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Therapeutics III '13
Pain, UTI, Skin Infections, Hepatitis, Cirrhosis, HIV, PUD/GERD
| Question | Answer |
|---|---|
| Pain is: | an unpleasant sensory and emotional experience associated with actual or potential tissue damage |
| Which type of pain has a biological function? | Nocioceptive |
| Which type of pain does not have a biological function? | Neuropathic |
| What is nocioceptive pain? | stimulation of peripheral pain receptors that can be somatic (musculoskeletal) or visceral (internal) |
| What is neuropathic pain? | dysfunction of peripheral or central nervous system |
| How do we describe neuropathic pain? | tingling, burning, shooting, numbing, electric |
| How do we describe nocioceptive pain? | sharp, dull, aching, stabbing, throbbing |
| Which type of pain commonly has a psychological component? | chronic |
| What are common features of acute pain? | anxiety, sympathetic hyperactivity, occurs less than 1 month |
| What are common features of chronic pain? | fatigue, anger, depression, insomnia, social disruption, occurs greater than 1 month |
| Activation of nerves that do not transmit pain signals then interfering with signals from pain fibers to inhibit the perception of pain is called what? | Gate Control Theory |
| What are some things that close the gate control theory and therefore help alleviate pain? | drugs, counter-stimulation, increased interest in activities, intense concentration, relaxation, happiness, rest, isolation |
| What are some things that open the gate to pain, making it worse? | injury, tension, anger, anxiety, worry, depression, boredom, inappropriate physical activity, focusing on pain |
| What are the 2 goals of pain management? | reduce average pain score by 30% and improve quality of life |
| Is pain managed best with opioids? | No |
| Is there any objective way to measure pain? | No |
| Is patient usually under or over-treated? | under-treated |
| What drugs fall into the category that you should should try first line (1)? | APAP, NSAIDs, anticonvulsants, antidepressants |
| What drugs fall into the category that you should try if category 1 drugs do not work for pain (2)? | tramadol, hydrocodone/APAP (vicodin), codeine/APAP |
| What drugs should you use if category 1 or 2 drugs don't work for pain (3)? | morphine, oxycodone, hydromorphone, fentanyl, methadone |
| APAP dosing | Max 1000mg every 6 hours |
| Pregabalin dosing | 50 mg TID, then titrate up to 100 mg TID in one week |
| Gabapentin dosing | 300 mg TID, but goal dose is 600 mg TID for 4 weeks Avg dose: 2400mg/day and max 3600mg/day |
| Nortriptyline dosing | 25 mg HS (10 if elderly), then titrate up by increments of 10-25 mg/day every 3-7 days; usual effective dose is 75-100mg/day |
| Amitriptyline dosing | 25 mg HS (10 if elderly), then titrate up by increments of 10-25 mg/day every 3-7 days; usual effective dose is 75-100mg/day |
| What are some non-pharmacologic options for treating pain? | hot/cold compress, PT, exercise, behavioral therapy, e-stim, biofeedback, relaxation, coping, group therapy, massage, pilates, yoga, water therapy |
| Does APAP have anti-inflammatory properties? | NO |
| Can APAP be used to treat both chronic and acute pain? | yes |
| Can you give APAP if patient has chronic kidney disease? | yes |
| What is the most common cause of acute liver failure? | APAP |
| When should you avoid APAP? | greater than 3 alcoholic beverages per day or severe chronic liver disease |
| What is the max daily dose of APAP? | 4 grams/day |
| Does ibuprofen have anti-inflammatory properties? | yes |
| Can ibuprofen be used to treat both chronic and acute pain? | no only acute |
| What are the 4 cons to using ibuprofen? | GI bleeds, Increased bleeding risk due to platelet dysfunction, renally toxic, cardio risk |
| If patient has bleeding gastric ulcer, what NSAID should be given? | Celecoxib (celebrex) because it is cox-2 selective and will not effect the GI, or salsalate |
| Avoid all NSAIDs in patients with what? | Kidney problems |
| If giving ASA and NSAID, how do you dose? | give ASA, then 30 minutes later, give NSAID; 8 hours after NSAID was given is when you can give next ASA dose |
| Why do we not recommend ASA for pain? | high risk of bleeding |
| What is capsaicin especially good for? | neuropathic, localized pain |
| What is lidoderm good for? | neuropathic or nocioceptive localized pain |
| Can lidoderm patches be cut? | yes |
| Absorption is non-linear and saturable for which pain drug? | gabapentin |
| Which drug is first line for neuropathic pain? | lyrica |
| What are the main cons of lyrica? | expensive, C-5, must be renally adjusted |
| Which class of TCAs has less adverse effects and more NE reuptake? | secondary amines like desipramine and nortriptyline |
