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96 Cards in this Set

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What patients are more susceptible to nosocomial pneumonias?
• abdominal surgery
• elderly
• thoracic surgery
What is the definition of community-aquired pneumonia (CAP)?
• acute infection of pulmonary parenchyma
• presence of acute infiltrate on chest X-ray or auscultory findings
• patient is not hospital prior to presentation
• patient can be in a long-term facility less than 14 days
What are symptoms of community-aquired pneumonia?
• chest discomfort
• cough (with or without sputum)
• fatigue
• fevers
• rigors
• SOB
• sweats

* must have two of the above
What are factors that can predict a complicated course of CAP?
• age > 65 y/o
• AMS
• bacteremia
• chronic disease (CHF, DM, lung, liver, & kidney disease)
• high fever
• immunosuppressed
• multilobe involvement or pleural effusions
What are organisms that can cause CAP?
• Unidentifiable 40-60%)
• M. Pneumonia (13-35%)
• S. Pneumonia (9-20%)
• H. Flu (3-10%)
• C. Pneumonia (1-17%)
• Legionella (0.7-12%
What is the definition of nosocomial pneumonia?
• infection of the lung developing more than 48 hrs after hospitalization
• accompanied by a physical exam showing rales, dullness to percussion, or an infiltrate on X-ray
What clinical findings are required for a diagnosis of nosocomial pneumonia?
• histopatholofic evidence of pneumonia
• isolation of pathogen from culture
• isolation of a virus in respiratory secretions
• purulent sputum

* must have at least one of the above
What are risk factors for nosocomial pneumonia?
• age
• COPD
• decreased consciousness
• ICU
• immunosuppression
• intubation
• nasogastric tubes
• prior antiobiotic therapy
• severity of underlying disease
• surgical procedures
What are microorganisms that can cause nosocomial pneumonia?
• unidentifiable (50%)
• S. aureus (10%)
• Pseudomonas (8%)
• Enterobacter (5%)
• Klebsiella (4%)
• Candida (3%)
• Acinetobacter (2%)
What is the duration of therapy for CAP?
5-14 days
What is the empiric treatment for healthy non-hospitalized patients suspected of having CAP?
• Macrolide (Azithromycin) or Doxycycline (with no recent antibiotic use)
OR
• Fluoroquinoline or Macrolide w/ high dose PCN, like Augmentin (with recent antibiotic use)

* macrolide covers the atypical bacteria
What is the empiric treatment of a patient with comorbidity (ex. DM, CHF) and suspected of having CAP?
• Macrolide or Fluoroquinoline (no recent antibiotic)
OR
• Fluoroquinolone or macrolide w/ 2nd gen. cephalosporin (Ceftin, Cefuraxime)
What is the empiric treatment of non-hospitalized patients with suspected aspiration?
• Augmentin
• Clindamycin
What is the empiric treatment for hospitalized patients with CAP?
• fluroquinolone (Levaquin 750 mg x 3 days) OR
• macrolide with 3rd gen cephalosporin (Azithromycin & Rocephin)
What is the difference in bioavailability of Levaquin IV and Levaquin PO?
both formulations have bioavailability of 99.9%
What is the empiric treatment for hospitalized patients with severe pneumonia?
• Zosyn (Pipercillin/Tazobactam) OR
• 3rd gen cephalosporin + fluoroquinolone or macrolide
What is the empiric treatment for a patient with nosocomial pneumonia with no risk factors?
• Ticarcillin or Piperacillin
• 3rd gen. Cephalosporin
• Fluoroquinolones
What is the empiric treatment for a patient with nosocomial pneumonia with aspiration or recent surgery?
• Ticarcillin or piperacillin
• 3rd gen. cephalosporin + clindamycin
• fluoroquinolone plus clindamycin

