Treatment of Meningitis and Respiratory Infections Flashcards
(28 cards)
Surgical Prophylaxis Agents
Cardiac/vascular = Cefazolin, cefuroxime
*alt: clindamycin or vancomycin
Orthopedic = Cefazolin
*alt: clindamycin or vancomycin
GI = Cefazolin + metronidazole, cefotetan, cefoxitin, or ampicillin/sulbactam (unasyn) (MF FU)
*alt: clindamycin or metronidazole + AG or quinolone (MC QA)
Notes:
-Cefazolin (preferred, MSSA/strepto)
-Clindamycin (alt, BL allergy)
-GI surgery: cover skin flora + G- and anaerobes
-Vancomycin if MRSA colonization/risk (also alt if BL allergy)
Surgical Prophylaxis Timing
Pre-Operative
-Infuse abx (cefazolin or cefuroxime) within 60 min before first incision
-If a quinoione or vancomycin is used, start the infusion 120 min before the incision
Intra-Operative
-Additional doses may be administered for longer surgeries (e.g., > 4 hours) or if there is major blood loss
Post-Operative
-Abx not usually needed, if used - d/c within 24 hours
Meningitis: Background
Sx: fever, HA, stiff neck*, AMS
Dx: LP for CSF (high CSF = infection)
Duration of Tx:
-7 days for N. meningitidis, H. influenzae
-10 to 14 days for S. pneumoniae
-At least 21 days for Listeria monocytogenes
(7 MI 10-14 S 21 L = MISL)
*Listeria monocytogenes is higher in neonates, age > 50, immunocompromised
Dexamethasone, administered 15-20 min prior to or with the first abx dose, can prevent neurological complications from S. pneumoniae (can be empiric for all cases then d/c if not strep)
-0.15 mg/kg (rounded to 10 mg) IV Q6H for 4 days
Meningitis: Empiric Tx + ALT
Age < 1 mo (neonates)
= Ampicillin + cefotaxime/ceftazidime/cefepime +/- gentamicin
Age 1 mo - 50 yr
= Ceftriaxone + vancomycin
50+ yr or immunocompromised
= Ampicillin + ceftriaxone + vancomycin
If severe PCN allergy (adults):
-Treat with a quinolone (e.g, moxifoxacin) + vancomycin +/- SMX/TMP
Acute Otitis Media (AOM): Background
Sx: bulging tympanic (eardrum), otorrhea (middle ear effusion/fluid), otalgia (ear pain), tugging or rubbing the ears
Most viral, but if bacterial:
-S. pneumoniae, H. infuenzae or Moraxella catarrhalis
Observe for 48-72 hours if 6+ mo with non-severe AOM
*Severe if
-Ill appearance, otorrhea, otalgia 48+ hr, >102.2F
and
-6-23 mo: one ear only
-or ≥ 2 yr: one or both ears
Observation is not an option in < 6 mo
AOM: First-Line Tx + Duration
First line
-Amoxicillin 90 mg/kg/day in 2 div doses
-Augmentin 90 mg/kg/day (amox) in 2 div doses (6.4 m/k/d of clavulanate)
*augmentin preferred if amoxicillin given within past 30 days
*augmentin ES-600 preferred (600 amox and 42.9 clav per 5 ml)
Duration
-10 days for < 2 yr
-7 days for 2-5 yr
-5-7 days for 6+ yr
AOM: Alternative Tx
For mild PCN allergy: PDUT
-Cefpodoxime 10 mg/kg/day in 2 div
-Cefdinir 14 mg/kg/day in 1-2 doses
-Cefuroxime 30 mg/kg/day in 2 div
-Ceftriaxone 50 mg/kg IM for 1 or 3 days
Tx Failure
-Augmentin (if amoxicillin first given)
-Ceftriaxone 50 mg/kg IM for 3 days
Pharyngitis
S. pyogenes (strep throat)
-Sore throat, swollen lymph nodes, white patches on tonsils (exudates)
Rapid antigen test or + culture of pyogenes = abx tx
Tx
-PCN or amoxicillin
-Mild allergy: 1-2nd cephalosporin
-Severe allergy: macrolide or clindamycin
Acute Sinusitis
S. pneumoniae, H. influenzae, M. catarrhalis
Nasal congestion/discharge, facial/ear pain, headache
10+ days of sx or 3+ days of severe sx (temp >102) = abx tx
Tx
-Augmentin
-Symptomatic care (OTCs)
Bronchitis: Ow/Tx
Sx
-Cough lasting 1-3 weeks
S. pneumoniae, H. influenzae or atypical (Mycoplasma pneumoniae)
Chest x-ray normal
Abx NOT recommended, sx are self-limiting and managed with supportive care (OTCs)
Pertussis: Ow/Tx
Bordetella pertussis (and commonly known as whooping cough)
-forceful coughs followed by an inspiratory “whoop” sound
Highly contagious
Tx:
-Macrolides (az, clari)
COPD Exacerbation: Ow/Tx
3 sx*:
-increased dyspnea
-increased sputum volume
-increased sputum purulence
Supportive tx (oxygen, inhaled bronchodilators, steroids)
Abx for 5-7 days IF:
-all 3 sx met
-increased purulence + 1 extra sx
-mechanically ventilated
Agents: DARA 57
-Augmentin
-Azithromycin
-Doxycycline
-Resp quinolone (LM)
