Infectious diseases

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VASUpharm14
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Infectious diseases
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2014-06-18 15:18:24
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ch. 16. ID
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  1. minimum inhibitory concentration
    • MIC
    • lowest drug concentration that prevents visible microbial growth in 24 hours
    • generally 90%
  2. breakpoint
    • level of MIC deemed susceptible or resistant
    • est by FDA and CLSI
  3. minimum bactericidal concentration
    • MBC
    • lowest drug concentration that reduces by 99.95% in 24 hours (kills bacteria)
  4. synergy
    2+ agents together is greater than alone
  5. pharmacokinetics (ADME)
    • DC BAG  - has water + vanco
    • No water - FQ, MAC, BAC, Rif, Line, Tetra, Chloram, Metron
  6. MOA
    • Kill them all, except ribosomes (except AMG/streptog
  7. aminoglycosides
    • TAG - tobramycin, amikacin, gentamicin
    • Coverage: N (pseudo), synergy + beta-lactam/vanc (P)
    • BBW: neurotox, nephrotox, no preggo
    • SE: nephrotox (ATN), hearing loss
    • Dose: IV/IM, extended better (4-7 mg/kg, 15-20 mg/kg), GT 1-3 mg/kg/dose (higher gram N, lower gram P), A 5-7 mg/kg/dose, renal intervals - 60=Q8, 40=Q12, 20=Q24, troughs - less than 2 mcg/ml
    • Goal: N - 5-10 mcg/mL peak, P - 3-4 mcg/mL peak, trough <2
  8. 5 types of penicillins
    • 1) aminopenicillins
    • 2) natural
    • 3) ureidopenicillins
    • 4) carboxypenicillins
    • 5) antistaphlococcal
  9. aminopenicillins
    • 1. amoxicillin (Amoxil) + clavulanate (Augmentin) WITH food
    • 2. ampicillin + sulbactam (Unasyn)
    • Coverage: P (strep, enterococci- synergy), some N. NO atypicals
    • Dose: amoxicillin (PO), ampicillin (IV/PO), Unasyn (IV) 
    • Notes: augmentin oral - FRIDGE, Amoxil RTx 14d, ampicillin IV in NS in RTx 8Hrs, **amoxicillin is DOC acute otitis media, H. pylori, preggo, prophy endocarditis
  10. natural penicillins
    • 1. penicillin (Pen VK)
    • 2. penicillin G benzathine (Bicillin L-A)
    • Coverage: P (strep), some N. NO atypicals
    • Dose: VK (PO), G (IV)
    • Notes: Pen VK on EMPTY stomach and FRIDGE
  11. ureidopenicillins
    • piperacillin + tazobactam (Zosyn)
    • Coverage: P (strep, Enterococci), some N (pseudo). NO atypicals.
