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54 Cards in this Set

  • Front
  • Back
Fungus
cell walls - chitin (cellulose)
contain ergo**sterol **
yeasts (unicellular - budding/fission)
hyphae (multicellular, spores, septate/non-septate)

High natural immunity (transferrin, langerhans cells) - immune compromised pts at risk
Bugs: Candida
4th leading cause of nosocomial infections
Albicans = most common

Fungicidal response to Ampohotericin B & Caspofungin
Fungistatic response to azoles
Bugs: Tinea
tinea corporis (ringworm), t. cruris (jock itch), t. pedis (athlete's foot)

imidazole: econazole = excellent topical antifungal for the tineas
Bugs: Aspergillus
opportunistic infection]

Fungicidal response to Amphotericin B, itraconazole and voriconazole
NO response to fluconazole
Fungistatic response to Caspofungin
Bugs: Cryptococcus
fungicidal response to Amphotericin B
fungistatic response to -azoles
NO response to caspofungin
Bugs: Histoplasma
-
Drugs: Polyenes
Amphotericin B, Nystatin, Natamycin
cell membrane, ergosterol binding & lysis , leakage of K+ cations
Drugs: Azoles
cell membrane disruption MOA - inhibit ergosterol production via a CYP-450 dependent enzyme inhibition

Older Azoles = Imidazoles (5 mem ring, 2 nitrogens) - useful drugs: clotrim-, micon-, econ-, and ketocon-

Newer Azoles = Triazoles (5mem ring, 3 nitrogens)
-useful drugs: itracon-, flucon-, and voricon-
-taken over for ampho B for some systemic mycoses
-candidemia in non-neutropoenic hosts

AE: Liver toxicity w/ long term use (less w/ triazoles), nausea/vomiting
**drug interactions - particularly w/ similar hepatic metabolized drugs (cyclosporins, antihistamines, anticoag, antiseizure etc.)
Drugs: Allyamines
synthetic antifungals - nail mycoses and ringworm

choice over ketocon or gisofulvin

use nail laquer first, then systemic (reduced liver AE)
Drugs: Antimetabolytes (5-FC)
inhibit DNA/RNA synthesis

- NOT for fluid sensitive pts (cardiac?) - b/c of amt fluid req.

-drug resistance is prob w/ these!

- combo w. Ampho B = DRUG OF CHOICE for cryptococcal meningitis
Drugs: Echinocandins
Cell wall - inhibit beta-1,3 glucan synthase
-major development in systemic antifungal therapy
caution w/ hepatic and renal pts!
-renal and hepatic metabolism - but not nephrotoxic

-good for bugs resistant to triazoles and ampho B
Amphotericin-B (Polyenes)
Ampho-B = concentration dependent (fungicidal and post-antifungal effect), most broad spectrum, "gold standard", in IV form is drug of choice for most systemic mycoses

-little known about excretion - very little by kidneys

-AE: fever/chills/phlebitis, nephrotoxic (damage to distal tubules, wasting Na+, K+, Mg++), hypokalemia, hypomagnesemia
Nystatin (polyenes)I
skin, mouth, vag & GI infections
extremely toxic - topical use only (po tab, liquid, pastille, cream, vag tablet, powder, ointment)
Natamycin (polyenes)
topical OPTHALMIC antifungal
good for yeasts and molds
Clotrimazole (imidazole)
synthetic -azole for vag/mouth/skin yeast infections

topical only - cream, po solution, tabs (po or vag)
Miconazole (imidazole)
topical or vaginal use only

cream, sprays, powder, suppositories - lots of OTC products available
Ketoconazole (imidazole)
began orally administered -azoles, either po or topical
good for: mucosal candidiasis, cutaneous mycoses

slow response noted - fungistatic at low concentration, cidal at high concentrations

Requires HCl for absorption - achlorydria, H2 antagonists, PPIs, anticholinergics interfere w/ absorption

NOT FOR ASPERGILLOSIS OR SYSTEMIC INFECTIONS!
Ciclopirox (imidazole)
cream/lotion/gel/nail laqer

for cutaneous candidiasis, the tinea infections, seborrheic dermatitis, NAIL FUNGUS
Ideal Antifungal?
-Fungicidal