Community-Acquired PNA (CAP): OW
Sx: SOB, fever, cough with purulent sputum, rales, tachypnea
-Chest x-ray with infiltrates, opacities, or consolidations*
Duration of tx: 5-7 days
Outpatient CAP Tx
Healthy (no comorbidities)
-Amoxicillin 1 g TID
-Doxycycline
-Macrolide (azi/clari) if res < 25%
High risk (heart/lung/liver/renal disease, diabetes, AUD, asplenia, malignancy)
-BL + macrolide or doxycline
(augmentin or cefpod/cefuroxime + marcolide or doxycycline)
-Resp quinolone monotherapy (LM)
MAD - MD BR
Inpatient CAP Tx
Non-severe (gen med unit)
-BL + macrolide or doxycline
(BL preferred: ceftriaxone, ampicillin/sulb (unasyn), or ceftaroline) TUT
-Resp quinolone monotherapy (LM)
Severe (ICU)
-BL + macrolide
-BL + RQ
(NO RQ monotherapy)
Risk factors for MRSA/PM: prior isolation, + nasal swab, hospitalization or parenteral abx within 90 days
-MRSA: add vanco or linezolid
-PM: use BL with PM like zosyn, cefepime, ceftazidime, meropenem, imipenem/cilastatin (MT PZ)
HAP/VAP: OW
HAP: onset > 48 hr after hospital admin
VAP: onset > 48 hr after mech vent
Nosocomial pathogens common
-Increased risk of MRSA and MDR gram-negative rods ( P. aeruginosa, Acinetobacter, Enterobacter, E. coli, Klebsiella)
Duration: 7 days
HAP/VAP: Tx
All patients get abx for PM/MSSA
-Cefepime, Zosyn, Levofloxacin, Meropenem, Aztreonam
Add vancomycin or linezolid for MRSA
(RF: IV antibiotic use within 90 days, MRSA prevalence is > 20% or uknown, prior MRSA infection or positive MRSA nasal swab)
Use 2 PM abx if risk for MDR G-
(RF: IV antibiotic use within 90 days, prevalence of G- resistance is > 10%, hospitalized ≥ 5 days prior to VAP onset)
-Zosyn + cipro + vanco
-Cefepime + gent + linezolid
*Do not use 2 BL together for PM
-BL: zosyn, cefepime, ceftazidime, imipenem/cilastatin, meropenem
-Levoflaxacin or ciprofloxacin
-Aztreonam
-Aminoglycosides (typically tobramycin)
Latent TB: OW
Caused by Mycobacterium tuberculosis
Lack of symptoms
Dx:
-Tuberculin skin test (TST)
*TST: inspect for induration/raised in 48-72 hr later
-IGRA: preferred in pts with hx of BCG vaccination (bacille calmette-guerin) due to a false + if TST is used
Active TB: OW
Caused by Mycobacterium tuberculosis
Transmitted via aerosolized droplets, very contagious
Symptomatic: hemoptysis, chest pain, chills, night sweats, dyspnea
Dx:
-TST/IGRA + is likely, but have to confirm
-Chest x-ray showing consolidation or cavitation (empty space)
-MTB is acid-fast bacilli (AFB), it can be detected with an AFB smear and definitive dx must be made via sputum culture or PCR (slow growing, can take 6 weeks)
Hospitalized pts:
-Isolation in a negative-pressure room
-Wear N95/respirator mask
Reading TST Results for LATENT TB
5+ mm induration
-Close contacts of recent TB cases
-HIV infection
-Immunosuppression (txp, chemo)
10+ mm
-Immigrants from high burden country
-Clinical risk (IV drug use, diabetes)
-Residents/employees of high risk congregates (prisons, healthcare facilities, homeless shelters)
15+
-Pts with no risk factors
HIC the RIC
Latent TB: Tx
Regimens
-INH + rifapentine once weekly for 12 weeks via directly observed therapy (DOT) or self-administered
(NOT FOR PREGNANCY)
-INH + rifampin QD x3 mo
-Rifampin 600 mg QD x4 mo
-INH 300 mg QD x6-9 mo
(may be preferred in HIV pts on ART bc lower DDIs, 9 mo course recommended)
Active TB: Tx
2 phases
Intensive (4 drugs)
-RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) for 2 mo (QD or 5x/week)
Continuation (scaled to 2 drugs)
-Rifampin, isoniazid for 4 mo (QD, 5x/w, or 3x/w)
*can be increased to 7 mo if sputum culture still + after 2 mo tx or if intensive phase did not have pyrazinamide)
Resistant TB Options
MDR-TB (QAKS)
-Resistant to INH and rifampin
-Alt: RFQ, streptomycin, amikacin, kanamycin
XDR-TB
-Bedaquiline (Sirturo)
*BBW for QTP, increased death
-Pretomanid approved for both with bedaquiline and linezolid
*AE: liver, PO neuropathy, myelo, QTP
DQB LMNQP
Rifampin: D/CI/AE
10 mg/kg (max 600)
CI: w/ protease inhibitors
AE
-Increase LFTs
-Hemolytic anemia
-Flu-like syndrome
-Orange/red fluid discoloration (can stain contact lenses/clothes/sheets)
Take on empty stomach
rif OP LEAF
