1

Gm +ve Bacteria

Bacilli

Cocci
Staphylococcus
S.aureus

Corynebacterium
Diphtheria

Streptococcus

(skin, bone, diabetic foot)

MSSA: Cloxacillin,
Gentamycin, Cefazolin,
Clindamycin.
MRSA: Vancomycin,

Clostridium
C.Tetany,
C.difficile
Watchi: gas
gangrene.

Linezolid, Tigecycline).

Gama-Hemolytic
GIT, UTI, Endocarditis

- Hemolytic

- Hemolytic
Pneumonia:
Cefotaxime, Ceftriaxone,
Vancomycin and Ampicillin
Viridans: (Endocarditis,
dental abscess and otitis
media): (Penicillin G,
Ceftriaxone, Vancomycin,
And Gentamycin).

Pyogenes: (nose, throat)

(Penicillin TID*10d)
Gentamycin

E.faecalis: (Imipenem / Cilastatin,

Ceftriaxone + Ampicillin)

E.faecium: (Linezolid, Dalfopristin,

Quinupristin).

Gm -ve Bacteria

Coccobacilli

Cocci-Neisseria
(Cefixime, Ceftriaxone,
Ciprofloxacin, Azithromycin

H.influenza

- Lactamase
inducer2nd, 3rd
Gen Cephalosporin
not affected by
erythromycin

N.meningitidis.

N.gonorrhoea

Atypical Microorganisms: (Have cell wall defect).

Mycoplasma (Pneumonia)
Chlamydia (-ve in culture, eye infection, STI)
(Both: Macrolide, Tetracycline, FQ-alternative)
Legionella (by inhalation (air condition) & in
immune compromised pts) (FQ, Azithromycin,
Doxacycline)

B-lactamase.
Respiratory
Heavy smokers
Elderly.
COPD exacerbation.

Coxiella: FQ,
Doxacycline or 3rd or
4th Gen Cephalosporin.

B-Pertussis

Bacilli

Moraxella Catarrhalis

3rd Gen Cephalosporin,

Carbapenem, Piperacillin /
Tazobactam

Klebsiella
E.coli: UTI, GI, wound
Enterobacter Spp.
V.cholerae
Pseudomonas
B-fragilis

Pseudomonas aeruginosa:
Withstand harsh conditions and up to 42C
Produce green or blue pigmentation.
Grape like odor.
Aminoglycosides, Ciprofloxacin.
Piperacillin / tazobactam.
Ceftazidime.

In all labor there is a profit Pro 14: 23

Anti-Microbial Agents
Cell wall
inhibitors:
Penicillins
Cephalosporins
Vancomycin
Not effective for
Atypical Bacteria.

Cephalosporins

Amoxicillin

(chewable tab, susp more

palatable than Ampicillin)

Ampicillin.

1st Generation: Gm +ve

Cephalexin.
2nd generation:
Cefaclor.
3rd Generation:
Cefotaxime (Q 6-8H0

Ceftriaxone (12-24h)
Ceftazidime (Q 8h)
4th Generation:
Cefepime.

Glycopeptides

Vancomycin

Folate inhibitors

Penicillin G.
Penicillin V.
Methicillin.
Naficillin.
Oxacillin.
Carbenicillin.
Piperacillin.
Dicloxacillin.

Amino Penicillin:

DNA Synthesis
Inhibitors:
Quinolones
Metronidazole

Cell Wall Synthetic Inhibitors

Tips

Drug

Penicillins ( Lactam).

Gp

Protein Synthesis Inhibitors:

30S
Aminoglycosides
Tetracyclines
05S
Macrolides
Lincosamides

Active against GM +ve only.

Administration: on empty stomach (except Amino Penicillin), Excretion: Tubular.
If antacid: Spacing.
Methotrexate level, efficacy of oral contraceptives.
Penicillin G: Non-acid stable Penicillin.
Penicillin G (DOC) in Syphilis, but Tarisch-Heexheimer reaction (fever, chills,
rigors, sweating), resolved 24h.
TTT of TSS, Meningococcal Encephalitis.
Penicillin not effective in Mycoplasma Bacteria.
Narrow spectrum: Amoxicillin, Ampicillin, Cloxacillin and Dicloxacillin.
Carbapenem: (Imipenem, Meropenem, Ertapenem) - Lactam class, DOC in
any broad spectrum resistant microorganism (P.aeruginosa (except Ertapenem),
C.difficile, Klebsiella).
Cephalosporins are nephrotoxic if mixed with Aminoglycosides.
Cephalexin: TTT of cellulitis, Pharyngitis and CAP.
Cefaclor: TTT of serum sickness, DOC in H.influenza & Catarrhalis.
3rd, 4th Gen Gm +ve, Gm ve (P.aeruginosa TTT)
Ceftriaxone& Cefotaxime:
Dont reconstitute or mix with Ca containing soln.
Cause thrombocytopenia due to thiazide side chain.
Cefotaxime is preferred over ceftriaxone in neonates due to hyperbilirubinemia.
Cefixime 200mg Q 12h, 400mg Q 24h.

DOC in MRSA, Clostridium difficile

TTT of TSS (Toxic Shock Syndrome), MRSA, C.difficile (po), osteomyelitis (IV)
Rapid administration: Red man syndrome.
Ototoxic, Nephrotoxic always monitor serum level.
Linezolid (Oxazolidinone) for any Vancomycin resistance (MSRA, C.difficile).

In all labor there is a profit Pro 14: 23

Protein Synthesis Inhibitors

Aminoglycosides

Group

Drug
Gentamycin.
Tobramycin.
Streptomycin.
Kanamycin.
Amikacin.
Gentamycin doses:
Conventional:
1.5mg/kg Q8h IV
Extended (Renal failure)
4-7mg/kg once daily IV

Tips

Macrolides.

Erythromycin.
Azithromycin.
Clarithromycin

(Gm +ve, Gm ve & Atypical)

Tetracyclines

Tetracycline.
Doxacycline.
(Lipid sol)
Minocycline.
(Lipid sol)

(Gm +ve, Gm ve & Atypical)

S.E:

The lowest therapeutic index, renal excretion.

Active against Gm ve & Aeruginosa
Has post dose effect due to high plasma binding (not t1/2).
Streptomycin is oral only.
Nephrotoxicity, Ototoxicity, optic nerve toxicity.
Mixing two Aminoglycosides toxicity.
Loop diuretics, Vancomycin also nephrotoxicity.
Monitor renal function, serum level.
Effect of anesthetic agents.
Penicillin its efficacy (Dont Mix in one syringe).
Not penetrate pulmonary tissues very well.
Safe in pregnancy, Breast feeding.
Renal& hepatic elimination.
CYP 3A4 Inhibitor.
Mycoplasma (bacteria that lack of cell wall) infection TTT.
Erythromycin Estolate is more absorbed than regular Erythromycin,
but cause Jaundice (cholestatic hepatitis) C.I in pregnancy.
Clarithromycin: oral only (Dont shake, dont fridge).
Azithromycin: fridge make it palatable (numb taste)
CI: with Digoxin, SAL, Corticosteroids and carbamazepine.
TTT of Acne, Lyme, Chlamydia, Rickettsia, Mycoplasma pneumonia
and dental works.
Photo sensitive.
Taken in empty stomach, avoid Ca, Fe, AL, Mg
inactivation (except minocycline).
Barbiturate, Carbamazepine, Phenytoin Level.
Lipid sol. agents can be used with renal impairment.
Should be discard when expired (Toxic)

Stain teeth, clothes, Fanconi like syndrome.

Systemic lupus Erythematous, Tinnitus.
Hepatitis, micro vesicular fatty liver.

C.I:

Lincosamide

Clindamycin.
Lincomycin.
(Anaerobic & Gm ve)

Pregnancy, Lactation and Age > 8y (Affects bone growth).

Children developing teeth (Teeth pigmentation).
Renal impairment, Myasthenia Graves, metabolic acidosis.
Mainly Anaerobic and MSSA
TTT of Acne, TSS, Osteomyelitis, Diphtheria.
Alsalts: absorption
Effect of anesthetic agents.
Clindamycin is the most causative of C.difficile (pt is counseled if
you get bloody diarrhea go to emergency).

In all labor there is a profit Pro 14: 23

DNA Synthesis Inhibitors

Gm +ve, Gm ve & Atypical Except

(Streptococci)

Fluroquinolones

Group

Drug

Tips

1st Generation:
Nalidixic Acid.
Norfloxacin (UTI)
2nd Generation:
Ciprofloxacin (P.aeruginosa)
Ofloxacin (STI)
3rd Generation: (Respiratory)
Gatifloxacin.
Moxifloxacin.
Levofloxacin.
4th Generation:
Trovafloxacin.

Ciprofloxacin
DOC: STI, Travelers Diarrhea, complicated COPD.
SE: Nephrotoxicity, Cartilage toxicity, Abdominal pain, Nausea,
vomiting and Pseudomembranous colitis, (may cause dysglycemia)
CI: Pregnancy (category C), Age > 18y.
INR if Warfarin ( Ofloxacin as well)
Theophylline, cyclosporine elimination.
caffeine serum level (headache, tremors, BP, restlessness,
insomnia and nervousness)
Avoid: Antacid, Ca, Fe absorption (Levofloxacin,
Moxifloxacin as well).
Photo sensitive.
Levofloxacin& Moxifloxacin:
QT prolongation, mainly respiratory Fluroquinolones.
Moxifloxacin 50% liver, 50% kidney (no nephro toxicity)
Antiprotozoal with anti-anaerobic bacterial, anti-inflammatory,
anti-oxidant actions.
TTT: Giardia Lamblia, Entameba, Trichomoniasis (STI).
Topically for Rosacea TTT.
SE:
Metallic taste, furry tongue, Glossitis.
GI upset, dark urine (or reddish brown).
CI:
Alcohol: Disulfiram like action.
Warfarin: INR.
Cimetidine: t1/2 of Metronidazole.
Dont mix with other drugs in IV.

Metronidazole

Folate inhibitors
Drug

Tips

Sulfamethoxazole (SMX)
Trimethoprim (TMP).
Clotrimazole.

Sulfasalazine.

Sulfisoxazole
(Sulfafurazole).

Antagonize par amino benzoic acid (PABA).

Taken with full glass of water to avoid crystalline urea.
Sulfasalazine discolors urine, skin or lenses (yellow, or orange).
1st trimester: folate teratogenicity.
Last 6wks. Neonatal hyperbilirubinemia.
Methotrexate: Myelosuppression.
Phenytoin level.
Doc for pneumocystis (PCP) in HIV pts.

