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89 3 Gastroenterology OUTLINE 3-1. Cholecystitis 90 3-2. Cholangitis 933-3. Crohn's Disease 953-4. Hepatic Encephalopathy 973-5. Intestinal Obstruction 1013-6. Pancreatitis (Acute) 1033-7. Peritonitis 1073-8. Ulcerative Colitis 109 Symptoms 3-9. Acute Abdominal Pain 111 3-10. Diarrhea with or without Abdominal Pain 116 3-11. GI Bleeding (Upper or Lower) 118

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90 GASTROENTEROLOGY TABLE 3-1: Diagnosis: Cholecystitis Disposition Surgical/medical floor Monitor Vitals Diet NPO Fluid MIVF O 2 PRN Activity Bedrest Dx studies Labs CBC with differential, BMP, Mg, LFT, lipid profile, amylase, lipase, γ -glutamyl transpeptidase (GGTP) Blood C&S, PT/PTT/INR, UA Radiology and cardiac studies If RUQ US negative HIDA scan (cholescintigraphy), CXR, ECG Special tests ?Morphine cholescintigraphy, ?MR cholangiography, ?CT of abdomen ?Endoscopic retrograde cholangio-pancreatography (ERCP) (if bile duct obstruction from stone), ?acute abdominal x-ray series Prophylaxis DVT Consults Surgery, ?GI Nursing ? Avoid ? (continued)

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GASTROENTEROLOGY 91 Management Supportive management Treat N/V with PRN medications Pain management: See Chapter 12 [commonly used: morphine, hydromorphone (Dilaudid)] Ampicillin/sulbactam (Unasyn): 3 g q6h IV first line Piperacillin/tazobactam (Zosyn): 3. 375 g q6h IV first line Ampicillin plus gentamicin (adjust for renal dose) first line (see dosing below) Ticarcillin/clavulanate (Timentin): 3. 1 g q6h IV first line Third-generation cephalosporin plus metronidazole (500 mg PO qid or 15 mg/kg IV q12h) second line Aztreonam, 2 g IV q8h, plus metronidazole (500 mg PO qid or 15 mg/kg IV q12h) second line Ciprofloxacin, 400 mg IV q12h, plus metronidazole (500 mg PO qid or 15 mg/kg IV q12h) second line Meropenem second line (see dosing on following page)Levofloxacin third line (see dosing on following page) Ampicillin, 2 g IV q6h, plus gentamicin (see dosing below) ± metronidazole, 500 mg IV/PO q8h Gentamicin: 2-2. 5 mg/kg q8h (adjust dosing in renal impairment) Cr Cl ≥ 60 m L/min: Administer q8h Cr Cl 40-60 m L/min: Administer q12h Cr Cl 20-40 m L/min: Administer q24h Cr Cl 10-20 m L/min: Administer q48h Cr Cl <10 m L/min: Administer q72h (continued) TABLE 3-1: Diagnosis: Cholecystitis (Continued)

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92 GASTROENTEROLOGY TABLE 3-1: Diagnosis: Cholecystitis (Continued) Meropenem: 1g IV q8h (adjust dosing in renal impairment) Cr Cl 26-50 m L/min: Administer 1 g q12h Cr Cl 10-25 m L/min: Administer 500 mg q12h Cr Cl <10 m L/min: Administer 500 mg q24h Levofloxacin: 500 mg IV q24h (adjust dosing in renal impairment) Cr Cl 20-49 m L/min: 250 mg q24h Cr Cl 10-19 m L/min: 250 mg q48h

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GASTROENTEROLOGY 93 TABLE 3-2: Diagnosis: Cholangitis Disposition Unit Monitor Vitals, temperature Diet NPO Fluid MIVF O 2 PRN Activity Bedrest Dx studies Labs CBC with differential, BMP, LFT, blood C&S, amylase, lipase, GGTP Blood C&S, PT/PTT/INR, UA Radiology and cardiac studies RUQ US, CT of abdomen, ?acute abdominal x-ray series, CXR, ECG Special tests ?ERCP (if bile duct obstruction from stone) Prophylaxis DVT Consults GI, surgery, ?ID Nursing ? Avoid Aminoglycoside in cirrhosis Management Supportive management Treat N/V with PRN medications Pain management: See Chapter 12 (commonly used medications: morphine, Dilaudid) Piperacillin/tazobactam (Zosyn): 3. 375 g q6h IV first line Unasyn: 3 g q6h IV first line Ampicillin plus gentamicin (adjust for renal dose) first line (see dosing on following page) (continued)

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94 GASTROENTEROLOGY TABLE 3-2: Diagnosis: Cholangitis (Continued) Timentin: 3. 1 g q6h IV first line Third-generation cephalosporin plus metronidazole (500 mg PO qid or 15 mg/kg IV q12h) second line Aztreonam, 2 g IV q8h, plus metronidazole (500 mg PO qid or 15 mg/kg IV q12h) second line Ciprofloxacin, 400 mg IV q12h, plus metronidazole (500 mg PO qid or 15 mg/kg IV q12h) second line Meropenem second line (see dosing below)Levofloxacin third line (see dosing below) Ampicillin, 2 g IV q6h, plus gentamicin (see dosing below) ± metronidazole, 500 mg IV/PO q8h Gentamicin: 2-2. 5 mg/kg q8h (adjust dosing in renal impairment) Cr Cl ≥ 60 m L/min: Administer q8h Cr Cl 40-60 m L/min: Administer q12h Cr Cl 20-40 m L/min: Administer q24h Cr Cl 10-20 m L/min: Administer q48h Cr Cl <10 m L/min: Administer q72h Meropenem: 1g IV q8h (adjust dosing in renal impairment) Cr Cl 26-50 m L/min: Administer 1 g q12h Cr Cl 10-25 m L/min: Administer 500 mg q12h Cr Cl <10 m L/min: Administer 500 mg q24h Levofloxacin: 500 mg IV q24h (adjust dosing in renal impairment) Cr Cl 20-49 m L/min: 250 mg q24h Cr Cl 10-19 m L/min: 250 mg q48h

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GASTROENTEROLOGY 95 TABLE 3-3: Diagnosis: Crohn's Disease Disposition Medical floor Monitor Vitals Diet NPO except ice chips and medications for 48 hrs start elemental or low residue diet Fluid MIVF; hydration essential O 2 PRN Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, ionized calcium, LFT, UA, blood C&S × 2 Stool leukocyte and C&S, stool Wright's stain, stool ova and parasite Radiology and cardiac studies Abdominal x-ray series, CXR, CT of abdomen, ?colonoscopy Special tests ?CRP, ?ESR, ?p-ANCA (commonly associated with ulcerative colitis), ?anti- Saccharomyces cerevisiae antibodies (commonly associated with Crohn's disease), ? Clostridium difficile toxin A and B Prophylaxis DVT Consults GI Nursing I/O, stool guaiac Avoid Dairy products Management Multivitamin: 1 tablet PO daily or 1 ampule IV daily Folic acid: 1 mg PO daily (continued)

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96 GASTROENTEROLOGY If vitamin B 12 deficiency vitamin B 12 100 mcg IM × 5 days, then 100 mcg IM every mo Methylprednisolone (Solu-Medrol), 10-20 mg IV q6h, or prednisone, 40-60 mg PO daily Mesalamine (Asacol): 400-800 mg PO tid-qid or Mesalamine (Pentasa): 250 mg PO qid or Sulfasalazine: 0. 5-1g PO q6h or Olsalazine: 500 mg PO bid or Mesalamine: 1 g PO q6h Etanercept (Infliximab): 5 mg/kg IV over 2 hrs ?Metronidazole: 250-500 mg PO q6h TABLE 3-3: Diagnosis: Crohn's Disease (Continued)

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GASTROENTEROLOGY 97 TABLE 3-4: Diagnosis: Hepatic Encephalopathy Disposition Unit Monitor Vitals ?Cardiac monitoring Electrolyte monitoring Neuromonitoring: neuro check q2-4h Diet NPO initially, then protein restriction diet (protein intake of 40-70 g/day) Fluid MIVF O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs Ammonia, CBC with differential, BMP, calcium, Mg, PO4, PT/PTT/INR, UA, ABG, LDH LFT, GGTP, urine C&S and blood C&S × 2 ABG, serum toxicology screen, acetaminophen (Tylenol), ASA level, ESR Hepatitis panel (Hep Bs Ag, Hep B Ig M, Hep B Ig G, Hep C Ig G, Hep C Ig M) Radiology and cardiac studies CXR, ECG, US of abdomen, CT of abdomen Special tests CRP, ceruloplasmin, ?DIC panel, iron studies (hemochromatosis) Copper and ceruloplasmin, urine copper (Wilson's disease) α 1-Antitrypsin globulin on SPEP ( α1-antitrypsin deficiency) (continued)

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98 GASTROENTEROLOGY Antimitochondrial antibody (primary biliary cirrhosis) p-ANCA (primary sclerosing cholangitis) Prophylaxis GI prophylaxis Consults GI, transplant Nursing Stool guaiac, Foley catheter, seizure precaution, I/O, neuro check Avoid Heparin, warfarin (Coumadin), narcotics, Tylenol, NSAIDs, sedatives, protein, benzodiazepines, herbal medications, diphenoxylate hydrochloride and atropine (Lomotil) Management If INR elevated vitamin K, 10 mg SQ daily If bleeding consider FFP and PRBC transfusion Sorbitol: 70% solution 30-60 g PO Lactulose: 30-50 m L PO q1h, then 15-40 m L PO bid-tid (titrate to achieve two to three soft stools/day) or Lactulose enema: 300-700 m L tap water; give 200-250 m L bid-qid via rectal tube Lactobacillus SF 68, ornithine-aspartate, benzoate Fermentable fibers, sodium benzoate 5 g bid Neomycin: 1-2 g PO q6h (max: 8-12 g/day, associated with ototoxicity and nephrotoxicity) or Metronidazole, 250 mg PO q6h, or paromomycin or rifaximin Thiamine: 100 mg IV/PO daily Folic acid: 1 mg IV/PO daily Multivitamin: 1 ampule IV daily or 1 tablet PO daily (continued)TABLE 3-4: Diagnosis: Hepatic Encephalopathy (Continued)

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GASTROENTEROLOGY 99 Flumazenil: 0. 2 mg (2 m L) IV every min until dose of 3 mg reached; if patient responds partially, then give the same dose up to total of 5 mg (may help reverse hepatic encephalopathy despite benzodiazepine use) ?Modified amino acid solution (“COMA” solution), ? L-dopa, ?bromocriptine ?Zinc Melatonin for sleep disturbance Consider transplantation if above modalities fail Stages of Encephalopathy II I III IV Change in mental status Lethargy and confusion Stupor Coma Etiology of Hepatic Encephalopathy in Patients with Cirrhosis Medications Benzodiazepines ETOHNarcotics First-degree hepatocellular carcinoma↑ Ammonia production ↑ Protein intake GI bleeding Infection Hypokalemia Constipation Metabolic alkalosis (continued)TABLE 3-4: Diagnosis: Hepatic Encephalopathy (Continued)

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100 GASTROENTEROLOGY TABLE 3-4: Diagnosis: Hepatic Encephalopathy (Continued) Dehydration Vomiting Diarrhea Hemorrhage Diuretics Vascular occlusion Portal venous thrombosis Hepatic venous thrombosis Portosystemic shunting Radiographic shunt Surgically placed shunt Spontaneous shunt

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GASTROENTEROLOGY 101 TABLE 3-5: Diagnosis: Intestinal Obstruction Disposition Medical/surgical floor, ?monitor floor Monitor Vitals Electrolyte monitoring Diet NPO Fluid MIVF O2 PRN Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, LFT, PT/ PTT/INR, amylase, lipase, UA, urine C&S Blood C&S, lactic acid, β-HCG if female Radiology and cardiac studies Abdominal x-ray, CT of abdomen, ?upper GI and small bowel series ?Gastrografin or barium enema (contraindicated if perforation) CXR (PA and lateral), pelvic and abdominal US Special tests ?Flexible colonoscopy Prophylaxis DVT Consults Surgery Nursing NG tube with suction, stool guaiac Avoid Narcotics Management Treat underlying cause (continued)

