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BCPS study guide

Infectious disease

QuestionAnswer
What characteristics would rule out CAP in a patient presenting with s/sx of pneumonia hospitalization lasting 2+days within the last 90 days, residence in a LTCF, receipt of IV abx therapy/chemo/wound care in the last 30 days, attendance at a hospital or dialysis clinic
predictors of CAP complications - ex CURB-65, PSI scores include these RFs age>65, comorbidities such as DM/CHF/COPD/CKD/liver dz, Temp>38C, bacteremia, AMS, immunosuppression due to drugs/cancer/etc, high risk bug (S. aureus, GNB, anaerobes), multilobe involvement, pleural effusions
CURB-65 confusion, urea >=20ml/dL, RR>30, [BP] SBP<90, DBP<60, age >=65
what CURB 65 scores warrant ICU admission vs inpatient vs outpatient pts with score of 0-1 can be outpatient, score of 2 can be either inpt or outpt, 3 inpatient, 4+ ICU
What factors increase a patient's risk of nosocomial PNA. (hospital risk factors) ETT, mech vent, supine, enteral feeding, oropharyngeal colonization, stress ulcer prophylaxs, blood transfusion, hyperglycemia, steroids, surgery, immobilization, NG tubes, prev abx, ICU, chronic lung dz, elderly
top three bugs for CAP mycoplasma, strep pneumo, h. flu
top three bugs HAP staph aureus, pseudomonas, enterobacter
treatment for CAP in non-hospitalized patients with no comorbid conditions macrolide or doxycycline
treatment for CAP in non-hospitalized pts with comorbid conditions or antibiotic therapy with in the last 3 months FQ/macrolide/doxy + amox/augmentin/cephalosporin
CAP treatment in hospitalize pts not in ICU FQ/macrolide/doxy + AMP/CTX/cefotax
CAP treatment in ICU pts AZM or FQ + CTX/cefotaxime/Unasyn
treatment duration for CAP 5+ days AND pt afebrile for 48-72 hours AND no more than one sign of clinical instability
HAP treatment in pts with low risk for MDR organisms (<5 days + no RFs for MDRs) ceftriaxone, FQ, unasyn, or ertapenem
HAP treatment in pts with late onset (>5 day) or RFs for MDRs cefepime (or ceftaz) OR carbapenem OR zosyn AND AG or FQ (cipro or levo for anerobes moxi less helpful for these bugs) can add vanco or linezolid if concern for MRSA
duration for HAP therapy 8 days found to be as good as longer regimens but if pseudomonas or acinetobacter do 14 days.
MDR risk factors abx in last 90 days, hospitalization of 5+ days, resistance in community, immune suppression OR RFs for HCAP such as 2+ days hospitalized in last 90 days, LTCF, home infusion, dialysis within 30 days, home wound care, exposure to known MDR pathogen.
annual gradual changes in antigens caused by mutations substitutions and deletions antigenic drift
less common dramatic changes in antigens leading to pandemics antigenic shift
which influenza type causes epidemics more frequently type A (1-3 yrs) vs every 5 yrs for type B
when is it indicated to use a neuraminidase inhibitor such as Tamiflu or zanamivir for flu pts. hospitalized pts, severe progressive illness, pts <2 >65, pts with chronic disease states, immune suppressed pts, preggers, pts <19 on ASA therapy, native americans, morbidly obese, LTCF residents
how soon must Tamiflu be started within 48 hours of symptom onset
why are the adamantanes not recommended anymore resistance to type A virus and they only work on type A.
treatment for bacterial sinusitis augmentin, 2g BID or 90 mg/kg/day div BID. OR resp FQ, doxycycline, cefixime or cefpodoxime with clinda,
duration of therapy for bacterial sinusitis 5-7 days for adults. 10-14 days for children
most common bugs for UTIs Ecoli, for community acquired staph saprofiticus is number two, for nosocomial it is pseudomonas
factors associated with complicated UTI male sex, hospital acquired, preggers, anatomical abnormality of the urinary tract, childhood UTIs, recent abx use, DM, indwelling urinary catheter, recent urinary tract instrumentation, immunesuppression
hallmark symptom of pyelonephritis flank pain AKA costovertebral angle tenderness
treatment for uncomplicated cystitis Bactrim x 3 days, nitrofurantoin x5 days, fosfomycin x1 dose. can also use cipro, or a beta lactam for 3-7 days
treatment for uncomplicated pyelonephritis Bactrim x14 days, FQ x 5-7 days, beta lactam x 10-14 days (third choice)
treatment for complicated UTI for inpatient therapy use a FQ, AG or extended spectrum beta lactam. treat for 5-14 days.
