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79 Cards in this Set
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Beta Lactam antibiotics:
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PCN, cephalosoporins, carbapenems, aztreonam
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Ampicillin/Amoxicillin
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cover the same organisms as PCN, as well as E. coli, lyme, and few other gram negative
- HELPS: h. influenzae, e. coli, listeria, proteus, salmonella best initial tx for? |
-otitis media
- dental infxn and endocarditis Ppx - lyme dz limited to rash, joint, or CNVII involvement - UTI in pregnant women - Listeria - Enterococcal infections amp/sulbactam: unasyn amox/sulbactam: augmentin |
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PCN
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viridans group strep, strep pyogenes, oral anaerobes, syphilis, leptospira
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Penicillinase-resistant penicillins (PRPs)
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oxacillin, cloxacillin, dicloxacillin, nafcillin
used to treat what? |
- skin infections: cellulitis, impetigo, erysipelas
- endocarditis, meningitis, and bacteremia from staphyococci - osteomyelitis and septic arthritis only when proven sensitive not active against MRSA or Enteroccos |
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Piperacillin, ticarcicillin, azlocillin, mezlocillin
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cover gram negative bacilli (e.coli, proteus) as well as pseudomonads.
best initial therapy for? |
- cholecystitis and ascending cholangitis
- pyelonephritis - bacteremia - HAP/VAP - neutropenia and fever Although these agents cover streptococci and anaerobes, they are not the answer when infxn is exclusively from these single organisms. Use a narrower agent! Nearly always used in combo with a beta-lactamase inhibitor such as tazobactam or clavulanic acid. pip/taz = zosyn ticarc/clav = timentin |
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Cephalosporins: cross reaction to PCN, universal coverage, gaps in coverage
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amt of cross-reaction between PCN and cephalosporins is very small (<3%)
All cephalosporins, in every calss, will cover group A< B, and C streptococci, viridans group streptococci, E. coli, Klebsiella, and Proteus mirabilis Gaps: Listeria, MRSA, and Enterococcus |
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First generation cephalosporin
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cefazolin, cephalexin
- staph: methicillin sensitive = oxacillin sensitive = cephalosporin sensitive - strep (except enterococcus) - some GNR such as E.coli (not pseudomonas) - osteomyelitis, septic arthritis, endocarditis, cellulitis |
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Second generation cephalosporin
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ONLY Cefotetan and Cefoxitin cover anaerobes for cephalosporins
cover all the same organisms as first generation and ADD coverage for anaerobes and more GNR - best initial therapy for PID combined with doxy -> DISULFIRAMLIKE reaction with alcohol + increased risk of bleeding - respiratory infections such as bronchitis, otitis media, and sinusitis |
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Third generation cephalosporin
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CTX, cefotaxime, ceftazidime
CTX: first line for pneumococcus, including partially insensitive organisms - meningitis - CAP (in combo with macrolides) - gonorrhea - lyme involving heart or brain - Avoid CTX in neonates bc of impaired biliary metabolism - Cefotaxima - superior to CTX in neonates - SBP - Ceftazidime has psuedomonal coverage |
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Fourth generation cephalosporin
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Cefepime has better staph coverage compared with 3rd generation. Used to treat
- neutropenia and fever - VAP |
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Adverse effects of cephalosporins
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Cefoxitin and cefotetan (2nd gen) deplete prothrombin and increase risk of bleeding
CTX: inadequate biliary metabolism |
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Carbapenem
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Imipenem, Meropenem, Ertapenem, Doripenem
- cover GNR, including many that are resistant, anaerobes, strep, and staph - used to treat neutropenia and fever Ertapenem DIFFERS from other carbapenems -> does NOT cover pseudomonas |
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Aztreonam
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only drug in class of monobactams
- exclusively for GNR including pseudomonas - NO cross reaction with PCN |
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Fluoroquinolones
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Cipro, levo, moxi