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102 GASTROENTEROLOGY TABLE 3-5: Diagnosis: Intestinal Obstruction (Continued) Etiology of Intestinal Obstruction Hernia Gallstones Adhesion in history of previous surgery Tumor Intussusception Radiation-induced enteritis Volvulus Impacted stool Granulomatous processes (abnormal tissue growth) Lead poisoning Ascaris Foreign body (bezoar) Paralytic ileus Abdominal injury Medications (mainly narcotics) Metabolic disturbances (K +) Intraperitoneal infection Complication of abdominal surgery Mesenteric ischemia

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GASTROENTEROLOGY 103 TABLE 3-6: Diagnosis: Pancreatitis (Acute) Disposition Unit Monitor Vitals Cardiac monitoring if hemodynamically unstable Diet NPO, ?TPN until amylase and lipase normalizes Fluid Replace deficit with NS, then MIVF O2 PRN Activity Bedrest and advance as tolerated slowly (usually after pain is relieved second to fourth day) Dx studies Labs CBC with differential, BMP, Mg, calcium, PO 4, amylase, lipase, lipid panel, LDH, UA PT/PTT/INR, LFT, blood C&S Radiology and cardiac studies US of RUQ, CT of abdomen with contrast (r/o pseudocyst/AAA), ?CXR, ?ERCP Special tests ECG, ?Hep Bs Ag, hepatitis A ?Blood C&S, ?stool guaiac, ?serum/urine toxicology, ?UA, urine C&S ?Secretin stimulation test, ?para-amino-benzoic acid test Prophylaxis DVT Consults ?GI, ?surgery Nursing I/O, urine output, NG tube if nausea or vomiting, fingerstick glucose qid, Foley catheter (continued)

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104 GASTROENTEROLOGY Avoid See medications listed below Management See Management: Pancreatitis Etiologies of Pancreatitis Gallstones ETOH Hyperlipidemia (I, IV, V) Hypercalcemia Trauma Atheroembolism Pancreatic cancer Duodenal stricture/ obstruction Post-ERCP Ampullary stenosis Scorpion venom Pregnancy Renal transplant α 1-Antitrypsin deficiency Choledochocele Vasculitis Medications (see below)Infections (see below) Medications associated with pancreatitis ACE inhibitor Thiazides Furosemide5-ASA Azathioprine Didanosine Estrogen Pentamidine L-asparaginase Metronidazole Sulindac Salicylates (ASA)Stibogluconate Protease inhibitor Sulfasalazine Tetracycline 6-Mercaptopurine Valproic acid (continued)TABLE 3-6: Diagnosis: Pancreatitis (Acute) (Continued)

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GASTROENTEROLOGY 105 TABLE 3-6: Diagnosis: Pancreatitis (Acute) (Continued) Infections associated with pancreatitis Ascaris Aspergillus CMV/EBV Coxsackie Cryptosporidium Hepatitis A and B HIV HSV Legionella Leptospira Mycoplasma Mumps/rubella Salmonella Toxoplasma Varicella zoster Ranson's Criteria 0 Hrs (GA LAW) 48 Hrs (C HOBBS) Give one point for each category Age >55 yrs HCT ↓ by ≥10% WBC >16,000/ µL BUN ↑ by ≥5 mg/d L (1. 8 mmol/L) Glucose >200 mg/d L (11. 1 mmol/L)Calcium <8 m Eq/L (2 mmol/L) LDH >350 IU/L Pa O2 <60 mm Hg AST >250 IU/L Base deficit >4 m Eq/L ALT >80 IU/L Fluid sequestration >6 L Prognosis Total score Mortality ≤2 <5% 3-4 15-20%5-6 40% ≥7 >99% (continued)

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106 GASTROENTEROLOGY TABLE 3-6: Diagnosis: Pancreatitis (Acute) (Continued) Management: Acute Pancreatitis Pain management Morphine: 2-5 mg IV q3-4hor Meperidine: 50-100 mg IV/IM q3-4h PRN (caution in elderly due to risk of delirium) GFR 10-50 m L/min: 75% of normal dose at normal intervals GFR <10 m L/min: 50% of normal dose at usual intervals or Fentanyl: 50-100 mcg/dose q1-2h as needed Other: Tylenol #3, acetaminophen and hydrocodone (Vicodin) Ranitidine, 50 mg IV q6-8h/famotidine, 20 mg IV q12h (to reduce acid release from stomach) or Famotidine, 20 mg IV q12h Pancreatic enzyme supplement [pancrelipase (Pancrease MT, Creon)] If there is necrotizing pancreatitis (involving more than 30% of the pancreas) initiate antimicrobial therapy with imipenem/ cilastatin (Primaxin), 0. 5-1 g IV q6h; continue for at least 7 days If infected pseudocyst or abscess: Timentin: 3. 1 g IV or Unasyn: 3 g IV q6h or Primaxin: 0. 5-1 g IV q6h Consider CT-guided aspiration if no improvement with antibiotic therapy

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GASTROENTEROLOGY 107 TABLE 3-7: Diagnosis: Peritonitis Disposition Medical floor Monitor Vitals Electrolyte monitoring Diet NPO Fluid MIVF O2 PRN Activity Bedrest Dx studies Labs CBC with differential, BMP, Mg, LFT, PT/ PTT/INR, lactic acid, amylase, lipase UA, urine R&M, urine C&S, ammonia, blood C&S × 2 Radiology and cardiac studies Abdominal x-ray (upright and lateral decubitus), CXR (PA and lateral), ECG CT of abdomen, US of abdomen Special tests ?GGTP, paracentesis tubes Tube 1 Tube 2 Tube 3 Cell count and differential Glucose Gram stain Protein Aerobic and anaerobic C&SAlbumin LDHTG Fungal C&S Amylase AFBBilirubin Specific gravity Prophylaxis ? (continued)

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108 GASTROENTEROLOGY Consults Surgery, ?ID Nursing Stool guaiac, ?NG tube Avoid ? Management: Peritonitis (Bacterial) Mild-moderate (2° from appendicitis, diverticulitis, etc. ) Ceftriaxone, 1-2 g IV q24h, plus metronidazole, 1 g IV q24h first line Moxifloxacin, 400 mg IV q24h, or Unasyn, 1. 5 g q6h, or ceftizoxime, 2 g IV q8h, or cefoxitin, 2 g IV q6h second line Severe peritonitis (2° from appendicitis, diverticulitis, etc. ) Meropenem: 1 g IV q8h first line Piperacillin/tazobactam: 4. 5 g IV q8h first line Ertapenem: 1 g IV q24h first line Imipenem: 500 mg IV q6h first line Spontaneous bacterial peritonitis Ceftriaxone: 1 g IV q24h first line Ciprofloxacin: 400 mg IV or 500 mg PO q12h first line Gatifloxacin: 400 mg IV/PO q24h first line Levofloxacin: 500 mg IV/PO q24h first line Moxifloxacin: 400 mg IV/PO q24h first line Aztreonam: 2 g IV q8h second line TABLE 3-7: Diagnosis: Peritonitis (Continued)

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GASTROENTEROLOGY 109 TABLE 3-8: Diagnosis: Ulcerative Colitis Disposition Medical floor Monitor Vitals Diet NPO except ice chips and medications for 48 hrs start elemental or low-residue diet Fluid Hydration essential O2 PRN Activity Bedrest Dx studies Labs CBC, BMP, calcium, LFT, Mg, ionized calcium, blood C&S × 2, UA Stool leukocyte and C&S, stool Wright's stain, stool ova and parasite Radiology and cardiac studies Abdominal x-ray series, CXR, colonoscopy, CT of abdomen Special tests ?CRP, ?ESR, ?p-ANCA (commonly associated with ulcerative colitis), ?anti-Saccharomyces cerevisiae antibodies (commonly associated with Crohn's disease) ?C. difficile toxin A and B Prophylaxis DVT Consults GI Nursing I/O, stool guaiac Avoid Dairy products Management Multivitamin: 1 tablet PO daily or 1 ampule IV daily Folic acid: 1 mg PO daily (continued)

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110 GASTROENTEROLOGY If B12 deficiency: vitamin B12, 100 mcg IM × 5 days, then 100 mcg IM every mo Loperamide, 2-4 mg PO tid-qid (max: 16 mg /day), or kaolin/ pectin (Kaopectate), 60-90 m L PO qid PRN Solu-Medrol, 10-20 mg IV q6h, or prednisone, 40-60 mg PO daily or Hydrocortisone, 100 mg IV q6h Asacol, 400-800 mg PO tid-qid, or 5-aminosalicylate, 400-800 PO tid/enema 4 g/60 m L PR qh or Sulfasalazine, 0. 5-1g PO q6h, or olsalazine, 500 mg PO bid, or mesalamine 1 g PO q6h or Hydrocortisone retention enema: 100 mg in 120 m L saline bid TABLE 3-8: Diagnosis: Ulcerative Colitis (Continued)

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GASTROENTEROLOGY 111 SYMPTOMS TABLE 3-9: Diagnosis: Acute Abdominal Pain Disposition Medical floor Monitor Vitals Diet NPO Fluid MIVF O2 PRN Activity ?Bedrest Dx studies Labs CBC, BMP, Ca+, Mg+, LFT, bilirubin, PT/ PTT/INR, amylase, lipase, β-HCG if female UA, lactic acid, blood C&S, urine C&S, ?troponin, ?hepatitis panel ?Toxicology screen, ?serum acetaminophen level Radiology and cardiac studies CXR (PA and lateral) (pneumonia, perforation) US of abdomen: gallstones, ovarian cyst if female, ectopic pregnancy, hydronephrosis, ascites Flat-plate/acute abdominal series: renal stones, perforation, impaction CT (abdominal/pelvic): malignancy, pseudocyst, abscess, appendicitis, aortic dissection ?Colonoscopy: malignancy, IBD, ischemic bowel disease (continued)

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112 GASTROENTEROLOGY Special tests ?C. difficile toxin A and B (if antibiotic use in past 1 mo) ?Upper endoscopy: gastritis, PUD?Upper GI series with small bowel follow-through (barium vs. gastrografin) ?ERCP: stone in bile duct?Manual cervical examination if female: PID, STD (GC and chlamydia Cx, wet mount/KOH) ?Bladder scan: urinary retention (BPH, prostate cancer) ?Laparotomy: malignancy, uterine fibroid, adhesions (history of previous surgery) ?Celiac disease: Ig A endomysial antibody or Ig A tissue transglutaminase antibody Prophylaxis DVT Consults ?GI, ?surgery Nursing Stool guaiac, NG tube if small bowel obstruction suspected, I/O Avoid ? Management Treat underlying etiology Etiologies of Abdominal Pain Right upper quadrant Left upper quadrant Cholecystitis/cholangitis Pelvic inflammatory disease if female Intussusceptions Ovarian cyst if female Pancreatitis Diverticulosis (continued)TABLE 3-9: Diagnosis: Acute Abdominal Pain (Continued)

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GASTROENTEROLOGY 113 TABLE 3-9: Diagnosis: Acute Abdominal Pain (Continued) Right upper quadrant Left upper quadrant Hepatitis/hepatomegaly Intussusceptions Ischemic bowel Ischemic bowel Intestinal perforation Intestinal perforation MI MIPneumonia empyema/ pleurisy Pancreatitis Gastritis/PUD Pneumonia Renal stones Gastritis/PUDHerpes zoster Renal stone Pericarditis Herpes zoster Retrocecal appendicitis Splenic injury/infarct/abscess Subdiaphragmatic abscess Empyema Acetaminophen overdose Budd-Chiari syndrome Right lower quadrant Left lower quadrant Appendicitis Intussusceptions Intussusceptions Diverticulitis Renal stone/nephrolithiasis IBD (Crohn's or UC)Intestinal perforation Ischemic bowel Ischemic colitis Renal stone Herpes zoster Intestinal perforation Psoas abscess Irritable bowel syndrome IBD (Crohn's or UC) Herpes zoster (continued)

