感染科Infectious diseases topic two: Antibiotics and bacteria

Antibiotics and bacteria

(Should consult professional advice because every doctor has his/her own perspective regarding antibiotic use.)

Author: Kendrick Johnson

1. Antibiotics and drug resistance
- mechanism: bacterial pump(1/10 of bac. genome coding for pumps); collateral damage caused by wide spectrum antibiotics and subsequent selection of resistant colonies

-  hospital monitoring:  Most bac. are sensitive to amikacin, but beware of renal toxicity); other indicators of resistance: ciprofloxacin, levofloxacin etc.

- example: E. coli resistance development(ampicillin-->cefazolin-->ceftriaxone-->carbapenem-->colistin)

2. Bacteria review

 GPC(Staphylococcus, Streptococcus, Enterococcus)

         Staphylococcus

        - coagulase (+): S. aureus

        - coagulase (-): other Staphylo

 GPB(Listeria, Bacillus, Clostridium)

 GNC(Neisseria)

 GNB(Enterobacteriaceae, NFGNB, Haemophilus)

                                           NFGNB(live on little amount of sugar)

                                           - Pseudomonas

                                           - Acinetobacter baumanii

                                           - Stenotrophomonas maltophilia 

                                              - Burkholderia

                                              - Moraxella catarrhalis

                     

3. Antibiotics categories

- Main force: cell wall inhibitors

- Assistance: protein inhibitors

- Second line: quinolone, rifampin

- Killers: Daptomycin (sounds effective but cannot kill intracellular pathogens)

4. Drug of choice( Newer drug isn't always better _)

- Syphilis, Spirochetes, Strep. group A: Penicillin G

(cp. strep group B: http://emedicine.medscape.com/article/229091-treatment)

- MSSA cellulitis: Oxacillin

- Enteroccocus: resistant to all cepha, use Penicillin G or Ampicillin

- MRSA: Vancomycin (but Vanco has poor CNS penetration)

- Infective endocarditis: Penicillin G 3-4 MU IV Q4H +Gentamicin 1mg/kg Q8H  for 4-6wks

Further reading: http://cid.oxfordjournals.org/content/49/2/320.full

-VRE: Ampicillin +Gentamicin (if sensitive), Linezolid(ZYVOX), Daptomycin
- Uncomplicated sinusitis, pharyngitis, otitis media: Amoxicillin(250-1000mg PO Q8H)
- Neonatal E. Coli infection/Adult Listeria meningitis: Ampicillin(1-3g IV Q4H-Q6H for Listeria)

- Respiratory tract infection: AUGMENTIN(Amoxicillin +Clavulanate),  UNASYN(Ampicillin +Sulbactam), sulbactam--> Acinetobacter baumannii

- Klebsiella pneumonia: Cephalosporins(3rd if community invasive infection) + aminoglycosides
- Enteric bacilli with ESBL: resistance to 3rd cephalosporins; use Imipenem or Meropenem, Ciprofloxacin
- Salmonella: Should not be treated with aminoglycosides, 1st- or 2nd- generation cephalosporins or imipenem, use 3rd cephalosporins, Quinolone, and TMP-SMZ, Ampicillin, Chloramphenicol if (S)

- Pseudomonas infection(HAP?): TAZOCIN
- Pseudomonas: aminoglycoside(UTI), Ceftazidime+aminoglycoside(pneumonia and/or bacteremia), ciprofloxacin/levofloxacin

- Stenotrophomonas infection: TMP-SMZ, TIMENTIN,  Levofloxacin 
                                                              (ticarcillin +clavulanate)
- Acinetobacter baumannii: ceftazidime, imipenem or meropenem; colistin+carbapenem or sulbactam

5. ß-Lactam antibiotics
- Penicillin, Cephem(Cephalosporin/Cephamycin), Monobactam, Carbapenem, ß-lactamase inhibitor

Penicillins
- Recite!  
                  Ampicillin + Sulbactam = Unasyn (MSSA, Acinetobacter, bacteroides)
                  Amoxicillin + Clavulanic acid = Augmentin
                  Ticarcillin + Clavulanic acid = Timentin
                  Piperacillin + Tazobactam = Tazocin
Cephems
-First-generation cephem
Cefazolin (IV)
Cephalexin (oral)

