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69 Cards in this Set

  • Front
  • Back
  • 3rd side (hint)
Impetigo is not as serious of a condition as those that require oral agents, so you may want to try topical. What topical drug should you give for impetigo?
Mupirocin (Bactroban®)
What are the 3 most common bugs that cause Cellulitis?
S pyogenes, MSSA, or MRSA
What bug causes Erysipelas?
S pyogenes so you want gram positive coverage
What is the IV drug of choice for Cellulitis caused by MSSA?

Which PO drug, if it is a minor infection?

IV and PO Drugs of choice for PCN allergic? Can you use for Type I hypersensitivity rxn?
IV DOC- Antistaph pcn - nafcillin, oxacillin if IV needed;

PO- DOC- dicloxacillin if it’s a minor infection and PO route acceptable

PCN Allergic- 1st gen cephs - cefazolin IV (Ancef® or Kefzol®); cephalexin PO (Keflex®) if minor infection; may be used in less severe PCN allergy, but not type I (anaphylactic) reactions
What bacterioSTATIC drug can be used to treat resistant strains of MRSA?
c. Doxycycline (Vibramyin®) - resistant strains of MRSA, coagulase negative staph are becoming more common. BacterioSTATIC
What are the 3 main SE of Doxycycline (Tetracyclins in general)?
i. Photosensitivity - all tetracyclines
ii. Polyvalent cations will inhibit oral absorption due to chelation
iii. Outdated tcn’s = risk of renal tubular acidosis
Clindamycin covers many _______ (aerobes/anaerobes?) EXCEPT _________

BacterioSTATIC or CIDAL?
ANAEROBES

C.DIFF- so CDAD is a bit more likely with this drug;

resistant strains of MRSA are common.

It will cover many strep species.

BacterioSTATIC
What bacterioSTATIC drug covers MSSA, Community acquired MRSA, most strep (NOT group A!), and coliforms? Its SE profile includes:
i. SJS/TEN, other drug eruptions
ii. Photosensitivity
iii. G6PD deficiency hemolysis (rare)
iv. Boards: Long-term use - folate deficiency(maybe?)
Sulfamethoxazole/trimethoprim (Bactrim® or Septra®)

***EXAM- G6PD Deficiency Hemolysis!**
What does Vancomycin IV cover? (5)

BacterioSTATIC or CIDAL?
Vancomycin intravenous - covers MSSA, MRSA, Coag neg staph, strep, Enterococci ?- (enterococcal resistance is emerging)

Cell wall active = bacteriCIDAL!!!
Why shouldn't you infuse Vancomycin too fast?
Rapid infusion = degranulation of mast cell = Red Man syndrome
Why shouldn't Vancomycin be combined with Loop Diuretics or Aminioglycosides?
Vancomycin is Ototoxic & Nephrotoxic; Even more so when combined with other oto- nephro- toxic drugs (loop diuretics, aminoglycosides)
What does Linezolid Cover? Bacterio- static or -cidal?
Linezolid (Zyvox®) IV or PO - covers **aerobic gram positives**, some enterococcal resistance has emerged. BacterioSTATIC. Used more in patients with PCN allergy.

FYI Boards: MAO inhibitor - problem with SSRI (can cause seratonin syndrome), tramadol, dextromethorphan, meperidine (serotonin syndrome); problem with tyramine, decongestants = hypertensive crisis
What IV antibiotic covers gram + (but is not effective in pneumococcal pnuemonia), and is VERY TOXIC - causing myotoxicity including rhabdomyolysis (problem with statins), is hepatotoxic, and causes pulmonary toxicity?
Daptomycin (Cubicin®) IV
The flora of chronic wounds changes over time. Describe the flora of Chronic wounds at the following stages:

1) Early
2) After 4 weeks
3) Several months
1) Early = gram + skin flora: S aureus, S epidermidis, beta-hemolytic Strep

2) After 4 weeks, see gram neg/coliforms: Proteus, E coli, Klebsiella spp

3) After several months, add anaerobes for a wound with 4-5 different organisms
Pressure & stasis ulcers in NON-DIABETIC patients are polymicrobial. What bugs do these often include?
gm +
Coliforms
Pseudomonas
Anaerobes
Empiric therapy for pressure ulcers in Non-diabetic patients doesn't usually need to cover MRSA unless the risk for MRSA is high. When would the risk for MRSA be high?
Nursing home with ↑MRSA rate

