Term
| T or F: When an organism is pathogenic it is also resistant. |
|
Definition
F: pathogenesis does NOT equal resistant.
Actually, because both require energy, they have an inverse relationship |
|
|
Term
| What are two examples of an antigen or antibody test? |
|
Definition
Strep Test (Group A Streptococcus)
Rapid HIV Test |
|
|
Term
| How can the mecA of S.aureus be detected? |
|
Definition
|
|
Term
| What is the MIC measuring |
|
Definition
| The drug/organism interaction (simplest method) |
|
|
Term
|
Definition
Can't usually get a true MIC (only 1,2,4,8...)
Additionally, lab standards are MIC+/- 1 dilution (so if says MIC = 4, could be anywhere between 2 and 8) |
|
|
Term
| How do you measure the MBC? |
|
Definition
| on agar plate (kills 99.9% of germs) |
|
|
Term
|
Definition
Strip with different concentrations of antibiotic placed on agar plate - zone of inhibition forms when bacteria is susceptible
Can get MIC by looking at lowest drug concentration it is susceptible to. |
|
|
Term
|
Definition
Multiple discs with antibiotics placed on agar plate with bacteria. Zone of inhibition around each antibiotic bacteria is susceptible to (~1 mm)
Doesn't give an actual MIC |
|
|
Term
| Which is worse, giving an antibiotic because the patient was thought to be susceptible and really wasn't, or not giving an antibiotic because they thought the patient was resistant? |
|
Definition
Giving an antibiotic to which the patient is actually resistant (still not getting adequate treatment)
if didnt give them an antibiotic that was falsely read as resistant, then most likely still got an antibiotic that works for them |
|
|
Term
| T or F: FQs can be used for Pseudomonas? |
|
Definition
F - even though the lab results will come back saying it is susceptible, it is not.
Never use a fluoroquinolone ALONE for Pseudomonas |
|
|
Term
| Vancomycin/MRSA MIC comes back as 2, what could be an issue? |
|
Definition
Resistance. Even though MIC of 2 is seen as susceptible (breakpoint) resistance is increasing so may need drug in greater concentrations
if MIC>2 for S.aureus, use alternative agent |
|
|
Term
| What is an instance in which the lab reports that Klebsiella (or other enterobacteriaceae) is susceptible to a certain antibiotic, but when used treatment fails? |
|
Definition
| When the bacteria is an ESBL producer and a penicillin is used - ESBLs get induced. |
|
|
Term
| When reading an antibiogram, the number that is reported is the susceptible or resistant population? |
|
Definition
|
|
Term
| What is selection pressure? |
|
Definition
(Think Natural Selection)
The idea that the resistant bacterium will live and multiply and others will die (vertical resistance) |
|
|
Term
What are the most common plasmid-mediated beta-lactamases in gram negative bacteria?
What drugs are stable in their presence? |
|
Definition
TEM-1, TEM-2, SHV-1
Extended-spectrum ceph (2nd/3rd)
beta-lactams + beta-lactamase inhibitors
Carbapenems |
|
|
Term
| What beta-lactams are stable in the presence of ESBLs |
|
Definition
Carbapenems
Clavulanic acid |
|
|
Term
| How do we screen for ESBL producers? |
|
Definition
If MIC> or = 2mcg/mL to ceftazidime, cefotaxime, or ceftriaxone then do an ESBL confirmatory test
(Test the drug with clavulanic acid - if the organism then presents as susceptible (having 3+ decreases in MIC read) the organism is an ESBL producer
Must report as resistant to ALL cephalosporins and penicillins |
|
|
Term
| What is the DOC for ESBL producing organisms? |
|
Definition
Carbapenem
**Amox/Clav Acid cant be used in high enough concentration to be therapeutic
Alt: Cefepime - still treatment failures
Tigecycline
Other drug that is susceptible |
|
|
Term
|
Definition
NOT inhibited by beta-lactamase inhibitors (clavulanic acid)
Chromosomal and Inducible
Produced by the SPACE bacteria (nosocomial pathogens)
'stably de-repressed' - there is no repression, always turned on |
|
|
Term
| 2 DOC for AmpC beta-lactamase producers |
|
Definition
|
|
Term
| Issue with culturing a patient who has a bacteria with the Amp-C gene |
|
Definition
| Stable de-repression - will appear to be susceptible upon initial testing, but then treating with the drug will induce beta-lactamase production - will be seen as resistant 3 days later. |
|
|
Term
|
Definition
Two types: serine beta-lactamases and metallo-beta-lactamases (MBL)
chromosomally or plasmid encoded
Can lead to resistance in carbapenems and anti-pseudomonal cephalosporin/penicillins |
|
|
Term
| Treatment of carbapenemase producers |
|
Definition
Polymyxin B + rifampin or imipenem
Tigecycline
Aminoglycosides |
|
|
Term
| What is gene that causes the replacement of PBP2 with PBP2a? |
|
Definition
|
|
Term
| What is the only beta-lactam that can target PBP2a? |
|
Definition
|
|
Term
| Penicillin resistance in what organisms is associated with 4 PBPs? |
|
Definition
Strep. pneumoniae
in resistant to PCN, then increased macrolide resistance, BUT FQ resistance still low |
|
|
Term
| Which gene carries clindamycin inducible resistance? How can the lab screen for this? |
|
Definition
erm gene
Disc Diffusion Test (D Test) |
|
|
Term
| Which organism has the highest incidence of changing the bacterial target site against vancomycin (change to D-ala-D-lac or D-ala-D-ser) |
|
Definition
|
|
Term
| What are the VanA and VanB genes? |
|
Definition
Genes that change the target site of penicillin to:
A: D-ala-D-lac
B: D-ala-D-ser |
|
|
Term
| When MRSA acquires the VanA gene it is considered _______. |
|
Definition
|
|
Term
| What PD parameter correlates to efficacy in vancomycin dosing? |
|
Definition
AUC/MIC
Target AUC/MIC is greater than 400
-to achieve, trough target = 15-20 mcg/mL |
|
|
Term
| What is a major mechanism of resistance against Tetracyclines? |
|
Definition
Efflux pumps
tet genes
NOTE: tigecycline has steric hindrance and is not a substrate for these pumps (why broader spectrum) |
|
|
Term
| T or F: tigecycline can be used to treat all common infections |
|
Definition
| F - very broad spectrum but doesnt cover Pseudomonas |
|
|
Term
| T or F: bacteria can have more that one mechanism of resistance. |
|
Definition
| T: ex, meropenem and Psuedomonas/Acinetobacter ->up-regulation of efflux pump gene and loss of porin channel protein are both required for resistance to be noted |
|
|
Term
| If someone has a drug hypersensitivity then they have a drug allergy - T or F. |
|
Definition
| F: if someone has a drug hypersensitivity it can be allergic or non-allergic hypersensitivity |
