Drugs for nosocomial infection, Hospital acquired infections, Pharmacology, Antibiotics

1. Dr. Jervin Mano, MD
The Hidden Epidemic

2.  Epidemiology of nosocomial infections
 Pathogens involved in nosocomial infection
 Therapeutic guidelines
 De-escalation approach
 Prevention
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3.  Definition
 Incidence
 Historical milestones
 Classification
 Risk factors
 Mode of transmission
 Pathologic agents
 Drugs used
 Rx of common NI
 Prevention
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4.  Nosocomial infection comes from Greek words
“nosus” meaning disease and “ komeion”
meaning to take care of - disease contracted by
a patient while under medical care.
 Also called as HOSPITAL ACQUIRED INFECTION
 Infections are considered nosocomial if they
first appear 48hrs or more after hospital
admission or within 30 days after discharge.
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5.  The incidence of NI is estimated at 5-10% in tertiary care
hospitals reaching up to 28% in ICU.
 One-third of nosocomial infections are considered
preventable.
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6.  Nosocomial infections are responsible for
about 100,000 deaths per year in hospitals
 The patients must stay in the hospital 4-5
additional days.
 More than 70% of bacteria that cause
hospital-acquired infections are resistant to at
least one of the drugs most commonly used in
treatment
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7.  New cutting edge diagnostic & therapeutic technologies for
prolonging life
 Population ages
 Compromised defenses
 high prevalence of pathogens
 high prevalence of immuocompromised hosts
 efficient mechanisms of transmission from patient to patient.
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8. 8

9.  The famous ancient physician Charaka and surgeon
Sushuruta (Ca. 400 B.C.) emphasized the need for
prevention of infection in clinical practice
 1800’s typhus was considered as HAI
 James Simpson (1830)-termed HAI
 Ingaz Semmelweiss (1861) emphasised importance of
hand hygiene in prevention of puerperal sepsis
 Lister introduced antiseptic theory
 Florence Nightingale “Do no harm”- Hospital hygiene.
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10.  Alexander Fleming -Penicillin
 1943- penicillin mass production
 1943- Marybaber
 1946- Pn resistant strains outnumbered
sensitive ones
 Pn resistant strains in Op patients
 1960 – Methicillin
 Broad-spectrum antibiotics seemed to keep
check on S.aureus infections
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The Story Of Superbug

11.  1961-MRSA
 Multiple drug resistant strains
 VRSA
 Superbugs today
 More recently the extensive use of indwelling medical devices
and the introduction of new antibiotics coupled with their
indiscriminate use the gram-positive cocci have once again
emerged as the predominant causes of infection
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Superbug Returns

12.  Nonspecific
 infections common among the normal population
 they follow a current regional epidemiological situation
 they do not need specific preventive arrangements
 Specific
 resulting from diagnostical or therapeutical procedures
 due to lack of personal hygiene of staff,
 wrong therapeutic technique
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13.  Endogenous (50%)
 Exogenous (15%)
 Cross infection (35%)
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14.  Patient Factors
 Immunocompromised
 Severity of illness
 Broken skin & mucous membrane
 Length of hospital stay
 Iatrogenic factors
 Pathogens on hands of medical personal
 Invasive procedure
 Misuse of antibiotics
 Acquired antibiotic resistance
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15.  Environmental
 Contaminated water systems
 Nurse to patient ratio
 Open beds close together
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16. There are five main modes of transmission
 Contact
 Vector borne
 Air borne
 Droplet
 Common vehicle
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17. DROPLET TRANSMISSION
Droplet generated by sneezing
Coughing or respiratory tract procedures like
Bronchoscopy or suction
VECTOR TRANSMISSION
Transmitted through insects and
Other invertebrates animals
such as mosquitoes and fleas.
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18. AIR BORNE TRANSMISSION
Tiny droplet nuclei that remain (<5)
suspended in air.
COMMON VEHICLE TRANSMISSION
Transmitted indirectly by materials
contaminated with the infections.
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19. 09-02-2017
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20. VIRUS
BACTERIA
FUNGI

