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100 Cards in this Set

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Gram + Aerobes
Retains grams stain dye and appear purple.
*Cocci(round)
-staph aureus-coag +
-staph epi-coag -
-strep pneumoniae
-group streps and viridans
-entercoccus
*Bacilli(rods)
-bacillus
-Listeria monocytogenes
-Nocardia
Gram - Aerobes
Do not retain the gram stain dye and appear red on lab slide
-Neisseria gonorrhoeae
-Neisseria meningitidis
*Bacilli
-E. Coli
-Enterobacter
-Klebsiella
-Proteus
-Pseudomonas
-Citrobacter
Anaerobes
Do not need O2 to grow
Above the diaphragm
-Peptococcus
-Peptostreptococcus
Below the diaphragm
-Clostridium difficile
-Bacteroides fragilis
Atypical Anaerobes
Legionella
Mycoplasma
Chlamydia
Mouth
peptococcus
peptostrepcoccus
Actinomyces
Pasteurella
Skin/Soft Tissue
S. aureus
S. Pyogenes
S. epidermidis
N. gonorrhea
Bone and Joint
S. aureus
Streptococci
gram - rods
Abdomen
E. Coli, Proteus
Klebsiella
Enterococcus
Bacteroides sp.
Urinary Tract
E. Coli, Proteus
Klebsiella
Enterococcus
Staph saprophyticus
Upper respiratory
S. Pneumonia
H. Influenzae
M. Catarrhalis
S. Pyogenes
Lower Respiratory(Community)
S. Pneumonia
H. Influen
K. Pnemonia
Legionella
Mycoplasma
Chlamydia
Lower Respiratory (hospital)
K pneumonia
P. aeroginosa
Enterobacter sp.
Serratia sp.
S. Aureus
Meningitis
S. Pneumonia
N. Meningitidis
H. Influenza
E. Coli
Listeria
Classes of Antimicrobials
Beta-lactams(PCN), Cephalosporins, Carbapenems, Monobactams, Quinolones, Aminoglycosides, Macrolides/Ketolides,Tetracyclines/Glycylcyclines, Sulfonamides, Lincosamides, Vancomycin, Streptogramins, Oxazolidinones
Selection of an Antibiotic
Spectrum
Cost
Toxicity
Routes of administration
Frequency of administration
Time Dependent Killing
Beta lactams and vancomycin
Concentration Dependent Killing
Aminoglycosides and quinolones
Bactericidal
Beta lactams, aminoglycosides, quinolone
Bacteriostatic
Macrolides, clindamycin, tetracyclines
Beta Lactam Pharmacology
MOA: inhibits cell wall synthesis by binding to PCN binding proteins.
Time dependent killing
Widely distributed in body except CFS
Most eliminated renally (except nafcillin and ceftriaxone)
Beta Lactam Adverse effects
Hypersensitivity 3-10%(cross sensitivity with cephalosporins around 3-7%.
Neuro- seizures esp with high doses.
GI- N/V, diarrhea, C.diff
Hematologic: neutropenia, thrombocytopenia
Renal-interstitial nephritis-esp with nafcillin
Bleeding: Cephs with MTT side chain
Fluid overload-PCN have high NA content-Ticar
Penicillins
Natural
Penicillinase-resistant(anti staph)
Aminopenicillins
Extendend Spectrum (anti-pseudomonal)
Natural PCNs
PCN G, PCN VK
strep infections
oral anaerobes
enterococcus
syphilis
N. meningitidis
Very little gram - and no s.aureus activity
Natural PCNs dosing
Four times daily (IV can be up to 6 times daily)
Very inexpensive
Long-Acting PCNs
Benzathine PCN(IM)
used for syphilis and strep throat

