Therapy

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zutz
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17331
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Therapy
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2010-05-09 23:54:34
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Exam 3
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  1. Gonococcal vs nonspecific urethritis (sx's)
    • *Gonococcal: discharge is yellow/green and profuse; severe dysuria; incubation of < 4 days
    • *Nonspecific: gray or clear discharge mixed w/ mucous and slight; mild-moderate often intermittent dysuria; incubation 7-14 days
  2. Diagnosis of urethritis
    • *Mucopurulent or purulent discharge
    • *Gram stain: >/= 5 WBC/oil field
    • *Positive leukocyte esterase test or >/= 10 WBC/HPF on 1st void
  3. What organisms cuase mucopurulent cervicitis?
    • Neisseria gonorrhoeae
    • Chlamydia trachomatis
  4. What organisms cause gonococcal urethritis?
    Neisseria gonorrhoeae
  5. What organisms cause nonspecific urethritis?
    • Chlamydia trachomatis
    • Ureaplasma biovar 2
    • Trichomonas vaginalis
    • Herpes simplex
    • Unknown (30%)
  6. Diagnosis of cervicitis
    • *Dx based on clinical picture:
    • -yellow endocervial exudate
    • -endocervical bleeding induced by swab
    • -increased # of PMN's on gram stain
  7. How many pts present w/ sx of Chlamydia?
    • Men: 50%
    • Women: 25%
  8. Complications of chlamydia
    • *Neonatal lung and eye infxn
    • *PID
  9. Tx for chlamydia
    • *Azithroymcin 1g x 1 dose OR
    • *Doxycycline 100mg po BID x 7 days
  10. Tx for chlamydia in pregnancy
    • *Azithroymcin 1g x 1 dose OR
    • *Amox 500mg TID x 7 days

    -Repeat testing 3 wks after completion of tx
  11. Complications of gonnorrhea
    • *Neonatal eye infections
    • *PID
    • *Bartholin's abscess
    • *Disseminated gonococcal infxn
  12. Dx of gonorrhea
    • *Culture all sites of sexual contact
    • *Gram stain of urethral discharge (men)
    • ->/= 5 WBC/oil field
    • -intracellular G- diplococci
  13. Tx for gonorrhea
    • *Ceftriaxone 125mg IM x 1 dose OR
    • *Cefixime 400mg x 1 dose
    • *PNC allergy: spectinomycin

    -If chlamydia infectio is not ruled out by nucleic acid amplification test also treat for that (Azith or doxy)
  14. Disseminated gonoccal infection
    • *Spread of gonorrhea to other parts of the body
    • *Occurs in 1-3% of untx'ed pts (4:1 females:males)
  15. Presentation of disseminated gonococcal infection
    • *Chills, polyarthralgias, fever, ans skin rash-->blood cultures often +
    • *Septic arthritis, primary monoarticular-->blood cultures typically - but joint fluid often +
  16. Tx of disseminated gonococcal infection
    • *Hospitalization
    • *Ceftriaxone 1g IV/IM q day until sx have improved for 24-48 h, then complete a 7 day course of PO
    • *Tx chlamydia if not ruled out
  17. Causative organisms of PID
    • *N. gonorrhoeae
    • *Chlamydia
    • *M. hominis
    • *Anaerobes: bacteroids and peptosteptococcus
    • *Aerobes: G. vaginalsi, S. agalactiae, E. coli, H. influenzae
  18. Complications of PID
    • *Infertility
    • *Ectopic pregnancy
    • *Chronic pain
  19. Dx of PID
    • *Unterine/adnexal tenderness
    • *Cervical motion tenderness

    -Begin empiric tx if these criteria are present and no other cause can be ID'ed
  20. Tx of PID: inpatient
    *Standard regimen: Cefotetan 2g IV q 12 h OR cefoxitin 2g IV q 6 h + doxycycline 100mg PO or IV q 12 h x 14 days

    *Prefered for abscesses: Clindamycin 900mg IV q 8 h + gentamicin 5mg/kg IV q 24 h
  21. Tx of PID: outpatient
    *Ceftriaxone 250mg IM x 1 OR Cefoxitin 2g IM x 1 + probenecide 1g PO x1

    • *Plus doxycycline 100mg PO BID x 14 days
    • *w/ or w/o metronidazole 500mg BID x 14 days
  22. Partners of PID patients
    Tx presumptively for both Neisseria gonorrhoeae and Chlamydia trachomatis
  23. Diseases which cause painful genital ulcers
    • *Chancroid
    • *Genital herpes
  24. Diseases which cause painless genital ulcers
    • *Syphilis
    • *Lymphogranuloma venereum
    • *Granuloma inginale
  25. Chancroids
    • *Painful
    • *Caused by Haemophilus ducreyi
    • *Rare in US
    • *Increased risk of HIV
    • *Incubation: 1-14 days (average 2-5)
  26. Tx of chancroids
    • *Azithromycin 1g x 1 OR
    • *Ceftriaxone 250mg IM x 1 OR
    • *Cipro 500mg PO BID x 3 days OR
    • *Erythromycin base 500mg PO TID x 7 days
  27. Granuloma inguinale
    • *Painless genital ulcer
    • *Caused by calymmatobacterium granulomatis
  28. Lymphogranuloma venereum
    *Caused by chlamydia serovas L1, L2, & L3
  29. Independent predictors of genital herpes
    Females, minorities, older age, poverty, less education, cocaine use, # of partners
  30. Genital herpes infections
    • *Most are due to HSV-2 (70-90%) {increase in GH due to HSV-1 in madison}
    • *Typical case shows crop of painful vesicles that ulcerate and eventually curest over w/o scarring
    • *Fever, malaise, myalgias, and tender lymphadenopathy common
  31. Recurrence of genital herpes
    • * 89% w/ HSV-2
    • *precipitated by fever, sunlight, emotional stress, trauma, and menstration
    • *asymptomatic viral shedding
  32. Impact of tx on primary genital herpes
    *Tx will decrease: duration of viral shedding, time to crusting of lesions, duration of sxs, formation of new lesions after primary infection
  33. Tx of primary genital herpes
    • *Acyclovir: 200mg 5x/day x 7-10 days OR 400mg TID x 7-10 days
    • *Famciclovir 250mg PO TID x 7-10 days
    • *Valacyclovir 1g BID x 7-10 days
  34. Tx of recurrent genital herpes
    • *Acyclovir: 400mg TID x 5 days OR 800mg BID x 5 days OR 800mg TID x 2 days OR
    • *Famciclovir 125mg BID x 5 days OR 1000mg BID x 1 day OR
    • *Valacyclovir 500mg BID x 3 days OR 1000mg qd x 5 days
  35. Tx of genital herpes for chronic suppression
    • *Indicated w/ >/= 6 episodes/yr
    • *Tx for 1 year
    • *Acyclovir 400mg BID OR
    • *Famciclovir 250mg BID OR
    • *Valacyclovir 500mg or 1000mg qd
  36. Prevention of genital herpes
    • *Valacyclovir decreases overall viral transmission by 50%
    • *Pearl: give to man only if man has HSV and partner doesn 't and wants to get pregnant
  37. Screening for syphilis
    • *Screen w/ non-treponemal test (sensititve but non-specific)
    • *Confirm dx w/ treponemal test (specific)
  38. Stages of syphilis
    • *Primary: painless, solitary chancre w/o 10-90 days after infection and heals w/in 6 wks
    • *Secondary: 2-8 weeks after chancre heals. Infectious skin leasions are maculo-papular (hands and soles); may have fever, malaise, pharyngitis, wt loss & nodes
    • *Latent: asymptomatic
    • -Early: infected <1 yr; infectious
    • -Late: infected >1 yr; non-infectious
    • *Tertiary: aortitis, vasulitis, gumm
    • *Neurosyphilis: dementia, tabes dorsalis
  39. Tx of syphilis (dependent on stage)
    • *Primary, secondary, or early latent:
    • -Benzathine penicillin G 2.4 million units IM x 1
    • -PCN allergy: doxycycline 100mg BID x 14 days
    • *Late latent (or if unknown duration)
    • -Benathine penicillin G 2.4 million units IM q week x 3
    • *Neurosyphilis: IV PCN x 10-14 days
  40. Distinguishing Chancroid vs Syphilis vs Herpes
    • *Chancroid: tender, purulent, undermined border
    • *Syphilis: painless, indurated, not purulent
    • *Herpes: multiple, painful, shallow, and not purulent
  41. Which HPV types have highest risk for malignancy
    *16 & 18
  42. Tx of genital warts (self-administered)
    • *Podofilox: 0.5% gel or soln BID x 3 days (repeat weekly up to 4 cycles)
    • *Imiquimod: 5% crm TIW x 16 wks
  43. Imiquimod
    • *Potent inducer of interferon
    • *Crm weakens condoms/diaphrams
    • *Works better in women (72%) than men (33%)
  44. Tx of genital warts (provider administered)
    • *Cryotherapy q 1-2 wks
    • *Podophyllin resin 10-25% weekly
    • *Trichloroacetic acid 80-90% weekly
    • *Surgical removal
    • *Laser tx
    • *Interferon alpha
  45. Tx of subclinical genital wart infection
    *No tx recommendations
  46. HPV testing
    • *Approved in women >/= 30 yo
    • -Cytology and HPV neg: rescreen in 3 yrs
    • -Cytology neg and HPV pos: rescreen in 1 yr
    • -Both positive: refer for colposcopy
  47. HPV vaccine recommendations
    • *Girls 11-12 (as early as 8 and late as 26)
    • *3 dose series (0, 2, 6 months)
  48. Tx of bacterial vaginosis
    • *Metronidazole 500mg BID x 7 days OR
    • *Metrogel 0.75% 5g intravaginally qd x 5 days OR
    • *Clindamycin 2% crm 5g intravaginally qHS x 7 days
  49. Tx of baginitis caused by trichomoniasis
    • *Metronidazole 2g PO x 1 dose OR
    • *Tinidazole 2g PO x 1 dose OR
    • *Metronidazole 500mg BID x 7 days
  50. Tx of vulvovaginal candidiasis
    *Many options
  51. Tx of pubic lice
    • *Lindane 1% shampoo: apply for 4 minutes then wash off
    • *Kids and pregnant women: permethrin 1% crm rinse to AA for 10 minutes then wash off