21.  Bacteria
 Commensal Bacteria
 Staph.epidermidis (iv infections)
 E. coli (UTI)
 Pathogenic Bacteria
 Gram-positive
 Staph.aureus- In hospitals commonly 40-50% of S. aureus isolates are MRSA
 Streptococci- Streptococcus beta-hemolyticus, Strept. Pyogenes
 Clostridia sp
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22.  Gram-negative
 Enterobacteriaceae (e.g. E. coli, Proteus, Klebsiella, Enterobacter,
Serratia marcescens)
 Pseudomonas spp.
 Legionella sp
 VIRUS
 Hepatitis B,C
 Respiratory Syncytial Virus
 Rotavirus
 Enterovirus
 Varicella Zoster
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23.  FUNGI
 Candida albigans
 Aspergillus spp.
 Cryptococcus neoformans
 Cryptosporidium
 PARASITES
 Pneumocystis carini
 Toxoplasma pneumoniae
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24.  90% due to bacteria
 10% (others: virus, fungi, protozoal etc)
 Most common pathogens isolated from any HAI:
 S. aureus (13%)
 E. coli (12%)
 CoNS (11%)
 Enterococci (10%)
 Pseudomonas (9%)
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25.  Most common isolated pathogens also depends on site of
infection
 UTI (E. coli-24%)
 SSI (S. aureus-20%)
 BSI (CoNS-31%)
 LRI (S. aureus 19%, Pseudomonas 17%)
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26.  Urinary tract infections (34%)
 Surgical site infections (17%)
 Pneumonia (13%)
 Blood stream Infection (14%)
 Nosocomial diarrhea
 Fungal infections
 Legionellosis
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27. 09-02-2017
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29.  Cell wall/membrane synthesis
inhibitors
 Vancomycin
 Cephalosporins
 Carbapenems
 Teicoplanin
 Daptomycin
 Piperacillin+tazobactum
 Colistin
 Protein synthesis Inhibitors
 Aminoglycosides
▪ Amikacin
▪ Netilmicin
▪ Tobramycin
 Tigecycline
 Linezolid
 Quinpristin/Dalfopristin
 Miscellaneous
 Levofloxacin
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30.  Glycopeptide antibiotic
 MOA
 inhibiting proper cell wall synthesis in Gm+ bacteria by
preventing cross-linking
 Antimicrobial spectrum
 MRSA & multi-resistant Staphylococcus epidermidis (MRSE)
 Clostridium difficile,Corynebacterium
 Indications
 pseudomembranous colitis , MRSA infections
 Adverse effects
 Red man syndrome
 Ototoxicity, Nephrotoxicity
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31.  β-lactam antibiotic
 MOA: Inhibit cell wall synthesis
 Drugs:
 Ceftazidime (3G)
 Cefepime (4G)
 Ceftaroline (5G)
 AMS:
 Ceftazidime : Pseudomonas, Gm-ve bacilli
 Cefepime : Gm-ve bacilli, MRSA, Strep.pneumonia
 Ceftaroline : Gm+ve , MRSA, Penicillin resistant Strep.pneumonia,
Enterococcus
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32.  Uses:
 Hospital acquired pneumonia
 Hospital acquired bacteremia
 Hospital acquired septicemia
 UTIs
 Febrile neutropenic pts (4G)
 ADR:
 Hypersensitivity reactions
 Superinfections
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33.  β-lactam antibiotics
 Highly resistant to β-lactamases
 Broad spectrum antibiotic
 Drugs:
 Imipenem
 Meropenem
 Ertapenem
 Doripenem
 MOA: Inhibits cell wall synthesis
 Antimicrobial Spectrum:
 Gm+ve, Gm-ve, Anareobes
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34.  extremely potent broad spectrum antibiotic
 Indications:
 Hospital acquired Infections- resistant to other β-lactam antibiotics
 Inactivated by renal dehydropeptidase -> given in combination
with cilastatin(inhibits the human enzyme dehydropeptidase)
 ADR:
 Decreases seizure threshold
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35. MEROPENEM
 Newer carbapenem not deactivated by dehydropeptidase
 Indications: -Reserve drug for serious HAI
 ADR: Similar to Imipenem but less potential to induce seizures
DORIPENAM
 ultra-broad spectrum
 Indications
 complex abdominal infections
 Nosocomial pneumonia
 complicated UTI including kidney infections with septicemia
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36.  Glycopeptide antibiotic
 MOA : inhibits cell-wall synthesis
 AMS :
 MRSA
 Listeria monocytogenes,Corynebacterium spp,Clostridium spp
 Nonviridans and viridans streptococci, enterococci
 Uses:
 MRSA and penicillin resistant Strep.infections
 Osteomyelitis, Enterococcal endocarditis
 ADR :
 Hypersensitivity, Skin rashes, Neutropenia
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37.  lipopeptide antibiotic
 MOA
 inserted into cell membrane – creates hole – leakage of ions – depolarisation- cell death
 AMS: Gram-positive bacteria
 glycopeptide-resistant Enterococci (GRE)
 MRSA, streptococci , corynebacteria.
 Indications
 skin and skin structure infections caused by Gram-positive infections
 Staphylococcus aureus bacteraemia
 Adverse effects
 Hypotension, Hypokalaemia, Hyperglycaemia
 Thrombocytopenia, Elevated creatine kinase
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38.  Group: polypeptide antibiotic
 MOA : Binds to LPSs -> Disruption of cell membrane ->leakage of
intracellular contents -> bacterial death
 Antimicrobial Spectrum : Gm –ve bacteria
 P. aeruginosa
 Acinetobacter species
 Enterobacteriaceae
 Indications:
 VAP, Nosocomial bacteremia
 ADR:
 Nephrotoxicity- Lesser toxic than aminoglycosides
 Neurotoxicity
 Bronchospasm (Inhalation)- treated with salbutamol
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39.  Group : Aminoglycoside
 MOA: Bids to 50 S ribosome – inhibits protein synthesis
 Antimicrobial spectrum:
 Pseudomonas aeroginosa
 Proteus, Serratia, Klebsiella, Enterobacter, E.coli
 Indications
 Serious Gm-ve HAI
 M.tuberculosis
 ADR:
 Ototoxicity, Nephrotoxicity
 Neuromuscular blockade
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40.  AMS: Aerobic Gm-ve bacilli
 Uses: Susceptible Enterobactericea, aerobic Gm-ve bacilli
 ADR: Similar to Amikacin but less toxic
 Uses: Ps.aeuroginosa in combination with β-lactam antibiotics
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Tobramycin

