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Other Topics EXAM 3
Other Topics EXAM 3 - Bratcher
79
Pharmacology
Graduate
04/16/2012

Additional Pharmacology Flashcards

 


 

Cards

Term
gestational age
Definition
weeks of gestation
Term
postnatal age
Definition
chronological age
Term
postmenstrual age
Definition
gestational age + postnatal age
Term
preterm
Definition
< 38 weeks gestation
Term
term
Definition
38-42 weeks gestation
Term
post-term
Definition
> or equal to 43 weeks gestation
Term
birth weight categories
Definition
low birth weight: < 2.5 kg

very low birth weight: < 1.5 kg

extremely low birth weight: < 1 kg
Term
pharmacokinetic considerations in pediatric patients: absorption
Definition
higher gastric pH
higher pH causes weak acids (phenobarbital) to be harder to absorb

immature conjugation and transport of bile salts
biliary conjugation and bile salts help absorb lipophilic drugs

immature intestinal enzymes and efflux transporters

larger body surface area to body mass ratio
increased absorption of topically applied medications
Term
pharmacokinetic considerations in pediatric patients: distribution
Definition
higher total body water = larger Vd for water soluble drugs
aminoglycosides are water soluble; larger Vd requires a larger dose to reach a therapeutic peak

lower plasma protein levels = increased free fraction of protein bound drugs = more active drug
Term
pharmacokinetic considerations in pediatric patients: metabolism
Definition
phase I enzyme development:
P450 - caffeine, midazoleam, phenytoin are not metabolized as quickly

phase II enzyme development:
conjugation reactions - morphine, acetaminophen are not metabolized as quickly
Term
pharmacokinetic considerations in pediatric patients: excretion
Definition
glomerular filtration rate increases rapidly with age

[image]

tubular secretion
Term
newborn care: APGAR scoring
Definition
A = activity (muscle tone)
0: absent
1: arms and legs flexed
2: active movement

P = pulse
0: absent
1: below 100 bpm
2: above 100 bpm

G = grimace (reflex irritability)
0: no response
1: grimace
2: sneeze, cough, pulls away

A = appearance (skin color)
0: blue-gray, pale all over
1: normal, except for extremities
2: normal over entire body

R = respiration
0: absent
1: slow, irregular
2: good, crying
Term
newborn care: "eyes and thighs"
Definition
erythromycin 0.5% ophthalmic ointment
prevention of gonococcal ophthalmia

vitamin K 0.5-1 mg IM
prevention of vitamin K deficient bleeding
small % of the population have vitamin K deficiency; recommended that all neonates get this to prevent bleeding
Term
newborn care: hepatitis B
Definition
mother's hepatitis B status: positive
infant birth weight: any
hepatitis B vaccine: give immediately
hepatitis B immunoglobulin: give immediately

mother's hepatitis B status: unknown
infant birth weight: < 2 kg
hepatitis B vaccine: within 12 hours of birth
hepatitis B immunoglobulin: within 12 hours of birth

mother's hepatitis B status: unknown
infant birth weight: > 2 kg
hepatitis B vaccine: within 12 hours of birth
hepatitis B immunoglobulin: within 7 days of birth
Term
neonatal intensive care: common neonatal disease states
Definition
neonatal seizures

neonatal abstinence syndrome (NAS)

respiratory distress syndrome (RDS)

apnea of prematurity

patent ductus arteriosus (PDA)

persisten pulmonary hypertension of the newborn (PPHN)

necrotizing enterocolitis (NEC)

neonatal sepsis
Term
neonatal seizures: incidence
Definition
they are more likely to occur during the neonatal period that any other time int he human lifespan

incidence: 1-3.5 per 1000 births
Term
neonatal seizures: etiology
Definition
hypoxic ischemic encephalopathy
hypoxic brain injury that occurs during delivery
ex. cord wrapped around infant's neck, stuck in birth canal

stroke (arterial or venous)

