LONG COVID (LC)
SYMPTOMS
MYALGIA
COVID 6 MONTHS AGO
VAGUE COMPLAINTS
FATIGUE
NO ENERGY
LESS FOCUSED
NO OTHER SX
LCDD
PERSISTENT SX
COGNITIVE DEFICITS
DYSPNEA
CHEST PAIN
COUGH
1/3 OF POST COVID
LESS COMMON
INSOMINA
SWEATING
REDUCED LIBIDO
DIARRHEA
DURATION 9 MONTHS HOSPITALIZE
4 MONTHS NON HOSPITAL
LC
DIFF DX
LYME
MASS CELL DIFFERRENTIATION
CHRONIC FATIGUE SYNDROME
FIBROMYALGIA
DYSAUTOMNOMIA?
LC TESTING
FATIGUE:
CBC W SIFF
CMP TSH
CREATININE KINASE
DYPSNEA
D DIMER
BNP
TROPONINS
ALL R/O
NO SPECIFIC TEST FOR LC
MGT
FATIGUE BRAIN FOG POST EXERTIONAL MALAISE
LET PT KNOW I BELIEVE THIER STORY
DECREASES STRESS
SX FLUCTUATE
ADDRESS FATIGUE R/T EXERTION
RX:LOWER EXERTION REDUCE EXERCISE HELP TO RECOVER
CDC SITE LONG COVID
SAME TREATMENT AS YOU WOULD TREAT OTHER DIFF DX
SECRET TO CARING FOR THE PATIENT IS CARING FOR THE PATIENT
ACUTE INFECTIONS IN PRIMARY CARE
PURULENT SOFT TISSUE
MRSA’
DON T MISS DX
ACUTE INFECTION
PURULENT ABSCESS MOST SSTI SOURCE CONTROL -I&D+ BACTRIM
IF MODERATE ABX, DEPENDS ON COMMUNITY ACQUIRED COMMON NOW
DECLINGING RATES OF MRSA LAST 10 YEARS
MRSA RISK FACTORS
- ABX USE, HISTORY OF MRSA, C/O SPIDER BITE
NOW ID WANTS BACTRIM TO COVER MRSA. CLINDAMYCIN EFFECTIVE BUT HIGH RISK FOR CDIFF
STAPH -PURULENT ABSCESSES ETC
STREP BETA HEMOLYTIC FAMILY
NON PURULENT
CONFLUENT CELLULITIS AND LYMPHANGITIS
DIABETIC FOOT ULCERS - GRAM NEG RODS AND ANAEROBES
ANIMAL BITES-PASTEURELLA AND CAPNOCYTOPHAGEN
WATER BORNE- VIBRIO - WORSE IN CIRRHOSIS, MYCOBACTERIUM MARINUM-LESS COMMON-FISHTANK
SPORATHRIX SCHANKII -ROSE THORN
MRSA
FEVER
LARGE BUTTOCK NODULE
I&D
BACTRIM
SSTI
I&d
GET CULTURES
SOURCE CONTROL I&D PACK - BIG ABSCESSES PACK
CEFADROXIL + DOXY OR CEFADROCIL + BACTRIM IF THINK STREP AND STAPH
PERIANAL ABSCESSES DO NOT PACK
IF OPEN AND DRAIN DO NOT DIG AROUND, OFTEN LOCULATED STILL NEED I &D
EMPIRIC ABX NOW RECOMMENDED
DOXY
LINEZOLID NEW BABY-SULFA ALLERGY , WITH CKD
CEFADROXIL/CEPHUROXIMES DOES NOT HAVE MRSA COVERAGE
CLINDAMYCIN TOO MANY S/E TOO MUCH RESISTANCE
ABX LARGE ABSCESS, FACE HANDS AND GENITALIA -ABX DEFINITE
LENGTH OF RX - SMALL ABSCESSES DRAINED 4-7 DAYS
LARGE UNDRAINED 1-2 WEEKS
LINEZOLID-EXCELLENT GRAM + INCL MRSA, GENERIC
ORAL BIOAVAILABILITY SAME AS IV
S/E NEUROPATHY , BONE MARROW SUPPRESSION ,SEROTONIN SYNDROME ( OVERBLOWN) CANSTILL USE
RECURRENT MRSA- REFER TO ID
DECOLONIZATION ENCOURAGED, NASAL MUPIROCIN, TOPICAL CHLORHEXIDINE AND REPEAT ABX FOR A WEEK
TICK
10 DAYS EARLY
2-4 WEEKS EARLY DISSEMINATED
LONE STAR TICK- EMERGING ALHA GAL SYNDROME, IXODIS NO TEST-PRESENTS AS
ALLERGY TO RED MEAT
ANIMAL BITES
AUGMENTIN, BETTER GRAM - COVERAGE
PASTEURELLA MULTOCIDA, CATS -NOT SUSCEPTIBLE TO FIRST LINE,USE AUGMENTIN, BETTER ANEROBIC ACTIVITY,GM_
DOGS-ADENOCTOPHEGA,RARE, IN DOG MOUTH, SIRS
CAT SCRATCH DX, ADENOPATHY NECK AXILLA - AUGMENTIN EMPIRIC
TICK BORNE
EARLY LOCALIZED EM, 30% SYSTEMIC
RX DOXY 10-14 DAYS
IF RASH MISSED
EARLY DISSEMINATED BRAIN AND HEART
LYME MENINGITIS
BELLS PALSY
HEART
AV BLOCK
ENDOCARIDITS?
