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) 3^rd 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 3^rd 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, 1^st 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 3^rd ceph + [clinda OR metron]	Shallow: treat like cellulitis PCN, 1^st 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: 3^rd ceph (cefotaxime, ceftriaxone) + Vanco

3. >50 yrs: 3^rd 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: 3^rd 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 + 3^rd Ceph Unknown source: Vanco + Metron+ 3^rd 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 Therapy: Mild to moderate initial episode: Metronidazole 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

And 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.

Infectious Disease. The topic that I like but loathe. At the same time. Pneumonia

Community Acquired Pneumonia (CAP) - not hospitalized 2 days or more within the past 90 days, not in a LTC facility/residence, no IV antibiotic therapy, IV chemo, or wound care in the past 30 days, or attendance at a hospital or dialysis clinic. Must have at least two of the following symptoms: fever or hypothermia, rigors, sweats, new cough (with or without sputum), chest discomfort, onset of dyspnea, or fatigue, pain, headache, myalgias, anorexia.CURB-65 - predictor of complicated course and whether to admit to the hospital. Give a point for each of the following: age > 65, comorbid illnes (DM, CHF, lung dz, renal dz, liver dz), high temp > 101F, Bacteremia, altered mental status (think elderly), immunosuppression (cancer, steroid use), High-risk etiology (S. aureus, legionella, G- bacilli, anaerobic aspiration), multilobe involvement or pleural effusion.
Nosocomial Pneumonia: Hospital Acquired Pneumonia (HAP) (48 hours or more after admission), Ventilator Assoc Pneumo (more than 48–72 hours after intubation), Health care Assoc Pneumo (2 or more days within 90 days of the infection) - know risk factors of nosocomial pneumonia. Pretty common sense.
CAP Organisms: Unidentifiable (40-60%), M.pneumo, S. pneumo, H.flu, C.pneumo, viruses, S. aureus, Moraxella cat,
Alcoholics - S. pneumoniae, oral anaerobes, gram negative bacilli
Nursing Home - S. pneumoniae, H. influenzae, gram negative bacilli, S. aureus
COPD - S. pneumoniae, H. influenzae, M. catarrhalis
Postinfluenza: H. influenzae, S. aureus, S. pneumoniae
Exposure to water: Legionella
Poor oral hygiene: oral anaerobes
HIV infection: P. jiroveci, S. pneumoniae, M. pneumoniae, Mycobacterium

HAP Organisms: S. aureus, Pseudomonas aeruginosa, Enterobacter spp., Klebsiella pneumoniae, Candida, Acinetobacter spp., Serratia marcescens, Escherichia coli, S. pneumoniae

P. aeruginosa is transmitted by health care workers’ hands or respiratory equipment S. aureus is transmitted by health care workers’ hands Enterobacteriaceae endogenously colonize hospitalized patients’ airways (healthy people seldom have gram negative upper airway colonization) Stress changes respiratory epithelial cells so that gram-negative organisms can adhere Up to 70% of patients in the intensive care unit have gram-negative upper airway colonization, and 25% of them will become infected through aspiration

TREATMENT

CAP - duration of treatment at least five days:

Empiric nonhospitalized - prev healthy and no abx in past 3 mos - macrolide or doxy (macrolide if H.flu suspected) and if comorbidities present or recent antibiotics in past 3 months - Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

-- OR -- Macrolide (or doxycycline) with high-dose amoxicillin (1 g 3 times/day) or amoxicillin/clavulanate (2 g 2 times/day) or with a cephalosporin (ceftriaxone, cefuroxime, or with cefpodoxime)

Empiric treatment of hospitalized patients with moderately severe pneumonia - Respiratory fluoroquinolone

--OR-- Ampicillin, ceftriaxone, or cefotaxime (ertapenem in select patients) plus a macrolide (or doxycycline)

Empiric treatment of hospitalized patients with severe pneumonia requiring intensive care unit treatment (may need to add other antibiotics if P. aeruginosa or MRSA is suspected)

Ampicillin/sulbactam plus either a respiratory fluoroquinolone or azithromycin
Ceftriaxone plus either a respiratory fluoroquinolone or azithromycin
Cefotaxime plus either a respiratory fluoroquinolone or azithromycin

Treatment duration—at least 5 days, with 48–72 hours afebrile and no more than one sign of clinical instability (elevated temperature, heart rate, or respiratory rate; decreased systolic blood pressure; or arterial oxygen saturation) before therapy d/c

Hospital Acquired Pneumonia - Treatment duration—Efforts should be made to decrease therapy duration to as short as 7 or 8 days (14 days for pneumonia secondary to P. aeruginosa).

Early onset (less than 5 days) and no risk factors for multidrug-resistant organisms - Common organisms include S. pneumoniae, Haemophilus influenzae, (MSSA), Escherichia coli, Klebsiella pneumoniae, Enterobacter spp., and Proteus spp. -- Treatment -- Third-generation cephalosporin (cefotaxime or ceftriaxone), Fluoroquinolone (levofloxacin, moxifloxacin, ciprofloxacin), Ampicillin/sulbactam, OR Ertapenem
Late onset (5 days or longer) or risk factors for MDR organisms - Common organisms include those listed above for early onset plus Pseudomonas aeruginosa, K. pneumoniae (extended spectrum β-lactamase positive), Acinetobacter spp., MRSA, and Legionella pneumophila. -- Treatment -- a. Ceftazidime or cefepime plus aminoglycoside or fluoroquinolone (cipro-, levo-) b. Imipenem, meropenem, or doripenem plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin), OR c. Piperacillin/tazobactam plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin) ***Vancomycin or linezolid should be used only if MRSA risk factors (e.g., history of MRSA infection/colonization, recent hospitalization or antibiotic use, presence of invasive health care devices) are present or there is a high incidence locally (greater than 10%–15%).

Risk factors for MDR organisms -- Antibiotic therapy within the past 90 days, Hospitalization of 5 days or more, High resistance in community or hospital unit, Risk factors for health care–associated pneumonia, Immunosuppressive disease and/or therapy

A wonderful article published just last November that I love. (Pharmacy Times) Only thing is it doesn't go into the detail of the different antibiotics with Late vs Early Onset of Hospital Acquired. Just CAP. That's OK

And because guidelines haven't changed, my quizlet from last year. Hope you enjoy:

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BCPS 2013: Infectious Diseases

BCPS 2013: Infectious Disease (Pneumonia)