intracranial hemorrhage
may be from birth trauma

meningitis

metabolic disorders
hard to diagnosis unless there is a family member with the same disorder

drug withdrawal

neonatal seizure syndromes
similar to epilepsy but presents earlier int he neonatal period
Term
neonatal seizures: treatment
Definition
first line agent = phenobarbital

is it really the best option?
phenobarbital has the most literature; controversial whether it is the best option (can cause respiratory depression)

second line agents:
fosphenytoin
midazolam
lidocaine
levetiracetam
topiramate

levetiracetam and topiramate have better side effect profiles but not a lot of literature out yet

topiramate may be neuroprotective and may be an advantage to these neonates
Term
neonatal seizures: long term effects
Definition
neuroapoptosis (killing brain cells) occurs with fosphenytoin, midazolam, and phenobarbital
Term
neonatal abstinence syndrome: scope of the problem
Definition
illicit drugs: 4.5% of pregnant women reported recent use of illicit drugs

non-illicit drugs:
15.3% of pregnant women reported tobacco use
2.3% of pregnant women use SSRIs
~1% of pregnant women use prescription narcotics

~12,000 infants impacted in 2008
Term
neonatal abstinence syndrome: mechanism
Definition
signal transduction occurs when adenylate cyclase converts ATP to cAMP or when Ca enters the sensory neuron of the autonomic nervous system through voltage gated channels

release of glutamate or substance P

potassium influx re-polarizes the neuron

painful stimulus: AC converts ATP to cAMP -> influx of Ca and release of neurotransmitters; after it is released the cell is repolarized with K

opioids prevent AC from coming in and there is no release of the neurotransmitters

because of decreased neurotransmitters, the postsynaptic receptors increase their surface area to make it more likely that they will bind to a neurotransmitter (leads to tolerance)

additionally, alternative pathways can be made postsynaptically

when the opioids are taken away there is an exaggerated response to pain
Term
neonatal abstinence syndrome: clinical presentation
Definition
75-100%
jitteriness
irritability
hyperactivity
hypertonicity
decreased sleep
shrill cry
excessive suck

25-75%
poor feeding
vomiting
diarrhea
sneezing
tachypnea
sweating

< 25%
fever

rare
seizures
Term
neonatal abstinence syndrome: impact of pharmacokinetic properties on timing and duration of withdrawal

IMMEDIATE
Definition
cocaine, methamphetamine, other stimulants

ADRs due to intoxication, not withdrawal (b/c drugs have such a short t1/2 that there isn't enough time to develop withdrawal symptoms)

symptoms occur immediately after birth and abate over several hours

nearly all infants experience symptoms

small percentage require treatment
Term
neonatal abstinence syndrome: impact of pharmacokinetic properties on timing and duration of withdrawal

EARLY
Definition
heroin

symptoms appear within hours and abate quickly

60-90% of neonates experience symptoms

most don't require treatment b/c it goes away relatively quickly
Term
neonatal abstinence syndrome: impact of pharmacokinetic properties on timing and duration of withdrawal

MEDIUM
Definition
SSRIs:

pronounced symptoms within 1-2 days of birth and abate over several days

30-60% of neonates experience symptoms

signs: EEG abnormalities, jerkiness, hyperreflexia, respiratory distress, shivering, hypothermia, high pitched cry, hypotonia, vomiting, screaming, trouble breathing, crying, posturing, tachypnea, seizures, agitation, tremor, trouble feeding, jitteriness, hypertonia, irritability

alcohol:

symptoms appear within 12-24 hours and persist for about 1 week

hypersensitivity to sensory stimulation and seizures are common in severely effected neonates

tobacco:

symptoms appear within 48 hours of life and abate slowly

greater number of cigarettes per day = greater signs of withdrawal
Term
neonatal abstinence syndrome: impact of pharmacokinetic properties on timing and duration of withdrawal

