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Moonlight Medicine

Moonlight Medicine

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Moonlight Medicine

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  1. Moonlight Medicine Adrian Paul J Rabe, MD

  2. 8 Targets of Moonlight Medicine • Infectious Disease • Cardiovascular Medicine • Pulmonary Medicine • Endocrinology • Gastroenterology • Poisons and Snakebites • Pain Medication • Electrolyte Correction

  3. Infectious Disease

  4. Infectious Disease • URTI • Pneumonia • UTI • Dengue • Typhoid • Leptospirosis

  5. Infectious Disease URTI

  6. URTI: Presentation • Symptoms • Cough, colds • 3 to 5 days duration • Signs • Nasal discharge (clear or yellowish) • Clear breath sounds • No signs of sepsis • Hemodynamically unstable

  7. URTI: Order Sheet • No labs necessary • Medications • Amoxicillin 1 g TID • Clindamycin 300 mg QID for 5 days • Azithromycin 250 mg OD x 5 days or 500 mg OD x 3 days or 1 g OD x 1 dose • Avoid using broad-spectrum antibiotics • Avoid prolonged regimens • Advice • Increased oral fluid intake (at least 2L/day)

  8. URTI: Watch Out For… • Persistence • Fever should lyse within 24-48 hours • Post-infectious cough occurs in 40% of patients • Recurrence • Consider allergic rhinitis – refer to an allergologist • Seasonal pattern • History of asthma or atopy • Relation to exposure to allergens/certain settings (bedroom, work) • If also with weight loss, obstructive ssx, refer to ORL

  9. URTI: Watch Out For… • Allergic Rhinitis • If with weekly symptoms, and bothers sleep/work, must start Fluticasonefuroate 2 puffs per nostril 2x a day for 4-6 weeks • Exacerbations: Loratadine 10 mg at night • Itching/Atopy: Cetirizine 10 mg OD • Discharge: Oxymetazoline spray (may use only up to 3 days) • Cough: Dextropmethophan+Phenylephrine • Tuseran Forte

  10. Infectious Disease Pneumonia

  11. Pneumonia (CAP): Presentation • Symptoms • Cough with/without sputum production • Fever • Generalized weakness, anorexia • Signs • Crackles • Decreased breath sounds • Increased fremiti – consolidation/mass • Decreased fremiti – pleural effusion • Wheezing

  12. CAP: Order Sheet • Initial Diagnostics • Chest X-ray • CBC with platelet count

  13. CAP: 2010 Guidelines Does the patient have: RR ≥ 30/min PR ≥ 125/min Temp ≥ 400C or ≤ 360C SBP < 90 or DBP ≤ 60 Altered mental status, acute Suspected aspiration Unstable co-morbids Chest X-ray: multilobar, pleural effusion, abscess No Moderate Risk vs High RIsk Yes • Co-morbidities • DM • Active Malignancy • Neurologic disease in evolution • CHF Class II-IV • Unstable CAD • Renal failure on dialysis • Uncompensated COPD • Decompensated Liver Disease Low Risk CAP

  14. CAP: 2010 Guidelines Does the patient have: Severe Sepsis Septic Shock Need for mechanical Ventilation No High Risk CAP Yes Moderate Risk CAP

  15. CAP: Antibiotics • Amoxicillin • Extended macrolides • Azithromycin • Clarithromycin • B-lactam/B-lactamase inhibitor combination (oral) • Co-amoxyclav • Amoxicillin-sulbactam • Sultamicillin

  16. CAP: Antibiotics • Oral second generation cephalosporin • Cefaclor • Cefuroximeaxetil • Oral third generation cephalosporin • Cefdinir • Cefixime • Cefpodoximeproxetil

  17. CAP: Antibiotics • IV non-antipseudomonal B-lactam • Co-amoxyclav • Ampicillin-sulbactam • Cefotiam • Cefoxitin • Cefuroxime • Cefotaxime • Ceftizoxime • Ceftriaxone • Ertapenem

  18. CAP: Antibiotics • Respiratory fluoroquinolones • Levofloxacin • Moxifloxacin • Aminoglycosides • Gentamicin • Tobramycin • Netilmicin • Amikacin

  19. CAP: Antibiotics • IV antipseudomonal B-lactam • Cefoperazone-sulbactam • Piperacillin-tazobactam • Ticarcillin-clavulanic acid • Cefepime • Cefpirome • Imipinem-cilastin • Meropenem

  20. CAP: Low Risk • Subsequent Diagnostics • Sputum GS/CS optional • Antibiotics • Previously healthy • Amoxicillin • Extended macrolides • Stable co-morbid condition (cover enteric G- bacilli) • B-lactam/B-lactamase inhibitor • 2nd generation oral cephalosporins +/- extended macrolide • 3rd generation oral cephalosporin +/- extended macrolide