Before starting AB we should investigate for:

Allergy Pregnancy Birth control (as most AB contraceptive efficacy
Advise pt to use back up method during the TTT period.

In all labor there is a profit Pro 14: 23

Infectious Diseases
1-Otitis Media
Pathogen, Symptoms & Treatment

Tips

Pathogens:
Streptococcus Pneumonia (20% self-limiting)
Haemophilus Influenza(50% self-limiting)
Moraxella Catarrhalis (75% self-limiting)
Symptoms:
Fever, pain, irritability (new born).
Goal of therapy:
Relieve symptoms.
Sterilize the middle ear.
To prevent complications (Mastoiditis,
intracranial infection and facial paralysis).
Avoid inappropriate therapy which may lead to
resistant pathogen or adverse effects.
Treatment:
DOC: Amoxicillin (3d failure considered as risk
factor)
If risk factors high dose Amoxicillin (3d failure
considered as Resistance.
Resistance amoxicillin/ Clavulanate.
Alternative: Cephalosporin, Macrolides (except
erythromycin as not effective against Hinfluenza)
Macrolides if type1 allergy for amoxicillin.
If mild Allergy: Cephalosporin
If moderate or severe Allergy: Macrolides
If Resistant: Amoxicillin High Dose.
Amoxicillin/Clavulanate.
Age 2 years 0 days TTT
Age > 2years 10 days TTT
Clindamycin can be used as alternative but
covers only streptococcus pneumonia.

Risk factors include:

Recent AB use (within last 3mo).
Daycare attendance.
Recent episode of AOM (Acute Otitis Media)
TTT failure (consider if 3days TTT
without improvement).
Early recurrence.
Watchful waiting for 2-3days for all pts except:
Age > 6 mo, refer directly to
Emergency.
Risk factor.
Other Recommendations:
Vaccination is recommended
routinely.
Decongestants and Antihistamine
have no shown efficacy in TTT.
Analgesics, antipyretics if needed.
Diarrhea may appears as side effect of
combination.
Counselling Pt with Amoxicillin:
Finish the AB.
Taken with/without food.
GI upset, loose stool.
Rash.
NB:
Toxic appearance if temp < 39C,
severe Otalgia.

In all labor there is a profit Pro 14: 23

2-Sore Throat (Acute Pharyngitis)

(+ve Throat culture is the only predictive feature).

Pathogen

Treatment

Bacterial (Strep Throat):

Group A -Hemolytic Streptococci

(GAS)
Group C&G -Hemolytic
Streptococci
Nisseria gonorrhea
Mycoplasma pneumonia
Chlamydia trachomatis
Chlamydophila pneumonia
Corynebacterium diphtheria
Arcanobacterium hemolyticum.

Viral:
Adenoviruses, Enteroviruses,
Influenza, Herpes simples,
Parainfluenza,
Cytomegalovirus, Epstein.

Tips

Non Pharm:
Strict hand washing.
Exclude from school,
daycare 24h after AB starts.
Strep Throat:

Penicillin (DOC): 10days

(Suspension has poor palatability)
Amoxicillin.
Cephalosporins.
Macrolides.
Clindamycin & Rifampicin
may be added to the final
4 days TTT of Penicillin to
interrupt chronic
pharyngeal carriage of
Group A Streptococci.

Differentiation between strep

throat and viral pharyngitis is very
difficult (only by culture or watching
period 3d)
Streptococcal serology is not useful
in acute sore throat but useful in
patients who have possible
complications (Rheumatic fever).
Erythromycin Estolate is contra
indicated in pregnancy as high risk
of cholestatic hepatitis.
Acute Rheumatic Fever may be
developed after mild or subclinical
streptococci infection.

3-Acute Bronchitis
Pathogen

Treatment

Tips

Viral infection < 90% :

RSV (Respiratory Syncytial Virus).
Parainfluenza.
Coronavirus.
Enterovirus.
Influenza.
Rhinovirus.
Non Pharm:
Patient education
Avoid tobacco & pulmonary
irritants.
Strict hand-washing technique.
Humidifiers to reduce cough

Analgesics & Antipyretics:

Acetaminophen.
Ibuprofen.
Antitussive:
Codeine.
Hydrocodone.
Dextromethorphan
(Not recommended > 12 y)
Bronchodilator:
-2 Agonist (salbutamol
& terbutaline).
Antibiotic:
Not recommended as it has no
impact on duration, severity, or
prevention of complications
(pneumonia, otitis media).

Investigation:
Cough (wet or dry).
Wheezing, Tachypnea,
Respiratory Distress, Hypoxemia.
Absence of tachycardia, and
presence of tachypnea (< 24
breath/m) and fever (< 38C)
suggests acute bronchitis.
Fever< 38C and abnormal breath
sound also suggest Pneumonia.
Chest X-ray to emphasize.
Pelargonium sidoides herbs may
be useful in TTT (symptoms and
severity)
Annual influenza vaccine is
recommended in high risk groups.

(Humidifier is recommended also if rhinitis

but not recommended in Asthma).

Fluid intakes to prevent

dehydration in children.
In Pregnancy:
NSAIDs increase the risk of premature closure of the ductus arteriosus.
Codeine cause respiratory depression.

In all labor there is a profit Pro 14: 23

4-Sinusitis
Allergic Viral Fungal - Bacterial

Pathogen

Treatment

Community acquired bacterial

Sinusitis:

Streptococcus pneumonia.
Haemophilus influenza.
Moraxella Catarrhalis (more
common in children).
Staphylococcus aureus.
Enterobacteriaceae.

Analgesics:
Acetaminophen & ibuprofen to
control pain.

Decongestant:

Non Pharm:

Saline Irrigation.
Rest and Hydration.
Warm facial packs.
Adding pine oil or menthol
preparation to steam
treatments.
Elevate the head of bed during
sleeping.

Pregnancy rhinitis de novo

usually disappear within 2
weeks after delivery.
Non pharm
Acetaminophen or Ibuprofen.
Topical decongestant.
Amoxicillin (DOC) or
Amoxicillin/Clavulanate.
SMX/TMP if used in 1st
trimester causes antifolate
teratogenicity and in the last 6
weeks it leads to neo -natal
hyperbilirubinemia.
Doxycycline cause teeth
discoloration.
Clindamycin, Macrolides are
safe but have poor efficacy.

Breast Feeding:

Antihistamines:

Avoided in acute phase as they

cause excessive dryness with
thickening of secretions and
crusting.
Second generation can be used
in chronic phase.

Corticosteroids:

Pregnancy Management:

Topical 3-5 days only (to prevent

rhinitis medicamentosa)
Oral is not recommended for
children > 6 years, Uncontrolled
Hypertension and elders.

The same regulations in

pregnancy but:
Oral decongestants reduce
milk production.
SMX/TMP is safe.

Are controversial, but nasal

corticosteroids may have benefits in
allergic rhinosinusitis and chronic
sinusitis due to their ability to
decrease nasal edema and
inflammation thus promote drainage.

Tips

Antibiotic Therapy:
Acute sinusitis:

Watchful period is 10days (70%

will resolve without antibiotic).
DOC is Amoxicillin (10-14d).
Amoxicillin-Clavulanate for
resistant cases.

Duration of TTT:

4-14 days
Some physicians continue TTT
for additional 7 days to eradicate
bacteria and prevent relapse.
Some physicians give several
different antibiotic for short
term TTT.

Chronic Sinusitis:
Antibiotic if only nasal purulence
present.

Acute (4 weeks)
Chronic (12 weeks)
(Unresponsive to TTT)
Recurrent: 4 or more episodes
in one year.
Acute sinusitis can be mixed in
diagnosis with viral upper
respiratory tract infectionURTI (common cold).
Acute sinusitis may associate
with concurrent dental
disease.
Color of nasal discharge cant
be used in bacterial diagnosis
as it related to presence of
neutrophils not bacteria.
Nasopharyngeal swap culture
not recommended as poor
correlation with sinus
pathogens.
X-ray & CT cant differentiate
between viral URTI and
bacterial sinusitis.
If no improve after 72 h with
the first line therapy switch to
the second line.
If the pt. receive antibiotic
within the last 3 months,
choose another class to avoid
multi drug resistant
s.pneumonia.
Presence of tenacious, thick,
brown nasal secretion refers
to fungal infection.
Cephalexin not recommended
as empiric TTT in otitis media
or sinusitis.
Clindamycin in chronic cases
only.

Refer to ENT specialist if:

2nd line therapy failed.

4 or more episode per year.
Not responding chronic
sinusitis.
Pt. with anatomic anomalies.
Developing of complications

In all labor there is a profit Pro 14: 23

5-Influenza
Typical season in Canada runs from October to April.

Pathogen

Management
Influenza vaccine: < 6 months

Influenza A.
Influenza B.
Adenovirus.
Para-influenza.
RSV.

Non Pharm:

Wash hands often &Hand

Sanitizer.
Cough& sneeze into tissue
or sleeve.
Stay home from work or
school.
Dont visit hospitals or
nursing homes.

If in nursing home:

Staff& visitors proper hand

washing (or sanitizers).
Confine ill residents to
their rooms.
Environmental controls
(more frequent cleaning).
Annual influenza
vaccinated staff care the ill
residents if possible, or
specify a staff member to
the ill ones or care for the
well individual 1st.
Limit meeting and
gathering activities.
Limit visitors.
Ill staff stay at home.

From October to mid-November,

Recommended for All people
Specially:
At risk of influenza
complications & and
people in contact to them.
With risk factors (CHF,
Diabetics, Cancer,
Immunodeficiency,
Renal).
Provide essential
community services (Police
officers, Fire fighters).
Travelers.
Nursing home residents.
Age < 65 years.

Antiviral Agents:
Given when outbreak of influenza
to all residents regardless they are
vaccinated or not.

Tips

Influenza A:
Amantadine.
(Not currently recommended due
to resistance).

Influenza A & B:
Neuraminidase Inhibitors:
Oseltamivir (DOC).
Zanamivir.

Children > 5Years, may

have GIT symptoms also
(Nausea, Vomiting,
Diarrhea).
Usual duration of
symptoms of influenza is
4-6 days.
Neuraminidase inhibitors
reduce duration of
symptoms by 24-60 hours.
TTT should be started
within 48 hours of onset
symptoms and last for 5
days.
Immunization of pregnant
woman protect infants
following birth.
Oseltamivir& Zanamivir
are pregnancy category C
drugs (No clinical studies
for safety).
Oseltamivir is
recommended over
Zanamivir as its better
delivered to respiratory
infected tissues.
Antiviral is not a substitute
to vaccine.
Influenza surveillance
information are provided
by Flue Watch Program
from HAC.
Oseltamivir capsule can be
opened and mixed with
sweetened liquid.