    • Dose: IV
  12. carboxypenicillins
    • ticarcillin + clavulanic acid (Timentin)
    • Coverage: P (strep), some N (pseudo). NO atypicals
    • Dose: IV
  13. antistaphylococcal penicillin
    • NOD - nafcillin, oxacillin, dicloxacillin
    • Coverage: P (strep, naf=MSSA), some N. NO atypicals
    • Dose: n/o (IV), d (PO)
    • Note: NO renal adjustments, nafcillin - vesicant USE cold packs+hyaluronidase inj
  14. 5 generations of cephalosporins coverage
    • 1. Better Staph, low Strep, N (PEK)
    • 2. P, Better N (HNPEK), cefotetan/cefoxitin (bacteroides fragilis = anaerobic)
    • 3. Better N (HNPEKS) + enteric N, less Staph, Better Strep, ceftazidime (Better N - Pseudo)
    • 4. Best N (HNPEKS + CAPES), same P
    • 5. Best P (MRSA), some N
  15. 1st gen cephalosporin
    • 1. ceFAZolin (Kefzol) - IV/IM
    • 2. cephalexin (Keflex) - PO
    • Note: cross-reactivity with PCN allergy
  16. 2nd gen cephalosporin
    • 1. cefaclor - PO
    • 2. cefoTEtan - IV/IM
    • 3. cefuroxime (Ceftin, Zinacef) - PO/IV/IM
    • Notes: cefotetan has MTT side chain = bleeding and disulfiram with ETOH, cefuroxime WITH food
  17. 3rd gen cephalosporin
    • 1. cefdinir - PO
    • 2. cefpodoxime (Vantin) - PO
    • 3. cefTAZidime (Fortaz, Tazicef) - IV/IM
    • 4. ceftriaxone (Rocephin) - IV/IM - only NOT renally adjusted
    • Notes: cefpodoxime WITH food, ceftriaxone - biliary sludging - no calcium, no neonates
  18. 4th gen cephalosporin
    cefepime (Maxipime) - IV/IM
  19. 5th gen cephalosporin
    ceftaroline fosamil (Teflaro) - IV
  20. carbapenems
    • DIME - 
    • 1. doripenem (Doribax) - IV
    • 2. Imipenem/cilastatin (Primaxin) - IV
    • 3. meropenem (Merrem) - IV/IM
    • 4. Ertapenem (Invanz) - IV
    • Coverage: most P, N (pseudo), ANAerobic. NO atypical, MRSA, VRE, C.diff, ERTA - no pseudo/actinobacter
    • CI: allergy with beta-lactams
    • SE: seizures
    • Notes: cilastatin prevents drug degradation by renal tubular dehydropeptidase
  21. fluoroquinolones
    • 1. ofloxacin (Floxin - otic) - PO
    • 2. ciprofloxacin (Cipro) - IV/PO
    • 3. levofloxacin (Levaquin) - IV/PO
    • 4. moxifloxacin (Avelox) - IV/PO
    • Coverage: N (pseudo for cipro/levo), P, atypical (not oflox), Moxi (Better P + ANAerobic = good mix infections), RESPI (gem, levo, moxi = strep pneumo + atypical)
    • BBW: tendon rupture (steroid, transplant, >60yo), worsen myasthenia gravis
    • CI: cipro + tizanidine
    • Warnings: QT prolongation, peripheral neuropathy, seizures, hypo glycemia
    • SE: GI, diarrhea
    • Notes: Cipro Susp (no feed tube - only ok with IR, no fridge), levo oral solution on EMPTY stomach, ok with PCN allergy, all renally adjusted, SEPARATE ANTACIDS (chelation)
  22. macrolides
    • ACE
    • 1. azithromycin (Zithromax, Z-Pak) - PO/IV
    • 2. clarithromycin (Biaxin) - PO (renally)
    • 3. erythromycin (EES, Erythrocin) - PO/IV
    • Coverage: Clarith - P (strep), Azith - N (HNM), atypicals, upper/lower RESPI, SEX
    • Dose: Z-pak - 250 mg BID d1 then 250 mg QD d2-5
    • CI: EES + simvastatin/lovastatin
    • Warnings: QT prolongation, Hepatotox
    • SE: GI
    • Notes: Zmax NO fridge, Clarith WITH food, EES with FRIDGE x10d, erythr powder RT x35d, Eryth+clarith - watch 3A4
  23. tetracyclines
    • DM
    • 1. doxycycline (Oracea) - PO/IV
    • 2. minocycline (Minocin, Solodyn, Dynacin) - PO/IV
    • Coverage: P (staph, strep, entero, nocar, bacillus, propio), N (RESPI = HM, atypicals), unique (spirochetes, ricketts, anthrax, syphi, acne, Chlamydia, malaria, etc).
