BCPS 2013: Infectious Diseases

My infectious disease review.  I've already talked about pneumonia and may be revising these to go from the direction of the bugs and then the drugs again.  One thing I will say:  Invanz is not active against MRSA, ampicillin-resistant enterococci, Pseudomonas aeruginosa or Acinetobacter species.  Hear me?  :)

BCPS ID Review

Pneumonia

CAP

HAP

Organisms M. pneumonia, S. pneumonia, H.flu, C. pneumonia, Legionella, Viruses S. aureus, Pseudomonas, Enterobacter, Klebsiella pneumo, Candida, Acinetobacter, Serratia, E.coli, S.pneumonia
Treatment Healthy no Abx in previous 3 months

Macrolide (clarith or azith) OR doxycycline

Cormorbidity or Abx in previous 3 months

FQ (moxi, gemi, levo 750mg)

Macrolide (or doxy) + [High-dose amox 1g

tid OR amox/clav 2g bid OR ceph ]

(ceftriaxone, cefuroxime, cefpodoxime)

Early onset (< 5 days)

3rd ceph (ceftriaxone, cefotaxime)

FQ (levo, moxi, cipro)

Amp/sulbactam

Ertapenem

Late onset (> 5 days or RF for MDR)

   Ceftazidime OR cefepime + AG or FQ (cipro, levo)

Imi, mero, or dori + AG or FQ (cipro, levo)

Pip/taz + AG or FQ (cipro, levo)

   + Vanco/linezolid only if MRSA risk factors

Duration At least 5 days 7 days (14 days for Pseudomonas)

 

Influenza: Type A (Annual, H1N1, H1N2), Type B

Prophylaxis:  if outbreak and cannot receive vaccine

1. Amantadine, Rimantadine 5-7 weeks

2. Neuraminidase inhibitors: Oseltamivir 75-150mg daily x6wks; 75mg daily x7days within 2 days of contact

Zanamivir 10mg daily through inhalation x4wks

Treatment: only if severe symptoms or at risk for complications

1. Amantadine, Rimantadine- only against Type A, decreases symptoms 1 day  *do NOT use for at risk for complications

Dosing: 100mg bid x3-7 days [Elderly 100 daily]; ADJUST FOR RENAL DISEASE (amantadine> rimantadine)

AE: CNS, GI, peripheral edema, orthostatic hypotension

2. Oseltamivir- decreases symptoms 1-1.5 days

Dosing: 75mg bid x5days [CrCl <30 75mg daily]

AE: GI

3. Zanamivir- decreases symptoms 1-1.5 days

Dosing: 2 inhalations (5mg/inhalation) bid x5days

AE: bronchospasm, cough

 

UTIs Treatment Other Comment
Uncomplicated cystitis Nitrofurantoin 100mg bid

     X 5 days

TMP/SMX DS bid x 3 days

Or Fosfomycin 3 gm once

Duration: 3 days vs 5

Alternatives:

Amox-clavulanate, cefdinir, cefaclor, or cefpodoxime x 3-7d or FQ x 3 d

 
Pregnancy Amoxicillin

Nitrofurantoin

Cephalexin

TMP/SMZ

Duration: 7 days

AVOID:

FQ

Tetracyclines

AG

TMP/SMZ (esp 3rd trimester

Pregnant women should be screened for UTI even if asymptomatic
Recurrent cystitis Relapse: treat 2-6 weeks Reinfection

<2/yr: pt initiated x3days

3+/yr: post-intercourse

TMP/SMZ SS, cephalexin 250mg, nitro 50-100mg

3+/yr: daily or 3x/wk

3+/yr other can also use TMP 100mg, or Norfloxacin 200mg
Uncomplicated Pyelonephritis Not requiring hospital:

Cipro 500mg BID x 7d

Cipro ER 1000mg daily x 7d

OR Levo 750 mg daily x 5d

OR TMP-SMX DS bid x 14d

 