Amantadine SE: *Confusion, nausea, vomiting, loss of appetite, ataxia, insomnia and seizures (CI).
Oseltamivir SE: *Nausea, vomiting and headache.
Zanamivir SE: *Headache, dizziness, GIT disturbance, Cough and bronchospasm (CI).
Vaccines:
Flue like symptoms, ORS (Oculorespiratory symptoms: red eyes, breathing symptoms or facial swelling)
Monitor INR and Theophylline blood levels.

In all labor there is a profit Pro 14: 23

6-Community Acquired Pneumonia (CAP)

Pathogen

Treatment

Strep. Pneumonia (50%).

Staph. Aureus
Gram +ve
Legionella spp.
Mycoplasma pneumonia Atypical
Chlamydia.
Moraxella Catarrhalis.
H.influenza
Gram -ve
E.coli
Klebsiella.
Elderly
Enterobacter spp.
Pseudomonas aeruginosa.
Aspiration: Anaerobic (Alcoholics)
RSV

*Symptoms:

Cough, Shortness of breath, Sputum.

Fever, chills, headache, myalgia.

Investigation:

Influenza like symptoms + respiratory

rate 30 breaths/minute.
Chest X-ray, Culture, CBC.
Pneumonia specific severity of illness
(PSI) score: if 90 TTT outpatient,
if more TTT in hospital.
CURB-65 criteria predicts risk of
death (Confusion, Blood Urea < 11.
Respiratory rate < 30, SBP > 90, Age <

Goal of therapy:

SMRT-CO predicts which pt. require

intensive respiratory or vasopressor
support (IRVS).

ICU Required CAP

Aspiration pneumonia:

1.
2.

Aspiration of gastric content,

usually sterile due to gastric acid.
Aspiration of oropharyngeal flora
into the lung with resultant
bacterial infection.

Methicillin-Resistant
Staphylococcus Aureus(MRSA)
Gram ve Bacilli: (E.coli, Klebsiella,
Enterobacter, Serratia, Pseudomonas).

H.Influenza.

*Aspiration Pneumonia:
If pts.:

Have poor dental hygiene

*Periodontal disease: anaerobes
* Or Edentulous (mouth burning
sensation): S.Viridens.
Have putrid sputum.
Alcoholics: anaerobic infection.
Prevention of Aspiration Pneumonia:
Chin down posture during
swallow.
Mouth hygiene.
Elevation of bed head

TTT:

65)

Assess severity of pneumonia

Eradicate pathogen.
Relieve symptoms.
Recognize, TTT complications
meningitides, osteomyelitis,
endocarditis, COPD, SIADH.

Tips

Metronidazole.
Clindamycin.
-lactam /-lactamase inhibitor.
Carbapenems + Fluroquinolones
with anaerobic activity
(moxifloxacin).

*MRSA:

Vancomycin (DOC).
Linezolid.
Tigecycline I.V: (tetracycline
related) improve lung
inflammation and reduce
pulmonary cytokines and
chemokines but excluded in
severe cases due to lack of data.
Daptomycin: inactivated by
pulmonary surfactant.
In severe PVL-producing MRSA:
Clindamycin + anti-MRSA to
block toxin production.

Start 4-8h of symptoms with

empirical AB (Erythromycin is not
effective in H.influenza).
Mycobacterium Tuberculosis is an
uncommon.
Streptococcus Pneumonia
accounts 50% of CAP that
required hospital admission, and
about 70% in those who required
home TTT.
Elderly: mainly anaerobic Gm-ve
bacilli.
Presence of underlying diseases
(DM, COPD, CHF) or homeless
cases Hospital admission.
Early mobilization during CAP
management can reduce length
of stay.
Aminoglycosides cant penetrate
pulmonary tissue very well.
Respiratory Fluroquinolones
(Levofloxacin& Moxifloxacin)
prolong QT interval so avoid with
SVTC.
Ceftriaxone: avoid with calcium
containing soln.

Erythromycin not used if COPD

Prevention of CAP:

Smoking cessation.
Influenza vaccine.
Pneumococcal Vaccine (PSV).

PSV booster dose:

In all labor there is a profit Pro 14: 23

Not recommended unless Chronic

renal Failure, or
Immunosuppression.
After 5 years in those age < 10
years.
After 3 years for age 10 years.
After 5 years for age < 65 years if
vaccine taken before age 65
years.

10

Pregnancy & breast feeding

Management ( 5days TTT) :

Group at high risk of death due to

complications are:

*H1N1:

23-valent capsular PSV is

recommended if risk factors.
Macrolides are recommended.
Amoxicillin (+Clavulanate if
lactamase resistance).
Fluroquinolones.
MSRA: Add Vancomycin.
Pseudomonas: Piperacillintazobactam or cefepime +
aminoglycoside + azithromycin.

Oseltamivir (DOC).
Zanamivir.
If complications:

Add proper AB (mainly due to

S.pneumonia, Gp A streptococcus or
S.aureus).

Risk Factors:

Morbidly obese.
Pregnant women.
Aboriginals.

Empyema: is the presence of pus in

the pleural cavity.

Ab within last 3mo.

Ab failure.
Age > 2 & < 65
Daycare child.
CVD, DM, Liver or renal
dysfunction.
Immune suppressive.
Alcoholism.
Chronic use of corticosteroid

Management of CAP
Out patient

In-patient

No-risk factors:
Macrolides po.
Doxacycline po (CI in pregnancy).
Risk factors:
Fluroquinolone (ciprofloxacin is not
effective with S. pneumonia).
High dose Amoxicillin + Macrolide.
Amoxiclave + Macrolide.

In Ward:
Fluroquinolone (Levofloxacin 750 once daily*5d)
High dose Amoxicillin + Macrolide.
Amoxiclave + Macrolide.
ICU: (septic shock requiring vasopressor, acute respiratory failure, aspiration pneum.)
- lactam IV + Macrolide IV
(Cefepime, Imipenem, Meropenem, Piperacillin /Tazobactam)

- lactam IV + Fluroquinolone IV
ICU + Pseudomonas:
- lactam IV + Ciprofloxacin IV
- lactam IV + Aminoglycoside IV + Macrolide IV.

Duration of Antibiotic Therapy

TTT starts I.V until the pt. becomes afebrile for 72 h, the continue P.O until the cavity has closed (12-16 wk)

Ambulatory Basis.
Hospitalized and those respond to TTT within 48 hours.
Bacteremic aerobic Gm-ve Bacilli pneumonia.
Empyema.
Sever Legionnaires, Pseudomonas aeruginosa.

5 days
10 days
14 days
Drainage and TTT for 14 days.
Up to 21 days

In all labor there is a profit Pro 14: 23

11

7-Tuberculosis (TB)
Mycobacterium Tuberculosis

Investigation

Pharmacotherapy

Mantoux test:
Intra-dermal administration of 5 TU
PPD (Tuberculin units Purified Protein
Derivative) used for:
1-Diagnosis of infection.
2-Diagnosis of disease.
3-Epidemiologic tool.
Mantoux test shouldnt performed if:
1-Prior TB history.
2-Extensive burns or eczema.
3-Major viral infection.
4-Live virus vaccination within
last month.
48-72 hours after inoculation the
widest transverse diameter of
induration (not erythema) is
measured :
If 5mm Groups I, II, III +ve
If 10mm Groups IV, V +ve
False ve results if:
1-Drawing tuberculin material up
in syringes more than 20 minutes
before administration.
2-Exposure of tuberculin to
sunlight.
False +ve if
*BCG (Bacillus) vaccinated person or
*Inappropriate reading technique.
Acid Fast Bacilli (AFB)
3 sputum specimens on 3 consecutive
days in the morning (50% sensitivity).
CSF samples (usually ve).

Vaccination:
Mycobacterium bovis Bacillus Calmette-Guerin (BCG), not used in
Canada as only 50% Efficacy.
Non Pharm:
Adequate nutrition.
Stop alcohol ingestion as it worsen drug-induced hepatitis.
Smoking cessation.
Pharmacological choices:
Latent Infection (LTBI):
INH (DOC) 5mg/kg up to 300mg/d * 9 months
or DOT 900mg twice weekly * 9 months
Rifampin 10mg/kg Up to 600mg/d* 4 months
If liver disease risky person: Monthly test for aminotransferase.
Active TB:
Never use single therapy.
Multiple drug using Direct Observe Therapy (DOT) Technique, used if
the risk of high resistance.
Phase 1:

2months intensive (INH + Rifampin + PZA).

(INH: Isoniazid &PZA: Pyrazinamide).
Phase 2:

Sterilization by INH + Rifampin (4-7 months).

If INH resistance: Ethambutol, Respiratory Quinolones (Levofloxacin,
moxifloxacin) and streptomycin may be added to phase 1 & Linezolid
and streptomycin may be added to phase 2.
TTT is monitored by monthly smear and culture of sputum until 2 ve
consecutive samples.
If pulmonary cavity: continue TTT for minimum more 9 months to
prevent relapse.
2nd line drugs are: Cycloserine, ethionamide, p-aminosalicylic acid,
amikacin and carpeomycin.
Pregnancy TB management:
TB latent test not indicated for pregnant woman except if her at high
risk of infection.
Woman receiving LTBI should avoid pregnancy.
INH + Pyridoxine daily or twice weekly*9mo is the preferred regimen,
and monitor for hepatotoxicity.
Breast feeding TB management:
INH, Rifampin and Ethambutol are with small concentration in milk.
If TTT with INH, Mother and infant should supplied with pyridoxine.

In all labor there is a profit Pro 14: 23

12

Tips

HIV +ve person: blood culture and stool sample may yield +ve TB cultures.
Interferon Gama Release Assays (IGRAs) are not used to diagnose active TB in adults.
Latent TB Infection (LTBI) is symptomatic but non-infectious.
Rifampin/Pyrazinamide 8 weeks of prophylaxis course has no longer recommended due to resistance and
liver injury lead to death.
Interruption of TTT in initial phase for 14days or < 3 mo in continuous phase, restart the TTT regimen
Initiate TB medication first then ART within 4-8wks to risk of immune reconstitution inflammatory syndrome.
Children with TB are not contagious.
Ethambutol not recommended for children.
Corticosteroids are indicated only for meningeal, Pericardial, pleural, adrenal TB.
Administration of Pyridoxine with INH prevent peripheral neuropathy.
Streptomycin is teratogenic and ototoxic.
All other drugs are pregnancy class c.
HIV patients:
Rifabutin (least potent enzyme inducer) is the DOC, as Rifamycins may the plasma level of PI, NNRTIs
The ART should be initiated before complication of Anti-TB regimen to reduce the risk of mortality.
Initiate ART within 2-4 wks if CD > 200 (> 50 in new guidelines).

