Infectious Disease Part 2

Front 1

Clinical importance:

Enterococci

Back 1

UTI
Endocarditis

Front 2

Clinical importance:

Group A Strep

Back 2

gram+

Cellulitis
Pharyngitis

Front 3

Clinical importance:

Group B Strep

Back 3

gram+
neonatal sepsis

Front 4

Clinical importance:

Viridans strep

Back 4

gram+

endocarditis
dental caries
abscess

Front 5

Clinical importance:

Strep pneumo

Back 5

gram+ diplococci

CAP
meningitis
bacteremia/septic shock

Front 6

Clinical importance:

Staph aureus

Back 6

gram+

furunculosis (boils)
cellulitis
abscess
endocarditis
bacteremia

Front 7

Clinical importance:

coag-negative staphylococcus

Back 7

gram+

infection of prosthetic devices
bacteremia

Front 8

Clinical importance:

E.coli

Back 8

gram-

UTI
bacteremia/septic shock
hemorrhagic colitis

Front 9

Clinical importance:

Klebsiella

Back 9

gram-

UTI
pneumonia
bacteremia

Front 10

Clinical importance:

Enterobacter/citrobacter

Back 10

gram-

UTI
pneumonia
bacteremia

Front 11

Clinical importance:

Pseudomonas aeruginosa

Back 11

gram-

UTI
pneumonia
bacteremia

Front 12

Clinical importance:

Neisseria meningitidis

Back 12

gram-

meningitis
bacteremia/sepsis

Front 13

Clinical importance:

H.flu

Back 13

gram-

respiratory tract infections
bacterial conjunctivitis
otitis media

Front 14

most common organism(s) in bacterial conjunctivitis

Back 14

Strep pneumo
Staph aureus
H.flu

Front 15

Clinical importance:

Clostridium spp.

Back 15

anaerobe

intestinal disease
tetanus
botulism
abscess
abdominal sepsis

Front 16

Clinical importance:

Bacteroidies (e.g. fragilis)

Back 16

anaerobe

abscess
abdominal sepsis
soft tissue infections

Front 17

common bacterial pathogens:

burns

Back 17

Staph aureus

Pseudomonas aeruginosa

Front 18

common bacterial pathogens:

throat

Back 18

Streptococcus pyogenes (Group A Strep, =Strep throat)

Front 19

common bacterial pathogens:

skin infections

Back 19

Staph aureus

Front 20

common bacterial pathogens:

otitis media

Back 20

Strep pneumo

H.flu
Moraxella

Front 21

common bacterial pathogens:

Pneumonia

Back 21

Strep pneumo

H.flu

Front 22

common bacterial pathogens:

endocarditis

Back 22

Staph aureus
Enterococcus faecalis
Viridans strep

Front 23

common bacterial pathogens:

GI tract

Back 23

Salmonella enterica
H. pylori
E.coli
Shigella dystentariae
C.diff

Front 24

common bacterial pathogens:

UTI

Back 24

Enterococcus

E.coli

Front 25

common bacterial pathogens:

Toxic Shock Syndrome

Back 25

Staph aureus
Strep pyogenes

Front 26

general mechanism of tetracycline antibiotics

Back 26

protein synthesis inhibitors

bacteriostatic

Front 27

RULE OF THUMB COVERAGE:

Tetracyclines

Back 27

Strep pneumo (minocycline also covers Group A&B)
(minocycline covers Staph aureus)
Bacillus anthracis (anthrax)

E.coli
H.flu
Neisseria
Moraxella
H.pylori
Brucella
Legionella
Vibro
Borrelia burgdorferi (Lyme disease)

Listeria monocytogenes
Clostridium (NOT difficile)
(does NOT cover B.frag)

ATYPICALS:
Rickettsiae (typhus, Rocky Mtn Fever)
Chlamydiophilia
Mycoplasma pneumoniae

Front 28

Clinical uses for tetracyclines

Back 28

Acne
Chlamydia
Rickettsial infections (Rocky Mtn Fever, typhus)
Lyme Disease
Atypical pneumonias (Mycoplasma pneumoiae & Chlamydia pneumoniae)
H. pylori
traveler's diarrhea
anthrax (Bacillus anthracis)

Front 29

Which tetracycline antibiotic can be used in renal failure?

Back 29

doxycycline (all others have prolonged t1/2 in renal failure)

Front 30

tetracycline antibiotics administration

Back 30

food decreases absorption (but GI upset may require it)
milk decreases absorption (avoid @ admin time, +/-2hrs)

calcium, magnesium & iron containing products chelate & reduce absorption, separate from admin time by 2 hrs

take with full glass of water & do not lie down for 30 minutes (to avoid esophageal ulceration)

Front 31

tetracycline antibiotics:

adverse effects?

Back 31

N/V/D
hypersensitivity
esophageal ulceration
photosensitivity
vestibular toxicity (tinnitus, dizziness, only with minocycline & reverses upon d/c)


tooth discoloration & enamel hypoplasia
depressed bone growth
renal dysfunction

NOT FOR USE IN PREGNANT OR LACTATING WOMEN OR CHILDREN UNDER 8 (b/c teeth & depressed skeletal growth)

Front 32

Tygacil

dosing?

Back 32

tigecycline (a glycylcycline, structurally related to minocycline)

100mg LD
50mg Q12H

NOTE: prolonged post-antibiotic effect!

Front 33

tigecycline should not be used empirically for nosocomial pneumonia because...?

Back 33

it is not active against Pseudomonas

Front 34

tigecycline & UTI's

Back 34

should not be used, poor urinary drug concentration

Front 35

tigecycline metabolism & elimination

Back 35

largely hepatic, ok to use in renal failure, no adjustment

note that clearance is inhibited in hepatic failure

tigecycline does NOT affect P450 pathways

Front 36

tigecycline MOA

Back 36

protein synthesis inhibitor

bacteriostatic

Front 37

RULE OF THUMB COVERAGE:

tigecycline

Back 37

RULE OF THUMB: "Everything except Pseudomonas"

Strep
Staph
MRSA
Enterococcus
Bacillus anthracis
...and most other gram+

E.coli
H.flu
Klebsiella
Neisseria
Moraxella
Serratia
Acinetobacter
(covers Enterobacteriaceae with ESBL's!)
(does NOT cover Pseudomonas or Proteus)

anaerobes/B.frag

ATYPICALS:
Chlamydophila spp.
Mycloplasma pneumoniae

NOTE: tigecycline is effective against most resistance mechanism, except multidrug efflux pumps (although it is effective against normal efflux pumps)

Front 38

tigecycline admin

Back 38

IV

food does not affect pharmacokinetics, but even though tigecycline is IV, food may increase tolerability

PAE

Front 39

adverse effects of tigecycline

Back 39

N/V/D (~45%)
prolonged aPTT
photosensitivity

tooth discoloration
depressed bone growth

PREGNANCY CATEGORY D! Like tetracyclines, should not be used in pregnant/lactating women or in children under 8

Front 40

tigecycline:

clinical uses

Back 40

only approved for complicated skin infections (e.g. MRSA) and complicated intraabdominal in resistant to other options (e.g. MRSA)

Front 41

Most commonly isolated Enterococcus? DOC?

Back 41

E. faecalis (80-85%)

Ampicillin +/- gentamicin

Front 42

DOC:

Staph aureus (MSSA)

alternatives?

Back 42

Nafcillin

cefazolin
Septra
clindamycin
vancomycin

Front 43

DOC:

Moraxella catarrhalis

Back 43

Septra


Augmentin
doxycycline
2nd or 3rd Generation Cephalosporin
erythromycin

Front 44

DOC:

Chlamydia spp.

Back 44

doxycycline

azithromycin
erythromycin

Front 45

aminoglycosides MOA

Back 45

inhibits bacterial protein synthesis

bactericidal

requires oxygen-dependent transport system, so ineffective against anaerobes

PAE

Front 46

aminoglycoside elimination

Back 46

renal

Front 47

aminoglycoside spectrum

Back 47

GRAM POSITIVE:
not preferred agents
weakly active against Staph & Strep
may be used in combination with cell-wall inhibitors like beta lactams or vancomycin against Staph & Strep because it exhibits synergy; use AG @ low doses

GRAM NEGATIVE: (good coverage)
E.coli
Klebsiella
H.flu
Pseudomonas

NO ANAEROBES (require oxygen-dependent transport into bacteria)

ATYPICALS:
Mycobacterium tuberculosis (amikacin & streptomycin)

Front 48

side effects of Aminoglycosides

Back 48

nephrotoxicity (usually reversible)
neuromuscular blockade (when neuromuscular transmission is already compromised, such as in myasthenia gravis; reversed by IV calcium gluconate)
ototoxicity (both vestibular and auditory, both usually reversible)

Front 49

risk factors for Aminoglycoside-induced nephrotoxicity

Back 49

prolonged duration of therapy
increased age
pre-existing renal insufficiency
concurrent use of other nephrotoxins
volume depletion

Front 50

clinical uses of aminoglycosides

Back 50

- empiric therapy of complicated gram-negative infections (septicemia, complicated UTI, nosocomial respiratory tract infections, osteomyelitis, complicated intra-abdominal)

- in combination with other abx (usually beta-lactams) for resistant SPACE organisms: Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter

- surgical prophylaxis for GI or GU tract

Front 51

DOC:

Pseudomonas aeruginosa

alternatives?

