QUANG BUI

S4BBT4L2 Heintz (Hepatitis virus)

HBV

PEP: HBIG 0.06 mL/kg IM

HbsAg + & HbeAg+ = highest risk of CA, biochem, histologic, virologic
Sx Tx in acute but Tx in chronic
Chronic: HbsAg+ > 6 mo, HBV DNA ≥ 20000 IU/mL = 105 copies/Ml, ALT > 2x ULN (ALT most specific to liver)

Peginterferon 180 mcg sq qwk x48wk (DOC); CI if severe 10xULN

a2a SE: flu-like Sx, fatigue, anorexia, nvd, sleep alteration, inj site rxn, BMS, hair thin/loss, retinopathy, thyroid,
(Pegasys) worse DM, depress, ↓libido, hepatitis (everything except nephrotoxicity)
Peginterferon 1.5 mcg/kg sq qwk x 48 wk (max 100 mcg sq qwk) – not FDA approved
a2b
(Peg-Intron)
Lamivudine 100 qd x ≥ 1 yr
need to add adefovir/TDF or switch to ETV b/c ↑resistance so 2nd line
300 if HIV coinfection
Adefovir 10 qd x ≥ 1 yr
Entecavir 0.5 – 1 qd x ≥ 1 yr
also as 1st line but expensive, only as monoTx
0.5 for naïve & 1 for LAM refractory
Telbivudine 600 qd x ≥ 1 yr; SE similar to LAM
Tenofovir 300 qd x ≥ 1 yr
or Emtricitabine not FDA approved
if HIV Co-flares: Travada (TDF + (3TC or LAM)) + NNRTI or PI/R

QUANG BUI
QUANG BUI

S4BBT4L2 Heintz (Hepatitis virus)

HCV

RVR (rapid) better PPV in SVR:

undetect HCV RNA (<50-100 IU/mL) @ 4 wk

EVR (early) better NPV in SVR:

≥ 2 log decline fr pre Tx level @ 12 wk

ETR: undetect HCV @ end of tx (48wk)

SVR: sustained @ 6 mo post Tx (72wk)

CI = uncontrolled depression (d/c if suicide),

solid organ transplant, autoimmune hep, unTx
HCV Genotype 1 HCV Genotype 2&3 hyperthyroid, preg, severe cardio/pulmon,
x 48wks x 24wks (48wk if coinfect) uncontrolled DM, <3yo, HSR
PegIFN a2a 180 mcg sq qwk (Hemodialysis: 135mcg) ANC <1.5 (1500 cell/mm3), Plt<80,
PegIFN a2b 1.5 mcg/kg sq qwk CrCl 30-50: ↓25%, 10-29: ↓50% ALT > 10xULN, CrCl<50(Peg)
PLUS Weight based dosing Regardless of weight RBC = anemia, Hgb <13 m, <12 fm
Ribavirin 1000mg/day (≤75kg) 800mg/day SCr>1.5, ClCr<50
in 2dd 1200mg/day (≥75kg) Severe CODP, asthma, cardiac

Other Meds (FDA approved): LATE: Lamivudine, Adefovir, Entecavir, Telbivudine

Non FDA approved: Tenofovir, Entricitabine: use in HIV-HBV coinfection

QUANG BUI
QUANG BUI

S4BBT4L7
Tx: CAP
Absence of abnorm VS is <1% chance PNA: RR>20, HR>100, T>100.4F(37.8C); CXR is definitive role in Dx; hard to collect sputum
DRSP: drug resist Staph P: age >65, abx tx 3mo prior (esp beta-lactam or FQ), EtOH, multiple comorbid, immunosupp meds

OUTPATIENT INPATIENT NONICU INPATIENT ICU

PATHOGEN Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae
RSV, influenza virus A & B,
Parainfluenzae, Adenovirus
TX 1. no abx in last 3 mo
- macrolide (azithro, clarith)
- doxycycline
2. comorbid (HF, DM, EtOH, asplen)
- resp FQ (moxi, gemi, levo)
- beta-lactam + macrolide
 
