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therapy exam 2
pharmacotherapy exam 2
| Question | Answer |
|---|---|
| classifications of compliated UTI | obstruction/prostatitis/calculi/catheter/stents/neurogenic bladder/abscess/fistulae/pregnancy/diabetes/renal impairment/transplant/neutropenia/ unusual pathogen |
| reinfection | caused by diff org than originally isolated |
| relapse | repeated infections w/ the same initial organism |
| 3 factors that determine development of infection | size of inoculum/ virulence of microorg/ competency of natural host defense |
| are most UTIs ascending or descending? | ascending |
| if descending UTI, most likely caused by what org | S. aureus |
| cystitis | dysuria, urinary freq, nocturia, hematuria, suprapubic heaviness |
| pyelonephritis | flank pain, fever, N/V, malaise |
| key to diagnosis of UTI | demonstrate significant #s of microorgs in an appropriate urnie specimen to distinguish contamination from infection |
| Outpatient lab workup | urine leukocyte esterase dipstick |
| dipstick test detects... | pyuria--presence of WBC in urine |
| Inpatient lab workup | urinalysis, urine culture & sensitivity |
| U/A components: | WBC > 10/mm, + nitrites-hematuria-proteinuria |
| what produces nitrate to give a + nitrite test | gram -s |
| what orgs can cause a false - nitrite test | gram +s & Ps. A. |
| cultures are... | quantitative, bacteria must be in diagnostic amounts |
| how do you confirm diagnosis of pyelonephritis? | CT scan |
| # CFU needed to confirm UTI in symptomatic male &/or catheterized patient | greater than or = to 10^3 |
| coliforms vs noncoliforms | coliforms= gram - noncoliforms= gram + |
| CFU neede to confirm UTI in Symptomatic female | greater than or = to 10^5 coliforms OR 10^2 noncoliforms |
| # CFU needed to diagnose UTI in Asymptomatic patient | greater than or = to 10^5 on 2 consecutive U/As |
| #1 cause of UTIs | E. coli |
| what has E.coli developed resistance to | amoxicillin, cephalosporins, bactrim, & FQ--can still use b/c get high urinary conc that overcomes resis |
| org that causes UTI in sexually active female | S. saprophyticus |
| org that causes UTI in elderly (esp males) | Enterococcus |
| org that causes UTI in pts w/ instrumentation of GU tract | Ps. A. |
| org that causes UTI in pt w/ diabetes, indwelling catheter, or currently received antibiotic | Candida |
| are doses for renally eliminated drugs lower or higher for UTIs than systemic infections | doses are lower for UTIs |
| tx for Acute Uncomplicated Cystitis | bactrim or fq x 3 days |
| main orgs in Acute Uncomplicated Cystitis | E. coli & S. saprophyticus |
| tx for UTI in pregnancy | augmentin, cephalosporin, or bactrim x 7d ( no bactrim in 3rd trimester) |
| treatment for acute pyelonephritis/complicated UTI | FQ or Bactrim x 14d if E. coli amox or augmentin x 14d if gram + FQ or extended spect PCN if KEEP or Ps.A |
| Bactrim (UTI) | 1 DS tab BID--needs renal adj--AE: gi upset, rash, hemolytic anemia--only use PO for UTI |
| FQ (UTI) | Cipro 500mg BID--adjust or Levo 250mg QD- no adjust--AE: prolonged QT, tendon rupture, CNS tox in elderly |
| B-Lactams (UTI) | all need renal adj Amox 500mg q8h, augmentin 875mg BID, Cefixime 400mg QD, Cefpodoxime 100mg BID |
| Nitrofurantoin | only used for UTIs 100mg BID x 7 days--needs renal adj--AE: hepatotox, hemolytic anemia |
| waht adjunct therapy can mask symptoms of UTI | urinary analgesic |
| Risk factors for Meningitis | AGE, environment, exposure to cigarette smoke, recent exposure to sick, contaminated food, hx of recent resp inf, immune defect, alcohol abuse, cancer, HIV, surgery, trauma, cochlear implants, cirrhosis, cancer, neurosurgery |
| in meningitis, nasopharyngeal colonization of host activates what to kill bacteria | IgA |
| Vasogenic edema in meningitis leads to... | increased: intracranial press, CSF protein, & lactate decreased: CSF glucose |
| is neurologic damage ther result of hosts immune response or invading bacteria | host immune response |
| org in newborn- 1mos (mening) | Group B strep, Gram - enterics, Listeria |
| drug of choice for listeria | Ampicillin |
| org in 1mo - 29yo | S. pneumo, N. mening, H. flu |
| org in 30-50 yr old | S. pneumo & N. mening |
| org in >50 yo | S. pneumo, gram - enterics, & listeria |