- best therapy for CAP, including PCN-resistant pneumococcus - GNR including most pseudomonads - cipro for CYSTITIS and pyelo - diverticulitis and GI infection, though must be combined with metronidazole bc won't cover anaerobes except for MOXIFLOXACIN adverse side effects? |
- bone growth abnormalities in children and pregnant women
- tendonitis and Achillis tendon rupture |
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Aminoglycosides
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Gentamicin, tobramycin, amikacin
- GNR (bowel, urine, bacteremia) - synergistic with beta-lactam antibiotics for enterococci and staphylococci - no effect against anaerobes, since they need O2 to work s/e? |
nephrotoxic and ototoxic
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Doxycycline
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- chlamydia
- lyme disease limited to rash, joint, or CNVII palsy - rickettsia - MRSA of skin and soft tissue (cellulitis) - primary and secondary syphilis in those allergic to PCN - Borrelia, ehrlichia, and MYCOPLASMA s/e? |
tooth discoloration (children), Fanconi syndrome (Type II RTA proximal), photosensitivity, esophagitis/ulcer
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Bactrim
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- cystitis
- PCP treatment and PPx - MRSA of skin and soft tissue (cellulitis) s/e? |
- besides rash, it causes hemolysis and G6PD deficiency and bone marrow suppression because it is a folate antagonist
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beta-lactam/beta-lactamase combinations
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amox/clav: augmentin
ticarc/clav: timentin amp/sulb: unasyn pip/taz: zosyn beta-lactamase adds coverage against sensitive staphylococci to these agents. They cover anaerobes and are a first choice for MOUTH and GI abscess |
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Gram-positive cocci: staph and strep
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best initial therapy:
- oxacillin, cloxacillin, dicloxacillin, nafcillin - first gen cephalosporins: cefazolin, cephalexin - fluoroquinolones - macrolides (azithro, clarithro, erythro) are third line agents because less efficacy than oxacillin or cephalosporins. |
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Oxacillin-resistant staphylococcus
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best treated with
- vanc - linezolid (reversible bone marrow toxicity) - daptomycin: elevated CPK - tigecycline - ceftaroline |
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nitrofurantoin
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one indication: cystitis, especially in pregnant women
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Minor MRSA infections of skin tx?
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bactrim, clinda, doxy, linezolid
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Anaerobes
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above diaphragm: PCN or clinda
below diaphragm: metronidazole, beta-lactam/lactamase combo piperacillin, carbapenems, and 2nd gen ceph also cover anaerobes |
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GNR:
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E. Coli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Citrobacter
infection of bowel (peritonitis, diverticulitis); UTI, liver (cholecystitis and cholangitis) - quinolones - aminoglycosides - carbapenems - pip/taz - aztreonam - cephalosporins |
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CNS infections
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fever, HA, N/V all can lead to seizures
distinguish between meningitis, encephilitis, abscess |
meningitis: stiff neck, photophobia, meningismu
encephalitis: confusion abscess: focal neuro deficits (though can also occur in meningitis) |
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Meningitis: def/etiology
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infection or inflammation of the covering or meninges of the CNS
Strep pneumo, group B strep, H.influenzae, N. mengitidis, and LIsteria account for 95%; staph in recent neurosurgery |
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Meningitis: presentation
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Fever, HA, nuchal rigidity, and photophobia
acute bacterial meningitis - presents over several hours. focal neuro deficits in up to 30% dx? |
LP
head CT is best initial test prior to LP only if there is a possibility that a space occupying lesion may cause herniation. -> requires initial head CT for the following: - papilledema - seizures - focal neuro abnormalities - confusion interfering with neuro exam |
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Organism specific presentations for meningitis
pg 9 |
9
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other ways to discover meningitis other than LP?
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bacterial antigen detection (latex agglutination) -> extremely specific, not sensitive enough. used when patient has received antibiotics prior to LP and cx may be falsely negative.