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114 GASTROENTEROLOGY TABLE 3-9: Diagnosis: Acute Abdominal Pain (Continued) Right lower quadrant Left lower quadrant Irritable bowel syndrome Psoas abscess Mesenteric adenitis Epididymitis (males)Inguinal hernia Seminal vesiculitis (males)Seminal vesiculitis (males) Ectopic pregnancy (females)Epididymitis (males) Endometriosis (females)Endometriosis (females) Ovarian causes (females)Salpingitis (females) Salpingitis (females)Ovarian causes (females)Ectopic pregnancy (females)PID (females) Epigastric Generalized Gastritis/GERD/PUD Peritonitis Pancreatitis Gastroenteritis Hernia Intestinal obstruction MI Fecal impaction Pericarditis Intestinal perforation Ischemic bowel Ischemic bowel disease Intestinal perforation Irritable bowel syndrome Pneumonia Porphyria Esophageal rupture (Boerhaave's syndrome)Metabolic/DKA/uremia AAA rupture Sickle cell crisis Periumbilical Pancreatitis Early appendicitis Adhesions from previous surgery (continued)

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GASTROENTEROLOGY 115 TABLE 3-9: Diagnosis: Acute Abdominal Pain (Continued) Periumbilical Generalized Gastroenteritis Trauma Bowel obstruction Malaria AAA rupture Leukemia Mesenteric adenitis Mesenteric adenitis Adhesions from previous surgery Mesenteric thrombosis Miscellaneous causes of abdominal pain AAA rupture Toxins (lead poisoning) Sepsis Narcotic withdrawal CHFHerpes zoster Sickle cell anemia Hypersensitivity reaction Psychogenic Acute adrenal insufficiency Henoch-Schönlein purpura

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116 GASTROENTEROLOGY TABLE 3-10: Diagnosis: Diarrhea with or without Abdominal Pain Disposition Medical floor, ?monitor bed if electrolyte disturbance Monitor Electrolyte monitoring Diet NPO except ice chips (if no diarrhea for ≥12 hrs consider placing patient on clear fluid) Fluid Correct deficit with NS, then D5NS or D5 1/2 NS for maintenance O2 PRN Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium (pancreatic insufficiency), Mg, PO4, LFT Stool leukocyte, ova and parasite, stool C&S, stool guaiac, UA, blood C&S Radiology and cardiac studies Abdominal x-ray (flat-plate and upright) CT of abdomen: ischemic colitis Special tests ?C. difficile toxin A and B, ?HAV-Ig M, β-HCG if female Stool for electrolytes to calculate stool osmolar gap to differentiate osmolar vs. secretory Stool Cx: Lab should be notified of Aeromonas and Yersinia Stool Cx for Salmonella and Shigella, stool Wright's stain for leukocyte ?Ig A endomysial antibody or Ig A tissue transglutaminase antibody for celiac disease (continued)

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GASTROENTEROLOGY 117 Prophylaxis DVT Consults ?GI (endoscopy if IBD suspected), ?surgery Nursing I/O, stool guaiac Avoid Loperamide hydrochloride (Imodium) if C. difficile suspected Management PPI or H2 blocker Note Consider not using any Kaopectate, Imodium, or Lomotil until etiology determined If C. difficile suspected start treatment empirically before Cx results Kaopectate: 1,200-1,500 mg PO after loose bowel movement or Imodium: 2 capsules PO initially or Lomotil: 2 tablets or 10 m L PO qid or Psyllium hydrophilic mucilloid (Metamucil): 1-2 tablets with juice or Sucralfate (Carafate), 1 g PO 1 hr before meal and qh TABLE 3-10: Diagnosis: Diarrhea with or without Abdominal Pain (Continued)

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118 GASTROENTEROLOGY TABLE 3-11: Diagnosis: GI Bleeding (Upper or Lower) Disposition Medical floor/unit if hemodynamically unstable Monitor Vitals Cardiac monitoring Diet NPO Fluid Initially resuscitate NS/LR (wide open to 125 m L/hr), then place on MIVF IV access: 2 large-bore (14-18), blood transfusion if low H&H O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs H&H q2-4h initially, then q4-8h CBC, BMP, Mg, PO4 Type and cross 2-4 PRBC and 2-4 units FFP, NG aspirate guaiac LFT, PT/PTT/INR, fibrinogen Radiology and cardiac studies EGD, portable CXR (PA and lateral), flat-plate of abdomen ECG, colonoscopy, ?upper GI series with small bowel follow-through Special tests ?Radionucleotide imaging, enteroclysis* ?Ammonia, ?Meckel scan?RBC scan (technetium 99m scan), ?angiography, ?capsule endoscopy Prophylaxis ? Consults GI, surgery, interventional radiology (continued)

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GASTROENTEROLOGY 119 Nursing I/O, NG tube (to evaluate upper GI bleeding in patients with hematochezia); monitor urine output Avoid Heparin, warfarin (Coumadin), NSAIDs, ASA, steroids Management Transfuse 2-6 units PRBC if profuse bleeding or low H&H Pantoprazole (Protonix): 80 mg IV over 15 min, then 8 mg/hr or 40 mg IV bid or Ranitidine, 50 mg IV q6-8h, or famotidine, 20 mg IV q12h If high INR vitamin K, 10 mg IV/SQ daily, and have FFP, 2-4 units, ready Variceal bleed Octreotide: 25-50 mcg IV bolus followed by continuous IV infusion of 25-50 mcg/hr or Vasopressin: 20 units IV over 20-30 min 0. 2-0. 3 units/min for 30 min ↑ by 0. 2 units/min until bleeding stops (max: of 0. 9 units/min) Nitroglycerin paste, 1 inch q6h off qh, or nitroglycerin, 10-30 mcg/min infusion (50 mg in 250 D 5W) *Enteroclysis: a double-contrast study performed by passing a tube into the proximal small bowel and injecting barium and methylcellulose; it is superior to standard imaging with small bowel follow-through for identifying other lesions such as small bowel tumors, ulcers, and Crohn's disease. Enteroclysis can also be performed with CT scanning (CT enteroclysis). TABLE 3-11: Diagnosis: GI Bleeding (Upper or Lower) (Continued)

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121 4 Hematology/Oncology OUTLINE 4-1. DVT 122 4-2. DVT Prevention 1244-3. Sickle Cell Crisis 126

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122 HEMATOLOGY/ONCOLOGY TABLE 4-1: Diagnosis: DVT Disposition Cardiac monitor bed Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest with elevation of extremity involved Dx studies Labs CBC, BMP, calcium, LFT, PT/PTT/INR, ABG, UA, urine R&M Radiology and cardiac studies CXR (PA and lateral), venous Doppler US, CT of chest, ?V/Q scan, ECG MRI from inferior vena cava to popliteal veins Special tests Coagulation panel (coagulation panel labs may vary from lab to lab), ?malignancy workup Protein C&S, antithrombin III, anticardiolipin antibody, factor V Leiden Plasminogen, antiphospholipid antibodies, lupus anticoagulant, ?ANA Prophylaxis ? Consults ?Hematology/oncology Nursing Measure circumference of the area involved, stool guaiac Avoid IM injections (continued)

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HEMATOLOGY/ONCOLOGY 123 Management Warm packs to area involved (for pain control) Heparin: bolus 80-100 units/kg IV, then 18-20 units/kg/hr; check PTT 6 hr after starting infusion (PTT 1. 5-2. 0 control) or Enoxaparin (Lovenox): 1 mg/kg SQ q12h/1. 5 mg/kg SQ daily (check factor Xa) Start warfarin, 5-10 mg PO daily, when PTT is therapeutic Overlap heparin or Lovenox and warfarin for at least 3-4 days and when INR has been between 2-3 for 2 consecutive days, then discontinue heparin Pain management (see Chapter 12, Table 12-21) Docusate (Colace): 100 mg PO qh for constipation TABLE 4-1: Diagnosis: DVT (Continued)

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124 HEMATOLOGY/ONCOLOGY TABLE 4-2: DVT Prevention Medical conditions Heparin: 5,000 units SQ q12h Enoxaparin (Lovenox): 40 mg SQ once daily; if Cr Cl <30 m L/ min 30 mg SQ daily Dalteparin (Fragmin): 2,500 units SQ once daily Nadroparin*: 2,850 units SQ once daily General surgery in moderate-risk patient Heparin: 5,000 units SQ q12h Enoxaparin: 20 mg SQ 1-2 hrs before surgery and daily after surgery Dalteparin: 2,500 units SQ 1-2 hrs before surgery and daily after surgery Nadroparin*: 2,850 units SQ 2-4 hrs before surgery and daily after surgery Tinzaparin (Innohep): 3,500 units SQ 2 hrs before surgery and daily after surgery General surgery in high-risk patient Heparin: 5,000 units SQ q8h or q12h Enoxaparin (Lovenox): 40 mg SQ 1-2 hrs before surgery and daily after surgery or 30 mg SQ q12h starting 8-12 hrs after surgery Dalteparin (Fragmin): 5,000 units SQ 8-12 hrs before surgery and daily after surgery Orthopedic surgery Heparin is not recommended Enoxaparin: 30 mg SQ q12h starting 12-24 hrs after surgery or 40 mg SQ daily starting 10-12 hrs after surgery Dalteparin: 5,000 units SQ 8-12 hrs before surgery, then daily starting 12-24 hrs after surgery or 2,500 units SQ 6-8 hrs after surgery, then 5,000 units SQ daily (continued)

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HEMATOLOGY/ONCOLOGY 125 Nadroparin*: 38 units/kg SQ 12 hrs before surgery; 12 hrs after surgery; and once daily on postoperative days 1, 2, and 3; then ↑ to 57 units/kg SQ daily Tinzaparin: 75 units/kg SQ daily starting 12-24 hrs after surgery; or 4,500 units SQ 12 hrs before surgery and daily after surgery Major trauma Heparin: 5,000 units SQ q8h Enoxaparin: 30 mg SQ every 12 hrs (for acute spinal cord injury) Enoxaparin: 30 mg SQ every 12 hrs starting 12-36 hrs after injury if the patient is hemodynamically stable *Not approved. TABLE 4-2: DVT Prevention (Continued)

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126 HEMATOLOGY/ONCOLOGY TABLE 4-3: Diagnosis: Sickle Cell Crisis Disposition Unit Monitor Vitals Diet Regular Fluid IVF is essential but promote PO intake as much as possible O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, LFT, blood C&S, UA, urine C&S, reticulocyte count, parvovirus titer Unsure of diagnosis: check Howell-Jolly bodies on peripheral smear and hemoglobin electrophoresis Radiology and cardiac studies CXR (PA and lateral), ?CT of chest Special tests Type and cross PRBC, LDH, bilirubin (direct and indirect), haptoglobin, direct Coombs' Prophylaxis DVT, pneumococcal vaccine polyvalent (Pneumovax), and influenza vaccine Consults Hematology/oncology Nursing Stool guaiac Avoid ? Management Note: If hemolysis, ↑ lactate dehydrogenase, ↑ indirect bilirubin, ↓ haptoglobin (continued)

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HEMATOLOGY/ONCOLOGY 127 Pain management Ketorolac tromethamine (Toradol): 30-60 mg IV/IM q6h PRN or Acetaminophen (Tylenol #3): 1-2 tablets PO q4-6h PRN or Morphine: 5-10 mg IV/IM/SQ q2-4h PRN or Meperidine (Demerol): 50-150 mg IV/IM q4-6h PRN or Hydroxyzine pamoate (Vistaril): 25-100 mg IV/IM/PO q4h PRN Supportive care Ondansetron (Zofran): 4 mg IV/PO q4-6h PRN for N/V Zolpidem (Ambien): 5-10 mg PO qh for insomnia Folic acid: 1 mg PO daily Haemophilus influenzae vaccine: 0. 5 m L IM Pneumococcal vaccine: 0. 5 m L IM Hydroxyurea: 15 mg/kg/day (max: 35 mg/kg/day), ↑ 5 mg/kg/day q12weeks TABLE 4-3: Diagnosis: Sickle Cell Crisis (Continued)