| Which class of TCAs has more adverse effects and more anticholinergic activity? | tertiary amines like amitriptyline, doxepin, imipramine |
| Why are TCAs good for neuropathic pain? | Because they are also good for concurrent insomnia or depression |
| What are the major cons of the TCAs for pain? | lots of drug intxs, adverse effects, caution in elderly, seizure, cardiac, dementia, constipation, BPH, glaucoma, urinary retention because these are all going to exacerbate anticholinergic effects BUT they are inexpensive |
| Which SNRI is probably the most likely to be used for pain? | Cymbalta because it is approved for diabetic neuropathic pain, fibromyalgia, and chronic musculoskeletal pain |
| Should muscle relaxants be used for chronic pain? | NO |
| Morphine dose: | Max daily dose is 120 mg unless patient has been on it for a long time and it has been slowly titrated up |
| Hydromorphone dose: | |
| Oxycodone dose: | |
| Methadone dose: | |
| Hydrocodone dose: | usually 5-10 mg every 4-6 hours, do not exceed APAP daily max |
| Tramadol dose: | 25-50 mg every 6 hours, then can titrate up to 100 mg every 6 hours; change dosing interval to BID if renal or liver disease |
| Fentanyl dose: | |
| T/F: Opioids have a high rate of adverse effects (80%) | T |
| Who receives benefit from opioid use? | Chronic cancer pain, short-term treatment of nocioceptive pain (<90 days), and neuropathic pain after trying non-opioid methods |
| Which 4 opioids have max daily doses (ceiling doses)? | tapendatol, tramadol, codeine, hydorcodone/APAP |
| Which opioid has the lowest potential for abuse? | tramadol |
| If patient has kidney problems and low CrCl, which is the safest opioid to use? | fentanyl |
| Which opioid should you avoid using in children? | codeine |
| Which opioid should you never use an equianalgesic chart to dose for? | codeine |
| Which opioid also inhibits the reuptake of serotonin and norepinephrine? | tramadol |
| If patient has seizure disorder, can you use tramadol? | no |
| What is the #1 prescribed pain med in America? | hydrocodone |
| What is the preferred opioid for acute and chronic pain in most patients? | morphine |
| T/F: morphine has a lower risk for euphoria than oxy or hydromorphone. | T |
| What is the most common of all infections? | skin and soft tissue |
| What 3 things would help to diagnose if a patient has SSTI and systemic toxicity? | fever/hypothermia, tachycardia, hypotension |
| What lab tests help to diagnose SSTI with systemic toxicity? | blood culture, CBC w/ differential, basic metabolic panel, CRP |
| When should we recommend ABX on top of incision and drainage for an SSTI? | severe or extensive disease, rapid progression of cellulitis, s/s of systemic illness, comorbities/immunosuppression, extremes of age, if the abscess is on the face, hands or genitalia, any association with septic phlebitis, or if it worsens after I and D |
| What are some normal skin flora? | yeast, bacillus, micrococcus, diphtheroids, streptococcus spp, staphylococcus aureus, staphylococcus epidermidis |
| What is the most common bacterial contaminant in cultures? | staphylococcus epidermidis |
| What are 3 examples of hematogenous spread? | measles, chickenpox, meningitis petechiae |
| What is a hematogenous spread? | the bacteria or virus spreads from another site to the skin |
| What are some examples of uncomplicated SSTIs? | gram +, superficial infections like impetigo, extending into dermis and subQ fat, folliculitis, furuncles, carbuncles |
| What classifies a complicated SSTI? | gram + or -, polymicrobial, involves deep tissues including subQ fat, needs significant surgical intervention, involves perianal area, significant coexisting diseases like DM, obesity, or immunocompromised |
| What are some examples of a complicated SSTI? | diabetic foot infxn, surg site infxn, decubitus ulcer, necrotizing fasciitis |
| What are 2 examples of diffuse areas of infection? | cellulitis, necrotizing fasciitis |
| What are 2 examples of local areas of infection? | impetigo, abscess |
| What are some examples of acute SSTIs? | cuts, burns, bites, trauma, surgery (any break in intact skin) |
| What are some examples of chronic SSTIs? | diabetic foot infections, pressure sores, venous stasis ulcers (any underlying mechanism that could cause infection) |
| Patient has a localized, pus-producing boil, abscess, or carbuncle. What type of organism and what type of infection? | uncomplicated staph (clusters of cocci) |
| Patient has a diffuse, cellulitis, erysipelas, or lymphangitis. What type of organism and what type of infection? | uncomplicated strep (chains) |
| What skin pathogen is associated with recurrent hospital admissions, contact sports, boils or abscesses? | MRSA |
| What skin pathogens are associated with diabetes? | S. aureus, streptococci, gram (-) bacilli, anaerobes |