Procaine PCN(IM)
intermediate acting, higher serum levels that benzathine
Used for sensitive pneumococcus
PCN resistant
Nafcillin, oxacillin, Dicloxacillin
Activity:
meth. sensitive staph aureus(50%)
No activity for MRSA
Streptococcus
No real gram - activity
skin and soft tissue infections, endocarditis
Dosing: q 4-6 hours
no renal dysfunction adjustment
Inexpensive
Aminopenicillins
Ampicillin, Amoxicillin
Activity: easy to kill gram - such as e. colu, p mirabilis, salmonella, and some H. influx
Strep activity but no S aureus
Enterococcus drop of choice
UTIs otitis media, strep pharyngitis
YID(Amoxil) to QID(amp)
inexpensive
Extended-Spectrum PCNs
Ticarcillin, Piperacillin
High Na content (5.2 mEq Na/gram
Tougher to kill grams -
Very good strep and anaerobe activity
Weak staph activity
Tx: HAP, resistant UTIs, skin/soft tissue/osteo infections
Moderately expensive d/t IV
PCNs Combinations
Amp/sulbactam(Unasyn), Amox/clavulanic acid(augmentin), Piperacillin/tazobactam(Zosyn)
Inhibits beta-lactamase
Activity: extends spectrum to betal lactamase producing S. Aureus(not MRSA), H. Flu, Klebsiella, and B. fragilis
No activity to pseudomonas
Tx: resist OM, intraadominal infections, HAP
TID-QID
more expensive than single drug
Cephalosporins
1-4 Generations
Gram - improves from first to fourth and gram + decreases
No activity against entercoccus
First generation Cephalosporins
Cefazolin(Ancef)
Cephalexin(Keflex)
Cefadroxil(Duricef)
Activity: MSSA and streptococcus
Easy to kill gram (-)s such as E. Coli, P. mirabilis, Klebsiella
Tx: UTIs, cellulitis, sx prophylaxis
BID to TID in most cases
Cephalexin can be QID
Very expensive
Second Generations(General)
Cefuroxime(Zinacef) IV
Cefuroxime axetil (Ceftin), Cefaclor(ceclor), Cefpodoxime(vantin), Loracarbef(Lorabid)-po

Activity: extended gram - activity H. flu, Klebsiella, M. Catarrhalis, poor S. pneumonia
Tx: OM, CAP, UTIs
BID to TID
Ceclor cheap but others moderately expensive.
Anaerobic Second Generation Cephalosporins
Cefoxitin(Mefoxin), cefotetan (Cefotan)
Acitivity: anaerobes including B. fragilis
Easy to kill gram - such as E. Coli, P. Mirabilis
Cefotetan has MTT side chain can increase bleeding risk
Tx: intraabdominal infections, prophylaxis for GI/GU sx
Cefotetan BID vs Cefoxitin QID
Inexpensive
Non-Pseudomonal Third Generation Cephalosporins
Ceftriaxone (Rocephin), Cefotaxime(Claforan), Cefdinir (Omnicef)-po, Cefpodoxime(Vantin) po
Activity: good gram - except pseudomonas
Resistant UTIs, CAP, bronchitis
Rocephin IM good for gonorrhea and lyme disease.
Rocephin and Claforan good CNS penetration and useful in Meningitis.
Rocephin is usually given QD except in meningitis when it is BID
Rocephin QD has advantages
Pseudomonal Third Generation Cephalosporins
Ceftazidine (Fortaz), Cefoperazone(Cefobid)
Actvity: excellent gram - activity including pseudomonas
Tx: documented pseudomonas infection
Cefobid contains MTT side chain and has recommendations about daily Vit K and coag monitoring
CefoBID is BID and Fortaz is BID-TID
Expensive compared with NP 3rd generations
Fourth Generation Cephalosporins
Cefepime(Maxipime)
Activity: Gram + activity similar to Rocephin
Excellent gram - activity including pseudomonas and particularly with enterobacter cloacae
Tx:Resistant infections such as enterbacter species
Febile neutropenia
BID-TID
Adverse Effects:Increase seizure activity and CNS activity with increase in mortality.
Very expensive no oral dose
Fifth Generation ??
Ceftaroline(Teflaro)
Activity: Gram positive including MRSA
Good gram negative except P. aeruginosa
Tx: CAP and skin and skin structure infections
600mg IV q12h with normal renal fx
Very expensive with no po
Carbapenem Pharmacology
MOA: inhibits cell wall synthesis
Bactericidal and time dependent killing
Highly stable to beta lactamases
Cross allergic with PCN
Seizures can be a problem with improper dosing esp w imipenem
Carbapenems
Imipenem/cilastatin(Primaxin), Meropenem(Merrem), Ertapenem(Invanz), Doripenem(Doribax)
Activity: excellent activity again grams (+), (- ) including enterbacter species, and anaerobes, no activity against MRSA.
Ertapenem-no p. aeruginosa
Tx: Resistant polymicrobial infections
Primaxin and Merrem TID-QID
Invanz QD often for outpatients
Doribax 4 h infusion
Very expensive
Monobactams
MOA: inhibits cell wall synthesis
Bactericidal and time dependent killing
No cross allergy with PCN