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129 5 Infectious Disease* *See Guide Tables: Antibiotic Spectrum for information on antibiotics. OUTLINE 5-1. Cellulitis 130 Cholecystitis (see Table 3-1)Cholangitis (see Table 3-2) 5-2. Clostridium difficile ( C. difficile ) 133 5-3. Diverticulitis 1345-4. Endocarditis 1365-5. HIV Management 1415-6. Meningitis 1535-7. Osteomyelitis 1585-8. Pelvic Inflammatory Disease (PID) 1605-9. Pneumonia 162 5-10. Prostatitis 1685-11. Pyelonephritis 1705-12. Septic Arthritis 1725-13. Septic Shock/Sepsis 1755-14. TB 1775-15. Urinary Tract Infection (UTI) 180

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130 INFECTIOUS DISEASE TABLE 5-1: Diagnosis: Cellulitis Disposition Medical floor Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity PRN Dx studies Labs CBC with differential, blood C&S × 2, BMP Radiology and cardiac studies X-ray of the site of cellulitis, ?CT scan, ?MRI, ?technetium/gallium bone scan Special tests ?Wound Cx, ?skin biopsy, ?sinus drainage/?aspirate Cx, ?ESR Diagnosing cellulitis associated with hemolytic streptococci group A, C, or G Antistreptolysin-O Antideoxyribonuclease BAntihyaluronidase Prophylaxis DVT Consults ?ID, ?skin/wound care Nursing Warm compresses (Curity heater), keep affected area elevated if possible Avoid ? Management Urgent surgery required for necrotizing fasciitis; see Management: Cellulitis Consider whirlpool therapy (continued)

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INFECTIOUS DISEASE 131 TABLE 5-1: Diagnosis: Cellulitis (Continued) Management: Cellulitis Cefazolin: 1 g IV q6-8h first line Nafcillin: 1. 0-1. 5 g IV q4-6h first line Ceftriaxone: 1 g IV q24h first line Cefazolin, 2 g IV q24h, plus probenecid, 1 g PO daily first line If MRSA or PCN allergy Vancomycin: 1-2 g IV daily first line Linezolid: 0. 6 g IV q12h first line Patient can be switched to oral medication once patient is afebrile and resolution of cellulitis is noted Dicloxacillin: 0. 5 g PO q6h first line Cephradine: 0. 5 g PO q6h first line Cephalexin: 0. 5 g PO q6h first line Cefadroxil: 0. 5-1. 0 g PO q12-24h first line Source: Reprinted from Morton N, Swartz, MD. Clinical practice. Cellulitis. N Engl J Med 2004;350:9, with permission. (continued)

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132 INFECTIOUS DISEASE TABLE 5-1: Diagnosis: Cellulitis (Continued) Management of Cellulitis Associated with Specific Condition PCN allergy: erythromycin, 500 mg PO q6h Human bite: amoxicillin/clavulanate (Augmentin) or cefoxitin IV Animal bite: PCN IV or nafcillin IV or cefoxitin IV Facial cellulitis: cefotaxime IV; if oral cavity involved, cover anaerobes with clindamycin/metronidazole (Flagyl) Diabetic patient: cefoxitin or clindamycin plus gentamicin IV drug abuse: vancomycin plus gentamicin Burn patient: vancomycin plus gentamicin Compromised patient: clindamycin plus gentamicin Suspicion of anaerobe: clindamycin, 600 mg IV q8h, or metronidazole, 500 mg IV q6h Gas-forming infection: clindamycin, 600 mg IV q8h, or metronidazole, 500 mg IV q6h

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INFECTIOUS DISEASE 133 TABLE 5-2: Diagnosis: Clostridium difficile (C. difficile) Disposition Medical floor/surgical floor; isolation precaution Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity ?Up ad lib in the room Dx studies Labs CBC with differential Radiology and cardiac studies ?CT of abdomen Special tests C. difficile toxin A and B Prophylaxis ? Consults ?ID Nursing ? Avoid Antidiarrhea agents Management Metronidazole: 500 mg PO tid or 250 mg PO/IV qid × 10-14 days first line Vancomycin: 125 mg PO qid × 10-14 days (IV not effective) second line Bacitracin: 25,000 units PO qid × 10-14 days third line Cholestyramine: 4 g PO tid × 10-14 days (use in addition to above antibiotics for relapsing C. difficile ) Note: Add Saccharomyces boulardii (Florastor), one 250-mg tablet PO bid for recurrent C. difficile

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134 INFECTIOUS DISEASE TABLE 5-3: Diagnosis: Diverticulitis Disposition Medical floor/surgical floor Monitor Vitals Diet NPO; advance to clear diet when tolerated Fluid Heplock (flush every shift) O 2 PRN Activity ?Bedrest Dx studies Labs CBC with differential, BMP, LFT, blood C&S × 2 Radiology and cardiac studies Acute abdominal series, CT of abdomen Prophylaxis DVT Consults ?Surgery, ?GI Nursing NG tube to intermittent low suction is obstructed Avoid ? Management Consider placing patient on clear liquid/NPO Mild (treat for 7-10 days) TMP/SMX DS PO bid first line Ciprofloxacin: 750 mg PO bid first line Levofloxacin (Levaquin), 750 mg PO daily, plus metronidazole, 500 mg PO q6h first line Amoxicillin/clavulanate ER 1,000/62. 5 mg 2 tablets PO bid second line Mild to moderate Piperacillin/tazobactam (Zosyn): 3. 375 g IV q6h or 4. 5 g IV q8h first line (continued)

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INFECTIOUS DISEASE 135 Ampicillin/sulbactam (Unasyn): 3 g IV q6h first line Ticarcillin/clavulanate (Timentin): 3. 1 g IV q6h first line Ertapenem: 1 g IV daily first line Ciprofloxacin: 400 mg IV q12h second line Levofloxacin, 750 mg IV q24h, plus metronidazole, 500 mg IV q6h second line Severe Imipenem/cilastatin (Primaxin): 500 mg IV q6h first line Meropenem: 1 g IV q8h first line Ampicillin, 2 g IV q6h, plus metronidazole, 500 mg IV q6h, plus ciprofloxacin, 400 mg IV q12h second line Ampicillin, 2 g IV q6h, plus metronidazole, 500 mg IV q6h, plus levofloxacin, 750 mg IV q24h second line Ampicillin, 2 g IV q6h, plus metronidazole, 500 mg IV q6h, plus gentamicin or amikacin second line TABLE 5-3: Diagnosis: Diverticulitis (Continued)

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136 INFECTIOUS DISEASE TABLE 5-4: Diagnosis: Endocarditis Disposition ?Unit/monitor floor Monitor Vitals Cardiac monitoring Neuromonitoring Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity Up ad lib Dx studies Labs CBC with differential, BMP, calcium, Mg, LFT, blood C&S (four sets over 24 hrs), UA, urine C&S Radiology and cardiac studies TEE, ECG, CXR (PA and lateral) Special tests ?Pulmonary V/Q scan useful in right-sided endocarditis CT of chest for locating abscess Serology of Chlamydia and Bartonella in Cx-negative endocarditis ?ESR, ?C 3, C4, CH50, ?CRP Prophylaxis ? Consults ?Surgery, ?ID, ?cardiology Nursing ? Avoid ? Management See Management: Endocarditis (continued)

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INFECTIOUS DISEASE 137 TABLE 5-4: Diagnosis: Endocarditis (Continued) Duke Criteria for Infective Endocarditis (IE) 2 Major criteria or 1 major plus 3 minor criteria or 5 minor criteria Major criteria Minor criteria 1. Positive blood Cx 1. Fever ≥38°C (100. 4°F) A. Atypical organism associated with IE2. History of heart condition or IV drug use Streptococcus viridans, Streptococcus bovis3. Microbiologic evidence HACEK* A. Positive blood Cx but does not meet major criteria B. S. aureus or enterococci in the absence of primary focusor 2. Persistently positive blood Cx B. Serologic evidence of active evidence with organism consistent with IE A. Defined as two positive blood Cx >12 hrs apart4. Vascular phenomenon B. All three or a majority of four Cx (first and fourth 1 hr apart)A. Major arterial emboli 3. Positive echocardiogram B. Septic pulmonary infarct A. Oscillating intracardial mass on valve or supporting structure C. Mycotic aneurysm B. Abscess D. Conjunctival/ intracranial hemorrhage C. New partial dehiscence of prosthetic valve E. Janeway lesion (continued)

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138 INFECTIOUS DISEASE Major criteria Minor criteria 4. New murmur 5. Immunologic phenomenon A. Glomerulonephritis B. Osler's node C. Roth's spots D. Rheumatoid factor 6. Echocardiographic finding that does not meet major criteria *Haemophilus species ( H. parainfluenzae, H. aphrophilus, and H. paraphrophilus ), Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella species Source: Reproduced from Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994;96:200-209, with permission. Von Reyn Criteria for Diagnosis of IE Definite IE 1. Direct evidence by histology, bacteriology, valvular vegetation, or peripheral emboli Probable IE 1. Persistently positive blood Cx plus one of the following: A. New regurgitant murmur B. Predisposing heart disease or vascular phenomenon 2. Negative or intermittently positive blood Cx plus the following: A. Fever B. New regurgitant murmur C. Vascular phenomenon (i. e., splinter/conjunctival hemorrhage, petechiae, Roth's spots, emboli) (continued)TABLE 5-4: Diagnosis: Endocarditis (Continued)

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INFECTIOUS DISEASE 139 TABLE 5-4: Diagnosis: Endocarditis (Continued) Possible IE 1. Persistently positive blood Cx plus one of the following: A. Predisposing heart disease (exclude permanent heart disease)B. Vascular phenomenon 2. Negative or intermittently positive blood Cx plus the following: A. Predisposing heart disease B. Vascular phenomenon C. Fever Management: Endocarditis Streptococci: PCN, 2-4 million units IV q4h, plus gentamicin × 2 weeks a Note: Use only PCN × 4 weeks in patients with renal insufficiency or cranial nerve VIII damage Enterococci: PCN, 5-10 million units IV q4h, plus gentamicin/ streptomycin × 4-6 weeksa Staphylococcus (native valve): oxacillin or nafcillin, 2 g IV q4h × 6 weeks (use gentamicin for initial 3-5 days) Staphylococcus (prosthetic valve): vancomycin, 15 mg/kg IV infused over 1 hr q12h × 6 weeks, plus rifampin, 300 mg PO q8h × 6 weeks, plus gentamicin for first 2 weeks HACEK organisms: ceftriaxone, 2 g IV/IM q24h × 4 weeks If PCN allergy PCN-susceptible streptococci Vancomycin, 15 mg/kg IV over 1 hr q12h, plus gentamicin for 4-6 hrs b Ceftriaxone, 2 g IV/IM × 4 weeksc or Ceftriaxone, 2 g IV, plus gentamicin, 3 mg/kg daily, × 2 weeksa (continued)

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140 INFECTIOUS DISEASE TABLE 5-4: Diagnosis: Endocarditis (Continued) Enterococci Consider PCN desensitization Vancomycin, 15 mg/kg IV over 1 hr q12h, plus gentamicin × 4-6 weeksa,b Staphylococcus (native valve)Cefazolin, 2 g IV q8h c Vancomycin, 15 mg/kg IV over 1 hr q12h × 6 weeksb a Patient with prosthetic valve treat for 6 weeks. b Vancomycin, usual dose 1 g over 1 hr q12h. c Consider not using in patient with type I hypersensitivity.