    • -Wash linens and clothes used in past 2 days
    • -Abstain from sex until partner tx'ed
  52. Tx of scabies
    • *Lindane (toxicity concerns)
    • *Permethrin (requires complete coverage)
    • *Ivermectin (?able safety, esp in kids)
  53. Prophylaxis tx in sexual assaults
    • *Ceftriaxone 125mg IM x 1 AND
    • *Metronidazole 2g x 1 AND
    • *Azithromycin 1g PO x 1 or doxycycline 100mg BID x 7 days
  54. Etiology of asymptomatic bacteriuria
    • *E. coli
    • *Klebsiella pneumoniae
    • *Coagulase neg staph
    • *Enterococcus
    • *Grp B strep
    • *Gardnerella vaginalis
    • *Proteus mirabilis
  55. Def asymptomatic baceriuria
    • Pregnant women: isolation of bacteria from urine specimen
    • Non-pregnant women: same bacterial strain isolated from 2 consecutive specimens in a quantity of >/= 1x105 cfu/ml
    • Men: single clean-catch urine w/ 1 bacterial spp in quantity of >/= 1x105 cfu/ml
    • Catheterized: single specimen w/ >/= 1 bacterial species in quantity of >/=1x105 cfu/ml
  56. Which pts do we screen and tx for asymptomatic bactiuria?
    • *Pregnant women
    • *Pts undergoing prostate or urological surgeries
    • *If persistent bacteriuria persits >48 h post-removal of catheter

    -Tx to cover bacteria found on culture
  57. "Uncomplicated" UTIs
    • *Pre-menopausal adult females
    • *Occasional infection
    • *Upper and/or lower infection
  58. "Complicated" UTIs
    • *Upper or lower tract infxns PLUS any of these 'risk factors':
    • -Pregnancy
    • -Male
    • -Functional or anatomic abnormalities of the urinary tract
    • -Immunosuppressed
    • -Presence of catheter
    • -Kids or elderly
    • -Recurrent infxn
  59. Sx's of UTIs
    • *Frequency
    • *Urgency
    • *Dysuria
    • *Suprapubic pain
    • *Hematuria
  60. Organisms in uncomplicated UTIs
    • *E. coli (up to 90%)
    • *Staph saprophyticus
    • *Enterobacteriaceae
    • *Enterocuccus
  61. Tx of uncomplicated UTIs
    • *TMP/SMX x 3 days
    • *FQ x 3 days
  62. Organisms in complicated UTIs
    • *E. coli
    • *Klebsiella pneumoniae
    • *Citrobacter
    • *Enterobacter
    • *Serrotia
    • *Proteus mirabilis
    • *Providencia
    • *Morganella morganili
    • *Pseudomonas aeruginosa
    • *Enterococcus
  63. Management of complicated UTIs
    *Urine specimen for gram stain and quantitative culture
  64. Tx of complicated UTIs (oral agents)
    • *Levofloxacin
    • *Ciprofloxacin
    • *TMP/SMX
    • *Nitrofurantion
    • *Cefuroxime/cefpodoxime
    • *Amox +/- clavulanate

    -Tx for 7-14 days and obtain follow-up cultures in 10-14 days
  65. Tx of complicated UTIs (parenteral agents)
    • *Levofloxacin
    • *Ciprofloxacin
    • *Gentamicin/tobramycin (+/- ampicillin)
    • *Amikacin (+/- ampicillin)
    • *Cefuroxime/cefotaxime/ceftriaxone
    • *Ampicillin + sulbactam
    • *Pipercillin + tazobactam

    • -After culture results, switch to PO
    • -Obtain FU cultures in 10-14 days
  66. Sx of pyelonephritis
    • *Fever (>38 C)
    • *Chills
    • *N/V
    • *S/sx of cystitis
    • *Flank or abdominal pain
    • *Costovertebral (CVA) tenderness
  67. Organisms in pyelonephritis
    • *Same as cystitis --> E. coli most common
    • *Perform urinalysis, urine, and blood cultures
  68. Tx of pyelonephritis (outpatient)
    • *Empiric tx: FQ OR TMP/SMX (if pathogen is known to be susceptible)
    • *G+ organism: amoxicillin OR augmentin

    *Tx PO for 7-14
  69. Tx of pyelonephritis (inpatient)
    • *Consider if pt is too ill or is unable to take PO
    • *Tx for 10-14 days w/ 48-72 hours of IV tx

    • *Empiric tx:
    • -FQ OR
    • -Ampicillin + aminoglycoside OR
    • -3rd gephalosporin + aminoglycoside
    • *G positive: amp/sulbactam +/- aminoglycoside
  70. Def of catheter associated UTI
    • *S/sx of UTI
    • *No other IDable source of infxn
    • *Single urine specimen w >/= 1 bacterial species in quantity of >/= 1x103 cfu/ml
    • *In pts with catheters or w/in 48 h of catheter removal
  71. Organisms in CA-UTIs
    • *<30 days: single spp
    • -E. coli (most common)
    • -Ecterobacteriaceae spp
    • -G+ cocci
    • *>/=30 days: polymicrobial
    • -organism above
    • -P. mirabilis
    • -Morganella morganii
    • -Pseudomonas stuartii
  72. Tx of CA-UTIs
    • *Replace indwelling catheters that have been in place >2 wks (obtain culture from now catheter)
    • *Tx for 7 or 10-14 days
  73. Recurrent UTI--relapse
    • *Persistance of pre-tx organism
    • *Often occurs <2 wks after completion of tx
    • *Extensive urologic evaluation
    • *Longer duration of tx
    • *Defined as "complicated"
  74. Recurrent UTI--reinfection
    • *"New" infxn
    • *Can be same or diff organism
    • *Often occurs >2 wks after completion of tx
    • *Occurs when sterile urine is documented btwn infxns
    • *Majority of cases of recurrent UTIs
    • *Common in young, sexually active women
    • *Defined as "uncomplicated"
  75. Management of recurrent UTIs
    • *Perform urine culture to determine relapse or reinfection
    • *Prevention w/ behavior modifications: contraception, post-coidal voiding, liberal fluid intake, cranberry juice, probiotics
    • *Abx
  76. Candidates for prophylactic UTI tx
    • *Young women w/ >/= 2 symptomatic UTIs w/in 6 months -OR- >/= 3 symptomatic UTIs w/in 12 months
    • *Tk pt's discomfort into concideration
  77. Continuous or post-coital prophylactic UTI tx
    • *TMP/SMX (80mg/400mg) TIW
    • *Nitrofurantion 50-100mg qd
    • *Cephalexin 250mg qd
    • *Trimethoprim 100mg qd (not for post-coital)
    • *Cipro 125mg qd
  78. Intermittent prophylactic UTI tx
    • *3 day course of:
    • -TMP/SMX
    • -FQ

    *Instruct pt to contact provider if sx not resolved in 48 h
  79. Management of asymptomatic candiduria
    • *Tx not usually indicated
    • *Tx only for high risk pts (low birth wt infants, neurtropenics, pts undergoing urologic manipulation)
  80. Tx of candiduria
    • *1st line: fluconazole 200mg d x 14 days
    • *Amphotericin B (via bladder irrigation or IV)
    • *Flucytosine (PO)
  81. Presentation and cause of acute bacterial prostatitis
    • *Presentation: obvious sx of UTI, intense suprapubic pain, urinary obstruction, fever, malaise, arthralgia, myalgia
    • *E. coli is most common pathogen
    • *Get gram stain and culture and DO NOT examine and massage the prostate
    • *A urologic emergency
  82. Tx of acute bacterial prostatitis
    • *Initial: PCN IV + AG
    • *When stable: FQ po
    • *Tx x 3-6 wks
    • *F/U w/ culture in 7 days to ensure its clean
    • *Consider NSAIDs to assist w/ pain and inflammation
  83. Presentation and cause of chronic bacterial prostatitis
    • *E. coli most common, but increasing prevalence of G+ org. compared to acute prostatitis
    • *Presentation: recurrent UTI sx's, perineal discomfort, fever
    • *Dx made from analyzing prostatic secretions post prostatic massage
  84. Tx of chronic bacterial prostatitis
    • *1st line: FQ (cipro or levo) -->assure G- etiology
    • *TMP/SMX
    • *Doxycycline

    *Tx x 4-6 wks
  85. What is one reason to avoid nitrofurantoin
    *Cannot reach the bladder if CrCl <40 ml/min
  86. Meninges
    The three membranes that cover the brain and spinal cord: dura mater, arachnoid mater, and pia mater
  87. Meningitis
    Inflammation of the subarachnoid space or spinal fluid
  88. Where are the most cases of meningitis found?
    Meningitis belt: sub-Saharan Africa
  89. Bacterial etiology of meningitis
    • *Strep pneumoniae (most common)
    • *H. influenzae
    • *N. meningitidis
    • *Listeria monocytogenes
    • *Strep agalactiae
    • *Aerobic G-: Klebsiella, E. coli, Pseudomonas, Salmonella
    • *Staph aureaus (especially post-neurosurgery)
  90. Non-bacterial etiology of meningitis
    • *Viral: enteroviruses (most common), mumps, herpes, HIV, West Nile
    • *Spirochetes: Treponema pallidum, Borrelia burgdorferi
    • *Amebas
  91. Signs and sx of meningitis
    • *Severe HA
    • *Nuchal rigidity
    • *Altered mental status
    • *Fever & chills
    • *Photophobia
    • *N/V
    • *Sz
    • *Kernig's and Brudzinski's signs
    • *Cutaneous infections (esp in neonates)
  92. CSF results post-lumbar puncture for meningitis
    • *WBC: <5-10
    • -Elevated in all infections: Bacterial: >1000; Fungal and TB <500; Viral 50-1000
    • *Neutrophils: predominant in bacterial infections and may be increased in viral infections
    • *Glucose: 50-66% of serum
    • -Decreased in all infections
    • *Protein: <50 mg/dL
    • -Increased in all infections
  93. Management of bacterial meningitis
    • *If there is a suspicion, get blood cultures and lumbar puncture STAT
    • *Give dexamethasone and emperic abx tx
    • *If CSF findings positive for bacterial meningitis target abx tx, if not continue ET (keep pt on dexamethasone either way)
  94. Why dexamethasone for meningitis?
    • *Decreases subarachnoid space inflammatory response and overall decreases rate of mortality, severe hearing loss, and neurologic sequelae
    • *Give w/ or just prior to 1st dose of abx
    • *May reduce penetration of vancomycin into CSF
  95. What meds do not reach therapeutic concentrations in the CSF regardless of meninges inflammation?
    • *AG
    • *Clindamycin
    • *Amphotericin B
    • *1st and 2nd gen cephlosporins (EXCEPT cefuroxime)
  96. Which drugs reach therapeutic levels in the CSF only if there is inflammation of the meninges?
    • *PCN G
    • *Ampicillin
    • *Cefotaxime
    • *Ceftriaxone
    • *Cefuroxime
    • *Vanco
    • *Meropenem
    • *Linezolid
    • *Cipro
  97. What is ET for a <1 month old with meningitis?
    • *Ampicillin + cefotaxime OR
    • *Ampicillin + AG
  98. What is ET for a 1mo to 50 yo w/ meningitis?
    • *Vanco + cefotaxime OR
    • *Vanco + ceftriaxone

