Pharm II Lecture 3

-What is most dangerous complication of GI infection?

-What do we think of when there is blood in stool for GI infection?

-What bug is opportunistic with Abx use?

-How long does someone need to have diarrhea in a hospital before we start thinking of C. diff?

-Death by dehydration (2nd leading cod worldwide)

 

-E. coli (ETEC)

 

-C. diff

 

-More than 3 days after admission

-What is the cornerstone of diarrheal illness regardless of the etiology?

-Describe how you go about doing this?

-What to avoid?

-Oral Rehydration Therapy (ORT)

-Small volumes at first, then larger volumes…then BANANAS APPLESAUCE, and CEREAL.

-Soda, applejuice, broth, sports drinks (draw free water into gut and increase serum sodium)

-Which of these bugs doesn’t give us watery diarrhea

(E. coli, C.diff, Yersinia, Cholera)

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-Where do we usually find Cholera outbreaks?

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-How do we Tx Cholera?

-Yersinia (it is a blood or pus-filled stool with urgency..INVASIVE DIARRHEA..**Shig, Salm, and Campy also do this**)

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-S and SE Asia (endemic)…some outbreaks in Latin America.

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-Doxycyclin (Bactrim or Erythro for kids)

-What is most common cause of TD?

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-What does its toxin resemble?

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-What strain of E. coli causes hemorrhagic diarrhea?

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-Found where?

-E. Coli (ETEC enterotoxigenic)

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-V. cholera’s toxin (watery diarrhea)

 

-Serotype 0157:H7

 

-food, water, undercooked beef, and VEGGIES

 

-How do we treat ETEC?

 

-How do we treat EHEC?

-FQ (cipro or moxi) or Bactrim

 

-Mostly supportative therapy (don’t want to release more toxins by lysing bacteria)

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-Most common cause of nosocomial diarrhea is?

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-How do you kill it?

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-What about using Pepto?

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-CDAD

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-Metronidazole

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-Don’t do it!  You need to get teh bacteria cleared…diarrhea can be your friend (in small doses)

-What differentiates Mild CDAD from Moderate CDAD?

 

-Treat differently?

-Moderate has systemic symptoms (fever, ab pain, leukocytosis)

 

-Yes, Flagyl for Mild….Vanco for Moderate

-What does severe CDAD require

 

– primarily disease of adolescents or younger, contaminated food or water, food = poultry, beef, pork, dairy, reptile pets (turtles)

-Name the 4 clinical manifestations of this dz.

 

-Surgical consult and Intraluminal Vancomycin with or without Flagyl

 

-Salmonella enterica (caused by 1 of 3 serotypes)

 

-Enterocolitis, Bacteremia, Enteric fever (over 104 with chills/HA/myalgia/nv)

For Salmonellaosis Entercolitis…who doesn’t get Abx?

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-How do we Tx those under 6 mo?

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-Is there a vaccine for Salmonellosis?

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-Because of the carrier state of this dz how long is it recommended you stay on FQ

-Adults

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-FQ, Bacterim, or Rocephin

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-Yes, (Vivitif)

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-4 weeks

-Which Salmonellosis Manifestation absolutely gets Abx?

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-How likely is it that a virus causes TD?

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-How do you prophylax for TD?

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-When do you Tx TD?

-Bacteremia or Localized Infection (Rocephin IV for 1-2 weeks)

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-Unlikely.. ETEC;Shigella;Campy;Salm;virus

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-Bismuth subsalicyclate (Pepto) 524 mg qid…Look out for black tongue, stools, and ringing!

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-More than 3 stools in 8hr period, or blood, or fever (USE FQ x 3 days)

What bacterias toxin is associated with Floopy baby syndrome after eating Honey?

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-Where else found?;

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-Tx?

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-What is onset like?

-C. botulinum

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-Canned foods

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-Resp support and Antitoxin

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-GI symptoms with slow decescending paralysis…progress over days to weeks

What is Sepsis really?

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-Define parameters of SIRS

-SIRS secondary to infectious dz.

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-2 or more of following

HR over 90

Temp 100.4 or…less than 96.8

-RR more than 20 breaths

-WBC greater than 12,000 or less than 4,000

-What 3 things do you need to Tx Sepsis?

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-What are 4 major complications fo Sepsis

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-What do DICs lead to?

-Fluid, Abx (broad) and vasopressors

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-DICs, ARDS, Hemodynamic effx, ARF (oligouric or anuritic)

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-Microthrombi…which can lead to end-organ failure

-What is holy trinity of Abx and used in Sepsis due to broad spectrum effects

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-What time frame do we have to Tx Sepsis

-Vanco, Zosyn, and Cipro

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-Must be addressed in first 6 hours (initial resucitation)

-What vasopressors do we use for Sepsis?

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-What reverses vasopressor effects if they accidentally get into skin?

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-What is the goal MAP for vasopressors?