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INFECTIOUS DISEASE 141 TABLE 5-5: Diagnosis: HIV Management Disposition Medical floor/?unit Monitor Vitals Cardiac monitoring Neuromonitoring Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest/?isolation Dx studies Labs CBC with differential, BMP, Mg, calcium, LFT Radiology and cardiac studies CXR (PA and lateral), ?CT of head Special tests Total lymphocyte count (TLC),* CD4 Prophylaxis See Prophylactics Consults ID Nursing ? Avoid ? Management See treatment tables on following pages *TLC can be used as proxy for CD4 when combined with clinical symptoms. TLC <1,200/ µL = CD4 <200 cells/ µL Prophylactics CD4 count Condition/organism Regimen <200 cells/ µL PCP TMP/SMX Dapsone Atovaquone (continued)

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142 INFECTIOUS DISEASE TABLE 5-5: Diagnosis: HIV Management (Continued) CD4 count Condition/organism Regimen S. pneumoniae Pneumococcal vaccine polyvalent (Pneumovax) Coccidioidomycosis Fluconazole <100 cells/ µL Toxoplasma gondii TMP/SMX Dapsone Atovaquone Histoplasmosis Itraconazole <50 cells/ µL Mycobacterium avium complex Clarithromycin Rifabutin Cryptococcosis Fluconazole Itraconazole CMV Ganciclovir HIV Treatment Guidelines: International AIDS Society-USA Guidelines for Starting Antiretroviral Therapy Symptomatic HIV Treatment needed Asymptomatic plus CD4 <200 cells/ µLTreatment needed Asymptomatic plus CD4 >200 cells/ µLTreatment needed for following: CD4 200-350 cells/ µL CD4 rate of decline >100 µL/yr Viral load >50,000-100,000 copies/m L Source: From Yeni PG, Hammer SM, Carpenter CC, et al. Antiretroviral treatment for adult HIV infection in 2002: updated recommendations of the International AIDS Society-USA Panel. JAMA 2000;288:222, with permission. (continued)

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INFECTIOUS DISEASE 143 TABLE 5-5: Diagnosis: HIV Management (Continued) Initial Regimen: Department of Health and Human Services Guidelines Select one from column A and one from column B AB Preferred Efavirenz (EVF) Stavudine (d4T)/ lamivudine (3TC) IDV Zidovudine (AZT)/ didanosine (dd I) Nelfinavir (NFV) AZT/3TCRitonavir (RTV)/ saquinavir (SQV) (Fortovase)d4T/dd I RTV/indinavir (IDV) dd I/3TC Lopinavir/r (LPV/r) Alternative Abacavir (ABC) AZT/zalcitabine (dd C) Amprenavir (APV)Delavirdine (DLV)Nevirapine (NVP)RTVSQVNFV/SQV (continued)

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144 INFECTIOUS DISEASE TABLE 5-5: Diagnosis: HIV Management (Continued) Initial Regimen: International AIDS Society-USA Preferred Alternative 2 Nucleosides + 1 protease inhibitor ± low-dose RTV1 protease inhibitor + nonnucleoside reverse transcriptase inhibitor ± 1-2 nucleoside reverse transcriptase inhibitors 2 Nucleosides + 1 nonnucleoside reverse transcriptase inhibitor 3 Nucleosides Source: From Yeni PG, Hammer SM, Carpenter CC, et al. Antiretroviral treatment for adult HIV infection in 2002: updated recommendations of the International AIDS Society-USA Panel. JAMA 2000;288:222, with permission. HIV Opportunistic Infection Aspergillosis Voriconazole: 6 mg/kg IV q12h × 1 day, then 4 mg/kg IV q12h first line Amphotericin B: 0. 7-1. 4 mg/kg daily second line Caspofungin: 70 mg IV daily, then 50 mg IV daily second line Bartonella henselae and Bartonella quintana Erythromycin: 500 mg PO qid first line Doxycycline: 100 mg PO bid second line Azithromycin: 0. 5-1. 0 g PO daily second line Doxycycline, 100 mg PO bid, plus rifampin, 300 mg IV/PO bid Candida species Esophagitis Fluconazole: 200 mg PO daily first line (continued)

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INFECTIOUS DISEASE 145 TABLE 5-5: Diagnosis: HIV Management (Continued) Itraconazole: 200 mg PO daily (take on an empty stomach) second line Voriconazole: 200 mg PO bid Caspofungin: 70 mg IV q24h × 1 day, then 50 mg IV q24h Thrush Clotrimazole oral troches: 10 mg 5 × a day first line Nystatin: 500,000 units; gargle 4-5 times a day second line Fluconazole: 100 mg PO daily second line Itraconazole: 100-mg oral suspension; swish and swallow daily second line Amphotericin B: 0. 3-0. 5 mg/kg IV daily second line Vaginitis Butoconazole 2% cream: apply daily first line Clotrimazole 1% cream: apply daily first line Miconazole 2% cream: daily or 100-mg vaginal suppository apply daily first line Ketoconazole: 200 mg PO bid Coccidioides immitis (coccidioidomycosis) Pulmonary or disseminated Amphotericin B: 0. 5-1. 0 mg/kg IV q24h with or without fluconazole Meningitis Fluconazole: 400-800 mg PO daily first line Itraconazole: 200-400 mg PO bid second line Cryptococcus neoformans Meningitis Amphotericin B, 0. 7 mg/kg IV daily, plus 5-fluorocytosine, 100 mg/kg PO daily first line (continued)

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146 INFECTIOUS DISEASE TABLE 5-5: Diagnosis: HIV Management (Continued) Fluconazole, 400-800 mg PO daily, plus 5-fluorocytosine, 100 mg/kg PO daily second line Amphotericin B (Am Bisome): 4 mg/kg IV daily second line Pulmonary or disseminated Fluconazole: 200-400 mg PO daily first line Itraconazole: 200 mg PO bid (take on an empty stomach) second line Cryptosporidium parvum HAART (highly active antiretroviral therapy) first line Nitazoxanide: 500 mg PO bid third line Paromomycin, 1 g PO bid, plus azithromycin, 600 mg PO daily third line Atovaquone: 750-mg suspension PO bid with meal third line CMV Retinitis Ganciclovir implant q6mo plus valganciclovir, 900 mg PO bid first line Ganciclovir: 5 mg/kg IV bid first line Foscarnet: 60 mg/kg IV q8h or 90 mg/kg q12h first line Valganciclovir: 900 mg PO bid Cidofovir, 5 mg/kg IV twice a week, plus probenecid, 2 g PO q3h second line Extraocular disease (GI: esophagitis or colitis) Valganciclovir: 900 mg PO bid first line Ganciclovir: 5 mg/kg IV bid first line Foscarnet: 60 mg/kg q8h or 90 mg/kg IV q12h first line (continued)

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INFECTIOUS DISEASE 147 TABLE 5-5: Diagnosis: HIV Management (Continued) Neurologic disease Ganciclovir, 5 mg/kg IV bid, plus foscarnet, 90 mg/kg IV bid first line Ganciclovir: 5 mg/kg IV bid second line Pneumonitis Ganciclovir: 5 mg/kg IV bid first line Foscarnet: 60 mg/kg q8h or 90 mg/kg IV q12h first line Valganciclovir: 900 mg PO bid first line Entamoeba histolytica Metronidazole, 750 mg IV/PO tid, plus diiodohydroxyquin, 650 mg PO tid, plus paromomycin, 500 mg PO tid first line Paromomycin: 500 mg PO tid second line Haemophilus influenzae Cefuroxime first line TMP/SMX second line Second-or third-generation cephalosporin second line Fluoroquinolones second line Herpes simplex Labialis Acyclovir: 400 mg PO tid; severe: 5-10 mg/kg IV q8h first line Famciclovir: 500 mg PO bid first line Valacyclovir: 1 g PO bid first line Penciclovir topical: q2h (use in conjunction with valacyclovir, famciclovir, or acyclovir) first line Pneumonitis, esophagitis, hepatitis, or dissemination Acyclovir: 5-10 mg/kg IV q8h Encephalitis Acyclovir: 10 mg/kg IV q8h (continued)

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148 INFECTIOUS DISEASE TABLE 5-5: Diagnosis: HIV Management (Continued) Herpes zoster Dermatomal Famciclovir: 500 mg PO tid first line Valacyclovir: 1 g PO tid first line Acyclovir: 30 mg/kg IV daily first line for severe disease Ophthalmic or visceral involvement Acyclovir: 30-36 mg/kg IV daily for first line Foscarnet: 40 mg/kg IV q8h or 60 mg/kg q12h second line Chickenpox Acyclovir: 10 mg/kg IV q8h or 800 mg PO qid first line Valacyclovir: 1 g q8h second line Histoplasma capsulatum Amphotericin B: 0. 7 mg/kg IV daily first line Am Bisome: 3-5 mg/kg IV daily first line Fluconazole: 800 mg PO daily second line Isospora belli (isosporiasis) TMP/SMX: two DS PO bid or one DS tid first line Pyrimethamine, 50-75 mg PO daily, plus leucovorin acid, 5-10 mg PO daily JC virus (progressive multifocal leukoencephalopathy) HAART first line Interferon alpha: 3 MU daily second line Cidofovir plus HAART second line Microsporidia (microsporidiosis) Enterocytozoon bieneusi : fumagillin (Fumidil B), 60 mg PO daily (may cause neutropenia and thrombocytopenia) first line Encephalitozoon intestinalis : albendazole, 400 mg PO bid first line (continued)

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INFECTIOUS DISEASE 149 TABLE 5-5: Diagnosis: HIV Management (Continued) Ocular: Fumidil B, 3 mg/m L saline eye drops first line Metronidazole: 500 mg PO tid second line Nitazoxanide: 500 mg PO bid (currently in an experimental stage) third line M. avium complex Clarithromycin, 500 mg PO bid, plus ethambutol (EMB), 15 mg/ kg PO daily first line Azithromycin, 500-600 mg PO daily, plus EMB, 15 mg/kg PO daily first line Severe symptoms Above two drugs plus ciprofloxacin, 500-750 mg PO bid first line Above two drugs plus levofloxacin, 500-750 mg PO daily first line Above two drugs plus rifabutin, 300 mg PO daily first line Mycobacterium chelonae Clarithromycin: 500 mg PO bid first line Cefoxitin or amikacin or doxycycline or imipenem or erythromycin or tobramycin second line Mycobacterium fortuitum Amikacin, 400 mg IV q12h, plus cefoxitin, 1-2 g IV daily Mycobacterium kansasii Isoniazid (INH), 300 mg PO daily, plus rifampin, 600 mg PO daily, plus EMB, 25 mg/kg daily, ± streptomycin, 1 g IM Ciprofloxacin, 750 mg PO bid, plus clarithromycin, 500 mg PO bid Mycobacterium scrofulaceum Surgical excision first line (continued)

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150 INFECTIOUS DISEASE TABLE 5-5: Diagnosis: HIV Management (Continued) Mycobacterium tuberculosis INH plus rifampin plus pyrazinamide (PZA) plus EMB × 8 weeks, then INH plus rifampin × 18 weeks first line INH plus rifabutin plus PZA plus EMB × 8 weeks, then INH plus rifabutin × 18 weeks second line Latent tuberculosis INH, 300 mg PO daily, plus pyridoxine, 50 mg PO daily first line INH, 900 mg PO twice a week, plus pyridoxine, 50 mg PO twice a week first line Nocardia asteroides Trisulfapyridine: 3-12 g PO daily first line TMP/SMX: 5-15 mg/kg PO daily first line Minocycline: 100 mg PO bid second line Penicillium marneffei Amphotericin B: 0. 7-1. 0 mg/kg IV daily first line Itraconazole: 200 mg PO bid P. carinii TMP, 15 mg/kg PO daily, plus SMX, 75 mg/kg PO/IV daily first line Hypoxemia: Add prednisone 40 mg PO bid TMP, 15 mg/kg PO daily, plus dapsone, 100 mg PO daily second line Pentamidine: 3-4 mg/kg IV q24h second line Clindamycin, 600-900 mg IV q6-8h, plus primaquine, 15-30 mg PO daily second line Atovaquone: 750-mg suspension PO bid second line Pseudomonas aeruginosa Aminoglycoside plus antipseudomonal β-lactam first line Antipseudomonal β-lactam second line (continued)

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INFECTIOUS DISEASE 151 TABLE 5-5: Diagnosis: HIV Management (Continued) Carbapenem second line Ciprofloxacin second line Aminoglycoside second line Salmonella spp. Ciprofloxacin: 500 mg PO bid first line TMP 1 DS PO bid second line S. aureus MSSA Nafcillin or oxacillin ± gentamicin 1 mg/kg IV q8h first line Cephalexin: 500 mg PO qid first line Dicloxacillin: 500 mg PO qid first line Clindamycin: 300 mg PO tid first line Fluoroquinolone first line First-generation cephalosporin ± gentamicin or rifampin second line MRSA Vancomycin, 1 g IV q12h, ± gentamicin or rifampin first line Linezolid: 600 mg PO/IV bid Streptococcus pneumoniae PCN or amoxicillin or cefotaxime, ceftriaxone, or fluoroquinolone first line Macrolide or vancomycin second line T. gondii Pyrimethamine, 200 mg PO loading dose, then 50-75 mg PO daily, plus leucovorin, 10-20 mg PO daily, plus sulfadiazine, 1. 0-1. 5 g PO q6h first line Pyrimethamine plus leucovorin plus clindamycin, 600 mg IV q6h second line (continued)

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152 INFECTIOUS DISEASE TABLE 5-5: Diagnosis: HIV Management (Continued) TMP, 5 mg/kg PO bid, plus SMX, 25 mg/kg PO bid second line 5-Fluorouracil, 1. 5 mg/kg PO daily, plus clindamycin, 1. 8-2. 4 g PO/IV bid second line Treponema pallidum (syphilis) Primary, secondary, and early latent syphilis (<1 yr) Benzathine PCN G: 2. 4 million units IM × 1 dose Primary, secondary, and early latent syphilis (>1 yr or unknown) Benzathine PCN G: 2. 4 million units IM weekly × 3 weeks Neurosyphilis Aqueous PCN G: 18-24 million units IV daily × 10-14 days Source: Reproduced from Bartlett J, Gallant J. Medical management of HIV infection. Baltimore: Johns Hopkins University Press, 2003, with permission.

