ID
#Suspected Community-Acquired Pneumonia
patient presenting with symptoms of xxxx in addition to radiographic evidence of pneumonia; CURB65 = given BUN >19, RR >29, SBP<90, Age >65. PORT/PSI score - indicating **% mortality with CAP.
-Start Ceftriaxone 1-2g IV daily plus Azithromycin 500mg PO / IV daily
-Vancomycin if risk factors (recent abx use, recent hospitalization, end stage kidney disease, IVDU, etc)
-Will check PCT, legionella urine, strep pneumo urine, sputum Cx
-Incentive spirometer, chest physiotherapy, Acapella/Aerobika
-Duonebs as needed (not currently wheezing)
-VBG PRN
-POCUS for dynamic air bronchograms or evidence of effusion
Per 2019 IDSA/ATS guidelines on community acquired pneumonia
For healthy outpatient adults without comorbidities or risk factors for antibiotic resistant pathogens:
1. amoxicillin 1 g three times daily OR
2. doxycycline 100 mg twice daily OR
3. azithromycin 500 mg on first day then 250 mg daily (only in areas with pneumococcal resistance to macrolides 25%)
Per PMID: 33773631, 3 days of antibiotics non-inferior to longer course in non-critical patients
#Suspected Hospital-acquired Pneumonia:
Patient with symptoms of *** starting >48h after recent admission. CXR with evidence of ***.
-Blood cultures x2, sputum cx
-Start Cefepime 2g IV q8h and Vancomycin 15mg/kg IV q8-12h
-Will check PCT, legionella urine, strep pneumo urine, sputum Cx
-Incentive spirometer, chest physiotherapy, Acapella/Aerobika
-Duonebs as needed (not currently wheezing)
-VBG PRN
#GNR bacteremia
1g CTX IV qday for 10-14 days
Susceptibilities pending
If ESBL, 1g ertapenem IV qday for 10-14 days
#Infective endocarditis
Duke criteria:
Surgery indications per AATS 2016 guidelines: heart failure due to valve, uncontrolled infection, vegetation >10mm
#Infective endocarditis prophylaxis:
Indicated: Prosthetic cardiac valves, previous IE, unrepeaired cyanotic congenital heart disease, completely repair CHD with device during first 6 months after procedure, transplant with valve disease, RHD if valve repair
Not indicated: ASD, VSD, PDA, MVP, HOCM, CABG, pacemaker/ICD, bicuspid aortic valve, coarc, AS, Pulm stenosis
#C diff infection
History of C diff?
Initial episode: Per IDSA 2021 guidelines, fidaxomycin 200mg BID for 10 days; alternatively PO vancomycin 125mg 4x daily for 10 days; if neither are available, flagyl 500mg TID for 10-14 days
Recurrent episode: fidaxomycin dosing, see above; OR vanc dosing above for 10 days + followed by rifaximin 400mg TID for 20 days + fecal microbiota transplant
Fulminant (defined by hypotension/shock, ileus, megacolon): vanc 500mg PO 4x daily; consider rectal instillation of vanc if ileus; if ileus, IV flagyl 500mg q8
#HIV PREP
3 month follow up, RFP, UA, G/C test x3, HIV test, RPR
Patient counseled on safe sex practices to include condom use, minimizing number of new partners
Patient counseled that PrEP does not protect from other STIs
#Hepatitis A exposure
Nonimmune persons exposed to hepatitis A virus (HAV) should receive postexposure prophylaxis with HAV vaccine as soon as possible after exposure.
Postexposure prophylaxis with both HAV vaccine and HAV immune globulin may be considered for nonimmune patients older than 40 years.
#fever of unknown origin
>38C for 3 weeks, 1 week of inpatient work up
Bcx, Ucx
DDx: TB, abscess, endocarditis, GCA/PMR, adult onset Still's disease, PAN, ANCA, vasculitis, lymphomas, RCC, HCC, pancreatic cancer, colon cancer, sarcoma, mastocytosis, atrial myxoma, drug induced, DVT/PE, hyperthyroidism, adrenal insufficiency, pheochromocytoma, sarcoidosis, Kikuchi's, Behcet's, Familial Mediterranean Fever
-Workup: CBC, RFP, HFP, ESR, CRP, ANA, RF, cyroglobulin, LDH, CK, SPEP, 3 sets of Bcx, u/a, ucx, ppd/IGTA, HIV, EBV antibody, CMV antigen, hepatitis serologies
-cxr, CT chest/abd/pelvis, TTE
-abx not indicated unless neutropenic
-empiric glucocorticoids not indicated unless strong suspicion for rheumatologic disease
-up to 30% of cases remain undiagnosed, most spontaneously defervesce (after weeks to months)
#hepatitis B
The four phases of chronic hepatitis B virus (HBV) infection are differentiated on the basis of immune response: immune tolerant, immune active, immune control, and reactivation.
Patients in the immune control phase of chronic HBV infection, also known as inactive chronic HBV infection, generally do not require treatment
#COVID
Per NIH treatment guideline Sept 2022, first line therapy in hospitalized adult: Remdesivir
PINETREE NEJM 2022: 3 days remdesivir; 200mg x1, 100mg x2