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254 Cards in this Set
- Front
- Back
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how many strains?
CA-MRSA- HA-MRSA- |
CA- USA-300 strains
HA- USA 100 strains |
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CA-MRSA
risk factors? location? mortality? growth rate? mec gene? |
RF- close quarters, poor, poor hygiene
locat- skin + soft tissue mainly mortality-low fast grower mec IV |
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HA-MRSA
RF? LOCATION? MORTALITY? GROWTH RATE? MEC GENE? |
RF- hosp, old, chronic disease, surgery, medical device w/i 1 yr
location-heterogenous- can be tissues, pulm, blood high mortality slower growing mec I-III |
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CA-MRSA
resistance patterns? susceptibility |
resistance to B-lactams
suscept- clinda, bactrim, tetra |
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HA-MRSA
resistant to? susceptible? |
multi-drug resistance
susceptible to vanco |
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examples of primary infection
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erysipelas
impetigo lymphangitis cellulitis necrotizing fascitis |
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examples of secondary infection
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previously damaged sking-polymicrobial
diabetic foot, pressure sores, bit wounds, burn wounds |
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define a complicated SSTI
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deep skin infxn
or require surgery or occur in immuno comped pt's |
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class 1 SSTI
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afebrile, NOT cellulitis
outpt; tx with topical or roal abx |
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class 2 SSTI
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febrile w.o co-morbidities
IV therapy, short obs. or hosp-->then OPAT |
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class 3 SSTI
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toxic appearing or nontoxic + 1 or > comorbidity
hosp + IV abx therapy--->OPAT may need vascluar remediation |
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class 4 SSTI
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sepsis syndrome or life threatening
NECROTIZING FASCITIS hosp-> may need surgery |
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what accounts for majority of SSTIs
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stap areus + streptococcus pyogenes
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alpha strep are which 2 organisms
beta strep are |
viridans, and pneumonia
beta-GroupA-strep pyogenes |
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3 types of follicular infxn
mainly caused by what? |
folliculitis
furuncle carbuncle staph aureus |
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whats the presentation of folliculitis
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superficial w/ pus at epidermis
pruritic erythematous papules evolve into pustule |
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tx of folliculitis
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wrm saline compress
ropical clindamycin, erythrom, mupirocin, benzoyl peroxide for 2-4 x a day for 7 days |
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another name for furuncle
presentation of furuncle |
boil
walled off mass of purulent stuff extends into subq tissue discrete lesions, singular or multiple |
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tx of furuncle
drugs durations |
small- moist heat
large-incision and drainage extensive surrounding celllitis or fever- use abx: dicloxacillin or cephalexin PCN allergy-clindamycin tx for 5-10days |
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a stye is what type of infection
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its a folliculitis of the eye
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presentation of carbuncle
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deep and painful follicular masses
seen on back of neck seen with fecer, chills, malaise |
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tx of carbuncle
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moist heat
all require IND use systemic abx: cephalexin or diclox 5-10days |
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cutaneous abscesses
what organisms? presentation? |
polymicrobial or staph aureus
pus in dermis + deeper -surrounded by rim of erythematous swelling contain bacteria of normal skin flora |
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tx of cutaneous abscess
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drainage!!!-break up loculations
-may pack with gauze to close gram-stain, abx are RARELY used |
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using abx in abscesses are rarely used..except...