| What pathogen do we associate with cat bites? | pasturella |
| What pathogen do we associate with water exposure? | vibrio most commonly |
| How would you describe a non-bullous impetigo? | fluid filled vesicles break open aka honey crusts |
| How would you describe bullous impetigo? | ruptured lesions give a "varnished" look to the skin |
| What population do we most commonly see impetigo? | 2-5 year olds |
| What are the 2 common pathogens of impetigo? | staph aureus and strep pyogenes |
| How do we treat impetigo? | mupirocin for 5-10 days (one application TID for kids and adults) |
| What skin infection is caused by strep pyogenes aka Group A Strep and is red, tender, fiery, and painful? | erysipelas |
| How do we treat erysipelas? | penicillin IV or PO |
| What pathogen usually causes a furuncle (boil)? | staph aureus |
| What is a furuncle aka 'boil'? | infection of the hair follicle |
| What is a carbuncle? | when the furuncle extends ito several adjacent follicles and forms a larger inflammatory mass with pus from multiple follicles; usually on the back of the neck and in diabetic patients |
| Do we need to treat carbuncles and furuncles with ABX? | no, just moist heat and I&D if large |
| What are some S/S of cellulitis? | fever, tachycardia, confusion, hypotension, and leukocytosis |
| How would you diagnose a diffuse, spreading skin infection affecting the deeper dermis and subQ fat that presents as either vesicles, bullae, petechiae, or ecchymoses? | cellulitis |
| Is aspiration of the skin helpful for cellulitis? | no, not is 80% of cases |
| How do we treat cellulitis? | elevate to drain edema, give ABX (first line is nafcillin/oxacillin, cefazolin, or clinda/vanc if they have penicillin allergy |
| How long to treat cellulitis with ABX? | 5-10 days |
| Should we use IV or Oral ABX for cellulitis? | either but can start with oral |
| What is the drug of choice for treating MSSA SSTIs? | IV nafcillin/oxacillin or PO dicloxacillin |
| Which cellulitis antibiotic has inducible MRSA resistance? | clinda |
| What is the drug of choice for treating MRSA cellulitis? | vanco |
| What are 2 oral options for treating MRSA cellulitis? | doxy and bactrim |
| What SSTI is deep and devastating and is usually secondary to trauma or surgery? | necrotizing fasciitis |
| What are some S/S of necrotizing fasciitis? | subQ tissue will feel hard, broad erythematous tract along the skin, and probing the edges of the wound will allow viewing down to fascia |
| What are some common organisms that cause necrotizing fasciitis? | strep pyogenes, vibrio, aeromonas hydrophila |
| What are 3 risk factors for a polymicrobial necro fasciitis infection? | post-op infection, decubitus ulcers, PVD/DM |
| Patient has severe, constant pain with skin bruising, necrosis, rapid spread of infection while on ABX, fever, delirium, renal failure, gas in the tissue, and cutaneous anesthesia. Do they have cellulitis or necrotizing fasciitis? | NF |
| What is the mainstay of treatment for NF? | Penicillin + clindamycin (because strep pyogenes is very sensitive to PCN) |
| Why do we use clindamycin in addition to penicillin to treat NF? | clinda reduces toxins and inflammatory mediators released by these bacteria |
| If you are bitten by a cat or a dog, which two vaccines should you consider? | rabies and tetanus |
| How do we treat cat/dog bites? | Augmentin (amox/clav) |
| What is more serious, a dog/cat bite or a human bite? | human bite |
| What pathogens are common to a human bite? | 1)anaerobic are fusobacterium, peptostreptococcus, prevotella 2)aerobic are streptococci, staph aureus, eikenella corrodens |
| How do we treat human bite infections? | ampicillin-sulbactam, cefoxitin, ertapenem |
| What bacteria is only found in our mouths? | eikenella |
| For both human bites and animal bites, what is the mainstay of treatment? | amoxicillin or ampicillin |
| If patient has had contact with an animal but you don't know if they have anthrax, tularemia, or yersinia, what do you empirically treat with? | doxy or cipro |
| What is the most common source of fever 48 hours post surgery? | surgical site infection |
| What type of surgeries most commonly cause polymicrobial infections? | nonsterile tissue surgeries like colon, biliary, respiratory, and vaginal |
| How do you know when to treat a surgical site infection? | if temp> 38.5 C or HR> 110 bpm you should treat with ABX and open the suture line |
| At least 1 of 4 of these criteria must be present to diagnose a surgical site infection? | purulent incisional drainage, positive wound culture results, pain/tenderness/swelling/erythema at incision site, or diagnosis by attending surgeon or physician |
| For surgical site infections, what type of coverage are we looking for? | gram (-) and anaerobic |