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INFECTIOUS DISEASE 153 TABLE 5-6: Diagnosis: Meningitis Disposition Monitor floor/isolation precaution Monitor Vitals Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O2 PRN Activity Bedrest Dx studies Labs CBC with differential, BMP, blood C&S, PT/ PTT/INR, throat swab, UA, urine C&S CSF analysis (get CT of head before LP; see below for ordering CSF tests) PPD, VDRL test, rapid plasma reagent Radiology and cardiac studies CT of head with contrast, CXR (PA and lateral), ECG Special tests If nasal discharge test for glucose and chloride to r/o CSF leak, ?HIV ?PCR for meningococcus, ?CSF for PCR for meningococcus or viruses ?Latex agglutination for meningococcus, pneumococcal, H. influenzae b Recurrent meningitis: Check CH 50 for terminal C6-C9 Prophylaxis Chemoprophylaxis for exposure (see Meningococcal Infection: Chemoprophylaxis for Exposure) Consults ID (continued)

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154 INFECTIOUS DISEASE Nursing Respiratory isolation, I/O, check neurologic status q2-6h Avoid ? Management See Empiric Therapy for Suspicion of Meningitis for empiric treatment Dexamethasone (0. 15 mg/kg IV q6h) Lumbar Puncture and Tube Contents Tube number Test for 1 Cell count 2 Gram stain, bacteria, viral and fungus C&S, AFB, India ink 3 Glucose, protein, LDH, VDRL test 4 Cell count, RBC count, WBC count Latex agglutination or counterimmunoelectro-phoresis for meningococcus, pneumococcal, H. influenzae b, Escherichia coli, group B streptococcus, cryptococcal antigen, Toxoplasma 5 Hold for other tests Signs and Symptoms: Meningitis Fever Headache Cough Stiff neck Photophobia Earache Rash Rhinorrhea (continued)TABLE 5-6: Diagnosis: Meningitis (Continued)

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INFECTIOUS DISEASE 155 TABLE 5-6: Diagnosis: Meningitis (Continued) Otorrhea Brudzinski's sign: Bending chin to chest can cause hips and knees flex Kernig's sign: Straight-leg raising can cause pain Empiric Therapy for Suspicion of Meningitis Antibiotic should be given empirically before LP if there is high suspicion of meningitis LP can be done up to 2 hrs after first dose of empiric antibiotic therapy without destroying CSF Cx result Bacterial meningitis empiric treatment Preterm and low-weight neonate Group B streptococcus, Listeria monocytogenes, E. coli, staphylococci, gram-negative Vancomycin, 15 mg/kg IV q6h, plus ceftazidime (Fortaz), 50-100 mg/kg q8h 0-3 mos Group B streptococcus, L. monocytogenes, E. coli Ampicillin, 50 mg/kg IV q8h, plus ceftriaxone, 50-100 mg/kg IV q12h 3 mos-18 yrs S. pneumoniae, H. influenzae, Neisseria meningitidis Ceftriaxone, 50-100 mg/kg IV q12h, plus vancomycin, 10 mg/kg IV q6h 18-50 yrs immuno-competent S. pneumoniae, N. meningitidis Ceftriaxone, 2 g IV q12h, plus vancomycin, 500 mg IV q6h (continued)

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156 INFECTIOUS DISEASE TABLE 5-6: Diagnosis: Meningitis (Continued) >50 yrs immuno-competent S. pneumoniae, L. monocytogenes, gram-negative bacilli Ampicillin, 2 g IV q4h, plus ceftriaxone, 2 g IV q2h, plus vancomycin, 500 mg IV q6h Immunocom-promised L. monocytogenes, gram-negative bacilli Ampicillin, 2 g IV q4h, plus ceftazidime, 50-100 mg/kg IV q8h Head trauma, shunt, or surgery Staphylococci, gram-negative bacilli, S. pneumoniae Vancomycin, 15 mg/kg IV q6h, plus ceftazidime, 50-100 mg/kg IV q8h Source: From Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med 1997;336:708, with permission. Meningococcal Infection: Chemoprophylaxis for Exposure Age Medication <1 mo Rifampin: 5 mg/kg PO q12h × 2 days >1 mo Rifampin: 20 mg/kg PO q12h × 2 days ≤12 yrs Ceftriaxone: 125 mg IM × 1 dose >12 yrs Ceftriaxone: 250 mg IM × 1 dose Adult Rifampin, 600 mg/kg PO q12h × 2 days, or ciprofloxacin, 500 mg PO × 1 dose Note Rifampin Not recommended for pregnant female; may ↓ efficacy of oral contraceptive pills May cause red-orange discoloration of body fluids (e. g., urine, tears) (continued)

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INFECTIOUS DISEASE 157 TABLE 5-6: Diagnosis: Meningitis (Continued) Ciprofloxacin Not recommended if <18 yrs of age, pregnant female, or lactating female Can be used in children if no other alternative available Source: From Meningococcal disease: evaluation and management of suspected outbreaks. MMWR Morb Mortal Wkly Rep 1997;46(RR-6):6, with permission.

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158 INFECTIOUS DISEASE TABLE 5-7: Diagnosis: Osteomyelitis Disposition Medical floor Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O2 PRN Activity Bedrest Dx studies Labs CBC with differential, blood C&S, BMP, ESR, CRP, UA, needle biopsy of bone for C&S × 2 Radiology and cardiac studies X-ray of the site, ?CT scan, MRI (preferred), ?technetium/gallium bone scan Special tests ?Wound Cx, ?sinus drainage/aspirate Cx, ?needle aspiration for C&S If patient with diabetes, consider probe to bone test Prophylaxis DVT Consults ?ID, ?orthopedics Nursing Elevate involved area if possible Avoid ? Management Nafcillin/oxacillin: 2 g IV q4h first line Cefazolin (Ancef): 1-2 g IV q8h first line Unasyn: 1. 5-3. 0 g IV q6h first line Zosyn: 3. 375-4. 5 g IV q6h second line Linezolid (Zyvox): 600 mg IV/PO q12h (side effect: thrombocytopenia) second line MRSA suspected or PCN allergy: vancomycin, 1 g IV q12h (continued)

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INFECTIOUS DISEASE 159 Anaerobe suspected: clindamycin, 600 mg IV q6h Aerobes and anaerobe suspected: clindamycin plus third-generation cephalosporin or quinolone Diabetic or bite wound: clindamycin plus third-generation cephalosporin or quinolone ?Hyperbaric oxygen (not proven by randomized controlled studies)TABLE 5-7: Diagnosis: Osteomyelitis (Continued)

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160 INFECTIOUS DISEASE TABLE 5-8: Diagnosis: Pelvic Inflammatory Disease (PID) Disposition Medical floor Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O2 PRN Activity Up ad lib Dx studies Labs CBC with differential, cervical Cx for GC and chlamydia, UA, urine C&S, BMP, Mg Blood C&S × 2, ESR, LFT Radiology and cardiac studies Pelvic US to r/o abscess, wet mount (NS/ KOH) of vaginal secretion Special tests β-HCG, ?HIV, ?VDRL, ?rapid plasma reagent Prophylaxis ? Consults Ob/gyn, ?ID Nursing ? Avoid ? Management: PID/Salpingitis/Tuboovarian Abscess Doxycycline, 200 mg IV q12h × 3 days, then 100 mg IV q12h × 11 days plus Cefoxitin, 2 g IV q6h × 2 weeks, or cefotetan, 2 g IV q12h × 2 weeks, or ertapenem, 1 g IV q24h × 3-10 days first line Doxycycline, 200 mg IV q12h × 3 days, then 100 mg IV q12h × 11 days plus Ampicillin/sulbactam: 3 g IV q6h × 2 weeks second line (continued)

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INFECTIOUS DISEASE 161 Ciprofloxacin, 400 mg IV/500 mg PO q12h, plus metronidazole, 1 g IV q24h × 2 weeks second line Gatifloxacin, 400 mg IV/PO q24h, plus metronidazole, 1 g IV q24h × 2 weeks second line Levofloxacin, 500 mg IV/PO q24h, plus metronidazole, 1 g IV q24h × 2 weeks second line Moxifloxacin, 400 mg IV/PO q24h, plus metronidazole, 1 g IV q24h × 2 weeks second line Ofloxacin, 400 mg IV/PO q12h, plus metronidazole, 1 g IV q24h × 2 weeks second line TABLE 5-8: Diagnosis: Pelvic Inflammatory Disease (PID) (Continued)

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162 INFECTIOUS DISEASE TABLE 5-9: Diagnosis: Pneumonia Disposition Medical floor Monitor Vitals, pulse oximeter Diet Regular Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, Mg, LFT, blood C&S × 2, sputum Gram stain Sputum C&S, UA, ?ABG, ?urine C&S Radiology and cardiac studies CXR (PA and lateral), ECG Special tests ?Silver stain (for P. carinii ) ?AFB smear and Cx, ?PPD ?Pneumococcal PCR?Influenza A and B: Rapid antigen assay can distinguish between influenza A and B Chlamydia psittaci, Coxiella burnetii ?Legionella urinary antigen (in severely ill patient) ?Bronchoalveolar lavage Prophylaxis DVT Consults ?ID Nursing ?Isolation if suspicion of MRSA, ?pulse oximeter, aspiration precaution Avoid ? Management See Management: Pneumonia for specific therapy (continued)

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INFECTIOUS DISEASE 163 Acetaminophen (Tylenol): 650 mg q4-6h (max: 4 g/day) PRN for temperature >38°C and pain NSAIDs PRN for pleuritic pain CURB-65: Assessing Risk of Mortality and Intensive Care Admission in Patients >65 Yrs Clinical Points Confusion 1 Urea ≥20 mg/d L 1 Respiratory rate 1 BP (SBP <90 mm/Hg or DBP ≤60 mm/Hg) 1 Age ≥65 yrs 1 Risk of mortality Score % Mortality 0 0. 7 1 3. 2 2 13. 0 3 17. 0 4 41. 5 5 57. 0 Site of care based on CURB-65 score0-1: Home treatment 2: Hospital or supervised home treatment 3-5: Hospital 4-5: Consider ICU Source: Reproduced from Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58:377-382, with permission. (continued)TABLE 5-9: Diagnosis: Pneumonia (Continued)