-Second-generation cephem
Cefuroxime (IV, oral)
Cefoxitin, cefmetazole (IV cephamycin)

-Third-generation cephem
Without antipseudomonal activity: Ceftazidime, Cefoperazone
With antipseudomonal activity: Cefotaxime, ceftriaxone (IV); Cefixime, cefpodoxime (oral)

-Fourth-generation cephem
Cefepime
Cefpirome

Carbapenems : for ESBL, anaerobics
- Imipenem
- Meropenem
- Ertapenem: NOT for pseudomonas, AB

Fluoroquinolones: CAN cover AB, Salmonella, Shigella, atypical, anaerobics, resistance strains, STD(gonorrhea)
- 2nd generation Ciprofloaxin (Cirpoxin): GNB, NFGNB
- 3rd generation Levofloxacin (Cravit), Moxifloxacin (Avelox)

Aminoglycosides: seldom used alone if G(+)
- Gentamycin
- Amikacin
- Recite!
                    Infective endocarditis: Penicillin G + gentamicin  
                    Enterococcus infection: Ampicillin + gentamicin
                    Staphylococcus infection: Oxacillin + gentamicin/ Vancomycin + gentamicin
Macrolides: MRSA, S. pneumonia, atypical
- Erythromycin
- Clarithromycin
- Azithromycin

SMX-TMP
- simple UTI
- PCP
- salmonella; traveler's diarrhea
- Steno/Burkholderia/Chryseo

Tetracycline (Mycoplasma, Chlamydia, Rickettsia)
-   Tetracycline: Q6H
    Minocycline: Q12H
    Doxycycline: Q24H
-   Tigercycline

Others
- Metronidazole: amoeba, Clostridium difficle
- Clindamycin: for G(+), alternative
- Chloramphenicol
- Colistin: multiple drug resistant G(-)

感染科 Infectious diseases topic one: NTM (nontuberculous mycobacteria)

NTM

1. Pathogen types

- Rapid growing: abscessus

- Soft tissue related: marinum

- Immunocompromised pts: kanasii

2. Pathogen from...

- Aquarium, fish: marinum

- Tap water: gordonae

3. Body parts involved

- LN: by MAC

- Soft tissue:  by marinum

- Lung: AFP(+), PCR(-), CT may present with TB-like patterns(tree in bud, LNs)

- Disseminated: beware of AIDS, interferon gamma pathway defect

4. Examination

- Use LJ culture with liquid

- Take samples from sputum, bronchial washing, soft tissue, blood

5. Diagnosis by

- Clinical symptoms

- Image proof

- Pathology or culture

*** Fungal infection of lung can also last long.

6.  Sweet's syndrome

- Epidemiology: rare

- Presentation: fever, painful skin lesions on arms, neck, head, and trunk

- Etiology: infection(ex:NTM), cancer, drug

7. Treatment

- Principle: treat early even with only one set of blood culture done

- Kanasii: treat as TB, except PZD(Pyrazinamide)

- MAC: macrolide with other drugs combined

8. Take home message:
Consider NTM infection if wounds do not heal for a long time
***Further reading: https://www.ncbi.nlm.nih.gov/pubmed/27109150

實戰課題Medical internship topic 4: Diabetes mellitus ADA guideline

Diabetes mellitus ADA guideline(2016)

1. DM types: type 1, type 2, GDM, MODY
2. Diagnosis

Diabetes Care Volume 39, Supplement 1, January 2016

3. Evaluation/Prevention

-- To test for prediabetes, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test, and A1C are equally appropriate.

-- For all patients, testing should begin at age 45 years. (repeat every 3 years)

4. Management for type 1 DM

-- Multiple-dose insulin injections (three to four injections per day of basal and prandial insulin) or CSII therapy(Continuous Subcutaneous Insulin Infusion)

5. Management for type 2 DM

-- first line: Metformin

-- insulin use: if newly diagnosed and markedly symptomatic and/or elevated blood glucose levels or A1C

-- add therapy if: goal failed after 3 months

6.  Drugs

Diabetes Care Volume 39, Supplement 1, January 2016

Diabetes Care Volume 39, Supplement 1, January 2016

Diabetes Care Volume 39, Supplement 1, January 2016

7. Mixed therapy

-- Noninsulin agents may be continued, although sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists are typically stopped once more complex insulin regimens beyond basal are used

