P2 Therapy exam 3 UTI/Pneumonia ABX

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1

CAP NO Risk Factors, Outpatient

1 drug: all have X in name
Macrolide alone —
Azithromycin (Zithromax) or Clarithromycin (Biaxin)
Doxycycline

2

CAP with Risk Factors, Outpatient
RISK FACTORS:

young and old, recent abx use, alcohol, immune suppression, daycare exposure, comorbidities (AAADIC)
AGE <2 or >65 years old
abx in last 3 months
alcoholism
daycare germs
immune suppression
comorbidities: HF, COPD, DM, cancer, liver disease, renal disease

3

**REMEMBER THAT HTN, ARRHYTHMIA, AND DYSLIPIDEMIA NOT PERTINENT RF
PNU RESISTANCE

...

4

CAP with Risk Factors, Outpatient

1 drug:
Respiratory FQ alone —
Levo (500 mg) or Moxi (Avelox) (Cipro reserved for pseudomonas)
2 drugs:
Beta Lactam + Macrolide —
Amoxicillin or Augmentin preferred
PLUS
Azith or Clarith
can use Doxy as alternative to macrolide

5

CAP, non ICU inpatient
(Same as CAP with Risk Factors, Outpatient but with IV options)

1 drug:
Respiratory FQ alone —
Levo or Moxi (Cipro reserve for pseudomonas)

2 drugs:
Beta Lactam + Macrolide —
Cefotaxime, Ceftriaxone, Ceftaroline, Ampicillin/Sulfbactam (Unisyn), Ertapenem
PLUS
Azith or Clarith
can use Doxy as alternative to macrolide
**In general the “tax” cephs are 3rd gen, when you start to get some Gram - coverage

6

CAP, ICU inpatient
Automatically means at least 2 drugs

If Pseudomonas NOT an issue

2 drugs:
Beta Lactam + either respiratory FQ or azith
Aztreonam + FQ for BL allergies

7

CAP, ICU inpatient

If Pseudomonas IS an issue
Pseudomonas RISK FACTORS: Structural lung disease, recent abx use/hospitalization

2 drugs:
AP Beta Lactam + FQ
Pip/taz
Cefepime
Imi/Meropenem
PLUS
Levo or Cipro

OR

3 drugs:
AP Beta Lactam + aminoglycoside + azith OR respiratory FQ
Gent/Tobi

8

IF MRSA AN ISSUE

Add:
Vanc 15-20 mg/kg IV Q12
Linezolid 600 mg Q12
Ceftaroline 600 mg Q12
No Daptomycin bc it can’t get past surfactant

9

Duration of PNU therapies: usually 7-10 days
EXCEPT
5 days, higher dose Levo (750 mg) and Azith
10-21 days for Legionella drugs (Azith is shorter, 7-10)
+ blood cultures (bacteremia, infection is broader than just lungs) ALWAYS ______________ from first positive test

2 weeks

10

CA-AP 7-10 days treatment
AP in general: WILL NEVER BE ATYPICALS
Think Gram + anaerobes (Bacteroides fragilis, Fusobacterium spp, Peptostreptococcus spp), can still have S pneumo/M cat/but H flu gets replaced by Klebsiella pneumo; Associated with poor oral hygiene, LTCF, neurological problems, AMS, stroke, NG tubes, alcoholism, IVDU

1 drug:

Clinda (Cleocin) 800 mg Q8
Augmentin 875 mg BID
OR
Levo/Moxi (Avelox) QD
Ceftriaxone (Rocephin) 1-2 g IV QD

11

Nosocomial AP 10-14 days treatment
S aureus, Pseudomonas, Klebsiella pneumo

2 drugs:
Clinda 600 mg IV Q8 or *Metronidazole 500 mg IV Q8
PLUS
respiratory FQ or Ceftazidime (treats pseudomonas) or Ceftriaxone
1 drug:
Zosyn (Pip/Taz) 4.5 g IV Q6
Ticarcillin/Clav 3.1 g IV Q4-6 [Don’t know]
Imipenem 0.5-1 g IV Q8
*Metronidazole does not cover Gram + and Gram - aerobes such as Pseudomonas. Mainly targets anaerobes

12

Risk factors for:
Resistance (MDR pathogens)
HAP - IV abx last 3 months
VAP - __________________
MRSA
HAP/VAP - IV abx last 3 months, >10-20% MRSA prevalence in hospital OR unknown prevalence
Pseudomonas - structural lung disease, >10% hospital resistance, abundance of Gram - on stain
Mortality

IV abx last 3 months, septic shock at time of VAP, ARDS, RRT (dialysis), hospitalized >5 days

13

REMEMBER: Ceftriaxone is IV only, and does not cover Pseudomonas, does cover some anaerobes but not well. Treats what 3 situations related to PNU?

