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  1. Gram Positive pathogengs
    • Staphylococcus aureus (MSSA, MRSA, GISA)
    • S. pyogenes
    • Streptococcus pneumoniae (PRSP)
    • Enterococcus faecium (VRE, LR-VRE)
  2. Gram negative pathogens
    • Pseudomonas aeruginosa
    • Acinetobacter
    • Klebseilla
    • Enterobacteriacea
    • E. Coli, Enterobacter,
    • Citrobacter, Serratia,
    • Proteus
  3. Mechanisms of resistance
    • •Enzymatic inactivation
    • •Efflux pumps : pump drug out of cell
    • •Changing in antibiotic binding site
    • •Change in permeability : increase thickness of cell wall
    • Mutations
    • Acquisition of Plasmid
  4. Mechanisms amoung B lactam
    • strep pnuemo: change in PBP
    • MSSA: enzymatic inactivation
    • MSRA: change in PBP
  5. Steps to preven antimicrobial resistance
    • Vaccinate
    • use local data
    • Stop treatment when cured
  6. Penicillin Advantages and Disadvantages
    • AD: low cost, easy administration, excellent tissue penetration, favorable therapeutic index
    • DIS: b lactamase, allergic reaction
    • allergy, dosing
  7. Penicillin adverse reactions
    • hypersensitivity
    • neutropenia, thrombocytopenia
    • interstitial nephritis
    • autoimmune hemolytic anemia
  8. Penicillin Spectrum
    • ABCG strep
    • viridans
    • syphilis
  9. Penicillin dosing
    cont. infusion--> should be written as infusion over 24hrs not q 24
  10. Aminopenicillins Sectrum
    • enteroccus
    • listeria
  11. Aminopenicillins
    • Ampicillin: 3g IV q 6h
    • Amoxicillin: 500 mg po q 8 h
    • CANNOT BE GIVE BY CONT INFUSION
  12. Aminopenicillins + B lactamase inhib
    • s. aureus
    • e coli
    • klebsiella
    • anerobes
    • used in polymicrobial infections (animal, human bits, bowel perforation, intra abdominal abcesses, PID, diabetic foot)

    • --> amp/sulbactam
    • --> amox. clav (fixed dose of clav)
  13. pseudomonas aeruginosa
    • whore
    • minimal nutrient req.
    • in tennis shoes
    • nosocomial
    • presents as UTA, pneumonia, UTI, osteomyelitis, burns, otitis, endocarditis
  14. anti-pseudomonal penicillins
    • extended gram ned spectrum
    • Ticarcillin-- high na content: CI in renal failure
    • Peperacillin-- 12-16 g per day in 4 divided doses
    • stable for cont. infusion
  15. anti- pseudomal + b lactamase
    • MSSA
    • h influenza
    • klebsiella
    • anerobes
    • polymicrobial infections
    • ticarcillin/ clav
    • piperacillin/tazobactam: 4.5 g q 6 hours based on kidney function
  16. Penicillinase resistant penicillins
    • Nafcillin
    • MSSA
    • strep ABCG

    • Coagulase positive = S. aureus
    • Coagulase negative = S. epidermidis, S. saprophyticus
  17. Cephalosporins advantages and distadvantages
    • Advantages
    • Dosed less frequently

    • Disadvantages
    • select for cephalosporinases and ESBL
    • no activity against Enterococcus sp.
    • expensive
  18. 1st generation ceph
    • cephalexin- 500mg q 6h
    • cefazolin- surgical prophylaxis, cellulitis,
  19. ceftriazone/ cefotaxime
    • s. pneumo
    • S aureus
  20. ceftazidime
    pseudomonal
  21. cefepine
    • staph aureus
    • pseudomans
    • BID: 2g q 8h
  22. Carbapenems
    • imipenem/ cilastatin
    • peropenem
    • doripenem

    • MSSA
    • b Fragilis
    • pseudomonas

    for serious nosocomial infections

    SE: seizures
  23. Ertapenem
    • once daily
    • - does not cover pseudomonas or enterococcus
    • - for intra-abdominal and complicaetd ssi
    • - T1/2= 4 hours
  24. Aztreonam
    • only gram neg (pseudomonas)
    • used when allergic to PCNs but cross reaction with ceftazidime
  25. b lactam allergy
    Type I: Immediate hypersensitivity, IgE mediated, anaphylaxis, minutes

