Therapeutics Winter Test 1

Front 1

Colic

Back 1

intense, inconsolable crying in healthy infant

during first 3 months of life
for 3 hours or more per day
on 3 or more days per week

Front 2

Possible causes of Colic

Back 2

1) abdominal pain/discomfort or gassiness
2) hunger
3) lactose intolerance
4) GERD
5) slowed developmental abilities
6) immature nervous system **

Front 3

Clinical Presentation of colic

Back 3

1) CRYING

peak at 6 weeks of age, decrease gradually around 3 months of age

Front 4

Pharmacological Treatment of Colic

Back 4

NONE

Simethicone if gassy

Front 5

Non-Pharmacological Treatment of Colic

Back 5

1) Environmental Strategy (swaddling, front sling, background noise, pacifier, swing, rub back/tummy)

2) Behavioral Strategy - Essential (intervene rapidly when crying starts, feed on demand, burp upright

3) diet Strategy - if related to feeding (switch to different formula, if breastfeeding - stop spicy foods, alcohol, caffeine, melons, apricots, etc)

Front 6

Outer Capsid of Rotavirus

Back 6

VP7 - G serotype

VP4 - P serotype

targets for neutralizing antibodies

Front 7

Inner Capsid of Rotavirus

Back 7

VP6 - target for common diagnostic tests

Front 8

Internal Core of Rotavirus

Back 8

11 segments of double-stranded RNA

Front 9

Rotavirus

Back 9

most common cause of severe diarrhea in infants and children worldwide

Incidence Peaks: 4-36 months
Most severe: 3-24 months

Front 10

Transmission of Rotavirus

Back 10

Predominate route - Fecal-Oral route

Theoretical Routes - respiratory secretions, contaminated surfaces

Front 11

Rotavirus

Back 11

Incubation period: 48 hours

Trasmitted - 10 days after onset

Front 12

Risk Factors for Overall infection with Rotavirus

Back 12

1) Children
2) Immunocompromised

Front 13

Risk Factors for Hospitalization of Rotavirus

Back 13

1) Birth weight < 2.5kg
2) Medicaid/no health insurance
3) living with another child < 24 months
4) Daycare

Front 14

Pathophys of Rotavirus

Back 14

1) ingestion
2) infection upper 2/3 of small intestine
3) replicates in mature enterocytes
4) new particle infect distal portions of small intestine OR are excreted in stool

Front 15

Symptoms of Rotavirus

Back 15

1) Diarrhea - watery, non-bloody (up to 2 weeks)
2) Fever (maybe) - low grade
3) Vomiting (maybe)

1st infection after 3 months - most severe
GI symptoms resolve in 3- days

Front 16

Symptoms of Rotavirus can lead to

Back 16

1) dehydration
2) Electrolyte imbalance
3) shock
4) death

Front 17

Physical Exam of Rotavirus

Back 17

1) Hyperactive bowel sounds
2) tachycardia
3) Sunken eyes
4) dry mucosa

Front 18

Diagnosis of Rotavirus

Back 18

Enzyme immunoassay - most widely used

Front 19

Treatment of Non-hospitalized patients of Rotavirus

Back 19

1) Vomiting - stop feedings; give small amounts of clear liquids frequently (Pedialyte)

2) Diarrhea - BRAT diet (bananas, rice, applesauce, tea/toast) for 1-2 days

No Medications are approved (antivirals, OTC, Probiotics)

Front 20

Treatment of Rotavirus in Hospitalized patients who are Non-Dehydrated

Back 20

FLuid Replacement
100ml/kg for 1st 10kg PLUS
50ml/kg for next 10kg PLUS
20ml/kg for each extra kg

Use:
<3 years: D5/0.2NaCl + 20mEq KCl
>/= 3 years: D5/0.45NaCl + 2-mEq KCl

Front 21

Treatment of Rotavirus in Hospitalized patients who ARE DEHYDRATED

Back 21

Step 1: determine pre-illness weight (parents/chart) and give bolus of 20mL/kg

Step 2: Calculate maintenance fluid replacement (same as non-dehydrated)