MEDIUM TO LATE
Definition
methadone:

symptoms appear late (~2-3 days) and abate slowly

reports exist describing onset of withdrawal at 4 weeks and persistence of symptoms up to 6 months

~80% of infants experience symptoms

~50% require treatmnet

t1/2 of methadone is long and variable

morphine is the DOC for treatmnet

buprenorphine:

symptoms appear ~2 days of life and peak 3 days

similar incidence of withdrawal and treatment to methadone

kinetically straight forward and no QT prolongation concern

morphine is the DOC for treatment
Term
neonatal abstinence syndrome: impact of pharmacokinetic properties on timing and duration of withdrawal

LATE
Definition
methadone + tobacco

methadone exposed mothers who are heavy smokers (> 20 cigarettes per day) have infants with higher peak scores

4-5 days vs 2 days
Term
neonatal abstinence syndrome: impact of pharmacokinetic properties on timing and duration of withdrawal

EXTRA LATE
Definition
long acting barbiturates

onset of 7-14 days of life and persistence of symptoms for several months

incidence difficult to estimate because of late onset; most of the time the infants are at home when they start presenting with symptoms
Term
neonatal abstinence syndrome: impact of pharmacokinetic properties on timing and duration of withdrawal

POLY-SUBSTANCE ABUSE
Definition
timing is unpredictable

reports suggest that 62% of illicit drug using women took a combination of heroin, cocaine, benzodiazepines, alcohol, marijuana, and methadone during pregnancy
Term
neonatal abstinence syndrome: non-pharmacologic treatment
Definition
quiet, dark environment

swaddling

prone positioning

feeding (higher caloric needs b/c of jitteriness)
Term
neonatal abstinence syndrome: pharmacologic treatment
Definition
morphine
methadone
buprenorphine
diazepam
phenobarbital
clonidine

receptor appropriate therapy is superior!
Term
neonatal abstinence syndrome: pharmacologic treatment

morphine
Definition
morphine is superior to phenobarbital

morphine has a shorter duration of therapy (8 vs. 12 days)

morphine had a trend towards fewer treatment failures (35% vs. 47%)

morphine had fewer NICU admissions (30% vs. 62%)

morphine t1/2 = 4-8 hours

morphine can stunt growth (decreased body weight, decreased brain weight, decreased cerebral width, decreased cerebellar weight, and decreased cerebellar width)

morphine can also cause neuroapoptosis in neonates

[image]
Term
neonatal abstinence syndrome: pharmacologic treatment

methadone
Definition
t1/2 = 19 +/- 14 hours

retrospective studies find equivalence to morphine

BBW: potentially fatal QT prolongation

difficult to determine when to wean and dosing

have to monitor EKGs!!!
Term
neonatal abstinence syndrome: pharmacologic treatment

buprenorphine
Definition
t1/2 = 20 +/- 8 hours

24 infants randomized to buprenorphine vs. oral morphine

mean lengths of treatment 23 days vs 38 days

mean length of stay 32 days vs. 42 days

solution prepared by mixing buprenorphine injection in 100% ethanol and diluting with simple syrup (final alcohol content 30%)

buprenorphine is promising but there isn't a good way to administer this drug
Term
neonatal abstinence syndrome: pharmacologic treatment

diazepam
Definition
potentially useful in poly-substance abuse

higher rate of treatment failure compared to morphine and phenobarbital

may not help with the receptor that the patient is withdrawing from, but can blunt some of the withdrawal symptoms
Term
neonatal abstinence syndrome: pharmacologic treatment

phenobarbital
Definition
inferior to morphine in trials

longer duration of therapy, more treatment failures

drug of choice for alcohol or barbiturate withdrawal (receptor appropriate therapy)

improves length of stay, symptoms, decreases opiate use when used as adjunctive treatment
Term
neonatal abstinence syndrome: pharmacologic treatment

clonidine
Definition
case series of 7 infants with methadone exposure
6/7 achieved control with no reported ADRs