-- Regular human insulin and human NPH-Regular premixed formulations (70/30) are less costly alternatives to rapid-acting insulin analogs and premixed insulin analogs, respectively, but their pharmacodynamic profiles make them suboptimal to cover postprandial glucose excursions

實戰課題Medical Internship topic 3: Hypertension guideline in Taiwan

Hypertension guideline in Taiwan

https://commons.wikimedia.org/wiki/File%3AKidney_nephron_molar_transport_diagram.png

All of the information collected below is from 2015 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension

"We disagreed with the ESH/ESH joint hypertension guidelines suggestion to loosen BP targets to <140/90 mmHg for all patients."
"We strongly disagree with the suggestion by the 2014 JNC report to raise the BP target to <150/90 mmHg for patients between 60-80 years of age. "

1.  For patients with diabetes, CHD, chronic kidney disease who have proteinuria, and those who are receiving antithrombotic therapy for stroke prevention, we propose BP targets of <130/80 mmHg in our guidelines.

2.  BP targets are <140/90 mmHg for all other patient groups, except for patients 80 years of age in whom a BP target of <150/90 mmHg would be optimal.

3. Lifestyle change for HTN patients: S-ABCDE
S- Sodium restriction, low salt but not no salt, <2.0 gram/day may be harmful
A- Alcohol limitation
B- Body weight reduction
C- Cigarette smoke cessation
D- Diet adaptation
E- Exercise adoption

4. Drug therapy, consider PROCEED
P- Previous experience
R- Risk factors
O- Organ damage
C- Contraindications
E- Expert's or doctor's judgment
E- Expenses or cost
D- Delivery and compliance

5. Rule of 10 & Rule of 5
"With a standard dose of any one of the 5 major classes of anti-hypertensive agents, one can anticipate approximately a 10-mmHg decrease in systolic BP (SBP) (Rule of 10) and a 5-mmHg decrease in diastolic BP (DBP) (Rule of 5). [...], when 2 drugs with different mechanisms are to be taken together, the decrease in BP is the sum of the decrease of the individual agents (approximately 20 mmHg in SBP and 10 mmHg in DBP). "

"When doses of the same drug are doubled, there is only a 2-mmHg incremental decrease in SBP and a 1-mmHg incremental decrease in DBP."

6. Adjustment algorithm: AT GOALs
A- Adherence
T- Timing of administration
G- Greater doses
O- Other classes of drugs
A- Alternative combination or SPC(single pill combination)
L- LSM(life style modification) + Laboratory tests

7. Initiation of drug therapy
Condition: HTN stage 1, after 3 months of LSM but fail to reach the goal
Special cases: "[...]diuretics and beta-blockers should not be considered as first-line therapy in patients with metabolic syndrome or glucose intolerance, unless strongly indicated or used as an add-on therapy to reach target.

8. Timing of administration
"Morning administration of antihypertensive drugs was routinely performed in the past. However, it has been recently more common to switch to a bedtime administration.[...]The nighttime BP was more effectively decreased by bedtime administration of drugs. More importantly, asleep BP was the most significant predictor of event-free survival."
-- safe and effective choices: ACE inhibitors, ARB, or CCB

9. Goal
"[...]appropriate to control BP to targets at 3 months, and preferably within 1 month, for high-risk patients."

10. Thiazides
-- merits: ↓CHD, ↓heart failure, adding low dose-->effective when BP cannot be controlled with ACE inhibitors or ARBs, more effective on OB patients?
-- demerits: hypokalemia (not corrected with Triamterene), hyponatremia, metabolic effects
(A dose more than 25 mg/d of hydrochlorothiazide is considered to be a high dose and is associated with a significant increase in side effects including metabolic derangement.)
-- Chlorthalidone might be preferred compared to hydrochlorothiazide ???