    -If Listeria is suspected add ampicillin
  99. What is ET for a >50 yo w/ meningitis?
    • *Vanco + ampicillin + cefotaxime OR
    • *Vanco + ampicillin + ceftriaxone
  100. What is ET for immunocompromised pts w/ meningitis
    • *Vanco + ampicillin + cefepime OR
    • *Vanco + ampicillin + meropenem
  101. What is ET for a pt w/ a head trauma or post-neurosurgery w/ meningitis
    • *Vanco + cefepime OR
    • *Vanco + ceftazidime OR
    • *Vanco + meropenem
  102. What is ET for a pt w/ meningitis who has a severe PCN allergy?
    • *<50yo: Vanco + TMP/SMX + chloramphenicol
    • *>50yo: Vanco + TMP/SMX
  103. How do you tx meningitis caused by H. influenzae type B, N. meningitidis, or E. coli?
    • *Cefotaxime OR
    • *Ceftriaxone

    -Tx x 7 days
  104. How do yo tx meningitis caused by Strep pneumonia?
    • *Vanco + cefotaxime OR
    • *Vanco + ceftriaxone

    -Tx x 10-14 days
  105. How do you tx meningitis caused by Listeria monocytogenes or Strep agalactiae?
    • *Ampicillin OR
    • *PCN G

    -Listeria and other G- tx for 21 days (or longer if immunocompromised)
  106. How do you tx meningitis caused by Pseudomonas aeruginosa?
    • *Ceftazidime OR
    • *Cefepime
  107. Ways to decrease intracranial pressure in meningitis
    • *Elevate head of bed 30 degrees
    • *Hyperventilation
    • *Hyperosmolar agents (ie: mannitol)
    • *Steroids
  108. Post-exposure prophylaxis for N. meningitidis
    • *Rifampin BID x 4 doses
    • *Cipro x 1
    • *Ceftriaxone IM x 1

    -Recommended for household and daycare contacts and anyone directly exposed to pt's oral secretions
  109. Post exposture prophylaxsis for meningitis caused by Hib
    *Rifampin qd x 4

    -Recommended for household contacts of unvaccinated kids <48 mo and possibly daycare contacts
  110. Post exposure prophylaxis for meningitis caused by Strep pneumoniae
    *None but sickle cell pts may benifit form oral PCN tx
  111. Post exposure prophylaxis for meningitis caused by Step agalactiae
    • *IV ampicillin or PCN G given intrapartum
    • *If allergy, IV clindamycin or erythromycin given intrapartum

    -Recommended for pregnant women if carrier + 1 risk factor (preterm labor, fever in labor, membrane rupture >18h ago, another child born w/ grp B strep disease)
  112. Primary prevention of meningitis
    *Vaccines!!!
  113. Chronic meningitis
    • *Indolent onset of symptoms for >/= 4 wks
    • *Physical exam may be normal
  114. Agents which can cause drug-induced meningitis
    • *NSAIDs (ibuprofen most common)
    • *abx
    • *azathioprine
    • *isoniazid
    • *carbamaepine

    -Tx by dc'ing causative agent + supportive tx
  115. What comprises the upper respiratory tract?
    • *Nasal cavity
    • *Pharynx
    • *Larynx
  116. Classifications of rhinosinusitis (acute, subacute, chronic, recurrent)
    • *Acute: sx <4 wks
    • *Subacute: sx 4-12 wks
    • *Chronic: sx that persist >12 wks
    • *Recurrent: >/=4 episodes/yr w/ sx resolution btwn episodes
  117. Clinical presentation of rhinosinusitis
    • *3 cardinal sxs: purulent nasal discharnge, nasal congestion and obstruction, & facial pain, pressure, or fullness or maxillary tooth discomfort
    • *Other sx: sneezing, fever, fatigue, cough, ear pressure, HA, decreased sence of smell (hyposmia), and bad breath (halitosis)
  118. Acute viral rhinosinusitis
    • *Common causes: rhinovirus, influenza, parainfluenza
    • *Self limiting sx resolution in 7-10 days
    • *Abx NOT indicated
  119. How to tell if rhinosinusitis caused by viral or bacterial pathogen
    • *Consider bacterial when:
    • -sx >/= 10 days
    • -worsening sx w/in 10 days after initial improvement (possibly bacterial infection superimposed over viral)
  120. Supportive tx for acute viral rhinosinusitis
    • *Recommended:
    • -Analgesics for pain/fever
    • -Topical decongestants for drainage
    • *Not benificial
    • -Topical glucocorticoids for inflammation
    • -Cough suppressants
    • -1st gen antihistamines
  121. What bacterial organisms cause the most cases of rhinosinusitis?
    • *Strep pneumoniea > H. influenzae > anaerobes = Streptococcus spp
    • *Others: M. catarrhalis, Staph aureus
  122. Tx vs. observation of rhinosinusitis
    • *Presentation mild to mod & sx <7 days: OBSERVE
    • *Presentation w/ sx >/=7 days:
    • -OBSERVE if pts have mild pain and a temp <38.3 C/101 F
    • -TX if pts have mod to severe sx's
    • *Presentation mod to severe sx and temp >38.3 C/101 F: TX regardless of sx duration
  123. How do you treat acute bacterial rhinosinusitis?
    • *1st line: amox, TMP/SMX, azithromycin, or erythromycin
    • *If risk factors for drug-resistant pathogens: levo, cefuroxime, or augmentin

    • -Tx x 10-14 days
    • -Reassess pt in 7 days
  124. Considerations for choice of abx in rhinosinusitis
    • *If use of abx in previous 4-6 wks: FQ or high dose augmentin
    • *If daycare child is in the household: high dose amox
  125. Supportive tx for acute bacterial rhinosinusitis
    • *Recommended:
    • -Analgesics for pain/fever
    • -Topical decongestants and mechanical irrigation for drainage
    • -Topical glucocorticoids to decrease inflammation
    • *No benefit:
    • -Systemic decongestants or mucolytics for drainage
    • -Cough suppressants
    • -1st gen antihistamines for sneezing
  126. Management and prevention of chronic rhinosinusitis
    • *Management: assess for modifying factors---> allergic rhinosinusitis, immunocompromised state, anatomic abnormality
    • *Prevention: hand hygiene, smoking cessation, saline nasal irrigation
  127. Presentation of pharyngitis
    • *sore throat
    • *tonsillar exudate
    • *difficulty swallowing
    • *fever and general malaise


    • -More common in kids/adolescents
    • -Seen seasonally in winter in spring
  128. Causitive agents of pharyngitis
    • *Primarily viral: rhinovirus, cornoavirus, adenovirus, HSV, parainfluenza, influenza
    • *Bacterial: Group A strep > group C strep > group G strep
  129. What organism is classified as 'group A strep'
    Streptococcus pyogenes
  130. What are the goals of txing pharyngitis caused by group A strep?
    • *prevent acute rheumatic fever
    • *prevent complications
    • *improvement in sx
    • *reduce transmission
  131. What are the criteria required before we test for pharyngitis caused by group A strep?
    • *Criteria: tonsillar exudates, tender anterior cervical adenopathy, fever, absence of cough
    • *If 0-1 criteria: DO NOT test
    • *If >/=2 criteria: TEST using rapid antigen detection test (RADT)

    -Alternative tx strategy is to epirically trealy anyone w/ 3 or 4 criteria w/o testing
  132. Dx pharyngitits caused by group A strep
    • *Rapid antigen detection test (RADT): rapid w/ excellent specificity but expensive and poor sensitivity w/ detection of "carriers" difficult
    • -This is the first test preformed. If possitive tx. If negative do not treat unless its a child and then get a throat culture to assure dx.
    • *Throat culture: gold standard by delay in results and determination of "carriers" is difficult
  133. Tx of pharyngitis caused by group A strep
    • *PCN VK po x 10 days (amoxicillin OK in kids due to bad taste of PCN)
    • *Benzathine PCN G IM x 1
    • *If PCN allergy: erythromycin or azithromycin x 10 days
    • *If PCN allergy and macrolide resistant: clindamycin x 10 days
  134. What is middle ear effusion?
    *The presence of fluid in the middle ear cavity