clonidine vs. placebo as adjunct to opiates
shorter length of stay, lower treatment failures
no ADRs reported

neuroprotection?
in patients that are suffering from withdrawal (dangerous to the growing brain) can be protective to their developing brains
Term
respiratory distress syndrome
Definition
caused by surfactant deficiency and pulmonary immaturity

clinical signs:
tachypnea, grunting, retractions, cyanosis, increased oxygen requirements

lungs are the last organ to develop in utero

in premature newborns, the lungs are often exposed to several sources of injury, both before and after birth

such exposures - as well as genetic susceptibility to problematic lung development - may cause direct airway and parenchymal damage and induce a deviation from the normal developmental path

depending on the timing and extent of the exposures, lung injury may range from early developmental arrest (new bronchopulmonary dysplasia) to structural damage of a relatively immature lung (old bronchopulmonary dysplasi)

premature infants born at a gestational age of 23-30 weeks (region shaded light red) - during the canalicular and saccular stages of lung development - are at the greatest risk for bronchopulmonary dysplasia

[image]

antenatal exposures: steroids, chorioamnionitis, intrauterine growth restriction

postnatal exposures: ventilator induced lung injury, oxidative stress, infections, steroids, pulmonary fluid overload, nutritional deficits

respiratory distress is due to surfactant deficiency and pulmonary immaturiry

canalicular stage (16-23 weeks gestation)

saccular stage (23-32 weeks gestation)
surfactant has not been produced yet

alveolar stage (32-38 weeks gestation)
full development of the lungs
Term
respiratory distress syndrome: incidence of RDS by gestational age
Definition
[image]

the younger they are, the increased risk of respiratory distress
Term
respiratory distress syndrome: treatment

antenatal steroids
Definition
betamethasone 12.5 mg IM q24h x 2 doses

indicated for women in preterm labor at 23-24 weeks gestation

decreases incidence of RDS, intraventricular hemorrhage, and death

speeds up process of lung development
Term
respiratory distress syndrome: treatment

surfactant
Definition
surfactant coats the alveoli and decreases surface tension

preterm babies have decreased surfactant production

surfactant from the preterm lung contains as percent composition less saturated phosphatidylcholine, less of the surfactant proteins, and more phosphatidylinesitol

surfactant helps with gas exchange by decreasing surface tension on the alveoli

[image]

type II cells make surfactant

liquid can inactivate the type II cells and less surfactant is produced

surfactant products:

Curosurf - organic solvent of pig lung

Exosurf - synthetic

Infasurf - lipid extract of calf lung lavage

Survanta - lipid extract of calf lung + synthetic lipids

Exosurf is the only synthetic product, the rest are animal derived

animal derived products are more effective

after surfactant administration via an endotrachial tube it works very quickly

the chest x ray of a neonate 2.5 hours after administration of surfactant demonstrates marked improvement in lung function
Term
apnena of prematurity
Definition
cessation of breathing > or equal to 30 seconds

cessation of breathing > or equal to 20 seconds + bradycardia (HR < 100 bpm)

cessation of breathing (any duration) if hypoxemmia present (SaO2 < 85)
Term
apnena etiologies
Definition
hematologic:
anemia

CNS:
IVH, seizures, hypoxemia, hypo/hyperthermia, depressant drugs

respiratory:
obstruction, pneumothorax, hypercarbia

cardiovascular:
hypotension, heart failure, hypovolemia

GI:
reflux, abdominal distention

infection:
pneumonia, sepsis

metabolic:
hypoglycemia, hypocalcemiam, hyponatremia

idiopathic:
apnea of prematurity

sepsis is the #1 differential diagnosis for apnea of prematurity
Term
apnena of prematurity: non pharmacologic treatments
Definition
respiratory support:
ventilator
CPAP

positioning:
supine vs. prone position
Term
apnena of prematurity: pharmacologic treatment
Definition
methylxanthines (theophylline/caffeine)
Term
apnena of prematurity: treatment