| If a surgical operation is clean, non-intestinal or genital procedure, what are the 2 most common organisms? | streptococcus and staph aureus |
| What is the primary therapy of a surgical site infection? | open the incision, remove the infected material, and continue to change dressing until the wound completely heals |
| DM causes a reduction in immune function and therefore more incidence of foot infections. What is the serum glucose level when this immune impairment begins? | >150 mg/dL |
| What are the 4 steps in the pathophysiology of a diabetic foot infection? | neuropathy-> deformity-> minor trauma-> ulceration |
| To classify a diabetic foot infection, you must have at least 2 of the following? | local swelling or induration, erythema, local tenderness/pain, local warmth, purulent discharge |
| What is the most common pathogen causing diabetic foot infections? | staph (aerobic gram +); you might see anaerobes if the tissue is already dead |
| Consider MRSA infection if..... | patient had MRSA in the last year, the prevalence is high (30-50%), or if it is a severe infection |
| Consider P. aeruginosa if..... | if it is a severe infection, patient failed non-pseudomonal agents, patient soaks feet or has frequent exposure to water, lives in a warm climate (only if there are risk factors because it is often a colonizer) |
| Consider ESBL (klebsiella or e.coli) if.... | patient lives in warm southern climate like India, if infection is associated with neuropathy, osteomyelitis, ulcer >4 cm squared, poor glycemic control, or the need for surgery |
| WWhat do we treat an ESBL (klebsiella or e.coli) with? | carbapenem |
| What is the common trough level we should aim for with vanco? | 15-20 mcg/mL |
| Which antibiotic does not cover pseudomonas? | ertapenem |
| How long do we give ABX for a mild SSTI? | 1-2 weeks |
| How long do we give ABX for a moderate SSTI? | 1-3 weeks |
| How long do we give ABX for a severe SSTI? | 2-4 weeks |
| How do we diagnose HIV (vs. AIDS)? | positive HIV antibodies on ELISA confirmed with a western blot |
| How do we diagnose AIDS (vs. HIV)? | HIV + with 1 or more of the following: CD4 < 200 or AIDS defining illness |
| What is the CONFIRMATORY test for HIV? | western blot |
| How long does it take to develop antibodies for HIV? | 3-4 weeks to up to 6 months |
| How long does the acute retroviral syndrome last? | 3-14 days |
| How long does clinical latency of HIV last? | many years |
| Why do we care about CD4 count? | tells us about disease progression and whether we need to start drug therapy or not, opportunistic infections |
| What is an adequate CD4 response for patients on ART? | increase by 50-150 cells per year (but in first 3 months is better) |
| Why do we care about viral load? | good indicator of transmission, it shows if patient is responding to ART, maybe they need new therapy |
| How often should viral load be measured and when do we expect to achieve suppression? | monitor every 4 weeks and it should take 12-24 weeks to suppress viral load |
| What is the goal viral load for HIV? | undetectable (not zero but so low that we can't find it on assay) |
| Has life expectancy for HIV patients increased or decreased? | increased by quite a bit |
| When should ART be initiated for HIV patient? | it depends, CD4 count is the best determiner |
| What is unique about stribild? | it is quadruple therapy |
| What are the treatment goals that drive the decision to start ART? | decrease viral load, increase CD4, increase life expectancy, prevent transmission, improve QOL |
| What are the 5 predictors of virologic success? | 1) adherence 2) starting early 3) low viral load 4) high CD4 counts 5) high potency ARV |
| Which HIV drug should pregnant women not take? | truvada |
| Which HIV drug should pregnant women take? | Reyataz/ritonavir + Combivir |
| Which class of HIV drugs inhibit viral RNA being transcribed into DNA via reverse transcriptase? | NRTIs and NNRTIs |
| What are the 2 most preferred (backbone) NRTIs according to Fox? | Truvada and Combivir (for prego) |
| Which drug has produced FATAL hypersensitivity reactions and specific HLA-B screening is required? | Ziagen (abacavir) |
| Which class of HIV drugs have minimal drug interactions? | NRTIs |
| Which ART drugs need to be renally dosed? | NRTIs |
| What are some disadvantages to NNRTIs? | conferred resistance to whole class if you become resistant to just one, and drug interactions by CYP450 |
| What is the liklihood that a person will contract a virus resistant to one medication? | 6-16% |
| What is the most common NNRTI that can be dosed once daily? | Sustiva |
| Which NNRTI is contraindicated with PPIs? | the new drug Edurant |
| What is the most common side effect of Sustiva? | CNS like dizziness and confusion (also teratogenic) |