|
|
Term
| Risk factors for having an allergy |
|
Definition
Genetic factors
Concurrent medical illness (Ebstein-Barr Virus, HIV, asthma)
Previous drug reaction
Multiple allergy syndrome
The nature of the drug (its interaction with the immune system, dose, duration, route, cross-sensitization) |
|
|
Term
| Mechanism of a Type I hypersensitivity reaction |
|
Definition
IgE mediated
triggers the release of histamine
manifests as urticaria, angioedema, anaphylaxia/shock, bronchial asthma |
|
|
Term
| Type II and III hypersensitivity reactions mechanism and presentation |
|
Definition
Antibody, immune-complex, or phagocyte-mediated
presents as:
Immune hemolytic anemia
Thrombocytopenia
Blood cell dyscrasias
Organ-specific reactions |
|
|
Term
| What is the mechanism and presentation of Type IV hypersensitivity |
|
Definition
| T cell mediated Delayed Rashes: maculopapular exanthema, SJS/TEN, delayed urticaria, eczema Organ-specific reactions |
|
|
Term
|
Definition
A chemically non-reactive drug that becomes reactive (to the immune system) upon metabolism
Potent and rapid intracellular detoxification of the hapten can prevent immunogenicity elsewhere in the body, but can cause an organ-specific reaction (liver-hepatitis or kidney-interstitial nephritis)
-Ex: GSH - depletion of glutathione in HIV patients |
|
|
Term
| Does a hapten cause a Type I, II, III, or IV reaction? |
|
Definition
Could cause any
Depends on:
1. Where it binds (surface vs soluble)
2. What binds it (IgE, IgG, T cells) |
|
|
Term
| If patient presents with urticaria after first exposure to a drug, how will they present if they are exposed a second time? |
|
Definition
| There is no way to know, they could just get urticaria again or they could progress to angioedema or worse |
|
|
Term
| Urticaria presentation and mechanism |
|
Definition
wheal and flare rxn (IgE)
-increased vascular permeability (small venules)
-mast cells and basophils release histamine, eicosanoids
-cutaneous neurons release neuropeptides (axon reflex)
Skin swells and itches
No mucus membrane involvement |
|
|
Term
| Angioedema presentation and mechanism |
|
Definition
well-demarcated non-pitting edema
rxn deeper in dermis and SQ tissue than urticaria
Usually face, tongue, lips, eyelids
Can get respiratory distress
GET PATIENT SEEN |
|
|
Term
| T or F: even though IgE mediated reactions usually occur within 1-2 hours and T-cell mediated reactions usually take 2 hr-10 days, timing doesn't always go by the book. |
|
Definition
|
|
Term
| Stevens Johnson Syndrome (SJS) and Toxic Epidermis Necrolysis (TEN) |
|
Definition
Fever, sore throat, cough, eye burning
facial swelling, target lesions, skin pain, red/purple rash, blistering (skin and mucous membranes), sloughing of skin
Nikolskys sign - scratch skin and epidermis comes off
Usual causes: Sulfa, PCNs, NSAIDs, anticonvulsants, infections
Treat like a burn patient |
|
|
Term
| Maculopapular exanthem (MPE) and Bullous Exanthem |
|
Definition
higher activation of circulating T Cells
MPE: CD4 (only certain MHC-II cells)
Bullous: CD8 (all cells)- more reaction [why they look fused together] |
|
|
Term
| What should be done if a patient presents with a delayed hypersensitivity reaction? |
|
Definition
Stop all ongoing antibiotics
Do liver, renal, and blood tests |
|
|
Term
| What is the most likely cause of a small petechiael rash? |
|
Definition
|
|
Term
| What is the most likely agent being used when someone with an Epstein-Barr viral infection presents with maculopapular exanthem |
|
Definition
| Aminopenicillins (amoxicillin/ampicillin) |
|
|
Term
| With what drug are HIV-patients most likely to have an increased risk of an allergic reaction? |
|
Definition
|
|
Term
| What are some lab (serology) tests that could be used to confirm a drug allergy? |
|
Definition
Immediate reactions:
1. serum tryptase
2. serum histamine
Delayed reactions
3. CBC: eosinophilia and lymphocytosis, leukocytosis
4. Liver function tests: increased ALT, AST, ALP
5. Serum creatinine: increased = +
6. Urine microscopy and dipstick: nephritis, proteinuria
7. CRP: can increase or decrease = sign of inflammation |
|
|
Term
| When is the skin prick or intradermal test used for drug allergies |
|
Definition
| use to deterimine if reaction is IgE mediated |
|
|
Term
| Skin prick test: time, sensitivity, and specificity |
|
Definition
15-20 minutes
Specific and fairly sensitive |
|
|
Term
| Intradermal skin test: when indicated and sensitivity and specificity |
|
Definition
Do it when skin prick test is negative and allergen is highly suspect
more sensitive than skin prick test
may induce false positive reactions (less specific)
May induce systemic reactions |
|
|
Term
| What is drug provocation tests and when should it be used |
|
Definition
Give a drug and monitor patients for allergic reaction
Indications:
1. Exclude hypersensitivity in non-suggestive history
2. Utilize structurally similar drugs in proven hypersensitivity (ex: want to use cephalexin in an penicillin allergic patient)
3. Definitive diagnosis in suggestive history with negative, non-conclusive or non-available tests
DO NOT USE IF:
1. pregnant
2. a co-morbidity exists where DPT can provoke a situation beyond medical control (ex: acute infection, uncontrolled asthma, cardiac disease, brittle)
3. immunobullous drug eruptions
4. severe systemic initial reactions (SJS)
Must explain risk vs benefit to patient (informed consent)
Ideal to: d/c antihistamines (3 days short acting and 7 days long acting); fasted overnight
careful observation and resuscitation equipment available |
|
|
Term
| When to desensitize a patient |
|
Definition
When there is no reasonable alternative
-NOTE: if anaphylaxis originally it is NOT contraindicated, but if the patient had SJS/TEN do NOT do desensitization
**Patient will still be considered allergic to the drug |
|
|
Term
| How to desensitize a patient |
|
Definition
Must be done by a physician (ICU preferred)
d/c all beta-adrenergic antagonists (including ophthalmics)
do NOT premedicate with corticosteroids/antihistamines (For some drugs, premedication is recommended - FQ, vanco)
monitor with ECG
Start low (can be oral or parenteral)
Double dose every 20-30 min until reach target
If skip a dose, must start all over
If patient has transient allergic reaction - dont stop treatment |
|
|
Term
| Possible mechanisms of desensitization |
|
Definition
IgE mediated reactions
Consumption of IgE in immune complexes
