TB and UTIs Flashcards
1
Q
What factors are necessary for a ≥ 5 mm induration to be positive on a PPD skin test?
A
- HIV co-infxn
- recent TB contact
- classic x-ray Δ’s
- organ transplant
2
Q
Treatment for cath-associated UTI?
A
- D/C or change cath
- Get UA w/ C/S first
- Then 7-14 days of ABX therapy
3
Q
What should initially be done for acute pyelonephritis?
A
- UA w/ C/S and Gm stains
- Initiate empiric therapy
- f/u w/ directed therapy on basis of infecting pathogen
4
Q
What factors are necessary for a ≥ 10mm induration to be positive on a PPD skin test?
A
- immigration from endemic area w/in 5 yrs
- IVDU
- high-risk congregate setting
- microbio lab workers
- CKD/DM/cancer
5
Q
What are some common risk factors for developing UTIs?
A
- Female gender
- ↑ age
- obstruction
- calculi, BPH
- ↓ flow
- Anti-Ach Rx, neuro Dz
- Catheters/Instruments
- Diaphrams
6
Q
What is the initial Rx therapy for active TB infxn?
A
Intensive phase (all 4 Rx, no abbrev.)
- rifampin + isoniazid + pyranizamide + ethambutol
- for 2 months
7
Q
What Sx do we look for when hepatotoxicity is a concern on TB agents?
A
- anorexia
- fatigue
- jaundice
- scleral icterus
8
Q
How do we administer the “rif” 1st line TB agents?
A
- Must take it on an empty stomach (food ↓ absorption)
- take 1 hr before or 2 hrs after meals
9
Q
What are the risk factors for contracting/communicating TB
A
- Foreign travel/residence
- Immune weakness
- IVDU
- Close contact
10
Q
What is a clinical pearl associated with moxifloxacin?
A
will cover E. coli, Ø concentrated in urine
11
Q
Why are there a lot of Rx interactions w/ 1st line TB agents, and what are some interaction examples?
A
- Potent inducer of CYP-450
- oral contraceptives
- anti-retrovirals
- anticonvulsants
12
Q
Why is latent TB treated w/ Rx therapy?
A
- to reduced lifetime risk of reactivation from 10% to 1% for non-HIV+ patients
13
Q
Which asymptomatic patients should you NOT screen for UTI and why?
A
- Groups Ø to screen:
- DM
- elderly
- spinal cord injuries
- indwelling catheters
- Likelihood of finding MO’s high but risk of complication extremely low
- want to avoid unnecessary treatment
14
Q
What is a clinical pearl associated with Sulfonamides?
A
Avoid after 32 wks of pregnancy if possible
15
Q
What is the treatment for culture positive, pan-susceptible TB during the contiuation phase?
A
- rifampin + isoniazid for 4 additional mo
- q day, q 5x/wk, or q 3x/wk
16
Q
What are things that need to be considered when treating UTIs?
A
- Regional ABX resistance (antibiogram)
- Uncomplicated vs Complicated
- That drugs make it to kidneys
- excretion, urine [Rx], molecular size/protein binding
17
Q
What are the latent TB infxn treatment options?
A
- isoniazid 300mg q day for 9 mo
- typically Ø done b/c it’s 9 months
- isoniazid 900mg + rifapentine 900mg q weekly for 3 mo
- most common and DOT
- rifampin q day for 4 mo
- Ø tolerate INH, or…
- exposed to INH resistant TB
18
Q
What Rx treatment approach is taken for TB relapse?
A
- six agent minimum for re-treatment
- RIPE + fluoroquinolone + aminoglycoside
19
Q
- Why is asymptomatic bacteriuria in pregnancy treated differently?
- How is it treated?
A
- b/c likelihood of developing pyelonephritis with bacteriuria during pregnancy is significantly higher
- treat like symptomatic bacteriuria
20
Q
What is unique about the SE profile of Ethambutol?
A
- can cause retrobulbar neurtitis
- least hepatotoxic of 1st line agents
21
Q
What are the two primary reasons why TB relapse occurs?
A
- Self admin therapy
- non-rifampin containing regimen
22
Q
What are the greatest risks for reactivation of TB?
A
- HIV coinfection
- Infected contact
- Corticosteroid use
- CKD/DM
- Smokers
23
Q
What is the treatment process for uncomplicated UTI?
A
- Get a UA
- Get antibiogram
- Treat
- Nitrofurantoin monohydrate
- Trimethoprim-Sulfamethoxazole
- Fosfomycin tromethamine
24
Q
What is multi-drug resistant TB?