| What is the most common integrase inhibitor? | Isentress |
| What is the dosing of Isentress and possible disadvantage? | twice daily unlike others which are once daily |
| What is a big advantage of Integrase inhibitors? | no food effect and fewer drug interactions |
| Which integrase inhibitor is contraindicated with any and all drugs that are metabolized by 3A4? | Stribild (quad therapy) |
| Can you use Stribild if a patient has kidney problems? | no |
| What are the two most common protease inhibitors that we use? | Reyataz and Prezista |
| Which ART class is more forgiving of non-adherence? | PIs |
| All of this drug class are INHIBITORS of CYP 450? | PIs |
| What is the big disadvantage of PIs? | really bad long-term effects like diabetes, increased lipids, other difficult things to treat |
| What drug classes do we give to treatment experienced patients? | fusion inhibitors and CCR5 antagonists (fuzeon and selzentry) |
| Which drug is dosed depending on drug interactions? | Selzentry |
| Which drug has a black box warning for hepatotoxicity? | Selzentry |
| Which drug is given as an injection for ART and added as salvage therapy? | Fuzeon |
| What is the % of doses that must be taken to achieve full viral suppression? | 95% |
| How many days can you miss of a 30 day regimen to still suppress your viral load? | only 1 (only 3 in a 3 month period) |
| Which adverse effect is common in Retrovir? | peripheral neuropathy |
| What is the preferred regimen of ART? | 2 NRTIs + INSTI |
| Intelence (etravirine) | NNRTI |
| Retrovir (zidovudine) | NRTI |
| What is a common adverse effect of Intelence (NNRTI)? | skin rash |
| Sustiva (efavirenz) | NNRTI |
| Reyataz (atazanavir) | PI |
| Truvada (tenofovir/emtricitabine) | NRTI (double) |
| Isentress (raltegravir) | integrase inhibitor |
| Norvir (ritonavir) | PI |
| Trizivir (zidovudine, lamivudine, abacavir) | combo of NRTIs |
| Fuzeon adverse effect? | injection site reaction |
| Ziagen (abacavir) adverse effect? | fatal hypersensitivity |
| What are the defense mechanisms for a UTI (6)? | 1. micturition 2. acidic pH of urine 3. osmolality of urine 4. high concentration of urea 5. prostatic secretions 6. high organic acid concentration |
| What are S/S of cystitis (bladder UTI)? | dysuria, frequency, urgeny, suprapubic pain, hematuria |
| Are vaginal irritation and discharge indicative of a UTI? | no |
| What are S/S of pyelonephritis (kidney infection)? | fever > 38C, chills, flank pain, N/V, with or without S/S of cystitis, costovertebral angle tenderness |
| What are some S/S that elderly might have when they have a UTI? | GI symptoms, change in eating habits, altered mental status, no specific urinary symptoms |
| What parts of the urinalysis are most important for dx a UTI? | blood, nitrites, leukocyte esterases, clarity |
| What does a positive nitrite level on UA tell us? | that there are enterobacteria in the urine |
| On microscopy of urine, what two things are we looking for to dx a UTI? | WBC >10 and bacteria > 10 to the fifth |
| When do we do a urine culture? | 1. complicated, lower UTI 2. upper UTI 3. uncharacteristic symptoms 4. persisting symptoms after treatment 5. recurring UTI less than 1 month after treatment 6. prostatitis |
| If a young, healthy woman has classic UTI symptoms and a positive dipstick, do we need to do a urine culture? | no |
| What are some potential bacteria that cause uncomplicated UTIs? | E. coli (most common), staph saprophyticus, Klebsiella pneumoniae, proteus |
| What is a common contaminant bacteria that could be seen but is not the cause of UTI? | staph epi |
| Which bacteria that causes complicated UTIs is very resistant to treatment? | pseudomonas aeruginosa |
| Which bacteria is the most common cause of both complicated and uncomplicated UTI? | E. coli |
| Which bacteria is the second most common cause of complicated UTI if patient is in the hospital? | Enterococcus spp |
| When do we recommend follow-up cultures for an uncomplicated UTI? | if symptoms are persisting even after 2-3 days of ABX, or they have recurring symptoms within a few weeks after treatment |
| When do we recommend topical estrogen for a UTI? | if postmenopausal with 3 or more recurrent UTIs and they must not be on an oral estrogen |
| Should we recommend lactobacilli or cranberry juice for a UTI? | no, there is inconclusive evidence (but it won't hurt) |
| When would you not recommend nitrofurantoin for a UTI? | 1) if it is pyelonephritis or 2) if CrCl <60 because it works specifically in the urine |
| When would you not recommend Bactrim for a UTI? | 1) if local resistance rates are >20% or 2) if patient has taken it in last 6 months |
| What is the duration of therapy for fosfomycin for a UTI? | one dose |
