Term
| Group A Streptococcus (GAS) Treatment |
|
Definition
š Antibiotics
š Excellent coverage
š Amoxicillin or cephalexin for PO
š Nafcillin, oxacillin, ampicillin, cefazolin for IV
š Alternative coverage
š Clindamycin
š Fluoroquinolones
š SMX/TMP
š Vancomycin, linezolid, and daptomycin |
|
|
Term
|
Definition
š CA-‐‑MRSA activity
š Doxycycline, minocycline, SMX/TMP, or clindamycin
š Fluoroquinolones may be used depending on culture results
š HA-‐‑MRSA (or SSTI involving hospitalization) activity
š Vancomycin, daptomycin, linezolid, ceftaroline
š Resistance
š Consider if your area or hospital has a high MRSA rate
š All penicillin based antibiotics despite beta lactamase inhibitors
š Cephalosporins (except the new 5th generation) |
|
|
Term
|
Definition
š Doxycycline, minocycline, SMX/TMP, or clindamycin
š Fluoroquinolones may be used depending on culture results |
|
|
Term
|
Definition
| š Vancomycin, daptomycin, linezolid, ceftaroline |
|
|
Term
|
Definition
š Gram (-‐‑)
š Highly resistant and very virulent
š Most antibiotics are not active against this bacteria
š Serious infections especially in diabetic and pressure ulcers
š Active antibiotics
š Piperacillin/tazobactam
š Cefepime
š Fluoroquinolones (except moxifloxacin)
š Aminoglycosides, carbapenems (except ertapenem), aztreonam |
|
|
Term
|
Definition
š Half the population will be bi[en at one point in their life
š Average wound yields 5 types of bacterial isolates
š Pasteurella are isolated from 50% of dogs and 75% cats
š Staph and strep species are found in ~40% from both animals
š Anaerobes are common
š Treatment (10-‐‑14 days)
š Amoxicillin-‐‑clavulanate
š Doxycycline
š Penicillin G + dicloxacillin
š Fluoroquinolones
š Piperacillin/tazobactam and 2nd gen cephalosporin if IV needed |
|
|
Term
|
Definition
š Oral flora of the mouth
š Streptococcus in 80%, staph, few gram (-‐‑), and >60% anaerobes
š Many of the anaerobes produce beta lactamases (heat seeking missiles)
š Treatment (7-‐‑14 days)
š Cleanse the wound and treat immediately with antibiotics
š Amoxicillin-‐‑clavulanate
š Ampicillin-‐‑sulbactam
š Cefoxitin
š Carbapenems
š Doxycycline
š Fluoroquinolones |
|
|
Term
| Cellulitis Therapy not requiring hospitalization (7-‐‑10 days) |
|
Definition
š Gram (+) active against both GAS and MSSA or CA-‐‑MRSA
š SMX/TMP, doxycycline or minocycline, clindamycin, cephalexin,
dicloxacillin |
|
|
Term
| Cellulitis Empiric therapy requiring hospitalization (10-‐‑14 days) |
|
Definition
š Gram (+) active against both GAS and HA-‐‑MRSA
š IV therapy is recommended
š Vancomycin is first line due to cost and proven efficacy
š Daptomycin and linezolid may be used if allergic to vancomycin |
|
|
Term
|
Definition
š Most common of the necrotizing infections
š Type Iàdestruction of fat and fascia with polymicrobials
š Type IIà”flesh eating” GAS and acts much quicker |
|
|
Term
|
Definition
š Type I necrotizing fasciitis specifically affects the male or female
genitalia
š Rapid onset without warning |
|
|
Term
| Necrotizing Soft Tissue Infections Clinical course for all types |
|
Definition
š Above all, this is a surgical emergency
š Multiple incision and debridements are needed on a daily basis
š Good cultures can be obtained through needle aspiration |
|
|
Term
| Necrotizing Soft Tissue Infections Bacterial organisms |
|
Definition
š Various types of streptococcus, especially GAS
š Gram (-‐‑) such as E. coli and PsA
š Anaerobes including clostridium species |
|
|
Term
Antibiotic treatment for both necrotizing fasciitis and gas
gangrene (treat until resolved) |
|
Definition
š IV over oral
š Broad spectrum including anaerobic coverage
š Clindamycin is drug of choice due to toxin suppression and
unaffected by large bacteria colony forming units
š Piperacillin/tazobactam+clindamycin+ciprofloxacin
š Penicillin G+clindamycin+aminoglyoside
š Cefepime+clindamycin (or metronidazole)
š Add vancomycin if suspected MRSA infection |
|
|
Term
| Diabetic Foot Infections Treatment |
|
Definition
š Intraoperative incision and debridement for moderate to severe wounds
š Retrieve intraoperative cultures if possible by scraping or aspiration
š Antibiotics
š Mild: treat like a cellulitis (10-‐‑14 days)
š SMX/TMP, doxycycline, clindamycin, cephalexin, dicloxacillin, amoxicillin-‐‑
clavulanate
š Moderate to severe: cover everything (up to 21 days)
š Fluoroquinolones
š 2nd, 3rd, 4th cephalosporins
š Penicillin with beta lactamase inhibitor
š Vancomycin, daptomycin, linezolid for MRSA
š Amputation |
|
|
Term
| Why is vancomycin + piperacillin/tazobactam the most frequently used combination for empiric therapy? |
|
Definition
|
|
Term
A quadriplegic has an infected sacral pressure ulcer. The a[ending
suspects MRSA so vancomycin is ordered. As the pharmacist on the
SCI team, you suggest adding an additional antibiotic. What would
you add? |
|
Definition
|
|
Term
This patient is in the emergency room, what antibiotics do we
start him on if MRSA is suspected and…..