A
resistant to isoniazid and rifampin
25
What is a clinical pearl associated with Nitrofurantoin?
Ø concentrates in urine adequately if CrCl \<60mL/min
26
How can hyperuricemia be distinguished from non-gout polyarthralgia w/ pyrazinamide use? What does this mean for SE treatment?
* hyperuricemia typically in one joint, polyarthralgia in many joints
* anti-gout Rx for one and anti-inflammatory Rx for the other
27
What are the SE of the rifampin 1st line TB agents?
* rash/mild GI discomfort
* discoloration of all bodily fluids
* hepatotoxicity
* pseudomenbranous colitis
28
What is the purpose of RNA amplification?
* rapid TB detection
* diff btw TB and non-TB mycobacterium
* can detect rifampin-resistant genes
29
What 3 factors does duration of therapy of the intensive phase depend on?
1. culture results
* 6 to 8 wks to finalize
* 90-95% should be neg at 3 mo
2. Cavitary dz (abscess)
3. Resistance profile
* rifampin resistance or detection of other resistance
30
Why do we use the TB two-step (TST) process?
* to identify anyone with a booster phenomena and avoid falsely labeling TB conversion (from - to +)
* initial test stim body to react → (+) rxn to subsequent TST
31
How are severely ill acute pyelonephritis patients treated?
1. Go to the hospital
2. IV antimicrobal agents for first 48-72 hr then 7 days oral therapy
3. Use C/S results to tailor therapy once received
32
What are the additional symptoms that can help differentiate upper UTI (pyelo) from lower UTI (cystitis)?
* flank pain
* fever, malaise
* N/V
33
1. What initial steps are taken to treat symptomatic abacteriuria?
2. What is done if Pt reports recent sexual activity?
1. Treat with 3 day course of TMP-SMX
* if ineffective, get culture
2. Recent sexual activity possible Chlamydia trachomatis
* Ø see Clap on UA
* Azithromycin 1 gram x 1 day + Doxycycline 100 mg BID x 7 days
34
How are recurrent UTI infxns treated?
* \< 3 episodes/yr
* short course therapy
* ≥ 3 episodes/yr
* suppressive at home/PPX therapy
* TMP-SMX 160mg/800mg PO q day 1/2 DS tab x 6 mo
* Levofloxacin 500 mg PO q day x 6 mo
* Nitrofurantoin 50-100 mg PO q day x 6 mo
* Indefinite cont therapy available if needed
35
1. What two criteria would extend the continuation phase to 7 mo+?
2. How many total months would treatment be?
1. _Two Criteria_
* initial CXR shows cavitary dz
* cultures drawn at 2 mo are positive
2. 9 months
36
What are the general ADRs with isoniazid?
* peripheral neuropathy
* results from ↓ B6
* hepatotoxicity
* hyperglycemia
37
What are the ADRs associated with pyrazinamide?
* hepatotoxicity
* GI
* hyperuricemia/gout
* non-gout polyartheralgia
38
What are the different types of cystitis?
* uncomplicated
* complicated
* recurrent
* relapse
39
1. What is asymptomatic bacteriuria defined as?
2. What does this typically mean?
1. Consecutive UA w/ \> 105 CFUs/mL of same organism w/ Ø Sx
2. Usually represents **COLONIZATION**, not infxn
* Can attempt to eradicate once
40
What 3 different patient presentations occur with UTIs?
1. asymptomatic bacteriuria
* technically Ø an infxn
2. symptomatic abacteriuria
3. symptomatic bacteriuria
41
How are complicated UTIs treated?
* treat as mild-moderate pyelonephritis
42
What are the elderly Sx associated with UTIs?
* AMS
* GI symptoms
* Δ eating patterns
43
What is a clinical pearl associated with Trimethoprim?
Should be avoided in 1st trimester or pregnancy
44
What are the 3 types of TB?
* Latent TB
* Active pulmonary TB
* Extra-pulmonary TB
45
What are the Sx of active TB
* fever
* weight loss
* night sweats
* productive cough
* hemoptysis
* fatigue
46
What is the treatment for chronic bacterial prostatitis?
* Initial Therapy
* TMP-SMX for 4-12 wks
* Quinolone for 4-12 wks
* Suppressive therapy
* 3/wk dosing
* Ciprofloxacin
* TMP-SMX reg str
* Nitrofurantoin 100 mg q day
47
What are the Rx, doses, and admin instructions for the 3 Rx's used to treat uncomplicated UTIs?