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multiple lesions
extensive surrounding cellulitis cutaneous gangrene high fever |
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common organism in erysipelas
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strep pyogenes
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erysipelas
aka europeans interchange with what? |
aka St. Anthony's fire-red color and burning pain
like cellulitis-but ery is more superfical-has demarcated raised margins |
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presenttion of erysipelas
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lower extremeties
fever, malaise BEFORE lesion streaking is common early diagnosis=excellent prognosis |
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tx of erysipelas
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mild to mod-pen G IM or Pen VK oral
severe-aqueous Pen G IV if staph- use diclox or cephalexin PCN allergy-clinda/erythromycin tx for 7-10 days |
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organisms in cellulitis
presentation |
strep pygoenes and stap aureus
acute, diffuse-does not have underlying foci skin looks like orange peel |
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presentation of cellulitis
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fever, tachycardia, leukocytosis- can appear before infxn
non elevated margins predisposing factors-obesity, edema, previous damage, IVDU->staph aureus |
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tx of cellulitis
mild to mod |
mild to mod w/o symptoms- step- oral PCN VK or IM
oral diclox or ceph tx for 5 days |
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cellulitis
severe illness tx |
tx for 10-14 days
PCN-ase resistant PCN OR 1st gen Ceph (nafcil, oxacillin or cefazolin) PCN allergy-clinda or vanco CA-MRSA- BACTRIM!!, clinda, doxy HA-MRSA-vanco VRE-linezo, dapto, tigecyclin, quinu/dalfopristin |
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impetigo
common organisms |
staph aureus + step pyogenes
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impetigo
common in? during? spreads how? |
usually on face, extremeties
in kids 2-5, during hot, humid weather minor trauma gives it entry-cuts spreads thru close contact |
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presentation of impetigo
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pruritis common
nonbollus-papules--> vesicles->pustules-> THICK crusts bollus- vesicles->yellow fluid filled bullae->can rupture leaving THIN brown crust like a lacquer |
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tx of impetigo
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symptomatic relief-soap and warm water to get crust off
PCN IM benzathing PCN-resistant PCN or 1st gen ceph augmentin topical-mupirocin oint TID x 7days |
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tx of MRSA in impetigo
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becoming more common
clinda, doxy, bactrim, mino, vano, linezo, dapto ran resolve by self tx 7-10 days |
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lymphangitis
common organism? what is it? |
strep pyogenes
inflam of lympathic channels-acute or chronic 2nd to puncture wounds, bisters |
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presentation of lymphangitis
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fever and chills before infxn
-leukocytosis common lesion with red linear streaks toward lymp nodes = acute infxn |
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tx of lymphangitis
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non drug tx-immobilization + elevation, warm water soaks q 2, 4 H
drug tx-PCN G IV x 72H, then PCN VK PO X 10 D PCN allergy-use clindamycin |
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Necrotizing Fasciitis
type1 |
after surgery or trauma
mix of anerobes and faculative bacteria ex-fournier gangrene 80% of necrotizing SSTIs |
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Necrotizing Fasciitis
type2 |
usually after minor trauma, called strep gangrene
90%-S pyogenes, 10% staph flesh eating bacteria -cause organ failure/shock |
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presentation of necrotizing fasciitis
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can be anywhere-mainly abdomen
predisposing factors-DM, trauma, infxn, surgery progresses to cutaneous gangrene w/o intervention |
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Necrotzing Fasciitis
type 3 aka |
clostridial myonecrosis
caused by clost. perfingens-gas gangrene advances over hours(quick) bronze skin->then purple->reddish blue |
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C. Myonecrosis
occur when? tx? |
after earthquake, surgery, trauma, IVDU
tx-supportive care (pressers), remove debris, give clinda + penicillin hyperberic 02 |
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tx of necrotizing infxn
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immediate and aggressive surgical debridement of ALL necrotic tissude
type2-give clinda + PCN |
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1st line abx for
mixed infxn-necrotizing infxn |
amp/sulb OR pip/tazo
+ clinda + cipro carbapenem cefotax + (metro or clinda) |
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1st line STREP necrotizing infxn
1st line STAPH necrotizing |
pencillin + clinda
nfacill, oxacill, vanco, or Clinda |
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Clostridium infxn tx
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clinda AND/OR PEN
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etiology of osteomyelitis
|
its uncommon
acute-several days chronic-months 3 classifcations- contiguous spread, hematogenous spread, peripheral vascular disease |
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hematogenous osteomyelitis
age site |
<1 yo in long bone
1-20 long bone >50 vertabrae involved |
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contiguous osteo
age site |
>50 yo mainly, seen in femur, tibia, mandible
RF- DM, trauma to spine, tattoos |
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vascular induffiencey
age site |
>50 yo in feet n toes
RF-DM, peripheral vascular disease |
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hematogenous osteomyelitis
what is sequestra? |
bloodstream infxn->bone infxn
disease of children sequestra=dead bone seperates from healthy bone cuz impaired blood flow |
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hematogenous osteomyelitis
organisms seen in: children? non-vaccinated immuno kids? IVDU- sickle cell anemia |
children-step aureus
immnocomped- H. flu type b IVDU-psuedomonas aeuroginosa, gram - sickle- salmonella |
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contiguous osteo
how does it enter? common in |
from outside body or spread of adjacent tissue
seen in >50 yo |
