Empiric Abx Therapy – Flashcards
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What is empiric tx?
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Tx started before pathogen is identified Based on most likely microbe
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Who makes the empiric tx recommendations?
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IDSA and ATS (Infectious Disease Society of America) (Academy of Thoracic Surgeons)
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What is most likely organism for skin infections? (aka SSTI)
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Staph Aureus, MRSA/MSSA Gram +
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What does a MSSA infection look like?
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Non purulent presentation, flat, cellulitic
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What does a MRSA infection look like?
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Likely a purulent/abscess presentation, abscess may have necrotic center
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Oral agents for Tx of MRSA?
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Sulfa/Trimeth- Bactrim 2(BID) double strength doses (check pharm book for specific doses) Clindamycin- every 8 hrs for 7-21 days Doxycycline- BID for 7-10 days Linezolid- Costly and toxic, only use if previous tx failure
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Parenteral agents for Tx of MRSA?
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Vancomycin- 1st choice for IV Daptomycin Linezolid
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Does penicillin kill staph well?
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NO
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What is not recommended for SSTI?
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PCN - it covers strep, not staph Fluoroquinolones- likely to develop resistance
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Oral Tx of MSSA?
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Cephalosporin (Cephalexin/Keflex) - good staph coverage
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Parenteral Agent for MSSA?
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Cefazolin (Ancef)- usually used prophylactic
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What is the likely pathogen for Dog/Cat bites?
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Pasteurella multocida Gram neg.......pencillin sensitive
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Oral agent for Dog/Cat bite?
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Augmentin- 5-10 days, length of time will be based on severity of infection vs. prophylaxis HIGH DOSE ALL DOG/CAT bites should be tx'ed prophylactically
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Likely microbe in human bite
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Polymicrobial- including pasteurella multocida
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What's oral agent for human bite tx?
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Augmentin 5-7 days prophy, active infection 7-10 days ALL HUMAN BITES tx'ed prophylactically
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Puncture wound foot microbe?
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Pseduomonas Aeruginosa Especially true if puncture was through rubber soled shoes
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What's the tx for puncture foot wounds?
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Cipro 500mg po q12hrs x 7 days
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Always update what immunization for all SSTI?
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Tdap (update tetanus)
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You can't give 2 tetanus shots within how many hours of each other for fear of reactivity and necrosis?
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within 48-72 hours
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What's the likely pathogen for oral/dental?
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Strep Viridans most common Found on dental caries Cause of endocarditis
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Treat oral/dental procedures prophylactically why?
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If you have artificial joints or heart valves, you need prophy tx to prevent endocarditis/septic joint
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Oral agents for oral/dental infections
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Penicillin: PenVK for 7-10days Clindamycin for 7-10 days Consider augmentin/PCN/Flagyl w/ dental abcess!
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Parental agents for oral/dental infection
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Ampicillin-sulbactam (Unasyn) Penicillin G plus Clindamycin or Flagyl
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Pathogens for Sinusitis?
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H. influenza, M.catarrhalis
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What used to be the most common cause of sinusitis until a certain vaccine?
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STREP PNEUMO....but Pneumococcal vaccine kicked it's butt.
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Oral agents for Sinusitis tx?
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1st line: Augmentin If PCN allergy: 1st line is Doxycycline Respiratory Fluroroquinolone- alt. for PCN allergy/peds: Levaquin or Moxifloxacin
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Not recommended for sinusitis?
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Not recommended for empiric therapy. High resistance of S. pneumoniae/H. influenza - Macrolides -Bactrim -Cephalosporin
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Most common pathogens for Otitis Media?
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Strep Pneumo, M. Cat, H. Flu
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Dental pain is pathopneumonic for what kind of sinusitis?
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BACTERIAL sinusitis
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Oral Otitis Media treatment
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Amoxicillin is 1st line Augmentin if Amox. failed Macrolide IF PCN allergy (ALL SAFE IN PREGNANCY)
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Use high dose amoxicillin when treating pediatric OM. What dose is this?
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per Maria: 90mg/kg/day dose BID or 3x daily for 7-10 days (check other sources)
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Common pathogen for Strep Pharyngitis?
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Group A Beta-hemolytic strep
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Oral agents (and one parenteral) for treatment of Strep Pharyngitis?
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Pen VK 500mg BID or 3x daily for 10 days Amoxicillin 500mg po twice daily for 10 days Parenteral: Bicillin IM 1.2 million units - 1 dose
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Typical Pathogens for CAP?
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Typical: Strep pneumo H. flu M. catarrhalis Group A strep
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Atypical pathogens for CAP?
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Legionella Mycoplasma pneumoniae Chlamydia pneumoniae
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Risk factors for resistance
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Age >65 yo, or <2 yo Beta-lactam/macrolide/fluoro therapy within past 3-6months Alcoholism Medical comorbities Immunosuppressive illness or therapy Exposure to child in daycare
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Oral agents for tx of NO RESISTANCE CAP
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Azithro Clarithryomycin Doxycycline Rx 7 day tx to ensure full 5 days compliance
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What makes someone be 'no resistance' for CAP?
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No recent abx use, none in last 3 months No other co-morbidities Low rate of macrolide resistance to S. pneumo in community
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Oral agents for tx of resistance suspected CAP?