| What is the duration of therapy for Bactrim (TMP-SMZ) for a UTI? | 3 days |
| What is the duration of therapy for nitrofurantoin for a UTI? | 5 days |
| What are second line options for treating an uncomplicated UTI? | fluoroquinolones (3 days) or beta-lactams (3-7 days) |
| How long do we generally treat a complicated UTI for (as compared to uncomp)? | 5-14 days |
| What is the first line treatment for complicated UTI? | fluoroquinolones like levofloxacin, cipro, cipro ER |
| What is the class of treatment that is second line for uncomplicated but first line for complicated UTI? | fluoroquinolones |
| When can you switch patient with comp UTI from IV to oral meds? | When they are afebrile for 24-48 hours |
| When do we always perform a urine culture? | if patient has pyelonephritis |
| What are the 3 oral treatment options for pyelonephritis? | fluoroquinolones, TMP-SMX, beta-lactams |
| What are the IV treatment options for pyelonephritis? | levofloxacin, ceftriaxone, ertapenem, gentamicin, ampicillin-sulbactam |
| How do we diagnose a catheter-associated UTI? | 1) midstream voided urine when catheter has been removed within 48 hours OR 2) 10 to the third or more bacteria and one or more bacteria present in the catheter urine specimen PLUS 3) UTI symptoms |
| What are the 7 s/s of a CA-UTI? | fever, chills, malaise, altered mental status, flank pain, pelvic discomfort, costovertebral angle tenderness (other urinary symptoms may not be present) |
| What 3 things are NOT diagnostic of a CA-UTI? | cloudy urine, odorous urine, pyuria (pus) in the urine |
| Do we do UA or urine culture if the patient has a suspected CA-UTI? | no because there will always be bacteria present in that case (only do it if the patient is symptomatic) |
| When do we do a urine culture for a catheter patient? | when they have UTI symptoms, prior to treatment, and from a fresh catheter |
| How do we treat a CA-UTI? | just like a complicated UTI; 7-14 days (fluoroquinolones or cipro) |
| How do we dx a male with asymptomatic bacteruria? | 1) one urine sample with one bacterial species > 10 to the fifth cfu/mL or 2) one catheterized urine sample with one bacterial species >10 to the second cfu/ml |
| How do we dx a female with asymptomatic bacteruria? | 1) two consecutive voided urine samples with the same bacterial species >10 to the fifth cfu/ml or 2) one catheterized urine sample with one bacterial species >10 to the second cfu/ml |
| When do we screen for a UTI? | pregnant women (once early on) and prior to urologic procedures |
| When do we not recommend screening for asymptomatic bacteruria? | pre-menopausal, non-pregnant women, diabetic women, older adults, spinal cord injuries, catheterized patients |
| When do we treat asymptomatic bacteruria with pyuria as a symptom? | childre, pregnancy (treat 3-7 days), TURP urologic procedure patients, catheter-acquired bacteruria lasting 48 hours after catheter is removed |
| If a pregnant woman gets a UTI or asymptomatic bacteruria and fails to treat it, what are the consequences? | stillbirth, low birth weight, prematurity |
| Which drug class is absolutely contraindicated for treating a UTI during pregnancy? | fluoroquinolones |
| What are the first line treatments for pregnant women with UTIs? | nitrofurantoin, augmentin (amox/clav), cephalosporins (keflex, cefpodoxime); there are no special warnings or considerations with augmentin so probably choose that one |
| What is the difference between a relapse and a reinfection when talking about UTIs? | Reinfection: caused by different bug; usually happens more than 14 days after the last UTI Relapse: caused by the same organism; usually occurs within 14 days |
| If a patient is reinfected with UTI within 1-2 weeks, what do we do? | treat with a broader spectrum ABX |
| If a patient is reinfected with a UTI within 1 month to within 6 months, what do we do? | treat with first line short course therapy and do not use the original agent again |
| What are the biologic mediators that can prevent reinfection of UT? | cranberry, d-mannose, topical estrogen |
| What are the behavioral changes that can help prevent a UTI reinfection? | avoid tight-fitting panties, wipe front to back, avoid douching and spermicides, fluids, pee after sex, reduce or stop sex |
| When do we allow patients to use drugs for prophylaxis of a UTI? | -3 or more UTIs in the past year -2 or more UTIs in the past 6 months - one of those must have been confirmed by culture -when non-pharmacologic measures fail |
| What are the regimens for single dose prophylaxis of a UTI (4)? | 1) TMP 100 mg once 2) TMP-SMX Bactrim 1/2 SS tab once 3) Nitrofurantoin 50-100 mg once 4) Keflex 250 mg once |
| What is more effective- single dose prophylaxis or continuous prophylaxis? | single dose |
| What is the duration for a continuous prophylaxis of a UTI? | 6 months |