-What is the goal CVP for using crystalloids or colloids?

-DA or NE

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-Phentolamine (do this to avoid tissue necrosis)

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-65 mm Hg

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-8…12 if on Vent (colloids have 5% albumin..need at least 0.5 L/hr)

-What is only recommended for adult septic shock after fluid resuscitation was a failure?

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-When can we use activated protein C (drotrecogin=promoted fibrinolysis and other anti-inflammatory properties)

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-Steroids.

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-APACHEII score of more than 25 (VERY SICK PT)

-Name a common secondary Peritonitis cause

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-Describe Tertiary Periotonitis

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-When do absesses often occur with peritonitis?

-Appendicitis

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-Infection persists or recurs after adequate Tx of primary or secondary…THESE PEOPLE ARE VERY VERY SICK

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-After or concurrently with peritonitis

;-fluid and albumin shift from circulating blood into abdomen (decreased BP, shock)

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-What 2 etiological bugs cause infections with Gallstones?

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-If they aren’t getting better on broad spectrums…what agent do you need to consider?

-Third spacing

 

-Klebsiella spp. and E. coli

 

-Anaerobes and CANDIDA

-What is crucial to Absess Tx?

 

-What will abdominal auscultation reveal in primary peritonitis?

 

-Key features of Secondary peritonitis?

-Drainage..Abx can’t always reach them.;

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-Hypoactive Bowel sounds

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-HIGH WBC 15,000 to 20,000…Abdominal pain with guarding.

-Primary peritonitis due to cirrhosis may be treated with what?

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-What else may have to be done?

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-Tx for absess?

-Cefotaxime (3rd gen ceph)

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-Peritoneal dialysis

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Drainage plus Carbapenem or extended spec plus betalctmase inhibitor (ZOSYN)

-Tx for secondary peritonitis due to appendicitis? (normal/inflammed)

-Gangrous/perforated?

-If you suspect your pt has an anaerobic bug…how long should you you monitor…4-7 days

-If Tx fails what do you think of?

-Anaerobic Ceph (Cefotetan or Cefoxin)

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-Gorillacylin, Zosyn, or Antianaerobic Cep (Rocephin)

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-SPACE BUGS and Candida

What is the the fastest TB test?

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-What is protocol once dx is made?

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-What is more highly resistent…INH (Isoniazid) or RIF (Rifampin)?

-QuantiFERON-TB Gold (24 hours…looks for IFN-gamma responses by WBCs in response to proteins normally expressed by M. tb)

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-Place pt in isolation (negative pressure rooms…personnel must wear masks)

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-Isoniazid

-how many days must one have acid-fast bacilli in morning sputum to have TB?

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-Where does TB like to hang out?

-What are the 4 drugs used to Tx active TB? (RIPE)

-3 consecutive days

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-Apex of lungs or upper part of lower Lobe

-Isoniazide, RIF, Pyrazinamide (PZA), and Ethambutol (ETB) x 2 months…then INH/RIF for 4 more months

-Is warfarin effectiveness blunted or potentiated by RIF?

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-How is RIF cleared?

-it is blunted…as are BC pills and Phenytoin (watch for breakthrough seizures)

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-Hepatically (10-15% increase in transaminases…can be hepatotoxic)

What must we adjust for with PZA?

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-What is a weird SE of ETB?

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-What do we monitor for liver fct during TB Tx?

-Renal Dysfct (ClCr;30…administer 3x weekly)

Retrobulbular retiinitis...decreased VA OR loss of ability to see green….check VA and monitor green discrimination

-Hepatotoxicity is examined by looking at tranaminases; (5x ULN)…look for concordant jaundice..also total bilirubin..if above 3 mg/dL…then stop drugs.

-T/F; more people die of Hep B than any other vaccine preventable illness?

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-How long does it generally incubate.

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-How long shed in Adults? Kids?

-False…more people die of flu than any other v-preventable illness.

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-2 day incubation

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-shed from day before symtoms..till 5 days after symptoms in Adults…10th day in Kids.

-Define Flu-like symptoms:)

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-What accompanies these in Kids?

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-what 2 symptoms stick around the longest?

-rapid onset fever, myalgia, H/A, malaise, nonproductive cough, sore throat, and rhinitis

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-OM and N/V

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-Malaise and cough (can be up to 2 weeks)

-How long do symptoms usually last with flu?

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-Who shouldn’t get Flu vaccine?

 

-When are the vaccinations given?

-most symptoms only present for 7 days

 

-Already sick, less than 6 mo old, had GB Syndrome rxn to last vaccine

 

-Oct to November

-Which Antiviral is for Influenza A only?

 

-What is Tamiflu (what class)

 

-What strains does it cover?

 

-Which meds is Flu A H3N2 resistant to?

