PHA 554 Infectious Diseases I: Exam 4 (Final Exam)
Infective Endocarditis (IE): Diagnosis: Modified Duke Criteria: Major Criteria: (2)
1. Positive Blood Culture 2. Positive Echocardiogram
Urinary Tract Infection (UTI): Lab Testing: Urinalysis (UA): The 2 MOST common abnormalities on a urinalysis for UTIs include:
1. Positive Nitrites (but does not have to be positive since all bacteria do not produce nitrites) 2. Positive Leukocyte Esterase (LE): (MOST sensitive)
What are known as the 2 highest risk factors associated with Infective Endocarditis (IE)?
1. Presence of a prosthetic heart valve 2. Previous Endocarditis
Infective Endocarditis (IE): What are 3 factors that may precipitate a negative culture finding? (What is the most important?) What are 4 considerations to evaluate prior to collection of blood culture?
1. Previous antibiotic therapy (most important) 2. Slow-growing fastidious organisms 3. Non-bacterial etilogies (e.g. fungi); 1. PMH of infections 2. PMH of antibiotics before blood culture collection 3. Determining if the infection is acute or subacute 4. Determining if the infection is native or prosthetic
Nosocomial-Acquired Pneumonia: Potential Pathogens: Pathogens that dictate antibiotic selection: (2)
1. Pseudomonas aeruginosa 2. MRSA
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Covers Pseudomonas Aeruginosa: (9)
1. Aminoglycosides (Gentamicin, Tobramycin, Amikacin) 2. ceftazidime (Fortaz): 3rd-Gen 3. cefepime (Maxipime): 4th-Gen 4. ciprofloxacin (Cipro) 5. levofloxacin (Levaquin) 6. meropenem (Merrem) 7. imipenem-cilastatin (Primaxin) 8. piperacillin-tazobactam (Zosyn) 9. polymyxin (Colistimethate and Polymyxin B)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Requires Renal-Dosing Adjustments: (12)
1. Aminoglycosides: (Gentamicin, Tobramycin, Amikacin) 2. ceftazidime (Fortaz): 3rd-Gen 3. cefepime (Maxipime): 4th-Gen 4. ciprofloxacin (Cipro) 5. levofloxacin (Levaquin) 6. ampicillin-sulbactam (Unasyn) 7. piperacillin-tazobactam (Zosyn) 8. imipenem-cilastatin (Primaxin) 9. ertapenem (Invanz) 10. meropenem (Merrem) 11. polymyxin (Colistimethate and Polymyxin B) 12. vancomycin (Vancocin)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: HYDROphilic: (11)
1. Aminoglycosides: (Gentamicin, Tobramycin, Amikacin) 2. ceftazidime (Fortaz): 3rd-Gen 3. ceftriaxone (Rocephin): 3rd-Gen 4. cefepime (Maxipime): 4th-Gen 5. ertapenem (Invanz) 6. meropenem (Merrem) 7. imipenem-cilastatin (Primaxin) 8. ampicillin-sulbactam (Unasyn) 9. piperacillin-tazobactam (Zosyn) 10. polymyxin (Colistimethate and Polymyxin B) 11. vancomycin (Vancocin)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: IV Only: (11)
1. Aminoglycosides: (Gentamicin, Tobramycin, Amikacin) 2. ceftazidime (Fortaz): 3rd-Gen 3. ceftriaxone (Rocephin): 3rd-Gen 4. cefepime (Maxipime): 4th-Gen 5. ertapenem (Invanz) 6. meropenem (Merrem) 7. imipenem-cilastatin (Primaxin) 8. ampicillin-sulbactam (Unasyn) 9. piperacillin-tazobactam (Zosyn) 10. polymyxin (Colistimethate and Polymyxin B) 11. vancomycin (Vancocin)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Neuromuscular Blockers: (2)
1. Aminoglycosides: (Gentamicin, Tobramycin, Amikacin) 2. polymyxin (Colistimethate and Polymyxin B)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Other Nephrotoxins: (2)
1. Aminoglycosides: (Gentamicin, Tobramycin, Amikacin) 2. vancomycin (Vancocin)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: PK/PD: Cmax:MIC: (2)
1. Aminoglycosides: (gentamicin, tobramycin, amikacin) 2. Fluoroquinolones: (ciprofloxacin (Cipro), levofloxacin (Levaquin), moxifloxacin (Avelox))
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Administration: PO only: (4)
1. Amoxicillin (Amoxil) 2. Amoxicillin-clavulanate (Augmentin) 3. Cefpodoxime proxetil (Vantin): 3rd-Gen 4. Clarithromycin (Biaxin): Macrolide
Infective Endocarditis (IE): ENTEROcoccal sp: Treatment Summary: (3)
1. Ampicillin + Gentamicin 2. Penicillin + Gentamicin 3. Vancomycin
Infective Endocarditis (IE): Enterococcus sp: Native or Prosthetic Valve: Treatments: (3)
1. Ampicillin + Gentamicin 2. Penicillin + Gentamicin 3. Vancomycin + Gentamicin
Urinary Tract Infection (UTI): What are the 2 types of Infections? Important to Note:
1. Ascending Infection 2. Hematogenous Infection; Important to Note: If somebody does have a positive urine culture of S. aureus, then that would prompt us to get a blood culture because S. aureus is NOT a pathogen associated with ascending UTIs.
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics are associated with QTc Prolongation? (4)
1. Azithromycin (Zithromax, Z-Pak, Tri-Pak) 2. Clarithromycin (Biaxin) 3. Levofloxacin (Levaquin) 4. Moxifloxacin (Avelox)
Which agents cover atypicals AND streptococcus pneumoniae? (4)
1. Azithromycin (Zithromax, Z-Pak, Tri-Pak) 2. Doxycycline (Doryx, Moridox, Oracea, Acticlate) 3. Levofloxacin (Levaquin) 4. Moxifloxacin (Avelox)
Which agents cover Pseudomonas?
1. Beta-Lactams: • Penicillins • Cephalosporins • Carbapenems • Monobactams 2. NON Beta-Lactams: • Fluroquinolones • Aminoglycosides • Polymyxins
Chronic Bronchitis (CB): COPD Hallmark/Cardinal Symptoms: (3)
1. SOB 2. Chronic Cough 3. Sputum Production
_________________ & _________________ are primarily associated with healthcare-associated meningitis; (i.e. CSF shunt and drain infections)
1. Staphylococcus sp. 2. Pseudomonas sp
Name 3 causative pathogens commonly associated with Bacterial Meningitis found in Neonates (< 1 month)?
1. Streptococcus agalactiae: (Group B Strep) 2. Gram Negative (-) Enterics 3. Listeria monocytogenes
Name 2 causative pathogens commonly associated with Bacterial Meningitis found in patients who are 2-50 years old?
1. Streptococcus pneumoniae 2. Neisseria meningitidis
Name 4 causative pathogens commonly associated with Bacterial Meningitis found in patients over the age of 50?
1. Streptococcus pneumoniae 2. Neisseria meningitidis 3. Gram Negative (-) Enterics 4. Listeria monocytogenes
Name 4 causative pathogens commonly associated with Bacterial Meningitis found in pediatric patients who are 1 month-23 months old?
1. Streptococcus pneumoniae 2. Streptococcus agalactiae: (Group B Strep) 3. Neisseria meningitidis 4. Haemophilus influenzae
Bacterial Meningitis: Etiology: What are the 5 causative organisms?
1. Streptococcus pneumoniae 2. Streptococcus agalactiae: (Group B Strep) 3. Neisseria meningitidis 4. Haemophilus influenzae 5. Listeria monocytogenes
Community-Acquired Pneumonia (CAP): "Typical" Pathogens: (3)
1. Streptococcus pneumoniae 2. Haemophilus influenzae 3. Moraxella catarrhalis
Acute Bronchitis (AB): Common Symptoms: (4)
1. Chest congestion 2. Chest pain 3. Productive cough 4. Wheezing
Bacterial Meningitis: Risk Factors: (9)
1. Cigarette Smoking 2. Children w/ Cochlear Implants 3. Respiratory Tract Infections 4. Otitis Media 5. Head Trauma 6. Alcoholism 7. High-Dose Steroids 8. Splenectomy 9. Immunosuppression
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: CYP1A2 interactions with caffeine: (3)
1. Ciprofloxacin (Cipro) 2. Levofloxacin (Levaquin) 3. Moxifloxacin (Avelox)
Nosocomial Pneumonia: De-escalate therapy based on: (2)
1. Culture 2. Susceptibility
Ventilator-Associated Pneumonia (VAP): Double Pseudomonas +/- MRSA Coverage: Approach to Empiric Treatment: (2)
1. Double Pseudomonas coverage if IV antibiotics within the past 90 days or local pseudomonas resistance is > 10%. 2. MRSA coverage if IV antibiotics within the past 90 days or local MRSA resistance is > 20%
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: Chelation with bivalent/trivalent cations: (3)
1. Doxycycline (Doryx, Moridox, Oracea, Acticlate) 2. Levofloxacin (Levaquin) 3. Moxifloxacin (Avelox)
Urinary Tract Infection (UTI): Typical pathogens: (5)
1. E. Coli (GN) 2. Klebsiella pneumoniae (GN) 3. Proteus mirabilis (GN) 4. Pseudomonas aeruginosa (GN) 5. Staph. saprophyticus (GP)
Infective Endocarditis (IE): Principles of Therapy: Prolonged: (3)
1. Eradication takes weeks to achieve since organisms are sequestered inside the vegetation 2. Repeat blood cultures should be obtained to ensure clearance of bacteremia 3. For most patients, at least 4-6 weeks is required
What signs and symptoms are consistent with endocarditis? (5)
1. Fever 2. Chills 3. Shortness of breath 4. Subconjunctival hemorrhage 5. Murmur
Infective Endocarditis (IE): Clinical Presentation: Symptoms: (6)
1. Fever 2. Chills 3. Weakness 4. Dyspnea 5. Night Sweats 6. Weight loss
Almost all adults with bacterial meningitis have at least 2 of what 4 symptoms?
1. Fever 2. Headache 3. Neck Stiffness 4. Altered Mental Status
Infective Endocarditis (IE): Clinical Presentation: Signs: (5)
1. Fever 2. Heart Murmor 3. Embolic phenomenon 4. Skin manifestations 5. Splenomegaly
A patient on the ventilator in the Medical ICU is diagnosed with VAP. The team asks for help selecting antibiotic therapy. What do you need to know first? (3)
1. Has the patient had IV antibiotics in the past 90 days? 2. Check the antibiogram to see if the institution has Pseudomonas isolates with >10% to monotherapy 3. Check the antibiogram to see if the institution has MRSA rates >20% Explanation: The VAP guidelines lay out criteria for selecting empiric coverage for a patient. Double coverage of Pseudomonas is indicated for patients with risk for MDR pathogens (for this class, we said that the only MDR pathogen risk factor you had to know was if the patient has had IV antibiotics in the past 90 days. See Table 2 of the guidelines for other criteria.) The other criteria for double coverage is an institutional rate of Pseudomonas with >10% resistance to monotherapy. For determining need for MRSA coverage, it is the same as for HAP. Has the patient had IV antibiotics in the past 90 days or is the local rate of MRSA >20%? "High risk for mortality" is a term used to decide if double antipseudomonal coverage should be given for HAP, not VAP.
Hospital-Acquired Pneumonia (HAP): Double Pseudomonas Coverage: What are the 2 important things to assess?
1. If the patient had IV antibiotics in the past 90 days or 2. If the patient is at a high risk of mortality. Explanation: "If the answer is no for both of these questions, the patient needs monotherapy or single coverage with a beta lactam (to cover pseudomonas)" -Metzger
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics LESS commonly cause tendon/aortic rupture (achilles), peripheral neuropathy, seizures, QTc prolongation, CNS stimulation, and hypo/hyperglycemia? (2)
1. Levofloxacin (Levaquin) 2. Moxifloxacin (Avelox)
Which antibiotics are NOT for use with Myasthenia Gravis? (2)
1. Levofloxacin (Levaquin) 2. Moxifloxacin (Avelox)
Which 2 agents have "really good coverage" for COMMUNITY-Acquired Pneumonia (CAP)?
1. Levofloxacin (Levaquin) 2. Moxifloxacin (Avelox)
Bacterial Meningitis: CSF Antibiotic Treatment: What are the 4 molecular characteristics that promote penetration and efficacy?
1. Low Molecular Weight (< 500 Daltons) 2. Low Protein-Binding 3. Un-Ionized Molecules 3. High Lipophilicity
Bacterial Meningitis: Staphylococcus sp: Treatments of Choice: (5+)
1. MSSA: Nafcillin or Oxacillin 2. MRSA: Vancomycin, Linezolid, or Daptomycin 3. Intracranial and/or spinal hardware is present: Add Rifampin
QTc prolongation occurs with which 2 drug classes?
1. Macrolides 2. Fluroroquinolones
AUC:MIC Therapeutic Goals: (2)
1. Maximize exposure 2. Enhance amount of drug
Cmax:MIC Therapeutic Goals: (3)
1. Maximize exposure 2. High/Increase peak serum concentration 3. Increase dose
What 3 atypical organisms cause Upper Respiratory Infection Coverage?