| What are the 4 regimens for continuous UTI prophylaxis? | 1) TMP-SMX 1/2 SS tab daily or 3 times/week 2) Levofloxacin 500 mg daily 3) Nitrofurantoin 50-100 mg daily 4) TMP 100 mg daily |
| When UTIs relapse, what other issues should we consider? | renal involvement, prostatitis, or structural abnormality |
| If a woman is experiencing UTI relapse, what do we do? | up treatment time to 2 weeks; then if still relapsing, up treatment time to an additional 2-4 weeks; if still relapsing 6 weeks out, perform urology exam |
| What are the s/s of acute prostatitis? | cloudy urine, dysuria, pelvic or perianal pain, myalgia, malaise, chills, fever, edematous or tender prostate |
| What is the most common bug to cause prostatitis? | E. coli |
| Do we order urine cultures for prostatitis or not? | yes (and a UA) |
| How long do we treat prostatitis for (either inpatient or outpatient)? | 2-6 weeks |
| What are the treatment options for prostatitis on an outpatient basis? | fluoroquinolones and Bactrim |
| What are the treatment options for inpatient prostatitis? | treat empirically with broad spectrum beta-lactams, a cephalosporin, and + or - an aminoglycoside (adjust according to culture results) |
| How do we choose ABX for cystitis and pyelonephritis? | -severity of infection -site of infection -classification of infection -patient factors -resistance factors |
| Screening and treatment for asymptomatic bacteruria is only recommended for whom? | pregnant women and patients undergoing urological procedures |
| Is PUD more common in men than women? | no; same prevalence |
| What are some risk factors for getting PUD? | genetic predisposition, tobacco, stress, diet |
| What are some causes of PUD? | H. pylori, NSAIDs, idiopathic, Zollinger-Ellison syndrome where acid is hypersecreted |
| What are some aggressive factors for PUD? | gastric acid, pepsin, bile, H. pylori |
| What are some protective factors for PUD? | bicarbonate, mucus, mucosal blood flow |
| Which part of the GI tract usually harbors the most H. pylori? | duodenum |
| NSAID-induced PUD is most common in which part of the GI tract? | gastric (stomach) |
| Stress-related mucosal damage leading to PUD is most common in which part of the GI tract? | gastric (stomach) |
| Cardio protective doses of _____ might be gastrotoxic and cause PUD? | aspirin |
| What are some risk factors for serious complications with PUD when using an NSAID? | advanced age, concurrent corticosteroid use, concurrent anticoag use, prior hx of PUD or upper GI bleed, using other NSAIDs concurrently |
| Do COX-2 specific NSAIDs cause PUD? | no but the risk is not zero |
| Does adding low dose aspirin to a COX-2 regimen harm or help the risk of PUD? | it negates the benefit of taking a COX-2 |
| How do we treat idiopathic ulcers? | H2RA or PPI for 4-8 weeks |
| What type of bacteria is H. pylori? | gram (-) spiral shaped rod |
| How does H. pylori cause an ulcer? | it attaches to the gastric mucosa, produces large amounts of urease which hydrolyze gastric juices and convert it to ammonia and CO2 |
| How do we acquire H. pylori? | person to person transmission either fecal to oral or oral-oral |
| How do we dx a duodenal ulcer and gastric ulcer concurrently that are caused by gastrin-secreting tumors? | serum gastrin level and secretin test |
| What is the gold standard for dx an ulcer? | endoscopy |
| If receiving an endoscopy, how do we counsel patients on what to do with their PPI and/or ABX? | d/c abx and bismuth prior to procedure; d/c PPI 1 week prior to procedure |
| What are some common causes of refractory or recurrent ulcers? | noncompliance, smoking, ASA/NSAID use, presence of H. pylori |
| What are the typical symptoms of an ulcer? | epigastric abdominal pain that is burning, discomforting, fullness, or cramping, heartburn, belching, bloating -N/V, anorexia common with gastric ulcer -nocturnal pain that awakens patient between 12 am and 3am -can be more common in spring and fall |
| What is a common sign of ulcer? | weight loss associated with N/V and anorexia; bleeding ulcer, perforation, penetration, or obstruction |
| What are some common side effects of H2RAs? | HA, depression, sedation, agitation, confusion, decreased platelets, galactorrhea, gynecomastia, impotence -cimetidine is the worst one because of intxns with warfarin, theo, phenytoin, propanolol |
| Are H2RAs safe in pregnancy? | yes |
| Who should be cautioned before taking an H2RA? | elderly, hepatic or renal dysfunction |
| What do we have to watch for if we recommend Zegerid OTC? | metabolic alkalosis or hypocalcemia because it contains sodium bicarbonate |
| What are side effects of PPIs? | HA, dizziness, somnolence, diarrhea, constipation, B12 deficiency, risk of fracture, possible low magnesium levels |