| orgs in basilar skull fracture | s. pneumo, H. flu, S. pyogenes |
| orgs in penetrating head trauma, post neurosurgery, & CSF shunt | S. aureus, s. epidermidis, areobic gram - rods (Ps. A) |
| Drugs that enter BBB regardless of inflammation | Bactrim/Chloramphenicol/ Rifampin/ Flagyl/ Isoniazid |
| drugs that wont ever enter BBB | Aminoglycosides/1st gen ceph/ 2nd gen ceph (except Cefuroxime)/ Clinda/ Ketoconazole/ Itraconazole |
| ...is the only 2nd gen Ceph w/ therapeutic value in meningitis | Cefuroxime |
| triad symptoms in meningitis | fever, nuchal rigidity, altered mental status |
| brudzinki sign | neck goes up when lift knees or press on lifted leg & flat leg raises too |
| Kernig sign | w/ knees bent push up on feet & knees will drop |
| bacterial meningitis CSF differential | high WBC, high protein and low glucose |
| viral meningitis CSF differential | high WBC but lower than bacterial & most of WBC are lymphocytes |
| want CSF glucose to be .... of peripheral glucose | 50-66% |
| Latex Agglutination test | rapid dx test to detect antibodies--most useful for pts pretreated w/ antimicrobials & gram stain + CSF culure is - |
| PCR text | detects DNA--useful to exclude diagnosis of bacterial meningitis |
| why is it ok to use an Aminoglycoside in newborns | b/c their BBB is still forming |
| empiric tx in newborn - 1 mo | amp + cefotaxime or ceftriaxone or aminoglycoside |
| empiric tx for 1mo-50yo | Vanc + cefotaxime or ceftriaxone |
| empiric tx for > 50yo | vanc + amp + cefotaxime or ceftriaxone |
| empiric therapy in basilar skull fracture | vanc + Ceftriaxone or cefotaxime |
| empiric tx in post neurosurgery, penetrating trauma, or csf shunt | vanc + cefepime or ceftazidime or meropenem |
| N. meningitidis | tx= 7 days 50% present w/ petechial rash MIC<0.1=pcn or amp, MIC 0.1-1= 3rd gen ceph, ALT= FQ or meropenem |
| #1 cause of meningititis in children | N. meningitidis |
| Strep pneumo (meningitis) | tx = 10-14days MIC<0.1= Pen G or amp, MIC 0.1-1= 3rg gen ceph, MIC 2 or > = Vanc +3rd gen |
| leading cause of meningitis in adults | strep pneumo |
| H. flu | 7 day tx B lactamase - = ampicillin B lactamase + = 3rd gen ceph ALT= FQ or cefepime |
| Listeria monocytogenes | 21 or more day tx DOC=Amp, can use Pen G, Bactrim or meropenem |
| E. coli & other enterobacteriacae (meningitis) | 21 day tx DOC= 3rd gen ceph/ alt=aztreonam, FQ, mero, or bactrim |
| Pseudomonas (meningitis) | DOC= cefepime or ceftazidime/ alt = aztreonam, FQ, mero, or intraventricular aminoglycoside |
| Dexamethasone in meningitis | 0.15mg/kg q6h x 2-4d 10-20min prior to 1st dose of antimicrobial--use in adults expected to have pneumococcal meningitis |
| continue using Dexamethasone in meningitis if... | Gram + diplocicci or blood culture + for strep pneumo |
| monitoring parameters for meningitis | clinical signs & syx q4h x 3d then just qd |
| prophylaxix for N. meningitidis | Rifampin 600mg BID x 2d or Cipro 500mg once or Ceftriaxone 250mg IM once |
| prophylaxis for H. flu meningitis | Rifampin 600mg QD x 4d, HiB vax for unvaccinated |
| aseptic meningitis | bacteria cultures come back neg but present w/ signs & syx of meningitis--usually viral |
| Hep B is or is not curable | is NOT |
| risk factors for Hep B | MSM, multiple heterosexual partners, IVDA, reciept of blood products, household contact, needle sticks, dialysis |
| risk factors for progression of Hep B into chronic | Persistence of HBV serum DNA, Infection w/ genotype C, coinfection w/ HIV or HCV, old, severity of liver disease @ ds, male, alcohol, abnorm liver fxn |
| ALT in acute vs chronic HBV | acute= elevated ALT chronic=slightly elevated or normal |
| Presence of HBsAg indicates patient is | infectious |
| + anti-HBs indicates | recovery or immunity via vaccination |
| + anti HBC indicates | previous or ongoing infection--present @ onset & persists for life |
| IgM anti-HBc indicates | acute infection, recent infection of 6 mos or less |
| immune due to Hep B vax= | + antiHBs - HBsAg & antiHBc |
| acutely infected w/ HBV | + HBsAg, antiHBc, IgM antiHBc - antiHBs |
| chronically infected w/ HBV | + HBsAg & anti HBc - IgM antiHBc & antiHBs |
| Pegylated Interferon alfa 2a & 2b | best tx for HBV--immunomodulator |
| Anti-viral tx in HBV | Lamivudine = DOC Tenofovir & Lamivudine: + HIV activity Telbivudine has cross resis w/ lamivudine |