* clindamycin covers anaerobes
What is the empiric treatment of a nosocomial pneumonia that you suspect to be caused by pseudomonas?
• (Ticarcillin or pipercillin) + (aminoglycoside or fluoroquinolone)
• (Ceftazidime or Cefepime) + (aminoglycoside or fluroquinolone)
What is the empiric treatment for a nosocomial pneumonia that you suspect to be cause by MRSA?
Vancomycin or linezolid
Describe the difference between the flu and a cold, regarding onset
• Flu: onset is sudden
• Cold: onset is gradual
Describe the difference in the flu and a cold, regarding fever.
• Flu: fevers can be high
• Cold: fevers are rare
Describe the difference between the flu and a cold, regarding cough.
• flu: cough is dry
• cold: cough is hacking
Describe the difference between the flu and a cold, regarding headache
• flu: headaches are common
• cold: headaches are rare
Describe the difference between the flu and a cold, regarding weakness
• flu: weakness can last 2-3 weeks
• cold: weakness is rare
Describe the difference between the flu and a cold, regarding chest discomfort.
• flu: chest discomfort is common
• cold: mild to moderate chest discomfort
Describe the difference between the flu and a cold, regarding stuffy nose.
• flu: can sometimes have a stuffy nose
• cold: stuffy nose is common
Describe the difference between the flu and a cold, regarding sore throat.
• flu: can sometimes have a sore throat
• cold: sore throat is common
List 3 drugs that can be used for flu proophylaxis
• Amantadine
• Rimantadine
• Oseltamivir (Tamiflu)
What type of drug is Oseltamivir (Tamiflu)? What is its dosage?
• Oseltamivir (Tamiflu) is a neuramidase inhibitor
• Dosage: 75 mg po daily within 2 days of symptoms
What is the MOA of Amantadine and Rimantadine?
inhibits viral uncoating and release of viral nucleic acid
Amantadine is effective against which strain of the influenza virus?
influenza A
When is Amantadine or Rimantadine given to prevent the development of flu symptoms?
• given as prophylaxis during presumed outbreak OR
• within 1-2 days of symptoms
What can given to a patient to prevent or reduce the symptoms of pneumonia?
• pneumococcal vaccine (23 purified capsular polysaccharide antigens of S. pneumoniae)
• antibodies remain elevated for 5 years
What patients are recommended to get the pneumococcal vaccine?
• alcoholics
• age > 65
• Cardiac disease
• Chronic lung disease
• COPD
• DM
• patients with funcitional or anatomic asplenia
• patient living in special settings (orphanage, jail, ALF)
• smokers
What people should be offered the influenza vaccine?
• person at high-risk for influenza-related complications (age > 50, comorbidities, COPD, nursing home residents, pregnant women in 2nd or 3rd trimester during flu season)

• person who can transmit influenza to those at high risk (ex. health-care workers)