 


Legionella 
Enterobacteriacea
Pseudomonas aerigunosa, Staph aureus
1. β-lactam (CTX or Unasyn) 1. DRSP, Enterobact & Leg (DEL)
+ macrolide - β-lactam + (macrolide or resp FQ)
2. DEL & Pseudomonas A
2. resp FQ - Zosyn, cefepime, or mero
+ cipro or (AG + azithro/cipro)
3. DEL, PA & Staph aureus
- (2) + linezolid or vanco

ATYPICAL PNEUMONIA: insidious presentation

Common pathogen: Chlamydophila pneumonia, Mycoplasma pneumoniae, Legionella pneumophila, influenza A & B
Tx: Double coverage for bact: macrolide, resp FQ, TCN (not Doxycycline); generally beta-lactam + Tx for atypical
For influenza: Oseltamivir (Tamiflu) initiate w/in 48 hours of Sx onset

QUANG BUI
QUANG BUI

S4BBT4L8 Heintz (HAP & VAP)

Def: PNA developing ≥ 48 h after admission (HAP) or endotracheal intubation (VAP

Risk factors: intubation, >60yo, AMS, major surger (esp neuro), trauma (esp head), acid suppression
Immunosupp, pulmon dz (COPD, ARDS), chronic lung dz (CF, bronchiectasis), GN colonization
Prolonged hospitalization, broad spectrum abx exposure

Criteria for Clinical DX: new or persistent pulmonary infiltrate on Xray AND
≥ 2 of : 36C > T > 38C, 5000 > WBC > 1000 cells/mm3; purulent endotracheal aspirate
- accuracy of aspirate sample fr LRT:
o endotracheal aspirate TA (least accurate)  bronchoalveolar lavage sample (BAL)  protected specimen brush
sample PSB aka Bartlett’s Brush (most accurate)
- Clinical Pulmonary Infection Score: CPIS score > 6 associated w/ high likelihood of VAP/HAP
CPIS POINTS 0 1 2
Tracheal secretions Rare Abundant Abundant & purulent (esp Bartlett’s)
CXR infiltrations None Diffuse Localized
T© 36.5-38.4 38.5-38.9 ≥ 39 and ≤ 36
WBC (/mm3) 4-11 K < 4K or > 11K & bands (L shift)
PaO2/FiO2 (oxygenation) > 240 or ARDS ≤ 240 and no evidence of ARDS
(A = arteriolar, a = alveolar) (ARDS = acute resp distress syndrome)
microbio Negative Positive

MDR = multiple drug resistant; abx 90d before, hosp ≥ 5d; hi freq of abx resistance in hosp; immunosupp dz &/or tx
Presence of RF for HCAP: hosp > 2d 90d before, nursing home, extended-care facility,

QUANG BUI
QUANG BUI

Home infusion tx (including abx), chronic dialysis w/in 30d, home wound care, family w/ MDR pathogen

S4BBT4L8 Heintz (aspiration pneumonia)

Def: inhalation (macroaspiration) of oropharyngeal or gastric contents into larynx & LRT; may cause A pneumonitis

Risk factors: anything that compromises ability to swallow:

Stroke, neuromuscular dz, sedation, lethargy, etOH, dysphagia, intubation & chronic illness
Most cases from normal flora aerobic & anaerobic GPC >> GN
Peptostreptococcus, S pneumoniae, viridans Streptococci, S aureus
More common in alcoholics, nursing homes & hospital acquired: Kleb, Ecoli, Saureus & anaerobic GNR

Empiric Tx (important to know setting ot pt aspirated) * do NOT use Clinda monotx if GN aerobes suspected (etOHic, SNF)
AsP (alone) CTX + MTZ preferred Or Clinda* or Moxi or Unasyn
CAP (inpt)
AsP + CAP (admitted to hospital) CTX + MTZ + Doxycycline Or Moxi/Levo ± MTZ
AsP (outpatient) Clinda, Augmentin, Moxi PO
AsP (LTC facility, SNA, HAP) Levo or Cefepime ± MTZ (documented aspiration) Or Zosyn/Meropenem alone
Sever periodontal dz, Zosyn Or Combo of 2 drugs:
Putrid sputum, or etOHism CTX/Cefepime + Clinda or MTZ
(admitted to hospital) Or FQ + Clinda or MTZ

