Step 3 Treatments

Adults

Arthritis: Nongonococcal arthritis

• Initial broad spectrum: 3rd gen cephalosporin (Ceftriaxone, Ceftazidime, Cefotaxime) AND IV Vancomycin
  
• MRSA: IV Vancomycin
  
• MSSA: IV Nafcillin or IV Cefazolin
  
• G- bacilli: 3rd gen cephalosporin (Ceftriaxone, Ceftazidime, Cefotaxime)

Asthma Exacerbation

• Perform PEFR (Peak Expiratory Flow Rate)
  
  • – If PEFR <40% of predicted: O2, Albuterol-Ipratropium nebulizer q20min, IV Methylprednisone, PEFR q1h
    
  • – If PEFR >40% of predicted: O2, Albuterol nebulizer q20min, consider steroids, Ipratropium if no improvement
    
  • – Admit: PEFR <40% at 4h; consider if 40-70% at 4h

CAD: UA/NSTEMI

• Morphine
  
• Oxygen
  
• Nitroglycerin
  
• ASA
  
• Beta-Blocker (for BP 60-70)
  
• Antiplatelet agents: Eptifibatide (GIIb/IIIa inhibitor; if PCI) & Clopidogrel (P2Y12) + ACEi (when stable)
  
• Statin
  
• Heparin (check FOBT before starting)

Cat scratch disease

• Azithromycin

Cellulitis

• Inpatient:
  • IV Vanc or Clindamycin
• Outpatient:
  • Purulent (MRSA suspected): Clindamycin, or TMP-SMX, or Doxycyclin, or Linezolid
    
  • Non-purulent (Strep or MSSA): Clindamycin, or Amoxicillin + TMP-SMX, or Amoxicillin + Doxycyclin, or Linezolid

Colitis: Ulcerative colitis

• Mesalamine
  
• Loperamide
  
• Dicyclomine

Constipation

• First line: Bulk-forming laxatives (Psyllium, Methylcellulose), &/or Milk of Magnesia
  
• If no response: Softeners (Docusate), Osmolar agents (Lactulose, Sorbitol, Magnesium citrate), Stimulants (Senna, Bisacodyl)

Cystic Fibrosis

• Acute pulmonary exacerbation:
  • Vancomycin (S aureus) + Cefepime or Ceftazidime (Pseudomonas) + Amikacin or Tobramycin (Pseudomonas 2nd coverage)

Cystitis

• Complicated:
  • TMP-SMX for 7 days
• Uncomplicated:
  • TMP/SMX for 3 days
    
  • Alternative: Ciprofloxacin for 3 days

Diabetic neuropathy

• First line: Duloxetine, or Pregabalin, or TCA
  
• Alternative: Gabapentin, or Lamotrigine, Carbamazepine

Diverticulitis

• Inpatient:
  • Ampicillin-Sulbactam, or Piperacillin-Tazobactam, or Ticarcillin-Clavulanate, or Metronidazole + 3rd gen cephalosporin (Ceftriaxone, Cefotaxime, Ceftazidime), or Metronidazole + Ciprofloxacin, or Metronidazole + Aztreonam
• Outpatient:
  • Ciprofloxacin + Ceftriaxone, or Amoxicillin-Clavulanate, or Moxifloxacin

Entamoeba Histolytica

• Metronidazole
  
• Paromomycin (intraluminal)

Furuncle/Carbuncle

• Cover for MRSA: Clindamycin, TMP-SMX, Doxycycline

Headache: Migraines

• BB (Metoprolol)
  
• TCA (Amitriptyline)
  
• Anticonvulsants (Valproate)
  
• Abortive: Ergotamines or Sumatriptan

Hemophilia

• Monoclonal recombinant factor VIII (Hem A) & factor IX (Hem B)
  
• Adjuncts: Desmopressin, Antifibrinolytic agents

Hypertension

• HTN in patients with Gout: Losartan

Immune thrombocytopenia (ITP)

Lice

• Permethrin

Meningitis

• Meningitis adults:
  • G+ cocci & empiric: 3rd gen cephalosporin (Ceftriaxone, Cefotaxime, Ceftazidime) + Vancomycin
    
  • G- cocci: Ceftriaxone, or Cefotaxime, or Ceftazidime
    
  • G+ Bacilli: Ampicillin + Gentamycin
    
  • G- Bacilli: 3rd gen cephalosporin (Ceftriaxone, Cefotaxime, Ceftazidime) + Gentamycin
    