TB: acid fast stain and cx on 3 high-volume LPs Lyme and Rickettsia: Specific serologic testing, ELISA, western blot, PCR Cryptococcus: india ink; cryptococcal antigen viral: dx of exclusion |
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bacterial meningitis tx:
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best initial treatment for bacterial meningitis is CTX, vanc, and steroids
base tx on cell count. (cx takes too long) gram stain is good if positive, however, false neg in 30-50%. Protein and glucose are too nonspecific to allow for a tx decision. Though steroids have been proven to lower mortality only in S. pneumoniae infxn, must give them when you see thousands of neutrophils because you will not know the cx results for several days. |
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listeria meningitis tx
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resistant to all cephalosporins but sensitive to PCN. Must add amp to CTX and Vanc if the case describes risk factors for Listeria:
- elderly - neonates - steroid use - AIDS/HIV - immunocompromised, including alcoholism - pregnant |
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Neisseria meningitidis tx
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- respiratory isolation
- rifampin, cipro, CTX to the close contacts to decrease nasopharyngeal carriage (close contacts means household contacts, kissing, or sharing cigs/eating utensils -> does not mean sitting in chair next to class) - healthcare workers only if they intubate patient, perform suctioning, or have contact with respiratory secretions |
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Contraindication to immediate LP
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neuro findings
treat immediately with CTX, Vanc, and steroids heat CT is also important but done after initiation of therapy. most common neuro deficit of untreated bacterial meningitis? |
CNVIII deficit or deafness
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encephalitis
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acute onset of fever and confusion. Herpex simplex by far most common cause.
Must do head CT FIRST bc of confusion dx? tx? |
dx: PCR more accurate than brain bx
tx: acyclovir for herpes encephalitis. famciclovir and valacyclovir not available as IV formulations. Do not use even if acyclovir causes Cr levels to rise (instead reduce acyclovir and hydrate) Foscarnet used for acyclovir-resistant herpes |
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Otitis media
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redness, immobility, bulging, and decreased light reflex of the tympanic membrane. pain is common. decreased hearing and fever also occur
most sensitive finding? dx/tx? |
immobility (so sensitive that a fully mobile tympanic membrane essentially excludes otitis media
dx: tympanocentesis = most accurate, choose if multiple recurrences or if no response to multiple antibiotics tx: amoxicillin is best initial therapy otherwise, - augmentin - azithromycin, clarithromycin - cefuroxime, loracarbef - levo, gemiflox, moxiflox |
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Sinusitis: dx, tx
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- most accurate: sinus bx or aspirate
- cx of nasal d/c is always the wrong answer for sinusitis - bx only if: sinusitis frequently recurs; no response to different empiric therapies tx: augmentin and decongestant - also can try doxy, bactrim - efficacy similar to more broad spectrum agents such as quinolones |
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Pharyngitis: presentation
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- pain on swallowing
- enlarged lymph node on neck - exudate in pharynx - fever - no cough and no hoarseness dx? tx? |
dx: best initial = rapid strep test -> group A detection
positive rapid strep = positive pharyngeal cx (cx more sensitive) - small vesicles or ulcers: HSV or herpangina - membranous exudates: diptheria or EBV tx: PCN or amox best initial - Cephalexin if allergic to PCN (only rash). - If allergy is anaphylaxis, use clinda or macrolide |
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Influenza: presentation, most approp next step?
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- arthralgia/myalgia
- cough - fever - HA and sore throat - N/V/D, especially in children most approp next step: if within 48 hrs since onset of sx, perform nasopharyngeal swab or wash in order to rapidly detect antigen a/w influenza tx? |
less than 48 hrs: oseltamivir, zanamivir
- neuramidase inhibitors shorten duration of sx. These drugs treat both influenza A and B. More than 48 hrs: symptomatic tx only. analgesics, rest, antipyretics, hydration. |
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Infectious diarrhea
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first distinguish btw blood and WBCs vs no blood or WBCs in stool, pg 16
dx? tx? |
dx:
best initial - fecal blood/leukocytes (stool lactoferrin greater sensitivity and specificity compared with stool leukocytes) most accurate: stool cx tx: mild: oral fluids severe: fluid resplacement and oral antibiotics such as cipro severe: hypotension, tachy, fever, abdominal pain, bloody diarrhea, metabolic acidosis page 17 |
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Acute Hepatitis: serotypes and transmission pattern
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hep A/B
Hep C rarely p/w acute infection B,C,D: sex, blood, perinatal AE: food and water, stool |
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Acute Hepatitis: presentation
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- jaundice
- fever, weight loss, fatigue - dark urine - hepatosplenomegaly - N/V/ abdominal pain dx? most worrisome lab finding? |
increased direct bili
increased ALT/AST ratio increased alkphos - PT elevation = markedly increased risk of fulminant hepatic failure and death. |
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Hepatitis specific diagnostic tests
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Hep A, C, D, E ->
best diagnostic test: IgM for acute infection and IgG for resolution of infection - dz activity of HepC assessed with PCR for RNA level, which tells the amt of active viral replication. - HepC PCR levels are the first thing to change as an indication of improvement with tx and are the best correlate of tx failure if they rise |
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HepB diagnostic tests
19 |
pg 19
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which HepB test is most directly correlated with the amt, or quantity, of active viral replication?
