diff

A

antibiotics
- vancomycin tapers
- vancomycin pulsed OR fidaxomicin

moAB
- actoxumab
- bezlotoxumab
*neutralize toxins

FMT (fecal microbiotic transplant)
- high efficacy
- within 24 hours
- from partner, housemate, family

237
Q

how to prevent c diff infection

A
  • hand hygiene
  • contact precautions

p2 year (9 decks)

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