    -Occurs in both acute otitis media and otitis media w/ effusion
  135. What is acute otitis media?
    An acute bacterial infection of the middle ear fluid:
  136. What is otitis media w/ effusion?
    • *Middle ear fluid that is not infected
    • *No clinical s/sx of infection but frequently precedes AOM or follows its resolution
  137. Risk factors for the development of AOM
    • *age (young)
    • *daycare
    • *breast feeding
    • *tobacco smoke
    • *pacifier use
    • *FH
  138. Presentation of AOM
    • *Otalgia (ear pain)
    • *Hearing loss
    • *Vertigo
    • *Otorrhea (discharge) or swelling of the ear
    • *Fever, irritability, HA, apathy, anorexia, vomiting, and diarrhea
  139. Dx of AOM
    • *Requires ALL of the following:
    • -the presence of fluid in the middle ear (MEE)
    • -h/o acute onset of sx
    • -s/sx of middle ear inflammation
  140. What are the likely causitive bacterial agents in AOM?
    • *Strep pneumoniae
    • *H. influenzea
    • *M. catarrhalis
  141. Problems with bacterial resistance in AOM
    • *100% of M. catarrhalis and 50% of H. influenzae procude beta-lactamases
    • *30% of Strep pneumo are resistant to PCN
    • -Can be overcome by using increased doses of PCN
  142. What are the risk factors for PCN-resistant AOM?
    • *< 30 days from time of last abx use (esp w/ beta lactamase)
    • *< 2 yo
    • *Close contact w/ pts w/ AOM (ie: daycares)
    • *Previous tx failure w. beta-lactam or macrolide antibiotic
  143. Who gets treated for AOM?
    • *Anyone with a "certain" diagnosis
    • -although if >/= 2 yo and nonsevere illness (mild otalgia and fever <39 C), observaiton is an option
    • *<6 mo even w/ "uncertain" diagnosis
    • *6-24 mo w/ severe illness (mod to severe otalgia or fever >/= 39 C)

    -Everyone else gets observation (defer x 48-72 hours)
  144. Tx for AOM
    • *1st line: amoxicillin 80-90mg/kg/day
    • *PCN allergy w/ non-type 1 hypersensitivity: cefdinir, cefpodoxime, or cefuroxime
    • *PCN allergy w/ type 1 hypersensitivity: azithromycin or clarithromycin

    *Tx for 10 days unless >/=6 yo w/ mild to moderate disease, then tx x 5-7 days
  145. Tx of AOM w/ severe illness
    • *Need coverage for H. influenzae or M catarrhalis (both produce beta-lactamases)
    • -1st line: Amox/clav
    • -PCN allergy (non-type 1): ceftriaxone
    • -PCN allergy (type 1): clindamycin

    *Tx for 10 days
  146. Tx of AOM in patients who cannot take oral meds
    *Ceftriaxone IM/IV x 1

    -May be repeated q 48h x 3 total doses
  147. What is the tx option if our inital tx fails?
    • *Tx failure is no improvement after 48-72h
    • *If inital tx was observation: tx w/ amox
    • *Switch to amox/clav---> if failure, tx w/ ceftriaxone x 3 days---> if failure, clindamycin or surgery
  148. When do you use abx prophylaxis for otitis media?
    *For recurrent AOM: >/= 3 episodes/6 months or >/=4 episodes/12 months
  149. Etiology of acute bronchitis
    • *Viral (>90%): influenza A & B, parainfluenza, RSV, rhinovirus
    • *Bacterial: Mycoplasma pneumoniae, Chlamydophila pneumoniae, & Bordetella pertussis
  150. Clincal presentation of acute bronchitis
    • *Persistent cough >5 days
    • *Sputum production (often purulent)
    • *Bronchospasms (decreased FEV1)
    • *Bronchial hyperreactivity

    • -Fever is uncommon
    • -Must rule out chronic bronchitis, pneumonia, postnasal drip, and asthma
  151. Tx of acute bronchitis
    • *Abx are DISCOURAGED (Canadian guidelines: if cough persists >10-14 days consider abx)
    • *Disease is often self-limiting
  152. Tx of whooping cough
    • *Macrolide: azithromycin, clarithromycin, or erythromycin (GI AE's)
    • *Abx is only of benefit only if begun <7 days but given if >7 days to limit spread of infection
  153. Definition of chronic bronchitis
    *Mucus producing excessive cough on most days of the week for at least 3 consecutive months for 2 consecutive years or more
  154. What is acute exasterbation of chronic bronchitis (AECB)?
    *A sudden clinical deterioration in a patient w/ chronic bronchitis

    -Sputum is often colonized and thus sputum culture is not useful
  155. Etiology of AECB
    • *Bacterial (30-50%)
    • -Most common: H. influenzae, Step pneumoniae, M. catarrhalis
    • -Advanced or severe disease: Pseudomonas aeruginosa & Enterobacteriaceae

    *Exacerbations are often caused by acquisition of a new strain of bacteria
  156. Risk stratification of AEBC patient's based on Anthonisen criteria
    • Criteria:
    • -Increased dyspnea
    • -Increased sputum volume
    • -Increased sputum purulence

    • *Type 1 (severe): all 3 sx's
    • *Type 2 (moderate): 2 sx's
    • *Type 3 (mild): 1 sx ----> no tx indicated
  157. Canadian risk factors for failing standard abx tx in AECB
    • *Cardiac disease
    • *>/=4 exacerbations/yr
    • *Use of O2
    • *Lengthy duration of COPD
    • *Malnutrition
    • *FEV1 <50% predicted
  158. Tx algorithm for AECB
    • *If type 3: no abx
    • *If type 1 or 2: assess pt's Canadian risk factors for tx failure (FEV <50%, >/=4 exacerbations/yr, heart disease, use of home O2, abx in last 3 months)
    • -No risk factors: GROUP 1
    • -1+ risk factors: GROUP 2
    • -Multiple risk factors: GROUP 3
  159. Tx for AECB pts in groups 1 and 2 (Canadian guidelines)
    *Group 1 (no risk factors for tx failure): azithromycin, clarithromycin, 2nd or 3rd gen cephalosporin, amoxicillin, TMP/SMX, doxycycline

    *Group 2 (1+ risk factor): beta lactam/beta lactam inhibitor (ie: amox/clav) or FQ

    *Group 3 (multiple risk factors): Get gram stain and culture of sputum and tailor tx to pathogen
  160. General approach to tx of AECB
    • *If no risk factors of tx failure use narrow spectrum abx:
    • -Amox
    • -TMP/SMX
    • -Doxycycline

    • *If risk factors for tx failure use broad spectrum abx:
    • -Azithromycin
    • -Clarithromycin
    • -Amox/clav
    • -FQ
    • -2nd gen cephalosporins
  161. Other tx to manage AECB
    • *SABA: 1st line bronchodilator
    • *Antichoninergics: initiate after SABA is maxed out
    • *Systemic steroids x 2 wks of pt requires hospitalization

    -Mucolytics and methylxanthine bronchodilators are not recommended
  162. Dx of community acquired pneumonia (CAP)
    • *Sx: cough, fever, sputum production, pleutritic chest pain
    • *Inflitrate by chest XR
  163. CURB-65 criteria for CAP
    • *Determines severity of illness
    • *One point given for each criteria to dermine 'score':
    • -Confusion
    • -Uremia (BUN >7 mmol/L or 20 mg/dL
    • -RR (>30 bpm)
    • -Low BP (SBP <90 or DBP <60)
    • -Age >/=65
  164. How to use the CURB-65 criteria for CAP
    • *Score 0-1: tx outpatient due to low mortality
    • *Score 2: consider supervised tx or hospitalization due to intermediate mortality
    • *Score 3+: hospitalize pt and consider ICU due to high mortality
  165. PSI: pneumonia severity index
    • *Another scale used to determine the severity of illness in CAP
    • *Used to determine where to tx the pt
    • -Class 1 & 2: outpatient
    • -Class 3: outpatient, observation unit, or short hospitalization
    • -Class 4 or 5: inpatient
  166. When do we admit pts to the ICU for severe CAP?
    • *Septic shock requiring vasopressor support OR
    • *Respiratory failure requiring mechanical ventilation OR
    • *Three of the following:
    • -RR >/=30 bpm
    • -PaO2/FiO2 ration </= 250
    • -multilobar infiltrates
    • -confusion/disorientation to person, place, or time
    • -uremia (BUN >/=20 mg/dL)
    • -leukopenia (WBC <4000 cells/mm3)
    • -thrombocytopenia (platelet cout <100,000)
    • -hypothermia (core temp <36 C)
    • -hypotension requiring aggressive fluid resuscitation
  167. What dx tests do we get in CAP
    • *Inpatient: sputum gram stain and culture & blood culture
    • *Severe CAP: sputum gram stain and culture, blood culture, and urinary antigen tests for Legionella pneumophila and Strep pneumo
  168. Etiology of CAP
    • *Strep pneumo
    • *H. influenzea
    • *Atypicals: M. pneumoniae, C. pneuoniae, Legionella

    *ICU pts: pseudomonas and Staph aureus
  169. What are the risk factos for drug resistant Strep pneumo in CAP?
    • *Age <2 or >65
    • *Beta lactam tx w/in last 2 months
    • *Alcoholism
    • *Comorbidities
    • *Immunosuppessed
    • *Exposure to a kid in daycare
  170. What is empiric tx for CAP as an outpatient?
    • *Healthy w/ no use of abx in last 3 months: macrolide (preferred) -OR- doxycycline
    • *Risk factor for drug resistant strep pneumo: respiratory FQ (moxi, gemi, or levo) -OR- beta-lactam (amox 1g TID, amox/clav 2g BID, ceftriaxone, defpodoxime, cefurxoime) + macrolide
  171. What is empiric tx for CAP as a non-ICU inpatient?
    • *Respiratory FQ (moxi, gemi, or levo) -OR-
    • *Beta-lactam (cefotaxime, ceftriaxone, ampicillin) + macrolide
  172. What is empiric tx for CAP as an ICU inpatient?
    • *Beta-lactam (cefotaxime, ceftriaxone, or amp/sulbactam) + azithromycin -OR-
    • *Beta-lactam (cefotaxime, ceftriaxone, or amp/sulbactam) + respiratory FQ (moxi, gemi, levo)

    *If PCN allergy: respiratory FQ + aztreonam
  173. If on IV meds for CAP when can you switch to PO?
    • *Hemodynamically stable
    • *Clinically improving
    • *Able to ingest meds
    • *Normally functioning GI tract
  174. When can you discharge a CAP pt?
    • *When clinically stable
    • *Candidate for oral tx
    • *No other active medical problems
    • *Save environment for continued care
  175. Duration of tx for CAP
    • *Minimum of 5 days!
    • *Pt must be afebrile x 48-72h and has </=1 sign of clinical instability