1. Mycoplasma pneumoniae 2. Chlamydia pneumoniae 3. Legionella pneumophilia
Community-Acquired Pneumonia (CAP): "Atypical" Pathogens: (3)
1. Mycoplasma pneumoniae 2. Chlamydia pneumoniae 3. Legionella pneumophila "More associated with a walking pneumonia"
Infective Endocarditis (IE): Staphylococcus sp: Prosthetic Valve: Oxacillin-Susceptible Treatments: (2)
1. Nafcillin + Rifampin + Gentamicin 2. Oxacillin + Rifampin + Gentamicin
Bacterial Meningitis: Staphylococcus sp: Treatment Monitoring: (2)
1. Nafcillin: vesicant (i.e. causes blisters), and extravasation (i.e. leaky blood vessels) 2. Vancomycin: TDM
What should be done to help confirm the diagnosis of endocarditis? (2)
1. Obtain 3 sets of blood cultures 2. Initial TTE, followed by TEE as soon as possible
T > MIC Therapeutic Goals: (2)
1. Optimize duration of exposure 2. Shorten interval
Infective Endocarditis (IE): Clinical Signs: (5)
1. Osler's Nodes (LS) 2. Splinter Hemorrhages (LS) 3. Janeway's Lesions (LS) 4. Petechiae (LS) 5. Roth's Spots (LS) Explanation: LS standing for Left-Sided Endocarditis because these are systemic outcomes rather than pulmonary, which is more associated with Right-Sided Endocarditis.
Infective Endocarditis (IE): Streptococcal sp. Treatment Summary: (3)
1. Penicillin +/- Gentamicin 2. Ceftriaxone +/- Gentamicin 3. Vancomycin
CA-Native Valve Endocarditis: Viridans Group Streptococci (VGS): Highly Penicillin-SUSCEPTIBLE: Treatments: (3)
1. Penicillin G +/- Gentamicin 2. *Ceftriaxone +/- Gentamicin 3. **Vancomycin Explanation: *If the strain is ceftriaxone-susceptible, ceftriaxone can be administered as monotherapy. **Vancomycin is ONLY recommended if patient has intolerance/ allergies to PCN-G, ceftriaxone, or ampicillin; due to it's slower killing effect when compared to beta lactams. Therefore, If vancomycin is warranted, do not have to give gentamicin per guidelines" -Sen
Bacterial Meningitis: Neisseria meningitidis: Definitive Treatments of Choice: (2)
1. Penicillin-G 2. Ampicillin
Bacterial Meningitis: Listeria monocytogenes: Treatments of Choice: (3)
1. Penicillin-G +/- Aminoglycoside 2. Ampicillin +/- Aminoglycoside 3. Bactrim, if severe PCN allergy is present.
Bacterial Meningitis: Diagnostic Tests: Cerebrospinal Fluid (CSF) Analysis: WBCs: Differential: Protein: Glucose:
"Bacterial Meningitis is characterized by a high neutrophil count, high protein, and low glucose." -Sen
Urinary Tract Infection (UTI): Outpatient Treatment: Uncomplicated Cystitis in Women: First-Line Empiric Treatment: (2) Alternative: (1)
"Macro in Macrobid has 5 letters so duration is for 5 days, then BID in MacroBID means it should be taken twice daily; Regimen: Macrobid 100 mg po BID x 5 days" "SMX and TMP are abbreviated with 3 letters so duration of therapy is 3 days, then since there are 2 components (SMX+TMP), it should be taken twice daily; Regimen: Bactrim DS po BID x 3 days" -Rizzo Supplemental: FQs and Beta lactams are not on here due to resistance potential.
Infective Endocarditis (IE): HACEK Group: Native or Prosthetic Valve: Treatments: (3)
*Treatments: 1. ceftriaxone (Rocephin) 2 g IV q 24H x 4-6W 2. ampicillin-sulbactam (Unasyn) 12 g IV over 24H x 4-6W 3. **ciprofloxacin (Cipro) 800 mg IV over 24H x 4-6W Explanations: -Native Valve Endocarditis: duration of therapy = 4W -Prosthetic Valve Endocarditis: duration of therapy = 6W **If unable to tolerate cephalosporin or ampicillin therapy
What agents can be added to ceftriaxone in the treatment of patients admitted to the hospital with severe CAP? (SATA) a. Vancomycin b. Azithromycin c. Levofloxacin d. Tobramycin
-- b. Azithromycin c. Levofloxacin -- Explanation: IDSA guidelines recommend the use of IV beta-lactam PLUS respiratory fluoroquinolone (Moxifloxacin or levofloxacin) OR IV beta-lactam PLUS azithromycin in the treatment of SEVERE CAP.
What antibiotics have to be separated from multivitamins due to chelation? (SATA) a. Clarithromycin b. Doxycycline c. Rocephin d. Levaquin e. Sulfamethoxazole/trimethoprim
-- b. Doxycycline -- d. Levaquin -- Explanation: Tetracyclines and fluoroquinolones chelate bivalent/trivalent cations.
Endocarditis Risk Factors: (SATA) a. Pneumonia b. Prosthetic valve c. PMH: Endocarditis d. IV drug use e. Cigarette smoking
-- b. Prosthetic valve c. PMH: Endocarditis d. IV drug use --
What pathogen(s) dictate antibiotic coverage in the treatment in HAP or VAP? (SATA) a. ESBL E Coli b. Pseudomonas aeruginosa c. MRSA d. MDR Streptococcus pneumoniae e. VRE f. Mycoplasma pneumoniae g. Anaerobes
-- b. Pseudomonas aeruginosa c. MRSA -- -- -- --
Bacterial Meningitis: CSF Antibiotic Treatment: Which agents do NOT penetrate the CSF well? (4)
1. 1st-Gen Cephalosporins 2. 2nd-Gen Cephalosporins 3. Beta-Lactamase Inhibitors 4. doxycycline: TET
Community-Acquired Pneumonia (CAP): Counseling Points for Respiratory Fluoroquinolones: (4)
1. Take in the morning 2. Apply sunscreen 3. Do NOT take with Tums 4. No strenuous exercise
Bacteremia Management: (3)
1. Targeted antibiotic therapy 2. Source control 3. Repeat blood cultures to document clearance
Urinary Tract Infection (UTI): Outpatient Treatment: Adjunctive Therapy: Cranberry Juice: (2 Main Points)
1. UTI Prevention, NOT treatment 2. May interact with Warfarin
A 23 year-old female presents to urgent care with dysuria and increased frequency of urination, fever, flank pain, and vomiting. She has positive CVA tenderness and a UA that has positive nitrites and positive leukocyte esterase. She is clinically stable for outpatient treatment. The urgent care provider asks for your help to select an empiric treatment regimen for the patient. What additional question do you need answered before you can make a recommendation? (5)
1. Uncomplicated or Complicated Pyelonephritis? 2. Drug Allergies? 3. Pregnant? 4. Local resistance rate of E. coli to Bactrim? 5. Local resistance rate of E. coli to Fluoroquinolones? Metzger Explanation: Resistance rates of E. coli to Bactrim are important for cystitis and since Bactrim can be used as an alternative to fluoroquinolones the local resistance would be nice to know.
Two sets of blood cultures are obtained and reveal Gram Positive (+) cocci in chains, what organism could this be? (2)
1. Viridans Group Streptococcus (VGS) or 2. Enterococcus sp
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics are primarily associated with mild diarrhea and allergies? (2)
1. amoxicillin (Amoxil) 2. cefpodoxime proxetil (Vantin): 3rd-Gen
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: None: (4)
1. amoxicillin (Amoxil) 2. amoxicillin-clavulanate (Augmentin) 3. cefpodoxime proxetil (Vantin): 3rd-Gen 4. ceftriaxone (Rocephin): 3rd-Gen
Community-Acquired Pneumonia (CAP): Name that Antibiotic: PK/PD: Which antibiotics follow by T > MIC ? (5)
1. amoxicillin (Amoxil) 2. amoxicillin-clavulanate (Augmentin) 3. cefuroxime axetil (Ceftin): 2nd gen 4. cefpodoxime proxetil (Vantin): 3rd gen 5. ceftriaxone (Rocephin): 3rd gen
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Requires renal-dose adjustments: (5)
1. amoxicillin (Amoxil) 2. amoxicillin-clavulanate (Augmentin) 3. cefuroxime axetil (Ceftin): 2nd-Gen 4. cefpodoxime proxetil (Vantin): 3rd-Gen 5. levofloxacin (Levaquin): CrCl < 50 mL/min
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics are hydrophilic? (5)
1. amoxicillin (Amoxil) 2. amoxicillin-clavulanate (Augmentin) 3. cefuroxime axetil (Ceftin): 2nd-Gen 4. cefpodoxime proxetil (Vantin): 3rd-Gen 5. ceftriaxone (Rocephin): 3rd-Gen
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics penetrate the lungs well with higher dosing? (5)
1. amoxicillin (Amoxil) 2. amoxicillin-clavulanate (Augmentin) 3. cefuroxime axetil (Ceftin): 2nd-Gen 4. cefpodoxime proxetil (Vantin): 3rd-Gen 5. ceftriaxone (Rocephin): 3rd-Gen
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics are bactericidal? (7)
1. amoxicillin (Amoxil) 2. amoxicillin-clavulanate (Augmentin) 3. cefuroxime axetil (Ceftin): 2nd-Gen 4. cefpodoxime proxetil (Vantin): 3rd-Gen 5. ceftriaxone (Rocephin): 3rd-Gen 6. levofloxacin (Levaquin): FQ 7. moxifloxacin (Avelox): FQ
A patient grows E.coli in his urine culture after hospitalization for a complicated UTI. His blood culture is negative. Ampicillin: S Ampicillin-sulbactam: S Cefazolin: S Ceftriaxone: S Cefuroxime: S Levofloxacin: S Meropenem: S Nitrofurantoin: S Piperacillin-tazobactam: S Sulfamethoxazole-trimethoprim: S What agents could you recommend he be discharged on? (3)
1. ampicillin (oral) 2. amoxicillin (oral) 3. cephalexin (oral) Explanation: Of the choices listed, amoxicillin is the narrowest spectrum ORAL agent. Oral beta-lactams can be used for urinary tract infections as long as the blood cultures are negative. Oral beta-lactams should not be used when the patient has positive blood cultures (bacteremia). Augmentin, Levofloxacin, and Bactrim are broader than needed and ceftriaxone is broader and only available as injection.