Previous recent MRSA infection
What monotherapy can be used for treatment of Pressure or stasis ulcers in non diabetic pts, if MRSA coverage is NOT needed?
1) Antipseudomonal pcns + β-lactamase inhibitor (piperacillin/tazobactam, ticarcillin/clavulanate)- can be used as monotherapy unless MRSA coverage required. (Ticarcillin contains significant sodium - might be a CHF - related board question)
2) Antipseudomonal carbapenems - imipenem/cilastatin (Primaxin®), meropenem (Merrem®) , doripenem (Doribax)- [ertapenem (Invanz®) has less reliable antipseudomonal activity]; cilastatin protects imipenem from degradation by renal brush border cells - it is NOT a beta-lactamase inhibitor
3) FQ (fluoroquinolone) + clinda or metronidazole - FQ covers everything except anaerobes.
See side 3 for boards stuff
Boards: Ciprofloxacin - gram + resistance has rapidly emerged - this is why levofloxacin and moxifloxacin are “respiratory” quinolones - they have better pneumococcal coverage; ciprofloxacin inhibits CYP1A2/3A4 - drug interactions aplenty; most likely to cause CNS problem, esp in elderly (confusion, seizures, etc) Moxi doesn’t have great anti-pseudomanal activity
Some Board info on FQ
Fluoroquinolones
a. Polyvalent cations inhibit oral absorption due to chelation
b. Photosensitivity
c. Tendonitis
d. Rarely used in peds or pregnancy (used in peds/pregnancy for anthrax, Tx of pulmonary infections in cystic fibrosis, etc.)
What are the ONLY 2 things that Metronidazole covers?
Covers ONLY protozoa and anaerobes
Boards:
a. NO ethanol! Due to inhibition of aldehyde dehydrogenase
b. Topically is choice for rosacea management (not a cure, though!)
What does Clindamycin Cover?

Does is cover C.Diff?
covers gram + and anaerobes but NOT C difficile, may cover some strains of MRSA (community acquired MRSA)
Which is more of a worry for simple diabetic ulcers of the foot: MRSA or Pseudomonas?
Generally, pseudomonas is not a worry for simple diabetic foot ulcers

These are polymicrobial, and MRSA is often a problem
What is the treatment for Smaller Diabetic ulcers caused by community acquired MRSA?
- SMX/TMP or minocycline will cover the less resistant MRSA strains
- PenVK, 2nd gen cephs, 3rd gen cephs will give more reliable Strep coverage including peptostreptococcus ;
- FQ will give Strep coverage;
- 2nd and 3rd gen ceph and FQ will also cover coliforms - probably not a problem in smaller lesions but not definitely excluded, more common in debilitated patients (nursing home)
What bugs do you DEFINITELY need to cover with larger deeper Diabetic ulcers?

How will you treat them?
Definitely need coliform coverage, MRSA, enterococci, peptostreptococcus
1. Amox/clav plus SMX/TMP
2. FQ plus linezolid
If a Diabetic Ulcer turns into a systemic Illness, what bugs should you cover?
cover *everything* empirically, try to id cause and narrow spectrum after etiology identified
What antibiotics are used in the treatment of systemic illness caused by ulcers in diabetics if MRSA is a concern?
MRSA with vanco, daptomycin, tigecycline or linezolid; pseudomonas and gram negs with antipseudomonal pcn/βlactamase inhibitor OR carbapenem
What antibiotics are used in the treatment of systemic illness caused by ulcers in diabetics if MRSA is a NOT a great concern?
FQ or aztreonam plus metronidazole (or carbacephem or antipseudomonal pcn + βlactamase inhibitor monotherapy)

Boards: Aztreonam (Azactam) - a β-lactam like drug that covers only gram negative and pseudomonas. IV only. SAFE in any type of penicillin/cephalosporin allergy
Is osteomyelitis contagious?