Back 51

antipseudomonal penicillin +/- aminoglycoside or quinolone
ceftazidime +/- aminoglycoside or quinolone

quinolone +/- aminoglycoside
imipenem +/- aminoglycoside

(most active agents include AG's, imipenem, meropenem, ceftazidime, cefepime, aztreonam, extended spectrum penicillins)

MONOTHERAPY IS SUFFICIENT FOR MOST PSEUDOMONAS

Front 52

AECB

Back 52

Acute Exacerbations of Chronic Bronchitis

Front 53

Macrolide spectrum

Back 53

Strep
Staph

E.coli
H.flu
Moraxella
Neisseria
H.pylori

ATYPICALS
Legionella
Chlamydophila pneumoniae
Mycoplasma pneumoniae

Front 54

telithromycin

Back 54

ketolide macrolide

better coverage than other macrolides

less susceptible to resistance mechanisms

Front 55

the only macrolide available in IV formulation

Back 55

azithromycin

Front 56

Erythromycin is now rarely recomoneded above otehr macrolides. Why?

Back 56

more frequent GI side effects
QT prolongation

(note: QT prolongation still occurs with other macrolides, but not as much)

Front 57

Macrolides & CYP enzymes

Back 57

many drug interactions involving CYP 3A enzymes

the only macrolide that doesn't have this problem is azithromycin

Front 58

fatal interaction involving a macrolide

Back 58

clarithromycin + colchicine

clarithromycin is a strong CYP3A4 inhibitor
strong CYP3A4 inhibitors increase serum levels of colchicine

dose reductions for colchicine are recommended if concurrently administered

Front 59

clinical use of macrolides

Back 59

upper respiratory tract infections

treatment & prevention of MAC (mycobacterium avium complex) clarithromycin & azithromycin

chlamydia (azithromycin)

note: erythromycin used mostly ophthalmically now

Front 60

chloramphenicol MOA

Back 60

protein synthesis inhibitor

Front 61

chloramphenicol class

Back 61

amphenicols

Front 62

chloramphenicol spectrum

Back 62

Strep
Staph
Enterococcus

E.coli
H.flu
Moraxella
Neisseria
Proteus
Salmonella
Shigella
Stenotrophomonas

ANAEROBES/B.frag

ATYPICALS:
Bacillus anthracis (anthrax)
Listeria

Front 63

chloramphenicol adverse effects

Back 63

N/V/D
hypersensitivity
mental status changes
fever
headache

serious blood dyscrasias
gray syndrome

Front 64

gray syndrome

Back 64

a serious side effect associated with chloramphenicol:

myocardial depression
circulatory collapse
cyanosis
acidosis
abdominal distension
coma
death

Front 65

chloramphenicol drug interactions

Back 65

inhibits CYP 2C9 & 3A4

caution with substrates

Front 66

quinupristin/dalfopristin:

class
MOA
brand name

Back 66

streptogramin

inhibits bacterial protein synthesis

Synercid

Front 67

quinupristin/dalfopristin:

clinical use

Back 67

complicated skin & skin structure infections caused by Strep pyogenes, Staph aureus

Sometimes used for MRSA bacteremia when resistant to vanco

Front 68

quinupristin/dalfopristin:

side effects

Back 68

COMMON:
hyperbilirubinemia
arthralgia/myalgia

LESS COMMON:
headache
rash
N/V/D

Front 69

quinupristin/dalfopristin:

spectrum

Back 69

Strep
Staph
MRSA
Enterococcus

Moraxella

Legionella

Front 70

peri-operative antibiotic treatment usually begins ________ before surgery, and continues no longer than ________ after surgery

Back 70

within 1 hour before

24 hours after

Front 71

antibiotic of choice for surgical prophylaxis

Back 71

generally 1st or 2nd gen Cephalosporin (cefazolin, cefuroxime)

penicillin-allergic patients: vancomycin

bowel surgeries: cefotetan (because of anaerobic coverage)

Front 72

empiric therapy:

outpatient skin/soft-tissue infection (cellulitis)

Back 72

if NON-purulent, treat with beta-lactam (e.g. cephalexin)

otherwise:

clindamycin
OR
Bactrim DS
OR
doxycycline
OR
minocycline
OR
linezolid

Duration of therapy: 5 to 10 days

Front 73

empiric therapy:

inpatient skin/soft-tissue infection

Back 73

(MRSA risk compared to outpatient)

vancomycin
OR
linezolid IV or PO
OR
daptomycin
OR
televancin
OR
clindamycin

Duration of therapy: 7 to 14 days

Front 74

definition: uncomplicated UTI

Back 74

not associated with structural or neurologic abnormalities that may interfere with the normal flow of urine

Front 75

definition: complicated UTI

Back 75

generally results from an obstruction/abnormality or neurologic deficit of the bladder

Front 76

cystitis

Back 76

lower urinary tract infection

Front 77

pyelonephritis

Back 77

upper urinary tract infection

Front 78

synonym for upper UTI

Back 78

pyelonephritis

Front 79

synonym for lower UTI

Back 79

cystitis

Front 80

typical symptoms of lower UTI

Back 80

dysuria
urgency
frequency
burning
nocturia
suprapubic heaviness
hematuria

fever is UNCOMMON

Front 81

typical symptoms of upper UTI

Back 81

flank pain
abdominal pain
fever
N/V
costovertebral angle pain
malaise

Front 82

acute, uncomplicated cystitis in females:

pathogens?
treatment?

Back 82

E. coli
S. saprophyticus
Enterococcus

SMX/TMP DS BID (3 days)
OR
Cipro 250 mg BID (3 days)
OR
levofloxacin 250 mg QD (3 days)
OR
nitrofurantoin 100 mg BID (5 days)
OR
fosfomycin x 1 (3g in water)

Front 83

acute, uncomplicated cystitis:

prophylaxis?

Back 83

if 3+ episodes in 1 year:

SMX/TMP SS daily
OR
macrodantin 50 mg daily
OR
1 SMX/TMP post-coitus

Front 84

acute, uncomplicated cystitis in pregnancy

Back 84

duration: 7 days

if pregnant women are not treated for 7 days, it can lead to premature birth or pyelonephritis

in pregnant women, AVOID QUINOLONES (cartilage toxicity & arthropathies) and AVOID TETRACYCLINES (teratogenic)
SMX/TMP is Category D in the 3rd term, otherwise category C

Front 85

moxifloxacin dosing in cystitis

Back 85

DO NOT use moxifloxacin for UTI (does not reach high levels in urine)

also, do not use gemifloxacin (poor to limited activity against normal UTI pathogens)

Front 86

which 2 drugs should NOT be used in UTIs (that may be mistakenly prescribed because of their drug class)

Back 86

MOXIFLOXACIN: does not reach high levels in urine

GEMIFLOXACIN: poor to limited activity against normal UTI pathogens

Front 87

ciprofloxacin vs. moxifloxacin vs. levofloxacin

which of these FQ's should NOT be used in UTI's?

Back 87

moxifloxacin:

does not reach high levels in urine

(also do not use gemifloxacin; limited activity against normal UTI pathogens)

Front 88

ciprofloxacin vs. moxifloxacin vs. levofloxacin

which of the FQ's is/are considered "respiratory" fluoroquinolone(s)?

Back 88

moxifloxacin + levofloxacin

because they are effective against:
Strep pneumo
H. flu
M. catarrhalis
intracellular atypical pathogens

gemifloxacin and gatifloxacin are also considered respiratory FQ's

Cipro is NOT a respiratory FQ because of limited activity against gram+ bugs, such as Strep pneumo

Front 89

ciprofloxacin vs. moxifloxacin vs. levofloxacin

which of these FQ's has/have activity against Pseudomonas aeruginosa?