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions: None: (5)
1. ampicillin-sulbactam (Unasyn) 2. piperacillin-tazobactam (Zosyn) 3. ceftazidime (Fortaz): 3rd-Gen 4. ceftriaxone (Rocephin): 3rd-Gen 5. cefepime (Maxipime): 4th-Gen
Nosocomial-Acquired Pneumonia: Name that Antibiotic: PK/PD: T > MIC: (8)
1. ampicillin-sulbactam (Unasyn) 2. piperacillin-tazobactam (Zosyn) 3. imipenem-cilastatin (Primaxin) 4. ertapenem (Invanz) 5. meropenem (Merrem) 6. ceftazidime (Fortaz) 7. ceftriaxone (Rocephin) 8. cefepime (Maxipime)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Covers anaerobes: (6)
1. ampicillin-sulbactam (Unasyn) 2. piperacillin-tazobactam (Zosyn) 3. imipenem-cilastatin (Primaxin) 4. ertapenem (Invanz) 5. meropenem (Merrem) 6. moxifloxacin (Avelox)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics do NOT require any renal dose adjustments? (5)
1. azithromycin (Z-Pak): Macrolide 2. clarithromycin (Biaxin): Macrolide 3. ceftriaxone (Rocephin): 3rd-Gen 4. doxycycline (Doryx, Moridox, Oracea): TET 5. moxifloxacin (Avelox): FQ
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics are lipophilic? (5)
1. azithromycin (Z-Pak): Macrolide 2. clarithromycin (Biaxin): Macrolide 3. doxycycline (Doryx, Moridox, Oracea): TET 4. levofloxacin (Levaquin): FQ 5. moxifloxacin (Avelox): FQ
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Administration: PO & IV (100% Bioavailable): (4)
1. azithromycin (Zithromax, Z-Pak): Macrolide 2. doxycycline (Doryx, Oracea, Acticlate): TET 3. levofloxacin (Levaquin): FQ 4. moxifloxacin (Avelox): FQ
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Covers Streptococcus pneumoniae and Atypical organisms: (2)
1. azithromycin (Zithromax, Z-Pak): Macrolide 2. clarithromycin (Biaxin): Macrolide
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics are bacteriostatic? (3)
1. azithromycin (Zithromax, Z-Pak): Macrolide 2. clarithromycin (Biaxin): Macrolide 3. doxycycline (Doryx, Moridox, Oracea): TET
Community-Acquired Pneumonia (CAP): Name that Antibiotic: PK/PD: Which antibiotics follow by AUC:MIC ? (3)
1. azithromycin (Zithromax, Z-Pak): Macrolide 2. clarithromycin (Biaxin): Macrolide 3. doxycycline (Doryx, Moridox, Oracea): TET
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics penetrate the lungs well with normal dosing? (5)
1. azithromycin (Zithromax, Z-Pak): Macrolide 2. clarithromycin (Biaxin): Macrolide 3. doxycycline (Doryx, Moridox, Oracea): TET 4. levofloxacin (Levaquin): FQ 5. moxifloxacin (Avelox): FQ
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: Caution with other QT-prolonging agents: (4)
1. azithromycin (Zithromax, Z-Pak): Macrolide 2. clarithromycin (Biaxin): Macrolide 3. levofloxacin (Levaquin): FQ 4. moxifloxacin (Avelox): FQ
Bacterial Meningitis: Streptococcus pneumoniae: Empiric Treatments of Choice: (4)
1. cefotaxime (Claforan): 3rd-Gen 2. ceftriaxone (Rocephin): 3rd-Gen Cephalosporin-Resistant: 3. Add vancomycin to either cefotaxime or ceftriaxone Severe PCN Allergy: 4. Vancomycin + FQ: (levofloxacin or moxifloxacin)
Which cephalosporins cover Pseudomonas? (2)
1. ceftazidime (Fortaz): 3rd-Gen 2. cefepime (Maxipime): 4th-Gen
If Bacterial Meningitis is being caused by a Pseudomonas sp, what are the treatment options available? (5)
1. ceftazidime (Fortaz): 3rd-Gen 2. cefepime (Maxipime): 4th-Gen 3. meropenem (Merrem) 4. *aztreonam (Azactam) 5. *ciprofloxacin (Cipro) *if beta-lactam allergy is present
Urinary Tract Infection (UTI): Name that Antibiotic: Bactericidal: (4)
1. ceftriaxone (Rocephin) 2. ciprofloxacin (Cipro) 3. levofloxacin (Levaquin) 4. fosfomycin (Monurol)
Urinary Tract Infection (UTI): Pharmacotherapy: Which antibiotics have "Good" penetration? (2)
1. ceftriaxone (Rocephin) 2. sulfamethoxazole-trimethoprim (Bactrim)
Urinary Tract Infection (UTI): Name that Antibiotic: Does NOT require a renal-dose adjustment: (2)
1. ceftriaxone (Rocephin) 2. fosfomycin (Monurol)
Urinary Tract Infection (UTI): Name that Antibiotic: Drug-Drug Interactions: None: (2)
1. ceftriaxone (Rocephin) 2. fosfomycin (Monurol)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Does NOT require Renal-Dosing Adjustments: (3)
1. ceftriaxone (Rocephin): 3rd-Gen 2. linezolid (Zyvox): Oxolidinone 3. moxifloxacin (Avelox): FQ
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: H2RAs and PPIs decrease effectiveness: (2)
1. cefuroxime (Zinacef): 2nd-Gen 2. cefuroxime axetil (Ceftin): 2nd-Gen
Urinary Tract Infection (UTI): Name that Antibiotic: Black Box Warning: Tendon (Achilles) rupture, aortic rupture, peripheral neuropathy, seizures* (AVOID use in children): (2)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Name that Antibiotic: Clinical Pearls: High risk of collateral damage: (2)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Name that Antibiotic: Cmax:MIC (2)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Name that Antibiotic: Common SE: GI, Headache, dizziness, photosensitivity: (2)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Name that Antibiotic: Drug-Drug Interactions: Chelation with cations (e.g. Mg, Ca, TUMS), QTc drugs, & warfarin: (2)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Name that Antibiotic: Less Common SE: hypo/hyperglycemia, psychiatric disturbances, QTc prolongation: (2)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Pharmacotherapy: Which antibiotics penetrate the bladder, kidney, and bloodstream? (2)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Name that Antibiotic: Clinical Pearls: Growing resistance of E. coli: (3)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. sulfamethoxazole-trimethoprim (Bactrim)
Urinary Tract Infection (UTI): Name that Antibiotic: Route of Administration: PO & IV: (3)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. sulfamethoxazole-trimethoprim (Bactrim)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Avoid Use in Children: (3)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. moxifloxacin (Avelox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Black Box Warning: Tendon rupture, aortic rupture, peripheral neuropathy, seizures: (3)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. moxifloxacin (Avelox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Chelation with cations, QTc drugs, warfarin: (3)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. moxifloxacin (Avelox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Less Common SEs Include: Hypo/Hyperglycemia, psychiatric disturbances, QTc prolongation: (3)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. moxifloxacin (Avelox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: MOST Common Adverse Events include: GI, Headache, dizziness, & photosensitivity: (3)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. moxifloxacin (Avelox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Lipophilic: (4)
1. ciprofloxacin (Cipro) 2. levofloxacin (Levaquin) 3. moxifloxacin (Avelox) 4. linezolid (Zyvox)
Urinary Tract Infection (UTI): Name that Antibiotic: Requires Renal-Dose Adjustment: (4)
1. ciprofloxacin (Cipro): FQ 2. levofloxacin (Levaquin): FQ 3. nitrofurantoin (Macrobid): CrCl < 40 mL/min 4. sulfamethoxazole-trimethoprim (Bactrim)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics (indicated for CAP) are associated with photosensitivity? (3)
1. doxycycline (Doryx, Moridox, Oracea): TET 2. levofloxacin (Levaquin): FQ 3. moxifloxacin (Avelox): FQ
Urinary Tract Infection (UTI): Name that Antibiotic: Route of Administration: PO only: (2)
1. fosfomycin (Monurol) 2. nitrofurantoin (Macrobid, Macrodantin, Furadantin)
Urinary Tract Infection (UTI): Pharmacotherapy: Which antibiotics penetrate only the bladder? (2)
1. fosfomycin (Monurol) 2. nitrofurantoin (Macrobid, Macrodantin, Furadantin)
Urinary Tract Infection (UTI): Name that Antibiotic: AUC:MIC (2)
1. fosfomycin (Monurol) 2. sulfamethoxazole-trimethoprim (Bactrim)
Infective Endocarditis (IE): Principles of Therapy: The most important approach to treatment is... (2)
1. isolation of the infecting pathogen and 2. determination of antimicrobial susceptibilities
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: Increased INR (i.e. more bleeding) when combined with Warfarin: (2)
1. levofloxacin (Levaquin) 2. moxifloxacin (Avelox)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: May cause HYPOglycemia when combined with DM agents: (2)
1. levofloxacin (Levaquin) 2. moxifloxacin (Avelox)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which CAP antibiotics lower seizure threshold? (2)
1. levofloxacin (Levaquin) 2. moxifloxacin (Avelox)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: PK/PD: Which antibiotics follow by Cmax:MIC ? (2)
1. levofloxacin (Levaquin) 2. moxifloxacin (Avelox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: PO & IV: (3)
1. levofloxacin (Levaquin) 2. moxifloxacin (Avelox) 3. linezolid (Zyvox)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotics MOST commonly cause GI upset/diarrhea, and photosensitivity? (2)
1. levofloxacin (Levaquin): FQ 2. moxifloxacin (Avelox): FQ
Urinary Tract Infection (UTI): Name that Antibiotic: Typically bacteriostatic, but bactericidal in the urine: (2)
1. nitrofurantoin (Macrobid, Macrodantin, Furadantin) 2. sulfamethoxazole-trimethoprim (Bactrim)
Urinary Tract Infection (UTI): Lab Testing: Urinalysis (UA): DM and kidney disease may show... (2)
1. protein 2. ketones
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Covers MRSA: (2)
1. vancomycin (Vancocin) 2. linezolid (Zyvox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: PK/PD: AUC:MIC: (2)
1. vancomycin (Vancocin) 2. linezolid (Zyvox)
How to calculate the resistance rate via an antibiogram?
100 - (Organism's % susceptibility to a specific antibiotic) Example: So if the organism (E. coli) was showing a 69% susceptibility to sulfamethoxazole, the resistance rate would be 100 - 69 = 31%
Infective Endocarditis (IE): Staphylococcus sp: Uncomplicated RIGHT-Sided IE in IV Drug Users: Treatment:
2 week Beta-Lactam
Bacterial Meningitis: Haemophilus influenzae: Empiric Treatments of Choice: (2)
3rd-Generation Cephalosporins: cefotaxime (Claforan) or ceftriaxone (Rocephin)
Nosocomial Pneumonia: Guidelines now recommend ______________ of therapy only
7 days
A patient has uncomplicated bacteremia when: (SATA) A. Her fever subsides after 2 days B. Her medical history states she has no implanted prosthesis C. She is diagnosed with endocarditis D. Her follow-up blood cultures did not grow MRSA after 3 days
A. Her fever subsides after 2 days B. Her medical history states she has no implanted prosthesis -- D. Her follow-up blood cultures did not grow MRSA after 3 days
Acute vs Subacute Endocarditis: Frequently caused by Staphylococcus aureus:
Acute Endocarditis
Acute vs Subacute Endocarditis: Fulminating (i.e. developed suddenly) Form:
Acute Endocarditis
Acute vs Subacute Endocarditis: High fevers and systemic toxicity:
Acute Endocarditis
Acute vs Subacute Endocarditis: If untreated, death may occur within days to weeks:
Acute Endocarditis
Bacterial Meningitis: Adjuvant Dexamethasone: Adult Dosing Regimen: Pediatric Indication: Concern: Monitoring:
Adult Dosing Regimen: dexamethasone 0.15 mg/Kg IV/PO q 6H x 2-4 days Pediatric Indication: Recommended if pediatric patient has Haemophilus influenzae Concern: Steroids reduce inflammation by reducing antibiotic penetration Monitoring: Steroid-related SEs
Community-Acquired Pneumonia (CAP): Counseling Points for Macrolides: (3)
Adverse SE: Diarrhea Precaution: PMH of CVD Drug Interaction: CYP3A4
Bacterial Meningitis: CNS Antibiotic Treatment: Agent: SMX-TMP (_____________) Adult IV Dose:
Agent: Bactrim Adult IV Dose: 10-20 mg/Kg/day IV divided q 6-8H (Don't need to know Pediatric dose for exam)
Bacterial Meningitis: CNS Antibiotic Treatment: Agent: meropenem (_____________) Adult IV Dose:
Agent: Merrem Adult IV Dose: 2 g IV every 8H (Don't need to know Pediatric dose for exam)
Bacterial Meningitis: CNS Antibiotic Treatment: Agent: ceftriaxone (_____________) Adult IV Dose:
Agent: Rocephin Adult IV Dose: 2 g IV every 12H (Don't need to know Pediatric dose for exam)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Other Nephrotoxins, neuromuscular blocking drugs:
Aminoglycosides: (Gentamicin, Tobramycin, Amikacin)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: Nephrotoxicity, ototoxicity (hearing and vestibular), muscle weakness:
Aminoglycosides: (Gentamicin, Tobramycin, Amikacin)
A 50 year-old female patient presents to her primary care physician's office complaining of difficulty breathing, cough, chills, and feeling "awful." The physician hears egophony and decreased breath sounds and notes that the patient is breathing 20 times per minute with a heart rate is 80 bpm and a BP of 122/86 mmHg. Her oxygen saturation is 95% on room air. She has no significant co-morbidities. Allergies: NKDA. The physician decides to treat her as an outpatient. The community has a 30% resistance rate of S. pneumoniae to macrolides. What do you recommend to treat her CAP? (2)
Amoxicillin or Doxycycline Explanation: The guidelines recommend amoxicillin or doxycycline first line for a patient with CAP and no co-morbidities. Azithromycin is an alternative; however, given high rates of S. pneumoniae resistance in the community, Amoxicillin is preferred. Moxifloxacin could be used in a patient with co-morbidities or in a hospitalized patient. Ceftriaxone + Azithromycin is a preferred inpatient regimen but is not convenient as an outpatient given parenteral administration of Ceftriaxone. Ciprofloxacin is not used for CAP because of inadequate coverage of S. pneumoniae.
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotic is primarily associated with more intense diarrhea and allergies?
Amoxicillin-clavulanate (Augmentin): (More so than amoxicillin)
When designing empiric treatment for Bacterial Meningitis, what drug regimen will be used to cover Listeria monocytogenes?
Ampicillin
Bacterial Meningitis: Haemophilus influenzae: Definitive Treatment of Choice:
Ampicillin (20% of strains are resistant)
A 45 year-old male is admitted to the medicine floor of a hospital due to non-severe CAP. He is started on ampicillin-sulbactam (Unasyn) + azithromycin. What is your assessment of his regimen?
Ampicillin-sulbactam (Unasyn) + azithromycin is a reasonable choice because the guidelines state a beta-lactam can be used in combo with a macrolide for inpatient non-severe CAP. Explanation: Table 4 of the IDSA guidelines for CAP states that inpatient treatment for non-severe CAP be either beta-lactam + macrolide OR respiratory fluoroquinolone (levo or moxi). IDSA guidelines list: Ampicillin-sulbactam (Unasyn), cefotaxime, ceftriaxone, and ceftaroline as beta-lactam options along with azithromycin or clarithromycin.
A patient on the ventilator in the Medical ICU is diagnosed with VAP. She has never had IV antibiotics. The local MRSA rate is 10% and the Pseudomonas isolates have a 15% resistance rate to most monotherapy agents. The patient has a history of anaphylaxis to Augmentin. She also has AKI as a complication from her course in the ICU. What regimen is BEST for this patient?