Latent infection can be reactivated by:

Tuberculin skin test (TST) if age 2years.

HIV (AIDS).
Organ transplantation.
End stage renal disease.
Diabetes Mellitus.
Hematologic malignancies.
Malnutrition.
Use of NTF- or immunosuppressants.
Abnormal chest x-ray.
Current smoking one pack per day.

INH Side effects:

Gynecomastia.
Asymptomatic hepatic aminotransferase and
bilirubin.
Hematologic effect.
GIT upset.
Seizures, drowsiness.
Systemic Lupus Erythematosus.
Toxic Encephalopathy
Mood change.
Peripheral neuropathy (mal nutrition neuropathy
more than INH).
Lymphadenopathy.

Drug-Drug interaction: (INH is CYP450 inhibitor)

INH Hepatotoxicity with Rifampin, acetaminophen and alcohol.

INH Serum level of carbamazepine, phenytoin and theophylline.
Avoid concomitant administration of Rifampin and Etravirine, Nevirapine and Protease inhibitors.

In all labor there is a profit Pro 14: 23

13

8-Bacterial Meningitis
Symptoms

Laboratory investigations

Neonates:
Fever or hypothermia.
Inconsolable crying,
irritability, lethargy.
Seizures, Jaundice, Poor
feeding, vomiting,
diarrhea.
General symptoms:
Fever, severe headache.
Stiff neck, Back pain.
Photophobia.
Unwell sensation
associate with Vomiting.
Purpura or petechial may
be a sign of
meningococcal meningitis.
Neurologic Symptoms:
Seizures, loss of balance,
confusion and altered
level of consciousness.
+ve Kernigs and
Brudzinski signs.
Cranial nerve palsies.
Signs of Intra-Cranial
Pressure (ICP), e.g.
Papilledema.
Signs of cerebral
infarction.

CSF examination +ve if:

WBCs counts with a
predominance of
neutrophils.
CSF glucose.
Normal or CSF
protein.
Gram strain is +ve in (80
-90%) of cases.
Culture is the Gold
standard (-ve result if
pretreated with
antimicrobials).
PCR.
CSF lactate elevated (
< 4mmol/L) if infection
after neurosurgery.
Lumbar Puncture (LP) for
CSF examination is contraindicated if CT, MRI or
clinical investigations show:
Elevated ICP
Papilledema.
Focal neurologic signs.
Infection at LP site or
bleeding disorders.

Age Group
Infants > 6 wk.

Tips

Cefotaxime is preferred over ceftriaxone in neonates

theoretically due to hyperbilirubinemia.
Penicillin G is no longer used in Canada due to Penicillin
resistant pneumococci and meningococci.
Cephalosporin resistant pneumococci add Vancomycin
Rifampin to high dose of cephalosporin to enhance
bacterial eradication in CSF.
If Vancomycin + cephalosporin: give cephalosporin 1st to
ensure initial coverage and penetration to CSF.
Use of Dexamethasone decrease the inflammatory
response in CNS, and reducing hear loss in children with
H.Influenza type B and S.pneumonia
Dose: 0.6mg/kg Q6h*2-4d OR 0.8mg/kg Q12h*2-4d
Adult: 10mg/6h*4d OR 0.15mg/kg Q6h*2-4d
TTT should include removal of Venriculoperitoneal shunt.
Ceftriaxone is the DOC in Pregnant women.
Ceftazidime: the cephalosporin DOC for aeruginosa.
Gentamycin add for synergy against GP B streptococcus &
L.monocytogenes.
Vaccines:
The conjugated vaccine against H.Influenza type B.
The conjugated vaccine against S.pneumonia.
The conjugated vaccine against N.meningitidis type C.
Quadrivalent vaccine against N.meningitidis types A, C,
W, Y-135. (Age < 2 years).
Polysaccharide vaccine against Pneumococcal and
meningococcal infections (age < 2 years).
Certain high risk individuals can be vaccinated with both
conjugated and polysaccharide vaccine.

Bacteria

Treatment

Group B streptococcus, E.coli & L.monocytogenes (from

Ampicillin + Cefotaxime (Add Gentamycin

if early neonatal meningitis)
Ceftriaxone or Cefotaxime
+ Ampicillin
AGC VAC CV VAC
+ Vancomycin.
Ceftriaxone or Cefotaxime + Vancomycin
Ceftriaxone or Cefotaxime + Ampicillin
+ Vancomycin.

mother)(S.pneumonia, N.meningitidis are rare)

Infants 6wk-3mo

Infants < 3 mo.

Adults < 50 y or
alcoholics

S.pneumonia (pneumococcus), N.meningitidis

(meningiococcus), Group B streptococcus, H.Influenza
type B (Rare due to vaccination),
S.pneumonia, N.meningitidis, H.Influenza.
E.coli, S.pneumonia, N.meningitidis, L.monocytogenes.

Post exposure Prophylaxis

H.Influenza: Rifampin 20mg/kg (max600mg) po q day * 4 days.
N.meningitidis: Children > month Rifampin 5mg/kg q 12h po * 2 days.
Children < month Rifampin 10mg/kg (max 600mg) q 12h po * 2days.
OR Ceftriaxone 125mg single dose if age (< month to 15 years >)
250 mg single dose if age 15 years.
OR Ciprofloxacin 20mg/kg (max 500mg) po single dose if age 1 month.

In all labor there is a profit Pro 14: 23

14

9-Diabetic Foot Infections

Investigation

Pathogen& infectious

Physical examination:

*Staphylococcus aureus (MRSA /

Discoloration of foot.
Malodourous foot.
Nail problems.
Corns& calluses.
Ulcer, skin crack or traumatic
wound.
Swelling, joint stiffness.
Deformity of toes, foot or ankle.
Warmth or coldness.
Neuropathy and loss of protective
sensation (insensitive to 10g
monofilament test.
Pedal pulses absence (arterial
insufficiency).
Ischemic gangrene, Fracture
discoloration, crystalline
arthropathy.

Charcot foot.

Radiographic investigations:
Show soft tissue swelling and
gas in soft tissues.
Vascular calcification.
Bony changes and erosion.
Laboratory studies:
CBC, ESR and C-reactive
protein.
Aggravation of glycemic control
may be a sign of sepsis.
Vascular studies:
ABI > 0.8 Delayed wound
healing potential.
ABI > 5.0 Inadequate arterial
inflow and very poor healing
potential.
Toe blood pressure > 45mm
poor healing potential.
Doppler.

Tips

MSSA):

Cellulitis.
Lymphangitis.
Abscess.
Suppurative tenosynovitis.
Osteomyelitis.
Septic arthritis (Erythema,
swelling, stiffness,
fluctuance).
*Streptococcus Pyogenes:
As S.aureus + Erysipelas.
*Pseudomonas aeruginosa:
Macerated foot (Tissues are
extremely moist).
*Polymicrobial (Gm+ve, Gm-ve
and Anaerobic bacteria):
Septic foot systemic sepsis:
Necrotic, foul-smelling foot
with extensive areas of
nonviable tissue. Gas may be
seen in the soft tissues.
Non Pharm for Septic foot:
Offload swelling, leg
elevation.
Surgery& Amputation.
Prevention:

Inspect feet& shoes daily.

Foot examination at least 4
times/year by specialist.
Avoid walking barefoot.
Fitted shoes with soft protective
insoles.
Regular nail care.
Stop smoking.
Avoid examination of ulcer by
instruments to avoid
osteomyelitis.
Examine water for path by
elbow to assure it is not too hot.

DM may develop: Neuropathy, loss

of protective sensation, foot ulcer,
foot ulcer, impaired arterial blood
supply (age is not a factor).
Initial TTT: offload, Immobilization
(splint, cast, or boot).
Cellulitis pathogens most likely
MSSA/ MRSA and B-hemolytic Gp A, B

Mild and localized infection: PO

More extensive infection: IV
Dressing used to provide a moist
environment for wound healing:
Saline moistened gauze.

Hydro active gel dressing.

Macerated wound:
Hydrofibre or alginate to absorb
exudate.
Wound with necrotic debris:
Saline moistened gauze.

Pharmacologic Choices

If mild and localized infections

o
o
o
o
o
o

(S.aureus and Pyogenes) 7d oral

therapy:
Cloxacillin.
Amoxicillin/Clavulanate
Cephalexin.
Clindamycin.
SMX/TMP.
Doxacycline.

More extensive infection:

Mainly aureus, Pyogenes, anaerobes and

Enterobacter spp. 21d IV/PO

o
o
o
o

In all labor there is a profit Pro 14: 23

1st, 2nd, 3rd Gen Cephalosporin +

Metronidazole.
3rd generation cephalosporin +
Clindamycin
Piperacillin/tazobactam
Carbapenem (risk of seizures if
used with Ganciclovir.

Osteomyelitis: 4-6wks TTT

MSSA / MRSA mainly or
coagulase-negative staph.

15

10-Acute Osteomyelitis
Antibacterial

Pathogen
MSSA
Methicillin Sensitive
Staphylococcus
Aureus.

Initial IV

Cloxacillin.
Cefazolin.
Clindamycin.

Oral for completion

Cloxacillin.
Cephalexin.
Clindamycin.
Amox. /clav.

Penicillin.
Amoxicillin.
Clindamycin.

Streptococcus A
Streptococcus B

Penicillin.

Enteric Gm-ve
bacilli

Cefotaxime.

Ceftazidime +
Gentamycin

Ciprofloxacin

P.aeruginosa

Vancomycin.

Clindamycin

Carbapenem
Moxifloxacin
Amox. /Clav.
Piperacillin/
tazobactam.

Ciprofloxacin +
Clindamycin.
Amox. / Clav.

MRSA

Mixed aerobic /
anaerobic.

Other Characteristics
*Hematogenous osteomyelitis:
Neonates:
S.aureus.
Group B Streptococci.
Gm-ve enterics.
Children:
S.aureus.
Group A streptococci.
H.Influenza.
S.pneumonia.
Adults:
S.aureus.
Gm-ve enterics.

*Spread from contiguous site: (common in Elderly)

Head, neck and soft tissues:

S.aureus (Clindamycin + Gentamycin, For soft

tissue Cloxacillin)

Genitourinary:
Gm-ve enteric bacilli (FQ)
Penetrating trauma:
S.aureus, P.aeruginosa (Cloxacillin + Ceftazidime
+ Gentamycin for children, FQ for adults.)