*Aztreonam(Azatam)
Activity: only gram (-) aerobes
No gram (+) or anaerobic activity
Tx: used in combo with clindamycin in PCN allergic pts
Used only as mono therapy in urinary infections.
BID-TID
Moderately expensive and no po form.
Fluroquinolones
Related to nalidixic acid.
Improved spectrum of activity and pharmacokinetics(better bioavvailability)
MOA: Inhibits DNA gyrase wh/ is responsible for DNA synthesis
Bactericidal and concentration dependent killing
Ciprofloxacin
Activty: Excellent gram (-) activity including pseudomonas and good S. aureus activity
Poor strep and anaerobic activity
PO agent only available for pseudomonal infections
Tx: UTIs, HAP, osteomyelitis, GI infections, prostatitis
AE: GI, CNS including insomnia, hallucinations, and seizures, low risk QTc prolongation, articular/tendon damage
DI: antacids, calcium supplements, iron, sucralfate, inhibit absorption
May increase theophylline and warfarin(INR) levels.
BID
Moderately expensive for po therapy
3rd generation Fluroquinolones
Moxifloxacin(Avelox(, Levofloxacin(Levaquin)
Activity:
Improved activity against s. pneumonia, very good atypical coverage, not as good at pseudomonas as Cipro
Avelox has some anaerobic activity.
Tx: CAP, bronchitis, UTIs
Moxifloxacin not as good in UTIs d/t renal excretion
QD-BID
Moderately expensive
Macrolides
MOA: Binds to 50s ribosomal unit and inhibits protein synthesis
Bacteriostatic and time dependent killing
First generation Macrolides
Erythromycin(E-mycin, EES)
Activity:
Staph and strep organism
Atypical pathogens including mycoplasma, shlamydia, and legionella
Poor gram(-) coverage
Tx: CAP often used in combo with a NP3rd generation cephaloporin
Skin and soft tissue infections in PCN allergic pt.
BID-QID
inexpensive
AE:Nausea, diarrhea,much higher erythromycin than with 2nd generations
Ototoxicity
DI: inhibitor of p450 system-less with azithromycin
Theo, warfarin, phenytoin, dig and many others
Macrolides-2nd generation
Azithromycin(Zithromax)
Clarithromycin(Biaxin)
Activity:
Greater gram(-) activity than erythro.
H. Pylori and MAC infections
Improved bioavailabilty and longer half than erythromycin
Tx: CAP, sinusitis, bronchitis, H. Pylori(PUD), MAC
Dosing: Z-pack(outpatient) vs 500mg qd(in patient)
Clarithromycing is BID
AE: Much less GI effects that e-mycin, Biaxin(metallic taste)
Cost effective esp 3-5 days
Aminoglycosides
MOA:
Binds to 30S ribosome and inhibits protein syntheisis