LATE -MNTHS TO YEARS
JOINTS
MONOARTICULAR ARTHRITIS EG LARGE KNEE
NEURO
ENCEPHALOPATHY BRAIN FOG
IV ABX
LYME DX -SIMILAR TO LONG COVID -REAL SYNDROME
EM
NEEDS TO MEASURE 5 CM GROWS QUICKLY
USU OVOID
CENTRAL CLEANING
PUNCTILE
CAN SPREAD TO MULTIPLE
DITINGUISH BETWEEN LOCAL TICK BITE, USU WHILE TICK IN, DOESNT GROW
EM TAKES A FEW DAYS
LYME TESTING IN EARLY DISEASE NOT RELIABLE
ANTIBODIES NOT MOUNTED- 2020 GUIDELINE RHEUM & ID
CLINICAL NOT LAB
EMPIRIC RX FULL COURSE 10 DAYS , DOXY
LYME PROPHYLAXIS 87%
GIVE DOXYCYCLINE 200MG X 1 PROPHYLAXIS
AMOXIL NO CLEAR BENEFIT,
ALTERNATIVE- JUST WATCH IT
EXCODIS TICK BITE
LYME PREVENTION
CRAWL UP FROM GROUND -MIGRATE TO WARM PLACES,
SHOWER AFTER WALK
DRYER ON HIGH HEAT
LATE LYME
ADDITIONAL TESTING
LOOK
BABESIA MICRODII AND IXODUS CARRIED IN SAME TICK
PRESENTS AS HEMOLYIC ANEMIA AND THROMBOCYTOPENIA
SPLEEN VERY IMPORTAN
PARASITE SMEAR
PCR OF BLOOD
RX:
LOOK UP , NOT TREATED BY DOXY
BABESIA
ANAPLASMA PHAGOCYTOPHILUM
BABESIA NO DOXY
3 MUSKKETEERS
HIGH FEVER
TEST ANAPLASMA PCR,
CURED W COUPLE DOSES DOXYCYCLINE
HIV
2 TESTS
HIV AG/AB ASSAY REACTIVE-LOTS OF FALSE POSITIVE
HIV 1/2 DIFFERENTIATION ASSAY NEG( VIRAL LOAD)
14 DAY WINDOW-
IN LOW RISK CASE A FALSE POSITIVE SCREEN IS LIKELY
CAN HAPPEN W FLU , MONO , ACUTE VIRAL
IF BOTH TESTS POSITIVE THEN LIKELY POSITIVE
HIV TESTING
FIRST TEST WINDOW PERIOD DOWN TO ANTIBODY AND ANTIGEN DOWN TO 14 DAYS
+ IF POSITIVE
ACUTE HIV -MULTISYSTEM FEBRILE ILLNESS , PRESENTS LIKE MONO
LOOK AT RISK FACTORS
VIRAL LOAD 10 MILLION
PSITIVE ANTIB, ANTIGEN
NEG
ENODCARIDTIS
FATIGUE MALAISE
NIGHT SWEATS FEVERS
NO SYMPTOMS LOCALLY
RIGORS
GET BLOOD CULTURES
ESP IF RISK FACTTOR FOR ENDOCARDITIS
HOST RISK - AREA OF VULNERABILITY
RHD, BICUSPID AORTIC VALVE, PROSTHEETIC VALVE, PAST ENDO
DM
EXPOSURES
DENTAL WORK
CLABSI PICC
GI OR GU PROCEDURE-S EED ING
IV DRUG ABUSE-
PE: FOOT , DENTAL , PROCEDURES
WHERE DID IT COME FROM WHERE DID IT GO? COTTON EYED JOE
DAIGNOSITS
LOOK AT MOUTH SKIN FOOT