Tips:

80% of infection occurs by CA-MRSA.

Culture of superficial ulcer or draining sinus may be unreliable due to the possible presence of colonizing organisms. ***
The best specimen is obtained surgery or by percutaneous biopsy through unaffected skin.
X-ray doesnt rule out diagnosis in diabetic foot as chronic osteopathy may be present. (may be more reliable in neonates)
MRI is a highly sensitive module to define the location, extent and complications.
Bone scan by 99m labelled methylene diphosphonate has improved early diagnosis.
Osteomyelitis with diabetic foot infection often requires surgical debridement and may involve amputation.
Investigation: CBC, ESR or (CRP), Blood culture, X-ray and bone scan.
TTT duration: Mild, or post-surgical aspiration 15-14d, sever 4-6 wk., starting IV then continue oral.
Oral antibiotic for neonates is not appropriate so we continue with IV.
Cephalexin suspension has more acceptable taste than Cloxacillin suspension.
Amoxicillin may efficacy of oral contraceptives, methotrexate serum level.
Imipenem may cause seizures with theophylline, Meropenem valproate level.
Switch: usually from IV to different one PO with the same potency (to stay in hospital, complication from IV)
Sequential: The same AB and dose equivalent from IV to PO (to stay in hospital, complication from IV)
Step down: Different class with less potency (mainly from broad spectrum to narrow spectrum to prevent resistance)

In all labor there is a profit Pro 14: 23

16

11-Infective Endocarditis (IE)

Investigation

Pathogen& TTT

*Duke Criteria:
Major Criteria:

*S.aureus: (40%)

+ve Blood culture:

*3+ve specimen within 1h or
*2+ve 12h apart or
*1+ve Coxiella burneti (Q fever) or
*IgE titer < 1:800.
Evidence of endocardial
involvement.
ECG +ve
New valvular regurgitation.

Minor Criteria:
Fever < 38C.

2Major criteria or
1Major + 3Minor or
5Minor criteria.

Possible IE:

1Major + 1Minor or
3Minor criteria.

S.Viridens include: S.anguis,

S.oralis (mitis), S.mutans,
S.salivariusS, morbillorum.
Penicillin G or Ceftriaxone (4
wks).
If penicillin resistance add to the
1st regimen Gentamycin for
2wks.
If prosthetic valve the duration
of TTT (6wks.).
Or Penicillin G or ceftriaxone +
Gentamycin (2wks.), or
Vancomycin (4wks.).

*Enterococci:

Ampicillin or Penicillin G +
Gentamycin (4-6wks.), or
Vancomycin + Gentamycin
(6wks.).
If gentamycin resistance, replace
with streptomycin.

If resistance to all above:

E.faecium Linezolid or

Rejected diagnosis of IE:

*Viridans Group Streptococci &

S.bovis: (20%)

Predisposing heart condition or IDU

(Intravenous Drug Use).
Vascular phenomena (Septic
pulmonary infarct, Mycotic
aneurysm, intracranial hemorrhage,
Janeways lesions).
Immunologic phenomena
(Glomerulonephritis, Oslers nodes,
Roths spots and Rheumatoid
factor).
Microbiological evidence (+ve
culture).

Definite IE:

MSSA Cloxacillin (6wks) or

Cefazolin (6wks) Gentamycin
(1st 3-5 days).
MSRA: Vancomycin 6wks

Alternative diagnosis.
Resolution of symptoms after TTT
with AB 4 days.
Doesnt meet above criteria.

*ECG:

Dalfopristin/Quinupristin
8wks.

E.faecalis
Imipenem/Cilastatin or
Ceftriaxone + Ampicillin 8wks.

*Gm-ve Bacteria (Coxiella)2% only:

Trans esophageal Echocardiography (TEE)

is more sensitive than Trans Thoracic
Echocardiography (TTE).

TTT by 3rd or 4th Generation

Cephalosporins or
Fluroquinolones.

Tips

If prosthetic valve add Rifampicin +

Gentamycin (1st 2wks), Except
elders
Daptomycin (Lipopeptide) may be
used in native valve regimen.
Daptomycin statins level& CK
should be monitored.
OPAT refers to Outpatient
Parenteral Antimicrobial Therapy.
Prophylaxis with antibiotic before
(or up to 2h after) dental, GIT, UT
works prevent against alpha
hemolytic (Viridans) streptococci
which may cause IE.

Risk factors:

Prosthetic valve, congenital heart

disease (CHD)..(All except MI)
Dental or surgical procedure cause
perforation of the oral
mucosa.(All except cleaning or
whitening)

e.g. of Regimen of prophylaxis:

Oral:

Usually against Viridans.

Amoxicillin 50mg/kg 2gm
Cephalexin 50mg/kg 2gm
Clindamycin 20mg/kg 600mg
Azithromycin 15mg/kg 500mg
Clarithromycin 15mg/kg 500mg

IV / IM

Ampicillin 50mg/kg 2Gm

Cefazolin 50mg/kg 1Gm
Ceftriaxone 50mg/kg 1Gm
Clindamycin 20mg/kg
600mg*3gm

*Blood Culture may remain ve IE in

8% of cases:

In all labor there is a profit Pro 14: 23

Mostly Coxiella burneti or

Bartonella spp.
Nonbacterial or u unusual
pathogens.
Administration of antibiotic prior
to blood culture.

17

12-Sepsis and Septic Shock

Management
Goal of therapy:
Restore tissue perfusion within the 1st 6h
Eradication of causative infection.
Prevent progression from sepsis to full septic shock.
Empiric broad spectrum antibiotics start immediately:
-Lactam + Macrolide or Fluroquinolone.
Vancomycin, Clindamycin or Linezolid.
Anticandidal Agent: Echinocandin (DOC), Fluconazole or Amphotericin B.
Fluid administration to obtain:

Tips

Central Venous Pressure (CVP) 8-12 mmHg (12-15 mmHg in mechanically ventilated pt.).

Mean Arterial Pressure (MAP) 65 mmHg.

Urine output 0.5ml/kg/hr.
Central venous (Superior Vena Cava) or mixed venous oxygen saturation 70%
(if not transfuse to Hematocrit 30%, if not Dobutamine infusion.
Vasopressor & +ve inotrope:
o Norepinephrine (DOC) Strong vasoconstricting activity
less action on heart, cause tachycardia

o
o
o
o

Superior to dopamine in increasing peripheral resistance and improving splanchnic

perfusion.

Combination with Dobutamine allow better control in term of inotropy and

vasopressor activity.

Dopamine +ve inotropic, chronotopic effects beside the vasoconstricting effect.

Septic shock with bradycardia.
Phenylephrine: 2nd line agent has +ve inotropic and vasopressor activity.
Vasopressin: Adjunctive or rescue vasopressor.
Dobutamine: +ve inotrope, but vasodilators.

Used with NE to splanchnic blood flow and to improve oxygen delivery to tissues.

DVT: LMWH or Unfractionated Heparin.

Corticosteroids:
Hydrocortisone: DOC in hypotensive pts not responding to fluids and
vasopressors and if renal impairment or Adison disease.
Prednisone is a second line TTT.
Fludrocortisone: if corticosteroids without mineralocorticoids wanted
Dexamethasone: used if previously succeeded or pneumococcal meningitides
and should be administrated before or concomitantly with AB. (discontinue if
culture is ve to pneumococcal).
Other drugs:
Insulin IV continuous infusion (glycemic goal 4.4-6.1 mmol /L)
Inhaled B-agonist for acute respiratory distress syndrome (ARDS).
Diuretics if Edema.
Disseminated intravascular coagulation (DIC) and thrombocytopenia
Heparin 1st line and consider fresh frozen plasma if elevated INR.

In all labor there is a profit Pro 14: 23

Immediately initiate 4
medications: Insulin (Check
glucose level Q 1h), Ab,
vasopressor and
corticosteroid.
Elevation of the bed head 45
to minimize the risk of passive
aspiration and ventilator
acquired pneumonia.
Avoid prolonged
neuromuscular blockade (NonDepolarizing Curare mimetics:
Cisatracurium (DOC),
Pancuronium, Rocuronium and
Vercurium) to the risk of
prolonged muscular weakness.
NaHCO3 for acidosis only if PH
> 7.15
Candida is the 4th most
common pathogen isolated in
blood stream in ICU.
Consider Drotrecogin-
(Activated Protein C) if pt. with
Acute Physiology and Chronic
Health Evaluation (APACHE II)
score 25 with multiple acute
organ dysfunction.
Methylene Blue has unknown
role in (MAP) and reducing
Catechol amine requirement.
Acute respiratory distress
Ventilation + SABA.
Linezolid may cause lactic
acidosis& optic neuropathy
and myelosuppression.
Amphotericin:
nephrotoxicity, anemia,
hypotension and phlebitis.
Amphotericin B Lipid
preparation has less
nephrotoxicity than normal
Amphotericin B.

18

13-Urinary Tract Infection (UTI)

Condition
Acute uncomplicated UTI.

E.coli (80-90%).
S.saprophyticus (5-10%).

Acute obstructive
pyelonephritis.

E.coli (90%)
P.mirabilis (5%)
K.Pneumonia (5%)

E.coli (50%).
P.mirabilis (20%).
E.faecalis (10%).

Complicated UTI.

2nd Line TTT

FQ po*3d
Cephalexin po*7d

Mild: Amoxiclave po *10-14d

SMX / TMP or TMP po *10-14d

Sever:
Aminoglycoside Ampicillin
IV *10-14d

Fluroquinolone po*7-14d
IV (3rd Gen Cephalo
Aminoglycoside) 10-14d

Mild Moderate:
Fluroquinolone po*7-10d
Or Nitrofurantoin po*7-10d

Amoxiclave po * 7-10d
Cephalexin po * 7-10d
Cefixime po * 7-10d

Sever: Aminoglycoside
Ampicillin 10-14d

FQ IV 10-14d
3rd Gen Cephalo. IV * 10-14d

SMX/TMP. Po*3d (DOC)

Trimethoprim po*3d
Nitrofurantoin po*5d
Mild Moderate:
Fluroquinolone po*7-14d

E.coli, Enterobacteriaceae,
P.aeruginosa & S.aureus.

IV (Aminoglycoside
Cloxacillin Ampicillin).

Fluroquinolone IV or po
SMX/TMP po

E.coli (80%), Klebsiella spp,

P.aeruginosa & Proteus spp.
E.coli (60-70%), P.mirabilis.

Fluroquinolone po
(4-6wks)
SMX/TMP.

SMX/TMP po* (4-6wks).