Step 3: % dehydration = [(pre-illness weight - illness weight)/pre-illness weight] x 100

Step 4: Fluid Deficit = (% dehydration x 10) x pre-illness weight

Step 5: [step 2 + step 4] - bolus given (step 1)

Step 6: Give 50% over 8 hours: divide by 8 then give 50% over next 16 hours: divide by 16

Front 22

Prevention of Rotavirus

Back 22

1) Hand washing
2) Clean surfaces
3) Vaccines

Front 23

Vaccines for Rotavirus

Back 23

1) Rotashield - pulled from market due to high rate of intussusceptions

2) Rotateq - pentavalent, live attenuated

3) Rotarix - monovalent live attenuated

Front 24

Rotateq for Rotavirus

Back 24

3 oral doses: 1st at 6-12 weeks, subsequent doses should be in 4-8 week intervals

Front 25

Rotarix for Rotavirus

Back 25

2 oral doses: 1st at 6-12 weeks, second dose in 4-8 weeks

Front 26

ADRs, Complications of Rotavirus vaccines

Back 26

1) Fever, vomiting, diarrhea, irritabiliy
2) Precautions - acute gastroenteritis, altered immunocompetence, history of intussusception
3) Contraindications - severe allergy reactions

Front 27

Benefits of vaccination for Rotavirus

Back 27

1) reduce hospitalization
2) reduced ED/physician visit
3) decreased rates of transmission
4) decrease in direct and indirect disease costs

Front 28

Toxins from Clostridium Difficile

Back 28

Toxin A - enterotoxin - causes apoptosis/inflammation
Toxin B - cytotoxin - apoptosis
Binary Toxin

Front 29

Clostridium difficilie

Back 29

most common nosocomial infection of the GI tract

Front 30

Risk factors for C. diff

Back 30

Patient Related: advanced age, recent surgery (GI), NG tube feedings, immunocompromised

Facility Related: prolonged hospitalization, admission to ICU, contact with infected patient

Medication Related: Gastric acid suppression (spores are not destroyed by stomach acids), antibiotics

Front 31

Pathophys of C. diff

Back 31

1) administered antimicrobial therapy
2) normal colonic flora altered
3) ingests spores
4) immune response (adequate-asymptomatic, inadequate-symptoms)
5) toxin production (A-diarrhea, B-directly toxic to enterocytes)

Front 32

Spectrum of disease with antibiotic associated diarrhea

Back 32

mild-moderate in presenation

subsides with discontinuation of antibiotic

Front 33

Pseudomembranous colitis

Back 33

*Classic presentation*

1) Loose, watery stools
2) Low Grade fever
3) leukocytosis
4) yellow, raised plaques
5) +/- ab pain/tenderness

Front 34

Fulminant colitis

Back 34

1) most severe presentation
2) toxic megacolon
3) severe ab pain, high fever, marked leukocytosis, severe diarrhea
4) Colectomy
5) Death

Front 35

Diagnosis of C. diff

Back 35

1) Enzyme immunoassay - most widely used, toxins A & B, quick results
2) Glutamate dehydrogenase (GDH) - presence of antigen, low sensitivity
3) 2 step process - GDH and toxin detection
4) Tissue culture assay -*GOLD* - tests for toxins, 24-48 hours
5) Stool culture - most sensitive, not for toxins, 48-72 hours
6) PCR - toxogenic strains, increasing use in settings

Front 36

Goals of Treatment of C. diff

Back 36

1) resolution of symptoms
2) prevent spread of disease
3) prevent complications (dehydration, electrolyte abnormalities)

Front 37

Treatment of C. diff

Back 37

1) Stop offending antibiotic
2) avoid anti-peristaltic meds
3) monitor fluid status and electrolyte abnormalities
4) control infection

Front 38

Treatment for initial episode of C. diff (symptoms WBC </= 15000, SCr < 1.5x pre-illness level)