Mediator depletion from mast cells and basophils
Antigen specific mast cell desensitization |
|
|
Term
| Cross-reactivity between penicillins and cephalosporins |
|
Definition
more common with type I reactions
IgE mediated reaction to PCNs is 10% cross-reactivity to ceph (esp. 1st gen)
If reactive to ceph but not pcn - there is a higher incidence of ceph cross-reactivity among drugs with similar R1 side chains
-Ceftriaxone = cefotaxime = cefepime
-Cefuroxime = ceftazidime
Low rate of cross-reactivity between PCN and carbapenems
NO cross-reactivity with aztreonam |
|
|
Term
| Up to 50% of HIV patients have an allergy to what medication? |
|
Definition
sulfonamides
SMX can be a hapten (able to cause all forms of drug allergies) |
|
|
Term
| T or F: if you are allergic to one fluoroquinolone you are considered allergic to all of them |
|
Definition
There is cross reactivity, so:
if an immediate hypersensitivity - must chose different drug
if delayed hypersensitivity can challenge and desensitize |
|
|
Term
| How to decide to treat a drug allergy as inpatient or outpatient |
|
Definition
Inpatient: observation, skin care, I/V, allergist referral
-Chose if: angioedema, severe skin (ex: SJS), systemic symptoms (fever, lymphadenopathy), possibly >1 implicated drug
Outpatient: treat if urticaria/maculopapular rash, fixed drug erruption, no systemic symptoms
Refer to allergist if: uncertain cause or if uncertain allergy |
|
|
Term
| Treatment of a drug allergy |
|
Definition
stop suspected drug(s)
Resuscitation (CPR in anaphylaxis)
Give:
Antihistamines (IV or PO)
IM epinephrine for anaphylaxis
Systemic corticosteroids for DiHS, SJS
High dose IVIG for early TEN/SJS
Emollients and skin care
Hydration and prevention of skin superinfections (TEN) |
|
|
Term
| What is another name for an upper UTI? |
|
Definition
|
|
Term
| What constitutes an uncomplicated (vs a complicated) UTI |
|
Definition
Uncomplicated: otherwise healthy female ages 15-45)
Complicated: men; lesions, obstruction, neurologic dysfunction (cant void completely), upper and lower tract |
|
|
Term
| What are the two types of recurrent UTIs |
|
Definition
3+ UTIs in 1 year in healthy, NONpregnany women
Reinfection: different organism (>2 weeks apart)
Relapse: same organism, persistent sourse of infection (stones, catheter) (<2 weeks apart) |
|
|
Term
| If there is non urinary pain, but UA comes back positive for bacteria, does the patient have a UTI? |
|
Definition
| No, asymptomatic bacteriuria |
|
|
Term
| T or F: you can only rule out a lower UTI, you cant really rule out an upper UTI |
|
Definition
T
usually if no symptoms then no UTI |
|
|
Term
| Clinical presentation of a UTI (upper vs lower) |
|
Definition
Lower: DYSURIA, urgency, nocturia, suprapubic heaviness, hematuria, foul-smelling
Upper: FLANK PAIN, fever, N/V, malaise, muscle weakness
Elderly: mental status changes |
|
|
Term
| Typical lab diagnosis of a UTI |
|
Definition
UA:
clarity is cloudy
Color: orange/red (blood)
pH: increased (normally acidic)
WBC or RBC may be present
Leukocyte esterase may be present (breakdown of WBC)
nitrite (gram negative bacterial metabolite)
Organisms present - lower threshold amount for men than for women
Urine culture (NOTE UA does not culture anything in urine - just quantifies how much is present)
CBC (done if UTI severe or worsens) |
|
|
Term
| What is the most common pathogen found in UTIs |
|
Definition
E.coli
(Proteus, Klebsiella, Staphylococci, saprophyticus, other) |
|
|
Term
| What are two drug classes that have been used to treat UTIs that cause A LOT of collateral damage |
|
Definition
|
|
Term
| What are some options for the treatment of UTIs |
|
Definition
1. Nitrofurantoin monhydrate/macrocrystals
Make sure patient has adequate renal function to make sure drug gets there and to avoid toxicity
SMX-TMP: DS BID x3 days
Fosfomycin 3 gm once
-minimal resistance/collateral damage; inferior efficacy
Augmentin or PO cephalosporins
Cipro/levo: 3 days is usually sufficient
-reserve for more serious infections because of collateral damage (and growing resistance) |
|
|
Term
| If patient presents with pyelonephritis what is the first thing you should do? |
|
Definition
| get a urine culture BEFORE starting antibiotics |
|
|
Term
| How do you decide to treat pyelonephritis inpatient or outpatient? |
|
Definition
Inpatient: pregnancy, diabetes, immunocompromised, structural abnormalities
treat with IV (at first) if inpatient because of big risk of N/V with most abx |
|
|
Term
| Treatments for pyelonephritis |
|
Definition
Can start PO regimens with IV x 24h or until hemodynamically stable
IV/PO cipro/levofloxacin (7-10 days)
IV extended spectrum beta-lactam +/- aminoglycoside
PO beta-lactams (cephalosporins>augmentin b/c of resistance) x10-14days
PO Bactrim x 14 days (only if susceptible) |
|
|
Term
| Should you treat asymptomatic bacteruria |
|
Definition
No, except for:
1. pregnant women (b/c development issues associated with bacteria in urine)
2. Children <5 yr (increased risk of long-term damage)
3. Patients undergoing TURP or urologic procedure
NOTE: recurrence is common and there is 100% incidence in patients with a catheter |
|
|
Term
| T or F: pregnant women have more pyelonephritis |
|
Definition
| T - they have higher incidence of acute pyelonephritis, but bacteriuria rates are equal in pregnant and non-pregnant women |
|
|
Term
| What do you use to treat UTIs in pregnancy and for how long |
|
Definition
Beta-lactams
Sulfonamides
Nitrofurantoin
Use for ~7 days |
|
|
Term
| Why should you treat a UTI in pregnancy? |
|
Definition
They are associated with significant morbidity for mom and baby
prematurity, low birth weight, still birth |
|
|
Term
| What are some risk factors for UTI recurrence? |
|
Definition
sexual intercourse
diaphragm or spermicide use |
|
|
Term
| How to treat recurrent UTIs |
|
Definition
If sex related: post-coital voiding and single dose bactrim
If no precipitating event:
-6 month therapy
-Bactrim, FQ, macrobid |
|
|
Term
|
Definition
| >101 F >100.4 x 2 readings >1 hr apart |
|
|
Term
| What is a common species of staph that is referred to as 'coag. negative staph?' |
|
Definition
|
|
Term
| What patient population is candiduria commonly seen in? |
|
Definition
|
|
Term
| Who should be treated for candiduria? |
|
Definition
ONLY treat symptomatic or high-risk patients
Neutropenic, neonates, urologic prodecure |
|
|
Term
| How should candiduria be treated? |
|
Definition
CHANGE THE CATHETER!