Aztreonam + levofloxacin Explanation: Double anti-pseudomonal coverage should include a beta-lactam backbone plus either an aminoglycoside, fluoroquinolone, or polymyxin. Since this patient has AKI, aminoglycosides and polymyxins would be less preferred since they may worsen the kidney function. Since this patient has an anaphylaxis history to Augmentin, a beta-lactam should be avoided, if possible. In this case, the monobactam, Aztreonam, is a good choice.
Community-Acquired Pneumonia (CAP): Outpatient Treatment WITH Comorbidities: (4)
Beta-Lactam + Macrolide: 1. Amoxicillin 875 mg po BID + ZPAK 2. Cefuroxime 500 mg po BID + ZPAK Fluoroquinolone Monotherapy: 3. Levofloxacin 750 mg PO q day 4. Moxifloxacin 400 mg PO q day
Antibiotic Pharmacodynamics: T > MIC: (4)
Beta-Lactam Antibiotics: Penicillins Cephalosporins Carbapenems Monobactams
Infective Endocarditis (IE): Diagnostic Procedures: Blood Culture Important Info: (2) What constitutes a sample to be "persistently positive"? (2)
Blood Culture Important Info: Picture; "Persistently Positive" Meaning: All 3 blood cultures are positive (+) or 2 of the blood cultures that were drawn 12 hours apart were positive (+)
Urinary Tract Infection (UTI): Outpatient Treatment: Adjunctive Therapy: Phenazopyridine HCl (________): Description: Regimen: Bacteriostatic or Bactericidal? Patient Education: Contraindicated Population(s)? Precautions:
Brand: AZO; Description: Dye used as antiseptic, analgesic, anesthetic upon urinary mucosa; Regimen: 100-200 mg PO TID with food x 2 days; Bacteriostatic or Bactericidal? Bacteriostatic; Patient Education: Discolors urine redish-orange; Contraindicated Population(s)? CrCl < 50 mL/min; Precautions: Methemoglobinemia and Hemolytic Anemia
Community-Acquired Meningitis vs Nosocomial Meningitis:
CA-Meningitis cause is unknown
Community-Acquired Pneumonia (CAP): Immunizations: (2)
Can pharmacists administer both of these vaccines under protocol in Georgia? Yes
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: GI, diarrhea, rash, seizures with renal accumulation: (3)
Carbapenems: 1. imipenem-cilastatin (Primaxin) 2. meropenem (Merrem) 3. ertapenem (Invanz)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Decreases [Valproic Acid] significantly: (3)
Carbapenems: 1. imipenem-cilastatin (Primaxin) 2. meropenem (Merrem) 3. ertapenem (Invanz)
Community-Acquired Native Valve Endocarditis in patients who are NOT injection drug users: Causative Agent: _______________________ Penicillin MIC Data: Penicillin Susceptible: ________________ Penicillin Intermediate: ________________ Penicillin Resistant: ________________
Causative Agent: Viridans Group Streptococci (VGS) Penicillin Susceptible: MIC ≤ 0.12 mcg/mL Penicillin Intermediate: MIC > 0.12 but ≤ 0.5 mcg/mL Penicillin Resistant: MIC > 0.5 mcg/mL
Community-Acquired Pneumonia (CAP): _________________ is a preferred inpatient regimen but is NOT convenient as an outpatient given....
Ceftriaxone + Azithromycin; ceftriaxone is IV only.
A patient is on Zosyn + Tobramycin extended interval + Vancomycin for empiric coverage of VAP. The patient has septic shock and her creatinine has gone from 1.0 mg/dL on admission to 3.0 mg/dL three days later. She is anuric. What can you do to minimize additional damage to her kidneys?
Change Vancomycin to Linezolid
A 50 year-old female patient presents to her primary care physician's office complaining of difficulty breathing, cough, chills, and feeling "awful." The physician hears egophony and decreased breath sounds and notes that the patient is breathing 20 times per minute with a heart rate of 80 bpm and a BP of 122/86 mmHg. Her oxygen saturation is 95% on room air. The physician decides to treat her as an outpatient. She has no significant co-morbidities. Allergies: NKDA. What is this patient missing to confirm a diagnosis of CAP?
Chest X-Ray Explanation: The patient has signs and symptoms of CAP but needs positive imaging results to confirm the diagnosis. A chest X-ray or chest CT would give you the radiologic evidence needed in combination with the signs and symptoms. A WBC would be helpful but not required to make the diagnosis. Streptococcus urinary antigen and sputum culture are not required and are often not clinically useful in the diagnosis and management of CAP.
Nosocomial-Acquired Pneumonia: What is required for a diagnosis?
Clinical Signs and Symptoms + Positive Imaging Findings
Bacterial Meningitis: Empiric Antimicrobial Therapy: Age: Neonates (< 1 month) Common Pathogens: (3) Empiric Therapy:
Common Pathogens: 1. Streptococcus agalactiae (Group B Strep) 2. Gram Negative (-) enterics 3. Listeria monocytogenes Empiric Therapy: Ampicillin + (either gentamicin or *cefotaxime) *Supplemental Info: ceftriaxone can NOT be given to neonates, so use cefotaxime as an alternative
Bacterial Meningitis: Empiric Antimicrobial Therapy: Age: 2-50 years Common Pathogens: (2) Empiric Therapy:
Common Pathogens: 1. Streptococcus pneumoniae 2. Neisseria meningitidis Empiric Therapy: Vancomycin + (either *ceftriaxone or cefotaxime) *Supplmental Info: ceftriaxone does NOT require a renal adjustment, but is contraindicated in pediatric patients due to precipitation of kernicterus
Bacterial Meningitis: Empiric Antimicrobial Therapy: Age: > 50 years Common Pathogens: (4) Empiric Therapy:
Common Pathogens: 1. Streptococcus pneumoniae 2. Neisseria meningitidis 3. Gram Negative (-) enterics 4. Listeria monocytogenes Empiric Therapy: Vancomycin + ampicillin + (either *ceftriaxone or cefotaxime) *Supplmental Info: ceftriaxone does NOT require a renal adjustment.
Bacterial Meningitis: Empiric Antimicrobial Therapy: Age: 1-23 months Common Pathogens: (4) Empiric Therapy:
Common Pathogens: 1. Streptococcus pneumoniae 2. Streptococcus agalactiae 3. Haemophilus influenzae 4. Neisseria meningitidis Empiric Therapy: vancomycin + cefotaxime Supplmental Info: ceftriaxone does NOT require a renal adjustment, but should NOT be used in pediatrics due to risk of kernicterus.
_______________ is the MOST common infection-related cause of death in the US.
Community-Acquired Pneumonia (CAP)
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: Catherization:
Complicated
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: Immunocompromised:
Complicated
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: Men:
Complicated
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: Pregnant Women:
Complicated
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: Presence of structural abnormalities:
Complicated
When only one of the blood cultures is positive, it is known as:
Contamination
Urinary Tract Infection (UTI): Cystitis vs. Pyelonephritis: Lower UTI or "bladder infection":
Cystitis
Urinary Tract Infection (UTI): Cystitis vs. Pyelonephritis: Typically does NOT have systemic signs & symptoms of illness; (e.g. No fever, No ↑ WBC, No sepsis):
Cystitis
Urinary Tract Infection (UTI): Subjective: Signs: Cystitis vs. Pyelonephritis:
Cystitis ("Bladder Infection") does NOT typically produce systemic signs of illness, but rather more local signs of illness (e.g. dysuria, urgency, increased frequency).
Urinary Tract Infection (UTI): Subjective: Symptoms: Cystitis vs. Pyelonephritis:
Cystitis: Local symptoms Pyelonephritis: Local plus systemic symptoms
Nosocomial Pneumonia: Therapy De-escalations: A patient's BAL returns positive for pan-susceptible P. aeruginosa. Patient is on meropenem, tobramycin, and vancomycin. How should the empiric therapy be changed?
D/C: Vancomycin, Tobramycin Continue: Meropenem
Nosocomial Pneumonia: Therapy De-escalations: A patient's BAL returns positive for MSSA. Patient is on meropenem, tobramycin, and vancomycin. How should the empiric therapy be changed?
D/C: Vancomycin, Tobramycin, and Meropenem Initiate either: (Based on Allergy Profile) • Isoxasolyl Penicillin: nafcillin or oxacillin or • 1st-Gen Cephalosporin: cefazolin or cephalexin
MRSA Bacteremia: Uncomplicated vs Complicated: Characteristics: Treatment Duration:
Defervescence = fever reduction/dismissal
A patient on the ventilator in the Medical ICU is diagnosed with VAP. She has never had IV antibiotics. The local MRSA rate is 10% and the Pseudomonas isolates have a 15% resistance rate to most monotherapy agents. What components of EMPIRIC therapy are required for this patient?
Double coverage for Pseudomonas Explanation: Since this hospital has >10% rate of Pseudomonas resistance to monotherapy, the patient should be on double anti-Pseudomonal coverage. The MRSA rate is <20%, so MRSA coverage is NOT required. The patient has never had IV antibiotics, so this doesn't change the empiric coverage.
What agent, used to treat CAP, covers both Streptococcus pneumoniae and Atypicals?
Doxycycline
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotic may cause GI upset and erosive esophagitis, diarrhea, discolored teeth (babies, kids), brittle bones, and photosensitivity?
Doxycycline (Doryx, Moridox, Oracea, Acticlate)
What is the most common pathogen that causes urinary tract infections?
E. coli
Community-Acquired Pneumonia (CAP): Physical Exam Findings:
Egophony: "EEE may sound like AAA" http://www.easyauscultation.com/egophony Inspiratory crackles: http://www.easyauscultation.com/cases?coursecaseorder=3&courseid=201
_________________ has an intrinsic resistance to cephalosporins.
Enterococcus sp.
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Bactericidal: (14)
Everything on the nosocomial drug table except linezolid (Zyvox)
Chronic Bronchitis (CB): Pathophysiology:
Excessive sputum production occuring for most days of the week for at least 3 months of the year for at least 2 years.
Chronic Bronchitis (CB): (T/F?) Antibiotics are required for all COPD exacerbations.
FALSE
Bacterial Meningitis: What factors should be considered when designing an empiric regimen? (5)
Factors that promote penetration and efficacy: Low MW, un-ionized molecules, high lipophilicity, low protein binding
(T/F?) "Start low, go slow" philosophy is best applied for medications to treat medical conditions with high mortality (e.g. meningitis, endocarditis, DVT, pneumonia).
False
(T/F?) β-Lactam Antibiotics cover atypical organisms.
False
Urinary Tract Infection (UTI): Outpatient Treatment: Uncomplicated Pyelonephritis in Women: First-Line Empiric Treatments: (2) Alternative Treatments: (2)
First-Line Empiric Treatments: (FQs) 1. ciprofloxacin 500 mg po BID x 7 days 2. levofloxacin 750 mg po daily x 5 days Alternative Treatments: 1. ceftriaxone 1 g IV q 24H x 10-14 days 2. Bactrim DS (800/160 mg) po BID x 14 days
Antibiotic Pharmacodynamics: Cmax:MIC: (4)
Fluoroquinolones Aminoglycosides Metronidazole Daptomycin
Community-Acquired Pneumonia (CAP): What is required for an official diagnosis?
For a diagnosis: S/Sx of Infection + a positive Chest CT
qSOFA Criteria:
GCS < 15 SBP ≤ 100 RR ≥ 22
Listeria monocytogenes: Gram Stain & Morphology:
Gram Positive (+) Bacillus/Rod
Haemophilus influenzae: Gram Stain & Morphology:
Gram-Negative (-) Coccobacilli
Neisseria meningitidis: Stain & Morphology:
Gram-Negative (-) Encapsulated Diplococcus
Streptococcus pneumoniae: Stain & Morphology:
Gram-Positive (+) Diplococcus, Lancet-shaped, Encapsulated
Which agents cover HA & CA-MRSA?
HA & CA-MRSA Treatments: 1. Cephalosporins 2. Glycopeptides 3. Oxazolidinones 4. Glycylcycline 5. Streptogramin 6. Fluoroquinolones 7. Lipopeptide CA-MRSA Treatments: 8. Clindamycin (Cleocin): pending D-test results 9. Sulfamethoxazole-trimethoprim (Bactrim, Septra) 10. Tetracyclines: doxycycline, minocycline
Bacterial Meningitis: Clinical Cues: Other household cases (spread by direct contact), preceded by otitis/sinusitis, did not receive vaccination. Causative Agent:
Haemophilus influenzae
What is a common pathogen that causes meningitis in patients 1 month-23 months old?
Haemophilus influenzae
What are the hallmark lab findings associated with Infective Endocarditis (IE) w/ vegetation(s)?
Hallmark: Persistent bacteremia from vegetation into the bloodstream
Urinary Tract Infection (UTI): Lab Testing: Urinalysis (UA): _____________ may indicate rhabdomyolysis; check CK, if applicable.
Hematuria
Haemophilus influenzae: Vaccine:
Hib
Mr. Lewis is a 70 year-old male admitted to the hospital for chest pain. He underwent cardiac catheterization and stenting of the LAD. He has been monitored in the coronary care unit (CCU) for the last 4 days. He is not on the ventilator. On hospital day 5, his labs demonstrate a WBC of 18,000 which is up from 12,000. He also complains of increasing cough and sputum production. The team is concerned about pneumonia. His chest CT comes back demonstrating a left lower lobe infiltrate. How do you classify Mr. Lewis's pneumonia?