Back 89

ciprofloxacin + levofloxacin

Front 90

acute uncomplicated pyelonephritis pathogens & treatment

Back 90

E. coli, Enterococcus, P. mirabilis, Klebsiella pneumo, Pseudomonas

FQ for 5 to 7 days
- cipro 500 mg BID
- levo 750 mg daily
- ofloxacin 400 mg BID

IF SEVERELY ILL, OR HOSPITAL-ACQUIRED (10-14 days):
FQ
or
ampicillin + gentamicin
or
piperacillin-tazobactam
or
ceftriaxone

Front 91

complicated UTI pathogens & treatment

Back 91

E. coli, Enterococcus, Pseudomonas, Enterobacter, Serratia, Klebsiella, Staph

treat x7 days if there is symptom relief, 10-14 with delayed response

ampicillin + gentamicin
OR
piperacillin-tazobactam
OR
ticarcillin-clavulanic acid
OR
ceftriaxone or cefotaxime (+/- FQ)

IF ESBL's PRESENT:
doripenem or imipenem or meropenem
2 weeks

Front 92

when would an uncomplicated UTI require longer duration of therapy?

Back 92

(longer than 3-5 days)

men
pregnancy
elderly
diabetics
children

Front 93

phenazopyridine class

Back 93

azo dye & urinary analgesic

Front 94

phenazopyridine dose & administration

Back 94

200 mg TID (prescription)
100 mg TID (OTC)

take with food to minimize stomach upset

use no longer than 2 days (b/c symptom masking)

may cause orange/red discoloration of body fluids

avoid in CrCl < 50 mL/min

Front 95

Signs of acute otitis media in children

Back 95

rapid onset
middle ear effusion
fever
middle ear inflammation
tugging or rubbing ears
crying

Front 96

Acute Otitis Media:

observation period

Back 96

48-72 hrs
used to assess clinical improvement without antibiotics

Children <6 months: NO observation period, always give abx when AOM is suspected, even if diagnosis is uncertain.

Children 6 mos - 2 yrs: use observation period, unless there is certain diagnosis (of BACTERIAL otitis media) or illness is severe

Children 2 years and over: use observation period, unless illness is severe

Front 97

Acute Otitis Media:

how do you treat pain in children?

Back 97

acetaminophen
or
ibuprofen

>5 years: can use topical benzocaine (Auralgan, Americaine otic)

Front 98

Acute Otitis Media:

primary treatment in children

Back 98

amoxicillin
90 mg/kg/day (divided Q12 or Q8)

the higher dose will cover most Strep pneumoniae

Front 99

Acute Otitis Media:

When would you not use the standard treatment?

Back 99

More severe cases, or cases where amoxicillin doesn't work:
Augmentin high dose (90 mg/kg/day of amoxicillin)
or
cefdinir (Omnicef)
cefpodoxime (Vantin)
cefprozil
cefuroxime (Ceftin)

In patients who have had anaphylaxis to penicillins:
azithromycin
clarithromycin (Biaxin)
erythromycin-sulfisoxazole (Eryzole, Pediazole)
sulfamethoxazole-trimethoprim
clindamycin

Front 100

Which of the Acute Otitis Media medications can be given for children who cannot tolerate oral medication?

Back 100

ceftriaxone (Rocephin)
50 mg/kg (max 1000 mg/day)
IV or IM

x3 days

Front 101

Prevnar

Back 101

Prevnar 13 is the Pneumococcal Conjugate Vaccine (PCV)
now given to all children 2-23 months

primarily for preventing pneumococcal meningitis and pneumonia, but also reduces otitis media

children receive 4 doses at ages:
2 months
4 months
6 months
12 - 15 months
(Pneumovax is the adult vaccine)

Front 102

When is Pneumovax recommended for children?

Back 102

Prevnar 13 is the children's pneumococcal vaccine, given to all children ages 2-23 months.

Pneumovax is only given to children >24 months who are at increased risk for pneumococcal vaccine due to factors such as:
sickle cell hemoglobinopathies
HIV
immunocompromising conditions

Front 103

Infective Endocarditis is determined by __________?

Infective Endocarditis treatment is based on _________?

Back 103

the Modified Duke Criteria

AHA Guidelines

Front 104

PRIMARY DRUG REGIMEN FOR:

Infective Endocarditis due to Viridans strep?

Back 104

Pen G (12-18 MU IV, divided Q4H)
+
gentamicin 1 mg/kg (IV Q8H)
(both x2 weeks)

OR

Pen G 12-18 MU (IV, divided Q4H)
(x 4 weeks)

OR

ceftriaxone 2 g IV (daily)
(x 4 weeks)

Front 105

PRIMARY DRUG REGIMEN FOR:

Infective Endocarditis due to Streptococcus bovis?

Back 105

SAME AS Viridans strep TREATMENT!

Pen G (12-18 MU IV, divided Q4H)
+
gentamicin 1 mg/kg (IV Q8H)
(both x2 weeks)

OR

Pen G 12-18 MU (IV, divided Q4H)
(x 4 weeks)

OR

ceftriaxone 2 g IV (daily)
(x 4 weeks)

Front 106

PRIMARY DRUG REGIMEN FOR:

Infective Endocarditis due to sensitive Enterococci

Back 106

(sensitive to PCN, gentamicin, vancomycin)

Pen G 18-30 MU IV (divided Q4H)
(x 4-6 weeks)

OR

ampicillin 12 g/day IV (divided Q4H)
+
gentamicin 1 mg/kg IV (Q8H)
(both x 4-6 weeks)

Front 107

PRIMARY DRUG REGIMEN FOR:

Infective Endocarditis due to Enterococci that is resistant to gentamicin

Back 107

PenG 24 MU IV (divided Q4H)
(x 4-6 weeks)

OR

ampicillin 12 g/day IV (divided Q4h)
+
streptomycin 7.5 mg/kg IV or IM Q12H
(both x 4-6 weeks)

Front 108

PRIMARY DRUG REGIMEN FOR:

Infective Endocarditis due to Enterococci that is resistant to PenG/ampicillin

Back 108

vancomycin 15 mg/kg Q12H
+
gentamicin 1 mg/kg IV Q8H
(both x 6 weeks)

Front 109

PRIMARY DRUG REGIMEN FOR:

Infective Endocarditis due to Enterococcus faecium species that is resistant to penicillin, vancomycin, gentamicin

Back 109

linezolid 600mg PO/IV Q12H
(x 8 or more weeks)

OR

quinupristin/dalfopristin 22.5 mg/kg/day (div. Q8)
(x 8 or more weeks)

Front 110

When using gentamicin for synergy in the treatment of Infective Endocarditis, what are the goal peak and trough levels?

Back 110

gentamicin peak levels:
do not need to exceed 4 mcg/mL (~3 mcg/mL is sufficient)

gentamicin trough levels:
< 1 mcg/mL

Front 111

Do not use _______________ dosing for aminoglycosides when treating Infective Endocarditis.

Back 111

extended-interval dosing

Front 112

Do not use extended-interval dosing for aminoglycosides when treating _______________.

Back 112

Infective Endocarditis

Front 113

Do not use extended-interval dosing for _________________ when treating Infective Endocarditis.

Back 113

aminoglycosides

Front 114

Why/when is prophylaxis for dental procedures recommended?

Back 114

When the following cardiac conditions are present (which are associated with highest risk of Infective Endocarditis):
- prosthetic cardiac valves
- previous endocarditis
- congenital heart disease
- palliative shunts and conduits
- any other prosthetic device in the heart
- cardiac transplant pt's who develop valvulopathy
- mitral valve prolapse with regurgitation and/or thickened valve leaflets
- hypertrophic cardiomyopathy
- acquired valvular dysfunction

Non-cardiac reasons:
- total joint replacement in the last 2 years

Front 115

oral prophylaxis in dental procedures?

Back 115

(for prevention of endocarditis or total joint replacement in last 2 years)

amoxicillin 2 g (adults)
amoxicillin 50 mg/kg (children)

Front 116

prophylaxis for dental procedures in patients unable to take oral medication?

Back 116

(for prevention of endocarditis or total joint replacement in last 2 years)

ADULTS:
ampicillin 2 g IV/IM
OR
cefazolin or ceftriaxone 1 g IV/IM

CHILDREN:
ampicillin 50 mg/kg IV/IM
OR
cefazolin or ceftriaxone 50 mg/kg IV/IM

Front 117

prophylaxis for dental procedures in patients allergic to penicillins?