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e-antigen -> directly correlated with degree of DNA polymerase. only present when there is a high level of DNA pol activity
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Which indicates that a pt is no longer a risk for transmitting HepB to another person?
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this means active infxn has resolved -> SURFACE ANTIGEN GONE (not surface antibody)
as long as surface antigen is present, there is still some viral replication present. |
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Which Hep B serology markers is best indication of the need for tx with antiviral meds in chronic dz?
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e-antigen
- greatest degree of viral replication. - although surface antigen means there is at least some active dz, it might be on the way to spontaneous resolution and would not benefit - everyone with e-antigen also has surface antigen - the person with the worst dz (highest DNA pol) will benefit the most from tx |
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Best indicator that a pregnant woman will transmit infxn to child?
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e-antigen (or DNA polymerase)
If woman positive for surface antigen, but e-antigen is negative, only 10% of children will become infected with hepB at birth. - When both e-antigen are pos, 90% of children will be infected at birth - perinatal transmission is the most common method of transmission worldwide! |
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Tx of acute hepatitis
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Hep A and E resolve spontaneously over a few weeks
Hep B becomes chronic in 10%!!! no tx to prevent this Acute hepC -> tx interferon, ribavirin and either boceprevir or telaprevir. -> decrease likelihood of developing chronic infxn with hepC - ONLY ACUTE HEPC GETS MEDICAL THERAPY |
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Chronic HepB: def and tx
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By definition, chronicity of hepB defined as persistence of surface antigen for more than 6mo
If pts are positive for e-antigen with elevated level of DNA pol, tx is ANY ONE of the following: - entecavir, adefovir, lamivudine, telbivudine, interferon, or tenofovir adverse effects of interferon? goal of chronic hep tx? |
- arthralgia/myalgia
- leuokopenia and thrombocytopenia - depression/flu-like sx goal: 1) reduce DNA pol to undetectable levels 2) convert those pts with e-antigen to having anti-hep e-antibody |
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Role of liver bx in chronic hepatitis
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presence of fibrosis on bx is strong indication to begin therapy for either hepatitis B or C right away.
*If there is active viral replication, fibrosis will progress to cirrhosis |
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Tx of chronic HepC
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no equivalent surface antigen test.
* Most pts do not have acute sx - If PCR-RNA viral load is elevated, pts should be treated with interferon, ribavirin, and either boceprevir or telaprevir. * goal = achieve undetectable viral load |
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urethritis vs cystitis
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urethritis has urethral d/c
both have cystitis sx: increased urinary frequency, urgency, and burning |
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urethritis: dx and tx
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best initial test = urethral swab for gram stain
- if gram neg diplococci are seen, sufficient evidence of gonorrhea to initiate tx. - most accurate: urethral cx, DNA probe or nucleic acid amplification test to detect gonorrhea/chlamydia tx: - gonorrhea: cefixime/ctx - chlamydia: azithro/doxy |
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Cervicitis
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presents with cervical d/c and an inflamed "strawberry" cervix on PE.