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164 INFECTIOUS DISEASE TABLE 5-9: Diagnosis: Pneumonia (Continued) PORT Criteria (Pneumonia Assessment Scale) If patient age ≥50 yrs go to risk factor table and assign patient in class II-V If patient age <50 assign class I to this individual If patient <50 yrs and has any of the following conditions or physical examination abnormalities go to risk factor table and assign patient in class II-V; otherwise assign class I to this individual. Conditions Physical examination abnormality Active neoplastic disease Altered mental status CHF Pulse ≥125/min Chronic renal disease Respiratory rate ≥30/min Chronic liver disease SBP <90 mm Hg Cerebrovascular disease Temperature <35°C or >40°C Risk factor table Points Demographic factors Age of men Age (yrs) Age of women Age (yrs)-10 Nursing home resident 10 Coexisting illnesses Active neoplastic disease 30 Congestive heart failure 10 Chronic renal disease 10 Chronic liver disease 20 (continued)

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INFECTIOUS DISEASE 165 Risk factor table Points Cerebrovascular disease 10 Physical examination findings Altered mental status 20 Pulse ≥125/min 10 Respiratory rate ≥30/min 20 SBP <90 mm Hg 20 Temperature <35°C or >40°C 15 Lab findings Arterial p H <7. 35 30 BUN ≥30 mg/d L (11 mmol/L) 20 Sodium <130 mmol/L 20 Glucose ≥250 mg/d L 10 Hematocrit <30% 10 Pa O 2 <60 mm Hg 10 Radiographic findings Pleural effusion 10 Disposition of patient according to the pneumonia scale Class Score Interpretation II <70 Class I and II Treat as outpatient III 71-90 Class III Admit for brief observation IV 91-130 Class IV and VInpatient treatment V >130 Source: Reproduced from Fine, Auble, Yealy, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336:243, with permission. (continued)TABLE 5-9: Diagnosis: Pneumonia (Continued)

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166 INFECTIOUS DISEASE TABLE 5-9: Diagnosis: Pneumonia (Continued) Management: Pneumonia Medical ward No recent antibiotic therapy Respiratory fluoroquinolone alone or advanced macrolide + β-lactam Recent antibiotic use Advanced macrolide + β-lactam or respiratory fluoroquinolone (regimen depends on nature of recent antibiotic use) Unit (ICU, MICU, etc. )Pseudomonas is not suspected Respiratory fluoroquinolone alone or advanced macrolide + β-lactam Pseudomonas is not suspected and has β-lactam allergy Respiratory fluoroquinolone ± clindamycin Pseudomonas is suspected Antipseudomonal agent + ciprofloxacinor Antipseudomonal agent + aminoglycoside + respiratory fluoroquinolone or macrolide Pseudomonas is suspected and has β-lactam allergy Aztreonam + levofloxacinor Aztreonam + moxifloxacinor Gatifloxacin ± aminoglycoside (continued)

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INFECTIOUS DISEASE 167 Nursing home Receiving treatment in nursing home Respiratory fluoroquinolone alone or amoxicillin + advanced macrolide Hospitalized: follow above hospitalized patient protocol Source: Infectious Disease Society of America. Practice guideline for the management of community acquired pneumonia in immunocompetent adults, November 7, 2003, with permission. Organisms Associated with Specific Conditions Alcoholism S. pneumoniae, P. aeruginosa, anaerobes, gram-negative bacilli Aspiration Anaerobes Bats or soil enriched with bird dropping Histoplasma capsulatum Bird exposure C. psittaci Bronchiectasis P. aeruginosa, Burkholderia (Pseudomonas) cepacia, S. aureus COPD/smoker S. pneumonia, H. influenza, Moraxella catarrhalis, Legionella spp Cystic fibrosis P. aeruginosa, B. cepacia, S. aureus Farm animals or parturient cats C. burnetii Nursing homes S. pneumoniae, gram-negative bacilli, H. influenzae, S. aureus, anaerobes, Chlamydia pneumoniae Poor hygiene Anaerobes Travel to southwestern United States C. immitis TABLE 5-9: Diagnosis: Pneumonia (Continued)

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168 INFECTIOUS DISEASE TABLE 5-10: Diagnosis: Prostatitis Disposition Medical floor Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O2 PRN Activity Bedrest Dx studies Labs CBC with differential, UA, urine C&S, urine R&M Radiology and cardiac studies?CT or US (to r/o abscess), ?transrectal US (to r/o calculi or abscess) Special tests ?PSA Prophylaxis ? Consults ?Urology Nursing ? Avoid ? Management Pain management Tylenol: 650 mg PO q6h PRN for fever Stool softener Sitz bath May consider suprapubic catheter for severe urinary retention Antibiotic selection Prostatitis (acute) IV agents Ampicillin, 1-3 g IV divided q6h, plus gentamicin, 2 mg/kg loading dose, then 1. 7 mg/kg IV q8h first line (continued)

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INFECTIOUS DISEASE 169 Ciprofloxacin: 400 mg IV q12h × 2 weeks first line Levofloxacin: 500 mg IV daily × 2 weeks first line Gatifloxacin: 400 mg IV daily × 2 weeks first line TMP/SMX: 2. 5 mg/kg IV q6h × 2 weeks first line Aztreonam: 2 g IV q8h × 2 weeks second line PO agents Ciprofloxacin XR: 1000 mg PO daily × 2 weeks first line Doxycycline: 200 mg PO q12h × 3 days then 100 mg PO daily × 11 days first line TMP/SMX SS (single strength): PO daily × 2 weeks first line Prostatitis (chronic) PO agents Ciprofloxacin: 500 mg PO bid × 1-3 mos first line Levofloxacin: 500 mg PO daily × 1 mo first line Doxycycline: 100 mg PO daily × 1-3 mos first line TMP/SMX DS: PO bid × 1-3 mos second line TABLE 5-10: Diagnosis: Prostatitis (Continued)

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170 INFECTIOUS DISEASE TABLE 5-11: Diagnosis: Pyelonephritis Disposition Medical floor Monitor Vitals Diet Regular Fluid MIVF O2 PRN Activity Up ad lib Dx studies Labs CBC with differential, BMP, Mg, LFT, UA, urine R&M, urine Gram stain and C&S Blood C&S × 2 Radiology and cardiac studies KUB, renal US, CT of abdomen Special tests ?ESR Prophylaxis ? Consults ?Nephrology, ?urology, ?ID Nursing Urine output Avoid ? Management See below Tylenol: 325-650 mg q4-6h (max: 4 g/day) Empiric treatment for acute uncomplicated pyelonephritis Parenteral Oral Ceftriaxone: 1 g IV q24h or Ciprofloxacin: 500 mg PO bid or Ciprofloxacin: 200-400 mg IV q12h or Ciprofloxacin XR: 1,000 mg PO daily or Levofloxacin: 250-500 mg IV q24h or Levofloxacin: 250-500 mg PO daily or (continued)

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INFECTIOUS DISEASE 171 TABLE 5-11: Diagnosis: Pyelonephritis (Continued) Ofloxacin: 200-400 mg IV q24h or Ofloxacin: 200-300 mg PO bid or Gatifloxacin: 400 mg IV q24h Gatifloxacin: 400 mg PO daily or Norfloxacin: 400 mg PO bid or Lomefloxacin: 400 mg PO daily or Enoxacin: 400 mg PO bid Empiric treatment for acute complicated pyelonephritis Cefepime: 1 g IV q12h or Ciprofloxacin: 400 mg IV q12h or Levofloxacin: 500 mg IV q24h or Ofloxacin: 400 mg IV q12h or Gatifloxacin: 400 mg IV q24h or Gentamicin, 3-5 mg/kg IV q24h, plus ampicillin, 1-2 g IV q6h or Gentamicin, 1 mg/kg IV q8h, plus ampicillin, 1-2 g IV q6h or Ticarcillin/clavulanate: 3. 2 g IV q8h or Piperacillin/tazobactam: 3. 375 g q6-8h or Imipenem/cilastatin: 250-500 mg q 6-8h Empiric treatment for acute pyelonephritis in pregnancy Ceftriaxone: 1 g IV q24h or Gentamicin, 1 mg/kg IV q8h, plus ampicillin, 1-2 g IV q6h or Ticarcillin/clavulanate: 3. 2 g IV q8h or Aztreonam: 1 g IV q8-12h or Piperacillin/tazobactam: 3. 375 g q6-8h or Imipenem/cilastatin: 250-500 mg q 6-8h

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172 INFECTIOUS DISEASE TABLE 5-12: Diagnosis: Septic Arthritis Disposition Medical floor Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O2 PRN Activity Up ad lib Dx studies Labs CBC with differential, blood C&S × 2, UA, urine C&S, urine R&M, BMP, Mg Male: urethral swab for GC; female: cervical swab, rapid plasma reagent/VDRL Radiology and cardiac studies CXR, x-ray of the joint, CT of joint, ?technetium and gallium scintigraphic scan, ?MRI, ?indium-labeled WBC scan Special tests Joint fluid analysis Color C&S Protein Gram stain WBC count Glucose Viscosity AFBBlood Cx for Neisseria gonorrhoeae : chocolate agar or Thayer-Martin medium Tuberculosis exposure: synovial fluid Cx for AFB, staining for AFB, histologic examination of the synovial membrane History of trauma, animal bite, endemic fungal infection, Lyme disease, immune suppression, or refractory to conventional therapy: ?fungal Cx, ?PCR for detection of Borrelia burgdorferi DNA (continued)

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INFECTIOUS DISEASE 173 ?ESR, ?rheumatoid factor, ?antiteichoic acid (elevated in Staphylococcus infection) ?Cryoglobulins, ?immune complexes, ?antistreptolysin-O antigen? Brucella- and rickettsial-related titer ?PCR techniques to detect gonococcal DNA in synovial fluid can ↑ the yield in Cx-negative cases and permits monitoring of the response to therapy. Prophylaxis PRN Consults ?ID, ?rheumatology, ?PT/OT Nursing Warm compresses to joint; immobilize joint involved Avoid Do not use tetracycline in pregnancy or children <8 yrs Management See Management: Septic Arthritis P. aeruginosa is common in following conditions: Patient with burn Inject illicit drugs Trauma, particularly after injury in aquatic environments Postoperatively Cellulitis in neutropenic patient Chronic decubitus ulcers Management: Septic Arthritis Arthroscopy or open drainage Gram-positive cocci: Community-acquired infections: cefazolin, 1-2 g IV q8h Hospital or nursing home-acquired infection: vancomycin (30 mg/kg daily IV in two divided doses) (max: 2 g/day) (continued)TABLE 5-12: Diagnosis: Septic Arthritis (Continued)

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174 INFECTIOUS DISEASE TABLE 5-12: Diagnosis: Septic Arthritis (Continued) Gram-negative bacilli: Third-generation cephalosporin such as ceftazidime (1-2 g IV q8h) or Ceftriaxone (2 g IV q24h) or Cefotaxime (2 g IV q8h) or P. aeruginosa suspected (e. g., in patients who inject illicit drugs): Ceftazidime plus aminoglycoside such as gentamicin Gram-negative pleomorphic: clindamycin MRSA: vancomycin, 1 g IV q12h Gonococcal suspicion: ceftriaxone, 1 g IV/IM q24h, or spectinomycin, 2 g IM q12h Physical therapy Daily aspiration Open débridement and lavage if no resolution with IV antibiotic and closed drainage

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INFECTIOUS DISEASE 175 TABLE 5-13: Diagnosis: Septic Shock/Sepsis Disposition Unit Monitor Vitals, continuous pulse oximeter Diet NPO, ?hyperalimentation Fluid Volume replacement then MIVF O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium, Mg, PO4, LFT, blood C&S × 2, UA, urine C&S Amylase, lipase, troponin, PT/PTT/INR, ABG, ?fungal Cx, LP, CD4, TLC Radiology and cardiac studies ECG, CXR (PA and lateral); KUB, ?CT of chest, ?CT of abdomen, ?CT of head, US of abdomen Special tests Lactic acid, serum/urine toxicology screen, ?CSF analysis, ?sputum C&S ?Fibrinogen degradation product, fibrinogen?Coombs' direct/indirect (if patient receiving blood transfusion) ?Peritoneal fluid analysis Prophylaxis DVT, GI prophylaxis Consults ?ID Nursing Stool guaiac, Foley catheter, I/O Avoid ? Management Resuscitation and treat hypotension (aggressive IVF, vasopressors) Treat the source of septic shock (continued)