for a pregnant pt with a UTI what is the optimal treatment amox, nitro or Keflex x 7 days
antibiotics to avoid in preggers FQs, tetracyclines, AGs and Bactrim (esp in 3rd trimester)
treatment for prostatitis Bactrim, FQ x 4 weeks for acute, for chronic do same therapies but for 1-4 months
treatment for epididymitis same as for prostatitis but treat for 10 days - 4 weeks. FQ or Bactrim - for pts >35 as mostly enteric organisms. if pt is under 35 then treatment with IM CTX x1 dose and doxycycline 100 mg BID x 10 days as usually related to STD
cellulitis or erysipelas? non-elevated with poorly defined margins. cellulitis
cellulitis or erysipelas? sharply demarcated, elevated margins erysipelas
most common bugs with cellulits strep pyogenes, staph aureus
most common bugs with erysipelas GAS - strep pyogenes is most common but GBS or GCS also possible.
first line trt for cellulitis nafcillin/oxacillin/dicloxacillin or Pen G if strep confirmed. more commonly used clindamycin or first generation cephalosporin (Keflex or Ancef), or augmentin/zosyn/unasyn.
when to empirically treat for staph with cellulitis if purulent, complicated and/or several abscesses or hospitalized pt with complicated SSTI
duration of therapy for cellulitis 5-10 days, default to 10 days if outpatient and MRSA concern. for inpatient do 7-14 days.
first line trt for erysipelas - duration of therapy pen G or clinda - treat for 7-10 days
signs of necrotizing fasciitis pain out of proportion to appearance, significant systemic symptoms including shock and organ failure, infection extensively alters surrounding tissue leading to gangrene or cutaneous anesthesia.
treatment for nec fasciitis surgical debridement, antibiotics given WITH surgery never alone. beta lactamase inhibitor combinations WITH clindamycin and cipro OR carbapenem, cefotaxime With clindamycin or metronidazole. if strep confirmed use high dose PCN with clinda
how is zostavax different from varivax more plaque forming units of virus per vaccine
what are the benefits of zostavax it is 50% effective and decreases the burden of illness, 40% effective at decreasing the persistence and indicence of post herpetic neuralgia
what microbes are typically responsible for diabetic foot infections usually polymicrobial ~2-6 microorganisms present
for mild diabetic foot infections what is the best therapy if no MRSA RFs then penicillinase resistant PCN, first gen ceph, FQ or clinda
for severe diabetic foot infections what is the best therapy use broad spec abx. unasyn, ertapenem, cefoxitin, third gen ceph, moxi or levo/cipro+clinda, tigecycline, add zosyn, ceftaz/cefepime or carbapenem if suspect pseudomonas. if RFs for MRSA add vanco/linezolid/dapto
what are the RFs for MRSA when treating diabetic foot infections hx of MRSA infxn or colonization, high local prevalence of MRSA, severe infection
what is the duration of therapy for diabetic foot infections if osteomyelitis present then 4+ weeks, post amputation 2-5 days if no remaining infected tissue or 4+ weeks if there is. 1-2 weeks for mild to moderate infections and 2-3 weeks for severe infections
definition of osteomyelitis infection of the bone with subsequent bone destruction
empiric adult treatment of osteomyelitis nafcillin, cefazolin or vancomycin. if pt has sickle cell anemia then may add ceftriaxone/cefotax or FQ, if prosthetic joint ifxn use pathogen specific therapy plus rifampin f/b FQ + rifampin x3 months.
when is oral therapy appropriate for osteomyelitis CRP <2.0 mg/dL, adequate surgical debridement, clinical course resolving, adherence, specific isolated organism with susceptibilities.
what bug requires additional coverage in neonates and elderly pts when treating for meningitis? listeria
what two bugs need coverage in ALL age groups when treating meningitis strep pneumo and neisseria
what are the common causes of ASEPTIC meningitis non-bacterial meningitis caused by viruses, fungus, parasites, TB, syphilis and drugs such as Bactrim and IBU
physical signs of meningitis brudzinski sign, kernig sign, bulging fontanel
symptoms of meningitis fever, chills, headache, backache, nuchal rigidity, mental status changes, photophobia, NV anorexia, poor feeding in infants
symptom that is specific to Neisseria in meningitis pts petechiae/purpura
signs of bacterial meningitis in CSF culture low to normal glucose (<50 mg/dL), high protein (>150 mg/dL), high WBC (>1200/mm3 - normal CSF has few to none <5, lower pH (7.1), high lactate >35
what drug should be added to therapy for neonates and adults over 50 ampicillin
neonatal empiric therapy for meningitis ampicillin + AG or amp + cefotaxime
infant (1-23 months), children and adult empiric therapy for meningitis ceftriaxone + vancomycin
older adult >50 yrs ceftriaxone plus vancomycin plus ampicillin
if associated with a penetrating head trauma what is the best empiric therapy for meningitis vancomycin plus cefepime/ceftaxidime/meropenem
infections with which two bugs makes the use of adjunctive dexamethasone beneficial in meningitis in children when the bug is H flu and in adults when the bug is strep pneumo.