How do you know when to treat osteomyelitis empirically vs. waiting for the cultures to return?
YES

If illness is not systemic, wait until bone tissue culture identifies specific organism. Empiric therapy is indicated in systemic illness
If a patient with osteomyelitis has developed systemic illness, you should treat them empirically. While you can treat them the same a systemically ill diabetic ulcer pateint, most evidence is with BACTERICIDAL DRUGS. What is the best treatment for Osteomyelitis caused by the following:

1. MRSA
2. MSSA
3. Gram Negative including pseudomonas

Give MSSA likely vs MRSA likely.
Vancomycin where MRSA is confirmed (or highly likely);

Antistaph pcns/cefazolin for MSSA;

FQ, ceftazidime or cefepime for gram negs including pseudomonas
Boards: Osteomyelitis, Rifampin, and Biofilms...
Rifampin- traditionally used where biofilms are a problem. Bactericidal, but resistance develops rapidly, so it is not used as monotherapy in treatment.
1. Stains everything orange (tears, saliva, etc.)
2. Enzyme inducer - on liver biopsy see ↑endoplasmic reticulum
3. TB treatment regimen (RIPE or RISE R = rifampin)
4. Prophylaxis for meningitis (Neiserria or Haemophilus) - used alone in prophylaxis
What causes Xerosis?
dry air, things that dry skin
How is Xerosis treated?
i. Keratolytics - 12% ammonium lactate
ii. Moisturizers
iii. Moderate to low potency steroids (classes III-VI)
What are the SE of moderate to low potency steroids, like those used in Xerosis?
systemic (hyperglycemia), striae, purpura
What type of steroids are allowed to put on the face?

What 3 meet this criteria?
ONLY lower potency non-fluorinated steroids on face!!!

a. Hydrocortisone
b. Alclometasone
c. Desonide

***EXAM***!!!!!
What is the Drug of Choice for Scabies?
permethrin or ivermectin are DOC (ivermectin is off-label for scabies)
Know about Herpes Zoster from Byrd's Lecture and that we have a vaccine now.
Know about Herpes Zoster from Byrd's Lecture and that we have a vaccine now.
What non-pharmacologic basics should you remember about treating or preventing Decubiti (chronic would)?
remember repositioning, skin care, and nutritional status are important
What are arterial chronic wounds caused by?

How do you treat them?
Reduced circulatory capacity

Tx:
Cilostazol and pentoxyphylline
If a patient with osteomyelitis has developed systemic illness, you should treat them empirically. While you can treat them the same a systemically ill diabetic ulcer pateint, most evidence is with BACTERICIDAL DRUGS. What is the best treatment for Osteomyelitis caused by the following:

1. MRSA
2. MSSA
3. Gram Negative including pseudomonas

Give MSSA likely vs MRSA likely.
Vancomycin where MRSA is confirmed (or highly likely);

Antistaph pcns/cefazolin for MSSA;

FQ, ceftazidime or cefepime for gram negs including pseudomonas
Boards: Osteomyelitis, Rifampin, and Biofilms...
Rifampin- traditionally used where biofilms are a problem. Bactericidal, but resistance develops rapidly, so it is not used as monotherapy in treatment.
1. Stains everything orange (tears, saliva, etc.)
2. Enzyme inducer - on liver biopsy see ↑endoplasmic reticulum
3. TB treatment regimen (RIPE or RISE R = rifampin)
4. Prophylaxis for meningitis (Neiserria or Haemophilus) - used alone in prophylaxis
What causes Xerosis?
dry air, things that dry skin
How is Xerosis treated?
i. Keratolytics - 12% ammonium lactate
ii. Moisturizers
iii. Moderate to low potency steroids (classes III-VI)
What are the SE of moderate to low potency steroids, like those used in Xerosis?
systemic (hyperglycemia), striae, purpura
What type of steroids are allowed to put on the face?

What 3 meet this criteria?
ONLY lower potency non-fluorinated steroids on face!!!

a. Hydrocortisone
b. Alclometasone
c. Desonide

***EXAM***!!!!!
What is the Drug of Choice for Scabies?
permethrin or ivermectin are DOC (ivermectin is off-label for scabies)
Know about Herpes Zoster from Byrd's Lecture and that we have a vaccine now.
Know about Herpes Zoster from Byrd's Lecture and that we have a vaccine now.
What non-pharmacologic basics should you remember about treating or preventing Decubiti (chronic would)?
remember repositioning, skin care, and nutritional status are important
What are arterial chronic wounds caused by?