Acute Prostatitis.
Chronic Prostatitis (if
bacterial).
Asymptomatic Bacteriuria

1st Line TTT

Pathogen

Tips:

Relapse is the recurrence with the same organism, Reinfection The recurrence with new spp.
Confirmed TTT means 2 -ve consecutive culture.
Screen for Asymptomatic Bacteriuria in pregnancy (at the wk 12-16), should be TTT or may cause pyelonephritis and cause
adverse effect on fetus.
In pregnant woman: Ceftriaxone is preferred empirically for pyelonephritis.
Culture not essential in cellulitis, but recommended in pyelonephritis (obtained before initiating therapy).
TTT 7d if woman with symptoms < 7d or recurrent infections in > 1mo, TTT 3d if woman 65 years.
SMX/TMP (DOC) has the same efficacy of Fluroquinolone but less expensive.
Renal excreted FQ are (Ciprofloxacin, Norfloxacin, Levofloxacin and Ofloxacin)- Moxifloxacin 50% renal & 50% hepatic
Nitrofurantoin*5d is as effective as SMX/TMP*3d in TTT of acute uncomplicated UTI, but contraindicated with renal
failure, pregnancy near term (cause neonate hemolytic anemia specially if G6P deficiency).
Aminoglycoside (Gentamycin or Tobramycin) Ampicillin used only in severe cases.
Cloxacillin is added only if S.aureus.
Cephalosporins may be associated with greater likelihood of vulvovaginal candidiasis.
3rd generation cephalosporin very effective parenteral against pyelonephritis.
Switch to oral therapy if symptoms and signs are settled (72-96h).
Cranberry effective in reducing incidence of UTI in young women.
Amoxicillin not used empirically, but Fosphomycin do in a dose: 3gm single dose if acute uncomplicated UTI.
Recurrent infection2time in 6mo, or 3times in 12mo, consider the following Regimen at the same time:
Short term self-therapy: Regular dose.
Post intercourse prophylaxis : 1/2regular dose once after intercourse of any effective UTI antibiotic)
Long term low dose prophylaxis 1/2 regular dose QHS daily or 3d/wk (e.g Macrocrystals Nitrofurantoin 50mg)

In all labor there is a profit Pro 14: 23

19

14-Sexually Transmitted Infections (STI)

Vaginal Discharges
Pathogen

Characteristics

Vulvovaginal
Candidiasis
(Not considered STI)

Only consider TTT of sex

partner if recurrent infection.

Trichomoniasis.

(Untreated Trichomoniasis
in Pregnancy membrane
premature rupture, preterm
delivery and birth weight).

Bacterial Vaginosis.

(Untreated B.vaginosis in

pregnancy Premature
rupture membrane, preterm
birth and postpartum
endometritis).

Symptoms
Men:
Sever dysuria

(fishy odor, no itching)

Miconazole cr.
Clotrimazole cr. (1, 3, 6 regimen).
Nystatin (less effective), safe in pregnancy
Butoconazole 2% (require RX).
Terconazole (Require Rx).
Boric acid V.capsules if recurrent infection (CI pregnancy)

(daily pv*14d then 300mg cap pv*5d/mo beginning 1st day of cycle*6mo

Metronidazole po 2gm single dose or 500mg BID*7d.

2gm single dose for pregnant woman risk of
preterm birth.

Clindamycin 300mg BID*7d po

Clindamycin cr. 1 app 5gm*7d (DOC) (CI in pregnancy).
Metronidazole 500 mg po BID*7d or v.gel 1app gm pv
daily*5d(DOC)
Topical metronidazole or Clindamycin not
recommended in pregnancy.

Infection Characterized by Urethritis and Cervicitis

(Chlamydia trachomatis & Nisseria gonorrhea):
Complication
TTT

Women:
Copious vaginal
discharge.
Dysuria.
Uterine bleeding
Menorrhagia.

White clumpy and curdy

discharge.
Pruritus.
Odorless. (No odor, itching)
PH > 4.5
+ve PMNs.
+ve Lactobacilli.
Off-white or yellow frothy
Discharge.
Pruritus. (odor + itching)
PH < 4.5
+ve PMNs.
Grey, milky, Thin, copious
discharge.
Fishy odor.
PH < 4.5
+ve Whiff test.

TTT

Epididymitis.
Seminal
vesiculitis.
Prostatitis.
Disseminated
infection.
Pelvic
inflammation.
Infertility.
Ectopic
pregnancy.

Chlamydia:

(TTT chlamydia only)

Azithromycin (DOC).
Doxycycline (2nd choice)
Erythromycin.
Levofloxacin.
Ofloxacin.
Amoxicillin.
No retest after TTT
Untreated chlamydia in
pregnancy membrane
premature rupture, preterm birth
and conjunctivitis & pneumonia
in newborn.

Gonorrhea:
(Always TTT Gonorrhea + Chlamydia)
Cefixime, Ceftriaxone are (DOC).
Ciprofloxacin, Ofloxacin.
Azithromycin.
Spectinomycin (Aminoglycoside,
pain at site of injection).
Retest in 3-12mo for reinfection
Untreated gonorrhea in pregnancy
endometritis, pelvic sepsis &
ophthalmia neonatorum and systemic
infection in newborn.

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20

Infections Characterized by Genital Ulcers:

Condition

Symptoms&
complications
Ulcer: Single, large and
painless.
Alopecia

Penicillin2.4 m (DOC)*1 dose (2nd dose after 1 wk if preg.)

Ceftriaxone 1gm/d *10d.
Doxacycline 100mg BID*14d

Ulcer: multiple, small

and painful.

Acyclovir, Famciclovir & Valacyclovir.

Lymphogranuloma venereum
(LGV):
C.trachomatis serovars
L1, L2, L3.

Proctitis, bloody anal

discharge
Colorectal fissure.
2ry infections.

Doxacycline (DOC).100mg po BID*3wks., partner

(7days).
Erythromycin 500mg QID*3wks.
Azithromycin (last resort) 1gm once weekly*3.
Partner single dose only.

Anogenital warts:
Human Papilloma virus (HPV).
(If pregnancy Respiratory
papillomatosis may rarely occur
in the newborn.

Antimitotic Agents:
Podophyllin 25% once/wk. wash after 1-4h., repeat1-2 times. (Office only),
protect adjacent normal skin with petrolatum, used externally only and if other
therapies are not appropriate.
Podophyllotoxin 0.5% BID*3d followed by 4days without therapy up to 3mo.,
more effective, less side effect, self-applying.
Caustic Agents:
Dichloroacetic acid (DCA), or trichloroacetic acid (TCA) 50-80% soln. in 70%
alc. Once weekly*6-8wks. (Safe for pregnant, breast feeding).
Immune response Modifiers:
Wash with soap&
Imiquimod 5% cr.3 times/wk.*16wks.
water after 8h of
Imiquimod 3.75% cr. QHS to external Genitalia up to 8wks.
application.
HPV Vaccines:
Quadrivalent human papillomavirus (types 6, 11, 16, 18)
Female (9-45y) & male (9-26Y), not recommended in pregnancy, but safe in
breast feeding.

Syphilis:
(Treponema pallidum)
(If pregnancy fetal loss risk.

TTT

Genital Herpes:

Tips:

Syphilis test: Darkfield examination & Fluorescent antibody test and syphilis serology.
After syphilis TTT follow pt. serologically to ensure TTT.
For LVG: test of cure is performed 3-4 wks. After TTT.
HPV has high recurrence rate (33%).
Risk factors for STI are: unsafe sex, injection drug use, recent child birth, IU device insertion, past history of STI

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21

Pelvic inflammatory Disease (PID):

Symptoms

In-patient TTT

Lower abdominal or pelvic pain.

Abnormal bleeding.
Dyspareunia.
Cervical motion tenderness or
adnexal tenderness/masses.

CDMM- F- PID

rd

Cephalosporin 3 Gen +
Doxycycline + Metronidazole.
FQ +Metronidazole.
Macrolide + Metronidazole.

Out-patient TTT

Aminoglycoside + Clindamycin
Cephalosporin + doxycycline
FQ + Metronidazole.
FQ + Tetracycline + Metronidazole
Ampicillin / Sulbactam + doxycycline

Tips:

Empiric antimicrobial therapy should cover: N.gonorrhoea, C.trachomatis, anaerobes, Gm-ve and
streptococci.
PID is uncommon in pregnancy.

15-Herpesvirus Infection
A-Varicella Zoster Virus (VZV)
Condition

Non Pharm

Chicken Pox:
Can be transmitted through the
air and by direct contact from
skin lesions.

Acute Herpes Zoster (Shingles):

TTT within 72h of onset may the
risk of postherpetic neuralgia.

TTT

Avoid direct contact, infected

person should be isolated.
Closely crop nails, and use
astringent soaks to avoid 2ry
bacterial infection.

Keep rash clean& dry.

Avoid topical antibiotic &
adhesive dressing that cause
irritation and delay healing.
Use sterile wet dressing.
Vaccine (Zostavax):
Contain 15 times more virus
that for Chicken Pox,
incidence of shingles by 51%
and neuralgia by 67%.
Avoid in Pregnancy

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VZV vaccine is a live

attenuated vaccine.
Acyclovir: if initiated within
24h of onset, it reduces: no. of
lesions, time to crusting and
duration of fever.
Topical antiviral not effective.
5 times daily*7 days of Oral
(Acyclovir, Famciclovir and
Valacyclovir).
Corticosteroids improve the
quality of life only (neuritis,
uninterrupted sleep and
maintain normal activity).
Analgesics& GABA for
postherpetic neuritis.

22

B-Herpes Simplex (HSV1, 2):

Condition

TTT
Acyclovir oral suspension
(Mg/kg po 5times / daily*7d).

Primary HSV
Gingivostomatitis
( common in children)
Recurrent Orolabial Herpes
(Cold Sores).

1ry Episode of Genital Herpes

(TTT is effective if initiated up
to 7 days after onset.

Guanine Nucleoside Analogues:

(Safe in Pregnancy& Breast feeding)
Acyclovir oral 5times/d * 1-5days.

Acyclovir 5% cr. (oint. Is not effective).

Valacyclovir 1day ttt age < 12y
Famciclovir.
Acyclovir (IV for severe cases).
Valacyclovir.
Famciclovir.

Genital Herpes & HIV

(HSV may be more severe and
prolonged with HIV).
Mutation in HSV may
happens with the
immunosuppressive drug for
HIV.

Acyclovir 400mg*3-5/daily until

complete healing.
Valacyclovir 1000mg BID*5-7d
Famciclovir 500mg BID*5-7d.
if possibility of mutation:
Foscarnet (IV or Topical) +
Trifluorothymidine (Topical)
Interferon Cidovir.