drawbacks to dexamethasone adjunctive therapy in meningitis decreased abx penetration but as it does improve outcomes in specific infections, often appropriate to add before susceptibilities back.
most common bugs with brain abscess and why polymicrobial, strep 50-60% of the time, and anerobes ~40%. this is due to the source often being associated with facial/oral infections from septic phlebitis
therapy for brain abscess I&D via craniotomy or stereotaxic needle aspiration. abx based on source of infxn. typically include anaerobic and staph/strep coverage. Flagyl + 3rd gen ceph/vancomycin. if unclear source use flagyl + vanco + 3rd gen cef. use steroids if inc ICP
most common bugs in infectious endocarditis. strep. viridans, staph aureus, enterococcus, HACEK
HACEK H. flu, actinobacillus cardiobacterium, eikanella, kingella
when is IE prophylaxis necessary pts with prosthetic/bioprosthetic/homograft valves, congenital heart disease, within 6 months of congenital heart defect repair, heart transplant pts with cardiac valvulopathy, previous IE infection.
standard IE prophylaxis for dental or respiratory procedures ampicillin/ancef/CTX if unable to take PO. amoxicillin if ok for PO. if PCN allergy clinda, cephalexin, macrolide. pcn allergy and NPO, clinda, ancef or ctx
typical bugs for primary peritonitis e. coli, klebsiella, strep pneumo, GAS
typical causes of primary peritonitis alcoholic cirrhosis/ascities, post necrotic cirrhosis, chronic active hepatitis, acute viral hepatitis, CHF, SLE, metastatic malignancy
signs of primary peritonitis in ascitic fluid sample low protein, high WBC, ph<7.35, lactic dehydrogenase >25, gram stain 60-80% negative but diagnostic if positive
causes of secondary peritonitis basically translocation of gut bacteria via damage/inflammation in associated organs.
first occurance therapy for C. Diff flagyl 500 mg TID x 10-14 days OR vancomycin PO 125 mg QID x10-14 days OR fidaxomicin 200 mg PO BID x10 days
second/third occurances of C. Diff therapy fidaxomicin if not given first time, higher doses of vanco such as 500 mg QID, rifaximin 400 mg BID x 14 days or nitazoxanide 500 mg BID x 10 days.
Appropriate antibiotic prophylaxis for gastric/duodenal surgeries cefazolin - indicated for obesity, esophageal obstruction, decreased gastric acidity or decreased GI motility
Appropriate antibiotic prophylaxis for biliary surgeries cefazolin/cefoxitin/cefotetan/ceftriaxone/Unasyn - indicated for high risk pts, typically biliary tract has no organisms but some guidelines indicate use in all pts
appropriate antibiotic prophylaxis for appendectomy cefoxitin/cefotetan or cefazolin+flagyl - indicated in cases of perforation, treat for 3-7 days.
appropriate antibiotic prophylaxis for colorectal surgery best to cover for both anaerobes and aerobes. cefoxitin/cefotetan or cefaz or ceftriaxone AND flagyl/unasyn/ertapenem. can also do more complicated regimens prior to surgery.
appropriate antibiotic prophylaxis for vaginal/abdominal hysterectomy cefazolin or cefoxitin or cefotetan or unasyn
appropriate antibiotic prophylaxis for cesarean cefazolin after cord is clamped
cardiac surgery cefazolin/cefuroxime preinduction then an intraop dose if needed. change to vanco if MRSA suspected
typical bugs for prostatitis C. trachomatis, Neisseria gonorrhea, E. Coli
treatment for acute prostatitis if gonorrhea, CTX 250 mg IM for 14-28 days cipro 500 mg BID SMX/TMP 960 mg BID or TMP 200 mg BID
treatment of chronic prostatitis Cipro, ofloxacin, norfloxacin. minocycline, doxycycline, TMP, SMX/TMP. 28 days
treatment of epididymitis CTX with doxy. alternatively if not gohorrhea can use ofloxacin or levofloxacin
Created by: mjuhlin