Fluconazole
Amphotericin B IV
Amp B bladder irrigation (irritating)
7-14 days |
|
|
Term
| What is the major difference between the treatment of UTIs and prostatitis? |
|
Definition
Duration of treatment
UTI: up to 2 weeks
Prostatitis: 4-6 weeks |
|
|
Term
| What can cause prostatitis? |
|
Definition
Identified by presence of bacteria and inflammatory cells
causes:
-reflux of urine into prostate
-sex
-functional abnormalities of prostate
-catheters
-urinary tract procedures
Bacterial causes similar to UTIs (E.coli) |
|
|
Term
| Treatments for prostatitis |
|
Definition
FQ (most common)
Bactrim
(Cephalosporins and Zosyn)
4-6 weeks |
|
|
Term
|
Definition
| the ability of a test to identify positive results in patients who actually have the disease (true positive rate) Higher sensitivity = lower chance of false negative High sensitivity is preferred when the consequences of not identifying the disease are serious (ex: cancer screenings) |
|
|
Term
|
Definition
| the percent of negative results in people without the disease (true negative rate) Higher specificity = less chance of a false positive Good for confirming a diagnosis because the tests are rarely positive in the absence of disease |
|
|
Term
| T or F: infections with any STD increases the risk of HIV acquisition. |
|
Definition
| T - sores/inflammation can decrease the skin's ability to prevent infection |
|
|
Term
| What is the number one risk factor for getting an STD? |
|
Definition
Number of sexual partners
Others:
Unprotected sex
Social/Cultural factors
Lower socioeconomic status
Drug abuse (IV drug user) |
|
|
Term
|
Definition
|
|
Term
| Which STDs are most painful |
|
Definition
Herpes
HPV
Both viruses are the most painful! |
|
|
Term
| Which STDs present with sores and which present with drips? |
|
Definition
Sores:
1. Syphilis
2. HSV (herpes)
3. HPV
**NOTE- these are the most painful and least painful
Drips:
1. Gonorrhea
2. Chlamydia
3. Trichomoniasis
NOTE - all of these can present with or without discomfort |
|
|
Term
| T or F: you can cure herpes? |
|
Definition
| F - cant completely eradicate |
|
|
Term
| What organism/virus causes gonorrhea? |
|
Definition
Neisseria gonorrhea
(G- diplococcus) |
|
|
Term
| Presentation of Gonorrhea |
|
Definition
50% females are asymptomatic
Sx: dysuria, urinary frequency, PURULENT DISCHARGE, rectal discharge, pharyngitis
drips +/-discomfort
NOTE: men are more likely to give it to women than vice versa |
|
|
Term
| DOC for gonorrheal (uncomplicated) infection |
|
Definition
Ceftriaxone 250 mg IM once
(Cefixime and FQ were once recommended, but not any more because of increased resistance)
+ Drug for chlamydia |
|
|
Term
| What two STDs are treated concurrently becuase they are often found together |
|
Definition
|
|
Term
| How to treat a disseminated gonorrheal infection (it has spread) |
|
Definition
| Ceftriaxone 1 gm IM/IV Q24h ->duration not well defined (individualize) |
|
|
Term
| What should you give to a pregnant women who presents with chlamydia? |
|
Definition
Azithromycin 1 g PO x1 dose
Erythromycin is an alternative
(dont give a tetracycline because contraindicated in pregnancy) |
|
|
Term
| What causes chlamydia, and what type of organism is it? |
|
Definition
C. trachomatis
obligate intracellular bacterial parasite
-important because symptoms wont manifest until 1-3 weeks have past |
|
|
Term
| What is the most frequently reported STD in the US? |
|
Definition
|
|
Term
| Who is more likely to know they have an STD, a man or a woman? |
|
Definition
| Man, because women are more likely to be asymptomatic in with most diseases (must be proactive and encourage screening) |
|
|
Term
| What are the screening criteria for chlamydia? |
|
Definition
All sexually active females should be screened annually
-Ages 20-25 (most common age group)
-Multiple sex partners |
|
|
Term
|
Definition
urethral/cervical discharge
-less profuse and more mucoid/watery compared to gonorrhea
drips
+/- discomfort
Asymptomatic in 50% men and 66% women |
|
|
Term
| What are the recommended treatment options for chlamydia and what are some alternatives? |
|
Definition
Recommended:
1. Azithromycin 1 gm PO once
2. Doxycycline 100 mg PO BID x7
Alternative
1. Levofloxacin 500 mg QD x 7 days
2. Erythromycin base 500 mg QID x 7 days
**Azithromycin 2g PO x1 dose treats both Chlamydia and Gonorrhea (more GI issues, good if allergic to ceftriaxone) |
|
|
Term
| How does Trichomoniasis uniquely present |
|
Definition
"Strawberry cervix" - cervical petechiae
Discharge: frothy, gray to yellow-green malodorous
Positive KOH "whiff" test
motile flagellated protazoa, many WBCs
Common among vaginal infections: itching, dysuria, discharge |
|
|
Term
| Recommended treatment of trichomoniasis and some alternatives |
|
Definition
Recommended:
1. Metronidazole 2 gm PO x 1 dose
2. Tinidazole 2 gm PO x 1 dose (esp if metro fails)
Alternatives:
Metronidazole 500 mg PO BID x 7 days (**Preferred if partner is NOT simultaneously treated - because is self-limiting in men after ~7 days) |
|
|
Term
| T or F: Metronidazole gel is just as effective in treating trichomoniasis as the oral regimen |
|
Definition
| F - only 50% as effective |
|
|
Term
| What are the stages of Syphilis? |
|
Definition
Primary: single, painless indurated lesion (chancre) - eventually heals
Secondary: rash +/- itching, mucocutaneous lesions, flu-like symptoms
Latent: Asymptomatic
Tertiary: CV (aortic insufficiency), neurosyphilis (meningitis, paresis, dementia), gummatous lesions SYSTEMIC (10-30 years) |
|
|
Term
| What is the treatment of syphilis |
|
Definition
Primary/Secondary/Early latent (<1 year)
Benzathine Pen G 2.4 mil units IM x 1 dose
Late Latent (>1 year) or unknown duration
Benzathine Pen G 2.4 mil units IM Qweek x 3 weeks
Neurosyphilis
-Aqueous crystalline Pen G 18-24 million units IV QD (can be intermittent or continuous infusion) x 10-14 days
-Aqueous cystalline Pen G 2.4 mil units IM daily + probenecid 500 mg PO QID x 10-14 days
Pen-allergic patients
Doxy 100 mg PO BID x 14 (x 28 in late latent)
Tetra 500 mg QID x14 (x28 in late latent)
Ceftriaxone 1 gm IM/IV QD x 8-19 days (only <1 yr disease) |
|
|
Term
| What is the Jarisch-Herxheimer reaction and with what treatment is it notorious for occurring? |
|
Definition
Acute syndrome of flu-like symptoms within 24 hours of penicillin treatment (seen with syphilis tx)
-Fever, HA, myalgia, tachycardia, flushing, increased respiratory rate