* Nitrofurantoin monohydrate 100mg PO BID x 5 days
* Ø if early pyelon is suspected
* Trimethoprim-Sulfamethoxazole 160mg/800mg (DS) PO BID x 3 days
* Ø if resistance \> 20%
* Ø if used to treat UTI in last 3 mo
* Fosfomycin tromethamine 3 gram powder PO x once
* ↓ efficacy
* Ø if early pyelo suspected
48
* What should never be done to a failing TB regimen and why?
* What should be generally done?
* Never add a single Rx to a failing regimen b/c all TB considered resistant
* Always add 2 Rx to a regimen
49
What is extensively drug-resistant TB?
resistant to isoniazid + rifampin + at least 2 other Rx
50
What defines a TB regimen failure?
* positive cultures after 4 mo of treatment
* never got negative result
51
What minimum regimen must HIV+ Pts be on during continuation phase?
≥ 3x/wk or more
52
What is the UA gold standards for C/S?
* \> 105 CFU/mL → reasonably assume infectious
* can still have cystitis w/ \< 105 CFU/mL
* just can't say 100% positive UTI
53
What factors make Mycobacterium tuberculosis (MTB) unique?
* aerobic bacilli w/ thick, waxy cell wall
* very slow growing
* \> 15 hr generation time
54
What are important things we should be doing and/or monitoring for while on TB therapies?
* HIV test (if status unknown)
* Pregnancy test
* LFTs
* initial and q month if baseline abnml
* visual acuity if on ethambutol
* initial and q month
* culture results every 2 mo
* positive at 4 mo = failure
55
What steps are taken if high suspicion of TB but all diag tests are negative?
1. Initiate RIPE (must spell out) therapy
2. Assess response and culture results at 2 months
56
Following treatment of highly suspicious TB for 2 months, what criteria is needed to:
1. d/c therapy
2. cont therapy (how long?)
1. neg culture and no change in CXR/clinical picture
* then → d/c therapy
2. neg culture and positive response to therapy
* then → cont for 4 additional mo
57
Why do we treat UTIs?
* Treat symptoms - don't like Sx and want them to go away
* Don't want infxn to travel
* to blood → urosepsis
* to kidney → pyelonephritis
58
What's the difference btw each of the "rif" 1st line TB agents?
* rifampin = most common in US
* rifabutin = ↓ Rx interactions (common in HIV+ Pts)
* rifapentine = longer DoA (weekly regimens)
59
What is the first-line rifampin Rx therapy choice for TB?
* rifampin
* rifabutin
* rifapentine
60
What are some Rx alternatives to uncomplicated UTIs?
* Urinary fluoroquinolones x 3 days
* cipro-, o-, levofloxacin
* ↑ resistance d/t overuse, so need good reason to use
* β-Lactams
* amoxicillin-CA, cefdinir, ceflacor, cefpodoximine x 3-7 days
* used when others can't
61
1. What is the recommended treatment for mild-to-moderate symptomatic acute pyelonephritis?
2. What are alternative Rx options?
1. Treat as outpatient
* Recommended therapy
* ciprofloxacin 500 mg PO BID x 7 days
* ok if resistance \< 10%
* TMP-SMX 160 mg/800 mg BID x 14 days
2. Alternative Rx's = q day
* Ciprofloxacin 1000 mg x 7 days
* Levofloxacin 750 mg x 5 days
62
Why is the first-line therapy Rx considered 1st line?
Because all other Rx therapies for TB take longer to work
63
What is the treatment for acute bacterial prostatitis?
* Oral
* TMP-SMX or quinolones for 4-6 wks
* IV
* rarely needed
* IV → PO
* if afebrile for 48hr, or
* after 3-5 days of IV ABX
64
What are some additional clues to help validate a UA sample?
* Non-specific findings:
* pyuria, hematuria, proteinuria
* Specific findings:
* nitrite from Gm (-) organisms
* leukocyte esterase (WBCs present)
65
What are the Sx we are monitoring for when looking for hepatoxicity?
* jaundice
* scleral icterus
* ABD pain
* nausea
* fatigue
* ↓ appetite (mentioned in lecture)
66
* What LFT results would lead to d/c'ing therapy?
* How is therapy then restarted?
* D/C all agents if LFTs
* \>5x ULN or
* \>3x ULN w/ Sx
* then restart agents one at a time
* rifampin +/- ethambutol 1st
* add isoniazid if LFTs remain nml x1 wk
67
What steps are taken to distinguish btw active vs latent TB?
* good history
* CXR
* 3 AFB smears/cultures taken ≥ 8 hrs apart
* RNA amplification and C/S