Testing and tx are identical to that previously described for urethritis |
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PID presentation + dx
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- lower abdominal tenderness
- lower abdominal PAIN - fever - CERVICAL MOTION TENDERNESS - leukocytosis - always exclude pregnancy first!!! in woman with lower abdominal pain/tenderness or cervical motion tenderness dx: - cervical swab for culture, DNA probe, or nucleic acid amplification to confirm etiology of PID. - most accurate test is laparoscopy!!! although rarely needed -> only needed if dx unclear, sx persist despite tx, or there are recurrent episodes for unclear reasons tx? |
PID treated with combo of meds for gonorrhea and Chlamydia
- inpt: cefoxitin or cefotetan combined with doxy - outpt: CTX and doxy (possibly with metronidazole) pts with anaphylaxis to PCN: levofloxacin and metronidazole as an outpt, or clinda, gent, and doxy as an inpt |
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Presentation of ulcerative genital dz
pg 23 |
pg 23
dx? tx? |
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Syphilis: presentation
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primary:
- painless genital ulcer with INDURATED EDGES (becomes painful if secondarily infected with bacteria) - painless adenopathy secondary: - rash (palms and soles) - alopecia areata - mucus patches - condylomata lata tertiary: - neurosyphilis meningovascular (stroke from vasculitis) tabes dorsalis (loss of position and vibratory sense, incontinence, CN) general paresis (memory/personality changes) argyll robertson pupils (reacts to accomodation, but not to light) - aortitis: aortic regurg, aortic aneurysm - gummas (skin and bone lesions) dx? false positives? |
- VDRL or RPR
- FTA-ABS (more sensitive) increasing sensitivity as your progress from primary to tertiary - false positive if infxn, older age, IVDU, AIDS, malaria, APLS, endocarditis |
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Syphilis: tx
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primary/secondary: single IM PCN; oral doxy if PCN allergic
tertiary: IV PCN. desensitize to PCN if PCN allergic Jarish-Herxheimer reaction |
-fever and worse sx after tx
- give ASA and antipyretics; it will pass |
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Genital warts (condylomata acuminata)
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from HPV diagnosed simply based on visual appeance (no bx, serology, stain, smear, or cx!!!)
- removal with CRYOTHERAPY WITH LIQUID N2, SURGERY for larger ones, laser, or melting them with PODOPHYLILIN or trichloroacetic acid. IMIQUIMOD is locally applied immunostimulant that leads to sloughing off of lesion. |
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Pediculosis (Crabs)
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- found on hair-bearing areas (axilla, pubis)
- causes itching - visible on the surface - treat with PERMETHRIN |
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Scabies
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- found in WEB SPACES btw fingers and toes or at elbows/genitalia
- found around nipples or near genitals - BURROWS visible (they dig) but smaller than pediculosis - SCRAPE and magnify - treat with PERMETHRIN - widespread dz is "crusted" or hyperkeratotic and responds to ivermectin; severe dz needs repeat dosing. |
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UTI: presentation
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- dysuria (frequency, urgency, burning) and fever
- U/A shows increased WBCs in all of them - E. coli most common cause - quinolones = best initial therapy for pyelo |
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Cystitis: presentation? tx?
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presents with dysuria and
- SUPRAPUBIC PAIN/discomfort - mild or absent fever tx: - nitrofurantoin (3d for uncomplicated; 7d for anatomic abnormality) or fosfomycin - Bactrim if local resistance is low - cipro: reserved from routine use to avoid resistance - cefixime (3rd gen) |
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Pyelo: presentation, dx, tx
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presentation: dysuria with flank or CVA tenderness, high fever, occasionally with abd pain from inflamed kidney
- UA shows increased WBCs. imaging CT or sonogram to determine anatomic abnormality causing infxn tx: - CTX (first line!!!), ertapenem - AMP/GENT until cx results known - cipro (oral for outpt) |
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Acute prostatis
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dysuria with
- PERINEAL PAIN - TENDER PROSTATE on exam - tx with same antibiotics in pyelo (see next slide for reminder) - long term therapy with bactrim for 6-8 wks for chronic pancreatitis |
tx:
- CTX (first line!!!), ertapenem - AMP/GENT until cx results known - cipro (oral for outpt) |
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Perinephric abscess
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Look for pyelo that does not resolve with appropriate therapy -> often from anatomic problem
- imaging study after 5-7d of therapy - DRAINAGE mandatory - cx of infected fluid to guide therapy |
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Endocarditis: presentation, dx
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FEVER AND MURMUR
dx: vegetations on echo and positive blood cx - best initial: blood culture (>95% sensitive) - TTE or TEE (more sensitive/specific) EKG rarely shows AV block if there is dissection of conduction system dx of culture neg endocarditis |