| Are PPIs safe to use in pregnancy? | yes |
| What CYP are PPI mostly metabolized by? | 2C19, some 3A4 |
| What drugs might PPI inhibit? | warfarin, diazepam, phenytoin, plavix -effects ketoconazole and tetracycline due to changes in pH |
| When should a patient take a PPI? | on an empty stomach in the morning because that is when the gastric acid surge occurs |
| What kind of ulcer can we use misoprostil for? | duodenal and gastric |
| What is misoprostil? | prostaglandin analogue |
| What are the side effects of misoprostil? | diarrhea (30-40%), abdominal pain, spontaneous abortion, infantile diarrhea if nursing mother |
| Who should be treated with misoprostil? | -patient on NSAID and corticosteroid -patient with history of DU/GU, with or without complications, and when NSAIDs cannot be stopped |
| What are the disadvantages of sucralfate? | need to take on empty stomach, multiple dosing, large tablet, constipation, decreases warfarin/ketoconazole/phenytoin/dig/theo/etc |
| What is the MOA of sucralfate? | adheres to defective mucosal barrier to protect, neutralizes acid, inhibits pepsin, binds to bile salts, stimulates the production of mucus, might stimulate prostaglandin synthesis and release |
| What is the dosing of sucralfate? | 1-2 grams 4 times daily (1 hour after meals and at bedtime) |
| What are side effects of antacids? | hypercalcemia, hypermagnesemia, constipation (aluminum and calcium products), diarrhea (magnesium), gas (sodium bicarb), aluminum toxicity, sodium increase, hypophosphatemia, constipation is most significant |
| Are antacids okay to use in pregnancy? | yes |
| What are some common drug interactions with antacids? | phenytoin, warfarin, fluoroquinolones, thyroxine |
| What is the triple therapy regimen to eradicate H. pylori? | 1) omeprazole 20 mg BID 30-60 min before meals 2) clarithromycin 500 mg BID 3) amoxicillin 1 gram BID, OR if penicillin allergy use metronidazole 500 mg BID with meals **Can use PrevPak for 7-14 days if available (amox + lansoprazole + clarithromycin) |
| What is the quadruple therapy regimen to eradicate H. pylori? | 1) omeprazole 20 mg BID before meals 2) metronidazole 250-500mg QID with meals 3) tetracycline 500 mg QID 4) bismuth salicylate 2 tabs (524 mg) QID with meals and HS **treat for 10-14 days |
| What are two combo products that can be used to eradicate H. pylori? | pylera and helidac |
| How do probiotics help with H. pylori? | help control the colonization, may reduce adverse effects *lactobacillus and bifidobacterium |
| What are the 6 things to consider when choosing an eradication regimen for H. pylori? | 1. compliance 2. cost 3. safety 4. efficacy 5. local resistance 6. prior patient exposure to abx |
| What are some non-pharmacologic measures for ulcers? | reduce stress, reduce NSAID use, lower NSAID dose, add antacids, avoid spicy food, coffee, alcohol |
| What are some foods that exacerbate GERD by decreasing LES tone? | peppermint, spearmint (carminatives), chocolate, fatty meals, coffee, coke, tea, citrus juices, tomato juice |
| What is something we can do to actually increase LES tone, thereby reducing GERD? | eat high protein meals |
| What are drugs that decrease LES tone and cause GERD? | barbituates CCB caffeine, ethanol, nicotine meperidine morphine nitrates, theo, dopamine, diazepam estrogen, progesterone |
| What are drugs that increase LES tone and help prevent GERD? | cisapride, metoclopramide, norepinephrine, phenylephrine |
| What are some hormones/other substances that might cause GERD by decreasing LES tone? | estrogen, progesterone, glucagon, prostaglandins |
| What are the 3 types of GERD? | typical, atypical, complicated |
| What are the symptoms of typical GERD? | waxing and waning heartburn, hypersalivation, belching, regurgitation, all common after a fatty meal, lying down, bending over, or shortly after eating |
| What are the symptoms of an atypical GERD? | nonallergic asthma, chronic cough, hoarseness, pharyngitis, chest pain that mimics angina |
| What are symptoms of compicated GERD? | continuous pain, dysphagia, odynophagia, severe esophagitis |
| What are some non-pharmacologic treatments for GERD? | smaller meals, less fatty meals, high protein meals, don't lie down right after a meal, cut alcohol and other food factors, lose weight, control diabetes |
| If antacids and lifestyle changes do not relieve GERD symptoms, what are 2 other alternative regimens? | 1) H2RA BID for 6-12 weeks 2) PPI QD for 4-8 weeks |
| What are the 4 clinical complications that we run into if we don't properly treat GERD? | 1) obstructions due to stricture formation 2) chronic, low grade bleeding 3) ulcer causing perforation 4) cancer due to development of columnar lining (Barrett's esophagus) |
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