• AIDS patients
What are organisms that can cause community-aquired UTI?
• E. Coli (73%)
• S. Saprohyticus (13%)
• P. Mirabilis (5%)
• K. Pneumoniae (4%)
• Enterococcus (2%)
What are organisms that can cause nosocomial UTI?
• E. coli (31%)
• Fungal (14%): usually in patients with indwelling catheters or immunosuppresion)
• Pseudomonas (10%): usually in patients with chronic catheters
• Gram-negative bacilli (10%)
• K. Pneumoniae (9%)
• S. Aureus (6%)
• Proteus (4%)
• Enterococcus (2%)
What are predisposing factors for UTI?
• age
• DM
• females
• immunosuppresion
• pregnancy
• renal disease
• Urinary obstruction
What are signs and symptoms of a lower UTI (cystitis)?
• Dysuria
• Foul-smelling urine
• Frequent urination
• Occasional hematuria
• Urgency
What are signs and symtpoms of an upper UTI (pyelonephritis)?
• CVA tenderness
• dysuria
• fevers and chills
• frequency w/ urination
• hematuria
• increased WBC
• nausea/vomiting
What patients are considered high-risk for complicated UTI?
• DM
• elderly (more prone to AMS due to elevated ammonia levels)
• hospital-acquired
• immunosuppression
• indwelling catheter
• males
• pregnancy
How do you treat hyperammoniumemia?
lactulose
What do you look for in the urinalysis when diagnosing UTI?
• casts (in pyelonephritis)
• cloudiness of the urine
• leukocyte esterase
• nitrates
• RBCs
• yeasts
What is the treatment of uncomplicated cystitis?
3 day regimens of:
• Bactrim
• Fluoroquiolones
• Nitrofurantin
When is single dose therapy recommended for UTI?
honeymoon cystitis
What is the dosing of Bactrim?
Bactrim DS (double strength) Q24 x 3 days
Describe the treatment for recurrent cystitis
• treatment is longer: 2-6 weeks
• Less than 2 UTI/year, give 3 day regimens
• greater than 3 UTI/year or post-intercourse: prophylax with Bactrim or Nitrofurantoin
Describe the treatment for uncomplicated pyelonephritis
• patient has no nausea/vomiting and is not immunocompromised
• treatment: 7-14 days of Bactrim or Fluoroquinolone
Describe the treatment for complicated pyelonephritis
fluoroquinolone or extended spectrum beta-lactam (Augmentin or Unasyn) for 10-14 days
Describe the treatment for a patient with pyelonephritis and a catheter
TX: 7-10 days of treatment if symptomatic
What type of bacteria usually causes prostatitis?
gram-negative bacteria
Describe the treatment for acute prostatitis
• 4 weeks of treatment
• Bactrim, Cephalosporin, or Fluoroquinolone
• usually: Levaquin 500 mg QD x 4 weeks
Describe the treatment for chronic bacterial prostatitis
• difficult to treat
• Bactrim or fluoroquinolone for 1-4 months
What is the definition of cellulitis?
an acute spreading skin infection which involves subcutaneous tissue but excludes muscle
What organisms exists as the normal flora on the skin?
• Streptococcus
• S. epidermis
• S. aureus
• yeasts
What are the 3 main types of cellulitis?
• acute cellulits
• Erysipelas
• necrotizing fascitis
What are characteristics of acute cellulits?
• involves deep dermis and subcutaneous tissue
• non-elevated, poorly defined
• warm, pain, edema, tender
• can have malaise, fever, & chills
What is the treatment of acute cellulitis?
treatment usually 7-10 days:

• anti-staphylococcal PCN (Nafcillin, oxacillin, or Dicloxacillin) or 1st generation cephalosporin (Cephazolin/Ancef)
• Penicillin G (if streptococcal)
• Vancomycin (for MRSA); Linezolid for discharge
What are characterisitcs of erysipelas?
• infects the superficial dermis
• spreads rapidly
• edge of infection is elevated and sharply demarcated
What areas of the body are most commonly affected with erysipelas?
occurs most commonly in legs and feet
What is the most common cause of erysipelas?
group A streptococcus
What is the treatment for erysipelas?
Tx: 7-10 days

• Pencillin G or erythromycin
What are characteristics of necrotizing fasciitis?
• an acute necrosis involving sub-q and superficial fascia
• associated w/ gangrene
• seen in diabetics
• commonly caused by Strep pyogenes
What is the treatment for necrotizing fasciitis?
• Tx: surgical debridment (antibiotics are not curative)
• empiric treatment: B-lactamase inhibitor (Augmentin or Unasyn) OR 3rd gen ceph. + clindamycin

* Clindamycin to cover anaerobes
What is a major cause of diabetic foot ulcers?
neuropathy
What are some organisms that can cause diabetic foot ulcers?
• B. Frag
• E. Coli
• Enterobacter
• Enterococcus
• Klebsiella
• Peptococcus
• Proteus
• Psuedomonas
• S. aureus
• Streptococcus
What is the treatment for diabetic foot ulcers?
• for shallow, non-threatening food ulcers: can treat as cellulitis

• deep ulcers: broad spectrum; 1-2 weeks if skin/soft tissue; 6-12 weeks if osteomyelitis
• ampicillin/sulfabactam (Unasyn)
• Ticarcillin/Clavulanic (Timentin)
• Pipercillin/Tazobactam (Zosyn)
• fluoroquinolone + Clindamycin
What are characterisitcs of osteomyelitis?
• infection of bone w/ subsequent bone destruction
• clinical presentation: fevers/chills, localized pain
• labs show: elevated WBC, ESR, & C-reactive protein
• diagnosed by: CT/MRI & bone scans
What is the treatment for an adult w/ osteomyelitis?
• Nafcillin or Cefazolin or Vancomycin
• Acute osteo: 4-6 weeks
• Chronic osteo: 6-8 weeks
What is the treatment for a patient with a prosthetic joint infection?
• Nafcillin + Rifampin OR
• Vancomycin + Rifampin

