COMON INFECTION OF THE BLOOD

Terms

Septicemia-a disease caused by toxic microorganisms in the bloodstream

 Bacteremia-presence of bacteria in the blood

Septicemia is a medical emergency and blood cultures should be taken b4 starting antimicrobial therapy

When septicemia follows GI or genital tract surgery, E coli or other gram –ve bacteria, anaerobes eg Bacteroides, Streptococci or Enterococci are likely pathogens.

Drug regimens:

Cefuroxime + metronidazole

OR

Gentamycin + amoxycillin + metronidazole

When related to urinary tract infns, it involves E coli or other gram –ve, enterococci

Regimen:

Gentamycin + amoxycillin or gentamycin + ceftazidime where P aeruginosa is suspected.

Neonetal septicemia is due to Streptococci or P aeruginosa

Give cefotaxime or with netilmicin

When there is abcess, it may be due to Staphylococci….flucloxacillin is DOC

NB. Give vancomycin to MRSA

Cardiovascular system

Infective endocarditis (IE)- a microbial infection of the heart valves or other endocardial tissue

Common microbes are staphylococci, streptococci, enterococci or fungal

Initial ‘blind’ therapy

Flucloxacillin (or pen G if symptoms less severe) + gentamicin

Substitute flucloxacillin (or pen G) with vancomycin + rifampicin if cardiac prostheses present, or if penicillin-allergic, or if meticillin-resistant Staphylococcus aureus suspected

Endocarditis caused by streptococci

Pen G (or vancomycin if penicillin- allergic or highly penicillin-resistant) + gentamicin

Treat more resistant organisms for 4–6 weeks (stopping gentamicin after 2 weeks for organisms moderately sensitive to penicillin.

Treat prosthetic valve endocarditis for at least 6 weeks (stopping gentamicin after 2 weeks if organisms fully sensitive to penicillin

Endocarditis caused by enterococci (e.g. Enterococcus faecalis)

Amoxicillin (or vancomycin if penicillin-allergic or penicillin-resistant) + gentamicin

Treat for at least 4 weeks (at least 6 weeks for prosthetic valve endocarditis); if gentamicin-resistant, substitute gentamicin with streptomycin

CNC

Meningitis

Infection causing inflammation of the membranes covering the brain and spinal cord.

Headache, fever, stiff neck, photophobia, drowsiness, myalgias, malaise, chills, sore throat, abdominal pain, nausea, and vomiting

                                                 

Meningitis caused by meningococci

Pen G or cefotaxime

Treat for at least 5 days; substitute chloramphenicol if history of anaphylaxis to penicillin or to cephalosporins.

 To eliminate nasopharyngeal carriage give rifampicin for 2 days

Meningitis caused by pneumococci

Cefotaxime

Treat for 10–14 days; substitute benzylpenicillin if organism penicillin-sensitive; if organism highly penicillin- and cephalosporin-resistant, add vancomycin and if necessary rifampicin.

Consider adjunctive treatment with dexamethasone starting before or with first dose of antibacterial (but may reduce penetration of vancomycin into cerebrospinal fluid)

Meningitis caused by Haemophilus influenzae

Cefotaxime

Treat for at least 10 days; substitute chloramphenicol if history of anaphylaxis to penicillin or to cephalosporins or if organism resistant to cefotaxime.

Consider adjunctive treatment with dexamethasone For

H. influenzae type b give rifampicin for 4 days before hospital discharge

Meningitis caused by Listeria

Ampicillin or Amoxicillin + gentamicin

Treat for 10–14 days

Urinary tract

Common pathogens are E coli, Proteus spp, K pneumoniae, P aeruginosa, Enterobacteriae, S saprophyticus

Acute pyelonephritis

A broad-spectrum cephalosporin or a quinolone

Treat for 14 days;

longer treatment may be necessary in complicated pyelonephritis

Acute prostatitis

A quinolone or trimethoprim

Treat for 28 days; in severe infection, start treatment with a high dose broad-spectrum cephalosporin (e.g. cefuroxime or cefotaxime) + gentamicin

‘Lower’ urinary-tract infection

Trimethoprim or nitrofurantoin or amoxicillin or oral cephalosporin

Treat for 7 days but a short course (e.g. 3 days) of trimethoprim or nitrofurantoin is usually adequate for uncomplicated urinary-tract infections in women

Genital system

Syphilis by Treponema pallidum

Procaine benzylpenicillin or doxycycline or erythromycin

Treat early syphilis for 14 days (10 days with procaine benzylpenicillin).