    -Longer duration may be needed for bacteremic S. aureus pneumonia, Pseudomonas, and other less common organisms
  176. How do you classify pneumonia based on time of aquisition in relation to hospital stay?
    • *0-2 days of hospitalization: CAP
    • *2-4 days of hospitalization: early onset HAP/VAP
    • *5+ days of hospitalization: late-onset HAP/VAP/HCAP
  177. What is hospital-associated pneumonia (HAP)?
    *Pneumonia that occurs >/=48h after admission

    -Classified as late onset if >/=5 days of admission
  178. What is ventilator-associated pneumonia?
    *Pneumonia that occurs >48-72h after endotracheal intubation

    -Classified as late onset if >/=5 days of admission
  179. What is healthcare-associated pneumonia?
    • *Pneumonia associated w/ a risk factor for multi-drug resistant organisms:
    • -Hospitalization for >/=2 days in teh preceding 90 days
    • -Residence in a NH or LTCF
    • -Home infusion tx
    • -Chronic dialysis w/in last 30 days
    • -Home wound care
    • -Family member w/ MDR organism
    • -IV abx in last 90 days
    • -Immunosuppressed
  180. Dx of HAP/VAP/HCAP
    • *New or progressing pulmonary infiltrate by CXR -PLUS-
    • *Clinical evidence of infection (2 required)
    • -Fever >38 C
    • -Leukocytosis or leukopenia
    • -Purulent secretions

    *Requires respiratory tract culture: endotracheal aspirates or bronchoalveolar lavage
  181. Empiric tx for HAP/VAP/HCAP
    • *Limited spectrum antibiotics if early onset (2-4 days after admission)
    • -Ceftriaxone OR
    • -Levo, moxi, or cipro OR
    • -Ampicillin/sulbactam OR
    • -Ertapenem

    • *Broad spectrum abx if late onset (5+ days after admission) to tx MDR pathogens
    • -Cefepime or ceftazidime (covers pseudomonas)
    • -imipenem or meropenem
    • -pip/tazo + cipro or levo
    • -AG + linezolid or vanco
  182. What are the risk factors for MDR pathogens?
    • *Abx in preceding 90 days
    • *Current hospitalization of 5+ days
    • *High frequencey of abx resistance in community or specific unit
    • *Any risk factors for HCAP
    • *Immunosuppressed

    ---If a pt has any of these risk factors tx w/ BROAD SPECTRUM ABX---
  183. Etiology of early onset HAP/VAP/HCAP
    • *Strep pneumo
    • *H. influenzae
    • *Staph aureus (methicillin-sensitive)
    • *G-: E. coli, K. pneumoniae, Enterobacter, Proteus, Serratia marcescens
  184. Etiology of late onset HAP/VAP/HCAP
    • *Early-onset pathogens
    • *Pseudomonas aeruginosa
    • *Klebsiella pneumoniae
    • *Acintobacter
    • *Legionella pneumophila
    • *MRSA
  185. Pearls to choosing abx for HAP/VAP/HCAP
    • *Pseudomonas aeruginosa: use combo tx
    • *Linezolid can be used as an alt to vanco
    • *Acinetobacter: consider carbapenem, amp/sulbactam, or colistin
    • *Avoid using a 3rd gen cephalosporin as monotx for ESBL producing Enterobacteriaceae--consider carbapenem or pip/tazo
  186. What is multi-drug resistant TB (MDR TB)?
    *TB that is resistant to isoniazid AND rifampin
  187. What is extensively drug resistant TB (XDR TB)?
    • *TB that is resistant to isoniazid AND rifampin -AND-
    • *Resistant to any FQ -AND-
    • *Risistant to at least one of the three injectable 2nd line anti-TB agents
  188. Exposure to TB infection
    • *Pulmonary TB is infectious (airborne droplet transmission)
    • *Extrapulmonary TB and culture-negative pulmonary disease is non-infectious
  189. Complications w/ pulmonary TB disease
    • *Enlarging nodules obstruct bronchi and large airways cause lung colapse, obstructive emphysema, or bronchiectasis
    • *Caseous necrosis causing destruction of lung parenchyma
    • *Vasculature invasion leading to hemoptysis and reduced perfusion
  190. What is post-primary TB?
    • *Reactivation of latent TB
    • *Fibrotic and calcified pulmonary lesion lead to progressively debilitating course led to the term 'consumption'
  191. What are some examples of extra-pulmonarry TB?
    • *TB lymphadenitits
    • *Genitourinary TB
    • *Skeletal TB
    • *TB meningitis
    • *TB pericarditis
    • *Disseminated TB
  192. 1st line agents for TB
    • *Rifampin (RIF)
    • *Isoniazid (INH)
    • *Ethambutol (ETB)
    • *Pyrazinamide (PZA)
  193. Rifampin (RIF)
    • *Most import and potent agent for TB
    • *Blocks RNA synthesis
    • *Great oral absorption and distribution (including meninges)
    • *Excretion in bile and by kidneys
    • *POTENT CYP INDUCER
  194. AE of RIF
    • *Body fluid discoloration
    • *GI upset
    • *Hepatocellular injury
    • *Rash
  195. Isoniazid (INH)
    • *Should be included in all TB regimens unless the organism is resistant
    • *Inhibits cell wall synthesis by inhibiting mycolic acid synthesis
    • *Great oral absorption and good distribution (including meninges and caseous granulomas)
    • *Hepatic metabolism
    • *Renal elimination
  196. AE of INH
    • *Hepatotoxicity
    • *Peripheral neuritis (administer w/ vit B6)

    *DC if asymptomatic ALT >5x ULN or symptomatic >3x ULN
  197. What should always be co-administered w/ INH?
    • *Pyridoxine (vit B6) 25-50mg PO daily
    • *Helps w/ peripheral neuritis
  198. Ethambutol (ETB)
    • *Only active against mycobacteria
    • *Inhibits cell wall synthesis
    • *75% bioavailable w/ fair distribution (poor in CSF)
  199. AE of ETB
    *Optic neuritis: loss of ability to see green, visual acuity testing monthly or w/ change in vision, slowly reversible
  200. Pyrazinamide (PZA)
    • *Prodrug converted to pyrazinoic acid in acidic environment of the phagocyte or caseous granuloma
    • *Inhibits FA synthesis in Mycoplasm tuberculosis
    • *Well absorbed w/ good distribution
  201. AE of PZA
    • *Hyperuricemia
    • *Polyarthralgias
    • *Hepatotoxicity
  202. What are the second-line agents for TB?
    • *Streptomycin
    • *Fluoroquinolones: levo or moxi
    • -Reserve for pts w/ MDR TB or who can't tollerate 1st line agents
  203. What are the drug regimen options for active TB?
    • *Isolate pt!
    • *QD regimen
    • -RIF 600mg x 26 wks
    • -INH 300mg x 26 wks
    • -PZA 2000mg x 8 wks
    • -ETB 15-25mg/kg x 8 wks
    • *Direct observed tx: TIW
    • -RIF 600mg qMWF x 26 wks
    • -INH900mg qMWF x 26 wks
    • -PZA 3000mg qMWF x 8 wks
    • -ETB 25-30mg/kg qMWF x 8 wks
  204. What is the tx regimen for MDR TB?
    • *Use all:
    • -Levo 750mg qd
    • -PZA 2000-3000mg qd
    • -ETB 25-30mg/kg qd
    • -Streptomycin 10-15mg/kg IM/IV
    • - +/- 2nd alternative agent

    *Tx for 18-24 months!
  205. What is the tx regimen for XDR TB?
    • *4 to 6 drugs which the organims is susceptible to
    • *tx for 18-24 months
  206. Monitoring of TB tx
    • *Sputum cultures q2 weeks until 3 consecutive negatives, then monthly until tx complete
    • -80% have neg cx at 2 mo
    • -Positive cx at >3mo: tx failure, drug resistance, pt adherence

    • *Hepatitis monitoring
    • -baseline and q4 wk LFTs
    • -pt to monitor for dark urine and loss of appetite

    *Hyperuricemia: tx w/ ASA but DC PZA if gouty arthritis

    *Optic neuritis: permanently DC ethambutol

    *Autoimmune thrombocytopenia: permanently DC rifampin
  207. Tx of latent TB
    • *Goal is to prevent active infxn (aka: "chemoprophylaxis")
    • *Candidates for tx id'ed by PPD skin test

    • *Isoniazid 300mg qd x 9 months -OR-
    • *Isoniazide 300mg twice weekly (DOT) -OR-
    • *Rifampin 300mg qd + pyrazinamide 2000mg qd x 2-4 months
  208. Trasmission of HIV in the US
    • *53% male to male sexual contact
    • *31% heterosexual contact
    • *12% IV drug use
  209. Whys to test for HIV
    • *Standard tests: immunofluorescent assay or anzyme immunoabsorbant assay/ELISA
    • *Confirmatory testing: Western blot (must use to confirm if ELISA test is postive)