  21. CAP: Moderate Risk (Admit) • Subsequent Diagnostics • Blood CS • Sputum GS/CS • Urine antigen for L. pneumophila • Direct fluorescent Ab test for L. pneumophila • Antibiotics • IV non-antipseudomonal B-lactam + extended macrolide • IV non-antipseudomonal B-lactam + respiratory fluoroquinolones

  22. CAP: High Risk (ICU) • Subsequent Diagnostics • Blood CS • Sputum GS/CS • Urine antigen for L. pneumophila • Direct fluorescent Ab test for L. pneumophila • ABG

  23. CAP: High Risk (ICU) • Antibiotics – no risk for Pseudomonas aeruginosa • Same as moderate risk • Antibiotics – with risk for Pseudomonas aeruginosa • IV antipseudomonal B-lactam + IV extended macrolide + aminoglycoside • IV antipseudomonal B-lactam + IV Ciprofloxacin or Levoflocacin (High dose)

  24. CAP: High Risk (ICU) • Pseudomonas aeruginosa • Malnutrition • Steroid use (Prednisone 2.5 mg in the past week) • Antibiotic use (at least 1 week in the past month)

  25. CAP: Watch Out For • Pleural effusion, Lung abscess • Do thoracentesis • Refer to TCVS for CTT if warranted • Hemodynamic instability/Progressing sepsis • Refer to Pulmo, IDS • Hospital-acquired pneumonia • Proper precautions in intubated patients • Exacerbation of co-morbid diseases

  26. CAP: Resolution • For low-risk • Follow-up after 3 to 5 days • For moderate-/high-risk • Step down when clinically improving • Some infections (e.g. ESBL organisms) require a full course via the IV route • Chest X-ray findings • May take up to 6 months to completely resolve • Vaccination (including those with co-morbids) • Pneumococcal: one time, then q5years • Influenza: annually

  27. Infectious Disease Urinary Tract Infection

  28. Urinary Tract Infection • Symptoms of Urethritis • Acute dysuria, hematuria • Frequency • Pyuria • Recent sexual partner change • Symptoms of Cystitis • Dysuria, Urgency • Suprapubic pain • Hematuria, foul-smelling urine, turbid urine

  29. UTI: Presentation • Symptoms of Acute Pyelonephritis • Rapid development • Fever, shaking chills • Nausea, vomiting, abdominal pain • Diarrhea • Diabetes, immunosuppression • Symptoms of catheter-related UTI • Minimal symptoms • Usually no fever

  30. UTI: Presentation • Signs of Urethritis • Grossly purulent discharge expressed in genital tract • Signs of Cystitis • Suprapubic tenderness • Fever • Signs of Acute pyelonephritis • Costoverterbal angle tenderness at side of involved kidney • Fever, signs of sepsis

  31. UTI: Presentation • Signs of catheter-related UTI • Turbid/foul-smelling urine • Purulent discharge • Suprapubic tenderness

  32. UTI 2004 Guidelines • Does the patient have complicating risk factors? • Anatomic abnormality • Functional abnormality • Recent UTI or Tract instrumentation (past 2 weeks) • Renal disease/transplant • Antibiotic use (Past 2 weeks) • Immunosuppresion • DM • Catheter, indwelling/intermittent • Hospital-acquired • Symptoms for > 7 days AFRRAID CH7

  33. UTI 2004 Guidelines • Uncomplicated Cystitis • Medications (do 7 day regimen in males) • Cotrimoxazole 800/160 PO BID x 3 days • Ciprofloxacin 250 mg PO BID x 3 days • Ofloxacin 200 mg PO BID x 3 days • Norfloxacin 400 mg PO BID x 3 days • Nitrofurantoin 100 mg QID x 7 days • Cefuroxime 125-250 mg PO BID x 3-7 days • Increase OFI • No need for U/A or urine cultures except in males • If unresolved after 7 days, consider as COMPLICATED

  34. UTI 2004 Guidelines • Acute Uncomplicated Pyelonephritis • Urinalysis (expect increased WBC; bacteriuria not the defining parameter; WBC cast is pathognomonic) • Urine GS/CS • Outpatient treatment: • No signs and symptoms of sepsis • Non-pregnant • Likely to comply with treatment • Follow-up after 3-5 days

  35. UTI 2004 Guidelines • Acute Uncomplicated Pyelonephritis • Empiric regimen should be started after culture is taken (Oral) • Ofloxacin 400 mg BID x 14 days • Ciprofloxacin 500 mg BID x 7-10 days • Levofloxacin 250 mg OD x 7-10 days • Cefixime 400 mg OD x 14 days • Cefuroxime 500 mg BID x 14 days • Co-amoxyclav 625 mg TID x 14 days (if GS is G+)

  36. UTI 2004 Guidelines • Acute Uncomplicated Pyelonephritis • Empiric regimen should be started after culture is taken (IV, given until patient is afebrile) • Ceftriaxone 1-2 g IV OD • Ciprofloxacin 200-400 mg IV q12 • Levofloxacin 250-500 mg IV OD • Ampicillin-Sulbactam 1.5 g IV q6 (if GS is G+) • Piperacillin-Tazobactam 2.25-4.5 g IV q6-8 • Post-treatment cultures are unnecessary