caffeine
Definition
increases central respiratory drive

improves respiratory muscle function

diuretic

neuroprotective?
Term
apnena of prematurity: treatment

caffeine vs. theophylline
Definition
advantages of caffeine

broader therapeutic index
caffeine: 5-50
theophylline: 5-20

earlier onset of action

longer t1/2
once daily dosing vs. q8-12h

oral dosage better tolerated with less GI irritation

caffeine is the standard of therapy
Term
Caffeine Therapy for Apnea of Prematurity
Definition
enrolled 2006 infants

gave caffeine citrate 20 mg/kg, then 5 mg/kg/day vs. placebo

if apnea persisted, daily dose could be increased to 10 mg/kg/day

results:

supplemental O2 requirements at 36 weeks lower
36% vs. 47%

ventilator was discontinued one week eariler
31 weeks vs 32 weeks

lower rate of death or neurodevelopmental disability
40.2% vs. 46.2%

rate of cerebral palsy (4.4% vs. 7.3%) and cognitive delay (33.8% vs. 38.3%) lower

use caffeine in all patients who are at risk of apnea of prematurity
Term
patent ductus arteriosus (PDA)
Definition
[image]

PDA is a condition in which the ductus arteriosus does not close (the word "patent" means open)

the ductus arteriosus is a blood vessel that allows blood to go around the baby's lungs before birth

soon after the infant is born and the lungs fill with air, the ductus arteriosus is no longer needed

it usually closes in a couple of days after birth

PDA leads to abnormal blood flow between the aorta and pulmonary artery

instead of going to the lungs, the blood goes back into systemic circulation
Term
patent ductus arteriosus (PDA): incidence
Definition
term infants: 57 per 100,000 live births

preterm infants (<1500 gm): 1 in 3 live births

60-70% of preterm infants < 28 weeks gestation require medical or surgical treatment
Term
patent ductus arteriosus (PDA): diagnosis
Definition
physical exam:
murmur
widened pulse pressures
bounding peripheral pulses

radiologic:
pulmonary edema
cardiomegaly

echocardiogram
Term
patent ductus arteriosus (PDA): clinical consequences
Definition
short term:

pulmonary edema, hemorrhage

decreased urine output and drug clearance

intraventricular hemorrhage

spontaneous intestinal perforation, NEC

long term:

congestive heart failure

chronic lung disease

pulmonary hypertension?

neurodevelopment?
Term
patent ductus arteriosus (PDA): treatment
Definition
nothing - in a small % of patients it will close on its own

NSAIDs

surgical ligation
Term
patent ductus arteriosus (PDA): treatment

COX1 vs. COX2
Definition
COX1 - constitutively expressed

produce prostaglandins for GI mucosal integrity, platelet aggregation, renal funcion

INHIBITION CONSTRICTS DA

COX2 - induce at inflammation site

produces prostaglandins for: pain and inflammation, mitosis and growth, renal function

inhibition does NOT constrict DA

[image]

indomethacin and ibuprofen are the 2 NSAIDs used (greater COX1 to COX2 ratio)
Term
patent ductus arteriosus (PDA): treatment

indomethacin vs. ibuprofen
Definition
MOA: inhibits prostaglandin synthesis throgh cyclooxygenase inhibition

equally efficacious

ADRs:

indomethacin - renal toxicity, platelet inhibition

ibuprofen - chronic lung disease, displaces bilirubin

vasoconstricting the DA (and other blood vessels in the body) = renal toxicity
Term
patent ductus arteriosus (PDA): treatment

surgical ligation
Definition
consequences:

increased chronic lung disease

increased necrotizing enterocolitis

increased retinopathy or prematurity

increased intraventricular hemorrhage

increased cognitive delay

potential vocal cord paralysis
Term
persistent pulmonary hypertension of the newborn (PPHN)
Definition
high pulmonary vascular resistance compared to the systemic vascular resistance

want to decrease PVR and increased SVR

PPHN is the failure of the normal circulatory transition that occurs after birth

it is a syndrome characterized by marked pulmonary hypertension that causes hypoxemia and extrapulmonary shunting of blood

pulmonary hypertension is a normal and necessary state for the fetus because the placenta, not the lungs, serves as the organ of gas exchange

normal cardiopulmonary transition:
a dramatic transition occurs at birth, characterized by a rapid fall in pulmonary vascular resistance and a 10 fold rise in pulmonary blood flow