Back 117

(for prevention of endocarditis or total joint replacement in last 2 years)

ADULTS:
cephalexin or cefadroxil 2g
OR
clindamycin 600 mg
OR
azithromycin or clarithromycin 500 mg

CHILDREN:
cephalexin or cefadroxil 50 mg/kg
OR
clindamycin 20 mg/kg
OR
azithromycin or clarithromycin 15 mg/kg

(NOTE: cephalosporins should not be used in pt's allergic to penicillins whose allergy was anaphylaxis, angioedema or urticaria)

Front 118

prophylaxis for dental procedures in patients allergic to penicillins AND unable to take oral medications?

Back 118

(for prevention of endocarditis or total joint replacement in last 2 years)

ADULTS:
cefazolin 1g IM/IV
OR
ceftriaxone 1g IM/IV
OR
clindamycin 600 mg IM/IV

CHILDREN:
cefazolin 50 mg/kg IM/IV
OR
ceftriaxone 50 mg/kg IM/IV
OR
clindamycin 20 mg/kg IM/IV

Front 119

classic triad of meningitis?

other sx of meningitis?

Back 119

fever
nuchal rigidity
altered mental status

OTHER SX:
chills
vomiting
photophobia
severe headache

Front 120

lumbar puncture in meningitis

Back 120

mandatory for all suspected bacterial meningitis, helps differentiate between bacterial & viral; cultures & sensitivities

Front 121

T or F:
A gram stain for meningitis is usually rapid and sensitive.

Back 121

True.

A gram stain for bacterial meningitis (from lumbar puncture) is a rapid and sensitive method of diagnosis for bacterial meningitis; decreased sensitivity in patients with recent antibiotic therapy.

Front 122

general rule of thumb for antibiotic dosing for bacterial meningitis

Back 122

maximize dosing (for optimal penetration of the CNS)

Front 123

most likely organisms for bacterial meningitis?

Back 123

Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenza
Listeria monocytogenes

Front 124

EMPIRIC THERAPY:

acute bacterial meningitis

Back 124

CEFOTAXIME 2 g IV (Q4-6)

CEFTRIAXONE 2 g IV (Q12)

MEROPENEM 2 g IV (Q8) - an alternative to the 3rd generation cephalosporins

+ dexamethasone (0.15 mg/kg IV Q6H x 2-4 days)

+ vancomycin 30-45 mg/kg/day (divided doses)
(high dose is needed to penetrate CSF)

(give dexamethasone 15-20 minutes prior to, or concomitantly with 1st dose of abx)

Add AMPICILLIN 2g IV (Q4) if:
- age < 1 month, or
- >50 years, or
- impaired immunity, or
- suspected Listeria

Front 125

EMPIRIC THERAPY:

acute bacterial meningitis
with severe PCN allergy

Back 125

CHLORAMPHENICOL 4,000 - 6,000 mg per day (in 4 doses)
+
VANCOMYCIN 30-45 mg/kg/day (divided doses)
+/-
SMX/TMP 5 mg/kg IV Q6

chloramphenicol + vancomycin will provide adequate coverage for Neisseria and Strep pneumo. SMX/TMP can be added for suspected Listeria

Front 126

Rickettsia species are carried by ___________.

Back 126

ticks, fleas, lice

Front 127

TREATMENT:

Rocky Mountain Spotted Fever

Back 127

(a Rickettsial disease)

doxycycline 100mg BID PO/IV
x 7 days

Front 128

TREATMENT:

Lyme disease

Back 128

(a Rickettsial disease)

doxycycline 100mg BID PO
or
amoxicillin 500mg TID PO (x 14-21 days)

Front 129

TREATMENT:

typhus

Back 129

(a Rickettsial disease)

doxycycline 100mg BID PO/IV
x 7 days

Front 130

TREATMENT:

ehrlichiosis

Back 130

(a Rickettsial disease)

doxycycline 100mg BID PO/IV
x 7-14 days

Front 131

TREATMENT:

tularemia

Back 131

(a Rickettsial disease)

gentamicin
or
tobramycin

(5 mg/kg/day div. Q8 IV
x 7-14 days)

Front 132

Systemic fungal infections usually don't occur unless __________________.

Back 132

the immune system is weakened

(however, Candidemia is the 4th most common nosocomial bloodstream infection in the U.S. with mortality rates up to 30%)

Front 133

Aspergillus

Back 133

fungal spp.

Front 134

Candida

Back 134

fungal spp.

Front 135

Crytococcosis

Back 135

fungal spp.

Front 136

Coccidiodomycosis

Back 136

fungal spp.

Front 137

Histoplasmosis spp.

Back 137

fungal spp.

Front 138

Candida infections can generally be treated with ____________.

Back 138

fluconazole

Front 139

fluconazole-resistant Candida spp?

Back 139

some, such as Candida krusei, cannot be treated with fluconazole

other spp, such as C. glabrata, require higher doses of fluconazole to be effective (although resistant strains of this species also exist)

Front 140

amphotericin B
MOA

Back 140

amphotericin B binds to ergosterol altering cell membrane permeability in susceptible fungi and causing cell death

Front 141

Amphocin

Back 141

amphotericin B desoxycholate (conventional amphotericin)

the most nephrotoxic amphotericin formulation

Infusion-related reaction comparison:
Amphotec > Amphocin > Abelcet > AmBisome

pre-medication for infusion reactions (given 30-60 minutes prior to infusion):
- APAP or NSAID
- diphenhydramine IV and/or hydrocortisone IV
- meperidine IV for reducing the duration of rigors
- saline boluses to reduce the nephrotoxicity

Front 142

Abelcet

Back 142

amphotericin B lipid complex

infusion-related reactions:
Amphotec > Amphocin > Abelcet > AmBisome

pre-medication for infusion reactions (given 30-60 minutes prior to infusion):
- APAP or NSAID
- diphenhydramine IV and/or hydrocortisone IV
- meperidine IV for reducing the duration of rigors
- saline boluses to reduce the nephrotoxicity

Front 143

AmBisome

Back 143

liposomal amphotericin B
(a lipid formulation of amphotericin B)

the most expensive formulation of amphotericin B

can cause back/chest pain with 1st dose

infusion-related reactions:
Amphotec > Amphocin > Abelcet > AmBisome

pre-medication for infusion reactions (given 30-60 minutes prior to infusion):
- APAP or NSAID
- diphenhydramine IV and/or hydrocortisone IV
- meperidine IV for reducing the duration of rigors
- saline boluses to reduce the nephrotoxicity

Front 144

Amphotec

Back 144

amphotericin B cholesteryl sulfate complex
(a lipid formulation of amph B)

the worst for infsion-related reactions

infusion-related reactions:
Amphotec > Amphocin > Abelcet > AmBisome

pre-medication for infusion reactions (given 30-60 minutes prior to infusion):
- APAP or NSAID
- diphenhydramine IV and/or hydrocortisone IV
- meperidine IV for reducing the duration of rigors
- saline boluses to reduce the nephrotoxicity

Front 145

T or F:
amphotericin B is compatible with D5W

Back 145

true

amphotericin B formulations are compatible with D5W

Front 146

the most nephrotoxic formulation of amphotericin B

Back 146

Amphocin
(amphotericin B desoxycholate)

Front 147

the most expensive formulation of amphotericin B

Back 147

AmBisome
(liposomal amphotericin B)

Front 148

which formulation of amphotericin B can cause back/chest pain with the 1st dose?

Back 148

AmBisome
(liposomal amphotericin B)

Front 149

the formulation of amphotericin B most likely to cause infusion related reactions

Back 149

Amphotec
(amphotericin B cholesteryl sulfate complex)

Front 150

adverse effects of amphotericin B

Back 150

hypokalemia, hypomagnesemia
nephrotoxicity, hypotension
fever, headache, malaise, rigors, N/V
tachypnea, normocytic anemia, normochromic anemia, others

infusion-related reactions (Amphotec is the worst): fever, chills, hypotension, nausea, etc.)

Front 151

infusion reactions from amphotericin B

Back 151

Amphotec > Amphocin > Abelcet > AmBisome

fever, chills, hypotension, nausea

PRE-MEDICATION:
APAP or NSAIDs
diphenhydramine 25mg IV and/or hydrocortisone 50-100 mg IV
meperidine 25-50 mg IV for reducing duration of rigors
saline boluses 500-1000 mL to reduce nephrotoxicity

Front 152

risk of nephrotoxicity with amphotericin B will be increased when?