    • Warning: ≤8 yo, preggo (d), breastfeeding - bone and teeth
    • SE: photosensitivity
    • Notes: Oracea - EMPTY stomach, doxy 1:1 NO fridge, SEPARATE ANTACIDS
  24. sulfonamides
    • sulfamethoxazole + trimethoprim (Bactrim, Septra)
    • Coverage: P (staph - MRSA), N (H PEK, enterobacter, acinetobacter, shigella, salmonella, steno), opportunistic (norcar, pneumocystis, toxopl), NO pseudo, enteroc, atypicals, anaerobic
    • CI: sulfa allergy, preggo, breastfeeding, anemia, renal, hepatic <2mo
    • SE: GI upset, skin reactions, crystalluria (water), photosen, hyper kalemia, hypo glycemia
    • Dose: PO/IV uncomp UTI - 1 DS BID x 3d, PCP prophy - 1 DS/SS QDay, 5:1 ratio (400/80, 800/160)
    • Notes: IV at RT in D5W, susp at RT, PO/IV is 1:1, renal, protect from light, FAB4*
  25. gram-positive only
    • 1. vancomycin (Vancocin)
    • 2. linezolid (Zyvox)
    • 3. quinupristin/dalfopristin (Synercid)
    • 4. daptomycin (Cubicin)
    • 5. telavancin (Vibativ)
  26. vancomycin
    • Vancocin
    • Coverage: Staph (MRSA), Strep, Entero (not VRE), c. diff
    • Dose: DOC MRSA - 15-20 mg/kg Q8-12H IV, C.diff - 125-500 MG QID x10-14d+ PO
    • SE: red man - rash, hypo tension, flushing, chills (30 min infusion for every 500 mg of drug), nephrotox
    • Monitor: troughs - 15-20 mcg/mL (B HOME)
    • Notes: MIC ≥2 consider alternative
  27. linezolid
    • Zyvox
    • oxazolidinone class
    • Coverage: MRSA, VRE F&F, pneumo, un/c S&ST (DM foot)
    • CI: MAOi
    • Warnings: myelo (CBC), neuropathy (>28 d), MAOi, hypo glycemia
    • SE: h/a, diarrhea
    • Dose: IV/PO 1:1
    • Notes: RT x 21d, AVOID tyramine + serotonergic drugs
  28. quinuprisitn/dalfopristin
    • Synercid
    • streptogramin class
    • Coverage: MRSA, VRE faeciam, c S&ST
    • SE: myalgias, edema/pain, phlebitis,hyper bili
    • Dose: IV
    • Notes: D5W
  29. daptomycin
    • Cubicin
    • cyclic lipopeptide class
    • Coverage: MRSA, VRE F&F, c S&ST, right-sided endocarditis (Staph aur in bloodstream)
    • SE: GI, CPK/myopathy (monitor weekly)
    • Dose: IV, extend interval in renal impairment
    • Notes: inactivated by surfactant (NO pneumo), NS, false inc PT/INR
  30. telavancin
    • Vibativ
    • lipoglycopeptide (derivative of vanc)
    • Coverage: NO VRE, c S&ST, HAP & MRSA (not first-line)
    • BBW: no preggo, nephrotox
    • Warning: QT prolongation, red man
    • SE: metallic taste, n/v
    • Dose: IV
    • Notes: Medguide
  31. gram-negative only
    • 1. aztreonam (Azactam)
    • 2. colistimethate (Colistin)
  32. aztreonam
    • Azactam IV
    • monobactam
    • Coverage: many + pseudo 
    • Dose: IV
    • Notes: Cat B, can use in PCN allergy
  33. colistimethate
    • Colistin
    • polymyxin class
    • Coverage: Enterobacter, EK pneumo, Pseudo, primarily for MDR N
    • Warning: nephrotox
    • SE: nephrotox, neurological disturb (dizzy, numb)
    • Dose: IV
  34. Broad spectrum - additional
    • 1. chloramphenical
    • 2. telithromycin (Ketek)
    • 3. tigecycline (Tygacil)