Recurrent Genital Herpes

Initiating TTT up to 12h of onset,

of episodes by1-2 days.
Only shorter courses of therapy 1-3
days.

Tips

Reduce transmission is not a goal

of therapy.
Oral Acyclovir is photosensitive.
Topical antiviral creams is less
effective than oral ones and may
carry a risk of self-inoculation.
Starting antiviral ttt 1-2h of onset
of episode duration of the
episode.
IV ttt is 25% more effective than
oral ttt.
Famciclovir 500mg BID*7d =
Acyclovir 400mg 5times/day*7d.
Valacyclovir 1000mg BID *5d =
Acyclovir 200mg 5times/d*5d.
Valacyclovir 500 or 1000mg is the
only treatment approved for once
daily dosing.
If recurrent genital herpes < 9
time / year Famciclovir or
Valacyclovir is recommended (not
Acyclovir).

Other conditions:
Herpes Proctitis
Eczema Herpeticum (Only TTT by Acyclovir 800*5 times daily*5days).
Encephalitis: detect HSV DNA in CSF
Keratoconjunctivitis: Topical Trifluridine dps is more effective than topical Idoxuridine dps.
oral Acyclovir.q8h*21d

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23

16- HIV-Infection (AIDS)

General Tips

CD4 (Helper T-cell) > 200 start prophylaxis for Pneumocystis Jirovecii Pneumonia (PCP).
SMX/TMP is preferred, or Dapsone (Sulphone antibiotic), or Atovacone (less effective) or monthly
inhaled Pentamidine (for severe cases), or Pentamidine IV for 21 days.
CD4> 100 start Toxoplasmosis prophylaxis.
CD4> 50 start MAC (Mycobacterium Avium Complex), CMV (Cytomegalovirus) prophylaxis.
Inability to keep HIV-RNA levels > 200copies/ml is a virologic failure.
If drug toxicity in 3-drug regimen, brief cessation of all medications is recommended, Avoid decreasing
the dosage or stopping only one medication as this develop resistance.
CD4 count shows diurnal variation: in the morning, at night.
Poor adherence is the single most critical determinant of therapeutic failure.
Avoid combination of Stavudine (d4T) with ddi (Didanosine) or AZT (Zidovudine) toxicity.
Regimen of therapy:
2 (NRTI) + 1 (NNRTI) Once daily
or 2 (NRTI) + 1 (PI) twice daily
Raltegravir: also considered a 1st line therapy.
Short Cut to memorize All Drugs: (LADZs TENDE to your FRANDS List).

Lab. Investigation

HIV antibody test.

CD4 lymphocyte count.
HLA-B*5701 for Abacavir
allergy.
Tropism assay to determine
the chemokine receptor
status (CCR5, CXCR4 or dualmixed tropic) if considering
use of CCR5 inhibitor
Maraviroc.

Pregnancy

AZT + 3TC + NNRTI or Ritonavir-boosted PI.

Avoid Combination of Stavudine + Didanosine lactic acidosis.
Tenofovir: fatal bone toxicity (animal data).
Efavirenz (NNRTI): 1st trimester teratogenic.
Nevirapine (NNRTI): recommended unless CD4 < 250
Lopinavir-ritonavir (PI): Recommended.
Zidovudine monotherapy in the 2nd, 3rd trimester may decrease
transmission of HIV to fetus.

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24

Antiretroviral Therapy (ART)

NRTI

Lamivudine (3TC)

Abacavir (ABC)

Didanosine (ddi)

Stavudine(d4T)

Zidovudine (AZT)
Metabolized by CYP450

Side Effects
Alternative 1 line therapy.
Safe in pregnancy.
MI, Can cause hyper sensitivity
(screen before initiating TTT)
Lactic acidosis, hepatic
steatosis, Pancreatitis, uric
acid, Neuropathy.
Lactic acidosis, hepatic
steatosis, Pancreatitis.
Lactic acidosis, hepatic
steatosis. (No pancreatitis, no
TSH effect).

NtRTI
Tenofovir (TDF)
( 1st Line therapy)

Delaviridine (DLV)

Efavirenz (EFV)*
(1st line therapy)
(Teratogenic)

Nevirapine (NVP)*
(Alternative 1st Line)

Pharmacological antagonism with AZT

Toxicity with ddi
Valproic acid AZT level
Avoid combination with Stavudine.
Amphotericin BAZT hemotoxicity
Safe in pregnancy.

Drug Drug interaction

Alprazolam, Midazolam, Triazolam, Pimozide, St.johns wort

Ergot derivatives, phenobarbital, phenytoin, rifampin
Inhibit metabolism of SAL statins and Maraviroc.
Midazolam, Triazolam, Cisapride, Pimozide, Maraviroc
St. Johns wort level of EFV.
Voriconazole, EFV if together.
Carbamazepine, Phenobarbital, Phenytoin, rifampin.
St. Johns wort
Fosamprenavir, Atazanavir exposure.
St. Johns wort, rifampin, ketoconazole.
Clarithromycin level
Fluconazole NVP level.

Tips:

Drug-Drug Interaction

Renal toxicity (monitor renal function,

ddi level.
Phosphorous level).

Etravirine (TMC-125)
Preferred in combination with PI
Dont use in combination with AZT/RTV

Contraindications:
Alcohol, CVD, Allergy (HLA-B*5701 test).
If used with Tipranavir space 2h
Avoid combination with Stavudine or Tenofovir
ddi level.

Side Effects

NNRTI

Tips
st

All NNRTI Liver enzymes.

Efavirenz Empty stomach, CNS toxicity& Teratogenicity (1st trimester).
Typical regimen in pregnancy: Atazanavir + Lamivudine + Nevirapine.
All ART not used during breast feeding.

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25

PI

Atazanavir (ATZ)*

Darunavir (TMC-14)*

Fosamprenavir (f-APV)

Indinavir (IDV)

Lopinavir/ritonavir

Tips
Drug Drug interaction:
Ergot alkaloids, Fluticasone, Lovastatin, Simvastatin Midazolam,
Triazolam Rifampin, Sildenafil, St. Johns wort
Rifabutin level (A drug used for TB TTT).

(LPV/RTV)*

Nelfinavir (NFV)

Ritonavir (RTV)

Saquinavir (SQV)

Fusion Inhibitors

Adverse Effects

Enfuvirtide (T20)

Injection site reaction.

Entry Inhibitors

Tips
Limited experience

Adverse Effects

Maraviroc
Tropism test required.
(Only effective with CCR5 tropic)

Integrase Inhibitors
Raltegravir

All PI can be used in combination with RTV.

All PI except unboosted ATZ pts. Cause hyperlipidemia.
All PI liver enzymes except Nelfinavir.
Risk of MI Indinavir, Lopinavir, Fosamprenavir.. (FLI)
Diarrhea, GIT upset Darunavir, Nelfinavir, Ritonavir (NRD)
Circumoral Paresthesia Ritonavir
Nephrolithiasis Indinavir.
Hepatotoxicity with RTV Darunavir.
Hyperbilirubinemia ATZ
QT, PR prolongation SQV
Saquinavir not used with drugs that prolong QT interval
(Quinidine, Sotalol..).
Tipranavir if used with ddi separate the doses by 12h.
1st line therapy ATZ, TMC-14.
Alternative 1st line Saquinavir, Fosamprenavir.
Pregnancy 1st line LPV/RTV twice daily.
Indinavir not preferred as high toxicity: nephrolithiasis, MI and
liver enzyme elevation.

Tips

Cough, fever, upper respiratory tract

infection, rash.
Abdominal pain, muscle pain, dizziness,
hepatotoxicity.

level with CYP3A4

inducer.
Level with CYP3A4
inhibitor.

Adverse Effects
Nausea, vomiting, diarrhea, Pyrexia

Tips
st

Alternative 1 line therapy.

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26

17-Opportunistic Infection in HIV-positive Patients.

CD4

Condition&
Pathogen

Prophylaxis

TB

> 200l

Pneumocystis Jirovecii
pneumonia (PCP):

> 100l

Toxoplasma gondii
encephalitis.

+ve PPD or IGRA

> 50l

Cytomegalovirus (CMV)

Fungal Infection:

Mycobacterium avium
complex (MAC).

Condition& Pathogen
Painful mouth and swallowing
(Odynophagia)
Oral Candidiasis.
HSV, CMV or aphthous
ulcers.

INH+ vitB6 9mo. (DOC).

SMX/TMP *21d (DOC).
Dapsone.
Pyrimethamine + Leucovorin.
Atovaquone.
Pentamidine IV 21 days
Inhaled Pentamidine (monthly)
SMX/TMP.
Dapsone.
Pyrimethamine + Leucovorin.
Atovaquone (Pyrimethamine + Leucovorin).
Azithromycin once weekly (DOC)
Clarithromycin twice daily.
Rifabutin (Caution with PI).
Prophylaxis is not cost effective.
Azole antifungal.

TTT
Empirical Azole ttt.
Candidiasis:
Initiate topical Nystatin susp.
Fluconazole susp. (DOC).
Itraconazole DOC if oral
susp.
Ketoconazole oral susp.
Amphotericin B susp.
Miconazole or
Clotrimazole. Vaginal
tablets as oral loz.

Tips

Regardless CD4 count, update

all non- living vaccines beside
MMR, Varicella if lCD4 < 200/l.
Pts. with low CD4 count may
experience fever of unknown
origin.
Diarrhea may be an adverse
effect of drug, chronic antibiotic
or if CD4>150/l MAC,
Parasitic infection.

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27

CNS Symptoms (TTT only):

Usually: TB, Viral
Unusually
o Meningitis

Meningitis:
Amphotericin B IV 26wks. Flucytosine
Fluconazole
400mg/day*12wks.
PML: no TTT

(Cryptococcus neoformans)

o
o

Focal lesion (T.gondii)

Progressive multifocal
Leukoencephalopathy
(PML) : (JC virus)

Cytomegalovirus (CMV):
Retinitis& visual
disturbances.
Enteritis, colitis,
pneumonitis, myelitis and
neuritis.
Pneumocystis Jirovecii (PCP):
Pneumonia

Toxoplasma gondii

Valganciclovir oral 14-21d.

Ganciclovir IV or Foscarnet
IV 14-21d.
(Available only through federal
Special Access Program).
Maintain with the same
drug or Cidovir.
SMX/TMP,
cotrimoxazole.
Pentamidine (IV if
severe).
Atovaquone.
Clindamycin +
Primaquine.
Prednisone (21d) :
Morbidity& SE. of
SMX/TMP.
(40mg*2*5d - 20mg*2*5d 20mg*1*11)
Empirically for 7days.
Standard therapy:
Pyrimethamine +
Leucovorin + Sulfadiazine
4-8wks.
Alternatives:
Pyrimethamine +
Leucovorin + Clindamycin.
SMX/TMP IV.
Maintenance: with the same
initial therapy.
Edema: Dexamethasone.