Back 152

when used with other nephrotoxic agents such as cyclosporine, aminoglycosides, flucytosine, cisplatin and others

nephrotoxic effects are additive

may enhance digoxin toxicity due to hypokalemia

Front 153

amphotericin B & electrolytes

Back 153

amph B may enhance digoxin toxicity due to hypokalemia

use caution with any agent that decreases potassium and magnesium, since amphotericin decreases both of these

Front 154

Ancobon MOA

Back 154

Ancobon = flucytosine (5-FC is another synonym)

antifungal

penetrates fungal cells and is converted to fluorouracil which competes with uracil, interfering with fungal RNA and protein synthesis

Front 155

5-FC

Back 155

flucytosine

(antifungal)

Front 156

Ancobon

Back 156

flucytosine

(antifungal)

Front 157

Ancobon monotherapy

Back 157

(flucytosine)

avoid monotherapy due to rapid resistance development in most fungal strains

increased effects (including adverse effects) when combined with Amphotericin B; may be used for synergy with Amph B for certain fungal infections (Cryptococcus)

Front 158

Ancoban adverse effects

Back 158

(flucytosine)

dose-related bone marrow suppression, many CNS effects, pancytopenia, aplastic anemia
hepatitis, increased bilirubin, increased SCr, increased BUN
hypoglycemia, hypokalemia

adverse effects may be worsened when combined with Amphotericin B

Front 159

Sporanox
- generic
- class
- dosing/administration

Back 159

itraconazole (azole antifungal)

PO

200 - 400 mg QD-BID

due to differences in bioavailability, oral capsules and oral solution CANNOT be used interchangeably

capsule form has low bioavailability on an empty stomach, take with food and requires gastric acidity for absorption

oral solution is more bioavailable than caps, take on an empty stomach

Front 160

azole antifungals:
MOA

Back 160

decrease ergosterol synthesis and inhibit cell membrane formation

Front 161

azole antifungals:
adverse effects

Back 161

N/V/D
rash
hypertriglyceridemia, hypokalemia, HTN, edema
increased LFTs

Front 162

azole antifungals:

Warnings & Contraindications

Back 162

ITRACONAZOLE (Sporanox) BBW:
heart failure or hx of heart failure: capsules should not be administered for the treatment of onychomycosis in patients with HF
concurrent administration with:
- cisapride
- dofetilide
- pimozide
- quinidine

KETOCONAZOLE (Xolegel, Kuric, Nizoral) BBW:
concurrent admin with cisapride (fatal ventricular arrhythmias)
has been associated with hepatotoxicity

FLUCONAZOLE (Diflucan) BBW:
concomitant use with cisapride

Front 163

Diflucan dosing

Back 163

(fluconazole, azole antifungal)

100 - 400 mg QD

PO/IV

PO:IV conversion - 1:1

Front 164

VFEND
- dosing
- admin

Back 164

(voriconazole, azole antifungal)

PO: 100 - 300 mg Q12
IV: 6 mg/kg Q12 x doses, then 4 mg/kg Q12

take 1 hour before or 1 hour after meals (empty stomach)

Front 165

VFEND adverse effects

Back 165

(voriconazole, azole antifungal)

visual changes (~20!) - dose-related, include blurred vision, photophobia, altered color perception, altered visual acuity, photosensitivity
increased SCr
hallucinations
correct Mg, Ca & K before initiating therapy

Front 166

VFEND contraindications

Back 166

(voriconazole, azole antifungal)

CI with many 3A4 substrates (rifampin, rifabutin, ergot alkaloids, long-acting barbiturates, carbamazepine, pimozide, quinidine, cisapride, efavirenz, St. John's wort)

Front 167

VFEND monitoring

Back 167

(voriconazole, azole antifungal)

LFT's, electrolytes, visual function

Caution driving at night! Avoid direct sunlight

Front 168

which azole antifungal is generally considered more active against a variety of fungal infections?

Back 168

voriconazole (VFEND)

more active against:
- Aspergillus
- C. glabrata
- C. krusei
- Fusarium spp.

...compared to itraconazole & fluconazole

Front 169

Noxafil
- dosing
- admin

Back 169

(posaconazole, azole antifungal)

40 mg/mL suspension in a 4 oz bottle
shake well before use

MUST BE TAKEN WITH A FULL MEAL

Front 170

Noxafil adverse effects

Back 170

(posaconazole, azole antifungal)

N/V/D, headache, rash
increased LFTs
hypokalemia
QT prolongation

correct K, Ca, Mg before initiating therapy

Front 171

Noxafil contraindications

Back 171

(posaconazole, azole antifungal)

concurrent administration with ergot alkaloids, pimozide, cisapride, quinidine or sirolimus

Front 172

Noxafil monitoring

Back 172

(posaconazole, azole antifungal)

LFTs, renal fxn
electrolytes (correct Ca, Mg, K before starting)
visual fxn (though not as bad as voriconazole)

Front 173

azole antifungals:
drug interactions

Back 173

ALL are 3A4 INHIBITORS:
- itraconazole is a MAJOR inhibitor of 3A4
- ketoconazole is also a strong inhibitor of 1A2, 2C9, 3A4; and a moderate inhibitor of 2C19 and 2D6
- fluconazole is a moderate inhibitor of 3A4, and a strong inhibitor of 2C9 & 2C19
- voriconazole is a strong inhibitor of 3A4 and a moderate inhibitor of 2C9
- posaconazole is a strong inhibitor of 3A4

itraconazole & ketoconazole have pH-dependent absorption: more basic pH decreases absorption, avoid use with antacids, H2 blockers & PPIs

voriconazole concentrations can increase dangerously when given with CYP inhibiting drugs, and with small dose increases (1st order kinetics)
concurrent use of voriconazole is CI with:
alfuzosin, barbiturates, carbamazepine, cisapride, darunavir, dofetilide, ergot derivatives, lopinavir, nilotinib, pimozide, quinidine, ranolazine, rifampin, rifabutin, ritonavir, St. John's wort, thioridazine & others

Front 174

VFEND drug interactions

Back 174

voriconazole concentrations can increase dangerously when given with CYP inhibiting drugs, and with small dose increases (1st order kinetics)
concurrent use of voriconazole is CI with:
alfuzosin, barbiturates, carbamazepine, cisapride, darunavir, dofetilide, ergot derivatives, lopinavir, nilotinib, pimozide, quinidine, ranolazine, rifampin, rifabutin, ritonavir, St. John's wort, thioridazine & others

Front 175

drug of choice for Aspergillus infections

Back 175

voriconazole (VFEND)

Aspergillus (invasive pulmonary disease):
voriconazole 6 mg/kg IV Q12 on day 1, then 4 mg/kg IV Q12 or 200 mg PO Q12

VFEND is also notable for drug interactions & visual changes

alternative therapies:
- liposomal Amphotericin B (AmBisome)
- Amphotericin B lipid complex (Abelcet)
- caspofungin (Cancidas)
- micafungin (Mycamine)
- posaconazole (Noxafil)
- itraconazole (Sporanox)

Front 176

echinocandins
MOA

Back 176

(antifungal class)

inhibit synthesis of Beta(1,3)-D-glucan, an essential component of the fungal cell wall

Front 177

Cancidas
- dosing
- admin

Back 177

caspofungin (echinocandin antifungal)

LD: 70 mg IV day 1, then 50 mg daily

do not mix with dextrose-containing solutions

increase dose to 70 mg IV daily when used in combination with rifampin or other strong enzyme inducers

Front 178

Cancidas monitoring

Back 178

(caspofungin, echinocandin antifungal)

LFTs

Front 179

Cancidas adverse effects

Back 179

(caspofungin, echinocandin antifungal)

increased LFT's, peripheral edema, decreased hemoglobin & hematocrit
N/V, headache, rash, fever
hypokalemia, tachycardia
increased SCr

rare: anaphylaxis

caution use with cyclosporine due to hepatotoxicity
caution in hepatic impairment