MILD - MODERATE DISEASE

Back 38

Metronidazole 500mg orally q8h x10 days

Front 39

Treatment of initial episode of C. diff (symptoms WBC > 15000, SCr >/= 1.5x pre-illness level)

SEVERE DISEASE

Back 39

Vancomycin 125 mg orally q6h x10d

Front 40

Fidaxomicin

Back 40

200mg q12h x10d

used if cant use vanco for C. diff

Front 41

Treatment of Fulminant Colitis

Back 41

1) Colectomy
2) Vanco 500mg PO q6h OR
3) Metronidazole 500mg IV q8h +/- Vanco enema

Front 42

Relapse of C. diff

Back 42

same organism causing infection

within 14 days

Front 43

Re-infection of C. diff

Back 43

new strain causing infection

after 14 days

Front 44

Treatment of first recurrence

Back 44

Treat with same drug as you did the first time (Vanco or Metronidazole)

Front 45

Treatment of Multiple recurrence of C. diff

Back 45

1) Vanco (taper dosing or pulse dosing)
2) Rifampin 600mg PO BID with vanco
3) Toxin binders (cholestyramine 4g BID - QID alone or with vanco)

Front 46

Other treatments for C. diff recurrence

Back 46

1) Fecal transplants - highly effective
2) IVIG
3) monoclonal antibodies

2 & 3 don't have enough data

Front 47

Prevention for C. diff

Back 47

1) hand washing (soap and water)
2) contact isolation (gowns, gloves)
3) decontamination (diluted bleach)
4) vaccine (in development)

Front 48

Risk Factors for Infective Endocarditis

Back 48

1) presence of prosthetic valves
2) history of endocarditis
3) chronic IV access or central cath
4) elderly
5) DM
6) Congenital Heart Disease
7) IV drug abuse
8) Rheumatic Heart Disease

Front 49

Pathophys of Endocarditis

Back 49

1) Trauma to endothelium (blood flow from high to low pressure, valve dysfunction, rheumatic fever, etc)
2) platelet activation & fibrin deposition (NBTE)
3) Bacterial source is from trauma (oral cavity, respiratory tract, GI or GU tracts)
4) Platlets and fibrin form a deposit - bacteria adhere
5) mature lesions grow slower

Front 50

Complications of infective endocarditis

Back 50

1) septic emboli may break off
2) local complications (abscess, CHF, arrhythmias, pericarditis)
3) immune complex formation (glomerulonephritis, septic arthritis)

Front 51

Symptoms of Infective Endocarditis

Back 51

**Non-specific signs and symptoms**
1) fever
2) chills
3) weakness
4) sweats
5) dyspnea
6) anorexia or weight loss
7) skin lesions

Front 52

Pertinent patient history and physical assessment for Infective Endocarditis

Back 52

1) history of endocarditis, rheumatic fever, valve replacement, IVDU
2) history of recent dental, GI, GU procedures or trauma
3) physical assessment - murmurs

Front 53

Endocarditis Stigmata

Back 53

1) osler nodes - purplish subq papules on fingers/toes
2) Janeway lesions - hemorrhagic, painless plaques on palms and soles
3) Slinter hemorrhages - thin, linear hemorrhages on nail beds
4) Petechiae - small, red painless hemorrhagic lesions
5) Clubbing of fingers - long standing
6) Roth Spots - retinal infarct (central white, hemorrhage around)
7) Emboli - stroke or PE

Front 54

Diagnosis of Infective Endocarditis

Back 54

1) non-specific signs/symptoms
2) imaging/clinical/lab data (increased WBC, elevated ESR)
3) blood cultures (3 sets in 24 hours)

Front 55

Major Criteria (Duke Criteria) for Infective Endocarditis

Back 55

1) positive blood culture (2 separate cultures)
2) endocardial involvement
*TTE - if negative, IE still suspected
*TEE - gold standard