Due to endotoxin release/cytokine cascade
Tx: supportive care, bed rest, NSAIDs
-self limiting |
|
|
Term
| Which is worse: the first episode or the recurrent episodes of genital herpes simplex virus? |
|
Definition
First episode: painful ulcers with flu-like sx
Recurrent episodes are usually milder and shorter + have a prodrome in ~50% of cases so can get treated sooner |
|
|
Term
| Genital Herpes is most commonly caused bu HSV-1 or HSV-2 |
|
Definition
HSV-2
NOTE: this is also the strain that is more likely to cause recurrent infections |
|
|
Term
| What is a major advantage of treating genital herpes recurrences? |
|
Definition
Reduce viral shedding which limits the risk of transmission
Maximal benefit when treatment is initiated early-management of symptoms |
|
|
Term
| What are two possible treatment regimens for herpes? |
|
Definition
Treating each episode on a case by case basis
Continual long-term suppressive therapy (good for more severe) |
|
|
Term
| Agents use to treat herpes episodically |
|
Definition
Acyclovir 400 TID x 7-10
Acyclovir 200 5xdaily x 7-10
Famciclovir 250 TID x 7-10
Valcyclovir 1 g BID x 7-10
If recurrent episode - use same drugs but usually only require treatment for 5 days |
|
|
Term
| Options for long-term suppressive therapy for herpes |
|
Definition
Acyclovir 400 BID
Famciclovir 250 BID
Valcyclovir 500 or 1 g QD |
|
|
Term
| How do you treat a severe herpes infection |
|
Definition
Acyclovir 5-10 mg/kg IV Q8H x2-7 days or until improvement
Follow up with PO therapy to complete a 10 day regimen (can go up to 14 days, or until improvement) |
|
|
Term
| If someone presents with deafness and confusion, which STD would you suspect they have? |
|
Definition
|
|
Term
| What are two instances when you want to always was to desensitize |
|
Definition
1. Necrotizing facitis
2. Tertiary syphilis
Both with penicillin |
|
|
Term
| C. diff is most commonly transmitted how? |
|
Definition
|
|
Term
| Which antibiotic is associated with a high prevalence of C.diff diarrhea? |
|
Definition
Clindamycin
Others: FQ, 3rd/4th gen Ceph, broad-spectrum Pen |
|
|
Term
| What is the first line treatment for C.diff diarrhea? |
|
Definition
Vancomycin 125 mg PO Q6h
remember: never IV for GI vanc |
|
|
Term
|
Definition
G+ spore forming anaerobe
endotoxins: detected by PCR
Toxin A (TcdA): osmotic changes/secretions
Toxin B (TcdB): mucosal damage/inflammation |
|
|
Term
| Symptoms of C.diff diarrhea |
|
Definition
watery diarrhea
abdominal pain
nausea
leukocytosis
fever |
|
|
Term
| Risk factors for C.diff diarrhea |
|
Definition
*Antibiotic use
*Contact with C.diff spores
*Gastric acid suppression (PPIs)
Advanced age
Immunosuppresion (Chemo)
Female gender (unknown why)
Prolonged hospital/healthcare exposure
* = modifiable |
|
|
Term
| Issues that we are now facing with C.diff treatment |
|
Definition
Resistance (ex: with FQ)
Increased virulence via more toxin production (loss of suppressor gene)
NAP1/BI/027 - resistant strain |
|
|
Term
| What are some non-drug considerations/treatments for C.diff treatment |
|
Definition
1. D/c antibiotic if possible
2. Do NOT use antidiarrheal or antiperistaltic (loperamide, metoclopramide)
3. Do NOT use anion-exchange resin (cholestyramine - binds vancomycin)
4. Isolate patient with contact precautions
5. Disinfect hands with SOAP AND WATER (no alcohol sanitizers - cant kill spores) |
|
|
Term
| T or F: When treating for Gonorrhea (either diagnosed or suspected) you should always treat for chlamydia too BUT when you have a diagnosis of Chalmydia you do not have to treat for Gonorrhea. |
|
Definition
T - if just suspect chlamydia still treat for both, but if you know it is chalmydia, dont have to treat for gonorrhea
(refer to discussion board) |
|
|
Term
What constitutes mild/moderate C.diff infection?
What is the treatment? |
|
Definition
WBC<15,000 and SCr<1.5x baseline (normal)
Metronidazole 500 mg PO Q8H x10-14 days |
|
|
Term
| What is the treatment of an elderly person with C.diff? |
|
Definition
Automatically classified as Severe
Vancomycin 125 mg PO Q6H x10-14 days |
|
|
Term
What are the classifications for Severe C.diff diarrhea?
What is the treatment? |
|
Definition
WBC>15,000 and SCr >1.5 (inflammation and kidney dysfunction)
OR if they are elderly
Vancomycin 125 mg PO Q6h x10-14 days |
|
|
Term
Examples of complicated C.diff infection
What is the treatment? |
|
Definition
Hypotension or shock
ileus
megacolon
Vancomycin 500 mg PO or NGtube Q6H AND Metronidazole 500 mg IV Q8H x10-14 days
**If ilues present consider rectal administration of vancomycin |
|
|
Term
| T or F: if you only have IV vancomycin on hand, you can not treat C.diff infection |
|
Definition
| F - the IV formulation can be given PO |
|
|
Term
| If get a 2nd recurrence of C.diff infection, you should not treat with metronidazole for a 3rd time, why? |
|
Definition
Potential neurotoxicity (increased risk)
peripheral neuropathy |
|
|
Term
| When is metronidazole present in higher concentrations during the treatment of a C.diff infection? |
|
Definition
| At the beginning - higher concentrations found in water diarrhea (as infection improves, concentration of flagyl falls) |
|
|
Term
| Which is more effective for the treatment of C.diff, vancomycin 125 Q6H or 500 mg Q6h? |
|
Definition
Both are equally effective - so give 125 mg since probably more tolerable and cheaper
(But the 500 mg is seen in practice) |
|
|
Term
| T or F: fecal drug concentrations after PO administration of metronidazole may be reduced in the presence of shock, ileus, or megacolon with a C.diff infection. |
|
Definition
| T - so for complicated infections give metronidazole IV and vancomycin PO/NG |
|
|
Term
| What is the most likely cause of C.diff relapse |
|
Definition
|
|
Term
| What is an alternative to vancomycin and metronidazole for C.diff infection |
|
Definition
Fidaxomicin
-macrolide - inhibits RNA polymerase (transcription inactivation)
-PO, minimal absorption
-no activity against B.frag or enterococcus (less disruption of normal flora
$$$$ and just as effective as vancomycin |
|
|
Term
| What are some things that can be employed with recurrent C.diff infections? |
|
Definition
Taper and Pulse vancomycin
Supplemental probiotics
Nitazoxanide
Adjuvant rifaximin
Fecal microbiota transplant
IVIG (iv immunoglobulins) |
|
|
Term
General outline of vancomycin taper and pulse dosing?