Front 180

Mycamine
- dosing
- admininstration

Back 180

micafungin, echinocandin antifungal

CANDIDEMIA DOSING:
100 mg IV daily

ESOPHAGEAL CANDIDIASIS DOSING:
150 mg IV daily, over 60 minutes

Front 181

Mycamine adverse effects

Back 181

micafungin, echinocandin antifungal

increased LFTs, bone marrow suppression
fever, headache, N/V/D
hypomagnesemia, hypokalemia

rare: anaphylaxis

Front 182

Mycamine monitoring

Back 182

micafungin, echinocandin antifungal

LFTs
minor 3A4 interactions

Front 183

Eraxis dosing

Back 183

anidulafungin, echinocandin antifungal

ESOPHAGEAL CANDIDIASIS DOSING:
100 mg IV day 1, then 50 mg daily

CANDIDEMIA:
200 mg IV day 1, then 100 mg IV daily

Front 184

Eraxis adverse effects

Back 184

anidulfungin (echinocandin antifungal)

increased LFTs
diarrhea
hypokalemia

rare: anaphylaxis

Front 185

Eraxis monitoring

Back 185

anidulafungin, echinocandin antifungal

LFTs

Front 186

T or F:
echinocandin antifungals are usually dosed Q12

Back 186

False

echinocandin antifungals:
- caspofungin (Cancidas)
- micafungin (Mycamine)
- anidulafungin (Eraxis)

all 3 agents are usually dosed once daily

Front 187

echinocandin drug interactions

Back 187

echinocandin antifungals:
- caspofungin (Cancidas)
- micafungin (Mycamine)
- anidulafungin (Eraxis)

all 3 agents have very little drug interactions, although caspofungin dosing may need to be increased when used in combination with rifampin or other strong enzyme inducers

Front 188

T or F:
echinocandin antifungals do not require adjustment in renal impairment

Back 188

True

echinocandin antifungals:
- caspofungin (Cancidas)
- micafungin (Mycamine)
- anidulafungin (Eraxis)

Front 189

TREATMENT:

Candida albicans

Back 189

(bloodstream infection)

fluconazole (Diflucan)
OR
caspofungin (Cancidas)
OR
micafungin (Mycamine)
OR
anidulafungin (Eraxis)

treatment duration: 2 weeks AFTER the last positive blood culture

Front 190

TREATMENT:

oral candidiasis

Back 190

(thrush)

NON-AIDS PATIENTS:
clotrimazole troches 10mg 5x/day
OR
nystatin suspension or 1-2 pastilles 4x/day
OR
fluconazole 100-200 mg daily PO

AIDS PATIENTS:
fluconazole 100-200 mg daily PO
OR
itraconazole oral solution 200 mg PO daily
OR
posaconazole 100 mg BID x1, then 100 mg daily
OR
echinocandins
OR
amphotericin B 0.3 mg/kg IV daily

(treatment duration: 7-14 days)

Front 191

TREATMENT:

esophageal candidiasis

Back 191

fluconazole 200-400 mg/day IV/PO
OR
itraconazole oral solution 200 mg PO daily
OR
voriconazole 200 mg Q12 IV/PO
OR
posaconazole 400 mg BID x3days, then 400 mg daily PO (refractory cases)
OR
caspofungin 50 mg daily IV
OR
micafungin 150 mg IV daily
OR
anidulafungin 100 mg IV day 1, then 50 mg daily
OR
amphotericin B 0.3-0.7 mg/kg daily

(treatment duration: 14-21 days)

Front 192

dermatophytoses

Back 192

superficial mycotic (fungal) infections of the skin

Front 193

Superficial mycotic infections of the skin are called ___________.

Back 193

dermatophytoses (mycotic = fungal)

Front 194

risk factors for fungal skin infection

Back 194

prolonged exposure to sweaty clothes
infrequent bathing
many skin folds
sedentary lifestyle
confinement to bed

Front 195

diagnosis of dermatophytoses

Back 195

(i.e. fungal skin infections)

history & physical
direct microscopic exam of a specimen after the addition of potassium hydroxide

Front 196

treatment of dermatophytoses

Back 196

(i.e. fungal skin infections)

topical agents are 1st line
oral therapy when the infection is extensive or severe or when treating tinea capitis (scalp/hair follicle infection) or onychomycosis

keep infected area clean & dry & limit exposure to infected reservoir

Front 197

% of women who have at least one vaginal candida infection

% of women who will have recurrent vaginal candida infections

Back 197

75%

<5%

Front 198

vaginal "yeast infection":
- causative agent
- predisposing factors

Back 198

usually caused by Candida albicans

predisposing factors are broad-spectrum antibiotic use, oral contraceptives (particularly with high estrogen), poorly controlled diabetes, pregnancy, chronic use of steroids, obesity

Front 199

vaginal candidiasis:
signs & symptoms

Back 199

intense pruritis
thick, curd-like (white) vaginal discharge
soreness
vulvar pain, swelling and irritiation

(itching is universal, discharge may or may not be present)

Front 200

T or F:
Itching and vaginal discharge are present in most cases of vaginal candidiasis, but not all.

Back 200

False.

itching is universal
discharge may or may not be present

Front 201

diagnosis of vaginal candidiasis

Back 201

confirmed by a wet preparation of vaginal secretions using a 10% potassium hydroxide solution showing budding yeast and pseudohyphae

Front 202

TREATMENT:

vaginal candidiasis

Back 202

topical azoles are typicially used
- usually do not have systemic side effects
- may have local side effects such as burning or irritation
- all equally effective (except nystatin, less effective, technically a polyene antifungal not azole) and have >80% curative rate
- only topical azole therapies, applied for 7 days, are recommended in pregnancy
- 7 days also recommended in severe infection
- 7-14 days recommended in recurrent infection (>4 episodes per year)

not usually required to treat partner because it's not usually acquired through sexual contact, but do treat partner if infections are recurrent

in patients with diabetes or HIV, pt should see their doc because it may be a sign of uncontrolled disease

do not recommend self-treatment unless a first infection has been diagnosed by the PCP

Front 203

which topical agents are generally used to treat vaginal candidiasis?

Back 203

butoconazole (Femstat-3, Gynazole-1)
clotrimazole (Gyne-Lotrimin-7, Mycelex-7)
miconazole (Monistat-3, Monistat-7, Monistat-1)
nystatin (Mycostatin)
terconazole (Terazol, Zazole)
tioconazole (Vagistat-1)
fluconazole (Diflucan - only oral)

Front 204

Femstat-3

Back 204

butaconazole 2% vaginal cream

FOR VAGINAL CANDIDIASIS:
x 3 days

Front 205

Gynazole-1

Back 205

butaconazole 2% vaginal cream

FOR VAGINAL CANDIDIASIS:
x 1 day

Front 206

Gyne-Lotrimin-7

Back 206

clotrimazole 1% vaginal cream

FOR VAGINAL CANDIDIASIS:
x 7 days

Front 207

Mycelex-7

Back 207

clotrimazole 1% vaginal cream

FOR VAGINAL CANDIDIASIS:
x 7 days

Front 208

clotrimazole 100 mg vaginal tabs

Back 208

FOR VAGINAL CANDIDIASIS:
daily for 7 days
OR
two tabs daily for 3 days

Front 209

clotrimazole 500 mg vaginal tabs

Back 209

FOR VAGINAL CANDIDIASIS:
one tab once

Front 210

Monistat-7

Back 210

miconazole 2% vaginal cream

FOR VAGINAL CANDIDIASIS:
x 7 days

Front 211

Monistat-3

Back 211

miconazole 200 mg vaginal suppository

FOR VAGINAL CANDIDIASIS:
1 suppository daily x 3 days

Front 212

Monistat-7

Back 212

miconazole 100 mg vaginal suppository

FOR VAGINAL CANDIDIASIS:
1 suppository daily for 7 days

Front 213

Monistat-1

Back 213

miconazole 1200 mg vaginal suppository

FOR VAGINAL CANDIDIASIS:
1 suppository once

Front 214

Mycostatin

Back 214

nystatin 100,000 unit vaginal tab

FOR VAGINAL CANDIDIASIS:
1 tab intravaginally daily x 14 days

Front 215

Vagistat-1

Back 215

tioconazole 6.5% vaginal ointment

FOR VAGINAL CANDIDIASIS:
x 1

Front 216

Terazol

Back 216

terconazole 0.4% OR 0.8% vaginal cream

FOR VAGINAL CANDIDIASIS:
x 7 days (0.4%)
x 3 days (0.8%)

Front 217

Zazole

Back 217

terconazole 80 mg vaginal suppository

FOR VAGINAL CANDIDIASIS:
x 3 days

Front 218

Diflucan for Vaginal Candidiasis

Back 218

fluconazole oral tab

150 mg PO x 1

Front 219

patient counseling for vaginal azole antifungal treatment of vaginal candidiasis

Back 219

insert applicator, suppository or tab at night before bed; complete entire course of treatment

creams/ointments/suppositories are oil-based medications that can weaken latex condoms & diaphragms; avoid sexual intercourse

use protective pad if desired

if you get your menstrual cycle during treatment, continue treatment

medical care is warranted if sx persist/recur within 2 months after using an OTC product