A. He does not have a penicillin allergy |
|
Definition
|
|
Term
This patient is in the emergency room, what antibiotics do we
start him on if MRSA is suspected and…..
He does have a true penicillin allergy |
|
Definition
1. Vancomycin+levofloxacin
Moxiflox dos not cover pseudomonis |
|
|
Term
After his below the knee amputation, the patient quickly
developed a foul smelling greenish infection at the incision
site. What type of SSTI infection is it (besides being a surgical
site infection)? What antibiotic do you want to make sure is
on board for this patient? |
|
Definition
| 3. Gas gangrene add clindamycin |
|
|
Term
|
Definition
¡ Nose
§ S. aureus, pneumococcus, meningococcus
¡ Skin
§ S. aureus, S. epidermidis
¡ Mouth/pharynx
§ Streptococci, pneumococcus, e. coli,
bacteroides, fusobacterium,
peptostreptococcus
¡ Urinary tract
§ E. coli, proteus, klebsiella, enterobacter
¡ Colon
§ E. coli, klebsiella, enterobacter, bacteroides
spp, clostridia,
¡ Biliary tract
§ E. coli, klebsiella, proteus, clostridia, enterobacter
¡ Vagina
§ Streptococci, staphylococci, E. coli,
peptostreptococci, bacteroides species
¡ Upper respiratory tract
§ Pneumococcus, H. influenzae |
|
|
Term
|
Definition
¡ Cefazolin is the most common agent
utilized when skin flora is the source of contamination
§ 1 gram in patients who are < 80 kg
§ 2 grams in patients who are ≥ 80 kg
¡ Clean procedures |
|
|
Term
| Administration of antibiotic |
|
Definition
¡ Pre-operative antibiotic
§ Given within 60 minutes before initial surgical incision
§ Exception: Vancomycin and the
fluoroquinolones should be given within 60 – 120 minutes
▪ Prolonged infusion time with these antibiotics
¡ Cefazolin, other cephalosporins, and
ampicillin-sulbactam can be given IV or IV push over 3-5 minutes |
|
|
Term
| Nasal screening and decolonization |
|
Definition
¡ Colonization of nares with S. aureus =
risk factor
¡ Intranasal application of mupirocin
ointment may reduce the rate of nasal
carriage of S. aureus
¡ Chlorhexidine (CHG) may also benefit |
|
|
Term
|
Definition
¡ Temperature
¡ Glucose
¡ Hair removal
¡ Catheter
¡ VTE prophylaxis |
|
|
Term
|
Definition
¡ Common pathogens:
§ S. aureus, S.epidermidis
¡ Recommended Antimicrobial
§ Cefazolin1-2 g, Cefuroxime 1.5 g
§ Vancomycin 10-15 mg/kg |
|
|
Term
|
Definition
¡ Esophageal, gastroduodenal surgery
¡ Common pathogens
§ Enteric gram negative bacilli, gram positive
cocci
¡ Recommended Antimicrobial
§ Cefazolin |
|
|
Term
|
Definition
¡ Common pathogens
§ Enteric gram negative bacilli, enterococci, anaerobes
¡ Recommended Antimicrobial
§ Cefazolin + Metronidazole
§ Cefoxitin
§ Ciprofloxacin + Metronidazole |
|
|
Term
|
Definition
¡ Common pathogens
§ S. aureus, S. epidermidis
¡ Recommended Antimicrobial