Treat late latent syphilis with procaine benzylpenicillin for 17 days (or with doxycycline for 28 days).

 Treat asymptomatic contacts of patients with infectious syphilis with doxycycline for 14 days.

Uncomplicated gonorrhoea (Neisseria donorrhoeae)

Cefixime or ciprofloxacin

Single-dose treatment in uncomplicated infection.

Choice depends on locality where infection acquired.

 Pharyngeal infection requires treatment with ceftriaxone.

 Use ciprofloxacin only if organism sensitive.

Uncomplicated genital chlamydial infection, non-gonococcal urethritis and non-specific genital infection

Doxycycline or azithromycin

Treat with doxycycline for 7 days or with azithromycin as a single dose;

alternatively, treat with erythromycin for 14 days.

Pelvic inflammatory disease(N gonorrhoeae, C trachomatis, M hominis)

Doxycycline + metronidazole + i/m ceftriaxone or ofloxacin + metronidazole

Treat for at least 14 days (use i/m ceftriaxone as a single dose).

 In severely ill patients initial treatment with doxycycline + i/v ceftriaxone (as a single dose) + i/v metronidazole, then switch to oral treatment with doxycycline + metronidazole to complete 14 days' treatment.

Bacterial vaginosis

Oral or topical metronidazole or topical clindamycin

Oral treatment for 5–7 days (or with high-dose metronidazole as a single dose); topical treatment for 5 days (7 days with clindamycin)

Chancroid-Haemophillus ducrey

Erythromycin for 7 days or single dose of Rocephin™ or azithromycin

Granuloma inguinale-by Calymmatobacterium granulomatis

Ampicillin or CTX or tetracycline for 2 weeks

CLASSIFICATION OF INFECTIOUS ORGANISMS

BACTERIA AEROBIC   Gram-positive   Cocci      Streptococci: pneumococcus, viridans streptococci; group A streptococci   Enterococcus      Staphylococci: Staphylococcus aureus, Staphylococcus epidermidis   Rods (bacilli)   Corynebacterium   Listeria Gram-negative    Moraxella      Neisseria (Neisseria meningitides. Neisseria gonorrhoeae).   Rods (bacilli)      Enterobacteriaceae (Escherichia coli, Klebsiella, Enterobacter, Citrobacter, Proteus, Serratia, Salmonella, Shigella, Morganella, Providencia)   Campylobacter   Pseudomonas   Helicobacter   Haemophilus (coccobacilli morphology)   Legionella Anaerobic  Gram-positive   Cocci   Peptococcus   Peptostreptococcus   Rods (bacilli)      Clostridia (Clostridium perfringens, Clostridium tetani, Clostridium difficile)   Propionibacterium acnes

Gram-negative   Cocci     None   Rods (bacilli)      Bacteroides (Bacteroides fragilis, Bacteroides       melaninogenicus)      Fusobacterium      Prevotella 2. FUNGI    Aspergillus, Candida, Coccidioides, Cryptococcus, Histoplasma, Mucor, Tinea, Trichophyton 3. VIRUSES    Influenza, hepatitis A, B, C, D, E; human immunodeficiency virus; rubella; herpes; cytomegalovirus; respiratory syncytial virus; Epstein-Barr virus, severe acute respiratory syndrome (SARS) virus 4. CHLAMYDIAE Chlamydia trachomatis Chlamydia psittaci Chlamydia pneumoniae    Lymphogranuloma venereum (LGV) disease caused by Chlamydia trachomatis of immunotype L1–L3 5. RICKETTSIAE Rocky Mountain spotted fever, Q fever Ureaplasma 6. MYCOPLASMAS Mycoplasma pneumoniae, Mycoplasma hominis 7. SPIROCHETES Treponema pallidum, Borrelia burgdorferi (Lyme disease) 8. MYCOBACTERIA Mycobacterium tuberculosis Mycobacterium avium intracellulare