    -Sensitivity and specificity of >99.9%
  210. HIV-1 vs. HIV-2
    • *HIV-1: type found most commonly in the US
    • -2 major subgroups: M & O
    • *HIV-2: type found primarily in West Africa
    • -slower decline of CD4 count
    • -standard viral load test inaccurate
  211. What is a CD4 count?
    • *T cell analysis which determines the extent of immune damage
    • *Goal is >500 cells/mm3 (range: 500-1300)
    • *Monitor at dx and q3-6 months
  212. What is plasma viral load?
    • *Measures the amount of HIV RNA in blood samples to determine the magnitude of HIV replication and rate of CD4 destruction
    • *Used to evaluate the risk for disease progression and response to tx
    • *Goal: undetectable (range= <50-1,000,000 copies/ml)
    • *Monitor at dx, q3-6 months, and q2-8 wks after tx change
    • *Avoid testing w/in 4 wks of immunizations or infections
  213. HIV vs. AIDS
    • *HIV: infected w/ the human immunodeficiency virus
    • *AIDS: having a CD4 count <200 or hx of an AIDS-defining illness
  214. Examples of AIDS defining illnesses
    • *Candidiasis
    • *Invasive cervical cancer
    • *CMV
    • *HIV-related encephalopathy
    • *HSV
    • *Histoplasmosis
    • *Lymphoma
    • *Pneumocystis carinni/jiroveci pneumonia
    • *Recurrent pneumonia
    • *Recurrent Salmonella septicemia
    • *TB
  215. Classes of anti-retrovirals (ARV)
    • *NRTI: nucleoside/tide reverse transcriptase inhibitor
    • *NNRTI: non-nucleoside reverse transcriptase inhibitor
    • *PI: protease inhibitor
    • *INSTI: integrase inhibitor
    • *Entry inhibitor
  216. How do entry inhibitors work?
    Prevent entry of genetic material from the attached virus into the cell
  217. What agents are entry inhibitors?
    • *enfuvirtide (FUZEON), T-20
    • *maraviroc (SELZENTRY)
  218. Enfuvirtide
    • *Entry inhibitor
    • *FUZEON
    • *Prevents fusion of viral and cellular membranes by binding to the first heptad-repeat in teh gp41 subunit of the viral envelope thereby preventing necessary conformational changes
  219. Maraviroc
    • *Entry inhibitor
    • *SELZENTRY
    • *Selectively binds to the CCR5 receptor to prevent attachment of the gp120 and CCR5 to prevent entry of HIV-1 into the host cell
  220. How do NRTIs and NNRTIs work?
    *Blocks reverse transcriptase to inhibit transcription
  221. What agents are NRTIs?
    • *abacavir (ZIAGEN), ABV
    • *didanosine (VIDEX), DDI
    • *emtricitabine (EMTRIVA), FTC
    • *lamivudine (EPIVIR), 3TC
    • *stavudine (ZERIT), D4T
    • *tenofovir (VIREAD), TDF
    • *zidovudine (RETROVIR), AZT
  222. NRTI combos
    • *TRIZIVIR: abacavir + lamivudine + zidovudine
    • *COMBIVIR: lamivudine + zidovudine
    • *EPIZICOM: abacavir + lamivudine
    • *TRUVADA: emtricitabine + tenofovir
  223. What agents are NNRTIs?
    • *efavirenz (SUSTIVA), EFV
    • *nevirapine (VIRAMUNE), NVP
    • *delavirdine (RESCRIPTOR), DLV
    • *etravirine (INTELENCE), TMC-125/ETR
  224. NRTI + NNRTI combo's
    *ATRIPLA: emtricitabine + tenofovir + efavirenz
  225. How do integrase inhibitors work?
    *Inhibits integrase thereby preventing integration of HIV DNA into the host cell genome
  226. What agents are integrase inhibitors?
    • *Raltegravir (ISENTRESS), MK-0518
    • -Only efficacious in HIV-1
    • -No known drug interactions (not metabolized by CYP)
  227. How do protease inhibitors work?
    *Inhibits HIV protease resulting in the inhibition of viral maturation/proliferation
  228. What agents are PIs?
    • *atazanavir (REYATAZ), ATV
    • *amprenavir (AGENERASE), APV
    • *darunavir (PREZISTA), DRV
    • *fosamprenavir (LEXIVA), FPV
    • *indinavir (CRIXIVAN), IDV
    • *lopinavir/ritonavir (KALETRA), LPV/RTV
    • *nelfinavir (VIRACEPT), NFV
    • *ritonavir (NORVIR), RTV
    • *saquinavir (FORTOVASE/INVIRASE), SQV
    • *tipranavir (APTIVUS), TPV
  229. What are the goals of tx in HIV?
    • *Reduce HIV-related morbidity/mortality
    • *Improve QOL
    • *Restore and preserve immunologic fxn
    • *Suppress viral load
    • *Prevent HIV transmission
  230. Indications for tx initiation
    • *Hx of AIDS-defining illness
    • *CD4 count <350
    • *Pregnant
    • *HIV-associated nephropathy
    • *Co-infection w/ hep B when HBV tx is indicated

    *Recommended, but not required, when CD4 count >350
  231. Benefits of DEFFERING HIV tx
    • *Avoid neg effects on QOL
    • *Avoid drug-related toxicity
    • *Presserve future drug options
    • *Delay development of drug resistance
    • *Decrease total time on meds
  232. Risks of DEFFERING HIV tx
    • *Possibility of irreversible immune system depletion
    • *Increased possibility of progression to AIDS
    • *Possible increased riks of HIV transmission
  233. Preferred initial tx of HIV in pt's not previously tx'ed
    • *2 NRTIs (tenofovir/emtricitabine) -PLUS-
    • -NNRTI (efavirenz) -OR-
    • -PI (boosted---> atazanavir + ritonavir or darunavir + ritonavir) -OR-
    • -Integrase inhibitor (raltegravir)

    *Fusion inhibitor, CCR5 antagonist not recommended for initial tx
  234. Advantages and disadvantages of using NRTI has initial tx for HIV
    • *Advantages:
    • -Backbone of combo tx
    • -Minimal drug interxns
    • -PI and NNRTI preserved for future use

    • *Disadvantages:
    • -Lactic acidosis and hepatic steatosis reported
    • -Triple NRTI regimens show inferior response compared w/ EFV- and IDV-based regimens
  235. Advantages and disadvantages of using NNRTI has initial tx for HIV
    • *Advantages:
    • -Long t1/2
    • -PI and integrase options preserved for future use

    • *Disadvantages:
    • -Single mutations can cause resistance
    • -Cross-resistance among the class of NNRTIs
    • -Rash
    • -Hepatotoxicity
    • -Potential drug intrxns
  236. Advantages and disadvantages of using PIs as intial tx for HIV
    • *Advantages:
    • -High genetic barrier to resistance
    • -PI resistance uncommon w/ failure (boosted PI)
    • -NNRTI options preserved for future use

    • *Disadvantages:
    • -Metabolic complications (fat maldistribution, dyslipidemia, insulin resitance)
    • -GI intolerance
    • -Greater potential for drug interxns (esp w/ ritonavir)
  237. Advantages and disadvantages of using integrase inhibitors as intial tx for HIV
    • *Advantages:
    • -Virologic response noninferior to Efavirenz
    • -Fewer AE and lipid changes than Efavirenz
    • -No food effect
    • -Fewer drug interactions than PIs or NNRTIs

    • *Disadvantages
    • -Less long term experience
    • -BID dosing
    • -Lower genetic barrier to resistance than w/ boosted PI regimens
    • -No data w/ NRTIs other than tenofovir/emtricitabine
  238. Preferred initial tx for HIV
    *Tenofovir/emtricitabine (NRTIs) -PLUS-

    • *Efavirenz (NNRTIs) -OR-
    • *Atazanavir + Ritonavir or Darunavir + Ritonavir (PIs) -OR-
    • *Raltegravir (II)
  239. Acceptable HIV intial tx regimens (NOT PREFERRED)
    • *NNRTI-based: Efavirenz + didanosine + lamivudine
    • *PI-based:
    • -Atazanavir + abacavir --OR--
    • -Zidovudine + lamivudine
  240. Considerations for HIV tx
    • *Efavirenz is CI'ed in pregnancy
    • *Atazanavir shouldn't be used if pt takes >20mg of omeprazole (or equivalent)
    • *Lamivudine can be substituded for emtricitabine (or vice versa)
    • *Nevirapine shouldn't be used in pts w/ hepatic impairment
    • *Nevirapine shouldn't be used in women w/ pre-ARV CD4 >250 or men w/ CD4>400
  241. What HIV med is CI'ed in pregnancy
    *Efavirenz

    -Especially in 1st trimester
  242. Initial tx for pregnant women
    *Lopinavir/ritonavir (BID) + zidovudine/lamivudine
  243. What HIV med should not be used if pts take >20mg of omeprazole qd?
    *Atazanivir
  244. What combo of HIV meds has a high rate of early virologic failure?
    *Didanosine + tenofovir

    -Don't use as initial tx
  245. What unique regimens have no benefit over standard regimens in inital HIV tx?
    • *3 class regimens
    • *3 NRTIs + NNRTI
  246. What HIV regimens have a high incidence of toxicities and thus shouldn't be used as inital tx?
    • *Stavudine + lamivudine
    • *Indinavir + ritonavir
    • *Ritonavir used as sole PI
    • *Nevirapine
  247. What ARV meds should NEVER be offered as HIV tx due to inferior virologic efficacy & rapid development of resistance?
    • *Monotx w/ NRTI
    • *Dual NRTI tx
    • *3 NRTI regiment (except w/ abacavir/lamivudine/zidovudine when other regimens are undesirable)
  248. What ARV meds should NEVER be offered as HIV tx due to high incedence of AEs?
    • *Didanosine + stavudine
    • *Atazanavir + indinavir
    • *2 NNRTI combos
  249. What ARV combo has antagonistic effects and thus shouldn't be used in initial tx?
    *Stavudine + zidovudine
  250. Which HIV meds have poor bioavailability and thus shouldn't be used in initial tx?
    • *Saquinavir (unboosted)
    • *Darunavir (unboosted)
    • *Tipranavir (unboosted)
  251. What AEs are associated with all NRTIs?
    • *Lactic acidosis (highest w/ stavudine; stavudine> didanosine= zidovudine> tenofovir= abacavir= lamivudine= emtricitabine)
    • *Hepatic steatosis (highest w/ stavudine; stavudine> didanosine= zidovudine>
    • tenofovir= abacavir= lamivudine= emtricitabine)
    • *Lipodystrophy (higher w/ stavudine)
  252. AEs of abacavir (NRTIs)
    • *Hypersensitivity rxn
    • *Possibly increased risk of MI
  253. AEs of didanosine (NRTIs)?
    • *GI intolerance
    • *Pancreatitis
    • *Peripheral neuropathy
    • *Hepatotoxicity
  254. AE of stavudine (NRTIs)?
    • *Peripheral neuropathy
    • *Pancreatitis
  255. AEs of tenofovir (NRTIs)?
    • *HA
    • *GI intolerance
    • *renal impairment
  256. AEs of zidovudine (NRTIs)?
    • *HA
    • *GI intolerance
    • *bone marrow suppression
    • *anemia (Hg <7)
    • *leukopenia (ANC <500)

    -Monitor CBC q3 months or sooner
  257. AEs of all NNRTIs?
    • *Rash
    • *DD interactions
  258. AEs of nevirapine (NNRTI)?
    • *Hepatotoxicity (possibly life threatening)
    • *Rash (including SJS)
  259. AEs of efavirenz (NNRTI)?
    • *Neuropsychiatric sx
    • *Preg. cat. D (teratogenic in primates)
    • *Rash
  260. AEs of all PIs?
    • *Hyperlipidemia
    • *Insulin resistance & DM
    • *Lipodystrophy
    • *Elevated LFTs
    • *Possible increased bleeding in hemophiliacs
    • *Possible MI and CVAs
  261. AE of atazanavir (PI)?
    • *Hyperbilirubinemia
    • *PR interval prolongation
  262. AE of darunavir (PI)?
    • *GI intolerance
    • *Rash
  263. AEs of fosamprenavir (PI)?
    • *GI intolerance
    • *Rash
  264. AEs of indinavir (PI)?
    • *Nephrolithiasis
    • *GI intolerance
    • *Hyperlipidemia
    • *Hyperbilirubinemia
  265. AEs of lopinavir/ritonavir (PIs)?
    • *GI intolerance
    • *PR interval prolongation
  266. AEs of nelfinavir (PI)?
    • *D
    • *Possibly teratogenic and carcinogenic--by product has been in animal studies
  267. AEs of ritonavir (PI)?
    • *GI intolerance: full dose rarely used (600mg BID) due to this
    • -Combo w/ any other PI allows for lower doses
    • *Hepatitis
    • *Hyperlipidemia
    • *Hyperglycemia
    • *MANY DD INTERXNS!!!