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organisms in osteomyelitis
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staph aureus most COMMON
epidermidis, streptococci gram - from puncture foot wounds + psudeomonas anaerobes |
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vascular insufficency osteo
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hard to manage
50-70 yo comorbidities-DM usually in toes, fingers multiple organisms |
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tx of osteomy
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get deep tissue cultures
drain, hardware removal-rifampin |
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tx of osteomyl
duration? what dose of abx? |
tx for 4-6 wks
high dose-infected bone hard to penetrate |
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diabetic foot infection
organisms seen? |
polymicrobial + staph or strep common
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3 types of foot infections
deep abscess |
minor trauma, infxn from nail or web space of toes
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3 types of foot infections
-cellulitis of dorsum |
routine care related
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3 types of foot infections
Mal perforans ulcers |
chronic ulcer on sole of foot
on thickend, hardened calluses |
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diabetic foot infections
cost? |
$200 to 350 million
check bottoms of foot-to avoid amputations |
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presenetation of diabetic foot infxn
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neuropathy, angiopathy, ischemia, immunoogic defects
pt seeks swelling relief >pain cause neuropathy-can't feel pain foul smelling=prescene of anerobes (culture anerobes + aerobes) |
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organisms of diabetic foot infxn
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gram neg-pseudomans
anerobes-peptostrep, bacteroides, clostridium gram + staph ,strep |
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tx of diabetic foot infxn
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IND
FQ + clinda or (metro + augmentin) MRSA-vanco, linezo, dapto, tigec |
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duration of tx for diabetic foot infxn
|
7 to14 days -mild to mod
2 to 4 wks- mod to severe 6 to 12 wks-osteomyelitis if 6 wks of vanco-monitor for thrombocytopenia + CBC |
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pressure sores
AKA |
decubitus ulcer or bed sore
seen in bony areas-ass, heel not always infectious |
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4 stages of pressure sores
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1- reversible, only epidermis
2-maybe revers. gets into subq fat 3-extends further into subq 4-deep fascia, both muscle and bone |
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tx of pressure sores
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prevention-rotate on bed
goal-clean + decontaminate |
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animal bite wounds
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polymicrobial
-pasteurella multocida dog bites most common (80%) |
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organism in cat bite
cats associated with what infxn type dogs> |
capnocytophaga
cats-osteomy, abscess dogs-crush injury |
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presentation of bite wounds
2 groups |
1-w/i 12H of injury-wound care + repair tear wounds
2->12H, local cellulitis, fever is uncommon |
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tx of animal bite wounds
outpt 1st line |
-augmentin
-doxy -PCN VK +Diclox mainly need irrigation if allergy: bactrim, FQ, Macrolide(kids and preg) |
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tx of animal bite wounds
inpt 1st line |
blctam/b-lactamase combo
2nd gen ceph w/ anerobe carbapenem mainly need irrigation |
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post exposure rabies tx
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irrigate with soap
vaccine 5 1ml inj on days 0, 3,7,14,28 hyperimmune globulin 40 IU/kg |
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how do you give the hyperimmune flobulin in rabies tx
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u infiltrate into and around wound!!*** rest give IM
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human bite wounds
like organism? |
eikenella, prevotella + **** tons of others
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tx of human bite wounds
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irrigate
augmentin commonly used for 3-5 days if allergy-bactrim or (FQ + CLINDA) or metro |
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what is NOT recc for human bite wound
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1st gen ceph, macrolide, clinda, or aminoglycoside
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if serious infxn for human bite wound use what
|
cefoxitin, amp/sulfbactam or ertapenem
for 7 to 14 days |
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surgical site infx (SSI)
3 categories |
usually w/i 30 days of surgery
1superficial incision- subq 2deep incision-fascia + muscle 3organ/space-any part of anatamoy |
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presentation of SSI
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fever after surgery NOT ssi related
may take 2 weeks to appear if within 48H-pyogenes or Clostridium |
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tx of SSI
|
prophylaxis- right drug, dose, dur, route
can resolve byself clean infxn + no intest or genital involvement-staph aureus and strept. common |
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normal CD4 count
VL count does what? |
500-1500 cells/m3
-determines when to start regimen VL measures HIV RNA in blood, + effectiveness of ART |
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cycle of HIV
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attaches to door
enters room reverses transcrip (undoes zipper) intergrates into host DNA(puts it in) viral transcript + transla (busts) assembly of virion + budding (pregers) |
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HIV diagnosis
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1 Elisa-screens for antibodies
-may be (- )so confirm with Western blot takes days 2western blot- confirm test done for all + elisa tests takes weeks |
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AIDS diagnosis
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posistive test for HIV (elisa +wb)
+ 1 or more: CD4<200 or <14% or + kaposi, candidas in espogeal, cryptococcus, TB, PCP, wasting, MAC |
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IF CD4 count is 1000 and post elisa + wb, and pt has TB- whats diagnosis?