1) oscillating vegetation on echo
2) 3 minor criteria - fever >38C - risk such as IVDU or prosthetic valve - signs of embolic phenomena |
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Endocarditis: tx
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best initial empiric therapy -> vanc/gent
When cx results are available, treat as indicated in the table pg31 resistant organisms -> add aminoglycoside and extend tx duration When is surgery the answer? |
pg31
Surgery: - CHF or ruptured valve or chodae tendineae - prosthetic valve - fungal endocarditis - abscess - AV block - recurrent emboli while on antibx |
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Treatment of culture negative endocarditis
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most common = coxiella
HACEK organisms is an acronym for organisms that are difficult to cx that cause endocarditis Haemophilus aphrophilus Haemophilus parainfluenzae Actinobacillus Cardiobacterium Eikenella Kingella Use CTX! |
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PPx for endocarditis
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Two features needed:
1) significant cardiac defect - prosthetic valve - previous endocarditis - cardiac transplant recipient with valvulopathy - unrepaired cyanotic heart dz 2) risk of bacteremia - dental work WITH BLOOD - respiratory tract surgery that produces bacteremia PPx: amoxicillin prior to procedure - if PCN allergic, use clinda, azithro, or clarithro see pg 32 for more detailed description of procedures and anatomic abnormalities that do NOT need ppx |
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Lyme Dz: def, etiology, presentation
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def: arthropod-borne dz from Borrelia burgdorferi
- results from fever/rash - untreated infxn can recur as joint pain, cardiac dz, or neurlogic dz Lyme dz transmitted by deer tick (ixodes scapularis) Typically only occurs in NE states Presentation: - RASH accompanied by fever -> erythema migrans (round led lesion with pale area in center) - JOINT PAIN - NEUROLOGIC MANIFESTATIONS -> meningitis, encephalitis, CN palsy (most common) - CARDIAC manifestations -> damage to myocardium, pericardium, etc (transient AV block most common) dx? tx? |
rash is good enough
otherwise, IgM, IgG, ELISA, Western blot, and PCR tx: see pg 34 |
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HIV/AIDS: definition
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retrovirus infecting CD4 cells. Not HIV virus itself that leads to sx and death, but rather the depletion of CD4 leading to opportunistic infxn
Rarely do opportunistic infections occur below CD4 200 |
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HIV dx
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best initial test = ELISA, confirmed with Western
Infected infants diagnosed with PCR or viral cx. ELISA testing unreliable in infants bc maternal HIV antibodies may be present for up to 6mo after delivery |
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HIV monitoring therapy
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Viral load testing (PCR-RNA level)
useful for: - measuring response to therapy - detect tx failure - diagnose HIV in babies goal of therapy to drive down viral load below 50/ul (life expectancy equivalent to HIV-negative person if viral load is undetectable) |
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Viral resistance testing
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should be performed prior to initiating antiretroviral meds.
also used in event of tx failure |
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HIV tx: strongest indication
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strongest indication = CD4 < 350
Opportunistic infxn tx discussed with each dz Tx initiated when - CD4 < 500 in asymptomatic pt - Viral load is very high (greater than 100,000) - opportunistic infxn occurs Choice of Antiviral med? tx failure monitoring? |
best initial drug regimen: emtricitabine, tenofovir, and efavirenz -> combined in single, once-a-day pill called Atripla
tx failure detected by rising viral load or failure of viral load to suppress to undetectable levels. alternate drug regimens: combo of 3 drugs from at least 2 different classes see pg 37 for more detail |
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Postexposure HIV PPx
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all significant stick injuries and sexual exposures are given 4wks of therapy with combo therapy.
exposure to urine or stool, or kisses not indication for PEP unless blood present Bites should initiate therapy! |
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Adverse effects of HIV meds
zidovudine stavudine and didanosine abacavir protease inhibitors indinavir tenofovir |
pg 38
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Prevention of perinatal HIV transmission
fully controlled HIV (viral load undetectable) gives less than 1% transmission |
continue same antiretroviral meds if pt is already on tx and responding (except efavirenz should be avoided due to teratogenicity -> switch to protease inhibitor)
- give ARVs during whole pregnancy even with high CD4/low viral load - baby should receive zidovudine during delivery (intrapartum) and for 6wks afterwards see chart on pg38 C section delivery? |
performed to prevent transmission of virus if
- CD4 < 350 - viral load above 1000 at time of delivery |