[image]

oxygen from 1st breath -> NO diffuses from the endothelium to the smooth muscle cells -> cGMP is made -> decreased Ca -> relaxation

oxygen from 1st breath -> prostacylin made through arachidonic acid (COX) -> PGI2 diffuses from endothelium to smooth muscle and activates adenylate cyclase to convert ATP to cAMP -> decreased Ca -> relaxation

this is what should normally happen
Term
persistent pulmonary hypertension of the newborn: incidence
Definition
[image]

MAS = meconium aspiration syndrome
a newborn breathes a mixture of meconium (early feces) and amniotic fluid into the lungs around the time of delivery

incidence of PPHN is 2 in 1000 live birhts
Term
persistent pulmonary hypertension of the newborn: management
Definition
[image]

oxygen is the mainstay of therapy b/c it sets off both sides of the cascade

NO is another therapy (one side of the pathway)
Term
persistent pulmonary hypertension of the newborn: management

nitric oxide
Definition
dose 22 ppm (aerosolized)

ADRs: methemoglobinemia

must be weaned off slowly in order to avoid rebound hypertension!

may stop their own production if given exogenously so must be weaned
Term
persistent pulmonary hypertension of the newborn: management

sildenafil
Definition
[image]

PDE5 breaks down cGMP; if blocked will have increased cGMP = more relaxation of vascular smooth muscle

sildenafil MOA: phosphodiesterase 5 inhibitor which leads to vasodilation

ADRs: hypotension, ocular toxicity
Term
persistent pulmonary hypertension of the newborn: management

milrinone
Definition
[image]

PDE3 on the other side but works the same way (keep cAMP around longer)

milrinone MOA: phosphodiesterase 3 inhibitor which leads to vasodilation; also has inotropic actiivty

ADRs: hypotension
Term
persistent pulmonary hypertension of the newborn: management

epoprostenol (Flolan)
Definition
[image]

exogenous prostacycline

may be given intravenously or inhaled

ADRs: hypotension
Term
persistent pulmonary hypertension of the newborn: management

bosentan
Definition
[image]

endothelin 1 is a vasocontrictor in utero; give something to block ET1

bosentan MOA: endothelin 1 receptor antagonist

ADRs: hypotension, hepatotoxicity

not a therapy of choice
Term
persistent pulmonary hypertension of the newborn: management

adjunctive treatments
Definition
pressors:
increases systemic pressures
possible benefit with norepinephrine
bring systemic pressure up with vasopressors (DA, NE); is not specific to systemic and can increase pulmonary pressure at the same time

surfactant:
beneficial in disease states where surfactant is inactivated - meconium aspiration, pneumonia, surfactant deficienty

sedation
decreases oxygen consumption and agitation

paralytics:
improve ventilator compliance
for very agitated patients who aren't in sync with the ventilator
Term
persistent pulmonary hypertension of the newborn: management

refractory cases
Definition
ECMO: extracorporeal membrane oxygenation

[image]

heart/lung bypass

takes the blood out, go through the oxygenator, back to the baby

have to prime it with blood (b/c the baby doesn't have enough to go through) and this increases the Vd; dosing changes of drugs?
Term
necrotizing enterocolitis: incidence
Definition
1 in 1000 live births

occurs up to 7% of VLBW patients
underdeveloped intestinal motility and immune defenses