Hospitalized:

IV FQ

Aminoglycoside with or w/o ampicillin

OR extended-spectrum cephalosporin or an extended-spectrum pcn with or without an aminoglycoside or carbapenem

 

Not requiring hospital:

Or Oral beta-lactam (less effective) plus initial IV ceftriaxone 1gm OR IV 24-hour dose of aminoglycoside

 

For pts without N/V and not immunocompromised
Complicated UTIs FQ levo x 5 days

AG x 5-14 days

Extended spectrum Beta lactam  
Catheter-related UTIs Symptomatic pts x 7-10 days and cath removal Assymptomatic pts should NOT be treated E.coli, Candida, Enterococcus, Pseudo, Kleb pneumo, Enterobacter
Prostatitis Acute: Duration 4 weeks TMP/SMZ

Cephalosporins

FQ

Chronic: 1-4 months

TMP/SMZ

FQ

 
Epididymitis >35 yr: TMP/SMZ, FQ

x 10 days- 4 weeks

< 35 yr: Ceftriaxone 250mg IM AND doxycycline 100mg bid

x 10 days

 

Skin and Soft Tissue Infections

Cellulitis Nafcillin, Oxacillin, Dicloxacillin x5-10 days Alternatives: Clinda, BL combos, 1st ceph Vanco/Linezolid for MRSA

PCN G if streptococcal

Erysipelas Penicillin G, Clindamycin

x 7-10 days

   
Necrotizing Fasciitis B lactam combo + clinda  + cipro

Carbapenems

Cefotaxime + clinda OR metron

Streptococcal: High dose IV PCN + clindamycin ABX not curative, surgical debridement necessary!
DM Foot Infection Deep:  1-2 weeks

Amp/sulbac, Ticar/clav, Pip/taz

Ertapenem

FQ + [clindamycin OR metron]

Cefoxitin

3rd ceph + [clinda OR metron]

Shallow: treat like cellulitis

PCN, 1st ceph, etc.

Topical: Becaplermin 0.01%

Human platelet derived growth factor, improves healing from 35-50%

 

Surgery also important

 

Osteomyelitis: treat for 4-6 weeks (chronic IV 6-8 weeks + 3-12 months PO)

1. Neonates: Nafcillin + [cefotaxime OR AQ]

2. Infants: Cefuroxime OR ceftriaxone OR [Nafcillin + cefotaxime]

3. Peds (>3yr): Nafcillin OR Cefazolin OR Clindamycin

4. Adults: Nafcillin OR Cefazolin OR Vancomycin

5. Pts with Sickle Cell Anemia: Nafcillin + Ampicillin

6. Prosthetic Joint Infections: Vancomycin + rifampin OR Nafcillin + rifampin

 

CNS Infections: Meningitis

Empiric: 7-14 days

1. Neonates: Ampicillin + AQ OR + cefotaxime

2. 1 month- 50 yrs: 3rd ceph (cefotaxime, ceftriaxone) + Vanco

3. >50 yrs: 3rd ceph +Vanco + ampicillin

4. penetrating head trauma: Vanco + cefepime, ceftazidime, meropenem

Pathogen Known: MOSTLY PCN G 4mill units IV q4h OR Ampicillin 2g q4h, alt: 3rd ceph, vanco, mero, FQ

Corticosteriods: Dexamethasone 0.15 mg.kg q6h x2-4 days; give 10-20 mins before (or at time of ) Abx

Benefit in: Peds with H.flu and Adults with S. pneumo

Brain Abscess: Treat based on source: mostly metron + 3rd Ceph                               Unknown source: Vanco + Metron+ 3rd ceph

 

Endocarditis: Strep, Staph, Entero, HACEK    Duration: 4-6 weeks (8+ weeks with VRE)

Strep: PCN G ± gent, Ceftriaxone ± gent, Vanco

Staph: Oxa/nafcillin ± gent (+ rifampin if prosthetic valve), Cefazolin ± gent (+ rifampin if prosthetic)