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AIDS, EVERYONE HAS AIDS, AIDS, AIDS, AIDS, AIDS!
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4 STAGES of HIV infxn
exposure + initial infxn |
exposure to infxn- no symptoms, - ELISA
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4 STAGES of HIV infxn
acute retoviral sndrome |
1-4 wks after exp, flu like symptoms
high VL, low CD4 |
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4 STAGES of HIV infxn
clinical latency (steady state) |
6 wks after exposure
HIV has resrovoirs set up sero-con happened- +ELISA |
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4 STAGES of HIV infxn
clinically apparent |
AIDS symptoms may no occur for a decade later
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goals of ART
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extend life
reduce transmiss VL of <50 copies or undectable increase CD4 -no limit tx=prevention |
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when to start ART
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when CD4 <500 cells
or regardless of CD4: pregnant, HIV caused nephrotox, have hepB |
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risks vs benefirts of starting ART early
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risks-adverse effects, pill fatigue(burnout), develop resistance
benefit-increase survival, decrease transmiss, dec HIV secondary illnesses |
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ART should consist of how many drugs
|
3+....no monotherapy
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common HIV therapies
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2NRTIs + 1 NNRTI
2NRTIs + 1 PI (boosted) 2NRTIs + integrase inhib. |
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what is preferred Non nuke regimen for tx Naive pt
|
Atripla
EFV + TDF + FTC |
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PI based reigmen for tx niave pt
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reyataz+norvir+truvada
or prezista+norvir+truvada |
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3 tests to determine info about HIV virus
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VL
genotype + phenotype |
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impt lab test for HIV pt
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liver, kidney, lipid panel and glucose
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tests to determine best regimen for each pt
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tropism for maraviroc
HLA-B for abacavir |
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CD4 + VL monitoring
|
at diagnosis,
q 3 to 6 months for untreated pt -start of tx or switching, + 2-8 wks after starting then q 3 months |
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spontaneous resistance mutation
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HIV copies lots, n can have errors- offspring can be diff from parent- ART no longer as effective
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transmitted resistantance mutation
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is about 3-27% in N America
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resistance testing
genotype when is it indicated |
compares genest to wild types of HIV
results in 1-2 wks indicated at baseline + if tx failiing |
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resistance testing
phenotype when is it indicated |
measures ability of virus to grow in prescence of ARV
2-4 wks more exp indicated to do with genotype if resistance suspected |
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when is resistance testings reccommended?
note reccomended |
rec- if virologic failure during ART
not rec-after discont. drug >4wks -resistant virus can't be seen cause its not being provoked by the drug not rec-if VL <500 |
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types of ART failure
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virologic failure-unable to suppress viral repl.
immuno failure- failed to have enough CD4 response clinical progress- recurrence of HIV related events after 3 months of ART |
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when should u do resistance test
|
while on failing regimen or at least within 4 wks of D/C
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tips for changing ART if regiemn is failing
|
don't change just 1 drug or add 1 drug-change whole damn thing
try new class -Integ Inhib, entry inhib-less resistance never stop all ART-increase mortality |
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NRTIs class effex
|
few drug interactions
they r renally eliminated-nephrotox N/V/D-short term mitochondrial tox-long term |
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Nuke drugs
|
stavudine
zidovudine lamivudine emtricitabine abacavir didasonine tenofovir |
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whats analog of stavudine
|
zidovudine
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whats along of lamivudine
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emtricitabine
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along of didanosine
|
tenofovir-but is nucleoTIDE
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stavudine
whats brand name? abbrev |
Zerit
d4T |
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zidovudine
brand name? abbrev? |
Retrovir
AZT, ZDV |
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lamivudine
brand name? abbrev? |
Epivir
3TC |
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emtricitabine
brand name? abbrev? |
Emtriva
FTC |
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abacavir
brand name? abbrev? |
Ziagen
ABC |
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DIDANOSINE
brand name? abbrev? |
videx
ddl |
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tenofovir
brand name? abbrev? |
Viread
TDF |
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Epzicom
whats in it? |
ABC/3TC
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Truvada
whats in it |
TDF/FTC
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Combivir
whats in it |
AZT/3TC
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Trizivir
whats in it |
AZT/3TC/ABC
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Atripla
whats in it |
TDF/FTC/EFV
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Complera
whats in it |
TDF/FTC/RPV
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ALL NRTIs have this BBW
|
lactic acidosis and steatosis(hepatotox)
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if taking combo med with nukes and CrCL of <50 do what?