| does HBeAg + or HBeAg - get treated longer | HBeAg - (tx is > 1 year) |
| highest risk pop for HBV | healthcare workers |
| Hep B immune globulin (HBIG) | provides passively acquired anti-HBs & temporary protection for 3-6 mos--used in adjunct w/ vax |
| perinatal prophylaxis of HBV | + HBsAg= vax & HBIG to baby - HBsAg= vax only to baby |
| what HCV genotype is least likely to respond to treatment | genotype 1 |
| HCV risk factors | male, obese, alcohol, HBV or HIV, old |
| EVR in HCV | decrease in HCV RNA @ 24 wks tx |
| SVR in HCV | undetectable HCV RNA @ end of tx & 6 mos later |
| Anti-HCV | detectable w/in 8 wks of infection |
| HCV RNA | detectable w/in 1-2 weeks of infection |
| HCV infection = | + antiHCV & HCV RNA |
| resolving HCV infection = | + antiHCV & - HCV RNA |
| to be treated for HCV...must have | altered ALT values, Hep C, be in stable mental condition |
| who should not be treated for HCV | uncontrolled depression, transplant recepient, autoimmune hepatitis, pregnant, untreated hyperthyroidism |
| treatment lengths for genotype 1 vs genotype 2 | genotype 1 is longer (48 weeks) |
| PEG interferon side effects | psychiatric disorders, flu-like syx, headache, alopecia, nausea, neutropenia, thrombocytopenia, hypothyroidism--will get better after 1-2mos tx |
| Ribavirin | HCV only--co-admin w/ PeG food increases absorption genotype 1: <75kg=1000mg/day in 2 doses or > 75kg=1,200mg/day(2 doses) genotype 2 or 3: 800mg/day (2 doses) |
| Ribavirin adverse effects | hemolytic anemia, gi upset, caution in CrCl < 50 & Hgb <10--CI in pregnancy & hemoglobinopathies <8.5 |
| SIRS (Systemic Inflamm Response Syndrome) | need 2 or more of: temp, HR>90, WBC<4 or >10, RR>20 |
| Sepsis+ | SIRS + documented infection |
| in sepsis proinflammatory mediators? | DECREASE |
| proinflammatory mediators | contribute to eradiction of invading pathogen |
| antiinflammatory mediators | control response to invading pathogen |
| Early sepsis S | fever or hypothermia, rigors/chills, tachycardia, tachypnea, HYPERglycemia |
| Late Sepsis S | lactic acidosis, oliguria, HYPOtension, HYPOglycemia |
| most sepsis originates out of the | respiratory tract as pneumonia (HAP via S.aureus) |
| which is more dangerous in sepsis: gram + or gram - | gram - |
| most common fungi to cause sepsis | candida albicans |
| 1st step in sepsis therapy | Aggressive FLUID resuscitation |
| need Pseudomonas coverage in sepsis if... | hospitalized > 48h |
| how long should combo therapy be administered? | no longer than 3-5 days |
| CAP sepsis | Ceftriaxone + azithromycin + vanc-- if PCN allergy: Levo +vanc (gram +, gram -, atypicals) |
| HAP sepsis | Zosyn or Cefepime + levo or toby + vanc--if pcn allergy use aztreonam for zosyn/cefepime (s. aureus, Ps. A, ESBL) |
| CA-UTI sepsis | Ceftriaxone-- if PCN allergy: Levo + toby (KEEPS) |
| HA-UTI sepsis | Zosyn or Cefepime +/- Tobra if pcn allergy: Levo + tobra add Vanc if suspect MRSA |
| Abdominal source sepsis | Zosyn or cefepime + metronidazole if pcn allergy: levo+tobra+flagyl (gram - & anaerobes) |
| Diabetic foot infection sepsis | Zosyn + vanc if pcn allergy: levo+flagyl+vanc (gram +, gram -, anaerobes) |
| Cellulitus sepsis | Vanc (gram + staph & strep) |
| catheter source sepsis | cefepime + vanc if pcn allergy: tobra + vanc (staph, strep, ps.a) |
| unknown source sepsis | zosyn + tobra+ vanc if pcn allergy: Levo=tobra=vanc |
| fungal source sepsis | 1st line = Fluconazole |
| risk factors to treat for fungal sepsis | must have 2 or more of: candida conlniztion @ 2 or more sites/ exposure to broad spectrum AB, recipient of TPN, recent abdominal surgery, immunocompromised, presence of central venous catheter |
| MIC | minimum inhibitory conc: lowest antimicrobial conc that inhibits visible bacterial growth |
| breakpoint | conc @ which an antimicrobial will inhibit growht @ clinically achievale conc |
| if bacteria is resistant to Ceftazadime & susceptible to Cefepime | it is ESBL producing bacteria |
| ertapenem doesnt cover... | pseudomonas |
| doc for enterococcus | Ampicillin |
| dapto vs linezolid in catheter related sepsis | dapto! linezolid has a high mortality rate in this case |
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heljmaso
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