QUANG BUI
QUANG BUI

S4BBT4L9 Heintz (tb)

TUBERCULOSIS (Mycobacterim tuberculosis) – world 2nd leading cause of death from single infectious agent (after HIV)

DX: CXR: upper-lobe opacity w/ cavitation

TST (tuberculin skin test): wait 48-72 hours to measure first induration*:
≥ 5 mm HIV, close contact w/ tb case, signif immunosupp = organ transplant or ≥ 15 mg prednisone x ≥ 1 mo
≥ 10mm <5yr immigrant, IVDU, resident/employee of hi-risk congregate settings, ModImm**, malnourish
≥15mm No tb risk factors
*boost test = 2-step test (3 wks later) if TST all the time **mod immunosupp = DM, CA, ESRD

SYSTEMIC SX (sim to MAC): fever, night sweats, anorexia, weakness, chronic & productive cough
LOCAL SX: pulmonary cough
TX: nonpharm: controlling Tb transmission: ↓bacteria release, personal protection (N95 respirators), ↓environmental exposure
Combo [RIPE] req for cure of active dz. Never add single drug to failing regimen
LTBI (latent) Single drug is sufficient (INH x 9mo). R + P not recommended b/c risk of hepatic failure/death
Active RIPE x 2mo initial phase  check AFB (acid fast)  INH + RIF x 4mo (if -) or x7mo (if +)
continuation phase 7mo if cavitation CXR or if no cavitation but HIV +: INH/RIF

DOSE (qd preferred) ELIM DDI TOXICITIES

Hepatitis, not teratogenic but inc hepatitis
in preg; peripheral neuropathy (add VitB6
Isoniazid 5 mg/kg  300 max Hepatic PHT, CBZ pyridoxine 25-50 mg/d)
Rifampin 10 mg/kg  600 max Hepatic 3A4 (lots) Hepatitis (ALT 5xULN)
Rifabutin [10 mg/kg/wk  600 max] Usually use if Rifampin DDI
Pyrazinamide 20-25 mg/kg  2000 max Hepatic/Renal None Hepatitis, hyperuricemia

QUANG BUI
 QUANG BUI

Ethambutol 15-20 mg/kg  1600 max Renal None Retrobulbar neuritis (ocular)

2nd line for tx failure or resistant/tox to 1st line: FQ (moxi hep elim, levo renal elim), streptomycin
S4BCT4L3 Heintz (Infective Endocarditis)

Streptococcus viridans Aq Crystalline Or CTX PLUS Gentamicin Sulfate Vancomycin HCL

& S bovis PCN G Na
PCN Susceptible [IA] 12-18 MU/24H IV cont 2 g/d IV or IM
MIC ≤ 0.125 mcg/mL or dd Q4-6H x 4wks x 4wks
Preferred in most pts>65yo If non-type 1 PCN allergy
or pts w/ impairment of 8th May facilitate outpatient
Native Valve Endocarditis