§ Cefazolin
§ Vancomycin
§ Clindamycin |
|
|
Term
|
Definition
¡ Vaginal, abdominal, or laparoscopic
hysterectomy
¡ Common pathogens
§ Enteric gram negative bacilli, anaerobes,
Group B Strep, Enterococci
¡ Antimicrobial agent
§ Cefazolin, Cefoxitin |
|
|
Term
|
Definition
¡ Consider use in high suspicion of MRSA
¡ Life threatening allergy to penicillins and cephalosporins
¡ Justification needed for SCIP |
|
|
Term
1st Line Therapy Uncomplicated
Cystitis |
|
Definition
Nitrofurantoin macrocrystals 100mg twice a day for 5d
TMP-SMX DS twice a day for 3d
Fosfomycin 3g in a single dose
3-7d depending on the drug chosen |
|
|
Term
2nd Line Therapy Uncomplicated
Cystitis |
|
Definition
Ciprofloxacin 250mg twice a day for 3d
Levofloxacin 250-500mg once a day
Beta-lactams for 3-7d
3-7d depending on the drug chosen |
|
|
Term
1st Line Therapy Complicated
Cystitis |
|
Definition
Ciprofloxacin or Levofloxacin preferred
7-14d |
|
|
Term
| 1st Line Therapy Pyelonephritis |
|
Definition
Uncomplicated: TMPSMX DS twice a day for 2wks or a fluoroquinolone for 2wks
Complicated: Broad spectrum i.e. pip/tazo or carbapenem plus vancomycin if MRSA suspected
14-21d depending on severity |
|
|
Term
2nd Line Therapy Complicated
Cystitis |
|
Definition
Broad spectrum Betalactams
7-14d |
|
|
Term
| 2nd Line Therapy Pyelonephritis |
|
Definition
Depends on C&S
14-21d depending on severity |
|
|
Term
| UNCOMPLICATED CYSTITIS Choice of antibiotic |
|
Definition
Choice of antibiotic
Patient allergy/adverse reactions
Compliance
Local resistance pattern (if known)
Ampicillin resistance is 20% or higher in all regions
Growing resistance to fluroquinolones and trimethoprimsulfamethoxazole
Spectrum of antimicrobial activity
IDSA guidelines have placed fluorquinolones as
second line placement to try to slow the growth of
bacterial resistance to these agents** |
|
|
Term
| Nitrofurantoin Macrocrystals |
|
Definition
Macrobid
Common side effects: GI complaints, headache
Rare but serious adverse effects: Pulmonary toxicity,
Hepatic toxicity, Hemolytic anemia, Peripheral
Neuropathy
Administration: Take with food to increase
absorption and decrease side effects
Contra-indicated with CrCl <60ml/min?
Few serious drug interactions:
Interacts with birth control pills
Not used for pyelonephritis |
|
|
Term
Trimethoprim 160mg/Sulfamethoxazole 800mg
DS |
|
Definition
(Bactrim™ DS, Septra®DS)
Common side effects: GI complaints, rash, pruritis
Rare adverse effects: severe dermatologic reactions,
blood dyscrasias, and hepatotoxicity
Administer with 8oz of water with or without a meal
Dose adjust for renal impairment CrCl <30ml/min
use 50% of the normal dose, less than <15ml/min do not use. Use caution with hepatic impairment.