* Rifampin allows for higher level to penetrate the bone
What are some bacterial causes of meningitis in newborns?
• E. coli
• Enterobacter
• Herpes Simplex (type 2)
• Klebsiella
• Listeria
• S. agalactaie

* bacteria come from the birth canal
What are some bacterial causes of meningitis in a 1-2 month old?
• E. coli
• H. Flu
• N. meningitidis
• S. agalactaie
• S. pneumoniae
What are some causes of meningitis in patients ages 2-50?
• N. meningitidis
• S. pneumoniae
• viruses
What are some causes of meningitis in patients older than 50?
• gram-negative bacilli
• N. meningitidis
• S. pneumoniae
What are risk factors for meningitis?
• alcoholism
• CNS shunts
• fistulas
• head trauma
• immunosuppresion
• local infections
• sickle cell disease
How do patients with meningitis clinically present?
• backache
• fevers & chills
• headache
• nuchal rigidity
• petechiae/purpura (esp. in N. meningitidis)
How do you diagnose meningitis?
• history and physical
• lumbar puncture (looking for WBC, protein, & lactic acid)
• gram stain, acid fast stain, or India ink test (for cryptococcus)

* get CT scan before performing LP
What is empiric treatment of meningitis for neonates?
• Ampicillin + aminoglyocide OR
• Ceftriaxone
What is empiric treatment for meningitis in a 1-23 month y/o?
3rd gen. cephalosporin (Ceftriaxone) + Vancomycin
What is empiric treatment for a 2-50 year-old patient with meningitis?
3rd gen. cephalosporin (Ceftriaxone) + Vancomycin
What is empiric treatment for a patient with meninigitis age 50 or over?
3rd gen. cephalosporin (Ceftriaxone) + Ampicillin + Vancomycin
What is empiric treatment for a patient with meningitis due to either penetrating head trauma, post neurosurgery, or CSF shunt?
Vancomycin + (Cefipime or Ceftazadime)
What is the treatment of meningitis caused by S. pneumoniae?
• Pen G 4 mu Q4hrs OR
• Ampicillin 2gm Q 4hrs
What is the treatment for meningitis caused by N. meningitidis?
• 3rd gen. cephalosporin (Ceftriaxone) OR
• fluoroquinolone
What is the treatment for meningitis caused by H. Flu?
• if Beta-lactamase negative: Ampicillin
• if Beta-lactamase positive: 3rd gen. cephalosporin (Ceftriaxone) or Cefipime
What is the treatment for meningitis caused by S. agalactiae?
• Pen G 4mu Q4hrs OR
• Ampicillin 2gm Q4hrs
What is the treatment for meningitis caused by Listeria?
• Pen G 4mu Q4hrs OR
• Ampicillin 2 gm Q4hrs
What is endocarditis?
• infection of heart valves or other tissue
• platelets-fibrin complex becomes infected with organisms, causing vegetation
What are major risk factors for endocarditis?
• IV drug abuse
• mitral valve prolapse
• prosthetic valves
What are signs and symptoms of endocarditis?
• anorexia
• arthralgias
• cardiac murmur
• fatigue
• low-grade fever
• myalgias
• weight loss
What are some significant lab findings in a patient with endocarditis?
• CBC shows leukocytosis
• elevated ESR & C-reactive protein
• positive blood culture
What are complications of endocarditis?
• aneurysm
• CHF
• emboli
What are organisms that can cause endocarditis?
• Steptococci (50%)
• Staph aureus (25%)
• Enterococci (8%)
• Coag-negative Staph (7%)
• gram-negative bacilli (6%)
• Candida Albicans (2%)
What is the standard drug and dose used endocarditis prophylaxis for dental procedures?
• Amoxicillin 2 gm (in adults)
• Amoxicillin 50 mg/kg PO 1hr before procedure (in children)
What drugs are used for endocarditis prophylaxis for high-risk patients undergoing abdominal surgery?
• Ampicillin 2 gm IM or IV + Gentamycin 1.5 mg/kg within 30 minutes of starting the procedure
• 6hrs later: Ampicillin 1 gm IM/IV