cranial nerve fx, or renal therapy w/ QD dosing

PCN susceptible [IB]
MIC ≤ 0.125 mcg/mL
Relative PCN Resistant
0.125 < MIC < 0.5 mcg/mL
Tx as Enterococci if MIC >
0.5 mcg/mL
PCN Susceptible
Prosthetic Valve IE
impair
12-18 MU/24H IV cont 2 g/d IV or IM 3 mg/kg/d IV or IM 30 mg/kg/d IV dd Q12H
or dd Q4H x 2wks x 2wks in 1 dose x 2wks x 4wks
2 wk regiment not indicated for pts w/ known cardiac Only for pts who can’t tolerate PCN/CTX
or extracardiac abscesses or for those w/ CrCl < 20 mL/min, (allergy/toxicity)
impaired 8th cranial nerve fx, or Abiotrophia Granulicatella or Gemella sp infection Adjust dose for PK = 30-45; Tr = 10-15 mcg/mL
(these sp r often PCN-resistant & should be treated as Enterococci IE) (clinically Tr 15-20 mcg/mL ideal)
24 MU/24H IV cont 2 g/d IV or IM 3 mg/kg/d IV or IM 30 mg/kg/d IV dd Q12H
or dd Q4H x 4wks (CTX preferred) x 4wks in 1 dose x 2wks x 4wks
Only for pts who can’t tolerate PCN/CTX
24 MU/24H IV cont 2 g/d IV or IM 3 mg/kg/d IV or IM 20 mg/kg/d IV dd Q8-12H
or dd Q4-6H x 6wks x 6wks in 1 dose x 2wks x 6wks

Rel/Fully PCN Resistant
MIC > 0.125
[Tx same as NVIE by fully
PCN-resistant Streptococci
(MIC >0.5)]
PCN or CTX + Gent has NOT demonstrated superior cure rates Only for pts who can’t tolerate PCN/CTX
when compared to monoTx for pts w/ highly susceptible strains;
Gent is not rec for pts w/ CrCl < 30 mL/min
24 MU/24H IV cont 2 g/d IV or IM 3 mg/kg/d IV or IM 30 mg/kg/d IV dd Q12H
or dd Q4-6H x 6wks x 6wks in 1 dose x 6wks x 6wks
Only for pts who can’t tolerate PCN/CTX

Native & Prosthetic Valve Endocarditis: HACEK (Haemophilus, Actinobacilus, Cardiobacterium, Eikenella, Kingella) – use 1 agent

QUANG BUI
 QUANG BUI

CTX 2 g/d IV or IM x 4 wks native May substitute cefotaxime or another 3rd/4th gen (FQ?)
Unasyn 12 g/d IV dd Q6H But FQ = cipro, levo, moxi
Cipro (FQ) 1.5 g/d PO or 1200 mg/d IV dd Q8-12H x 6 wks prosthetic Only for pt not tol ceph & ampi or to facilitate PO tx
S4BCT4L3 Heintz (Infective Endocarditis)
Infective endocarditis req long tx courses w/ HIGH dose of BacteriCIDAL agents
Epidemiology: ♂:♀ 1.7:1, IVDU signif RF, 4th leading cause of life-threatening ID Syndrome, 30-50 yo (uncommon in children)
RF: preexisting cardiac valvular, complex (non)cyanotic congenital heart dz, prosthetic valve, prev endocarditis…
Native Valve Streptococci (esp viridans)
IVDU/Prosthetic Staphylococci (SA esp), GNR (also w/ cirrhosis)
Elderly/nosocomial Enterococci

Staphyloccocal (risk factors: IVDU & prosthetics)

Oxacillin Nafcillin or Oxacillin 12 g/d IV dd Q4-6H or 2 g IV Q4H X 6wks Nafcillin/Oxacillin for complicated
Susceptible ± Gentamicin Sulfate 3 mg/kg/d IV or IM in 2-3 dd X 3-5d RT-sided & LT-sided AG accelerate
MSSA & MSSE Killing in-vitro but clinical benefits of AG has not been
Native Valve

established
MSSA & MSSE Cefazolin 6 g/d IV dd Q8H or 2 g IV Q8H X 6wks Avoid cephalosporins in pts w/ anaphylactoid rxns to beta-
PCN-allergic ± Gentamicin Sulfate 3 mg/kg/d IV or IM in 2-3 dd X 3-5d lactams
(consider skin test) [AG benefits not established]
Oxacillin Resistant Vancomycin 30 mg/kg/d dd Q8-12H X 6wks Adjust Vanco dose to achieve 1 H PK = 30-45 mcg/mL or
MRSA & MRSE OR Daptomycin 6 mg/kg IV daily X 6wks Tr = 10-15 mcg/mL [Trough = 15-20 mcg/mL if MIC=2]
(never Linezolid) Daptomycin only FDA for Right-sided