***Many drug interactions: warfarin (increases bleeding risk), birth control pills (back up contraception should be used) |
|
|
Term
| Ciprofloxacin Levofloxacin |
|
Definition
(Cipro®)(Levaquin®)
Common side effects: neurologic events (i.e. dizziness,
drowsiness), GI complaints, LFT’s increased
Serious adverse effects: QTc prolongation,
hepatotoxicity, tendon rupture
Administer without regards to meals but take 2h
before antacids or other products containing calcium,
iron or zinc – including dairy products. DO NOT
TAKE with MILK
Dose adjust for renal impairment
Drug interactions: Avoid combining with moderate to
high QTc prolonging agents (i.e. Sotolol), Multivitamins (take 2h before), warfarin (increases INR) |
|
|
Term
|
Definition
Recurrence 1-2wks after treatment – culture and treat with a broad spectrum agent such as levofloxacin
Recurrence 1month after treatment – treat as a
first time infection
Recurrence 1-6months after treatment – choose a different agent than originally used |
|
|
Term
| PROPHYLAXIS OF RECURRENT CYSTITIS |
|
Definition
A woman with 3 or more UTI in one year or 2 or
more in the past 6months, and non-antimicrobial
therapy was not effective
Rule out complications (i.e. calculi, cyst)
2 strategies
Post-coital antimicrobial prophylaxis – one dose of
antimicrobial as soon as possible after intercourse
Nitrofurantoin 50-100mg, TMP-SMX SS, Cephalexin
250mg
Continuous daily prophylaxis at bedtime
Nitrofurantoin 50-100mg, TMP-SMX 40/200mg,
Cephalexin 125-250mg, Fosfomycin 3g sachet every 10d |
|
|
Term
| ACUTE UNCOMPLICATED PYELONEPHRITIS |
|
Definition
Presence of fever and flank pain – treat as pyelonephritis
Mild cases can be treated outpatient with oral
antibiotics
Moderate to severe cases (N/V, dehydration) should
be hospitalized and initiated on IV antibiotics
**Fluoroquinolones: Cipro 500mg BID or 1g daily
for 7d, Levofloxacin 750mg for 5d
TMP-SMX DS twice daily for 14d
Beta-lactams for 10-14d
After results of gram stain and C&S therapy can be altered if needed |
|
|
Term
|
Definition
Parenteral Therapy with broad spectrum antibiotics aimed at potential UTI bacterium
IV Fluoroquinolone
Beta-lactamase inhibitor combination like
piperacillin-tazobactam
Add vancomycin if MRSA is suspected
14-21d of treatment
Adjust treatment based on C&S results
Once the patient is a-febrile can convert them over to oral therapy to complete two weeks of oral antibiotics |
|
|
Term
|
Definition
Generally occurs in those >60y/o
Is always considered complicated
Usually caused by catheterization, obstruction (BPH, calculi)
Require prolonged treatment – initially at least 10-14 days
***Treatment should not be started until C&S results are received
***Males should be re-cultured 4-6wks after treatment to ensure cure
TMP-SMX or fluoroquinolones have both been affective, tailor treatment to the pathogen |
|
|
Term
|
Definition
Physiologic changes increase the prevalence of UTI during pregnancy
Dilation of the renal pelvis and ureters
Decreased ureteral peristalsis
Reduced bladder tone
All of the above cause urinary stasis
In addition increased urine content of nutrients encourages bacterial growth
Asymptomatic bacteriuria occurs frequently and should be treated to avoid pyelonephritis
Amoxicillin, amoxicillin-clavulanate, or cephalexin are all safe choices for 7d duration
Nitrofurantoin, tetracyclines = teratogenic
Fluoroquinolones may inhibit cartilage and bone development
Follow up culture 1-2 wks after treatment and then monthly until gestation is recommended |
|
|
Term
|
Definition
The most common cause of hospital acquired infection
Reasonably preventable no longer reimbursed by CMS
Related to a variety of factors
Method and duration of catheterization
Patient risk factors
Insertion technique
Bacteria get to the bladder in a number of ways
Direct insertion during catheterization
Bacteria may travel up the catheter
Bacteria may get around the sheath that surrounds the catheter in the urethra
Sterile technique is key to prevention of infection
Duration of catheterization is also important
Patients with indwelling catheters acquire UTI’s 5%/day
After 30d the incidence of bacteriuria is ~80-95% |
|
|
Term
|
Definition
Key to treatment is early diagnosis and treatment
Choice of antibiotic and route of administration is determined by:
Age of the child
Severity
Location of infection
Complications
Antibiotic resistance
Main concern with UTI in children is renal scarring ocurring ~15%
Younger children may not have typical symptoms
Urine culture should be obtained prior to treatment
Urine culture in younger children may be obtained via catheter, while clean catch can be used in older children
Young infants, severe dehydration, vomiting, or unable to take oral medication should be hospitalized for IV therapy
IV antibiotics should be received for at least three days or until culture is negative, or symptoms are relieved
If able to tolerate oral therapy, may switch to an
oral regimen for 7-14d depending on severity
Children with first febrile UTI between 2-24mon
should have a renal bladder ultrasound (RBUS)
Assess for renal scarring
Rule out/in any urinary tract abnormalities i.e.
vesicoureteral reflux (VUR)
Children with recurrent UTI or abnormal RBUS should have further testing done |
|
|
Term
|
Definition
UTI is the second most frequent infection in older adults
Physiologic changes i.e. decreased estrogen, BPH, other co-morbid conditions may contribute to the
prevalence
Because older adults may not be able to express symptoms it is difficult to distinguish between
asymptomatic bacteriuria (ASB) and UTI
ASB is frequently treated and leads to increasing resistance in this population
Pharmacists need to be vigilant in antibiotic stewardship to decrease the unnecessary tx of ASB
One proposed algorithm |
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|