Why is it thought to work? |
|
Definition
1. Taper - start with 125 mg Q6h -->Q12h x7days --> Q24h x 7days
2. Pulse - 125 mg q48h x7 --> Q3days x2-8 weeks
NO vancomycin promotes spores to germinate - then give vanc to kill live cells |
|
|
Term
| When should nitazoxanide be used for a C.diff infection? |
|
Definition
Approved for diarrhea associated with Cryptosporidia and Giardia
Shown to work with metronidazole failure, comparable to vancomycin |
|
|
Term
| When has rifximin been used in C.diff infections? |
|
Definition
Rifaximin "Chaser" Protocol: give for 2 weeks immediately after completion of last C.diff treatment and before recurrence of symptoms (used to prevent relapse)
ONLY USE ONCE - acquired resistance has been seen after initial treatment
Approved for traveler's diarrhea due to noninvasive E.coli |
|
|
Term
| T or F: Treatment with Fecal Microbiota Transplant in not very effective. |
|
Definition
F - 94-100% cure rate
It restores normal flora, reduces drug costs, low technology procedure |
|
|
Term
| T or F: low IgG concentrations are associated with symptom development in patients colonized with C.diff |
|
Definition
T
and IgM is low in patients with repeated recurrences |
|
|
Term
| T or F: IV immunoglobulin administration is a very effective way to treat recurring C.diff infections |
|
Definition
| F - seen to be modestly effective in providing passive immunity in patient with recurrent C.diff infection |
|
|
Term
| Which is associated with less recurrence of C.diff infections, vancomyin or fidaxomicin? |
|
Definition
|
|
Term
| Which beta-lactams cause the worst collateral damage? What do they cause? |
|
Definition
3rd generation Ceph (oximinocephalosporins)
Cefotaxime, ceftazidime, ceftriaxone
ESBL production
Selection of stably de-repressed isolates in SPACE bacteria
Selection of VRE
Contribution of MRSA emergence
Increased cases of C.diff associated with diarrhea/colitis
Carbapenems also cause much collateral damage |
|
|
Term
| What is the single most effective measure to prevent spread of resistant organisms |
|
Definition
|
|
Term
| Core members of the Antimicrobial stewardship team |
|
Definition
ID physician (director/co-director)
Clinical pharmacist with ID training (co-director)
-Microbiologist
-Information system specialist
-Infection control professional
-Hospital epidemiologist |
|
|
Term
| What are the two active core strategies of antimicrobial stewardship? |
|
Definition
1. Prospective audit with intervention and feedback to reduce inappropriate antimicrobial use
2. Formulary restriction and pre-authorization leading to reductions in antimicrobial use and cost
Neither is mutually exclusive |
|
|
Term
| What is prospective audit with intervention and feedback |
|
Definition
| When a pharmacist (or someone else) looks at the prescribed ID treatment for a patient. If it is inappropriate, the pharmacist lets the physician know and offers some alternative agents |
|
|
Term
| What is formulary restriction and pre-authorization? |
|
Definition
| Mechanism of antimicrobial stewardship where the hospital formulary is restricted to several antibiotics and if a prescriber wants to go outside of these antibiotics, they must get authorization |
|
|
Term
| What are some additional strategies for antimicrobial stewardship apart from prospective audit and formulary restriction with pre-authorization? |
|
Definition
1. Educational programs
2. Parenteral to oral conversion
3. Creation/implementation of guidelines
4. Antimicrobial order forms
5. Streamlining/de-escalation (when susceptibilities come back)
6. Dose optimization (based on PK/PD)
Combination therapy and antimicrobial cycling have insufficient evidence to support their use as stewardship strategies |
|
|
Term
|
Definition
MOA: inhibits cell wall synthesis - binds to substrate (not enzyme like BL) D-ala-D-ala
Bactericidal and time dependent |
|
|
Term
| Vancomycin indication restriction (UKCMC) |
|
Definition
| 1. Serious or life threatening infections due to beta-lactam resistant G+ organism 2. Patient with serious beta-lactam allergy 3. PO for colitis that fails metronidazole therapy or if severe 4. Unexplained fever (>101F or 100.4 over 1 hr - PO) in neutropenic patients **Before doing all the calculations make sure vanc in indicated |
|
|
Term
| Which is a bigger concern with vancomycin, nephrotoxicity or ototoxicity? |
|
Definition
| Nephrotoxicity (increased risk with other nephrotoxic drugs) |
|
|
Term
| Therapeutic target ranges for vancomycin |
|
Definition
Trough: 10-20 mg/L
Peak: 20-40 mg/L
NOTE: clinically, if trough = 20, then peak will be over 40 |
|
|
Term
| Three big ADRs concerning vancomycin (IV) |
|
Definition
1. Ototoxicity
2. Nephrotoxicity
3. Infusion rxn (Red Man's syndrome) - associated with tachycardia, hypotension |
|
|
Term
| If want to premedicate against infusion rxn related to vancomycin what would you give? |
|
Definition
| H2RA or Antihistamine (Benadryl) |
|
|
Term
| Do you need to adjust the dose of vancomycin if the patient has hepatic failure? |
|
Definition
No, it is not metabolized
only adjust in renal disease |
|
|
Term
| How much time is vancomycin usually infused over? When is the distribution phase assumed to be complete? |
|
Definition
It is infused over 1 hour (at least).
Distribution is assumed to be complete after 2 hours from the start of infusion |
|
|
Term
| T or F: with vancomycin there is a strong correlation between ABW and Vd/Cl |
|
Definition
| T - use ABW in Salazar Corocan Equation for CrCl |
|
|
Term
| Patients with expected altered vancomycin PK |
|
Definition
1. Obese - increased Cl (need bigger doses)
2. Renal failure - decreased Cl
3. Dialysis - hemodialysis does not significantly remove vancomycin from plasma; high-flux dialysis may remove
4. Surgery/Critically Ill/Burn - increased Cl (hypermetabolic), high incidence of renal failure
5. Age - Vd/Cl varies with age; lower doses in elderly |
|
|
Term
| What is the key PK component examined in vancomycin dosing? |
|
Definition
troughs - at steady state (after 4th dose)
minimum of 10 mg/L but 15-20 mg/L for complicated (includes MRSA)
for MIC = 1, target trough >15 mg/L to achieve AUC/MIC = 400 |
|
|
Term
| Typical dose of vancomycin? |
|
Definition
Maintenance: 15-20 mg/kg/dose Q8-12H (with normal renal function)
Cap at 2 gm/dose for obese
Loading dose = 25-30 mg/kg |
|
|
Term
| T or F: you need to monitor peak concentrations to watch for nephrotoxicity in vancomycin |
|
Definition
|
|
Term
| T or F: You need to monitor a patient who will be on vancomycin for 2 days |
|
Definition
| F - only if taking for 3+ days |
|
|
Term
| What is the definition of nephrotoxicity with vancomycin? |
|
Definition
| An increase in SCr of 0.5 mg/dL or >50% increase from baseline, whichever is greater AFTER SEVERAL DAYS of vancomycin (if just 48 hr prob not due to vanco) |
|
|
Term