  35. chloramphenical
    • - rarely used
    • Coverage: P, N, ANAerobes, Atypicals
    • BBW: blood dyscrasias (CBC)
    • Warnings: Gray syndrome
    • Dose: PO
  36. telithromycin
    • Ketek
    • ketolide class - related to macrolides
    • Coverage: P (primarily Strep, CAP), N, some ANAerobes, MYCO atypicals
    • BBW: NO myasthenia gravis (respi fail)
    • CI: allergy to macrolides, myasthenia gravis
    • Warnings: acute hepatic failure, QT prolongation
    • Monitor: LFTs, visual acuity
    • Dose: PO
    • Notes: 3A4, inhibits 3A4, AVOID class Ia+III antiarrhythmics (QT)
  37. tigecycline
    • Tygacil
    • glycylcylclines - derived from minocycline
    • Coverage: P (MRSA, VRE F&F), N (NO - pseudo, proteus, provid), ANAerobes, Atypicals, c S&ST, intraabdom, CAP (last-line)
    • BBW: death - last line
    • Warnings: hepatox, pancreat, photosen, ≤8 yo, preggo (bone and teeth)
    • Dose: IV
    • Notes: AVOID bloodstream infections - lipophilic
  38. OTHER antibiotics
    • 1. clindamycin (Cleocin)
    • 2. metronidazole (Flagyl)
    • 3. tinidazole (Tindamax)
    • 4. rifaximin (Xifaxan)
    • 5. fosfomycin (Monurol)
    • 6. nitrofurantoin (Macrodantin, Macrobid, Furadantin)
    • 7. fidaxomycin (Dificid)
  39. clindamycin
    • Cleocin
    • Coverage: aerobic P (not Entero), ANAerobic N/P
    • BBW: colitis (c.diff)
    • SE: GI
    • Dose: PO/IV/topical
    • Notes: D test (+ erythromycin)
  40. metronidazole
    • Flagyl
    • Coverage: ANAerobes, protozoal, DOC bacterial vaginosis, tricho, giard, amebiasis, C. diff
    • BBW: carcinogenic in animal data
    • CI: no preggo (1st), disulfiram x2weeks, ETOH x3d at d/c
    • SE: GI, metallic taste, CNS
    • Dose: IV/top/PO 500 mg TID x10-14d (mild-mod c.diff)
    • Notes: IV/PO 1:1, NO fridge IV (crystals), FAB4*
  41. rifaximin
    • Xifaxan - related to rifampin
    • Coverage: e.coli (traveler's diarrhea), prevention of hepatic encephalopathy
    • Dose: 200 mg PO TID x3d, or 550 mg PO BID
  42. fosfomycin
    • Monurol
    • Coverage: e. coli and E. faecalis (VRE) - single dose uncomp UTI (cystitis only) 
    • Dose: 3 grams + cold water PO
  43. nitrofurantoin
    • Macrodantin, Macrobid, Furadantin
    • Coverage: E. coli, S. aureus, Entero, Kleb, Enterbacter - uncomp UTI (cystitis only)
    • CI: renal < 60 ml/min, preggo (at term)
    • Dose: PO - QID Macrodantin, BID MacroBID
    • SE: n, h/a, hepatox (rare), neurop (rare), long term = pulmonary tox
    • Notes: WITH food to enhance absorption, dark urine - yellow/brown (harmless), AVOID probenacid, magnesium antacids
  44. fidaxomicin
    • Dificid
    • Coverage: c.diff diarrhea
    • Dose: 200 mg PO BID x10d
    • Notes: not systemic
  45. Difficult to treat with DOC
    • 1. S&ST, CA-MRSA: Bactrim DS Q12H (doxy, mino, clinda, line, dapto, Tige, ceftaro, vanc, telavancin)
    • 2. HA-MRSA: vancomycin (line, dapto, Synercid, ceftaro, telavancin, SMX/TMP, rifam)
    • 3. VRE faecalis: pen G, ampicillin (line, dapto, tige, suscept - nitrofuran, fosfo, doxy)