41.  Group: glycylcycline antibiotic
 MOA : bacteriostatic, broad spectrum antibiotic
Binds to 30S ribosome -> inhibits bacterial protein synthesis
 Antimicrobial Spectrum :
 methicillin-resistant Staphylococcus aureus (MRSA)
 Stenotrophomonas maltophilia
 Haemophilus influenza
 Neisseria gonorrhea
 multi-drug resistant strains of Acinetobacter baumannii
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42.  Indications:
 complicated intra-abdominal and skin and soft tissue
infections
 Adverse Effects :
 diarrhoea nausea and vomiting.
 pain at the injection site swelling and irritation; increased or
decreased heart rate and infections. Also avoid use in children
and pregnancy, due to its effects on teeth and bone.
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43.  Group : Oxazolidinone
 MOA : Binds to 50S ribosome -> inhibits bacterial protein synthesis
 Antimicrobial spectrum:
 MRSA, VRSA, VRE
 Strep.vidans, pneumonia
 Corynebacterium, Clostridia
 Indications:
 Nosocomial pneumonia
 SSI
 ADR: Neutropenia
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44.  Group: Streptogramins
 MOA: Binds to 50S ribosome -> inhibits bacterial protein synthesis
 AMA:
 Gm +ve bacteria
 M. pneumoniae, Legionella spp., and Chlamydia pneumoniae
 Indication :reserved for treatment of serious infections caused by
multiple-drug-resistant gram-positive organisms such as
vancomycin-resistant E. faecium.
 ADR :
 Arthralgia, myalgia, Phlebitis
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45.  2G Fluoroquinolones
 MOA: Inhibition of bacterial enzyme – DNA gyrase, topoisomerase IV
 AMS:
 Gm+ve esp. Strep.pneumonia
 Gm-ve bacilli
 Atypical pathogens- Chlamydia, Mycoplasma
 Anaerobes
 Uses :
 C/c bronchitis
 Pneumonia (CA & HA)
 UTI
 A/c sinusitis
 ADR: Tendonitis, Teratogenic
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46.  Caspofungin
 Echinocandin
 MOA: fungal cell wall lysis
 Use : Aspergillus inf, Candidiasis
 ADR: Abnormal liver fn
 Amphotericin B
 Polyene- binds to ergosterol in cell wall-> increase permeability
 Uses: invasive aspergillosis, histoplasmosis, Cocoidomycosis
 ADR : Nephrotoxic
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47.  Fluconazole
 Azole- inhibits ergosterol synthesis
 Uses: Candidiasis, Coiccoidomycosis
 Adr: GI upset
 Flucytosine
 Inhibits fungal DNA syn
 Use; in combi for candidiasis, Crytococcosis
 ADR: Bone marrow deppresion
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48. 49