ECHO
MRI
CARDIAC CT PET
NON RESOLVING PHARYNGITIS
RED FLAGS
TRISMUS-cant open mouth, jaw locks
DYSPHAGIA
DROOLING
UNILATERAL NECK SWELLING
3 SYNdROMES
ABSCESS, PERITONSILAR ( UVULA DEVIATION)
PAROTID ABSCESS
LEMIERRE SYNDROME-PE
LUDWIGS ANGINA J
SUBMANDIBULAR -PERDONTAL INFECTION
NEVER USE AZITHROMYCIN FOR THROAT- INEFFECTIVE AGAINST MOUTH ORGANISMS
AUGMENTIN AND REFER ENT OR ID
MULTI CANCER SCREENING TEST EARLY DETECTION
GALLERI
89 % SURVIVAL EARLY DETECTION
70% CANCERS HAVE NO USPSTF RECOMMENDED SCREENING TESTS
PATTERN OF DNA METHYLATION ON CELL FREE??? DNA
USE AI, PATTERN RECOGNITION OF DNA METHYLATION OF CANCER CELLS THAT IS DIFFERENT FROM HEALTHY CELL DNA METHYLATION
DOESNT DETECT INDOLENT CANCERS
COVID 19
ANTIVIRAL SELECTION
MGT OF DRUG DRUG INTERACTIONS FOR COVID IN OUPT SETTING
COVID SYMPTOMS
HEADACHE
CONGESTION
CAN HAVE ANOSMIA
MGT PLAN COVID
HELTHY UNDER 65 LOW RISK , NO EVIDENCE THAT PAXLOVID IMPROVES OUTCOMES
COVID MGT
NON HOSPITALIZED MILD TO MODERATE
NO OXYGEN
OTC ANTIPYRETICS,
ANALGESICS,
ANTITUSSINS-dextromethorphan,nmda receptor antagonist
REST
HYDRATION
COVID
RISK FACTORS FOR DX PROGRESSION
1 RISK FACTOR - TREAT
OVER 65
UNDER 65 W CHRONIC HEALTH ISSUES
OBESITY BM OVER 25
IMMUNOCOMPROMISE REGARDLESS VACC STATUS
CKD
COPD ASTHMA
CHF CAD
SMOKING
AA AND NATIVE AMERICANS PACIFIC ISLANDER
PREGNANT
COVID MEDS
PHARM MGT OUTPT
PAXLOVID- NIRMATRELVIR/RITONAVIR
REMDESIVIR VEKLURY
LAGEVRIO MOLNUPIRAVIR - IF PAX OR REMDESIVIR INAPPROPRIATE
COVID NON PHARM MGT
MONITOR FOR WORSENING SX
TIGHTNESS
DIZZINESS
MENTAL STATUS CHANGES
FLUIDS
COUGH SUPPRESSANTS
DO NOT USE GLUCOCORTICOIDS FOR LOW -MODERATE
OTHER MEDS QUINO, VITS
PAXLOVID ORAL
TWO DRUGS
NIRMALTREVIR - SARS COV 2 PROTEASE INHIBITOR PAXLOVID
88% REDUCTION
RITONAVIR -HIV-1 PROTEASE INHIBITOR, CYP 3A4 INHIBITOR- BOOSTED NIRMATRELVIR
MUST BE WITHIN 5 DAY WINDOW OF SYMPTOMS
EPIC HR TRIAL < DEATH/HOSP BY 89%
CHILDREN >12 YEARS WT >40 KG
DOSE: 3 PILLS BID X 5 DAYS
RENAL DOSING :