    Type II: Cytotoxic antibodies, IgG, IgM bind to renal/blood cells, anemia, leucopenia, thrombocytopenia, nephritis, dose and duration dependant

    Type III: Immune Complexes, IgG, IgM bind to antigens and form circulating complexes, serum sickness, 7-14 days after initiation

    Type IV : Cell mediated, no antibody involved, T-cell dependant, T-cells recognize the antigen leading to WBC recruitment to the site leading to inflammation, contact dermatitis
  26. Entercococcus
    • - Normal gut flora
    • - E. faecalis accounts for 90% of isolates and E.faecium ~10% of isolates
    • - Multidrug resistant (including vanco.) strains of E.faecium have increased and referred to as VRE
    • - Not intrinsically virulent but may act synergistically with other organisms
    • - Contact precautions are critical
  27. Vanco
    • - gram pos for resistant organisms
    • - not for MSSA
    • - potential for VRE
    • - for c. difficile
  28. Vanco PD
    • 1 g q 8-12 h or 15mg/kg q 12-- dose for renal
    • -AUC/MIC monitoring
    • - maintain 10-20 mcg/ml
    • - dont use if MRSA isolate is 2mcg/ml
  29. Quinupristin/ Dalfospristin
    • VRE facium
    • Step
    • MRSA
    • MRSE
    • monitor myalgias and LFTS
  30. Linezolid
    • Oxazolidinone
    • VRE
    • MRSA
    • s. pneumo
    • t>mic and auc.mic
    • SE: serotonin syndrome, thrombocytopenia
  31. Daptomycin
    • MRSA
    • VRE
    • cSSTI and bacterema
    • skeletal muscle toxicity
  32. Tigecycline
    • MRSA
    • VRE
    • enterobacteriacea
    • Acinebacter
    • not active agains pseudo bc of efflux pumps
    • SE: NV
  33. Ceftaroline
    the new miracle cephalosporin
  34. Aminoglycosides
    • gentamicin
    • tobramycin
    • amikacin
    • streptomycin

    • MSSA
    • enterococcus
    • pseudomonas (amikacin>tobramycin>gentamycin)
    • NOT anerobes
  35. Amindoglycosides dose
    gentamicin and tobramycin

    • 1-2mg/kg q 8-12 h-- for enterococcal
    • 5-7 mg/ kg q 24h -- for gram neg

    adjust for crcl < 60ml/min
  36. Aminoglycosides Tox
    Nephrotoxicity- elderly, renal insuff. dehydration, cirrhosis, long duration

    ototoxicity- exposure dependent
  37. Fluoroquinolones
    cipro, levo, mox, gemi

    • gram + = pnuemo
    • mycoplasma
    • chlamycia
    • ricketssia
    • legionela

    peak/mic auc/mic
  38. Cipro
    • staph (not first line bc of resistance)
    • mycobacteria
    • UTS
    • BID
  39. Levo
    • s pneumo
    • CAP and HAP
    • qd
  40. Moxifloxacin
    • CAP
    • cSSI
    • qd
    • not removed by kidney (no UTI)
  41. Flurorquinolone SE
    • dizziness, ha, insomnia
    • nvd
    • drug interactions: caffiene, metal
    • tendinitis
    • hypersensitivity
    • QT prolongation
    • dysglycemia
  42. Macrolides
    • Erythromycin
    • -Potent P-450 inhibitor which results in multiple potential drug interactions
    • -Dosed q6h, frequent GI distress associated with erythro

    • Clarithromycin (Biaxin®)
    • -Moderate P-450 inhibitor with significant profile for drug interactions
    • -Dosed q12h