|
cant take combo...give individual drugs and adjust dose
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what 2 nukes have overlapping toxicities
|
stavudine + didanosine
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Tenofovir
pros, cons, + counseling |
1st line ART
covers HepB causes renal insuff-monito SCr CrCl must stay hydrated |
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lamivudine
pros, cons, + counseling |
coverss HepB
minimal toxicity need to renally dose |
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emtricitabine
pros, cons, + counseling |
its Epivir(3TC) + Florine
covers HepB causes hyperpigmentation of palms + soles renally dose |
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abacavir
pros, cons, + counseling |
alternative ART
BBW-hypersensitivity react.-use HLA B to make sure pt is negative before starting increases risk of MI |
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HLA-B screening
|
should be done before starting abacavir
if + must be documented as true allergy DO NOT RECHALLENGE mainly in whites (FML) |
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zidovudine
pros, cons, + counseling |
used in pregnancy, + peds
not preferred as alt BBW-liver tox causes anemia, monitor CBC 36%Nausea |
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didanosine
pros, cons, + counseling |
used in peds
TK ON EMPTY STOMACH S.E.-pancreatisis, peripheral neuropathy |
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stavudine
pros, cons, + counseling |
NO food restrictions
BBW-pancreatitis + peripheral neuropathy (mito tox) |
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NNRTIs class effex
|
adv-less metabolic tox than PI
no renal adjustments needed causes rash, hepato-tox, and high resistance |
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which NRTIs cover hepB
|
tenofovir, lamivudine, emtricitabine
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nonnuke drugs
|
efavirenz
rilpivirine nevirapine etravirine |
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efavirenz
brand name? abbrev? comment? |
Sustiva
EFV teratogen, CNS SE |
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Rilpivirine
brand name? abbrev? comment? |
Edurant
RPV needs acidic environment-PPI C/I |
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Nevirapine
brand name? abbrev? comment bout it? |
Viramune
NVP dose esclation to avoid rash + hepta tox |
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Etravirine
brand name? abbrev? comment? |
Intelence
ETR 2nd gen nonnuke-active against resistant virus |
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Efavirenz
pros,cons, pt counseling |
preferred ART-QD regimen
neuropschiatric-wierd dreams, drowisness teratogenic Cat D(1st trimester) tk at BEDTIME, w/o FOOD use contraception |
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Rilpivirine
pros,cons, pt counseling |
QD regimen
alt. therapy tk WITH food(high calorie) don't give to pt's with VL >100,000 avoid PPI's..seperate H2 and antacids |
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Nevirapine
pros,cons, pt counseling |
has XR form
BBW-SJS, hepato tox don't give to women w/ >250CD4 or men w/ >400 CD4 cuz rash tk 1 qd x 2 wks, then BID -if rash in 1st 2 weeks, don't increase |
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Etravirine
pros,cons, pt counseling |
2nd gen NNRTIs
for tx experienced only tk WITH food drug interactions with PI |
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|
PI Class Effex
|
highly resistant to resistance ha
no renal adjustment lots of DIARRHEA!!! metabolic prob-CV/MI |
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Ritonavir
pros,cons, pt counseling brand name, abbrev? |
Norvir, RTV
only to boost PI conc. many interactions tabs-heat stable, caps-need fridge |
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Ritonovir does what
|
inhibits metab
eases pill burden of PIs increase AUC, decreases variablity in through |
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Ritonovir
don't boost this med with ritonovir? already comes boosted? |
nelfinavir
kaletra alrady boosted |
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ritonovir boosting helps?