Concentration dependent killing and bactericidal
Amino glycosides
Gentamycin, Tobramycin, Amikacin
Activity:
Very good gram (-) including pseudomonas (amikan is best)
Good in gram(+) including MSSA and enterococci (Gent. is best)
Usually used in combo with a beta-lactam unless UTI
Tx:
Used with beta-lactams for HAP and other serious (-) infections, endocarditis
AE: nephrotoxicity, ototoxicity, neuromuscular blockade
Very inexpensive
Traditional: 1-2 mg/kg q8-24h based on renal fx
Must monitor peaks and troughs
PKs 6-8 mcg/ml(T,G); Tr <2 mcg/ml.
Daily: 5-7 mg/kg daily. Levels checked b/w 6-14 hours and placed on nomogram
Peaks usually around 20mcg/ml and troughs should be close to ). But not usually checked.
Advantages to once daily dosing of Aminoglycosides
Greater efficacy d/t concentration dependent killing
Less toxicity
Ease of administration and levels
Less costly
Disadvantages:
Not useful in gram(+) infections
Vancomycin
MOA: inhibits well wall synthesis differently than beta lactams
Bactericidal for most pathogens
Increasing usage d/t rate of MRSA in hospitals
Seeing increasing incidence of VRE
Activity: Excellent gram + including MRSA, entercoccus, c. diff.
No gram (-) activity
TX; MRSA, HAP, bacteremia and PCN resistant entercoccus
its with severe B lactam allergies
Orally for metronidazole resistant C. diff
Usually 1 gram q12h, trough levels(15mcg/ml)
AE: very rarely nephrotoxcity, and ototoxicity (Redman syndrome-slow infusion)
Inexpensive
Sulfonamide
Trimethoprim/Sulfamethoxazole(Bactrim, Septra)
MOA: PABA antagonist, inhibits folic acid synthesis
Bacteriostatic
Activity: Gram (-) urinary pathogens, protozoans, PCP, community acquired MRSA, UTIs
BID
AE: rash, renal dysfunction, hematologic
Very inexpensive
Lincosamides
MOA: Binds to 50S ribosomal subunit and inhibits protein synthesis
Mostly bacteriostatic

Clindamycin(Cleocin)
Activity:
Anaerobes including B. fragilis
MSSA, strp pneumo
Tx: anaerobic infections above the diaphragm and with Cipro in beat lactam allergy
Usually TID-IV to QID po
No dose adjustment for renal dysfunction
AE: C. Difficile colitis
Inexpensive
Flagyl
MOA: Inhibits DNA synthesis
Concentration dependent killing and bactericidal
Activity:
Anaerobes, C. diff, protozoal infections, H. Pylori
Tx: Anaerobic infections below diaphragm, DOC for C. Diff colitis, H. Pylori infections (PUD)
TID-QID
AE: Disulfiram rx with alcohol
Inexpensive
Streptogramins
Synercid-combo of 2 agents quinupristin:dalfopristin
MOA: works of 50S ribosomal subunit and inhibits protein synthesis
Bacteriostatic
Activity: E. Faccium, MRSA, other grams +s
TX: VRE, MRSA and can't take Vancomycin
QID
Expensive
Oxazolidinones
Linezolid(Zyvox)
MOA: Binds to 50S ribosomal subunit
Activity: E. Faecium and E.Faecalis, MRSA, VRSA
Tx: VRE, MRSA, in vanc intolerant pts.
BID
AE: GI, HA, thrombocytopenia
DI: SSRIs, tyramine foods since Zyvox is an MAOI
Expensive
Tetracyclines
Doxycycline(Vibramycin)
MOA: Inhibits protein synthesis
Bacteriostatic
Activity:
Atypical pathogens, rickettsia, some gram + and gram -
Tx: RMSF, VRE urinary infections, chlamydia
BID
AE: GI, rash, photosensitivity, tooth discoloration
Inexpensive
Glycylcycline
Tigecycline(Tygacil)
Semisynthetic derivative of minocycline
MOA: Bids to 30S ribosomal subunit
Activity: Very broad spectrum with gram +, -, anaerobes, MRSA, VRE
Tx: complicated intraabdominal infections, complicated skin and soft tissue infections
BID IV only
Expensive
Fosfomycin(Monurol)
Activity: E. Faecium and e. faecalis including VRE
Gram - including ESBL producing urinary pathogens
TX: uncomplicated/complicated ??? lower urinary infections
NOT for pyelonnephritis or abscesses
Single 3 gram packet mixed with 4oz of water. May repeat in 3 days
Expensive per dose $50, but only one dose
Monitoring parameters
WBC, WB with diff, temperature, s/s(CXR ,mental status, pain, redness, etc)
Culture data
Sensitivity Testing
Organism grown on special culture medium then id
Once id antibiotic disks placed on medium to check sensitivity and resistance
Community Acquired Pneumonia(CAP)
Outpatient:
-Standard Regimen
*Macrolide
*Doxycycline(alterative)
-COPD Patient
*Moxifloxacin
*Augmentin plus Macrolide(alternative)