    • Azithromycin (Zithromax®)
    • -No interaction with cytochrome P-450
    • -High drug concentration achieved intracellularly
    • -Dosed QD
  43. Azithromycin
    • 60 hr t1/2
    • gram pos (strep)
    • respt tract gram neg
    • atypicals and mycobacteria
    • not UTIs
  44. Tetracyclines
    • Doxycycline: CAP caused mycoplasma and chlamydia
    • Minocycline: p. acnes
  45. Metronidazole
    • B fragilis
    • c dificile
    • metallic taste
    • peripheral neuropathy
    • inhibits alc dehydrogenase
  46. Clindamycin
    • b fragilis
    • MRSA
    • bone penetration
  47. Bactrim
    • broad
    • MRSA
    • prophylaxis
  48. nitrofurantion
    • UTI- VRE, urthritis
    • precautions: peripheral neuropathy, lung, g6pd def.
  49. colistin
    • pseudo
    • cystic fibrosis pts
  50. Fosphomycin
    preggers resistant UTI
  51. Limitations of MIC
    • Time course
    • rate of bacterial kill
    • dose-kill relationshipPA
  52. cmax:mic
    • aminoglycosides
    • fluroquinolones
  53. AUC:MIC
    fluroquinolones
  54. t> MIC
    • carbapenems
    • cephalosporins
    • penicillins
  55. Strategies to increase t>MIC
    • increase dose frequency
    • increase duration of infusion
    • select agent with lower MIC
    • want it between 8 and 16
  56. Aminoglycosides HDODA
    want cmax ratio to be 8-10 to get a peak of 16-20mcg/ml for gentamicinand tobramicin

    first dose: 4-7 mg/kg then adjust

    aim for undetectable trough

    Peak occurs 2 hours after end of infusion
  57. aminoglycoside traditional dosing
    get peak concentration of 4-10 mcg/ml with a ratio of 2-5

    for gram positive organisms

    • give 1-2 mg/kg q 8 hours then adjust
    • - peak concentrations range between 4-8 ug/ml and trough is 1-2 ug/ml

    Peak occurs 1 hour after infusion
  58. Exclusion criteria for HDODS of aminoglycosides
    • crcl of <40ml/min
    • entercoccus infection
    • spinal chord injury
    • burn pts
    • meningitis
  59. A patient has renal def. and is getting once daily aminoglycoside
    this is traditional dosing not hdoda
  60. distribution of vanco
    • t1/2a = 30 mins
    • variable protein binding

    • cl relates to crcl
    • t1/2 = 3-9 hours
  61. target trough for vanco
    15-20mg
  62. infusion rate for vanco
    <15mg/min
  63. Vanco TDM
    peak: 2 hours after 1 hour infusion

    Trough: within 1 hour of next dose
  64. Loading dose
    • <50kg= 1g
    • 50-100kg = 2g
    • >100kg = 3g
  65. Vanco dose
    • 50-79kg = 1g
    • 80- 100kg = 1.5g
    • >100 = 2g
  66. Vanco dose interval
    • q8h (CrCl> 100 ml/min)
    • q12h (CrCl> 50-100 ml/min)
    • 24h (CrCl< 50 mL/min)
  67. what side are teh aortic and mitral valve on?
    left side
  68. risk factors of endocarditis
    • -prosthetic valve
    • - mitral valve prolapse with regurgitation
    • - IV drug abuse
  69. viridans strep
    - common in mouth and gingiva
  70. streph bovis
    found in gi tract
  71. enterococci
    • found in gi tract
    • - includes enteroccus faecalis and faecium
    • - difficult to treat and needs combination therapy always
  72. right sided IE
    • IVUD
    • MRSA
    • low mortality
    • treated with abs
  73. left sided IE
    • mostly prosthetic valves
    • MRSA and MRSE
    • surgery + abs
    • three drug regimen
  74. Virdams strep / S bovis that's PCN- S
    • 1. penicllin/ ceftriaxone only
    • 2. penicillin/ ceftriaxone + gentamicin
    • 3. vanco only
  75. Vidans/ bovis that PCN- R
    • 1.penicillin/ ceftriaxone + gentamicin
    • 2. vanco only
  76. EI- Enterococci that's PCN-S
    • 1. Penicillin/ Amp + gent/ strep
    • 2. vanco + gent/ strep
  77. EI- enterococci that's PCN- R
    • 1. Vanco + gent/ strep
    • 2. Gent+ amp/sulbactam
  78. EI staph - MSSA
    • 1. nafcillin/ cefazolin + gent
    • 2. vanco only (pen allergy)