    *Must be refrigerated, but can remain at room temp for up to 30 days
  268. AEs of tipranavir (PI)?
    • *GI intolerance
    • *Rash
    • *Hyperlipidemia
    • *Liver toxicity
    • *Cases of intracranial hemorrhage (increased risk w/ CNS lesions, head trauma, neurosurgery, coagulopathy, EtOH abuse, anticoag tx, vit E usage)
  269. AEs of enfuvirtide (EI)?
    • *Inj site rxns
    • *Hypersensitivity rxns
    • *Increased risk of bacterial pneumonia
  270. AEs of maraviroc (EI)?
    • *Abd pain
    • *URI's
    • *Cough
    • *Hepatotoxicity
    • *Musculoskeletal sxs
    • *Rash
    • *Orthostatic HoTN
  271. AEs of raltegravir (IIs)?
    • *N
    • *HA
    • *D
    • *CPK elevation
  272. CV AEs of ARVs
    • *MI and CVAs associated w/ PIs but not NNRTIs
    • *Abacavir has possible increased risk of MI
    • *Occurs months to yrs after starting tx
    • *Risk factors: HTN, lipids, smoking, age, DM, FH
    • *Avoid agents w/ higher risk
  273. Lactic acidosis and hepatic steatosis w/ ARVs
    • *Rare but high mortality
    • *Due to mitochondrial toxicity
    • *Associated w/ NRTIs (esp d4t, ddl, ZDV)
    • *Dx: lactate >2-5 mmol/dL plus sx's
    • *Tx: DC ARV & supportive care
  274. Hepatotoxicity w/ ARV
    • *Severity is variable, usually asymptomatic
    • *May resolve w/o tx interruption
    • *May occur w/ all NNRTIs or PIs, some NRTIs and Maraviroc
    • -Nevirapine: risk of severe hepatitis in 1st 18 wks of tx (monitor LFTs), increased risk w/ hep B/C, women, and hight CD4 count at initiation (women >250, men >400)
    • -PI: esp RTV, RTV/SQV
  275. Endocrine AEs of ARV
    • *Insulin resistance, hyperglycemia, and DM associated w/ all PIs, zidovudine, and stavudine
    • *Screen FBS regularly
  276. Fat maldistribution w/ ARV
    • *Peripheral fat wasting more associated w/ NRTIs (esp. stavudine)
    • *Central fat accumulation more associated w/ PIs
    • *Tx: switch to other agents (may slow or halt progression) or cosmetic txs
  277. Hyperlipidemia w/ ARV
    • *Elevatiosn in TC, LDL, and TGs
    • *Associated w/ all PIs (except unboosted atazanavir)--> most w/ stavudine and afavirenz
    • *Tx: consider ARV switch, lipid-lowering agents (caution w/ PI and certain statins)
  278. Bone abnormalities w/ ARVs
    • *Osteoporosis/osteopenia: associated w/ tenofovir and stavudine
    • *Osteonecrosis: due to avascular necrosis
    • -Associated w/ PIs, corticosteroid tx, EtOH abuse, hemoglobinopathies, hyperlipidemia, hypercoagulable states
    • -Tx: surgical for severe disease, pain relief
  279. Dermatologic & rash w/ ARVs
    • *Most common w/ NNRTIs (esp nevirapine)
    • -most cases occur w/in 6 wks of tx
    • -no benefit of prophylactic steroids or antihistamines
    • *Also occurs w/ NRTIs (esp abacavir), PIs (esp amprenavir, fosamprenavir, darunavir, and tipranavir) and maraviroc
  280. Nephrotoxicity w/ ARVs
    • *Associated w/ indinavir and tenofovir
    • *Increased risks in pts w/ renal disease
    • *Renal dosing w/ lamivudine, emtricitabine, and tenofovir
  281. GI sx's w/ ARVs
    • *Associated w/ all PIs, zidovudine, and didanosine
    • *Must rule out infectious causes
    • *Tx: anti-diarrheal, anti-gas, and/or anti-emetic
  282. HLA-B*5701 testing
    • *Recommended prior to tx w/ abacavir to reduce the risk of hypersensitivity
    • *If positive, don't initiate tx and deem pt "abacavir allergic"
  283. Hypersentitivy w/ abacavir
    • *HLA-B*5701 testing recommended
    • *Sx's: fever, rash, fatigue, dyspnea, cough, abd pain, N/V/D
    • *Usually occurs w/in 2nd wk of tx but can take up to 6 wks
    • *Don't rechallange w/ drug----> can cause DEATH
  284. Coreceptor tropism testing
    • *Should be done prior to tx w/ maraviroc
    • *CCR5 vs CXCR4 vs mixed tropism
  285. Which ARVs are gastric pH dependent?
    • *Didanosine
    • *Atazanavir
    • *Delavirdine
    • *Indinavir
  286. Which ARVs absorptions are effected by food?
    • *nalfinavir---> needs high fat foods
    • *efavirenz---> increased SEs w/ food
    • *atazanavir---> 70% inc in AUC w/ food
  287. Drug interactions: statins and ARVs
    • *Avoid simva and lova due to metabolism by CYP3A4
    • *Pravastatin and fluvastatin have no drug interactions
    • *<20mg atorva is acceptable
  288. Drug interactions: H2RA/PPIs/antacids and ARVs
    • *H2RA:
    • -Avoid cimetidine due to CYP 3A4 inhibition ---> ranitidine or famotidine ok
    • *PPIs:
    • -Atazanavir should be avoided due to decreased absorption (can use H2RA if separated by >12h) but ok if equivalent dose of 20mg omeprazole qd
    • *Antacids:
    • -Separate from atazanavir and piranavir by 1-2h
  289. Drug interactions: ED drugs and ARVs
    • *PIs inhibit the 3A system and the ED drugs will therefore have higher concentrations
    • *Use 1/2 the dose and extend teh interval to q48-72h
    • -Sildenafil: <25mg/48h
    • -Tadalafil: <10mg/72h
    • -Vardenafil: <5mg/48h
  290. Drug interactions: Abx and ARVs
    • *Macrolides: avoid erythromycin; azithromycin the best choice
    • *FQs: caution w/ DDI tabs
    • *NO RIFAMPIN! (use only rifabutin at a reduced dose)
  291. Drug interactions: antifungals and ARVs
    • *Dose adjustments needed for:
    • -intraconazole
    • -ketoconazole (w/ PIs)
    • -posaconazole (causes increased levels of ritonavir and atazanavir; avoid w/ efavirenz)
    • -voriconazole (w/ ritonavir and other PIs, efavirenz, and etravirine)
  292. Drug interactions: antidepressants and ARVs
    • *TCAs: amitriptlyine and desipramine interact w/ RTV and increase teh effects of both drugs
    • *SSRIs: none
    • *Trazodone: increased effect of traz w/ PIs thus use low doses
  293. Drug interactions: antiepileptics and ARVs
    • *AVOID PHENYTOIN AND PHENOBARB
    • *Gabapentin, levetiracetam, and topiramate have NO drug interxns
    • *Lamotrigine: may need dose adj w/ lipinavir/ RTV
  294. Drug interactions: steroids and ARVs
    • *Prednisone: RTV increases AUC by 30% due to inhibition of 3A4
    • *Probably minimal clinical significance but avoid if possible
  295. Drug interactions: methadone and ARV
    • *Decreased effect of methadone w/ abacavir, atazanavir, efavirenz, lopinavir, nevirapine, and ritonavire
    • *Decreases effects of didanosine
  296. Drug interactions: ARV-ARV
    • *Efavirenz, nevirapine, or etravirine w/ PIs
    • *Atazanavir + tenofovir
    • *Didanosine + tenofovir
    • *Didanosine + stavudine
    • *Maraviroc + many PIs
    • *Maraviroc + efavirenz or etravirine
  297. Discontinuation and reintroduction of nevirapine
    *If nevirapine has been DC'ed for 2+ wks, restart w/ the usual dose escalation period
  298. DC'ing emtricitabine, lamivudine, or tenofovir
    • *If pt also has hep B, may cause flair
    • *Consider initiating adefovir or entecavir for HBV tx
  299. Structured/supervised tx interruption in HIV tx
    • *Insufficient data to recommend planned tx interruptions
    • *Risks: decline in CD4 count, disease progression, increase in HIV transmission, development of resistance
    • *Benefits: reduction in drug toxicities, preservation of future tx options
  300. What is immune reconstitution?
    *Paradoxical deterioration in clinical status after ARV tx initiation despite improved immune fxn due to inflammatory response against infectious antigen, which may or may not have been dx at initiation of ARV