is required in which drugs? |
helps indinavir(TID to BID)
atazanavir, fosamprenavir required: STD-saquinavir, tipranavir, darunavir |
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atazanavir
pros,cons, pt counseling brand name, abbrev |
most lipid friendly PI
Qd dosing causes hyperbilirubinemia + scleral icterus tk with food, avoid antacids,PPIs, H2RA Reyataz, ATV |
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Darunavir
pros,cons, pt counseling brand, abrrev |
good for resistant virus
pt naive or exp QD liver toxic must give with Ritonovir Sulfa allergy DRV, Prezista |
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Fosamprenavir
pros,cons, pt counseling brand? abbrev? |
skin rash
sulfa allergy Lexiva, FPV |
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Kaletra
pros,cons, pt counseling gen name, abrev |
QD or its BID if resistance
Diarrhea(50%) GI problems Lopinavir/ ritonavir (LPV/r) |
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Saquinavir
pros,cons, pt counseling brand name, abbrev? |
use with caution
PR + QT interval prolong. TK WITH food(w/i 2 H of food) Invirase, SQV |
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Indinavir
pros,cons, pt counseling brand name? abrev? |
NO PROS
nephrolithiasis(kid stones) hyperbillirubinemia drink > 2L fluid/day cuases metalic taste Crixivan IDV |
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Nelfinavir
pros,cons, pt counseling BRAND? abbrev? |
only PI never boosted
use in preg, kids mad Diarrhea!! give with loperamide tk with fat ml to incr. absp. Viracept, NFV |
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Tipranavir
pros,cons, pt counseling brand? abbrev? |
only for exp pt-active for resistant virus
BBW-intracranial hemm. hepatotox!! sulfa allergy refig caps prior to opening Aptivus, TPV |
|
|
WHICH drugs have sulfa allergy
|
darunavir
fosamprenavir tipranavir |
|
|
2 Entry inhibitor drugs
|
selzentry- maraviroc
Fuzeon-enfuvirtide |
|
|
Maraviroc
pros,cons, pt counseling brand |
CCR5 antag
must do tropism test to see if virus is R5 BBW-hepato tox, rash MVC, Selzentry |
|
|
when should you obtain topism test
|
prio to MVC to confirm r5
and when virologic failure on MVC tropism assasy determines isolate-r5, x4, or mixed |
|
|
enfuvirtide
abbrev, brand name? MOA SE |
inhibits gp41 fusion
no renal/hep adjustments SQ injection salvage therapy causes painful nodules ENF, Fuzeon T20 or ENF |
|
|
Raltegravir
pros,cons, pt counseling Brand, abbrev? |
preferred inital tx-integrase inhib.
no p450 interaction no BBW easily cause resistance rhabdo reported Isentress RAL |
|
|
entery inhibitor interaction potentials
enfuvirtide maraviroc |
enfuvirtide-green- no interactions
maraviroc-yellow-med interaction-metab by 3A4 |
|
|
integrase inhib interaction
|
raltegravir-yellow
metab by UGT1A1 |
|
|
Interactions
Nukes- Nonnukes- |
Nukes-yellow
nonnukes-red- mainly induce |
|
|
nonnukes: most induce except-
|
efavirenz-inducer/inhibitor
rilpivirine- 450 substrate etravirine-inducer/inhibitor |
|
|
Interactions
PI |
mainly inhibit metab
RTV is worst SQV is least |
|
|
Antiretrovirals interact with
|
antacids
statins rifamycin macrolides PIs and ARVs |
|
|
which drug is contraindicated with PPIs
|
Rilpivirine
|
|
|
if taking atazanavir with PPI what are directions
|
ataz must be boosted with ritonavir
only for tx niave pt's if pt is exper. this combo is CONTRAINDICATED |
|
|
PI + statin interaction
|
PI increases stating levels
-avoid simva, lova, pitavastatin atorvastatin, prava are safest |
|
|
NNRTI + statin interaction
|
NNRTI can decrease statin levels
|
|
|
PI + Rifampin interaction
|
Rifampin will dec PI by 75%
AVOID!! |
|
|
NNRTI + Ridampin interaction
|
decreases EFV AUC by 25%
|
|
|
maravirox + Rifampin interaction
|
avoid, combo not reccommended
|
|
|
rifabutin + NNRTIs
|
its a weaker inducer-prolly safer
decreases Rilprivine AUC by 45%- AVOID |
|
|
macrolide interactions
|
inhibitors
eryth>clarith>azith if maraviroc+clarith- dec mara dose to 150 azithromycin is preferred, no interactions with ART |
|
|
ETR can be safely given with which PIs
|
only*
Lopinavir/Ritonovir Saquinavir/R Darunavir/R |
|
|
Maraviroc has how many doses?