    • 4. VRE faecium: daptomycin (line, synercid, tige, suscept - nitrofuran, fosfo, doxy)
    • 5. Pseudo aeru: (DIM, cefepime, ceftaz, cipro/levo, aztreo, ticar, piper, colistin, TAG)
    • 6. ESBL-GNR (beta-lactase producing enteric gram-neg rods) - PEK: carbapenems (high dose cefepime, piper, FQ, suscept - AMG)
    • 7. Acinetobacter: DIM (Unasyn, colistin, mino, tige, FQ, SMX/TMP)
    • 8. Bacteroids fragilis: (metron, carbapen, beta-lactams, tige, cefoxitin, cefotetan, clinda, moxi)
    • 9. C. diff: (metronidazole, vanc (PO), fidaxomicin)
  46. surgical prophylaxis
    • DOC 1st/2nd gen cephalosporins (cefazolin, cefuroxime, vanco - for PCN allergy)
    • within 60 minutes, or 120 minutes with FQ/Vanc
    • bowel surgery or ANAerobic - need BROAD (cefotetan, ertapenem, ceftriaxone + metronidazole)
  47. meningitis
    • triad sx: h/a, stiff neck, AMS 
    • mostly viral
    • steps:
    • 1. lumbar puncture - viral vs bacterial
    • 2. stains
    • 3. max dose for CNS penetration
    • 4. empiric therapy - based on AGE, immune, and allergy
    • 2-50 yo (S. pneumo, N. meningitidis): cephs, meropenem+vanc+/- dexamethasone
    • <1 mo, >50 (Listeria): ADDITIONAL ampicillin 2 grams IV Q4H 
    • immunocompr, >50 (S. pneumo, N. men, L.mono): vanc+ amp+cef 
    • PCN allergy: chloramphen + van +/- SMP/TMX (Listeria)
  48. Upper respiratory tract infections- acute otitis media
    • AOM
    • most common in children to get AB tx
    • S/SX: bulging tympanic membrane, otorhea, otalgia, fever, crying and tugging/rubbing ears
    • mostly viral
    • steps:
    • 1. APAP or IBU or (topical > 5yo) 
    • 2. non-severe OBSERVE (no prophy) 48-72 hrs
    • 3. Primary tx (S. pneumo) - HIGH-DOSE amoxicillin (80-90 mg/kd/day) Q12H, or Augmentin (90 mg/kg/day) Q12H. 
    • 4. Duration - AGE
    • <2 yo: 10 d
    • 2-5 yo: 7 d
    • ≥6 yo: 5-7 d
    • 5. vaccines - PCV 13 IM, Peumovax ≥24 mo + risk, influenza ≥6+mo
  49. Upper respiratory tract infections - Common cold
    • Etiology: rhinovirus, coronavirus, RSV
    • Tx: n/a, treat for symptomatic
    • Adjunctive: cough suppressants, decongestants, APAP
    • Duration: per symptoms
  50. Upper respiratory tract infections - Influenza
    • Etiology: influenza virus *A+B
    • Tx: <48 hours with oseltamivir, zanamavir
    • Adjunctive: APAP, NSAIDs, cough suppressants, rest, fluids
    • Duration: 5 days
  51. Upper respiratory tract infections - pharyngitis
    • Etiology: S. pyogenes
    • Tx: fever, no cough, tonsil/LN swelling +RADT/ cx for Strep with penicillin, amoxicillin, 1st/2nd gen cephalosporin, macrolides
    • Adjunctive: APAP, NSAIDs, cough suppressants, throat lozenges/anesthetics
    • Duration: 5-10 days
  52. Upper respiratory tract infections - sinusitis
    • Etiology: S. pneumo, H. influe, Moraxella catar, Staph species - anaerobes, Gram neg rods
    • Tx: >7-10 days of sx, tooth/face pain, nasal drainage/discharge, congestion or severe/worsening sx with amoxicillin, SMX/TMP, doxycycline; 2nd line: azith, amox/clav, oral 3rd gen ceph, respi FQ