Outpatient + RFs

Inpatient non ICU

Aspirational: both CA-AP and Nosocomial AP

14

ABX that treat anaerobes:

Clinda, Zosyn, Levo/Moxi, Metronidazole, Augmentin, Imi, Cetriaxone treats some but not well

15

ABX that treat atypicals:

F, M, T

FQ, Macrolides, Tetracyclines

16

Counsel patient to:
–  Take ____________ 2 hrs before or 2 hrs after
–  Take ____________ 2 hrs before or 2 hrs after
–  Take ____________ 3 hrs before or 2 hrs after
–  Take ____________ 4 hrs before or 8 hrs after

LDGM 2,2,2,2,3,2,4,8

17

________________ - A & B flu, PO, renal adjustment
________________- A & B, inhaled, avoid is severe flu and lung disease
________________ - A & B, IV, renal adjustment, avoid in severe flu
________________ - AVOID for type A (resistance)

Tamiflu (Oseltamivir) - A & B flu, PO, renal adjustment
Relenza (Zanamivir) - A & B, inhaled, avoid is severe flu and lung disease
Rapivab (Peramivir) - A & B, IV, renal adjustment, avoid in severe flu
Amantadine/Rimantidine - AVOID for type A (resistance)

18

**Basically the only time you consider observation is > 6 months for unilateral (> 2 yrs old bilateral) AOM when there is NO otorrhea or severe symptoms:

(any ONE of these: toxic-appearing child, persistent pain for more than 2 days, mod-severe TM bulging, fever over 102.2)

19

Antibiotics with Additional B-lactamase Coverage Recommended for AOM if:
Patient had amoxicillin in last 30 days
Patient has concurrent __________________
Patient has history of recurrent AOM not responsive to amoxicillin (Recurrent otitis media = 3
episodes in past 6 months or 4 episodes in past year with 1 in last 6 months)

purulent conjunctivitis

20

Dosing Regimens for AOM:
Amoxicillin 80-90 mg/kg/day BID
Augmentin (if failed Amox treatment, conjunctivitis, or recurrent AOM)
Amox 90 mg/kg/day
Clav 6.4 mg/kg/day BID
Cefdinir ______________________
Ceftriaxone __________________

Cefdinir 14 mg/kg/day BID or TID (turns feces red)

Ceftriaxone 50 mg/kg/dose IM injection Q24 for 1-3 days

21

Standard length of therapy ____ days for children < 2
7 days for pts between 2 – 5 years of age with mild- moderate AOM
5 – 7 days adequate for children > _____
Basically the older they get, the shorter duration you can consider

10 days under 2

5-7 over the age of 6

22

**Azithromycin 5 Day Dosing Regimen:

10 mg/kg on day 1 (LD) then
5 mg/kg daily x 4 days
(Max: 500 mg day 1 then 250 mg per dose)

23

Acute Bacterial Rhinosinusitis treatments:

Amox, Augmentin, Doxy, levo/moxi

24

Primary bacterial cause of pharyngitis is

Group A beta-hemolytic Strep pyogenes (GABHS)s

25

4 Treatments for Strep:

Pen V, PO 10 days, no resistance to GABHS
Children <60 pounds 250 mg BID
Adults 500 mg BID
Amoxicillin 50 mg/kg one dose or split dose
Benzathine Pen G IM injection
PCN Allergy: Cephalexin

26

Treatment for asymptomatic bacteriumia is recommended ONLY for:

children, pregos, UT procedures, females 48 hrs after catheter removal

27

Symptomatic Abacteriuremia is usually caused by

STI

use Doxy or Azith/Clarith

28

Males with UTIs should be treated for a minimum of ________ days because ____________

10-14 days, it’s always complicated

29

Pregnant patients with UTI ALWAYS require ____________ therapy

Conventional 7 day