Front 220

antibiotic suspensions & refrigeration

Back 220

all need shaking

most should be refrigerated,
but NOT:
- azithromycin
- clarithromycin
- clindamycin
- voriconazole (antifungal)

Front 221

antibiotics & C. diff

Back 221

clindamycin is the worst

however, should instruct patients to report C. diff sx with any abx, including watery diarrhea several times a day, possibly with mild abdominal cramping

these symptoms can occur during treatment or weeks after treatment is completed; instruct pt not to treat these sx with anti-diarrheal medication

yogurt & probiotics may help prevent C. diff, but instruct pt's to take separately from abx (by a few hours)

Front 222

COUNSELING:

Zovirax

Back 222

acyclovir (antiviral)

works best when taken at the first sign of outbreak, within the first day

most common side effect is nausea (3%)
headache can also occur

with or without food, usually 2-5 times daily as directed, intervals should be evenly spaced

drink plenty of fluids while taking Zovirax

for the cream: side effects include dry/cracked lips, burning, stinging, flaky skin; report to doctor or pharmacist if they persist or worsen

Front 223

COUNSELING:

amoxicillin products

Back 223

with meal or snack, usually every 8-12 hours

see doc right away if you develop a rash

suspensions should be refrigerated (especially Augmentin)

Front 224

COUNSELING:

Zithromax

Back 224

azithromycin

nausea or abdominal discomfort is the most common side effect

extended-release suspension should be taken on an empty stomach (1 hour before or 2 hours after food)

tablets & immediate release suspensions can be taken with or without food

DO NOT refrigerate suspensions

Front 225

COUNSELING:

Biaxin

Back 225

clarithromycin

common adverse effects: diarrhea, nausea, abnormal or metallic taste

Biaxin XL tablets should be taken with food

tablets & oral suspension can be with or without food, and can be taken with milk

DO NOT refrigerate suspension

Front 226

COUNSELING:

Cipro

Back 226

ciprofloxacin

common adverse effects: nausea, diarrhea, rash, dizziness. Rarely, seizures (fluoroquinolones should be avoided in pt's with seizure history)

can make skin sensitive to sun, burn more easily; avoid sun & use sunscreen

rare cases of tendon swelling/rupture; if you notic pain, swelling or inflammation in Achilles, shoulder, hand or other sites, stop med & see doc right away; uncommon but occurs more frequently in pt's >60, or those who have had transplants and use steroid meds

NOT a 1st choice med for pt's under 18 because of bone & joint problems; however, sometimes used on a short-term basis

Do not use if you take tizanidine (Zanaflex)

Front 227

COUNSELING:

Levaquin

Back 227

levofloxacin

same as for Cipro

tabs can be taken with or without food; suspension is on an empty stomach

maintain adequate hydration to avoid crystalluria

INR may increase if on warfarin

may lower blood sugar if you use hypoglycemic meds

lower dose for kidney disease

2 hours before or 4-6 hours after antacids, vitamins, Mg, Ca or Zn supplements, dairy products, bismuth subsalicylate or sucralfate or didanosine (Videx)

Front 228

COUNSELING:

Doryx

Back 228

doxycycline

common adverse effects: N/V/D, headache

skin can get sensitive to sun, burn more easily

drink plenty of fluids

take 2 hours before, or 4-6 hours after taking antacids, vitamins, Mg, Ca, iron, Zn, dairy products, bismuth subsalicylate, sucralfate, didanosine (Videx)

tell your doc immediately if you get severe stomach pain, yellowing of eyes/skin, vision changes, mental/mood changes

Front 229

COUNSELING:

erythromycin

Back 229

typical dosing is 400 mg Q6

chew tab thoroughly before swallowing, take with or without food

nausea is very common, especially when taken on an empty stomach; take with food or milk

cramping & diarrhea may also occur

Front 230

COUNSELING:

Pediazole

Back 230

erythromycin + sulfisoxazole suspension

same counseling as for erythromycin
also: refrigerate solution

Front 231

COUNSELING:

Diflucan

Back 231

fluconazole

headache, nausea, abdominal pain

if taking more than 1 dose, counsel on possible hepatotoxicity or serious skin rash issues

contact your doc right away if you have dark urine, pale stools, feel more tired than usual, or signs of jaundice; these may indicate liver damage

should be seen right away for rash

kidney dz requires lower dose

FOR KETOCONAZOLE or ITRACONAZOLE:
same as above, do not use with antacids (2 hour separation), stop PPIs or H2-blockers because these meds will decrease the absorption of the antifungal

Front 232

COUNSELING:

Cleocin

Back 232

clindamycin

common adverse effects: diarrhea (>10%), nausea, abdominal pain, abnormal taste

C. diff possible, even if you have finished the med; do not self-treat with anti-diarrheal meds, see doc right away

take with or without food, 3-4 times daily

take with full glass of water

DO NOT refrigerate liquid suspension

Front 233

COUNSELING:

Flagyl

Back 233

metronidazole

generally 250-500 mg TID-QID

common adverse effects: nausea (12%), occasional headache, loss of appetite

do not drink alcohol with this, and for at least 1-2 days after! (disulfiram-like reaction)

take with food or water or milk to help prevent stomach upset

Front 234

COUNSELING:

Tamiflu

Back 234

oseltamivir

start within 2 days of sx onset
adult treatment: 75 mg BID x 5 days
prophylaxis: 75 mg daily x 10 days
children (1-12): 30-75 mg BID x 5 days for treatment based on weight, prophylaxis is QD x 10 days

common adverse effects: N/V; take with or without food, stomach upset may be less if you take with food/snack/milk

let doc know if you have had the NASAL flu vaccine within the last 2 weeks

may occasionally cause severe rash, contact doc in case of rash

people with flu may be at increased risk of confusion/self-injury shortly after taking this med & should be closely monitored; contact doc immediately in cases of abnormal behavior

Front 235

COUNSELING:

Macrodantin

Back 235

nitrofurantoin macrocrystals

take with food; do not use Mg antacids while taking this med

take at evenly spaced intervals

nausea, headache may occur

may turn urine dark yellow or brown; usually a harmless, temporary effect; however, dark urine may also indicate rare liver problems or anemia, see doc if dark urine is accompanied by persistent N/V, stomach pain, yellow eyes/skin, tiredness, fast/pounding heartbeat

tell doc if you get eye pain, vision changes, mental/mood changes, severe or persistent headaches, new signs of infection, bruising/bleeding

may rarely cause fatal lung problems; see doc if you get persistent cough, chest pain, SOB, joint/muscle pain, blue/purple skin

may cause C. diff

Front 236

COUNSELING:

Macrobid

Back 236

nitrofurantoin monohydrate macrocrystals

take with food; do not use Mg antacids while taking this med

take at evenly spaced intervals

nausea, headache may occur

may turn urine dark yellow or brown; usually a harmless, temporary effect; however, dark urine may also indicate rare liver problems or anemia, see doc if dark urine is accompanied by persistent N/V, stomach pain, yellow eyes/skin, tiredness, fast/pounding heartbeat

tell doc if you get eye pain, vision changes, mental/mood changes, severe or persistent headaches, new signs of infection, bruising/bleeding

may rarely cause fatal lung problems; see doc if you get persistent cough, chest pain, SOB, joint/muscle pain, blue/purple skin

may cause C. diff

Front 237

COUNSELING:

Bactrim

Back 237

sulfamethoxazole/trimethoprim (a.k.a Septra)

nausea, rash

take with full glass of water to prevent crystalluria

take with food or milk

DO NOT refrigerate suspension; shake prior to use

skin sun-sensitivity, burn more easily

see doc if you get a rash

Front 238

COUNSELING:

Lamisil

Back 238

terbinafine

with or without food

may take several months after finishing the course to see full effects, takes time for healthy nails to grow

diarrhea, stomach upset, temporary change/loss of taste

tell doc immediately if you get new signs of infection (fever, chills, etc.) or vision changes

rarely causes serious (possibly fatal) liver disease; tell doc immediately if you get persistent nausea, loss of appetite, severe stomach pain, dark urine, yellow eyes/skin, pale stools

Front 239

COUNSELING:

Valtrex

Back 239

valacyclovir

if used daily with safer sex practices, can lower the chances of passing herpes to your partner
- do not have sexual contact w/ partner during outreak
- use condom

does not cure herpes infections

with or without food

start as soon as possible after sx start

headache, N/V, dizziness (all usually mild)

store suspension in refrigerator up to 28 days; store tabs at room temp

kidney failure & nervous system problems are rare; tell doc if you get aggressive behavior, unsteady mvmt, shakiness, confusion, speech problems, hallucinations, seizures, coma; dose adjust in kidney impairment