How do you treat them?
Reduced circulatory capacity

Tx:
Cilostazol and pentoxyphylline
How do you approach chronic woulds due to venous problems?
**Avoid things that cause edema**
Na restriction
Stop edema- causing Meds
1. Vasodilators in absence of blocked sympathetic response
2. ***NSAIDs***
3. Thiazolidinediones
***EXAM***!!!
What is the treatment for chronic Diabetic Ulcers?
Becaplermin gel = PDGF = increased risk of cancer
This was in italics, and not on one of her "hint hint wink wink' slides, so I assume its FYI

What are some common drugs that increase the risk of falls in the elderly?
a. Anticholinergics = delirium
b. Drugs that cause postural hypotension (alpha blockers, DHP CCB, alpha-blockers including phenothiazines and tricyclic antidepressants, antiarrhythmics, sedatives)
The remaining cards are from the Derm ID Chart.
The remaining cards are from the Derm ID Chart
Tips from Dr. Babos on how to answer bug and drug questions.
1. What is the most likely bug based upon site/type of infection (if not stated in stem)
2. Consider the severity of the infection
- Minor - oral or topical
- Moderate - oral
- More severe - severe - IV, bactericidal agent preferred; usually double cover Pseudomonas sepsis
3. Select agents that will cover the bug AND reach the site of infection (very important in meningitis!)
Look out for contraindications. When is it ok to use a cephalosporin for a patient with a PCN allergy?
OK to use ceph in mild (Not type I) PCN allergy (e.g., OK in rash) - do not use another penicillin (e.g., amox) in any kind of PCN allergy

Watch for drug intractions, allergies, age, & hepatic and renal function.
Age and pregnancy should be taken into consideration when giving pateints FQs or tetracycline. When might it be ok to give a child or a pregnancy woman FQ or tetracycline?
Bioterror
CF
Severe Osteomyelitis
What 3 drugs can be used to treat Superficial Tineas?
Topical azole creams
Undecylenic acid
Clioquinol, iodine
Which of the following can Selenium Shampoo be used to treat?
A) Superficial Tineas
B) Systemic tineas
C) Tinea capitis
D) Nail
E) Diaper candida
C) Tinea capitis
True or False:

It is appropriate to use Clioquinol (Iodochlorhydroxyquin) in children under 2 for diaper rash.
Do NOT use in children < 2 years old
Do NOT use for diaper rash
Athlete’s Foot= Tinea _______

What is the treatment?
Tinea Pedis

Any of the following can be used for any of the Superficial Tineas:
Topical azole creams
Undecylenic acid
Clioquinol, iodine
Jock Itch= Tinea _______

What is the treatment?
Tinea Cruris

Any of the following can be used for any of the Superficial Tineas:
Topical azole creams
Undecylenic acid
Ringworm= Tinea _______

What is the treatment?
Tinea Corpris

Any of the following can be used for any of the Superficial Tineas:
Topical azole creams
Undecylenic acid
How do you treat systemic Tineas?
Oral -azoles other than Itraconazole (monitor LFT, CBC for all including itracon)

OR

Oral terbinafine
What are the possible treatments for Tinea Capitis?

Which one is associated with ↑QTc and induces 3A4 metab?
Any of the following:
Clioquinol, iodine
Oral -azoles other than Itraconazole (monitor LFT, CBC for all including itracon)
Oral terbinafine
Oral griseofulvin
Oral itraconazole (↑QTc, 3A4 metab)
Selenium shampoo
What should you be sure to monitor in patients taking oral azoles?
Monitor LFT & CBC for all including itraconazole
What is 1st line treatment for a fungal infections of the nail?
Oral terbinafine OR Oral itraconazole (↑QTc, 3A4 metab)

Can also use Ciclopirox lacquer x 48 wks, but compliance is low, NOT 1st line

Maybe Oral griseofulvin ?
Would you choose Nystatin CREAM or Nystatin SUSPENSION for Diaper Candida?
CREAM!

Suspension is for TOPICAL treatment of oral mucosa, not diaper area
Which of the following is NOT helpful in the treatment of Diaper Candida?

A) Ciclopirox Cream
B) Clotrimazole Cream
C) Miconazole Cream
D) Miconazole Powder
D) Miconazole Powder

Ciclopirox cream, clotrimazole, miconazole cream NOT POWDER
How do you treat Herpes Simplex (Cold Sore)?
Misc OTC numbing agents
Docosanol (Abreva)
Penciclovir, acyclovir topical
What is the treatment for Herpes Zoster?
Acyclovir, famciclovir, valacyclovir PO/IV
1st line treatment for ALL Verruca?

What else can you give to a patient with Verruca Plana?
ALL: Salicylic acid

Plana: Salicylic acid & Imiquimod