11. Aldosterone antagonists
-- merits: beneficial for primary aldosteronism, resistant hypertension, prior CV events?(systolic, but no preserved ejection fraction)
"Treatment-resistant hypertension is defined in a recent review as high BP ( 140/90 mmHg), resistant to a treatment regimen that includes proper lifestyle modification plus a diuretic and two other antihypertensive agents of different classes at their optimal doses."
--demerits: hyperkalemia, rapid reduction of eGFR

12. Loop diuretics
-- merits: good for edema(+), CKD, CHF 
-- demerits: not as effective in lowering BP

13. Other potassium sparing diuretics
-- demerits: not as effective in lowering BP

14. Beta-blockers
-- merits: good for CHD, MI, HR↑
-- demerits: increase stroke if pt's without CHD? Only in the elderly ( 60 years), atenolol was inferior to other drugs in reducing stroke? reduced sexual function, fatigue, reduced exercise capacity, and body weight increase, newly onset diabetes(with diuretics!) ; contraindication(both selelctive and non-selective)--> asthma

15. Calcium channel blockers
 Dihydropyridine (DHP)
-- merits: ↓stroke,
-- demerits: less effective in ↓HF, peripheral edema,
Non-dihydropyridine (non-DHP)
-- demerits: less potent than DHP groups, more negatively chronotropic and inotropic, metabolized by CYP3A4

16. Angiotensin converting enzyme inhibitors
-- merits: pre-hypertension,  preferentially indicated in patients with HF/diabetes/CKD
-- demerits: cough and angioedema

17. Angiotensin receptor blockers
-- merits: tolerability↑ discontinuation↓
-- demerits:  should not be combined with ACE inhibitors (renal impairment)

18. Direct renin inhibitors (aliskiren)
-- safely combined with hydrochlorothiazide or amlodipine in the elderly (age 65 years) with stage 1 hypertension
-- demerits: hyperkalemia, hypotension and renal impairment if combined with ACEI or ARB

19. Other drugs(not first line)
-- alpha blockers(Doxazosin): treat resistant HTN/BPH
-- clonidine, alpha-methyldopa
-- hydralazine, minoxidil: cause fluid retention and tachycardia, hemolytic anemia, vasculitis, glomerulonephritis, and a lupus-like syndrome; (+)isosorbide dinitrate(Imdur)-->effective for African-American symptomatic HF 
-- LCZ 696: dual-acting angiotensin receptor-neprilysin inhibitor (ARNI)

20. Combination
Early combination is suggested!
Preferred: A+C. A+D; B+C; R+C, R+D; A+C+D 
Not recommended: B+D, A+R, A/R+DRI

***Recommendation*** 
1. Med Data Speaks
This is a website arranging data concerning oral antihypertensive drugs
https://meddataspeaks.wordpress.com/2015/11/29/%E8%87%A8%E5%BA%8A%E8%97%A5%E5%AD%B8-%E9%AB%98%E8%A1%80%E5%A3%93%E5%8F%A3%E6%9C%8D%E8%97%A5%E7%89%A9%E7%B8%BD%E6%95%B4%E7%90%86/

2. JNC 7(comorbidities and drug choice, not detailed): 
https://s3.amazonaws.com/hcplive/n_media/image3/card-8-25-09.JPG

3. JNC 8(initial dose of drugs)
http://www.measureuppressuredown.com/HCProf/Find/BPs/JNC8/specialCommunication.pdf

小兒科雜記Pediatrics topic 1: Unconjugated hyperbilirubinemia in the newborn

Unconjugated hyperbilirubinemia in the newborn

0. Metabolism process review
-- Heme-->[heme oxygenase]-->biliverdin-->[biliverdin reductase]-->bilirubin-->[UGT1A1]-->conjugated bilirubin-->[beta-glucuronidase]-->unconjugated bilirubin

1. Total bilirubin:
-- usually > 1mg/dL
               # hematocrit 50~60% (more RBC)
               # shorter life span of RBC (85 days)
               # deficient UGT1A1

               # increased enterohepatic circulation

-- can reach 10~14 mg/dL @ 3~5 days old (East-Asians) 
-- resolves within the first one to two weeks after birth
-- >25 mg/dL:  bilirubin-induced neurologic dysfunction (BIND)--> kernicterus


2. Neonatal hyperbilirubinemia (>35 wks)
-- check hour-specific Bhutani nomogram: >95th percentile
-- severe if
             # appear at first 24 hrs
             #  >95th percentile
             # 0.2 mg/dL ↑ per hour
             # after 2 weeks
             # conjugated >1 mg/dL or >20 percent

3. Breast milk jaundice
-- >5 mg/dL for several weeks (max. 12 wks)
-- etiology: some unknown factor in milk promoting enterohepatic circulation

4. Breast feeding failure jaundice
-- combined with low output (urine+stool), hypovolemia, weight loss

實戰課題Medical Internship topic 2-2: Physical examinations

Medical Internship topic 2-2: Physical examinations

So let's continue with the PE video review...