MRSA: Vanco (+ rifampin if prosthetic); may also use Vanco in severe PCN allergy

Entero: [PCN G or ampicillin or vanco]  + [gent or streptomycin]                 VRE: linezolid, Quin/Dalf

HACEK: ceftriaxone, Amp/sulbactam, FQ

PPx: dental and resp tract procedures: Amoxicillin 2g PO 1 hr prior                          PCN Allergy: Clinda, azith/clarith

Perotonitis/ Intra-Abdominal Infections

Mild-Mod: cefoxitin, Ticar/clav, ertapenem, moxifloxain,tigecycline;  [cipro/levo +metronidazole],

[cefazolin/ cefuroxime/ceftriaxone/cefotaxime + metronidazole]

Severe, healthcare acquired, High-risk: Pip/Taz, [ceftazidime/cefepime +metronidazole], imi/cil, mero, dori, [cipo/levo +

metronidazole (not for healthcare acquired)]

Duration: 4-7 days, [injuries repaired in 12hr can be treated for only 24 hr]

 

C. difficile: diagnose by presence of endotoxins

Initial TherapyMild to moderate initial episodeMetronidazole 500mg PO/IV tid x 10-14days OR Vanco 125mg PO QID x 10-14days

Severe initial episode:  Vancomycin 125 mg PO QID for 10-14 days

Severe complicated CDI: Vancomycin 500mg PO plus Metronidazole IV 500mg Q8H

Recurrences:  First recurrence:  Same as for initial episode

Second recurrence: Vancomycin tapered/pulsed

 

Medical/Surgical PPX

Procedure Treatment Comment
Gastric/duodenal Cefazolin 1-2g Indicated: morbid obesity, esophe obstruction, decreased gastric pH or motility
Biliary Cefazolin 1-2g Indicated with (without?): acute cholecystitis, obstr. jaundice, common duct stones, >70yr
Appendectomy Cefoxitin 1-2g

Cefazolin 1-2g  + metronidazole

OR amp/sulbactam

If perforated treat x 3-7 days
Colorectal Cefoxitin 1-2g

Cefazolin + metronidazole OR amp/sulbacam

Gent/tobra 1.5mg/kg + clinda 600mg/metron 0.5-1g

± neomycin +erythromycin/

metronidazole

PO/IV may be better bc PO only may cause Cdiff

Mechanical bowel prep is not recommended

Obstetrics/GYN Hysterectomy: Cefazolin/cefoxitin 1-2g

Caesarian: cefazolin 1-2g

 

Caesarian: administer AFTER cord clamped

Cardiothoracic Cardiac surg/Pulm resection:

cefazolin/cefur oxime 1-2g

Vascular surg: cefazolin 1g q8h x3doses

For all: Use Vanco if MRSA risk

 

Orthopedic Cefazolin 1-2g (or cefur or vanco) Indicated: surgery involves prosthetics
Head/Neck Cefazolin 1-2g

Amp/sul 1.5-3g

Gent 1.5mg/kg + clinda 600-900mg

Indicated: major surgery when incision through oral or pharyngeal mucosa
Urologic NOT recommended If (+) urine culture, treat then operate

Pseudomonas Putida BacteriaAnd because pseudomonas is always mentioned:

Pseudomonas aeruginosa
Drugs of Choice:  Piperacillin-tazobactam, Imipenem, Meropenem, Ceftazidime, Cefepime, Amikacin, Gentamycin, Tobramycin, Ciprofloxacin
Alternatives:  Timentin, Aztreonam, Levofloxacin
Third-Line agents: 
Comments:  (Gram-negative bacilli).   Consider using two agents from two different classes as empiric treatment in critically ill patients if P. aeruginosa is suspected. Once susceptibilities known, narrow to one drug according to susceptibility report. 

 

Pills, Thrills and Methadone Spills!

BCPS 2013: Cardiology II