JIFUNZE ZAIDI KUHUSU ARTEMISININ

Artemisinin is a Chinese herb (qinghaosu) that has been used in the treatment of fevers for over 1,000 years, thus predating the use of Quinine in the western world. It is derived from the plant Artemisia annua, with the first documentation as a successful therapeutic agent in the treatment of malaria is in 340 AD by Ge Hong in his book Zhou Hou Bei Ji Fang (A Handbook of Prescriptions for Emergencies). Ge Hong extracted the artemesinin using a simple macerate, and this method is still in use today.The active compound was isolated first in 1971 and named artemisinin. It is a sesquiterpene lactone with a chemically rare peroxide bridge linkage. It is this that is thought to be responsible for the majority of its anti-malarial action, although the target within the parasite remains controversial. At present it is strictly controlled under WHO guidelines as it has proven to be effective against all forms of multi-drug resistant P. falciparum, thus every care is taken to ensure compliance and adherence together with other behaviors associated with the development of resistance. It is also only given in combination with other anti-malarials.  
Artemisinin has a very rapid action and the vast majority of acute patients treated show significant improvement within 1–3 days of receiving treatment. 
It has demonstrated the fastest clearance of all anti-malarials currently used and acts primarily on the trophozite phase, thus preventing progression of the disease. Semi-synthetic artemisinin derivatives (e.g. artesunate, artemether) are easier to use than the parent compound and are converted rapidly once in the body to the active compound dihydroartemesinin. On the first day of treatment 20 mg/kg should be given, this dose is then reduced to 10 mg/kg per day for the 6 following days. Few side effects are associated with artemesinin use. However, headaches, nausea, vomiting, abnormal bleeding, dark urine, itching and some drug fever have been reported by a small number of patients. Some cardiac changes were reported during a clinical trial, notably non specific ST changes and a first degree atrioventricular block (these disappeared when the patients recovered from the malarial fever). Artemether is a methyl ether derivative of dihydroartemesinin. It is similar to artemesinin in mode of action but demonstrates a reduced ability as a hypnozoiticidal compound, instead acting more significantly to decrease gametocyte carriage. Similar restrictions are in place, as with artemesinin, to prevent the development of resistance, therefore it is only used in combination therapy for severe acute cases of drug-resistant P. falciparum. It should be administered in a 7-day course with 4 mg/kg given per day for 3 days, followed by 1.6 mg/kg for 3 days. Side effects of the drug are few but include potential neurotoxicity developing if high doses are given. Artesunate is a hemisuccinate derivative of the active metabolite dihydroartemisin. Currently it is the most frequently used of all the artemesinin-type drugs. 
Its only effect is mediated through a reduction in the gametocyte transmission. It is used in combination therapy and is effective in cases of uncomplicated P. falciparum. The dosage recommended by the WHO is a 5 or 7 day course (depending on the predicted adherence level) of 4 mg/kg for 3 days (usually given in combination with mefloquine) followed by 2 mg/kg for the remaining 2 or 4 days. In large studies carried out on over 10,000 patients in Thailand no adverse effects have been shown.  
Dihydroartemisinin is the active metabolite to which artemesinin is reduced. It is the most effective artemesinin compound and the least stable. It has a strong blood schizonticidal action and reduces gametocyte transmission. It is used for therapeutic treatment of cases of resistant and uncomplicated P. falciparum. 4 mg/kg doses are recommended on the first day of therapy followed by 2 mg/kg for 6 days. As with artesunate, no side effects to treatment have thus far been recorded.  
Arteether is an ethyl ether derivative of dihydroartemisinin. It is used in combination therapy for cases of uncomplicated resistant P. falciparum. The recommended dosage is 150 mg/kg per day for 3 days given by IM injections. With the exception of a small number of cases demonstrating neurotoxicity following parenteral administration no side effects have been recorded.