Pts. initiating ART, may

experience Immune
Reconstitution Inflammatory
Syndromes.
Ganciclovir-resistance strains of
CMV may have cross resistance
to Cidovir& Foscarnet.
Foscarnet: Inorganic
Pyrophosphate Analogue.
(Nephrotoxic).
Ganciclovir& Valganciclovir:
Guanine Nucleoside Analogue.
(Nephrotoxic).
Cidofovir: Cytidine Nucleotide
Analogue. (Nephrotoxic).
Foscarnet: prehydrate to
nephrotoxicity.
Ciprofloxacin: seizure
potential of Foscarnet.
Ganciclovir: AZT levels,
renal excretion of Tenofovir.
Pregnancy:
Conception preferred when
CD4< 200l.
PCP SMX/TMP
MAC Azithromycin
Ethambutol
Toxoplasmosis SMX/TMP
Breast feeding is not allowed
with HIV.
Non Pharm:
Hand washing (sanitizers)
Drink from treated water
source.
Avoid raw or uncooked meat&
eggs (e.g. Caesar salad).
Avoid handling sick animals or
pets.
Avoid cat scratches, to lick
wounds.
Avoid contact with reptiles.

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28

18-Infections in the Cancer patients

Immunologic Defect&
Pathogens

Therapies

Neutrophils:

Empiric Out pt. therapy:

E.coli.
Klebsiella spp.
Candida spp.
S.aureus.
P.aeruginosa.
S.epidermidis.

B cells:
S.pneumonia.
H.influenza.
T cells:

Listeria monocytogenes.
TB.
Legionella spp.
Cryptococcus spp.
P.Jirovecii (PCP)
HSV.
Cytomegalovirus (CMV)

Non-Pharm:

(Amox. /Clav. + Ciprofloxacin) po.

(DOC).
IV/PO Clindamycin + PO Ciprofloxacin
or IV penicillin/ Tazobactam.

Environmental
precautions to prevent
infection.
Hand washing.
High efficacy filtration
rooms.
Use specialized infection
control procedure for
pts. Colonized with
multiple resistant
organisms (MRSA,
VRE).use droplet or airborn precautions to
avoid viral infections.
For neutropenic pts.,
avoid raw fruits&
vegetables and avoid
fresh flowers and plants
in the pt. room.

Inpatient therapy:
Vancomycin (DOC) for mucositis,
venous access infection or MRSA.
Antifungal therapy:
Non neutropenic pt:
*Polyene Antifungals:
Nystatin (Topical).
Amphotericin B (Parenteral)
*Triazole Antifungals:
Fluconazole.
Itraconazole (PO only)
Posaconazole.
Voriconazole.
*Echinocandin Antifungals:
Anidulafungin.
Capsofungin.
Micafungin.

Tips

Prophylaxis:

SMX/TMP: If in T cells
(P.Jirovecii).
(Alternatives: Pentamidine inh. &
Dapsone).
Acute Leukemia, Bone Marrow
transplantation: Ciprofloxacin&
Levofloxacin (500mg*7d): febrile
morbidity, fluconazole as antifungal
prophylaxis.
Micafungin: in hematopoietic stemcell transplant recipients.
Fluconazole: if used empirically,
continue with Amphotericin B or
Capsofungin in documented fungal
infection in neutropenic pts.

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Neutropenic pt.: neutrophil

0.5*10/L.A.
Low risk pt.: Neutropenia7d.
High risk pt.: Neutropenia
<7d.
Fever: single oral temp. =
38.3C or 38C last for 1h.
Vancomycin (Gm+ve): is the
initial therapy for venous
access catheter related
infections, MRSA.
Linezolid, Daptomycin:
MRSA, VRE.
Metronidazole, Clindamycin:
anaerobic infection.
Neutropenic pt.: continue
Ab until Neutrophil0.5*10 /
L, and afebrile for 48h.
(Minimum 10-14d).
Non neutropenic Pts. TTT
duration 7d.
Persistent febrile,
neutropenic 4-7d add
antifungal therapy.
Aspergillus spp.
Itraconazole (DOC).
Voriconazole has superior
activity than Amphotericin B.
against Aspergillosis, and
Scedosporium spp.
Viral RTI: Oseltamivir
(DOC).
Acyclovir Resistant spp.:
Foscarnet available through
federal Special Access
Program.
Nadir: The point of lowest
neutrophil count, occur 5-10d
after chemotherapy.
Filagastrim, Pegfilagastrim:
are used for neutropenia.

29

19-Travellers Diarrhea (TD)

3 times or more of unformed stool within 24h+ 1 symptom of enteric disease.

Pathogens

TTT

ETEC (Enterotoxigenic Escherichia coli)

Shigella spp.
Campylobacter Jijinum.
Salmonella.
Giardia Lamblia.
(All except staph.)
Pregnancy managements:
ORS, Fluid intake + Azithromycin.
SMX/TMP (less effective).
Loperamide in severe diarrhea.
BSS Encephalopathy.

Prophylaxis:
BSS (40% efficacy).
Management& TTT:
Highly clear carbonated
fluid intake& ORS
(Gastrolyte, Pedialyte).
Fluroquinolones (90%
efficacy).
Azithromycin.
Rifaximin (74% efficacy,
but not exist in Canada.
SMX/TMP, Doxycycline
no longer used as high
resistance.
Vaccines:
Cholera vaccine: active
50% against ETEC, 25%
against all TD.

Breast feeding:
ORS, fluids + Azithromycin.
Loperamide in severe diarrhea.
Iodine for water sterilization.
BSS, Fluroquinolones Avoided.

Non-Pharm

Boil it, bottled it, or forget it.

Boiled, bottled or carbonated
beverages.
Sterilize water (5dps 2%
Tr.iodine / L).
Ceramic filtration is effective
against: Protozoa, Bacteria, and
Viruses.
Avoid ice cubes.
Avoid watermelon, unwashed
fruits, salads and raw
vegetables.
Eat only through, recently
cooked meats& fish.
Wash hands (sanitizers).

Tips:

TD is the passage of 3 unformed stools /24h + 1 symptom of enteric disease (abdominal pain, nausea,
vomiting, fever, bloody diarrhea or tenesmus).
Incubation period is short and many pts develop diarrhea in the 1st wk of travel (self-limiting > 7d)
BSS: not used in children (Reyes syndrome), Pregnancy (Bismuth encephalopathy), and pts on anticoagulants.
BSS: cause dark stool, used for max. 3wks.
Fluroquinolones: not used in Thailand, India, Nepal and Indonesia.
Campylobacter (Mexico): Azithromycin is DOC (as Fluroquinolone resistance).
ORS: can be prepared by: 5ml tablet salt + 30ml sugar + 1000ml safe water.
Antimotility agents (Antiperistaltics: e.g Loperamide): not used alone in bloody diarrhea or fever < 38C
prolong infection and cause complications (ileus megacolon, toxic megacolon).
Loperamide: Contraindicated for age > 3 years toxic megacolon.
ETEC self-limiting, may needs Ab for 1-3 days only.
Ciprofloxacin Affects cartilage development in children.
Iodochlorhydroxyquin prolong use Neurologic damage and optic atrophy.

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30

20-Malaria Prevention
Chemoprophylaxis

Tips

Chloroquine
& Hydroxychloroquine:
Central America-except Panama-,
Dominican Republic, Middle East.
Mefloquine (P.falciparum).
(Not used in Thai-Cambodian and
Thai-Myanmar borders & Eastern
Myanmar &Western Cambodia and
south central Vietnam.

Doxacycline
If Chloroquine, and Mefloquine
resistance.

Primaquine used for (PART)

Presumptive anti-relapse therapy
(Central America)

Atovaquone / Proguanil

1-2 wks. Prior to exposure and continue weekly for 4wks after leaving.
No pediatric formulation, has bitter taste if crushed.
CI: in seizures, psychosis, psoriasis.
Safe in pregnancy, all ages.
Wt should be < 5 KG.
1 week prior to exposure, weekly until 4wks. After leaving.
CI: with history of seizure, Psychosis, depression and anxiety.
Has long half-life women advice to avoid pregnancy within 3 months of
stopping the drug, dont use in the 1st trimester.
1-2days prior to exposure, daily up to 4wks. After leaving.
Avoid prolonged sun exposure.
Should be taken with food, fluids, upright position.
CI: in pregnancy, children> 8y.or > 11kg.
In long term travelers returning from areas with P.vivax which has a dormant
liver form (hypnozoites). (DOC for P.vivax).
Start 1-2d prior to exposure / daily up to 3day after leaving.
Also for Chloroquine resistant malaria.
If G6PD deficiency (Blacks, Mediterraneans, Asian and South Asians) severe
hemolytic anemia.
CI: Pregnancy & G6PD deficiency.
1-2 d prior to exposure, daily up to 1wk. after leaving.
CI: pregnancy, children > 5kg.
S.E: GI upset, headache, insomnia, cough and mouth ulcers.

Children management:

Pregnancy & Breast feedings management:

Chloroquine in young children.

Doxacycline if < 8ys or < 11kg.
If Chloroquine resistant area: Mefloquine, or Atovaquone /
Proguanil if wt < 5kg (but can be taken if high risk).
Azithromycin: can be used for wt > 5kg but suboptimal
efficacy.

Anopheline mosquito more attracted to

pregnant woman.
Malaria reduction in birth wt., maternal
anemia, and premature labour and fetal death
as fever cause uterine contraction.
Chloroquine is safe (Azithromycin is alternative)

Tips:

Malaria transferred by Anopheline mosquito mainly occur between dusk and dawn
In sub-Saharan Africa, false +ve films for Malaria 40% at least follow the advice of a local practitioner, but dont stop
prophylaxis.
Center for Disease Control and Protection: wwwnc.cdc.gov/travel.
Public Health Agency of Canada: www.phac-asp.gc.ca/tmp-pmv/index-eng.php.
Personal protection only recommended in large urban centers of India.

NON Pharm:

Insect repellent Diethyltoluamide (DEET) has neurologic side effect in children if conc. < 35%
30%DEET can be used for age < 2mo., effective for 4-6h.
Citronella is effective for > 1h.
Use bed nets impregnated with pyrethroids.
Use mosquito coils, aerosolized insecticides, electrically operated insecticide generator containing pyrethroids

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