    -Typically occurs in pts w/ low inital CD4 (usually <50) and rapid decline in viral load; onset usually w/in 6 wks of ARV initiation but sometimes several months later
  301. Pneumocystis pneumonia (PJP)
    • *Pneumocystis jerovici
    • *Fungus
    • *Majority of pts exposed by the age of 2-4 yrs and infection is due to reactivation of latent infection or new exposure
  302. Sxs of PJP
    • *Subacute onset of progressive exertional dyspnea, fever, nonproductive cough, & chest discomfort that worsens over a perior of days to wks
    • *Hypoemia
    • *CRX: diffuse bilateral symmetrical interstitial infiltrates
  303. Tx of PJP
    • *1st line:
    • -TMP/SMX (15-20mg/kg/day based on TMP PO divided BID-QID)
    • -Dapsone + TMP (use if pts intolerant of SMX)
    • *2nd line:
    • -Clindamycin and primaquine
    • -Pentamidine
    • -Atovaquone (better tolerated than TMP/SMX but administer w/ food due to poor bioavailability)

    • *Tx x 21 days
    • *Pt's clinical status can worsen over 1st 72h due to inflammatory responses
    • *Steroids may improve survival in severe PJP
  304. Prophylasis tx for Pneumocystis
    • *Primary: pts w/ CD4 </= 200
    • *Secondary: all pts following initial episode of PJP
    • *Tx may be DC'ed if CD4 >200 for >/=3 mo

    *TMP/SMX: 1 ds qd or TIW (not as effective)
  305. Toxoplasmosis
    • *Caused by protozoan, Toxoplasma gondii
    • *Host: cats
    • *May spread through eating contaminated meats (esp lamb and pork)
    • *Relapse is 100% once tx is stopped
  306. Toxoplasmic encephalitis
    • *Most common presentation of toxoplasmosis among AIDS pts
    • *Risk increases as CD4 <100
    • *Sxs: altered mental state, sz, weakness, cranial disturbances, sensory abnormalities, cerebral signs, meningism, movement disorders, neuropsychi manifestrations
    • *Dx: CT scan w/ multiple bilat cerebral lesions, serologic testing to detect Ab's
  307. 1st line tx of toxoplamsosis
    • *Sulfadiazine + pyrimethamine
    • *Administer w/ leucovorin bc drugs inhibit folic acid synthesis
    • *Response usually seen in 7-10 days
    • *Tx for 3-6 wks after sx's resolve
    • *Tx-limiting SE observed in ~40% of pts
  308. 2nd line tx's for toxoplamosis
    • *Clindamycin + pyrimethamine
    • -administer w/ leucovorin
    • *Pyrimethamine + [clarithromycin, azithromycin, atovaquone, or dapsone]
    • *TMP/SMX
  309. Prophylaxic tx for toxoplasmosis
    • *Primary prophylaxis: TMP/SMX (1 ds tab qd)
    • -Tx if CD4<100 and + IgG ab titer
    • -May DC tx if CD4 >200 x 3-6mo

    • *Secondary: Pyrimethamine + sulfadiazine QID (w/ leucovorin)
    • -May DC tx if pt has completed initial tx, pt is asymptomactic, and CD4 >200 x >6mo
    • -Restart tx if CD4 <200

    -Even w/ prophylaxis, 20-30% of pts will relapse
  310. Cryptococcus
    • *Caused by Cryptococcus neoformans from bird droppings
    • *Common cuase of meningeal infection in HIV pts
    • *More likely to occur if CD4 <200
    • *FATAL if untx'ed
    • *Mortality w/ tx= 25-30%
    • *Sx's: nonspecific CNS-related, sz
    • *Dx: examination of CSF: increased pressure, dec glucose, increased protein and WBCs (>/=20)
    • *Not cleared from pts--->only suppressed
  311. Tx of severe cryptococcus
    *Amphotericin B +/- flucytosine

    • -Ampho causes rapid CSF sterilization
    • -Continue until pt is afebrile and no N, V, HA then fluconazole may be initiated x 8-10 wks
  312. Tx of less-severe cryptococcus
    *Fluconazone 400-800mg QD
  313. Prophylatic tx of cryptococcus meningitis
    • *Primary: not recommended
    • *Secondary:
    • -1st line: Fluconazole 200mg qd
    • -2nd line: Amphotericin B IV qw-tiw
    • -Tx until pt has completed initial tx, pt is asymptomatic for cryptococcus, and CD4 >100-200
  314. Histoplasmosis
    • *Caused by a soil fungus, Histoplasma capsulatum
    • *Pathogenesis is similar to TB
    • *Tx: intraconazole
  315. Tx of TB in HIV pts
    • *HIV pts are at 400-800x's greater risk
    • *Tx for 6-9mo
    • *Tx and prophylasis same as in 'healthy' individuals
  316. Mycobacterium avium complex
    • *Infection caused by M. avium or M. intracellulare
    • *Occurs when CD4 count <100
    • *Sx: fever, night sweats, wt loss, D, malaise, abd pain
    • *Dx: blood cx
  317. Tx of Mycobacterium avium complex
    • *Clarithromycin/azithromycin + ethambutol + rifabutin/rifampin (+/- cipro/levo/amikacin)
    • *Tx lifelong unless 12mo of tx and asymptomatic and CD4 >100 or >6 mo
  318. Prophylactic tx for mycobacterium avium complex
    • *Primary prophylasis: initiate when CD4 count <50-100
    • -Azithromycin or clarithromycin or rivabutin
    • -Can DC when CD4 >100 x 3-6mo

    *Secondary prophylaxis until CD4 >100 x 3-6mo
  319. Cytomegalovirus
    • *Bloodborne pathogen
    • *Likely to occur when CD4 <50
    • *Tetinitis is the most common presentation but colitis also common
  320. Prophylactic tx of CMV
    • *Primary when CD4 <50 and pt has CMV + ab's
    • *Secondary prevention until CD4 >100 x 6mo
  321. Tx of CMV
    • *1st line: ganciclovir IV q12h x 14-21 days then IV qd or intraocular implant
    • *2nd line:
    • -Valganciclovir PO BID x 14-21 days then qd
    • -Foscarnet
    • -Cidofovir
  322. Tx of candidiasis
    • *Topical tx: nystatin or clotrimazole trouches
    • *Systemic tx: fluconazole 100-200mg qd or itraconazole 200mg qd
    • *Cont tx until sx's eliminated for several days
  323. Immunizing HIV pts
    • *Pneumococcal: initial, 5 yrs later, and when >65 (if 1st immunization was w/ CD4 <200, revaccinate when >200)
    • *Hep B: pts at risk esp if HCV
    • *Hep A: pts at risk incl. co-infections w/ HBV HCV, IV drug use, MSM
    • *Influenza

    *Live vaccines CI'ed if CD4 <200
  324. When to prophylax for PJP, Toxoplasmosis, MAC, CMV, and cryptococcus
    • *CD4 <200: PJP
    • *CD4 <100: toxoplasmosis
    • *CD4 <50: MAC, CMV, cryptococcus (if hx of)
  325. Uncomplicated vaginal cutaneous candidiasis
    • *Sporatic or infrequent disease
    • *Mild to moderate
    • *Likely to be Candida albicans
    • *Non-immunecompromised women
  326. Tx of uncomplicated vaginal cutaneous candidiasis
    • *3 day topical (same efficacy as 7 day), but if early in course 1 day tx can be recommended
    • *Fluconazole PO
  327. Complicated vaginal cutaneous candidiasis
    • *Recurrent (>/=4 episodes/yr)
    • *Severe
    • *Non-albicans candidiasis or
    • *Uncontrolled DM, immunosuppression, pregnancy
  328. Tx of complicated vaginal cutaneous candidiasis
    • *Topical tx x 7-14 days
    • *Fluconazole 150mg PO, repeat in 3 days
    • *Immunocompromised: oral azoles or IV tx x 7-14 days
    • *Pregnancy: topical azoles x 7 days
  329. Tx of recurrent vaginal cutaneous candidiasis
    • *Fluconazole 150mg po q72h x 3 doses -OR-
    • *Topical x 7-14 days
  330. Maintenance tx of vaginal cutaneous candidiasis
    • *Tx x 6 mo
    • -Fluconazole 1-2x/wk
    • -Intraconazole
    • -Clotrimazole
    • -Boric acid
    • _Gentian violet
  331. Counseling pearls for topical products for tx'ing vaginal cutaneous candidiasis
    • *Complete full course of tx
    • *Use HS
    • *If sx don't resolve in 24-48h see MD
  332. Tx of Candidia glabrata vaginitis
    • *Sx: intense vulvo-vaginal burning (as apposed to itching w/ albicans)
    • *Tx:
    • -Butoconazole
    • Imidazoles x 7-14 days
    • *Boric acid x 14 days
    • *Topical gentian violet

    ***Fluconazole not recommended***
  333. Nystatin
    • *Swish and swallow oral susp QID
    • *Contact PCP if increased irritation or no relief in 24-72h
  334. Counseling pearls for ring worm and athletes foot
    • *Continue tx for 1 wk after lesion resolves
    • *Infection is spread by human to human
    • *If no improvement, see PCP bc oral tx may be needed
  335. Tx of nail fungus
    • *Systemic tx needed after spread to nail matrix
    • *Terbinafine x 3 mo
    • *Intraconazole x 3 mo
    • *Griseofulvin x 12-24 mo
  336. Ciclopirox
    • *Broad spectrum antifungal w/ activity against dermatophytes
    • *QD administration x 48 wks
  337. Tx of scalp ringworm
    • *Griseofulvin PO
    • *Recurrent: terbinafine or intraconazole
    • *Adjunct w/ topicals (selenium sulfide)
  338. Griseofulvin
    • *AEs: rash, HA, photosensitivity, NVD
    • *DD intrnxs: decreased effects of warfarin and COCs, increased toxicity w/ EtOH
  339. What organisms is ketoconazole used to tx?
    • *Candidiasis
    • *Blasto
    • *Histo
    • *Cocci
    • *Cutaneous dermatophytes
  340. What organisms is intraconazole used to tx?
    • *blasto
    • *histo
    • *aspergillosis
    • *onychomycosis of the nails
    • *dermatophytosis
    • *chronic candidiasis
    • *crypto
    • *cocci

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