1. Kussmaul respirations

https://www.youtube.com/watch?v=TG0vpKae3Js

-- DKA (metabolic acidosis-->respiratory alkalosis)

2. Kussmaul's sign

https://www.youtube.com/watch?v=VCQKA_SPCGs

-- restrictive cardiomyopathy, pericardial effusion, constrictive pericarditis, RV infarction or failure

3. Marcus Gunn pupil
https://www.youtube.com/watch?v=xXIIoMhitqQ
-- retinopathy, nerve damage

4. Horner's syndrome
https://www.youtube.com/watch?v=TToQbaZvNns
https://www.youtube.com/watch?v=JBVGh0gyyYc
-- PAM(ptosis, anhidrosis, miosis)

5. Oppenheim's sign
https://www.youtube.com/watch?v=EiwD6s8dmu4
--UMN lesion

6. Palmomental reflex
https://www.youtube.com/watch?v=Y3Ebk5Yv1Ns
-- frontal lobe lesion

7. Quincke's pulse
https://www.youtube.com/watch?v=ZzwoYTYVHSI
-- aortic insufficiency

8. Cushing syndrome and related findings (no picutres)
This clip contains no pictures but I like it so much. Cushing syndrome is well explained.
https://www.youtube.com/watch?v=2-5XAbjAKpE

9. Tinel's sign
https://www.youtube.com/watch?v=VtrC9dnVrrQ
-- carpel tunnel syndrome

10. Titubation
https://www.youtube.com/watch?v=FpiEprzObIU
-- cerebellar disease

11. Trousseau's sign
https://www.youtube.com/watch?v=SBuquydjZDc
-- hypercalcemia, tetany

12. Xanthelasma
https://www.youtube.com/watch?v=fUdxDxTtCRE

實戰課題Medical Internship topic 2-1: Physical examinations

Medical Internship topic 2-1: Physical examinations

There are some physical examinations that are just too hard to remember.

I think watching videos is a good way to memorize them, so....

here are some YouTube links I think would benefit our learning .

※ Copyrights belong their owners. This is just sharing for a non-profit purpose.

0. Breathing sounds
https://www.youtube.com/watch?v=O8OC7EiqBKQ

1. Anisocornia

https://www.youtube.com/watch?v=jgVJyEOXVvM

-- CN3 palsy

-- Adie's pupil : post viral infection, denervation, sphincter function↓, more common in young women

-- Argyll Robertson pupil: bilateral, related to DM, syphilis, and other systemic diseases

-- Horner's syndrome

Way of description:

mydriasis --> dilated pupils

myosis     --> constricted pupils

2. Angiokeratomas

https://www.youtube.com/watch?v=ddwGZcxBchY

3. Arcus senilis

https://www.youtube.com/watch?v=rhAs5LjXoN8

cp. limbus sign

4. Pterygium, pinguecula

https://www.youtube.com/watch?v=8CcPA9WxEig

5. Brushfield spots

https://www.youtube.com/watch?v=gqSVGaQB4eE

6. Buffalo hump

https://www.youtube.com/watch?v=Y5AvsSUm9pg

7. Bullous myringitis
https://www.youtube.com/watch?v=R2KDzw9TMFM
-- mycoplasma pneumonia

8. Cafe au lait spot
https://www.youtube.com/watch?v=NOqNGq3iG9c
-- neurofibromatosis
-- Von Recklinghausen disease

9. Chaddock's reflex
https://www.youtube.com/watch?v=PFoKzgLxFzw
-- pyramidal tract lesion

10. Chvostek's sign
https://www.youtube.com/watch?v=kvmwsTU0InQ
-- tetany

11. Corrigan's pulse
https://www.youtube.com/watch?v=5YQsd6di6B4

12. Erythema marginatum
https://www.youtube.com/watch?v=5RTeRwfcD9o

13. Gibbus deformity
https://www.youtube.com/watch?v=xXNIuOdjQ24
--Pott's disease(tuberculosis spondylitis)

14. Hoffman's sign
https://www.youtube.com/watch?v=QjtiasgMgwY
-- pyramidal tract disease (unilateral!!!)

15. Koplik's spot
https://www.youtube.com/watch?v=UxKv77tS7bY