Front 56

Minor Criteria (Duke Criteria) for Infective Endocarditis

Back 56

1) predisposing heart condition on IVDU
2) fever
3) vascular phenomenon (septic emboli, Janeways)
4) immunologic phenomenon (oslers nodes, roth spots)

Front 57

Streptococcus Viridans in Infective Endocarditis

Back 57

1) S. mutans
2) S. sanguis
3) S. mitis
4) S. bovis

Front 58

Source of Strep viridans for infective endocarditis

Back 58

mouth, gingiva

most commonly - mitral valve (diastolic murmurs)

symptoms develop over time

Front 59

Treatment of IE - Strep Viridans

Highly Penicillin Sensitive (MIC <0.12mcg/mL)

Back 59

Pen 12-18 million units/day divided q4h or q6h (continuous infusion) x 4 weeks
OR
Ceftriaxone 2g IV q24h x4wks
OR
Pen 12-18 million units/day divided q4h (continuous infusion) PLUS Gent 2mg/kg IV q24h x2wks
OR
Ceftriaxone 2g IV q24h PLUS Gent 3mg/kg IV q24h x2wks

Front 60

Treatment of IE - Strep Viridans

Highly Penicillin Sensitive (MIC < 0.12mcg/mL)

Pen/Ceph Allergy

Back 60

Vanco 15mg/kg IV q12h x4wks

trough 10-15mcg/ml

Front 61

Treatment of IE - Strep Viridans

Relatively PCN resistant (MIC > 0.12 but </= 0.5)

Back 61

Pen 24 million units/day divided q4h or q6h x 4wks PLUS Gent 3mg/kg IV q24h x2 weeks
OR
Ceftriaxone 2g IV q24h x4wks PLUS Gent 3mg/kg IV q24h x2wks

Peak Gent goal ~3mcg/mL

Front 62

Treatment of IE - Strep Viridans

Relative PCN resistant (MIC >0.12 but </= 0.5)

PCN/Ceph Allergy

Back 62

Vanco 15mg/kg IV q12h x 4 weeks

Front 63

Treatment of Strep Viridans (Abiotrophia defectiva, Granulicatella, Gemella, Strep Viridans w/ PCN MIC > 0.5)

Back 63

Ampicillin or PCN G PLUS Gent

Vanco

Front 64

Prosthetic Valve S. Viridans Treatment

PCN susceptible (MIC </= 0.12)

Back 64

PCN 24 million units/day divided q4h or q6h x6wks WITH OR WITHOUT Gent 3mg/kg IV q24h x 2wks
OR
Ceftriaxone 2g IV q24h x6wks PLUS Gent 3mg/kg IV q24h x 2wks

Allergy:
Vanco 15mg/kg IV q12h x6wks

Front 65

Prosthetic Valve S. Viridans Treatment

PCN relatively or fully resistant (MIC >0.12)

Back 65

Pen 24 million units/day divided q4h or q6h PLUS Gent 3mg/kg IV q24h x6wks
OR
Ceftriaxone 2g IV q24h PLUS Gent 3mg/kg IV q24h x6wks

Allergy:
Vanco 15mg/kg IV q12h x6wks

Front 66

Staph Infective Endocarditis

Back 66

*common in IVDU and patients with central IV access
*most common cause
*most severe

Front 67

Treatment of Infective Endocarditis

MSSA

Back 67

Nafcillin/oxacillin 2g IV q4h x6wks PLUS optional Gent 1mg/kg IV q8h x3-5days

Non-anapylactic PCN allergy:
Cefazolin 2g iV q8h x6wks PLUS optional Gent 1mg/kg IV q8h x3-5days

Severe PCN allergy:
Vanco 15mg/kg IV q12h x6wks

Front 68

Treatment of Infective Endocarditis
MRSA

Back 68

Vanco 15mg/kg IV q12h x6wks

trough levels 15-20mcg/mL

Front 69

Prosthetic Valve Staph aureus Treatment

MSSA

Back 69

Nafcillin/Oxacillin 2g IV q4h x6weeks+ PLUS rifampin 300mg IV/PO q8h x6wks+ PLUS Gent 1mg/kg IV q8h x2 weeks