    • for prostetic
    • 1. add gent + rifampin
  79. EI- MRSA
    1. vanco

    • for prostetic
    • 1. vanco + gent + rif
  80. Prophylactic treatment
    • Amox 2g
    • clindamycin 600mg po
    • cephalexin
    • azith
    • clarith
    • one hour prior to procedure
  81. Common pathogens of CNS infections
  82. –Streptococcus pneumoniae
    • –Neisseria meningitidis
    • –Haemophilus inflenzae
  83. s/s of meningitis
    • stiff neck
    • headache
    • photophobia
    • irritable
    • kernig and brudzinski
    • seizures
  84. opening pressure
    • normal is 100
    • over 200 is concerning
  85. bacteria: eat __ and poop ___
    • glucose
    • protein
  86. pathogen in minigitis based on age
    • 1-2 years: pneumo, h influenzae
    • 2-50: s pneumo, maybe flu, neisserria
    • >50: pneumo, nesserria, listeria,
  87. Emperic therapy of meninigits
    • 1-2: dex if h.flu or pneumo + ceftriazone + vanco
    • 2-50: dex if pneumo + ceftriaxone + vanco
    • >50 : dex if pneumo + ceftriaxone + vanco + amp
  88. dexamthasone dose
    • children: .4mg/kg q 12h for 2 days
    • adults: .15mg/kg q 6 h for 2-4 days
  89. emperic dosing for meningitis
    • ceftriaxone: 2g q 12 hours
    • vanco: 15 mg/kg q 12
  90. Neisseria Meningitidis
    • Behavioral change, seizures, coma
    • •Up to 50% , DIC, purpuric lesions

    • •Drug of choice (high doses) X 7 days:
    • •Penicillin G IV (if Pen MIC= S)
    • •Ceftriaxone or cefotaxime (if Pen MIC= I/R)
  91. prophylaxis of meningitis
    Rifampin po for 4 days
  92. Streptococcus pneumoniae for meningitis
    • DOC (x10-14 days)
    • –Ceftriaxone or (cefotaxime)
    • –Vancomycin (Cephalosporin allergy or resistance)
  93. H influenzae for meningitis
    DOC: ceftriaxone or cefotaxime
  94. SIRS
    • can be infection or non-infectious etiology
    • ► 2 or more of the following are clinical insults:
    • -Temperature >38°C or <36°C
    • -HR >90 beats/min
    • -Respirations >20/min
    • -WBC count >12,000/mL or <4,000/mL or >10% immature neutrophils
  95. Sepsis
    • clinical insults which are due to infection
    • ► 2 or more of the following are clinical insults:
    • -Temperature >38°C or <36°C
    • -HR >90 beats/min
    • -Respirations >20/min
    • -WBC count >12,000/mL or <4,000/mL or >10% immature neutrophils
  96. Severe sepsis
    sepsis with >1 organ dysfunction
  97. septic shock
    • severe sepsis thats hypotensive
    • perfusion abnormalities
  98. pathogen of sepsis
    • SA
    • pneumo
    • e coli
    • klebisiella
    • psuedo
  99. adjuctive therapies for sepsis
    • Hemodynamic- fluid - NS. vasopressor, inotropic
    • oxygen
    • nutritional support (high protein low carbs)
  100. fluic support in sepsis
    • isotonic cyrstalloids
    • 0.9% nal --> may need 10L in 24 hours
  101. Inotrope therapy
    dopamine and dobutamine
  102. vasopressor therapy
    norepinephrine, phenylephrine, epinephrine
  103. staph aureus
    • anti b lactam
    • cephalexin
    • ceftriaxone/ ceftaxime
    • cefepime
    • cipro
    • aminoglycosides
    • nafcillin
  104. s. pneumo
    • pen
    • ceftriaxone/ ceftaxime
    • linezolid
    • levo
    • azith
  105. pseudo
    • anti-pseudo
    • ceftazidime
    • cefepine
    • cipro
    • aminoglycosides
    • azetreonam
    • azith
    • carbapenams
    • colistin
    • fosphamycin
  106. enterococc
    • NOT CEPHS
    • aminopens
    • tigecycline
    • aminoglycosides (Td)
  107. B lactams inhibitors
    • klebsiella
    • e coli
    • h influenza
    • anerobes
    • MSSA
  108. MRSA/VRE
    • vanco
    • quin.dal
    • dapto
    • trigecycline
    • trim/sul
  109. acinobacter
    • carbapenams
    • trigecyclin
  110. anerobes
    • carbapename
    • ertapenem
    • metronazole
    • clindamycin
  111. atypical
    • quiolones
    • macrolides

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