QUANG BUI
 QUANG BUI

Oxacillin Nafcillin or Oxacillin 12 g/d IV dd Q4H or 2 g IV Q4H X ≥ 6wks Cefazolin 2g IV Q8H may be substituted (if allergy); PCN
Susceptible + Rifampin 300 mg/d IV or PO Q8H X ≥ 6wks G 24 MU/d can be used if strain is PCN-S (MIC≤0.1) &
Prosthetic Valve

MSSA & MSSE + Gentamicin Sulfate 3 mg/kg/d IV or IM in 2-3 dd X 2 wks doesn’t produce beta-lactamase (rare): if T1-HSR then
substitute Nafcillin w/ Vanco 15mg/kg IV Q12H or Dapto
6mg/kg IV/d (Rt-sided IE only)
Oxacillin Resistant Vancomycin 30 mg/kg/d dd Q12H X ≥ 6wks Adjust dose to achieve Vanco 1 H Peak = 30-45 mcg/mL &
MRSA & MRSE OR Daptomycin 6 mg/kg IV daily (Q48H – CrCl<30) X ≥ 6wks Tr = 10-15 mcg/mL [T=15-20 if MIC =2]
If allergic to Vanco or fail on Vanco, then sub w/ Dapto (Rt-
+ Rifampin 300 mg/d IV or PO Q8H X ≥ 6wks sided IE only)
+ Gentamicin Sulfate 3 mg/kg/d IV or IM in 2-3 dd X 2 wks Gentamicin dosed as synergistic

S4BCT4L3 Heintz (Infective Endocarditis)

Enterococcal Species – Native or Prosthetic Valve IE

N/PVE Enterococci Ampicillin Na 12 g/d IV dd Q4H or 2g IV Q4H X 4-6wks Ampi native valve:
& Fully PCN-Resist Or Aq Cryst PCN G Na 18-30 MU/d IV cont or dd Q4H X 4-6wks 4 wks rec for pts w/ Sx ≤ 3mo
Streptococci, Abiotrophila 6 wks tx rec for Sx ≥ 3mo
sp, Granulicatella sp + Gentamicin Sulfate 3 mg/kg/d IV or IM dd Q8H X 4-6wks PCN min 6 wks prosthetic valve
Or CTX 2 g Q12H CTX 2g Q12H opt for synergy if not gent
Vancomycin 30 mg/kg/d IV dd Q12H X 6 wks Vanco/Gent only for pts who can’t tol
+ Gentamicin Sulfate 3 mg/kg/d IV or IM dd Q8H X 6 wks PCN/ampi w/ 6 wks rec b/c Vanco has
Or Strepto 15 mg/kg/d IV dd Q12H ↓act vs enterococci
Or CTX 2 g IV Q12H Use strepto or CTX if resist to gent
Suscept to AG & Vanco, Unasyn 12 g/d IV dd Q6H X 6 wks Unlikely that strain will be susceptible to
Resistant to PCN & Ampi + Gentamicin 3 mg/kg/d IV or IM dd Q8H X 6wks gent; if strain is gent resistant, >6wks of
[beta-lactamase producing E Vancomycin 30 mg/kg/d IV dd Q12H X 6wks unasyn is req
faecalis] + Gentamicin 3 mg/kg/d IV or IM dd Q8H X 6wks Vanco only if pt can’t tol Unasyn
Resistant to Linezolid 600 mg IV or PO Q12H X ≥ 8 wks Should consult ID specialist; cardiac
PCN, AG & Vanco Or Synercid 22.5 mg/kg/d dd IV Q8H X ≥ 8wks valve replacement may be necessary for
[E faecium] (Quinupristin-Dalfopristin) bacteriologic cure; cure w/ abx alone

QUANG BUI
QUANG BUI

<50%; severe usu reversible

thrombocytopenia may occur w/ >2wks
linezolid tx; Synercid only effective vs E
faecium & can cause severe myalgia

QUANG BUI