  37. UTI 2004 Guidelines • Acute Uncomplicated Pyelonephritis: WOF • Fever after 72 hours of treatment, or recurrence of symptoms • Imaging studies (KUB-UTZ , KUB-IVP if Creatinine clearance acceptable) • Repeat urine culture • If without urologic abnormality, treatment duration is 2 weeks based on culture • If same organism between initial and repeat culture, treatment duration is 4-6 weeks

  38. UTI 2004 Guidelines • Asymptomatic bacteriuria • Defined as ≥ 100,000 cfu in 2 consecutive midstream urine specimens or 1 catheterized specimen • Should screen for, and treat in • Patients who will undergo GU manipulation or instrumentation • Post-renal transplant patients up to first 6 months • DM with poor glycemic control, autonomic neuropathy or azotemia • All pregnant women • Same antibiotics as acute uncomplicated cystitis

  39. UTI 2004 Guidelines • Recurrent UTI • More 2x a year, with no urinary tract abnormalities • May give prophylaxis (if symptoms are unacceptable) • Post-coital (immediately after intercourse) • Daily for 6 to 12 months • Nitrofurantoin 100 mg at bedtime • Cotrimoxazole 200/40 mg at bedtime • Ciprofloxacin 125 mg at bedtime • Norfloxacin 200 mg at bedtime • Cefalexin 125 mg at bedtime • Same antibiotics as acute uncomplicated cystitis, or may also take 2 double strength Cotrimoxazole single dose as soon as symptoms first appear

  40. UTI 2004 Guidelines • Complicated UTI • Urine GS/CS • Outpatient • No signs of sepsis • Without marked debilitation • Inability to comply with treatment • Inability to maintain oral hydration/take oral medications

  41. UTI 2004 Guidelines • Complicated UTI • Oral • Ciprofloxacin 250 – 500 mg BID x 14 days • Norfloxacin 400 mg BID x 14 days • Ofloxacin 200 mg BID x 14 days • Levofloxacin 250 – 500 mg OD x 10-14 days

  42. UTI 2004 Guidelines • Complicated UTI • Parenteral • Ampicillin-sulbactam 1.5 – 3 g IV q6 • Ceftazidime 1-2 g IV q8 • Ceftriaxone 1-2 g IV OD • Imipenem-cilastin 250-500 mg IV q6-8 • Piperacillin-Tazobactam 2.25 g IV q6 • Ciprofloxacin 200-400 mg IV q12 • Ofloxacin 200-400 mg IV q12 • Levofloxacin 500 mg IV OD • At least 7 to 14 days of therapy

  43. UTI 2004 Guidelines • Complicated UTI • At least 7 to 14 days of therapy • Urine culture should be repeated 1 to 2 weeks after completion of medications • If persistent, refer to urology/nephrology • If no response, may do • Plain KUB x-ray • KUB-UTZ • Helical CT scan

  44. UTI 2004 Guidelines • Catheter-associated UTI • If asymptomatic, no need to treat, except if • With bacterial agents with high-incidence bacteremia • With neutropenia • Pregnant • Will undergo urologic procedures/post-renal transplant • Indwelling catheter should be removed • Long-term indwelling catheters should be replaced before treatment

  45. UTI 2004 Guidelines • Candiduria • May treat if • Symptomatic • Critically ill • Neutropenic • Will undergo urologic procedures/post-renal transplant • Control diabetes (if present) • Remove catheter, other urinary tract instruments (if present)

  46. UTI 2004 Guidelines • Candiduria • Cystitis • Fluconazole 400 mg LD then 200 mg OD x 7-14 days • Pyelonephritis • Surgical drainage • Fluconazole 6 mg/kg/day or Amphotericin B IV 0.6 mg/kg/day for 2 to 6 weeks

  47. Infectious Disease Dengue Fever

  48. Dengue Fever: Presentation • Probable Dengue • Live in or travel to endemic area • Fever and any 2 of the following: • Nausea and vomiting • Rash • Aches and Pains • Tourniquet test positive • Leukopenia • Any warning Sign • Labs: when there are no signs of plasma leakage

  49. Dengue Fever: Presentation • Probable Dengue • Live in or travel to endemic area • Fever and any 2 of the following: • Nausea and vomiting • Rash • Aches and Pains • Tourniquet test positive • Leukopenia • Any warning Sign • Labs: when there are no signs of plasma leakage

  50. Dengue Fever: Presentation • Warning Signs • Abdominal pain or tenderness • Persistent vomiting • Clinical fluid accumulation • Mucosal bleed • Lethargy, restlessness • Liver enlargement > 2 cm • Increase in hematocrit WITH decrease in platelet count