Hospitalized to a ward service:

Ceftriaxone plus Azithromycin
Moxifloxacin
Unasyn plus Macrolide(alternative)
Health Care Acquired Pneumonia(HCAP)
Hospital stay <5 days and no risk factors for drug resistant pathogens
Treat like CAP with Moxifloxacin
Risk factors for multi resistant bacteria
-Antibiotics in previous 90 days
Resident of nursing home
Hospitalized >2 days in last 90 days
Dialysis within 30 days
Immunosuppressive disease or therapy
Hospital stay 5-9 days or risk factor of MDR pathogen (Zosynor Maxipime)
Check cultures and clinical response and de-escalate if possible
Hospital stay >10 days (Vanco plus Amikacin plus Zosyn or Maxipime)
Check cultures and clinical response and de-escalate if possible
Upper respiratory infections(URIs)
otitis media
sinusitis
pharyngitis
acute/chronic bronchitis
Otitis Media
Usually middle ear
Follows a viral URI
Pathogens: S. Pneumoniae, H. Flu, M. Cararrhalis
Tx: Amoxicillin drug of choice (high dose with resistant s. pneumo)
Failure usually d/t beta lactamase producing H. Flu or , M. cat.( Augmentin, 2nd generation cephalosporin
TX duration 7-10 days
Sinusitis
Tx: Amoxicillin is drug of choice but often something stronger needed.
Second line agents include:
Augmentin, 2nd generations cephalosporins, TMP/SMX, macrolides
Tx duration can be up to 3 weeks.
Pharyngitis
Acute infection of oropharynx
Commonly viral
Bacterial pathogens include:
Group A beta hemolytic strep
strep pyogenes
Tx to prevent rheumatic fever
Tx: PCN drug of choice, kids-Amoxil
PCN allergic: Keflex, Erythromycin
Tx is 10 days
Acute Bronchitis
Almost always viral
Routine antibiotics not recommended
OTC cough and cold preps discouraged
Limiited efficacy with inhaled beta agonist
Chronic Bronchitis
Usually seen in COPD
Pathogens: H. flu, M. Cat, S. Pneumo
Tx: Augmentin, 2nd or 3rd generation fluoroquinolone, 2nd generation macrolide
Tx. duration is 10-14 days
Urinary Tract Infections
Uncomplicated-Cystitis
Complicated-Pyelonephritis(Men)
Catheter associated
-Foley catheter prior to UTI
Urinalysis-look for presence of nitrites and leukocyte esterase
Microscopic-look for presence of WBC, RBC, and bacteria
Gram Stain-not always what grows on culture
Culture-base final antibiotic selection on culture
Previous pathogens helpful in selection empiric antibiotics
Common pathogens: E. Coli, P. Mirabilis, S. Saprophyticus, Enterococci-catheters-some VRE
Urinary Tract Infections
Lactose fermenters
-CAKE
*Citrobacter
*Acinoetobacter
*Klebsiella
*E. Coli