Hospital-Acquired Pneumonia (HAP) Explanation: Mr. Lewis has HAP- hospital acquired pneumonia- because he developed the pneumonia >48 hours after hospitalization without any evidence of pneumonia on admission. He does not have VAP because he is not on the ventilator. He does not have HCAP because the pneumonia developed in the hospital and this classification is no longer included in the guidelines. He does not have CAP because he did not come into the hospital with symptoms of pneumonia. He does not have aspiration pneumonia because there is not any description of an aspiration event and imaging report doesn't say anything about aspiration
Infective Endocarditis (IE): What is optimal therapy for patients who are allergic or intolerant to beta-lactams?
If non-anaphylactoid reaction: cefazolin is reasonable Other options: • Vancomycin - associated with poorer outcomes for MSSA infections (if considered allergy evaluation should be done) • Daptomycin is reasonable alternative for both right and left sided endocarditis (only FDA approved for R sided)
A 50 year-old female patient presents to the ED and is admitted with signs of sepsis and concern for pyelonephritis. The patient has a history of UTIs caused by ESBL E. coli. What is the best empiric therapy for this patient?
Imipenem-cilastatin (Primaxin) Explanation: Since the patient has a history of ESBL producing E. coli, then a carbapenem would be the empiric drug of choice given that she is septic and being admitted to the hospital.
Papilledema
Increased swelling in the optic disc due to an increase in intracranial pressure.
IESA Review:
Indication: Site of Infection Severity of Illness Effectiveness: PK/PD Bacteriostatic or Bactericidal Clinical Evidence Safety: Allergies Adverse Effects Organ Dysfunction Dose Assessment Drug-Drug Interactions Adherence: Dosage Form Dosing Interval Duration Cost
Bacterial Meningitis: Clinical Cues: Extremes of age, immunocompromised (HIV, malignancy, transplant, diabetes, alcoholism) Causative Agent:
Listeria monocytogenes
__________________ is a GI tract colonization occuring from unpasteurized food sources.
Listeria monocytogenes
__________________ is the cause of 10% of meningitis cases in those older than 65.
Listeria monocytogenes
__________________ primarily causes disease in neonates, alcoholics, immunocompromised adults, and the elderly (age > 50 years).
Listeria monocytogenes
TN is a 72 year old female who has been diagnosed with viridans group streptococcus endocarditis. PMH: HTN, DM. No known surgical procedures. No known drug allergies. The viridans group streptococcus culture and susceptibility report from the microbiology lab reports the penicillin MIC = 0.42 mcg/mL. Allergies: PCN (anaphylaxis) What is the MOST appropriate treatment regimen for this patient?
MIC reports an Intermediate Penicillin-Susceptibility. Therefore, the most appropriate treatment in this scenario would be: vancomycin 15 mg/Kg/dose IV x 4 weeks (allegedly)
CA-Native Valve Endocarditis: Viridans Group Streptococci (VGS): Intermediate Penicillin-Susceptibility: MIC: __________________ Treatments: (3)
MIC: 0.12-0.5 mcg/mL; Treatments: • *Penicillin G + Gentamicin • **Ceftriaxone +/- Gentamicin • ***Vancomycin Explantions: *Penicillin-G x 4 weeks + gentamicin x the first 2 weeks **If the strain is ceftriaxone-susceptible, can give ceftriaxone as monotherapy; otherwise give with gentamicin. ***Vancomycin recommended only for patients that can NOT tolerate penicillin, ceftriaxone, or ampicillin therapy. Therefore, if vancomycin is warranted, do not have to give gentamicin per guideline. -Sen
CA-Native Valve Endocarditis: Viridans Group Streptococci (VGS): Penicillin-Resistant: MIC: ________________ Treatments: (4)
MIC: > 0.5 mcg/mL Treatments: (a/b/c PLUS gentamicin) a. Ampicillin 12 g IV over 24H x 4-6 weeks (or) b. Penicillin-G 18-30 million units IV over 24H x 4-6 weeks (or) c. Ceftriaxone 2 g IV every 24H x 4-6 weeks a/b/c PLUS gentamicin 3 mg/Kg every 24H x 4-6 weeks Alternative: *Vancomycin 15 mg/Kg IV every 24H x 4-6 weeks Explanation: *Vancomycin recommended only for patients unable to tolerate penicillin-G, ceftriaxone, or ampicillin therapy
Community-Acquired Pneumonia (CAP): Pathophysiology: MOST Common Cause: Less Common Causes:
MOST Common = Inhalation Less Common = Aspiration & Bloodstream
Antibiotic Pharmacodynamics: AUC:MIC (7)
Macrolides Tetracyclines Clindamycin Fosfomycin Vancomycin Linezolid Sulfamethoxazole-trimethoprim
nitrofurantoin (Macrobid): MOA:
Metabolized by susceptible organisms to reactive intermediates that damage DNA, RNA, and proteins
Test Question: ________________ is NEVER used as empiric treatment in UTIs.
Moxifloxacin
What agent can be used as monotherapy to treat inpatient CAP?
Moxifloxacin
What agent is highly lipophilic, covers E. coli, but should not be used to treat urinary tract infections due to poor concentration in the urine?
Moxifloxacin
HACEK Group: Bacteria Names: Description: Possible causes of... (2)
Names: Picture Description: Slow-Growing Gram Negative (-) Coccobaccili (Fastidious) Possible causes of: 1. CA Native-Valve Endocarditis 2. Culture-Negative Endocarditis
Bacterial Meningitis: Clinical Cues: Petechial rash (i.e. redish-purple spots), other possible household cases spread by droplets Causative Agent:
Neisseria meningitidis
________________ is the leading cause of bacterial meningitis among children and young adults in the world.
Neisseria meningitidis
_________________ has a unique immune reaction that occurs 10-14 days after the onset of disease; presenting as fever, arthritis, and pericarditis.
Neisseria meningitidis
Hospital-Acquired Pneumonia (HAP):
New lung infiltrate > 48 hours after hospital admission and was NOT present on admission and patient is NOT mechanically ventilated
Ventilator-Associated Pneumonia (VAP):
New lung infiltrate ≥ 48 hours after endotracheal intubation.
Bacterial Meningitis: Neisseria meningitidis: Treatment Monitoring:
No ceftriaxone in neonates: biliary sludging and calcium precipitation (fatal)
A 50 year-old female patient presents to her primary care physician's office complaining of difficulty breathing, cough, chills, and feeling "awful." The physician hears egophony and decreased breath sounds and notes that the patient is breathing 20 times per minute with a heart rate is 80 bpm and a BP of 122/86 mmHg. Her oxygen saturation is 95% on room air. She has no significant co-morbidities. Allergies: NKDA. The physician decides to treat her as an outpatient. The physician asks if ciprofloxacin is a reasonable choice since it is very inexpensive? How do you respond?
No, ciprofloxacin does NOT cover Streptococcus pneumoniae. Explanation: Ciprofloxacin penetrates the lung and covers atypicals but does NOT have adequate S. pneumoniae coverage.
Which doxycycline brand is taken on an empty stomach?
Oracea
Bacterial Meningitis: Initial Management Approach:
Order a blood culture!
Mr. Lewis is a 70 year-old male admitted to the hospital for chest pain. He underwent cardiac catheterization and stenting of the LAD. He has been monitored in the coronary care unit (CCU) for the last 4 days. He is not on the ventilator. On hospital day 5, his labs demonstrate a WBC of 18,000 which is up from 12,000. He also complains of increasing cough and sputum production. The team is concerned about pneumonia. What should they do next?
Order a chest x-ray Explanation: To confirm any case of pneumonia, imaging of the chest is required by Chest XRay or chest CT. In this case, in order to know if it is a nosocomial pneumonia with the patient's symptoms and new increase in WBC, imaging should be obtained before empiric antimicrobials start since this patient is not unstable.
Infective Endocarditis (IE): Pathogenesis: Hematogeneous Spread: (List order of events): (6)
Pathophysiology of IE via hematogenous spread: 1. Endothelial surface of the heart is damaged 2. Platelet and fibrin deposition causes non-bacterial thrombotic endocarditis 3. Bacteremia due to trauma results in colonization of endocardial surface 4. A vegetation forms to protect bacteria from antibiotics and host defenses 5. Destruction of valvular tissue leads to acute heart failure 6. Complications include chronic heart failure, abscess, emboli, infarcts, etc.
β-Lactam Antibiotics: (4)
Penicillins Cephalosporins Carbapenems Monobactams
Urinary Tract Infection (UTI): Lab Testing: Urinalysis (UA): What is known as a surrogate marker for WBC count in the urine, and therefore indicates the presence of inflammation?
Positive Leukocyte Esterase (LE)
Urinary Tract Infection (UTI): Lab Testing: Urinalysis (UA): What is the MOST sensitive lab finding that indicates the patient has a UTI?
Positive Leukocyte Esterase (LE)
Urinary Tract Infection (UTI): Inpatient Complicated Pyelonephritis: Preferred Treatment: Other Options: If Concerned about Pseudomonas: If Concerned about ESBL:
Preferred: 1. ceftriaxone (Rocephin): 3rd-Gen Other options: 2. ciprofloxacin (Cipro) 3. levofloxacin (Levaquin) If concerned about Pseudomonas: 4. ceftazidime (Fortaz): 3rd-Gen 5. cefepime (Maxipime): 4th-Gen 6. piperacillin-tazobactam (Zosyn) If concerned about ESBL: 7. Carbapenems
ceftriaxone (Rocephin) and ceftaroline (Teflaro) lack _________________ coverage.
Pseudomonal
Moxifloxacin does NOT cover...
Pseudomonas
Urinary Tract Infection (UTI): Cystitis vs. Pyelonephritis: May cause sepsis and bacteremia:
Pyelonephritis
Urinary Tract Infection (UTI): Cystitis vs. Pyelonephritis: May have systemic signs & symptoms of illness; (e.g. fever, ↑ WBC):
Pyelonephritis
Urinary Tract Infection (UTI): Cystitis vs. Pyelonephritis: Upper UTI or "kidney infection":
Pyelonephritis
Urinary Tract Infection (UTI): Lab Testing: Urine Microscopy is a(n) ________________ method that indicates the liklihood of infection if...
Quantitative; WBCs > 5-10 cells
Bacterial Meningitis: Streptococcus pneumoniae: Treatment Monitoring: (4)
Quinolones: 1. Tendon inflammation/rupture (Achilles) 2. Avoid use in children 3. QTc interval prolongation 4. Drug interactions (antacids)
Bacterial Meningitis: Adjunctive Therapies: Dexamethasone: Rationale & Clinical Data:
Rationale: Dexamethasone reduces Streptococcus pneumoniae-related morbidity and mortality by reducing sub-arachnoid inflammation and pressure. Clinical Data: Picture
Infective Endocarditis (IE): Enterococcus sp: Native or Prosthetic Valve Treatments: Double β-lactam Regimen: Indications: (2)
Regimen: ampicillin 12 g IV over 24H x 6W + ceftriaxone 2 g IV q 12H x 6W; Indication: (when AGs are NOT applicable due to): 1. CrCl < 50 mL/min and/or 2. AG resistant strains are present.
Urinary Tract Infection (UTI): Lab Testing: Urinalysis (UA): Specific Gravity =
Relative hydration status (Higher than normal = dehydration; Lower than normal = diluted e.g. Nephrodinic diabetes insipidus)
Nosocomial-Acquired Pneumonia: Tissue Penetration & PK: Epithelial-lining Fluid Penetration: (5)
Reminder: Do NOT use Daptomycin for pneumonia bc efficacy is reduced by lung surfactants.
_________________ and _________________ are serious ADEs associated with fluoroquinolones.
Seizures; Achilles tendon rupture
Which agents are indicated for MSSA? (13)
Semi-Synthetic Penicillinase-Resistant Penicillins: 1. cloxacillin 2. dicloxacillin 3. methicillin 4. nafcillin 5. oxacillin Antipseudomonal Penicillins: 6. piperacillin 7. ticarcillin Carbapenems: 8. doripenem (0.06) 9. meropenem (0.12) 10. imipenem (< 0.5) 1st-Gen Cephalosporin: 11. cefazolin (Ancef) 4th-Gen Cephalosporin: 12. cefepime (Maxipime) 2nd-Gen Lipoglycopeptide: 13. dalbavancin (Dalvance)
___________________ is the most common cause of IE in much of the developed world.
Staphylococcus aureus
What is the treatment for MOST patients with Acute Bronchitis?
Steroids: Prednisone 40 mg PO daily x 5 days.
Bacterial Meningitis: Clinical Cues: Neonatal disease, diabetes, age > 60 years old, pregnancy or postpartum Causative Agent:
Streptococcus agalactiae (Group B Strep)
Bacterial Meningitis: Clinical Cue: Preceded by upper respiratory tract infection, otitis, sinusitis, or head trauma Causative Agent:
Streptococcus pneumoniae
What is the MOST common "typical" organism that causes Community-Acquired Pneumonia (CAP)?