|
3
half dose-if given with inhib (PI) standard-if with nukes double dose-if with inducers(nonnukes) |
|
|
MVC should be halved with PIs except which one
|
tipranavir/ritonavir
|
|
|
whats first sign of advanced AIDS
define it |
wasting- involuntary weight loss of 10%
correlates with death |
|
|
what metabolic disorders are associated with ART
|
insulin resistance, high fasting glucose
increase in triglycerides, Tchol, LDL |
|
|
what morphological probs are seen with ART
|
lipodystrophy-fat loss(lipoatrophy) in face, ass, arms
lipohypertophy-buffalo hump, breast enlargement, fat stomach |
|
|
glucose metabolism probs seen in what drugs
monitor glucose how often |
PIs, d4T, AZT
at baseline, then 3-6 months, tx like DM2 |
|
|
what to monitor if pt is wasting
|
CD4, VL
Testosterone level annually depression assessment check food intake |
|
|
non-pharmacy tx for wasting
|
manage concurrent diseases
-diarrhea, depression(anorexia) nutritonal counseling |
|
|
interventions for wasting
ARV |
tx underlying HIV
doesn't lead to wt gain, but minimizes wasting |
|
|
interventions for wasting
appetite stimulants-megace |
FDA approved HIV tx for wasting
suspension weight gain is fat, $$$ |
|
|
interventions for wasting
appetite stimulants-periactin |
cyproheptadine
stimulates appetite, cheaper FDA approved antihistamin- not appeptite stim not recc of HIV wasting |
|
|
interventions for wasting
appetite stim- marinol |
dornabinol
approved in AIDS app stim. wt doesn't incr consistently |
|
|
interventions for wasting
protein anabolic agents |
serostim HGH- approved for HIV, increases wt + decr. fat
SQ inj. $$$ once D/Ced lose wt |
|
|
interventions for wasting
anabolic steroids |
testosterone
not FDA approved may increase CV risk |
|
|
risk of lipid probs seen in which drugs
|
LPV, EFV, D4T
monitor fasting, 2-8 wks, then q 6 months use ATP3 guidelines- avoid simva, lova, pitavstatin with PIs |
|
|
lipohypertophy
which drugs have higher risk |
PI or NNRTI with d4T or AZT
dorsocervical fat pad-buffalo hump |
|
|
lipoartrophy
seen in what drugs |
NRTI...d4T
thinning of extremeties-with venous guttering |
|
|
switching ARV will it help progression of morphologic changes?
|
it will slow/halt progession but NOT fully reverse
sculptra-fillers for facial atrophy |
|
|
NNRTI class SE
|
Rash AND hepato tox
but efavirenz has this + CNS if mild to mod rash-tx through with antihistamine |
|
|
whats the mech of NRTI mitochondrial tox
|
inhibit DNA polymerase gamma- enzyme required for synt of mitochondrial DNA
TDF is least risky |
|
|
which NRTI has BMD effects
|
TDF + d4T
|
|
|
which NRTI has GI problems
|
AZT, ddl
|
|
|
how to tx
GI effects with NRTIs |
self limiting
if N-tk with small snacks use ginger or anitemetics D-use antimotility |
|
|
Abacavir and MI consensus
|
there is none
use in caution in those with strong CV factors avoid if pt has high risk |
|
|
TDF SE
|
osteopenia + osteoporosis
screen with DEXA nephrotoxic- presents as fanconi syndrome hydrate, if proteinura usually reversible |
|
|
abacavir hypersenstivity reaction
must have how many symptoms |
2
rash fever or N/V, D cough, weak |
|
|
which PI has high risk of diarrhea
|
nelfinavir- give with loperamide
also lopinavir |
|
|
which 2 PIs increase billirubin levels
|
atazanavir
indinavir |
|
|
how long do PIs GI intol effects last
|
transient..usually 1st few doses
|
|
|
enfuvirtide
injection directins |
do at room temp, in fatty sq area, massage after to decrease nodule formation
|
|
|
if OI within 12 wks of starting ART do what?
|
start OI tx
continue ART |
|
|
if OI occurs when virlogic failure, do what?
|
start OI
but do ARV resistance testing |
|
|
whats most common OI in AIDS pts
|
PJP (jiroveci)...used to be called PCP
occurs in 70-80% of AIDS pt |
|
|
symptoms of PJP
|
NONPRODUCTIVE cough
SOB hypoxemia |
|
|
gold standard for diagnosising PJP
|
bronchoalveolar lavage (BAL)
LABS- cd4<200 |
|
|
what to start primary prophylaxis for PJP
when to stop |
if CD4<200, OR oropharyngeal candidiasis
stop if cd4>200 for at least 3 months...restart if goes lower again |
|
|
whats DOC and alt for prophylaxis tx of PJP
|
Bactrim (TMP/SMX) 1DS daily
or 1SS daily alt- dapsone, aerosolized pentamidine, atovaquone |
|
|
whats DOC for acute tx of PJP (PCP) and how long
|
21 days!