49.  It is the most common cause of
nosocomial infections
 80% of the infections are
associated with indwelling
catheters.
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50.  Mild-Moderate
 Ciprofloxacin 500mg po / 400mg iv Q12H
 Levofloxacin 500-750mg iv/po q24h
 Ceftriaxone 1g iv
 Severe
 Cefepime 2g iv q12h
 Ceftazidime 2g iv q8h
 Piperacillin+tazobactum 3.375-4.5giv q6h
 Carbapenems
 vancomycin
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Hooton TM. Nosocomial urinary tract infections. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of
Infectious Diseases. 7th ed. New York, NY: Churchill Livingstone; 2010:3725-3737
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51.  Fluconazole 200-400mg/day x 14d
if resistant
 Oral flucytosine &/or Parenteral Amphotericin B
 Bladder irrigation with Amphotericin B is NOT recommended
 Fluconazole iv 200mg/day
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52.  The incidence is increasing particularly
for certain organisms such as multi
resistance coagulase negative
staphylococcus and candida.
 Infections may occurs at the skin entry
site of the IV device or in the sub
cutaneous path of catheter.
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53.  A thin coating containing biologically
active agents, which coats the surface of
structures such as teeth or the inner
surfaces of catheter, tube, or other
implanted or indwelling device. It
contains viable and nonviable
microorganisms that adhere to the
surface and are trapped within a matrix
of organic matter (for example, proteins,
glycoproteins, and carbohydrates).
09-02-2017 Farlex Partner Medical Dictionary
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54. Simple Multi drug resistant
Coagulase –ve Staph. Semisynthetic Penicillins Vancomycin
Staph.aureus Penicillin, Cefazolin Vancomycin
Gm-ve FQ FQ+rifampin
Pseudomonas
Candidia Fluconazole Amphotericin_B
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55.  They are also frequent
 The definition is mainly clinical
(purulent discharge around wounds
or the insertion site of drain, or
spreading cellulites from wounds)
 The infections can be exogenously
or endogenously
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56. + Vancomycin 1g iv Q12H
57
 Wound infection without sepsis ( not GIT, FGT)
 Mild-Moderate
 Cephalexin 500mg po QID
 Augmentin 875/125mg po BD
 Doxycyline 100mg po BD
 Complicated
 Ticarcillin + Clav 3.1g iv Q6H
 Piptaz 3.375g iv Q6H
 Ertapenem 1g Q24H

57.  Wound infection with sepsis ( not GIT, FGT)
 Ampicillin + sulbactum 1.5-3g iv Q6H
 Ticarcillin + Clav 3.1g iv Q6H
 Piptaz 3.375g iv Q6H
 Cephazolin 1g iv Q8H
 Wound Infection (GIT , FGT)
 Ampicillin + sulbactum 1.5-3g iv Q6H
 Ticarcillin + Clav 3.1g iv Q6H
 Piptaz 3.375g iv Q6H
 Ceftriaxone+metronidazole
 Imipenem 500mg iv Q6H
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58.  Recommendations
 Administer within 1 hour of incision to maximize tissue concentration
▪ Once the incision is made, delivery to the wound is impaired
 Duration of prophylaxis
 Stop prophylaxis
▪ within 24 hours after the procedure
▪ within 48 hours after cardiac surgery
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Bratzler et al Arch Surg 2005, 140:174-82
Harbarth S et al. Circulation 2000;101:2916–2921

59. Primary Alternate
Cardiac Cefazolin +/- Gentamicin Vancomycin +/- Gentamicin
GIT Cefazolin(or) Cefoxitin +/-
Metronidazole
Clindamycin + Gentamicin
GUT Ampicillin +/- Gentamicin +/-
Cefazolin
Clindamycin + Gentamicin
OBG Cefazolin Clindamycin + Gentamicin
Head & Neck Cefazolin Clindamycin + Gentamicin
Neurosurgery Cefazolin Vancomycin
Ophthal Gentamicin,
tobramycin,Moxifloxacin, gatifloxacin
Ortho Cephazolin Clindamycin/ Vancomycin
60