Non-Anaphylactic PCN allergy:
Cefazolin 2g IV q8h x6wks+ PLUS Rifampin 300mg IV/PO q8h x6wks+ PLUS Gent 1mg/kg q8h x2 wks

Front 70

Prosthetic Valve Staph aureus Treatment

MRSA

Back 70

Vanco 15mg/kg IV q12h x6wks+ PLUS Rifampin 300mg IV/PO q8h x6wks+ PLUS Gent 1mg/kg IV q8h x2weeks

trough levels 15-20 mcg/mL

Front 71

Enterococcus Infective Endocarditis

Back 71

*not covered by cephalosporins
*resistance is increasing

Front 72

Native/Prosthetic Valve Enterococcal Infective endocarditis

PCN, Gent, Vanco susceptible

Back 72

Ampicillin 12g/day divided q4h PLUS Gent 1mg/kg IV q8h x4-6wks
OR
PCN 18-30 million units/day continuous or q4h PLUS Gent 1mg/kg IV q8h x4-6wks

Allergy:
Vanco 15mg/kg IV q12h PLUS Gent 1mg/kg IV q8h x6weeks

Front 73

Duration of treatment for native or prosthetic valve enterococcal IE

Back 73

symptoms <3 months = 4 weeks
Symptoms >/=3 months or prosthetic valve = 6 weeks

Front 74

Native or Prosthetic Valve Enterococcal Infective Endocarditis Treatment

PCN, Streptomycin, Vanco Susceptible

Back 74

Ampicillin PLUS Streptomycin
OR
PCN PLUS Streptomycin

Allergy:
Vanco PLUS Streptomycin

Front 75

Native or Prosthetic Valve Enterococcal Infective Endocarditis Treatment

Aminoglycoside and Vanco susceptible
Beta lactamase producing strain

Back 75

Ampicillin-sulbactam PLUS Gent

Allergy
Vanco PLUS Gent

Front 76

Treatment of Infective Endocarditis

PCN, Aminoglycoside, Vanco resistant

Enterococcal faecium (VRE)

Back 76

Linezolid 600mg IV/PO q12h x8weeks
OR
Dalfopristin/quinupristin 22.5mg/kg IV q24h x8wks
OR
Daptomycin 6mg/kg IV q24h x8wks

Front 77

Treatment of Infective Endocarditis

PCN, Aminoglycoside, Vanco resistant

Enterococcal faecalis

Back 77

Imipenem-cilastatin 500mg IV q6h PLUS Ampicillin 2g IV q4h x8wks
OR
Ceftriaxone 2g IV q12h PLUS ampicillin 2g IV q4h x8wks (Synergy)

Front 78

HACEK group that causes IE

Back 78

H: Haemophilis
A: Actinobacter
C: Cardobacterium
E: Eikenella
K: Kingella

Front 79

Treatment of HACEK caused Infective Endocarditis

Back 79

Ceftriaxone 2g IV q24h x4wks
OR
Ampicillin/sulbactam 3g IV q6h x4wks
OR
Cipro 400mg IV q12h or 500mg PO q12h x4wks

Front 80

Treatment of Infective Endocarditis with culture negative or Bartonella

Back 80

Ampicillin/Sulbactam PLUS Gent
OR
Vanco PLUS Gent PLUS Cipro
OR
Ceftriaxone PLUS Gent PLUS Doxy

Front 81

Treatment of Endocarditis caused by enterobacteriaceae or Pseudomonas

Back 81

Drugs that cover them (Zosyn, cefipime)

Front 82

Treatment of ENdocarditis caused by fungus

Candida or Aspergillus

Back 82

Amphotericin B

Front 83

Monitoring for Endocarditis

Back 83

1) Symptoms (resolve)
2) Fever (improve within 1 week of starting med)
3) Blood Culture (check daily until neg cultures)
4) Therapeutic Drug Monitoring (Vanco goal troughs)