Non lactose fermenters
-P's and S's
*P. Mirabilis
*P.aeruginosa
*Providencia
*Salmonella
*Shigella
*Serratia
Categories of UTIs
CA: Ampicillin or TMP/SMX
HA: TMP/SMX or Cipro, Rocephin
Catheter associated: Cipro or ampicillin/gent. Fosfomycin for VRE-single dose.
Duration: 3-14 days
Cellulitis
Pathogens: Likely staph or strep
Diabetes-increased risk of gram (-) and anaerobes
Tx: non-diabetic (Ancef, Nafcillin, Keflex)
Diabetic: Unasy, Zosyn, Cipro/Flagyl
Meningitis
Diagnosis:
CSF from LP
Elevated WBC-neutrophils particularly
Increase protein and decreased glucose
Grams stain very helpful
Follow culture for definitive diagnosis
Pathogens:
Strep Pneumoniae, Neisseria meningitdis
Elderly-Listeria monocytogenes also seen
Children- < 2 H. Flu also seen
Tx: Empiric tx
Rocephin BID/Claforan plus
Ampicillin (if pt > 50 years old)
Steroids- Dexamethasone used in adults.
Endocarditis
Diagnosis
-TTE/TEE-vegetations
-splinter hemorrhages, osler nodes
-blood cultures(check 6 cultures)
Pathogens: Strep viridans, S. aureus-usually in IVD users
Enterocococcus
Tx:Varies based on native valve vs mechanical valve and of course on cultures
General Recommendations:
Vancomycin/Nafcillin for 4-6 weeks plus gentamycin for first 2 weeks(4 wks if enterocococcus)
PCN G can be used for sensitive viridans
Rickettsial Diseases
Lyme Disease
Rocky Mountain Spotted Fever
Doxycycline is the drug of choice for both diseases
Clostridium difficile
Leads to mild diarrhea to fatal pseudomembranous colitis
Hx of previous antibiotic can cause it-Clindamycin highly
Diagnosis: Diarrhea symptoms plus + c. diff toxin stool
High sensitivity test available now
Tx: Initial mild/mod-Metronidazole 500mg po TID
x10-14 days,
Severe WBC > 15,000 Vanc 125mg po qid x10-14days

Severe complicated(shock, hypotension, ileus) Vanc 500mg po QID plus Metronidazole 500mg po/IV
Prevention: Hand washing with antimicrobial soap and water, isolation or pts, minimize use of antibiotics
Levels of Fungal Infections
Cutaneous-Tinea infections(athlete's foot, jock itch)

Mucocutaneous-Candidal infections (thrush, vaginitis)
Invasive- Candidiasis, aspergillus, cryptococcus
Cutaneous Infections
Tx: Usually topical(lotion, cream, ointment, gel, powder, or shampoo depending on location)
Options:
Nystatin(Mycosatin)
Miconazole(Lotrimin AF)
Tolnaftate(Tinactin)
Terbinafine(Lamisil)
Mucocutaneous Infections
Tx: thrush usually lozenges, troches, or suspensions that swish and spit
Vaginitis usually uses creams or vaginal tabs
Options:
Magic mouthwash(combo that includes nystatin)
Clotrimazole(Mycelex)
Miconazole(Monistat)
Invasive
Tx: Involves systematic antifungals
Options:
Amphotericin B
Fluconazole
Voriconazole
Caspofungin
Amphotericin B
Adverse Effects:
Infusing related-fever, chills, rigors(premed with APAP, benadryl, heparin?
Nephrotoxicity- may be minimized by sodium loading

Lipid based formulations
Reduced nephrotoxcity but with a huge cost increase
Better in treating aspergillosis and histoplasmosis
Preparations:
Ampho B lipid complex (abelcet)
Liposomal Ampho B (AmBisome)
Ampho B colloidal dispersion (Amphotee)
Fluconazole
MOA: Inhibits enzyme responsible for ergosterol synthesis
Used for esophageal candidiasis and for cryptococcal meningitis
Single dose for vaginitis
AE:Very well tolerated, heptatoxicity
DI: Numerous interactions (Warfarin, Phenytoin, Theophylline)
Voriconazole
MOA: Similar to fluconazole
Drug of choice for aspergillosis infections
AE: Numerous
Blurred vision, altered visual and color perception, photophobia
Photosensitivity
LFT abnormalities
DI: Potent inhibitor of p450 system
Interactions: Warfarin, statins, omeprazole, cyclosporine
Caspofungin
MOA: Inhibits the cell wall of fungal pathogens(the PCN of antifungals)
An echinocandin class of anti fungal
Very broad spectrum anti fungal agent
AE: Very well tolerated (Some infusion related effects including fever, HA, flushing)
Asymptpmatic elevations in LFTs
DI: Not as significant as some other antifungals (cyclosporine)
Viral Infections
60% of illness, self limiting.