60.  The most important are patients
on ventilators in ICU.
 Recent and progressive
radiological opacities of the
pulmonary parenchyma,
purulent sputum and recent
onsite fever.
Most commonly caused by acinetobacter.
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61.  Hospital-acquired pneumonia (HAP)
 Occurs 48 hours or more after admission, which was not incubating at the time of admission
 Healthcare-associated pneumonia (HCAP) is defined as
pneumonia that occurs in a non-hospitalized patient with
extensive healthcare contact, as defined by one or more of the
following:
 Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days.
 Residence in a nursing home or other long-term care facility
 Hospitalization in an acute care hospital for two or more days within the prior 90 days
 Attendance at a hemodialysis clinic within the prior 30 days
 Ventilator-associated pneumonia (VAP)
 Arises more than 48-72 hours after endotracheal intubation
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62. Non-MDR Pathogens MDR Pathogens
Streptococcus pneumoniae Pseudomonas aeruginosa
Other Streptococcus spp. MRSA
Haemophilus influenzae Acinetobacter spp.
MSSA Antibiotic-resistant Enterobacteriaceae
Antibiotic-sensitive Enterobacteriaceae Enterobacter spp.
Escherichia coli ESBL-positive strains
Klebsiella pneumoniae Klebsiella spp.
Proteus spp. Legionella pneumophila
Enterobacter spp. Burkholderia cepacia
Serratia marcescens Aspergillus spp.
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63. Patients without Risk Factors for MDR Pathogens
Ceftriaxone (2 g IV q24h) or
Moxifloxacin (400 mg IV q24h), ciprofloxacin (400 mg IV q8h), or levofloxacin (750
mg IV q24h) or
Ampicillin/sulbactam (3 g IV q6h) or
Ertapenem (1 g IV q24h)
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64. Patients with Risk Factors for MDR Pathogens
1. A β-lactam:
Ceftazidime (2 g IV q8h) or cefepime (2 g IV q8–12h) or
Piperacillin/tazobactam (4.5 g IV q6h), Imipenem (500 mg IV q6h or 1 g IV q8h), or
meropenem (1 g IV q8h) plus
2. A second agent active against gram-negative bacterial pathogens:
Gentamicin or tobramycin (7 mg/kg IV q24h) or amikacin (20 mg/kg IV q24h) or
Ciprofloxacin (400 mg IV q8h) or levofloxacin (750 mg IV q24h) plus
3. An agent active against gram-positive bacterial pathogens:
Linezolid (600 mg IV q12h) or
Vancomycin (15 mg/kg, up to 1 g IV, q12h)
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65.  Etiology :
 Cl. Difficle
 Antibiotics associated :
 Clindamycin
 Ampicillin
 Cephalosporins
 Fluoroquinolones
 Transmission
 Acquired exogenously in hospitals
 Transmitted through infected stools of patients or carriers
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66.  Initial episode
 Mild to mod
 Tab. Metronidazole 500mgTID X 10-14d
 Severe
 Tab. Vancomycin 125mg QID X 10-14d
 Fulminant
 Tab. Vancomycin 500mg + Inj. Metronidazole 500mgiv Q8H
+rectal instillation of Vancomycin (500mg in 100ml NS) as retention
enema Q6-8H
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67.  First : Similar to initial episode
 Second : Vancomycin tapering regime
 125mg QID x 10-14d; BID x 7d ; OD x 7d ; Q2-3d x 2-8 weeks
 Multiple :
 Vancomycin tapering regime
 Vancomycin 500mg QID x 10d + Saccharomyces boularetii 500mg BID
x 28d
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68.  Etiology:
 Candida
 Aspergillosis
 Candida
 Echinocandin : Caspofungin
 Fluconazole
 Amphotericin B
 Fluconazole+Amphotercin B
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69.  Aspergillosis
 Voriconazole
 Liposomal AMB
 Caspofungin/Micafungin
 Posiconazole
 Itraconazole
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70. 09-02-2017
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71. 72