    • Adjunctive: nasal corticosteroids, decongestants, APAP/NSAIDs
    • Duration: variable - acute - 7-14d, chronic ≥ 21 days +/- surgical intervention
  53. lower respiratory tract infections
    • 1. bronchitis
    • 2. CAP
    • 3. HAP
    • 4. TB
  54. acute bronchitis
    • mostly viral or mycopla pneumo, strep pneumo, H. influ, Bordetella pertussis, etc
    • - treat sx and supportive- fluids, antipyretics, cough suppressants, vaporizers
    • s/sx: cough (2 weeks), sore throat, coryza, malaise, h/a, low-grade fever, sputum
    • Persistent cough (>14 dyas)/pertussis (whooping cough): ACES - 
    • Azithro - 500 mg x1, 250 mg QDx 2-5 d
    • Clarithro - 500 mg BID or 1 gm ER QDx7d
    • Erythro - 500 mg QID x14d
    • SMX/TMP - DS 1 tab BID x 14d
  55. acute exacerbation of chronic bronchitis
    • AECB
    • 2+ sx: increased dyspnea, increased sputum production, purulence
    • Tx: no AB or amoxicillin, doxycycline, SMT/TMP, ceph
    • USE: inhaled anticholinergic bronchodilator + oral corticosteroid (taper 2 weeks)
  56. community-acquired pneumonia
    • CAP
    • 85% Strep pneumo, H. influ, Moraxella cat
    • s/sx: fever, productive cough (+purulent sputum), chest pain, rales
    • TX: ICU vs NOT
    • 1. Outpatient: macrolide (ACE) or doxycycline, resistant/or previous AB (HF, DM, cancer, renal/liver dysfunction, alcoholism, asplenia, immunosuppression) - respi FQ or Beta-lactam+macrolide/doxycycline
    • 2. Inpatient (non-ICU): beta-lactam+macrolide or respi FQ (IV/PO)
    • 3. Inpatient (ICU): IV - beta-lactam+azithro/FQ, pseudo - antipneumo+antipseudo beta-lactam+cipro/levo/aminogly&FQ/Azithr, CA-MRSA - add vanco/linezolid
    • Duration: most 5-10d
  57. hospital acquired pneumonia/ventilator associated pneumonia
    • HAP/VAP
    • leading cause of death in ICUs
    • Onset:
    • 1. early (<5 days) - strep pneumo, MSSA, H PEK
    • tx - LUCE - levo/moxi, amp/sulba (Unasyn), ceftriaxone, ertapenem
    • 2. late (≥5 days)  - + MRSA, pseudo, acineto, entero, nosocomial pathogens
    • tx - antipseudo beta-lactam (aztreonam if PCN allergy) + 2nd antipseudo +/- anti-MRSA (vanc/linezolid)
    • Duration: 7-8 d, 14 d (N + bloodstream)
  58. tuberculosis
    • TB
    • highly contagious - aerosolized
    • Dx: TST/PPD (48-72 hrs)
    • Latent vs active
    • 1. Latent: INH, RIF, INH + Rifapentine
    • 2. Active: 4 drugs - (RIPE) RIF, INH, pyrazinamide, ethambutol, MDR-TB = PRIME (moxi)
    • Notes: use DOT (direct observation therapy) on weekly dosings, active - must be isolated in single negative pressure rooms!!, add pyridoxine (vit B6) 25-50 mg PO daily to INH to DEC neuropathy + EMPTY stomach + inhibitor CYP (weak/mod),
    • -rifampin - EMPTY stomach, SE - INC LFTs, GI, rash, orange-red, flu-like sx
    • -INH - SE: lupus-like
    • -pyrazinamide - GI, malaise, hyperuricemia (gout), fatal hepatox + rifampin
    • -ethambutol - optic neuritis
  59. infective endocarditis
    • IE