morality is 15-30% and even higher in lower birthweight infants
Term
necrotizing enterocolitis: pathophysiology
Definition
[image]

immature intestinal barrier: decreased mucus, decreased IgA, low intercellular junction integrity and increased permeability

exaggerated inflammation and tissue injury -> intestinal necrosis
Term
necrotizing enterocolitis: clinical presentation
Definition
feeding intolerance

abdominal distention

bilious emesis

bloody stools

hemodynamic instability
Term
necrotizing enterocolitis: treatment
Definition
bowel rest

broad spectrum antibiotics

IV nutrition/fluid support

surgical intervention
Term
necrotizing enterocolitis: outcomes
Definition
20-40% require surgical intervention
50% mortality rate in these patients

long term concerns:
disease recurrence
short bowel syndrome
ostomy/stoma
failure to thrive
neurodevelopmental delays
Term
necrotizing enterocolitis: prevention
Definition
breast milk

probiotics?
Term
necrotizing enterocolitis: prevention

probiotics
Definition
oral supplement or food products containing sufficient number of viable microorganisms to alter microflora or the host

common strains:
Lactobacillus, Bifidobacterium, Streptococcus

don't know if it is completely effective or not

[image]

promote GI motility

provide vitamins and short chain fatty acids

promote immune function

probiotics may prevent:
acute infectious diarrhea
antibiotic associated diarrhea
atopic disease (eczema, allergic rhinitis, asthma)
colic
systemic infection
cancer

evidence for NEC:
11 trails including 2176 infants
the risk of NEC was lower (2.4% vs. 6.6%)
the risk of death was lower (3.5% vs. 8.5%)

many products, many strains in each product
not as regulated b/c it is a food product

minor concerns:
products/strains
dose
duration
administration

major concerns:
safety (sepsis reported)
identity
long term impact
Term
neonatal sepsis: common etiologies
Definition
group B Streptococcus
leading cause of neonatal sepsis

Escherichia coli

Listeria monocytogenes
Term
neonatal sepsis: early onset
Definition
before prevention strategies, approximately 80% of sepsis occurred int he first week of life

early onset neonatal sepsis occurs in the first 24-48 hours of life

vertical transmission

risk factors:
maternal vaginal colonization
maternal chorioamnionitis
prolonged rupture of membranes
preterm labor
Term
neonatal sepsis: intrapartum (during birth) antibiotic prophylaxis (IAP)
Definition
all pregnant women should be screened at 35-37 weeks gestation

efficacy up to 90%

candidates:
delivery < 37 weeks gestation
intrapartum fever (>38C)
rupture of membranes > 18 hours
known colonization
group B strep bacteriuria
previous infant with invasive group B strep disease

agents: penicillin G or amipicillin

should be administered at least 4 hours prior to delivery for best efficacy

penicillin allergic patients: cefazolin, clindamycin, vancomycin
Term
neonatal sepsis: other risk factors
Definition
chorioamnionitis:
maternal fever
maternal tachycardia
uterine tenderness
fetal tachycardia

premature rupture of membranes:
baseline risk of sepsis = 2%
24-47 hours of rupture = 7%
> 48 hours of rupture = 11%
Term
neonatal sepsis: diagnosis
Definition
signs:
increased WBCs
left shift
decreased platelets
metabolic acidosis
hyperglycemia
increased CRP, ESR
positive cultures (blood, trach, urine)

symptoms:
lethargy
respiratory distress
apnea/bradycardia
feeding intolerance
temperature instability
coagulopathy
systemic hypoperfusion

[image]
Term
neonatal sepsis: empiric antibiotics
Definition
ampicillin + gentamicin OR cefotaxime

gentamicin:
advantages - narrow spectrum, low rate of resistance
disadvantages - narrow therapeutic index, therapeutic drug monitoring, nephrotoxicity/ototoxicity

cefotaxime:
advantages - CNS penetration, no monitoring
disadvantages - high rate of resistance
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