300/100 EGFR >60 3 TABS
150/100 EGFR 30-60ML-
2 PILLS BID X 5 DAYS
CONTRAI
EGFR <30ML
SEVERE HEPATIC IMPAIRMENT
S/E
METALLIC TASTE
HTN
REMDESIVIR/ VEKLURY- IV
PEDS >28 DAYS
>3KG WEIGHT BASED DOSING
3 DAY REGIMEN FOR MILD -MOD.
MUST GIVE WITHIN 7 DAYS OF SX ONSET
5 DAY FOR HOSPITALIZED PTS
IV IFUSION 30 MINUTES DAILY X 3 DAYS
87% EFFECTIVE
NO SIGNIFICANT DDI
200 MGS DAY 1, 100 MG DAY 2+3
NO DOSE ADJUSTMENT WITH RENAL INSUFF , CAN BE USED LIVER
IV < HOSP/DEATH 87%
N+V
> TRANSMAINASES AND PT TIME
MOLNUPIRAVIR LAGEVRIO ORAL
USE WITHIN 5 DAYS OF SX ONSET
USE WHEN REM AND PAX NOT APROPOS OR DDI R/O
NO USE IN PREGNANCY
31% EFFICACY
NO DOSE REDUCTION FOR KIDNEY AND LIVER DX
800 MG PO BID
NAUSEA
THERAPY SELECTION FACTORS
ALL 3 ARE AGAINST OMICRON VARIANTS
MOLNUIRAVIR HAS LOWER EFFICACY
ONLY FOR HIGH RISK PATIENTS
MUST BE WITHIN 5 DAYS
PREGNANCY - NIH RECOMMEND OFFERING PAXLOVID IN PREGNANCY, ENDORSED SMFM
NOT RECOMMEND PREGNANCY EUROPE UK CANADA
NIH PREGNANCY RECOMMEND REMDESIVIR
CANNOT USE LAGEVRIO
PAXLOVID
DRUG INTERACTIONS
RETONIVIR IS STRONG CT 450 3A4 INHIBITOR
CYP 3A4 IS A LIVER ENZYME
P GLYCOPROTEIN IMPORTANT IN METABOLISM
HMG COA REDUCTASE INHIBITORS STATINS
SIMVASTATIN AND LOVASTATIN- HOLD 12 HOURS BEFORE , RESTART 5 DAYS AFTER PAXLOVID ENDS
ROSUVASTATIN AND ATORVASTATIN- DC DURING TREATMENT W PAX, DO NOT NEED TO HOLD OR WAIT 5 DAYS
PLAVIX-FIRST 6 WEEKS OF CORONARY STENTING -NO USE PAX
OCT-IF HAS ETHINYL ESTRADIOL USE NON HORMONAL METHOD OF CONTRACEPTION DURING 5 DAYS OF PAX AND UNTIL ONE MENSTRUAL CYCLE AFTER STOPPING PAX
HIV MEDS
CAN BE COADMINISTERED INCLDUING RITONAVIR BUT NOTIFY HIV PROVIDER ( S/E )
CANNOT USE MARAVIROCDD
ANY DRUG THAT IS STRONG CYP 3A4 INHIBITOR
CYP 3A4
3 AVM COST
COVERED BY CMS COMMERCIAL -PAXLOVID AND REMDESIVIR
UNISURED-FREE
REMDESIVIR
DDI
UNLIKELY BASED ON ITS METABOLISM AND CLEARACE
NO QUINOLONES AS THEY REDUCE ITS EFFICACY
STOP THE CONCOMITNAT MED PAXLOVID
TOO MANY TO NAME
https://www.covid19treatmentguidelines.nih.gov/therapies/antiviral-therapy/ritonavir-boosted-nirmatrelvir--paxlovid-/
https://www.fda.gov/media/158165/download
UNIVERSITY OF LIVERPOOL COVID 19 INTERACTION CHECKER
CHECK WITH PHARMACISTS AND SPECIALIST COLLEAGUES
PAXLOVID DDI MGT
PRESCRIBE AN ALTERNATE MED
TEMPORARILY WITHHOLD OTHER MED
PRESCRIBE AN ALTERNATE COVID MED
ADJUST DOSE OF CONCOMITANT MED ( NOT PAX MED)
MONITOR
MOST COMMON MEDS WHERE YOU DONT USE PAXLOVID ARE:
KNOW THIS
SILDAFENIL, TADAFILIL (WHEN USED FOR PULMONARY HTN)
ST JOHNS WORT
AMIODARONE, PLAVIX ,FLECAINIDE ( ANTIARRYTHMIC)
SEIZURE MEDS OLD :
CARBEMAZAPINE,PHENOBARB CYP 3A4 INDUCERS
PHENYTOIN
PRIMIDONE ALSO
RIFAMPIN- TREATS TB AND MRSA, C DIFF CYP 3A4 INDUCER
FROM TREATEMENT FOR NON HOSPITALIZED PTS WITH COVID 19 VIDEO
NATIONAL GUIDELINE RECS
IN US :
NIH
IDSA
AS OF 2023 NO RECS FOR MEDS FOR
TREATMENT FOR LOW RISK PTS
PST EXPOSURE PROPHYLAXIS
COVID TESTING
HOME TEST LESS SENSITIVE
CONFIRM NEGATIVE WITH PCR IF SYMPTOMATIC
POTENTIAL REPEAT 48 HOURS LATER -MAY BE NOT PRESENTING
PAXLOVID VIRAL REBOUND
10% OF PEOPLE
SURPRISE CARD
WHAT IS CYP 3A4 AND ITS FUNCTION
CYP3A4 IS A HEPATIC ENZYME INVOLVED IN BREAKDOWN OF DRUGS FROM YOUR SYSTEM
CYP3A4 INHIBITORS STOP OR INHIBIT THE BREAKDOWN, POTENTIATING A THERAPEUTIC CONCENTRATION
SO E.G AMIODARONE DEPENDS ON CYP3A4 FOR CLEARANCE FROM THE BODY, LIFE THREATENING LEVELS COULD BUILD IF YOU TAKE A CYP3A4 INHIBITOR
OTHER NON P450 ENZYMES THAT METABOLIZE DRUGS ARE
CARBOXYLESTERASE
ARYLACETAMIDE
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