    • Dx: Modified Duke Criteria, echocardiogram
    • Tx: depends on pathogen, prosthetic valve, susceptibility results
    • -Strep - penicillin or ceftriaxone preferred
    • -MSSA - nafcillin or cefazolin
    • -MRSA, PCN allergy for Strep/MSSA/Enterococci - vancomycin 
    • -prosthetic valve/Staph - ADD rifampin 
    • -synergy - gentamicin - peak 3-4 mcg/mL, trough <1 mcg/mL (NO extended)
    • Duration: 4-6 weeks
  60. dental IE prophylaxis
    • prosthetic valves, hx endocarditis, abnormal valve transplant, congenital heart defects
    • Tx: PO amoxicillin 2 G, IV/IM ampicillin 2 G, PCN allergy - PO/IV/IM clindamycin 600 mg
    • Duration: 1x dose 30-60 mins before dental procedure
  61. intra-abdominal infections
    • second most common infectious mortality in ICUs
    • Types: 
    • 1. primary (spontaneous) - generally with liver dx - strep, enteric N (PEK), rarely ANAerobes
    • DOC: ceftriaxone 5-7 d
    • 2. secondary (ulceration, ischemia, obstruction, surgery) - strep, enteric N, ANAerobes (Bacteroides fragilis), CAPES+pseudo (ICU)
    • DOC: ticarcillin/clavulanate, ertapenem, cefoxitin, tigecycline, moxifloxacin, combo: cefazolin/cefuroxime/ceftriaxone + metronidazole, cipro/levo+metronidazole
    • DOC (ICU): DIM, piperacillin/tazobactam, combo: ceftazidime/cefepime+metronid, cipro/levo+metro, aztreonam/AMG+metro
    • Duration: 7-14 days
    • 3. biliary tract infections (cholecystitis and cholangitis) - 
    • cholecystitis: gallbaladder - surgical
    • cholangitis: biliary duct - bile compression + same as secondary
  62. skin and soft tissue infections
    • S&STis
    • cellulitis: all layers of skin - S. pyogenes, S. aureus
    • s/sx: skin lesions painful, erythematous, hot and tender, poor margins, spread
    • nonpharm tx: elevation, immobilization of area, cool sterile saline dressings, drained
    • TX: 
    • 1. outpatient (P- staph, strep) - nonpurulent - beta-lactams, purulent - PO clinda, SMX/TMP, doxy, mino, linezolid
    • Duration: 5-10 d
    • 2. inpatient (MRSA) - vanc, linezolid, dapto, telavancin, clinda
    • Duration: 7-14 d
  63. diabetic foot infections
    • Aerobic, ANAerobic, P, N
    • Tx: Single - unasyn, zosyn, timentin, DIME, tigecycline, moxiflox
    • combo- 3rd/4th gen cephs+metro/clind+/-vanc (MRSA), clinda+FQ, Vanc+ceftaz+metro, Dapt/Line+aztreo/AMG+metro/clinda 
    • Duration: 7-14 d
    • Note: low blood flow - hard to treat lower extremities
  64. urinary tract infections
    • 1. lower urinary tract: bladder (cystitis), urethra
    • s/sx - dysuria, urgency, frequency, burning, nocturia, suprapubic heaviness, hematuria, fever uncommon
    • dx: positive urinalysis with pyruria and bacteriuria
    • 2. upper urinary tract: kidneys (pyelonephritis)
    • s/sx - flank pain, abdominal pain, fever, nausea, vomiting, costovertebral angle pain, malaise
    • uncomplicated vs complicated: women, F/M
    • Note: must treat PREGGO women x7d even asymptomatic with negative urinalysis - NO FQ, NO tetracyclines, NO SMX/TMP (3rd), USE - beta-lactams or PCN allergy - nitrofurantoin, fosfomycin