Front 240

COUNSELING:

VFEND

Back 240

voriconazole

eyesight changes, rash, N/V/D, headache, chills, fever
avoid driving at night; avoid driving at all if you have vision changes

avoid sunlight, may burn more easily

tablets contain lactose

take on empty stomach (at least 1 hour before or 1 hour after meals)

do not use if you are pregnant, breastfeeding, or may become pregnant

call doc right away if you have dark urine, feel more tired than usual, skin/eyes yellow, or if you have rash or difficulty breathing

Front 241

Most appropriate therapy for CAP:

a. Zithromax 500 mg PO x 1, then 250 mg PO QD days 2-5
b. Avelox 400 mg IV QD x 5-7 days
c. Levaquin 500 mg PO x 1, then 250 mg PO QD x 5-7 days
d. Ceftin 500 mg PO Q12 x 5-7 days
e. Bactrim 1 DS tab PO Q12 x 5-7 days

Back 241

A

Levaquin (levofloxacin) or Avelox (moxifloxacin), both respiratory fluoroquinolones, would be more appropriate if the patient was at risk for drug-resistant S. pneumo (>65 y.o., immunosuppressed, comorbidities such as HF, DM, renal/liver dys, or use of abx within the past 3 months)

Ceftin (cefuroxime) would be more appropriate in patients at risk for drug-resistant S. pneumo as described above, and would be used IN COMBINATION with a macrolide (azithromycin, clarithromycin, erythromycin)

B, C or D (in combination) would also be preferred options in inpatients

Front 242

In a pt who is admitted to the hospital with CAP, which of the following is the best treatment option?

a. Cipro 500 mg PO QD
b. Rocephin 1 g IV daily
c. Rocephin 1 g IV daily + Zithromax 500 mg IV daily
d. vancomycin 1 g IV Q12 + imipenem 500 mg Q6
e. gemifloxacin 320 mg PO daily + clarithromycin 500 mg PO Q12

Back 242

C: ceftriaxone + azithromycin

Inpatient treatments would be:
- respiratory FQ (includes gemifloxacin, but NOT ciprofloxacin) alone
OR
- beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) PLUS macrolide (azithromycin, clarithromycin or erythromycin)

option A is not a respiratory FQ and would not be used for CAP
option B is not combined with a macrolide
option D is overkill
option E is overkill (because the respiratory FQ gemifloxacin could be used alone)

Front 243

A pt is admitted to the hospital with CAP, and while in the hospital she develops a Pseudomonal infection in her lungs as well. Which of the following abx would be an appropriate choice of coverage for Pseudomonas?

a. ampicillin
b. Cubicin
c. Invanz
d. Doribax
e. Tygacil

Back 243

D

Doribax (doripenem) covers pseudomonas

remember that Invanz (ertapenem) is the only carbapenem that does NOT cover Pseudomonas

Front 244

Which of the following is true regarding linezolid?

a. it is in a new class called cyclic lipopeptides
b. it is a weak MAO inhibitor and should be avoided with serotonergic agents
c. it is a combination product containing quinupristin and dalfopristin
d. it needs to be dose adjusted in patients with renal impairment
e. it is not effective for treating infections in the lungs

Back 244

B: it is a weak MAO inhibitor and should be avoided with serotonergic agents

it is in a new class called oxazolidinone abx

it does NOT need to be dose adjusted in renal impairment

it IS effective in the lungs

Front 245

Which of the following is correct regarding anidulafungin?

a. this medication should be taken with meals for best absorption
b. this medication can cause an increase in liver transaminases
c. this medication is not effective for the treatment of candidemia
d. this medication needs to be dose adjusted in renal impairment
e. the brand name is Epistaxis

Back 245

B: anidulafungin (Eraxis) can cause an increase in liver transaminases

it can be taken with or without food

it IS effective against candidemia

is DOES NOT need to be dose adjusted in renal impairment

Front 246

Which of the following is the best treatment option for a sulfa-allergic female patient with a UTI caused by E. coli, which is shown to be sensitive to everything when cultured?

a. Bactrim SS 1 tab PO BID x 3 days
b. Bactrim DS 1 tab PO BID x 3 days
c. nitrofurantoin 100 mg PO BID x 3 days
d. nitrofurantoin 100 mg PO BID x 5 days
e. phenazopyridine 200 mg TID x 2 days

Back 246

D

nitrofurantoin 100 mg PO BID x 5 days

Front 247

which of the following statements regarding the IV formulation of Bactrim is/are correct?

a. Bactrim IV should be protected from light
b. Bactrim IV should be refrigerated
c. Bactrim IV is compatible with NS
d. A and B
e. A and C

Back 247

A: Bactrim IV should be protected from light

(Bactrim IV should be stored at room temp)
(Bactrim IV should be diluted with D5W)

Front 248

What is the best treatment for a patient with a gonorrheal STD infection?

a. Levaquin 750 mg PO x 1
b. Doryx 100 mg PO BID x 7 days
c. Benzathine penicillin G 2.4 million units IM x 1
d. Flagyl 2 g PO x 1
e. Rocephin 250 mg IM x1 PLUS azithromycin 1 g PO x 1

Back 248

E:

ceftriaxone 250 mg IM
+
azithromycin 1 g PO x 1

Front 249

which of the following is true regarding Valtrex?

a. Valtrex is a prodrug of acyclovir and can be used as suppressive therapy in patients with herpes simplex virus
b. Valtrex is a prodrug of penciclovir and should not be used as a suppressive therapy in patients with herpes simplex virus
c. Valtrex should only be used for herpes zoster virus
d. Valtrex needs to be taken with a fatty meal for best absorption
e. Valtrex is contraindicated in patients with a CrCl < 30 mL/min

Back 249

A

Front 250

Which of the following is/are TRUE regarding INH?

a. INH should be taken 1 hour before or 2 hours after a meal on an empty stomach
b. INH is a potent enzyme inducer
c. INH is contraindicated in gout
d. A and B
e. A, B and C

Back 250

A:
INH (isoniazid) should be taken 1 hour before or 2 hours after a meal on an empty stomach

INH is a major enzyme INHIBITOR
INH doesn't affect uric acid levels

Front 251

which of the following medications will prevent peripheral neuropathies in patients taking INH?

a. pyrazinamide
b. pyridoxine
e. pyridium
d. pyridostigmine
e. pyrimethamine

Back 251

B:
pyridoxine (vitamin B6)

Front 252

a patient taking amphotericin B is at risk for which electrolyte abnormalities?

a. hypocalcemia and hypomagnesemia
b. hyponatremia and hypokalemia
c. hypernatremia and hyperkalemia
d. hypokalemia and hypernatremia
e. hypokalemia and hypomagnesemia

Back 252

E:
hypokalemia and hypomagnesemia

Front 253

A patient comes into your clinic. She is 5 months pregnant and has a UTI. She is allergic to penicillin. Which of the following regimens would be the best choice for her?

a. Bactrim DS tab BID x 3 days
b. Cipro ER 500 mg PO daily x 7days
c. nitrofurantoin 100 mg PO BID x 7 days
d. cefpodoxime 100 mg PO Q12 x 7 days
e. do not treat since she is pregnant

Back 253

C:
nitrofurantoin 100 mg PO BID x 7 days

(remember to treat UTIs in pregnancy for 7 days)
(remember to avoid FQ's during pregnancy)
(remember to avoid Bactrim during the 3rd trimester; although she is not in her 3rd trimester, option A was only for 3 days)

Front 254

Which of the following statements is/are TRUE regarding VFEND?
a. VFEND can cause visual changes and patients should be instructed not to operate heavy machinery while taking the medication
b. VFEND must be taken on an empty stomach
c. VFEND oral tablets should not be used in patients with poor renal function
d. A and B
e. A, B and C

Back 254

D: (A & B)
VFEND can cause visual changes and patients should not operate heavy machinery, and VFEND must be taken on an empty stomach

(the IV vehicle for VFEND may accumlate in pt's with CrCl <50, so oral dosing is recommended in these patients after the initial loading dose because the oral tabs are ok in renal impairment)

Front 255

Which of the following antibiotics do NOT require dose adjustment in renal impairment?

a. gentamicin
b. clarithromycin
c. cefixime
d. tigecycline
e. daptomycin

Back 255

D:
tigecycline does not require renal adjustment

Front 256

Which of the following antibiotics should be refrigerated?

a. Cipro
b. Keflex
c. Levaquin
d. Septra
e. Zithromax

Back 256

B: Keflex (oral suspension)