  • Pneumoccocal meningitis: Add Dexamethasone

Necrotizing fasciitis

• Piperacillin/Tazobactam or Carbapenem (Group A Strep & Anaerobes) + Vancomycin (Staph aureus) + Clindamycin (Inhibits Staph/Strep toxin formation)

Obesity

• Phentermine/topiramate
  
• Orlistat
  
• Bupropion/naltrexone
  
• Liraglutide

Onychomycosis

• Terbinafine or Itraconazole
  
• Alternative: Griseofulvin, Fluconazole, Ciclopirox

PCOS

• Ovulation induction in PCOS:
  • Weight loss!
    
  • Letrozole

PCP

• TMP-SMX
  
• Alternative: TMP-Dapsone, or Clindamycin-Primaquine, or Atorvaquone, or Pentamidine isethionate
  
• If severe (pO2<70, &/or A-a gradient>35): Add steroids

Perforated Bowel

• Morphine
  
• Phenergan
  
• Pantoprazole
  
• Enteric Antibiotics

Pericarditis

• Acute Pericarditis:
  • First line: NSAIDs (ASA in post-MI) & Colchicine
    
  • Resistant or autoimmune-related: Steroids

Pertussis

• Macrolides (Azithromycin)

PID

• Inpatient:
  • IV Cefoxitin or Cefotetan plus IV/PO Doxycyclin
    
  • Alternative: Clindamycin & Gentamycin,
    
  • or Ampicillin-Sulbactam plus IV/PO Doxycyclin
• Outpatient:
  • Ceftriaxone IM once plus Doxycyclin for 14 days
    
  • Alternative: Cefoxitin IM once plus Probenecid PO once plus Doxycyclin for 14 days

PNA: Aspiration PNA

• Clindamycin
  
• Alternative: Betalactam/betalactamase inhibitor

Porphyria cutanea tarda

• Phlebotomy
  
• Hydroxychloroquine
  
• Interferon-alpha (if HepC+)

Pre-operative antibiotics

• Cefoxitin or Ampicillin-Sulbactam or Cefazolin + Metronidazole(if abdominal)

Prolactinoma

• Cabergoline/bromocriptine (dopamine agonists)

Raynaud phenomenon

• First line: Dihydropyridine CCB: Nifedipine or Amlodipine or Diltiazem
  
• Adjunctive: Topical Nitroglycerin

SBP ppx

• IV Ceftriaxone, or PO TMP-SMX, or PO Ciprofloxacin

Scabies

• First line: Topical Permethrin
  
• Second line: Topical Ivermectin

Schistosomiasis

• Praziquantel

Tinea

• Tinea capitis: Griseofulvin or Terbinafine

Thrombotic Thrombocytopenic Purpura (TTP)

• Plasma exchange

Vibrio vulnificus infection

• Ceftriaxone + Doxycycline

Intoxications/Withdrawals

Cocaine intoxication

• Benzodiazepines
  
• Nitroglycerin
  
• CCB
  
• Phentolamine

Psychiatric

Acute panic attack

• Alprazolam

Pregnancy

Abortion

• Pharmacological abortion: Misoprostol

Cystitis in pregnancy

• Nitrofurantoin
  
• Alternative: Amoxicillin-Cavulanate, Cephalexin, Fosfomycin

Postpartum endometritis

• clindamycin and gentamicin

Pyelonephritis in pregnancy

• IV Ceftriaxone or Cefepime

Pediatrics

Conjunctivitis: Neonatal gonococcal conjunctivitis

• Ceftriaxone or Cefotaxime once

Croup

• Mild: Humidified air +/- Dexamethasone
  
• Moderate-severe: Nebulized Epinephrine & Dexamethasone

Osteomyelitis in children

• Low likelihood of MRSA: Nafcillin/Oxacillin OR Cefazolin
  
• High likelihood of MRSA: Clindamycin OR Vancomycin
  
• Sickle Cell Patients: Add Ceftriaxone or Cefotaxime

Pediatric sepsis <28 days

• Ampicillin + Gentamicin or Cefotaxime

Pediatric sepsis >28 days

• Ceftriaxone or Cefotaxime +/- Vancomycin (if meningeal involvement)

Septic Arthritis in children

• <3mo old: Cefotaxime & Vanc (Staph a., GBS, G- Bacilli)
  
• >3mo old: Vanc (Staph a., GAS)