Streptococcus pneumoniae
__________________ is the leading cause of meningitis in patients > 2 months in the United States.
Streptococcus pneumoniae
Ciprofloxacin is NOT used for CAP because of inadequate coverage of _____________________.
Streptococcus pneumoniae.
Acute vs Subacute Endocarditis: Caused by less invasive organisms like Viridans streptococci:
Subacute Endocarditis
Acute vs Subacute Endocarditis: Indolent (i.e. "Lazy"):
Subacute Endocarditis
Acute vs Subacute Endocarditis: Usually occurs in pre-existing valvular heart disease:
Subacute Endocarditis
Bacterial Meningitis: CSF Antibiotic Treatment: Which agents penetrate the CSF "well"? (9)
T > MIC Agents: (Beta-Lactams) 1. Penicillin G 2. Ampicillin 3. Nafcillin 4. Meropenem (Merrem) Cmax:MIC Agents: 5. Fluoroquinolones 6. Daptomycin (Cubicin) AUC:MIC Agents: 7. Sulfamethoxazole-trimethoprim (Bactrim) 8. Linezolid (Zyvox) 9. Vancomycin (Vancocin)
SIRS Criteria:
Temp: > 38C or < 36C HR: > 90 beats/min WBC: > 12,000 or < 4,000 RR: > 20 breaths/min
_______________ and _______________ will chelate bivalent/trivalent cations.
Tetracyclines; fluoroquinolones
Community-Acquired Pneumonia (CAP): Outpatient Treatment with Comorbidities: Why would a macrolide be added to a beta-lactam?
The macrolide is added to cover atypicals.
A patient is started on Vancomycin, Zosyn, and Tobramycin for coverage of HAP. What would be a description as to why this regimen was chosen?
The patient must be in an institution where the local MRSA rate is >20% and be at "high risk for mortality" to need a three drug combination regimen.
Bacterial Meningitis: Initial Management Approach: What would initiate the retrieval of ONLY "blood cultures" if a patient was suspected to have bacterial meningitis? (6)
The patient presents as/with: 1. Immunocompromised 2. PMH: CNS Disease 3. New Onset Seizures 4. Papilledema (optic disc swelling) 5. Altered consciousness 6. Focal neurologic deficits
A 23 year-old female presents to urgent care with dysuria and increased frequency of urination, fever, flank pain, and vomiting. She has positive CVA tenderness and a UA that has positive nitrites and positive leukocyte esterase. She is clinically stable for outpatient treatment. What does positive leukocyte esterase mean?
There is evidence of WBC in the urine Explanation: Leukocyte esterase is a surrogate marker for the presence of WBC in the urine on the dipstick. This is the most sensitive test on the UA for diagnosing a UTI but is not necessarily always specific to a UTI.
Urinary Tract Infection (UTI): Inpatient Treatment: Acute Complicated CYSTITIS in Men & Women: Catheter-Related UTI (CAUTI): Treat only ______________ patients. Treatment selection is based on... Treatment Duration:
Treat only SYMPTOMATIC patients; Treatment selection is based on risk factors for resistant Gram Negative (-) pathogens and severity of infection; Treatment Duration: 7 days for prompt resolution; otherwise 10-14 days for delayed response.
Urinary Tract Infection (UTI): Inpatient Complicated Pyelonephritis: Treatment Criteria: Requires ____________ and ____________ to assess ____________.
Treatment Criteria: Must have at least 2/4 SIRS criteria or ≥ 2 qSOFA score; hospitalization; blood cultures; bacteremia.
Infective Endocarditis (IE): Viridans Group Streptococci (VGS): Prosthetic Valve: Treatments: (3)
Treatment Options: 1. Penicillin-G +/- *Gentamicin 2. Ceftriaxone +/- *Gentamicin 3. **Vancomycin Explanations: *If MIC ≤ 0.12 mcg/mL, Gentamicin may or may not be given for the first 2 weeks of therapy. *If MIC is > 0.12 mcg/mL, Gentamicin should be given for entire 6 weeks of therapy. *If CrCl is < 30 mL/min, Gentamicin is NOT recommended. **Vancomycin is only recommended if penicillin-G or ceftriaxone is NOT tolerated.
Community-Acquired Pneumonia (CAP): Outpatient Treatment WITHOUT Comorbidities: (3)
Treatment Options: 1. amoxicillin 1000 mg PO q 8H 2. doxycycline 100 mg PO q 12H 3. *azithromycin (Z-Pak) 500 mg PO on Day 1, then 250 mg PO daily x 4D *Explanation: "When in doubt, amoxicillin or doxycycline is probably a better choice than azithromycin (Z-Pak), unless you know for absolute certainty that Streptococcus pneumoniae resistance to macrolides is < 25%. Azithromycin tends to be used more in acute bronchitis rather than pneumonia. Also, don't forget about allergies" -Metzger
Community-Acquired Pneumonia (CAP): Inpatient Treatment for NON-Severe CAP: (3)
Treatment Options: 1. ceftriaxone 1-2 g IV daily + azithromycin 500 mg PO/IV daily 2. levofloxacin 750 mg IV/PO daily 3. moxifloxacin 400 mg IV/PO daily Supplemental Question: What about Ciprofloxacin? "Cipro does penetrate the lung but does NOT cover Streptococcus pneumoniae well." -Metzger
Community-Acquired Pneumonia (CAP): Monitoring: Duration of Therapy:
Treatment duration is initially 5 days for CAP if the patient is improving. If not improving, treatment may extend to 7-10 days.
Acute Bronchitis (AB): Antibiotic Treatment: (2) Indicated Populations: (3)
Treatment: 1. doxycycline 100 mg po BID 2. azithromycin: Z-Pak dosage Indicated Populations: 1. Otherwise healthy patients with a fever and respiratory symptoms lasting > 4 days. 2. Elderly (≥ 65 years) 3. Immunosuppressed patients Reminder: AB is sometimes caused by Mycoplasma and Streptococcus pneumoniae
Community-Acquired Pneumonia (CAP): Severe Inpatient CAP: Treatments: (2) Goal:
Treatments: 1. Ceftriaxone 1-2 g IV QD + Azithromycin 500 mg IV/PO QD 2. Ceftriaxone 1-2 g IV QD + Levofloxacin 750 mg IV/PO QD Goal: Maximize coverage of Streptococcus pneumoniae
(T/F?) It is important to start with intravenous antibiotics and then transition to oral antibiotics in acute infections that has high morbidity and mortality rates.
True
(T/F?) Pharmacists should recommend annual influenza vaccinations to decrease risk of CAP.
True Explanation: Annual influenza vaccination and pneumococcal vaccinations should be recommended and given to eligible patients to reduce the risk of CAP.
(T/F?) ALL fluoroquinolones penetrate the lungs well.
True" -Metzger Explanation: (ECHO360: (Feb 9th, 2021: 44:49)
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: Healthy women:
Uncomplicated
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: No instrumentation or catheters are present/needed:
Uncomplicated
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: No structural abnormalities:
Uncomplicated
Urinary Tract Infection (UTI): Uncomplicated vs. Complicated: Not pregnant:
Uncomplicated
What is the MOST commonly occuring bacterial infection?
Urinary Tract Infection (UTI)
Antimicrobial Stewardship: Should hospitals carry levofloxacin, moxifloxacin, and ciprofloxacin on formulary?
Usually not all 3. "Ciprofloxacin (Cipro) does NOT cover Streptococcus pneumoniae well." -Metzger
When designing empiric treatment for Bacterial Meningitis, what drug regimen will be used to cover Streptococcus pneumonia?
Vancomycin + (ceftriaxone or cefotaxime) Reminder: ceftriaxone is NOT used in neonates.
Infective Endocarditis (IE): Staphylococcus sp: Prosthetic Valve: Oxacillin-Resistant Treatment:
Vancomycin + Rifampin + Gentamicin
Is doxycycline taken with or without food?
WITH food and a large glass of water, unless it's the brand oracea because that formulation has to be taken on an empty stomach.
Contamination vs Bacteremia:
When only 1 blood culture of all blood cultures (usually 2-4 vials) have S. aureus, it is more than likely a contamination; same goes for susceptibilities. True bacteremia will have multiple vials with organism(s) and signs/symptoms associated with infection.
cefuroxime (__________): Drug Class: Drug Interactions: (2)
Zinacef; 2nd-Generation Cephalosporin; 1. H2RAs 2. PPIs
Urinary Tract Infection (UTI): Lab Testing: Urinalysis (UA): Proteus organisms lead to...
a more BASIC pH.
What adverse effects are concerning for moxifloxacin? (SATA) a. Achilles tendon rupture b. QTc prolongation c. Erosive esophagitis d. Seizures e. Chelation with calcium f. Cholestatic jaundice g. Hyperkalemia h. Photosensitivity
a. Achilles tendon rupture b. QTc prolongation d. Seizures h. Photosensitivity (Not chelation with calcium?)
MN is a 66 year old male presents with suspected bacterial meningitis. PMH: HTN, OA, BPH, HL. A lumbar puncture is performed prior to administration of antibiotics and the CSF results are available. The Gram stain from the CSF shows Gram Positive (+) rods/bacilli. Allergies: amoxicillin (nausea as a child). a. What is the MOST appropriate empiric treatment regimen for this patient? After administration of the empiric antibiotics, MN had shortness of breath, hives, swelling of the lips within the hour of administration. b. In addition to supportive therapy for his anaphylactic reaction, what is the MOST appropriate empiric treatment regimen at this time for the treatment of bacterial meningitis? MN did not receive routine pneumococcal vaccines during his routine vaccine series as a child. c. What is the correct pneumococcal vaccine sequence and interval appropriate for MN?
a. Ampicillin 2 g IV every 4H; b. Bactrim 5 mg/Kg IV every 6H; c. Administer Prevnar13 IM x 1 dose now. Then, 6 months-1 year later, give an IM dose of Pneumovax23.
Diagnosis: Prosthetic Valve IE Blood Culture: Enterococcus faecalis Penicillin: R Ampicillin: S Ceftriaxone: S Gentamicin: S Daptomycin: S Vancomycin: S a. What would you recommend for definitive therapy (including drug, route, dose, duration)? b. What monitoring parameters would you evaluate?
a. Ampicillin 2 g IV q 4H x 6W + Gentamicin 1 mg/kg daily x 6W: most narrow, evidence based regimen; could also consider double beta lactam regimen with ampicillin and ceftriaxone x 6 weeks - need to calculate CrCl and see if CrCl < 50 (consider that there is a great possibility of low CrCl given patient is 75 and co-morbidities but need more info) b. Monitor: • clearance of blood cultures • clinical improvement in symptoms • adverse effects of antibiotics nephrotoxicity, GI intolerance, rash, drug fever, leukopenia, thrombocytopenia, interstitial nephritis (TDM of gent, goal peak 3-4 mg/L and trough < 1 mg/L)
Mr. Lewis is a 70 year-old male admitted to the hospital for chest pain. He underwent cardiac catheterization and stenting of the LAD. He has been monitored in the coronary care unit (CCU) for the last 4 days. He is not on the ventilator. On hospital day 5, his labs demonstrate a WBC of 18,000 which is up from 12,000. He also complains of increasing cough and sputum production. The team is concerned about pneumonia. His chest CT demonstrates a left lower lobe infiltrate. He has NKDA. Mr. Lewis had a course of cephalexin two months ago for a cellulitis of his left leg. The antibiogram demonstrates a local rate of MRSA as 30%. The team says he is not at high risk for mortality. What coverage does Mr. Lewis need? (SATA) a. Coverage for MRSA b. Coverage for Pseudomonas c. Double Coverage for Pseudomonas d. Coverage for Anaerobes e. Coverage for Tuberculosis
a. Coverage for MRSA b. Coverage for Pseudomonas -- -- -- Explanation: Mr. Lewis has HAP. Double coverage for Pseudomonas in HAP is determined by having 1) IV antibiotics in the past 90 days or 2) being at high risk for mortality with septic shock or mechanical ventilation. Mr. Lewis had a course of cephalexin in the past 60 days but cephalexin is not IV, therefore he would only need monotherapy for Pseudomonas. To determine if Mr. Lewis needs empiric MRSA coverage, you would need to know 1) if he had had IV antibiotics in the past 90 days or 2) the local rate of MRSA. Since in this case the local MRSA rate is greater than 20%, Mr. Lewis needs MRSA coverage. Since there is not mention of abscess or aspiration, Mr. Lewis does not have to have anaerobic coverage. Mr. Lewis doesn't have risk factors for TB.
A 50 year-old female patient presents to her primary care physician's office complaining of difficulty breathing, cough, chills, and feeling "awful." The physician hears egophony and decreased breath sounds and notes that the patient is breathing 20 times per minute with a heart rate is 80 bpm and a BP of 122/86 mmHg. Her oxygen saturation is 95% on room air. The physician decides to treat her as an outpatient. She has no significant co-morbidities. Allergies: NKDA. What signs and symptoms does this patient have of CAP? (SATA) a. Difficulty breathing b. Egophony c. Heart rate of 80 bpm d. Cough e. Blood pressure of 122/86 mmHg
a. Difficulty breathing b. Egophony -- d. Cough -- Explanation: Difficulty breathing and cough are symptoms associated with pneumonia and egophony is a physical exam finding associated with pneumonia. The patient's HR is not >90 bpm and her BP is within the normal range.