  65. UTI - acute uncom cystitis females
    • 15-45 yo
    • Coverage: PEK, saprophy, enterococci
    • DOC: nitrofurantoin 100mg BID 5d, SMX/TMP 1 DS BIDx3d, fosfomycin x1, Sulfa allergy - cipro/levo x3d
    • ADD - phenazopyridine 200 mg PO TID x2d for dysuria
    • Prophy - ≥3/yr - 1 SMX/TMP SS QD, nitrofurantoin 50 mg PO QDay, 1 SMX/TMP DS post coitus
  66. UTI - acute uncom pyelone
    • Coverage: E.coli, Enterococci, P. mirabilis, K. pneumo, P. aeru
    • DOC: PO outpatient based on FQ resistances
    • - <10% - Cipro x7d, Levo x5d
    • - >10% - ceftriaxone 1 gram x1, 24 hours AMG then SMX/TMP or beta-lactam x 14d
    • -severe - hospitalized - IV FQ/AMP+gent/PIP-Tazo, ceftriaxone, stepdown x14d
  67. UTI- complicated
    • Coverage: EK, enterobacter, serratia, PSEUDO, enterococcus, staph
    • Tx: same as pyelonephritis, ESBL - carbapenems
  68. phenazopyridine
    • Azo, Uristat, Pyridium
    • urinary analgesic
    • CI: <50 ml/min, liver dx
    • SE: h/a, dizziness, stomach cramps, body secretion discoloration
    • Notes: food+8 oz water, red-orange stains
  69. clostridium difficile infection
    • CDI
    • releases toxins on the intestinal lining = colitis
    • pseudomembranous colitis = inflamed colon
    • s/sx: abdominal cramps, bloody, soft or watery stools (frequent), fever
    • Steps: 
    • 1. d/c offender ASAP
    • 2. AVOID antimotility agnets
    • 3. wash hands
    • 4. contact precautions
    • 5. metronid for 1st recurrence only (cumulative neurotox)
    • 6. probiotics considered
    • TX: 
    • a) mild/mod - metron 500 mg PO TID x10-14d
    • b) severe (WBC ≥15000, SCR >1.5x premorbid level) - vanc 125 mg PO QID x10-14d
    • c) severe, complicated (hypo tension, shock, ileus, or megacolon) - vanc 500 mg PO QID + metron 500 mg IV Q8H, ileus = ADD vanc 500 mg in 100 mL NS PR Q6H
    • 3rd infection/2nd recurrance - Vanc taper/pulse
  70. traveler's diarrhea
    • TD
    • most common travel-related illness - ingestion of fecally contaminated food and water
    • "boil it, cook it, peel it, or forget it"
    • DOC: FQ, NO prophy, young/elderly - oral rehydration therapy
  71. sexually transmitted infections
    • STIs
    • Tx: k
    • 1. syphilis - Pen G (LA not CR), 2.4 million units x1 IM, unknown duration = x3 weeks
    • 2. gonorrhea - ceftriaxone (Rocephin) + azith/doxy (chlamydia combo) 250 mg IMx1
    • 3. chlamydia - azithromycin 1 G POx1
    • 4. bacterial vaginosis - metronidazole 500 mg PO BID x7d, or metron 0.75% gel 5 G intravaginally QD x5d
    • *ALL partners should be treated
  72. rickettsial dx
    • ticks, fleas, lice
    • Doxy for all except TULAREMIA = gent/tobra 5 mg/kg/d divided Q8H IV x7-14d
    • PREGGO = amoxicillin
  73. concentration dependent killing
    • 1. AMG
    • 2. FQ
    • 3. daptomycin
    • 4. telavancin
  74. time dependent killing
    • 1. B-lactams
    • 2. vancomycin

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