72.  Hand washing
 Isolation
 Sterilization
 Gloves and aprons
73

73.  Prevention of Central Venous Catheter Infections
 Educate personnel about catheter insertion and care.
 Use chlorhexidine to prepare the insertion site.
 Use maximal barrier precautions during catheter insertion.
 Consolidate insertion supplies (e.g., in an insertion kit or cart).
 Use a checklist to enhance adherence to the bundle.
 Cleanse patients daily with chlorhexidine.
 Ask daily: Is the catheter needed? Remove catheter if not needed or
used.
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74.  Prevention of Ventilator-Associated Pneumonia and Complications
 Elevate head of bed to 30–45 degrees.
 Decontaminate oropharynx regularly with chlorhexidine.
 Give "sedation vacation" and assess readiness to extubate daily.
 Use peptic ulcer disease prophylaxis.
 Prevention of Surgical-Site Infections
 Administer prophylactic antibiotics within 1 h before surgery; discontinue within
24 h.
 Limit any hair removal to the time of surgery; use clippers
 Prepare surgical site with chlorhexidine-alcohol.
 Maintain normal perioperative glucose levels (cardiac surgery patients)
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75.  Prevention of Urinary Tract Infections
 Place bladder catheters only when absolutely needed (e.g., to relieve
obstruction), not solely for the provider's convenience.
 Use aseptic technique for catheter insertion and urinary tract
instrumentation.
 Minimize manipulation or opening of drainage systems.
 Ask daily: Is the bladder catheter needed? Remove catheter if not needed.
 Prevention of Pathogen Cross-Transmission
 Cleanse hands with alcohol hand rub before and after all contacts with
patients or their environments.
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76.  Razupenem
 2G glycopeptides
 Telavancin- sup. To Vancomycin in Rx MRSA
 Dalbavancin - sup. To Vancomycin in Rx catheter BSI
 Oritavancin – VRSA , VRE
 Ramoplanin
 Cl.difficle, VRE
 Torezolid
 Staph., Enterococci, More potent than Linezolid
 Phase III trial
 Cephalosporins 5G
 Ceftobiprole
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77.  The progressive emergence of gram-positive organisms as
dominant isolates in nosocomial infections has become a
primary health care concern
 Antibiotic therapy regimens should balance the care of
individual patients and the general patient population welfare.
 Antibiotic treatment should start as soon as possible after
infection is diagnosed and its duration should be minimized
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78. Monotherapy Conventional Combination Alternatives
E.coli Ceftazidime,Cefepim
e
Amox-clav,FQ
Cefotaxime+ Amikacin
Piperacillin+ Tazobactum
Imipenem
Imipenem+ AG/FQ
Klebsiella sp
SBL -
Ceftazidime
Cefipime
Amox-clav
Cefotaxime+ Amikacin
Piperacillin+ Tazobactum
Imipenem
Imipenem+ AG/FQ
ESBL+ Imipenem,Cefapime
FQ
Imipenem+AG
Piperacillin+Tazobactum + Amikacin
Imipenem+FQ
Enterobacte
r
Imipenem
Cefapime,Piptaz
3G Cephalosporin+AG Imipenem+FQ
AG+FQ
Pseudomon
as
Piperacillin
3G,4G Cephalosporin
Carbapenem
Ticarcillin/ceftazidime+
Sulbactum+AG
Cefftazidime+FQ
Piperacillin+FQ
AG+FQ
09-02-2017
79

79. Monotherapy Conventionall
combinations
Alternatives
MRSA Vancomycin
Imipenem+cilastin
Meropenem
Vancomycin+FQ
Rifampicin+Vancomyci
n
Imipenem+Vancomycin
Staphylococci
(Coaagulase-ve)
Vancomycin
Imipenem+cilastin
Meropenem
Vancomycin+FQ
Rifampicin+Vancomyci
n
Imipenem+Fosfomycin
AG
Entercoccus Ampicillin
Imipenem
Piperacillin
Vancomycin
Ampicillin+Gentamicin
Vancomycin+AG
Teicoplanin+
piperacillin
Imipenem
+vancomycin
09-02-2017
80

80.  Harrison’s principles of internal medicine , 18th edition
 Goodman and Gilman's the pharmacological basis of therapeutics 12th edition
 Atul Jain, Kanwardeep Singh, Vol. 9 No. 1, January-March 2007, Recent Advances in
the Management of Nosocomial Infections
 Basic & Clinical pharmacology , 12th Ed., Betram g. Katzung
 Leu HS, Huang CT. Clearance of funguria with short-course antifungal regimens: a
prospective, randomized, controlled study. Clin Infect Dis 1995;20:1152-7
 Oxford textbook of medicine 4th edition
 Principles of Pharmacology 2nd edition, HL Sharma KK Sharma
 WHO Prevention of hospital-acquired infections 2nd Edition
 Prevention & Management of Catheter Associated UTI-Diane K. Newman
 http://www.optimusise.com/history-hospital-infection
 http://www.ncbi.nlm.nih.gov/pubmed/
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81

81. 82