IV bactrim for severe PO for mild-mod |
|
|
whats alt drugs for acute tx of PCP
severe? mild to mod? |
still 21days!
severe- Pentamidine, primaquine+clindamycin mild-primaquine+clindamycin, atovquone |
|
|
whats an adjunct to PCP tx
|
prednisone or IV methylprednisone
give within 72H of starting PCP tx ONLY if severe |
|
|
common ADR with bactrim
|
SJS
|
|
|
whats the tx for secondary prophylaxis of PCP
when do you disonctinue? |
same as primary
can stop if: cd4>200 at least 3 months AND sustained VL AND on ART |
|
|
IF CD4>200 and get PCP
do what? |
****** is taking meds LIFELONG
|
|
|
whats the clinical presentation of toxoplasmosis
yes we know-gandi cat tacos |
focal encephalitits-confusion, motor weakness
if untx-seizure, coma, stupor |
|
|
if pt has Toxoplasmosis whats the MRI gonna show
|
a ring enhanced lesion in brain-GIANT CIRCLES OF DEATH!
|
|
|
when to start primary prophylaxis for TE(toxoplasmosis)
|
+ anti-toxoplasma IgG
AND CD4 <100-need both to tx stop if cd4>200 at least 3 months |
|
|
whats DOC for primary prophylaxis of TE
alt? |
TMP/DMS 1DS daily
alt- bactrim 3x/wk -dapsone+pyrimeth+leuco |
|
|
preferred tx of acute TE
|
for 6 weeks
pyrimeth+sulfadiazine+leuco |
|
|
alt tx of acute TE
|
pyrimeth+leuco+clindamycin x 6 weeks
|
|
|
when to start secondary prophylaxis of TE
|
once pt completes intital tx
second. proph lifelong unless- CD4>200 for at least 6 month+ pt is asymptomatic w/ sustained Viral suppress. |
|
|
what drugs to use for secondary prophylaxis of TE
|
same as primary
pyrimeth+leuco+sulfadiazine |
|
|
presentation of MAC
not receiving ARV |
multi-organ infxn
night sweats, abdominal pain |
|
|
presentation of MAC
receiving ARV |
localized
pneumonitis abscess ulcers CNS infection |
|
|
abnormal labs for MAC pts receiving ARV
|
anemia, neutropenia, increased alk phosphate
enlarged spleen, liver, + lymphadenopathy |
|
|
when to start primary prophylaxis for MAC
when stop? |
CD4<50
stop if cd4>100 for at least 3 months |
|
|
DOC for primary prophylaxis for MAC
alt? |
azithromycin 1200mg/wk
or azithromycin 600 2/wk or clarithro alt- rifabutin (adjust ART) |
|
|
Acute tx of MAC
|
clarithromycin + ethambutol
alt- azithro + ethambutol azithro + ethambutol + rifabutin TX FOR AT LEAST 12 MONTHS!! |
|
|
when to do secondary prophy for MAC
can D.C when |
its lifelong maint. tx unless IRIS on ART
D/C- if >12 month tx completed +asymptomatic+ cd4>100 for 6months on ARV tx-same as primary |
|
|
latent TB shows as-
active TB shows as |
latent-asymptomatic
active- varies on degree of immunosupp |
|
|
pumlonary TB presentatins
|
cd4 >350 (200-350 also)
upper lobe-nodular,patchy infiltrates frank hemolysis, night sweats |
|
|
diagnostic tests for TB
|
TST- + if >5mm at 48-72H
false negatives-in adv. immunosupp. so look at clinical presentation also |
|
|
who should be tested for TB
how to rule out active TB? |
all HIV pts
if + TST test- use Chest radiography + evaluation to rule out active TB |
|
|
Latent TB tx when?
|
if +LTB and no hx of tx for active or latent TB
-TB but close to ppl w TB |
|
|
primarty tx for latent TB
|
isoniazid x 9 months DOT
IF resistant- rifampin x 4 months INH+rifapentine x 12 wks |