| When should you monitor for ototoxicty with vancomycin |
|
Definition
| When it is given with other ototoxic drugs, not with monotherapy |
|
|
Term
| T or F: vancomycin monitoring is required for therapy with target troughs under 15 mg/L |
|
Definition
|
|
Term
| How often should you monitor vancomycin levels in hemodynamically unstable patients? |
|
Definition
|
|
Term
| In general, what is the dosing change required for Pediatrics with vancomycin and why? |
|
Definition
| They have larger volumes of distribution, but kidneys arent working all the way - so give a higher dose and extend the interval |
|
|
Term
| How often should you draw a vancomycin level for uncomplicated and complicated patients? |
|
Definition
Uncomplicated - once every 2 weeks
Complicated - once every week |
|
|
Term
| What other labs should be monitored with vancomycin therapy |
|
Definition
| Scr and BUN twice weekly (if complicated Q48H) |
|
|
Term
| T or F: you should always obtain a vancomycin trough for obese patients? |
|
Definition
| T - considered to have altered Cl |
|
|
Term
| T or F: you always need to monitor vancomycin troughs when treating pneumonia? |
|
Definition
T - considered life threatening/need higher doses to penetrate to site
(meningitis, endocarditis, pneumonia, sepsis, osteomyelitis) |
|
|
Term
| What are the three types of osteomyelitis |
|
Definition
1. Hematogenous: non-injury/mainly kids
2. Contiguous: injury-caused
3. Peripheral Vascular Disease |
|
|
Term
| Which type of osteomyelitis is most common in children? |
|
Definition
Hematogenous
hair-pen turns in bones |
|
|
Term
| Is osteomyelitis acute or chronic? |
|
Definition
Can be either
Chronic if over 1 week |
|
|
Term
| If an adult has hematogenous osteomyelitis, where is it most likely to have occurred? |
|
Definition
| Vertebrae (small hairpin turns in these bones) |
|
|
Term
| Symptoms associated with osteomyelitis |
|
Definition
Local: tenderness, swelling, pain
Systemic: fever, chills, malaise, decreased ROM (will always be present, but less prevalent in diabetic foot ulcer) |
|
|
Term
| What labs should be obtained if osteomyelitis is suspected? |
|
Definition
Culture from bone aspirate
Culture potential sources (ex: if wound)
Blood culture
bone scan - can show disease in 1 day
Radiograph - not seen until day 14 of infection (still always get)
**do an MRI if vascular insufficient osteomyelitis (dye cant get to site easily) instead of bone scan |
|
|
Term
| If a patient suspected of having osteomyelitis gets a radiograph and the results are negative, does it mean they dont have osteomyelitis? |
|
Definition
| Not necessarily - radiograph wont be useful until day 14 of infection. |
|
|
Term
| What is one of the most important things to look at when deciding what to treat with for osteomyelitis? |
|
Definition
| Bone culture! always get one! |
|
|
Term
| Mechanism of the development of hematogenous osteomyelitis |
|
Definition
Kids or vertebral = small bones
Slowed blood flow through hairpin turns of vasculature at growth plate
-Cause avascular necrosis, infection, exudate in bone
over 50% have positive bone culture |
|
|
Term
| Pathogens of hematogenous osteomyelitis? |
|
Definition
Biggest cause: S.aureus
Other in kids: H.flu, S.pyogenes (neonates)
Other in Adults: E.coli, M.tb
IV drug users: G-, often in combination (Pseudomonas)
Sickle Cell: Salmonella (S.aureus, G-) |
|
|
Term
| What is the greatest cause of hematogenous osteomyelitis is people with sickle cell? |
|
Definition
| Salmonella - from GI tract |
|
|
Term
| What agent is incorporated into any empiric treatment of hematogenous osteomyelitis? |
|
Definition
Vancomycin (because Staph is most prevalent)
Also include Cefepime/3rd gen Ceph if G- on gram stain (H.flu, E.coli)
Alternatives: bactrim or linezolid |
|
|
Term
| What drug should be used to treat hematogenous osteomyelitis in sickle cell patients? |
|
Definition
| Usually cipro or levofloxacin (Cover salmonella) |
|
|
Term
| What is the most common pathogen in contiguous osteomyelitis? |
|
Definition
| S. aureus (remember, common on skin and this type is caused by an injury) |
|
|
Term
| What are typical pathogens in contiguous osteomyelitis? |
|
Definition
S. aureus
Strep, S.epidermidis
PEcK, Pseudomonas
Anaerobes
Usually multiple organisms if vascular insufficiency (+ enterococcus risk) |
|
|
Term
| What is the gold standard in imaging for suspected osteomyelitis in diabetic foot infections? |
|
Definition
| MRI (bone scan if contraindicated/unavailable) |
|
|
Term
Is recurrence common in osteomyelitis?
What is recurrence associated with for osteomyelitis? |
|
Definition
YES! major problem (~30%)
Correlated with Pseudomonas and use of vancomycin for Staph aureus |
|
|
Term
| What are two critical dosing considerations when treating osteomyelitis? |
|
Definition
1. Must use HIGH doses to get a high enough concentration in bone (can use impregnanted bone cement/spacers)
2. Adequate duration:
-1-3 weeks: if no residual infected bone
-4-6 weeks: if there is some residual infected bone
-over 3 months: if no surgery |
|
|
Term
| When can oral therapy be used, specifically in osteomyelitis? |
|
Definition
When compliance can be ensured
When good response to IV therapy |
|
|
Term
| Treatment of osteomyelitis with vascular insufficiency? |
|
Definition
Treat like diabetic foot:
-go by the severity classifications for DFI
-must cover staph! (not necessarily MRSA)
-consider covering anaerobes if deep (zosyn, metronidazole, aug) |
|
|
Term
| Empiric therapy for contiguous osteomyelitis without vascular insufficiency |
|
Definition
Foot bone: Levofloxacin OR Cefepime +/- Vancomycin (covers G- and G+)
Long Bone: Vancomycin OR Linezolid + cefepime (DEF COVERING MRSA) |
|
|
Term
| In general, recent antibiotics use increases the chance of what kind of pathogen causing the infection? |
|
Definition
|
|
Term
|
Definition
interfere with protein synthesis by binding to ribososmal subunits
bactericidal, concentration-dependent killing with post-antibiotic effect |
|
|
Term
| Indications for aminoglycosides |
|
Definition
aerobic gram-negative bacilli
SPACE
typically used for synergy with beta-lactams
different dosages for G- (target therapy) or G+ (synergy) |
|
|
Term
| Which toxicity associated with aminoglycosides is reversible/irreversible |
|
Definition
nephrotoxicity = reversible
ototoxicity = irreversible |
|
|
Term
| Ways to minimize aminoglycoside toxicity |
|
Definition
-limit total cumulative dose
-use alternative drugs if available for high risk patients/sensitivities known
-monitor renal function tests
-avoid volume depletion
-avoid concomitant nephrotoxic/ototoxic drugs
-PK monitoring/dosing
-QD dosing might be better (maybe) |
|
|
Term
| How long is the distribution phase for aminoglycosides? |
|
Definition
Conventional dosing: 1 hour after start of infusion
Once-Daily Dosing: 2 hours |
|
|