A 23 year-old female presents to urgent care with dysuria and increased frequency of urination, fever, flank pain, and vomiting. She has positive CVA tenderness and a UA that has positive nitrites and positive leukocyte esterase. She is clinically stable for outpatient treatment. What symptoms are seen with pyelonephritis but NOT with cystitis? (SATA) a. Flank pain b. Dysuria c. Increased frequency of urination d. Fever
a. Flank pain -- -- d. Fever Explanation: All patients with urinary tract infections can experience dysuria, increased frequency, increased urgency, and suprapubic fullness. Patients with pyelonephritis also have systemic symptoms like fever, flank pain, nausea/vomiting, malaise. These symptoms should not be present for cystitis
Mr. M is a 62 y/o male who presents to the ED with complaints of fever, chills, nausea, vomiting, a headache, and a stiff neck for the past 24 hours. He also states he had nasal congestion and a cough for the past week but otherwise has been healthy. PMH: Hypertension, Alcohol abuse PE: Temp: 101.7°F, Pain on flexion of neck, questionable papilledema (i.e. swollen optic nerve) a. What is your initial management approach for this patient? b. What risk factors does this patient have for bacterial meningitis? c. What signs and symptoms are consistent with acute bacterial meningitis? d. Identify the organism(s) that is/are likely causes/ing (of) this patient's illness. e. What laboratory tests or procedures is necessary to diagnose meningitis? f. What would you expect the CSF chemistry to look like in this patient? g. What are the goals of treatment for this patient? Due to concerns about the presence of a central nervous system mass, TL is sent to have a CT scan prior to obtaining an LP. h. When should blood cultures be obtained? i. Should antibiotic therapy be administered now, why or why not? The CT shows no evidence of a mass lesion and an LP is performed. CSF analysis results: WBC 98 RBC 1100 Protein 359 Glucose 26 j. What is your assessment of the patient's CSF? k. What factors should be considered when designing an empiric regimen? l. What empiric antibiotics should be recommended for this patient? (Medications should include a dose, route, and frequency) The Gram stain reveals Gram Positive (+) cocci in pairs. m. What organism is likely the cause of Mr. M's illness? n. As a result of this information, describe changes you would make to the patient's antibiotic regimen. The microbiology lab now reports that S. pneumoniae is growing from the CSF with the following susceptibility report: Streptococcus pneumoniae: Penicillin: R Ceftriaxone: S Vancomycin: S Linezolid: S o. What would you recommend for definitive therapy (drug, dose, route, frequency)? p. What is the duration of antimicrobial therapy for this patient? q. What adjunctive therapies should be given to this patient? The patient is worried about an outbreak of meningitis. r. What strategies are recommended for meningitis prophylaxis?
a. Initial approach based on clinical presentation: Obtain blood cultures, initiate dexamethasone + empiric antibiotics, and perform a head CT +/- LP b. Risk Factors: Alcoholism, potential respiratory tract infection c. S/Sx: Fever, pain on flexion of neck (i.e. stiff neck), questionable papilledema, N/V, headache, chills d. Causative organism(s): Streptococcus pneumoniae, Streptococcus agalactiae (Group B Strep), Listeria monocytogenes, and Neisseria meningitidis (Gram negative enterics is more related to HA-Meningitis; so not considered here) e. Lab Tests & Procedures: Blood culture, Head CT scan, LP, PCR, CSF lactate analysis, Procalcitonin f. Chemistry Expectations: "Bacterial Meningitis is characterized by a CSF Analysis showing a high neutrophil count, high protein, and low glucose." -Sen g. Goals of Therapy: Stabilize cardiopulmonary status, eradication of infection, amelioration of signs and symptoms, prevent morbidity and mortality, initiate appropriate antimicrobials, provide supportive care, prevent disease through vaccination and chemoprophylaxis h. Obtain blood culture immediately upon presentation. i. Empiric antibiotics should be started immediately as well to prevent morbidity and mortality. j. CSF: high protein, high neutrophils, low glucose; PMNs; meets criteria for bacterial meningitis k. Empiric Principals: IV, bactericidal, high-dose, un-ionized, low MW, lipophilic, and coverage of probable pathogens. l. Recommended Empiric Regimen: ceftriaxone 2 g IV every 12H + ampicillin 2 g IV every 4H + vancomycin 1 g every 12H m. Likely Organism: Streptococcus pneumoniae n. Changes: Discontinue ampicillin because Listeria is not present; continue vancomycin and ceftriaxone due to being unaware of susceptibility report. o. Post-Susceptibility Report Recommendation: ceftriaxone 2 g IV every 12H p. Duration: 10-14 days q. Dexamethasone 0.15 mg/Kg IV every 6H x 2-4 days (Initial dose; not maintenance): (First dose administered 10-20 minutes before the first dose of antibiotic, can be discontinued if Gram-stain is negative for S. pneumoniae) r. Vaccinations and chemoprophylaxis: Prevnar13 now followed by Pneumovax23 in 6 months due to being 19-64 years old and having a history of alcohol abuse
GL is a 53 year-old male who presents to the ED with complaints of fever, nausea, and vomiting x 1 week. PMH: rheumatic heart disease, HTN, gout, diabetes. SH: history of heroin and cocaine x 10 years. Surgical History: mitral valve replacement with mechanical heart valve X 1 year ago. No known drug allergies. TTE reveals 5-cm vegetation on the tricuspid valve with severe tricuspid regurgitation. Blood cultures: 3 out of 3 sets reveal S. aureus. Susceptibilities are pending. a. Is this patient eligible for 2 weeks course of therapy for right-sided endocarditis, why? b. What is the MOST appropriate empiric treatment regimen for this patient? c. What safety monitoring parameters would be appropriate to monitor for this patient? (4)
a. No, patient has a mechanical mitral valve replacement; b. vancomycin 15 mg/kg/dose IV daily + gentamicin 3 mg/kg IV daily + rifampin 300 mg PO every 8H; c. SCr, Skin ∆s, Urine color, & LFTs
WOTF represents an adverse effect of Fluoroquinolones? (SATA) a. Peripheral Neuropathy b. Tendinopathy c. Photosensitivity d. Hypotension e. QT Prolongation
a. Peripheral Neuropathy b. Tendinopathy c. Photosensitivity -- e. QT Prolongation
Mr. B is a 74 year old man who presents with one week history of fevers, chills, and increasing shortness of breath. He denies any recent dental procedures; received a colonoscopy 5 months prior. PMH: Mitral valve placement 8 months prior (prosthetic valve), Hypertension, Diabetes, GERD Home medications: Lisinopril, warfarin, omeprazole, metformin Vitals: T 101.1°F, HR 80 beats/min, RR 16, breaths/min BP 107/64 mm Hg, oxygen saturation 96% on room air Physical Exam: HEENT: left subconjunctival hemorrhage, normal dentition CV: systolic murmur Abdomen: normal Skin/extremities: normal a. What are Mr. B's risk factors for endocarditis? TTE and TEE are obtained. Mechanical valve shows evidence of dehiscence, mass visualized on mitral valve. b. Does Mr. B have "definite" endocarditis according to the Modified Duke Criteria? After obtaining blood cultures, Mr. B is started on vancomycin, gentamicin, and rifampin. c. Do you agree with the initial antibiotic regimen? d. What are the goals of treatment for this patient?
a. Risk factors: prosthetic valve ("biggest" risk factor), diabetes, may be health-care related exposure b. Yes, definite endocarditis: 2 major criteria - positive blood cultures and positive TEE (mass visualized) c. Ampicillin or PCN G plus Gent are reasonable (but we don't know allergy status - need to find out); Vancomycin is reasonable (because we do not know what organism it is yet) + gentamicin is fine while covering empirically - but NEED to verify allergy status; do not need rifampin since not Staph. Also, interaction between rifampin and warfarin. "mitral valve placement" → prosthetic valve: Need empiric coverage → prosthetic valve strep or enterococcus d. Primary goal = eradicate infection, including sterilizing vegetations. Within vegetation: high bacterial density, slow rate of growth within biofilms, low microorganism metabolic activity. Due to challenges, need prolonged, parenteral, bactericidal antibiotic therapy to cure infection Inoculum Effect: Effect of high bacterial densities on antibiotic activity. Some antibiotics are less active against highly dense bacterial populations. Stationary growth phase conditions make it less likely the cell wall active antibiotics are optimally effective. Right sided vegetations tend to have lower bacterial densities - possible to get away with shorter course of abx.
What are the safety parameters you will monitor for in a patient receiving penicillin to treat their infective endocarditis? (SATA) a. Skin changes b. N/V/D c. Creatinine d. Hyperkalemia e. Orange discoloration in urine
a. Skin changes b. N/V/D c. Creatinine -- --
In a patient with a history of infective endocarditis, what may be an appropriate antiobiotic regimen that may be given prior to a dental surgery?
amoxicillin 2 g PO x 1 dose given 30 minutes prior to procedure.
Urinary Tract Infection (UTI): Outpatient Treatment: Antimicrobial Stewardship: Empiric _____________ and _____________ should be avoided due to HIGH resistance.
amoxicillin; amoxicillin-clavulanate
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events: GI; Diluted with NS only:
ampicillin-sulbactam (Unasyn)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotic may cause QTc prolongation, GI upset, diarrhea?
azithromycin (Zithromax, Z-Pak, Tri-Pak) Explanation: Macrolides and Fluoroquinolones are associated with QT prolongation.
Mr. Lewis is a 70 year-old male admitted to the hospital for chest pain. He underwent cardiac catheterization and stenting of the LAD. He has been monitored in the coronary care unit (CCU) for the last 4 days. He is not on the ventilator. On hospital day 5, his labs demonstrate a WBC of 18,000 which is up from 12,000. He also complains of increasing cough and sputum production. The team is concerned about pneumonia. His chest CT demonstrates a left lower lobe infiltrate. What questions do you need to find out the answers to before you can recommend an empiric regimen? (SATA) a. What is the rate of Pseudomonas resistance? b. What is the local rate of MRSA? c. Has the patient had IV antibiotics in the past 90 days? d. Is the patient at high risk for mortality? e. Does the patient have ARDS?
b. What is the local rate of MRSA? c. Has the patient had IV antibiotics in the past 90 days? d. Is the patient at high risk for mortality? Explanation: Mr. Lewis has HAP. You need to know if double coverage for Pseudmonas is necessary and if MRSA coverage is necessary. Double coverage for Pseudomonas in HAP is determined by having 1) IV antibiotics in the past 90 days or 2) being at "high risk for mortality" with septic shock or mechanical ventilation. The rate of Pseudomonas resistance to monotherapy and ADRS are for VAP. To determine if Mr. Lewis needs empiric MRSA coverage, you would need to know 1) if he has had IV antibiotics in the past 90 days or 2) the local rate of MRSA.
Acute Bronchitis (AB) involves ____________ and ____________ but NOT ____________.
bronchi; bronchioles; alveoli
A 32 year old female presents to her OB/GYN complaining of burning on urination, increased frequency of urination, and increased urgency of urination. Her gynecologist diagnoses her with uncomplicated cystitis. The patient is uninsured and has no allergies. Local resistance of E.coli to sulfamethoxazole-trimethoprim is 17%. What do you recommend for this patient? a. Fosfomycin 3 g po once b. Nitrofurantoin 100 mg po BID c. Bactrim DS 1 tab PO BID d. Ciprofloxacin 500 mg po BID e. Amoxicillin 500 mg po BID
c. Bactrim DS 1 tab PO BID Explanation: Since the patient has uncomplicated cystitis, first line choices are nitrofurantoin or Bactrim. Since this patient does not have insurance, Bactrim would be a better choice since it is cheaper. The local resistance is <20% so Bactrim is still a viable option. Fosfomycin is cost prohibitive. Fluoroquinolones should be conserved to minimize collateral damage and dose is too high for cystitis. Amoxicillin should not be used empirically due to high rates of E.coli resistance.
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: CNS side effects, seizures with renal accumulation:
cefepime (Maxipime)
Mr. Lewis is a 70 year-old male admitted to the hospital for chest pain. He underwent cardiac catheterization and stenting of the LAD. He has been monitored in the coronary care unit (CCU) for the last 4 days. He is not on the ventilator. On hospital day 5, his labs demonstrate a WBC of 18,000 which is up from 12,000. He also complains of increasing cough and sputum production. The team is concerned about pneumonia. His chest CT demonstrates a left lower lobe infiltrate. He has NKDA. Mr. Lewis had a course of cephalexin two months ago for a cellulitis of his left leg. The antibiogram demonstrates a local rate of MRSA as 30%. The team says he is not at high risk for mortality. What EMPIRIC regimen would be appropriate for him?
cefepime (Maxipime) + linezolid (Zyvox) Explanation: We determined in the previous question that Mr. Lewis requires monotherapy for Pseudomonas and MRSA coverage. You are looking for beta-lactam agents that cover Pseudomonas. Ciprofloxacin can be used for double coverage but not as monotherapy empirically. A beta-lactam should be used as the monotherapy "backbone." You are also looking for agents that cover MRSA and are recommended for pneumonia (currently vancomycin and linezolid (Zyvox) are listed in the guidelines). Daptomycin (Cubicin) is inactivated by lung surfactant and Imipenem-cilastatin (Primaxin) does NOT cover MRSA.