-Adamantanes (Amantidine or Rimantidine)

 

-Neuraminidase inhibitor (along with Zanamavir)

 

-A and B

 

-Adamantanes

-What vascular insufficiency type dz can predispose you to osteomyelitis.

 

-What is most common bug causing this?

 

-along with S. aureus, what other bug forms biofils that impede Abx penetration?

-DM

 

-S. aureus

 

-S. epidermidis

What must be done to help Dx osteomyelitis?

 

-Will there be a skin lesion in Osteomyelitis?

 

-Should we rely on WBC counts?

 

-What is best imaging technique for dx?

-BONE BIOPSY (not simple swab), debridement (removal of necrotic tissue), Gram Stain

 

-There shouldn’t be, just swelling and bone pain/tenderness on palpation

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-They aren’t reliable, use ESR and CRP (c-reactive protiein…elevated in inflammation)

 

-CT and MRI…reveals it earlier than X-ray

-What is another method that can be very expensive, but is very effective for Dx osteomyelitis

 

-In kids which bones are commonly affected?  In adults?

 

-T/F…can often be secondary to pressure sores/ulcers?

-WBC tagging and readministeration

 

-Long bones (Kids), Hip/vertebrae(adults)

 

-True

What joint does osteo hit for IV Drug users or those whith indwelling devices?

-What about those who have had cardiac surgery?

 

-What do we need to watch for in vertebral manifestations?

 

-What part of vertebral column is most often affected.

-sternoclavicular

 

-Sternum

 

-Cord Compression

 

-Lower Spine (very rare that cervical is infected)

-What Abx do we use to prophylax against osteo 30 min before incision or within 24 hrs of closure?

 

What do we use for Acute Tx of Osteo

-Cefazolin

 

-Abx + surgery to remove necrotic bone…

CS report and Tx….IV route 4-6 Weeks

Cipro or Rifampin for PO

What might a complicated case of Vulvovaginal candiasis have as teh etiological agent?

 

-Which of these is not a risk factor for VVC?:

Abx use, Diet, Tight clothing, IUD, condoms, virgin

 

-T/F…VVC is an STD?

-Non-albican species

 

-Condom and Virgin

 

-False

-THose with VVC should have more or less yogart?

 

-For infections topical azoles should be used for?

 

-What is the oral azole? (convenient azole)

 

-Should pregos do topicals or orals?

-More…at least 240 ml yogurt. 

 

-1-7 days

 

-Difluconazole (Diflucan)

 

-Topicals

-How many infections of VVC must you have in a year to be considered RECURRENT?

 

-How do you treat antifungal-resistant VVC?

 

-In Esophogeal Candiasis…what part of esophagus is usually affected?

-Four or more (fluconazole x 10 days…then once per week x 6 months)

 

-Boric acid intravaginally x 14 days..then twice weekly or 5-FC cream x 7 days

 

-Lower part

 

OPC Tx?

 

-What requires longer Tx….OPC or EC?

-(Tx for 7-14 days)Topical – nystatin swish and swallow 5ml qid or clotrimazole troches 5x day dissolve slowly
Oral azole – fluconazole 100mg daily or itraconazole solution (empty stomach) 200mg daily

 

-EC (14-21 days…21-28 for refractory EC…Fluconazole for both)

What are risk factors for infections of skin, nails, and hair?

 

-What might nails look like?

 

-How long do you Tx Athletes foot?

-Lazy, fat, and dirty (sendentary lifestyle)

 

-Chalky, dull, yellow/white, brittle, and crumbly

 

-2 to 4 weeks

HIstoplamosis…where is it found..how is it transmitted?

 

-Txs?

 

-What about Blastomycosis?

-Ohio/Mississippi River Valleys…bird and bat droppings (a fungus)…mild to life-threatening dz.  caused by Histoplasma capsulatum…it is INHALED

 

-LFamb or Itraconazole

 

-Same regions…may infect lungs or even skin/bone/joint/GU (Amp B or Itraconazole)

Which infectious fungus is present in Lower Sonoran Zone? (desert SW)

 

-What common pneumonia does it cause?

 

-What pathogen is found in pigeon droppings and soil?

-Coccidioiodomycosis (Coccidiodes immitus)

 

-CAP (1/2 to 2/3 of SUBCLINICAL CAP)

 

Cryptococcus neofrmans (AIDS pts can have CNS comlications and require lifelong fluco)

For invasive candidiasis…what is the key factor in deciding Tx?

-Neutropenic or not

if not, fluco or echinocandin x 2 weeks after last positive blood culture

-If so Tx with Candin, LFamb, or voriconazole

Must Aspergillosis be treated immediately?

 

-If bronchopulmonary allergy develops?

If INVASIVE, YES!  invasive pulmonary can result in fatal pneumonia…with spread to CNS and adjacet intrathoracic structures…Tx with Voriconazole, LFamb, and Candin for 6-12 weeks.

 

-Tx the asthma…and treat with Itraconazole.

x

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