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Respiratory fluoroquinolone -Levaquin -Moxifloxacin
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CAP Inpatient Tx
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Parenteral therapy- empiric tx should include macrolide/3rd gen cephalosporin Azithro Ceftriaxone (no resistance or comorbidities)
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What is HAP?
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Hospital Acquired Pneumonia Occurs >48 hrs after admission
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What is VAP?
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Vent acquired pneumonia 48-72 hrs. after intubation
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What is HCAP?
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Health care Associated Pneumonia- occurs in a non hospitalized pt.
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What is HCAP defined as?
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One of more of the following: IV therapy/wound care/chemo in past 30 days Nursing home/rehab Hospitalized for >2 days within last 90 days Attendance at hospital or dialysis within past 30 days
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Resistance tx for CAP?
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VARIES BY INSTITUTION
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Most likely pathogen for acute uncomplicated cystitis in females?
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If gram negative, positive nitrate E. coli Proteus mirabilis (gram -) Klebsiella pneumoniae
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How do you find out about nitrates for genitourinary infections?
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UA! (find out via dip) If you have nitrates in the urine- consider it UTI
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What's a typical UTI look like on UA?
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Nitrate + (bacteria/nitrate producing) Leukest + (enzyme meaning leukocytes) Bact + (an actual count) WBC 120 (per field, consistent w/ leuk) RBC 5 (count)
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If it's nitrate negative, is it a UTI?
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YES- just means it's not nitrate producing bacteria.
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What makes a UTI uncomplicated?
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Absence of fever, flank pain, signs of sepsis, tachy, hypotension, leukocytosis, or possible pyelonephritis
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Oral treatment for acute uncomplicated?
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Nitrofurantoin (good option for pregnancy as well if no pyelo signs) Bactrim One DS Keflex Fosfomycin 3g single dose
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Is nitrofurantoin (Macobid) bacteriostatic or bacteriocidal?
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BACTERIOSTATIC
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Most common pathogens for Pyelonephritis?
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Gram - and Nitrate + -E. coli -Proteus mirabilis -Klebsiella Basically the same for your acute/uncomplicated UTI
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Oral agents for pyelonephritis
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Cipro/Levaquin
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What is NOT recommended for UTI/pyelo?
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Moxifloxacin- lower levels in urine vs. other fluoroquinolones
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How long do you treat pyelo for?
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14 days, no matter the agent
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Pyelo tx in pregnancy?
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HAS to be IV therapy/hospital admission Consider OB consult esp. 2/3rd trimester Should cover for E. coli/Group B strep Should have suppressive therapy for remainder of the pregnancy Should consider local sensitivities
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What do you add to the diff dx for Acute cystitis in men?
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Prostatitis STI treatment if under 50
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Oral tx for acute cystitis in men?
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Bactrim- one DS Cipro
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What is NOT recommended for prostatitis
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B- lactams Nitrofurantoin
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When do you treat asymptomatic cystitis?
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Pregnancy Patient undergoing urological procedure where mucosal bleeding is suspected DON'T TREAT ANYONE ELSE
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STI tx?
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Chlamydia - Azithromycin/Doxy Gonorrhea- Cef. IM
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Trich tx?
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Metronidazole oral or gel Clindamycin oral/cream Tinidazole oral/cream
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What does gonorrhea look like?
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Gram - diplococci
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PID suspected pathogens?
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Enterobacteriaceae Gr. B streptococci Chlamydia N. gonorrhea
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Oral agents for PID tx
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Ceftriaxone + DOX!!! Tx for 14 days
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Parenteral Treatment
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Cefoxitin/Doxycycline Gentamicin/Clindamycin
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Indications for hospitalization in PID
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Pregnancy N/V (can't take meds) Fever/chills Suspected pelvic abcess
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Epidydimitis most common pathogen
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N. gonorrhoeae or C. trachomatis
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Oral Treatment for Epidydimitis
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Ceftraixone, Doxy
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What do you give for STI/PID if a severe PCN allergy?
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Azithyromycin 2g, pretreat antimetic
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Clinical Pearls for Vanco?
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Red Man's Flush: must infuse slowly or will have flushing to face/itching Must take PO to tx C. Diff Class C in pregnancy
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Doxycycline pearls
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Can affect teeth/bones in peds/causing yellowing/browning Can have chelation between Iron salts, antacids, laxatives, and tetracyclines so take at least 1 hour before or 4 hours after the above drugs CLASS D- DO NOT USE IN PREGGO
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What drugs are common causes of drug induced SJS and TEN?
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BACTRIM Allopurinol Dilantin Lamotrigine Oxicam
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What pregnancy class is Bactrim?
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Class D - especially 1st trimester
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Clindamycin is what pregnancy class?
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Class B
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Cipro has a significant interaction with what medication?
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Warfarin- causes increased serum concentration
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Cipro can cause spontaneous what? and why is it contraindicated in peds?
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Can cause spontaneous tendon ruptures (Achilles) Contraindicated in peds- d/t effects on joints/surrounding tissue
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What cardiac effects does Cipro have?
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QT prolongation and possible Torsades
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What pregnancy class is Cipro?
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Class C
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Do not use Nitrofurantoin in over what age population?
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Over 65 yo
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Metronidazole (Flagyl) can have a reaction with what?
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Alcohol or any product containing alcohol. Causes n/v
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Is Flagyl safe to use during pregnancy?
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Yes. CDC says Class B and is safe at any stage.