Which cephalosporins cover MRSA?
ceftaroline (Teflaro)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: GI, seizures with renal accumulation, increased LFTs with high doses; cross reactivity with aztreonam:
ceftazidime (Fortaz)
Bacterial Meningitis: Neisseria meningitidis: Empiric Treatment of Choice:
ceftriaxone (Rocephin)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Administration: IV only:
ceftriaxone (Rocephin)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotic is associated with diarrhea increased bilirubin in neonates, and allergies?
ceftriaxone (Rocephin)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: GI, allergies, increased bilirubin in neonates:
ceftriaxone (Rocephin)
Urinary Tract Infection (UTI): Name that Antibiotic: Adverse Effects & Counseling Includes: GI, allergies, increased bilirubin in neonates:
ceftriaxone (Rocephin)
Urinary Tract Infection (UTI): Name that Antibiotic: Clinical Pearls: Once daily dosing and is "good" for fluoroquinolone-resistant strains:
ceftriaxone (Rocephin)
Urinary Tract Infection (UTI): Name that Antibiotic: Route of Administration: IM & IV:
ceftriaxone (Rocephin)
Urinary Tract Infection (UTI): Name that Antibiotic: T > MIC
ceftriaxone (Rocephin)
What antibiotic is NOT used in neonates, and why?
ceftriaxone (Rocephin) Why? It will displace bilirubin > increase free bilirubin in blood > bilirubin travels to the brain and precipitates Krenicterus > brain dysfunction and damage.
Community-Acquired Pneumonia (CAP): What's unique about ceftriaxone (Rocephin) compared to the other cephalosporins?
ceftriaxone (Rocephin) does NOT require renal dose adjustments
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotic is associated with diarrhea, increased LFTs, and allergies?
cefuroxime axetil (Ceftin)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Administration: PO & IV (Bioavailability not denoted)
cefuroxime axetil (Ceftin): 2nd-Gen
Infective Endocarditis (IE): Enterococcus SYNERGY Mechanism: Combinations of a(n) ___________________ and a(n) ___________________ are necessary for killing Enterococcus.
cell-wall active agent; aminoglycoside
Meningococcal Outbreaks: Highest rates are seen in...
children < 1 years of age
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Chelation with cations, QTc drugs, warfarin; contraindicated with tizandine:
ciprofloxacin (Cipro)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Strong CYP1A2 inhibitor → increased concentrations of caffeine and theophylline:
ciprofloxacin (Cipro)
Urinary Tract Infection (UTI): Name that Antibiotic: Drug-Drug Interactions: Contraindicated with tizanidine:
ciprofloxacin (Cipro)
Urinary Tract Infection (UTI): Name that Antibiotic: Drug-Drug Interactions: Strong CYP1A2 inhibitor causing increased concentrations of caffeine and theophylline:
ciprofloxacin (Cipro)
Urinary Tract Infection (UTI): Outpatient Treatment: Antimicrobial Stewardship: Fluoroquinolones (____________ & ____________) are effective but should be reserved for _________________ due to high risk for _________________.
ciprofloxacin; levofloxacin; pyelonephritis; "collateral damage"
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotic may cause QTc prolongation, GI upset, diarrhea, and hepatotoxicity?
clarithromycin (Biaxin)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: Caution with agents metabolized by CYP3A4:
clarithromycin (Biaxin): Strong CYP3A4 Inhibitor
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Drug Interactions: Do not use with lovastatin, simvastatin, ergotamine, or colchicine: Why?
clarithromycin (Biaxin); Why? increased liklihood of rhabdomyolysis
Cmax:MIC agents kill organisms in a(n)...
concentration-dependent manner.
Which antibiotic used to treat CAP has potent coverage of Streptococcus pneumoniae and atypicals? a. Augmentin b. Ceftriaxone c. Azithromycin d. Doxycycline
d. Doxycycline Explanation: Augmentin and Ceftriaxone are beta-lactams and do not cover atypicals. Azithromycin has excellent atypical coverage but their is growing Strep pneumo resistance to azithromycin. Doxycycline covers both well and so do respiratory fluoroquinolones (levofloxacin and moxifloxacin)
Community-Acquired Pneumonia (CAP): Name that Antibiotic: Which antibiotic needs to be taken with a full glass of water while being up right for at least 30 min; meaning the patient should NOT take this right before bed because it may cause erosive esophagitis?
doxycycline (Doryx, Moridox, Acticlate) NOT brand oracea.
A 23 year-old female presents to urgent care with dysuria and increased frequency of urination, fever, flank pain, and vomiting. She has positive CVA tenderness and a UA that has positive nitrites and positive leukocyte esterase. She is clinically stable for outpatient treatment. She has an allergy to sulfa drugs described as Stevens-Johnson syndrome. Her urine pregnancy test is negative. The local resistance rate of E. coli to fluoroquinolones is 5%. What do you recommend for this patient? a. Fosfomycin 3 g po once b. Bactrim DS 1 tab PO BID c. Ceftriaxone 2 g IV daily d. Ciprofloxacin 250 mg po BID e. Levofloxacin 750 mg po daily
e. Levofloxacin 750 mg PO daily Explanation: Levofloxacin is the best choice here because the patient has no allergies, is not pregnant, and local fluoroquinolone resistance is <10%. Ciprofloxacin is also a good option but this dose is too low for pyelonephritis. Cefriaxone is also an option but this patient does not need IV managment. Fosfomycin is not an option for pyelonephritis. Bactrim is contraindicated given her history of SJS.
Urinary Tract Infection (UTI): Name that Antibiotic: Adverse Effects & Counseling Includes: Headache, N/D (well-tolerated), mix with cool water:
fosfomycin (Monurol)
Urinary Tract Infection (UTI): Name that Antibiotic: Clinical Pearls: Can be used for MDR cystitis infections: (e.g. VRE, ESBL-E. coli)
fosfomycin (Monurol)
____________________ comes as a powder and should be mixed with cool water prior to administration and should only be used for ____________________.
fosfomycin (Monurol); cystitis
Bacterial Meningitis: "When deciding on EMPIRIC therapy, neonates can be at risk for gram-negative enterics as well, for which ________________ can be given empirically until more information is available. So in a patient scenario where you do NOT have any gram stains or cultures, and the patient is a neonate, you want to start with: (2)" -Sen Email (02/16)
gentamicin; 1. ampicillin + gentamicin or 2. ampicillin + cefotaxime
"Bacterial Meningitis is characterized by a(n) __________ neutrophil count, __________ protein, and __________ glucose." -Sen
high; high; low
Urinary Tract Infection (UTI): Bacteria in the bladder will ______________ the bladder to ______________.
induce; void
Foley Catheter:
indwelling catheter inserted through the urethra and into the bladder that includes a collection system allowing urine to be drained into a bag; the catheter can remain in place for an extended period Most common type of catheter
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Chelation with cations, QTc drugs, warfarin; increased risk for hypoglycemia with DM drugs:
levofloxacin (Levaquin)
Urinary Tract Infection (UTI): Name that Antibiotic: Drug-Drug Interactions: Increased risk for HYPOglycemia when used with DM drugs:
levofloxacin (Levaquin)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: Reversible myelosuppression (> 2wks), peripheral neuropathy, optic neuropathy (>4 wks), serotonin syndrome, hypoglycemia:
linezolid (Zyvox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Bacteriostatic:
linezolid (Zyvox)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Drug Interactions include: Serotonin agents (SSRIS, SNRIs, TCAS, MAOIs, Tramadol, ondansetron):
linezolid (Zyvox)
What agent demonstrates HA-MRSA coverage, has excellent lung penetration, and has 100% oral bioavailability?
linezolid (Zyvox)
What drug has excellent lung penetration, covers HA-MRSA, and has a significant drug-drug interaction with SSRIs?
linezolid (Zyvox)
Doxycycline is commonly used to treat... What are important adverse events to consider when recommending its use? (SATA) a. Diarrhea b. Seizures c. QTc prolongation d. Photosensitivity e. Achilles tendon rupture f. Erosive esophagitis
mild community-acquired pneumonia (CAP) in the outpatient setting; a. Diarrhea d. Photosensitivity f. Erosive esophagitis Explanation: • Doxycycline SEs include: Nausea and diarrhea, recommend taking with food and a full glass of water; not lying down for 30 minutes after to reduce erosive esophagitis; photosensitivity, tooth discoloration in children; (pregnancy D) • QTc prolongation occurs with macrolides and fluoroquinolones • Seizures and Achilles tendon rupture with fluoroquinolones
What is the main difference between levofloxacin and moxifloxacin?
moxifloxacin does NOT require renal dose adjustments like levofloxacin.
"You can still have pneumonia, but have a(n)...
negative culture." -Metzger
A 20 y/o non-pregnant female comes into the health clinic with a burning sensation, increased frequency of urination, and is diagnosed with uncomplicated cystitis. Local resistance to sulfamethoxazole-trimethoprim is high (~40%). What is the best empiric antibiotic regimen for this patient?
nitrofurantoin (MacroBID) 100-200 mg PO w/ food BID x 5 days
Urinary Tract Infection (UTI): Avoid ________________ in patients with significant renal impairment.
nitrofurantoin (Macrobid)
Urinary Tract Infection (UTI): Outpatient Treatment: Antimicrobial Stewardship: ________________ is preferred due to minimal resistance and decreased "collateral damage".
nitrofurantoin (Macrobid)
Urinary Tract Infection (UTI): Name that Antibiotic: Adverse Effects & Counseling Includes: Common: Nausea & headache Rare: Peripheral neuropathy, pulmonary reactions w/ chronic use:
nitrofurantoin (Macrobid, Macrodantin, Furadantin)
Urinary Tract Infection (UTI): Name that Antibiotic: Adverse Effects & Counseling Includes: Take with food, may discolor urine brown-harmless and temporary:
nitrofurantoin (Macrobid, Macrodantin, Furadantin)
Urinary Tract Infection (UTI): Name that Antibiotic: Clinical Pearls: Should NOT be used for pyelonephritis:
nitrofurantoin (Macrobid, Macrodantin, Furadantin)
Urinary Tract Infection (UTI): Name that Antibiotic: Drug-Drug Interactions: Increased absorption when taken WITH food:
nitrofurantoin (Macrobid, Macrodantin, Furadantin)
Urinary Tract Infection (UTI): Name that Antibiotic: Unknown PK/PD:
nitrofurantoin (Macrobid, Macrodantin, Furadantin)
Transient Bacteremia:
normal bacterial flora are exposed to blood through manipulation or trauma
Infective Endocarditis (IE): Principles of Therapy: Almost always administered _______________.
parenterally
Community-Acquired Pneumonia (CAP): Moxifloxacin could be used in... (2)
patients with comorbidities and/or in the inpatient setting.
Bacterial Meningitis: Clinical Presentation: Blunted responses to infection may be observed in _______________ and _______________.
pediatrics; immunocompromised
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: GI/Nephrotoxicity:
piperacillin-tazobactam (Zosyn)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: Nephrotoxicity and neurotoxicity:
polymyxin (Colistimethate and Polymyxin B)
Nosocomial-Acquired Pneumonia: Name that Antibiotic: PK/PD: Cmax:MIC & AUC:MIC:
polymyxin (Colistimethate and Polymyxin B)
Bacterial Meningitis: Diagnostic Tests: CSF cultures are positive (+) in 70-85% of patients who have not...
received prior antimicrobial therapy.
Defervescence
reduction/dismissal of fever
Asplenia
refers to the absence of normal spleen function
Urinary Tract Infection (UTI): Name that Antibiotic: Adverse Effects & Counseling Includes: N/V/D, rash (SJS), photosensitivity, increased SCr, HYPERkalemia, myelosuppression, & hepatotoxicity:
sulfamethoxazole-trimethoprim (Bactrim)
Urinary Tract Infection (UTI): Name that Antibiotic: Drug-Drug Interactions: Strong 2C9 inhibitor > significant increase in INR when used with warfarin; watch agents that increase K (RAAS):
sulfamethoxazole-trimethoprim (Bactrim)
AUC:MIC agents kill organisms in a(n)...
time & concentration-dependent manner.
T > MIC agents kill organisms in a(n)...
time-dependent manner.
Nosocomial-Acquired Pneumonia: Name that Antibiotic: Adverse Events include: Phlebitis, Red-Man Syndrome, nephrotoxicity, ototoxicity, thrombocytopenia:
vancomycin (Vancocin)
Infective Endocarditis (IE): Clinical Presentation: Highly ____________ and ____________. Therefore, ____________ and ____________ diagnosis is IMPORTANT. ____________ is the MOST common finding and ____________ ____________ are found in a majority of patients.
variable; non-specific; early; accurate; Fever; heart murmurs
Infective Endocarditis (IE): Selection of Empiric Therapy: Select drugs that penetrate _______________:
vegetations
Acute Bronchitis (AB) is typically caused by...
viruses that cause the Common Cold, but may also be caused by bacteria that cause Community-Acquired Bronchitis: Mycoplasma pneumoniae, Streptococcus pneumoniae