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176 INFECTIOUS DISEASE Antibiotic therapy if infectious etiology suspected (consider broad-spectrum antibiotics) Neutropenia: ceftazidime, 1-2 g q8-12h, plus vancomycin or Zosyn plus gentamicin or tobramycinor Imipenem plus gentamicin or tobramycin Corticosteroids (stress dose: hydrocortisone, 100 mg IV q8h) Correction of electrolytes, give HCO 3 if p H <7. 1TABLE 5-13: Diagnosis: Septic Shock/Sepsis (Continued)

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INFECTIOUS DISEASE 177 TABLE 5-14: Diagnosis: TB Disposition Medical floor (respiratory isolation) Monitor Vitals Diet Regular Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Up ad lib in the room, ?bedrest Dx studies Labs CBC with differential, sputum for AFB, PPD, LFT, BMP, Mg, hepatitis panel HIV serology, anergy testing (mumps, Candida, and tetanus toxoid) Latent TB infection: serum Quanti Feron-TB Test and Quanti Feron-TB Gold Test Radiology and cardiac studies CXR (PA and lateral), CT of chest Special tests ?CD4 count, ?TLC, pleural fluid analysis ?Bone marrow biopsy to diagnose miliary tuberculosis Extrapulmonary: UA, urine C&S, CSF, bone marrow, and liver biopsy for Cx Prophylaxis ? Consults ID, pulmonary Nursing Respiratory isolation Avoid ? Management See Management: TB PPD interpretation (measure induration and not erythema) ≥5 mm of induration People with HIV infection (continued)

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178 INFECTIOUS DISEASE TABLE 5-14: Diagnosis: TB (Continued) Close contacts People who have had tuberculosis disease before People who inject illicit drugs and whose HIV status is unknown ≥10 mm of induration Foreign-born person HIV-negative persons who inject illicit drugs Low-income groups People who live in residential facilities People with certain medical conditions Children younger than 4 yrs old People in other groups as identified by local public health officials ≥15 mm of induration People with no risk factors for tuberculosis Source: From http://www. cdc. gov. Management: TB Direct observation therapy First line INH, 15 mg/kg (max: 900 mg) PO, plus rifampin, 600 mg PO plus EMB, 30 mg/kg PO (max: 2,500 mg), plus PZA (if ≥75 kg = 3 g; if ≤50 kg = 2 g; if 51-74 kg = 2. 5 g PO) three times a week for 6 mos Second line INH, 300 mg PO, plus rifampin, 600 mg PO, plus EMB, 15 mg/ kg PO (max: 2,500 mg), plus PZA (if ≥75 kg = 2. 5 g; if ≤50 kg = 1. 5 g; if 51-74 kg = 2 g PO) daily for 2 mos Then INH, 300 mg PO, plus rifampin, 600 mg PO, daily for 4 mos (continued)

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INFECTIOUS DISEASE 179 TABLE 5-14: Diagnosis: TB (Continued) If HIV-positive INH, 15 mg/kg (max: 900 mg) PO, plus rifampin, 600 mg PO, plus EMB, 15 mg/kg PO (max: 2,500 mg), plus PZA (if ≥75 kg = 3 g; if ≤50 kg = 2 g; if 51-74 kg = 2. 5 g PO) daily for 2 mos Then INH, 300 mg PO, plus rifampin, 600 mg PO, daily for 7 mos Whenever patient is on INH, he or she should be supplemented with pyridoxine, 10-50 mg PO daily

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180 INFECTIOUS DISEASE TABLE 5-15: Diagnosis: Urinary Tract Infection (UTI) Disposition Medical floor Monitor Vitals Diet Regular Fluid IV hydration essential O2 PRN Activity Up ad lib Dx studies Labs CBC with differential, BMP, LFT, UA, urine R&M, urine Gram stain, urine C&S ?Blood C&S Radiology and cardiac studies?Renal US Prophylaxis ? Consults ?Urology Nursing ? Avoid ? Management See below for specific treatment Tylenol: 325-650 mg q4-6h (max: 4 g/day) Uncomplicated—treat for 7-10 days TMP/SMX DS: 1 tablet PO bid × 3 days first line Nitrofurantoin: 100 mg PO q12h first line Fosfomycin (Monurol): one 3-g packet PO × 1 dose first line Augmentin: 500 mg PO q12h first line Ciprofloxacin, 250 bid × 3 days, or ciprofloxacin, 500 daily × 3 days second line Levofloxacin: 250 mg PO daily × 3 days second line Ofloxacin: 200 mg PO bid × 3 days second line (continued)

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INFECTIOUS DISEASE 181 Gentamicin: 1 mg/kg IV q8h × 3 days second line Ticarcillin/clavulanate: 3. 2 g IV q8h × 3 days second line Complicated UTIAmpicillin, 1 g IV q6h, plus gentamicin, 1 mg/kg IV q8h, × 2-3 weeks first line Zosyn: 3. 1 g IV q4-6h × 2-3 weeks second line Ticarcillin/clavulanate: 3. 2 g IV q8h × 2-3 weeks second line Ceftriaxone: 1-2 g IV daily × 2-3 weeks or TMP/SMX: 800 mg PO bid × 2-3 weeks first line Norfloxacin: 400 mg PO bid × 2-3 weeks first line Ciprofloxacin: 500 mg PO bid × 2-3 weeks first line TABLE 5-15: Diagnosis: Urinary Tract Infection (UTI) (Continued)

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183 6 Electrolyte Disturbance and Nephrology OUTLINE Electrolyte Disturbance 6-1. Hyponatremia 184 6-2. Hypernatremia 1896-3. Hypokalemia 1926-4. Hyperkalemia 1956-5. Hypomagnesemia 1996-6. Hypermagnesemia 2026-7. Hypocalcemia 2036-8. Hypercalcemia 2066-9. Hypophosphatemia 208 6-10. Hyperphosphatemia 2106-11. Metabolic Acidosis (Gap or Non-Anion Gap) 212 Nephrology 6-12. Acute Renal Failure 215 6-13. Nephrolithiasis 2206-14. Rhabdomyolysis 222

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184 ELECTROLYTE DISTURBANCE AND NEPHROLOGY ELECTROLYTE DISTURBANCE TABLE 6-1: Diagnosis: Hyponatremia Disposition ?Unit/medical floor (depends on level of hyponatremia) Monitor Vitals Electrolyte monitoring: Check electrolytes q4h while patient on 3% NS Neuromonitoring Diet Regular Fluid See below for type of fluid to be used O 2 PRN Activity Bedrest Dx studies Labs Urine studies stat, BMP (q4h with rapid correction), calcium, Mg, PO 4 , LFT TSH, uric acid, UA, serum osmolality, U osm , U Na , U Cr Radiology and cardiac studies CXR (PA and lateral), ECG, ?CT of head/ chest Special tests ?Cortisol level (adrenal insufficiency), ?ADH, ?BNP (r/o CHF), ?aldosterone ?TG level Prophylaxis ? Consults Nephrology Nursing I/O, daily weights (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 185 Avoid Asymptomatic patient: when correcting hyponatremia, the rate of rise in P Na+ should not exceed 0. 5 m Eq/L/hr (12 m Eq/L/24 hrs), and do not exceed P Na+ 130 m Eq/L Symptomatic patient: initial rate of correction could be as high as 2 m Eq/L/hr × 3-4 hrs decrease to 10-12 m Eq/L/ day Rapid correction of hyponatremia can cause central pontine myelinosis Management See Investigation and Management: Hyponatremia Etiologies: Hyponatremia Diuretic therapy Nephropathy/ATN/nephritic syndrome Adrenal insufficiency Metabolic alkalosis Pseudohypoaldosteronism SIADH (lung disease, antidepressants, and seizure medications) Third spacing (burn, ascites, effusion) Glucocorticoid deficiency Hypothyroidism CHF Hyponatremia (<135) Pseudohyponatremia Secondary to ↑ plasma glucose and high lipid and high protein contents (continued) TABLE 6-1: Diagnosis: Hyponatremia (Continued)

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186 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-1: Diagnosis: Hyponatremia (Continued) Correction of Na + (glucose, protein, and TG) For every 100 ↑ in glucose above 200, Na + will ↓ by 1. 6 N a + deficit (m Eq/L) = [plasma protein (g/L)-8] × 0. 025 N a + deficit (m Eq/L) = plasma TG (g/L) × 0. 002 Note When correcting hyponatremia, the rate of rise in P Na+ should not exceed 0. 5 m Eq/L/hr and should not exceed P Na+ 130 m Eq/L A major complication is central pontine myelinolysis (osmotic demyelination), which occurs due to rapid correction; this can be accompanied by pituitary damage and oculomotor nerve palsy. Signs and symptoms: diplopia, weakness, muscle spasm, paralysis, confusion, delirium, dysphagia, dysarthria Investigation and Management: Hyponatremia If hypovolemic (patient is dry) get U Na+ level (m Eq/L) If U Na+ >20 m Eq/L secondary to diuresis, adrenal insufficiency If U Na+ <20 m Eq/L diarrhea, vomiting Treatment Symptomatic 3% saline Asymptomatic 0. 9% NS (200-250 m L/hr up to 1 L, then 125-250 m L/hr) If isovolemic differential : hypothyroidism, cortisol deficiency, thiazide, SIADH U Na+ <10 m Eq/L water intoxication U Na+ >20 m Eq/L SIADH, diuretic-induced Treatment water restriction to 500-1,000 m L/day; if severe use 3% NS (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 187 TABLE 6-1: Diagnosis: Hyponatremia (Continued) If hypervolemic (edema) get U Na+ level (m Eq/L) If U Na+ <20 m Eq/L heart failure, cirrhosis, nephrosis If U Na+ >20 m Eq/L renal failure Treatment Water restriction to 500-1,000 m L/day Furosemide (Lasix): 40-80 mg IV/PO daily bid Calculating Sodium Deficit in Hypovolemic Hyponatremia 1. Total body water (TBW) (L): male = [0. 6 × wt (kg)] or female = [0. 5 × wt (kg)] 2. Na+ concentration deficit (m Eq/L) = 130-current Na+ level (m Eq/L) 3. Na+ deficit (m Eq/L) = TBW × (Na+ concentration deficit) 4. Fluid to be infused: 3% saline = 513 m Eq/L of Na+, NS = 154 m Eq Na+ 5. Volume to be infused (m L) = (Na+ deficit/Na+ m Eq/L in solution) × 1,000 6. Total hours for correction of sodium deficit = Na+ concentration deficit/0. 5 [the result of this calculation is the speed of correction of Na+ (m Eq/L/hr)] 7. Rate of infusion = volume to be infused/hours for the infusion Note: Do not correct the rise in PNa+ to 0. 5 m Eq/L/hr or 12 m Eq/24 hrs; correct to 130 m Eq/L Example 1. A 60-kg female with Na+ level of 120 m Eq/L 2. TBW (L) = (0. 5 × 60) = 30 L 3. Na+ concentration deficit = 130-120 = 10 m Eq/L 4. Na+ deficit (m Eq/L) = (30 L) × (10 m Eq/L) = 300 m Eq/L 5. Fluid to be infused: 3% saline = 513 m Eq/L of Na+ 6. Volume to be infused (m L) = (300/513) × 1,000 = 585 m L (continued)

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188 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-1: Diagnosis: Hyponatremia (Continued) Note: Do not correct the rise in PNa+ to 0. 5 m Eq/L/hr or up to 130 m Eq/L 7. Total hours for correction of sodium deficit = [(10 m Eq/L)/ (0. 5 m Eq/L)] = 20 hrs 8. Rate of infusion = 585 m L/20 hrs = 29 m L/hr 9. Check electrolytes q4h while patient on 3% NS

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