Herpes Simplex(Type1, Type 2)
Influenza-causes epidemics of acute illness transmitted respiratory route
Influenza type A(common) and type B
Anti-Viral Treatment for Herpes
Acyclovir, valacyclovir and famiciclovir(inhibit viral DNA synthesis

Topical Therapy-less effective than oral

Oral Therapy more effective the earlier the tx
Acyclovir is the least expensive
Doses vary but usually several times daily
Can crystallize in the kidneys adjust for renal fx
Can cause common GI complains of N/V diarrhea.
Anti-Viral Treatment for Influenza
Receive yearly influenza vaccine
Contains 3 strains (2 type A and 1 type B)
Inactivated vaccine
Flu-Mist is an inhaled vaccine that is a live attenuated vaccine
For ages 2-49 years
Amantadine and rimantadine are now poor agents for prophylaxis

Tamiflu(oseltamivir)
significantly decreases transmission in nursing homes and personal homes
May be effective in avian influenza
For treatment begin within 2 days of symptoms
Risk of neuropsychiatrin adverse events.
Anti-Protozoal Therapy
Malaria
-plasmodium falciparum, p. vivax, p.ovale, p. malariae
*Giardiasis
-Giardia lamblia
Malaria Presentation
Headache
Malaise
Myalgias
Cyclical fevers (48-72 hours)
Must have visited an endemic area
Malaria Treatment
Acute attack:
-Chloroquine(if sensitive) or
-Mefloquine , PLUS
Primaquine if suspect p.vivax or p.ovale
Malaria prophylaxis
Chloroquine- 500 mg q weekly beginning 1-2 wks before and continuing 4 weeks after last exposure

Mefloquine 250mg q weekly and similar regimen as above
Doxycycline 100 mg DAILY for 1-2 days before, daily while in area and daily for 4 wks after return
Malarone (atovaquone/proquanil) 1 tab DAILY for 1-2 days before, daily while in area and then daily for 7 days after return
Giardia Presentation
Acute onset of diarrhea, abd cramps, bloating, and flatulence
Contracted from contaminated water found in mountain streams
Systems occur 5-15 days after ingestions of the cysts
Most common protozoal infection in US.
Giardia Treatment
Metronidazole(Flagyl) 250mg TID for 5-7days
Tinidazole (Tindamax) 2g once
Often cheaper to treat empirically than to send a giardia sample
Tubercular (TB) Infections
Caused by Mycobaterium tuberculosis
Symptoms: Fever, cough, painful breathing, blood sputum, and wt loss
Risk factors: HIV, contact with TB pt, foriegn born, IVDA, HC workers exposed.
Diagnosis: skin testing (ID injection of 5 TB units, measure area of indurations(not redness) >15 mm=positive but 5-10mm can be positive in certain populations
CXR (may not be diagnostic)
(TB) infections cont'd
Culture- acid fast smear (AFB) of sputum is a fast and simple method
Follow with a culture of sputum that may take up to 5 weeks to grow. (confirms diagnosis)
Treatment of TB
Latent infections:
Isoniazide (INH) 300mg daily for 6 months (non HIV)
Must assess compliance, may give 900 mg twice weekly
Monitor LFTs monthly, give Vit B6 (pyridoxine) daily

Active TB: respiratory isolation until 3 negative AFB smears. Tx with 4 drugs: INH, rifampin, pyrazinamide(PZA), and ethambutol or strptomycin
Continue 4 drugs for 8 weeks(until susceptibility testing is done)
INH (TB)
monitor LFTs
monitor signs of peripheral neuropathy
no alcohol ingestion
take on an empty stomach
minimize tyramine-containing foods
Rifampin (TB)
Take on an empty stomach
Monitor LFTs
Red/Orange coloring of urine, feces, saliva and tears(may stain soft contacts)
Potent inducer of P-450 hepatic metabolism
Pyrazinamid (PZA) (TB)
may cause hyperuricemia and gout
Monitor LFTs
May cause a mild arthralgia and myalgia
Ethambutol (TB)
Requires renal adjustment
Can cause hyperuricemia gout
May cause optic neuritis and visual testing is essential(periodically)
Be aware of visual acuity changes or a loss of red-green discrimination.