Term
| Normal half-life of aminoglycosides |
|
Definition
|
|
Term
| How is renal function monitored when a patient is on an aminioglycoside? How often? |
|
Definition
SCr/BUN are measured
at least twice weekly
Monitor other signs too |
|
|
Term
| How often should a peak and trough be drawn and measured when a patient is on aminoglycoside therapy (>2 weeks) |
|
Definition
|
|
Term
| T or F: the peritoneum is usually a sterile space |
|
Definition
|
|
Term
| What are the three classes of peritonitis? |
|
Definition
Primary: spontaneous, unidentified sourse (common in alcoholics)
Secondary: perforation in GI tract, uterus, or urinary tract INJURY
Tertiary: persistent or recurrent infection after surgery or antimicrobial therapy |
|
|
Term
| If there is peritonitis due to colon perforation, what must be covered? |
|
Definition
|
|
Term
| What are the two types of primary peritonitis? |
|
Definition
| 1. Cirrhotic Origin 2. Dialysis origin |
|
|
Term
| What are the usual organisms for the two types of primary peritonitis? |
|
Definition
Cirrhotic:
-E.coli (*)
-Klebsiella
-Strep
Dialysis (from skin/plastic)
-Staph (*)
-Strep
-Some enteric G- |
|
|
Term
| What is a good therapeutic option for treatment of cirrhotic peritonitis? |
|
Definition
| Ceftriaxone (covers E.coli, Klebsiella, Strep) x 5-10 days |
|
|
Term
| Which do you treat longer, cirrhotic or dialysis caused primary peritonitis? |
|
Definition
| Dialysis (10-14 days) [cirrhotic = 5-10 days] |
|
|
Term
| Which carbapenem doesnt cover pseudomonas? |
|
Definition
|
|
Term
| Possible antimicrobial regimens for healthcare-associated infections (intraabdominal infection) |
|
Definition
Zosyn
Antipseudomonal carbapenems (all but Erta)
3rd/4th gen Ceph + metronidazole
FQ + metronidazole
Pseudomonas and Anaerobes |
|
|
Term
| Candida is often cultured with intraabdominal infections, should it be treated? |
|
Definition
| Not usually, unless immunosuppressed |
|
|
Term
| When should you cover enterococcus in peritonitis? |
|
Definition
NOT for most community-acquired peritonitis
Cover if patient has VRE or are immunocompromised |
|
|
Term
| Does zosyn or ceftriaxone cover psuedomonas? |
|
Definition
zosyn does
ceftrixaone does not cover Pseudomonas |
|
|
Term
| What antibiotics cover anaerobes |
|
Definition
metronidazole
Tigecycline
Zosyn |
|
|
Term
| How would Aspergillus be described by the lab? |
|
Definition
Septate hyphae
Conidia/spores
flat,velvety consistancy |
|
|
Term
| What does hyaline hyphae mean? |
|
Definition
|
|
Term
| What does dematiaceous fungi mean? |
|
Definition
pigmented fungi (produce melainin)
brown or black coloring |
|
|
Term
| What type of patients are fungal infections commonly seen in? |
|
Definition
|
|
Term
| How would the lab describe Zygomycetes? |
|
Definition
Aseptate hyphae
Rapid growth (compared to Aspergillus)
Sporangium formation (sac-like structure containing spores) |
|
|
Term
| What two types of dimorphic fungi do we need to be concerned with Kentucky? |
|
Definition
|
|
Term
| How are dimorphic fungi usually transmitted? |
|
Definition
|
|
Term
| Dimorphic fungi can be either mould-like or yeast-like, what environmental conditions decide this? |
|
Definition
At environmental temps: mould
At body temps: yeast |
|
|
Term
| What advantage did the lipid formulations of Amphotericin B have over the original formulation? |
|
Definition
| They are equally effective, they are less toxic |
|
|
Term
| What is itraconazole used for (DOC) |
|
Definition
|
|
Term
| What patients still use conventional amphotericin B? |
|
Definition
| Only dialysis patients (because lipid formulations are expensive and their kidneys are already dying) |
|
|
Term
| Which antifungal has the broadest spectrum of activity? |
|
Definition
|
|
Term
| What is the DOC for Aspergillus? |
|
Definition
|
|
Term
| What toxicities are associated with Amphotericin B? |
|
Definition
nephrotoxicity (70% of people taking the conventional form) - less with kids
infusion-related toxicity: slow it down (fever, chills, rigors, N/V, myalgias) |
|
|
Term
| How is the infusion-related toxicity of Amp B managed? |
|
Definition
Low-dose corticosteroids
APAP
Meperidine (rigors) |
|
|
Term
| How is the nephrotoxicity of Amp B managed? |
|
Definition
Hydration/salt loading
USE LIPID PRODUCT |
|
|
Term
| MOA of Amp B compared to Azoles |
|
Definition
Amp B: binds to ergosterol and creates pore in membrane
Azoles: prevents synthesis of ergosterol
Both at high doses will start to target cholesterol too--not seen with echinocandins because they target cell wall, which humans dont have |
|
|
Term
| What is the conventional dose and lethal dose of Amp B? What is the liposomal dose? |
|
Definition
Conventional: 0.5-1 mg/kg
Lethal Dose: 3 mg/kg
Liposomal Dose: 3-5 mg/kg |
|
|
Term
| What is fluconazole DOC for? |
|
Definition
|
|
Term
| Spectrum of activity of fluconazole |
|
Definition
|
|
Term
| What are the dosage forms of itraconazole? |
|
Definition
Solution: empty stomach and tastes bad
Capsule: FATTY meal in acidic environment |
|
|
Term
| When on itraconazole, do you need to monitor kidney or liver function? |
|
Definition
BOTH
Renal - cyclodextrine is the solvent used and is toxic to kidney
Hepatic - BIG drug interactions (3A4) |
|
|
Term
| Which anti-fungal has the WORST drug interaction profile? |
|
Definition
Voriconazole
substrate and inhibitor of 3A4, 2C9, 2C19 |
|
|
Term
| When on voriconazole what should be monitored? (kidney?Hepatic?) |
|
Definition
BOTH
Kidney: cyclodextrin solvent (can cause multiorgan failure); contraindicated in renal failure
Hepatic: BIG DRUG INTERACTIONS |
|
|
Term
| What is the dosage form of posaconazole and how is it administered? |
|
Definition
Oral solution
MUST be taken with high fat meal (50g) BID-QID |
|
|
Term
| What is posaconazole used for? |
|
Definition
|
|
Term
| Spectrum of activity of echinocandins? |
|
Definition
Aspergillus
Candida
(fairly narrow spectrum) |
|
|
Term
| What are some echinocandins? |
|
Definition
Micafungin
Capsofungin
Anidulafungin |
|
|
Term
| Toxicities associated with echinocandins? |
|
Definition
| none, very low toxicity -very safe |
|
|
Term
| What drug is typically added as a second agent in fungal infections to enhance efficacy? |
|
Definition
|
|
Term
| What are the three 'recipes' for AIDS therapy? |
|
Definition
2 NRTI + 1 NNRTI
2 NRTI + 1 PI
2 NRTI + 1 II
**if not on one of these regimens, the the patient probably has resistance** |
|
|
Term
| What antibiotics cover Pseudomonas? |
|
Definition
Pip/Tazo
Ceftazidime
Cefepime
Imipenem/Meropenem
Aztreonam
Aminoglycosides (in combo) |
|
|
Term
| What antibiotics have anaerobic coverage |
|
Definition
Metronidazole
Tigecycline
Beta-lactam + beta-lactamase inhibitors (ie Pip/Tazo, Amp/Sul, Amox/Clav)
Cefoxitin
Carbapenems
Moxifloxacin
PO Vanco (C.diff) |
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