-Has novel MOA

-Broad spectrum - including restistant orgs

-well tolerated
fluconazole (Triazoles)
concentration dependent - fungicidal
concentration independent - fungistatic

well tollerated, topical OR systemic, great bioavailability

renally excreted = great for fungal bladder infections!
itraconazole (Triazoles)
time & conc dependent, fungicidal for aspergillis
-negligible CSF
-
*metabolized hepatically* liver failure! (excreted fecally)
voriconazole (Triazoles)
time-dependent fungicidal for Aspergillus! first line for invasive systemic!

rapid PO absorption (+tastes good!)
50% CSF penetration - consider for fungal meningitis
96% po availability

*reversible visual disturbances x 1 hr*
griseofulvin
po agent for nail mycoses, + skin and hair

(keratinized tissues or precursors)

take w. high fat diet to increase blood levels
caspofungin
cidal for candida, NOT for cryptococcus

-salvage therapy for invasive aspergillosis and candida

-Interactions: RUDUCES AUC for multiple drugs!!!
micofungin
drug of choice for immunosuppressed pts - candida
Antifungal Resistance
primary vs secondary

increasing w/ repeated long term use (HIV pts)
Vaccines
smallpox - 1790
not eradicated until 1980

Short term goal: prevention for individual
Long term goal: eradication

Foege's method - surveillance & containment strategy, more effective than mass vaccination programs alone

National Childhood Vaccine Injury Prevention Act 1986 - responsible for documentation requirements & informed consent
Education - Vaccines & Thimerosal
EDUCATE ON VACCINATION
-measles rate in 2012 highest since 2006, more ppl not getting their kids vaccinated

-Florida w/ highest rate vaccine preventable deaths
-exemptions LOW in Mississippi & W. Virginia, HIGH in Oregon...
>45000 deaths annually in US

Thimerosal - pulled in 2001, cleared in 2012 - not the damaging ethyl-mercury, and was never even in MMR anyhow - banning could sig. effect accessibility to vaccines
VAERS
VFC
ACIP
VAERS - Vaccine Adverse Event Reporting System - how providers report rxns to DHHS

VFC - Vaccines for Children - for groups who can't afford (Wake County Health Department Clinic)

ACIP - Advisory Comittee on immunixation practices - revise/review schedule annually for peds & adults, work w/ CDC
-Yellow Book - CDC annually published recommendations for travellers, what to get and when, and what need to get back into the US.
Vaccine - define & describe types
-suspension of weakened or death pathogenic celles injected to stim antibodies

2 types: 1) Live or attenuated and 2) Killed

mostly use killed b/c inactive, OK for immunocompromised pts
BUT live vaccine has faster response
Conjugate vs. Non-Conjugate
Non-conjugate = No memory cells (so Thymus independent) - Requires Boosters!

Conjugate = memory cells (Thymus dependent) - good first response, better second response
Toxoid
Bacterial toxin itself broken down/weakened

still produces antibodies

ex: Tetanus
Active vs Passive immunization
ACTIVE - antigen given in some form - can be live attenuated (live polio), or inactivated/killed org (IPV), or natural exposure (getting chicken pox as a kid) - note - memory cells better if you had the illness than if just got the vaccine

PASSIVE - antibody given - holds you over...
-direct antibodies, gen. given due to exposure or near exposure (ex: immunoglobulins for RSV)
**pts who have immune globulin, whole blood or antibody-containing products should NOT have a vaccine for 6wks, preferably 3mo. EXCEPTION: Hep B mom, or unknown status - vaccinate and give baby immune globulin
Herd immunity
when community is fully immunized (above threshold), spread is limited, individuals NOT immunized are protected

-significant for immunocompromised pts when they can't get the vaccine
Diptheria, Tetanus & Pertussis
-DTaP over DTP as DTP has whole cells
-Repeat Tdap not recommended except preg adolescents w/ each pregnancy

Contraindications
- absolute - anaphylaxis, encephalopathy w/in 7 days of administration
-precautionary - T>105 of unknown cause, collapse/shock, persistent inconsolable crying >3hrs, seizure w/ or w/o fever w/in 3 days of admin

SE - mainly from whole cell pertussis component - local rxns decrease w/ repeated admin.
Pediarix
combo DTP, polio and HepB
-can decrease injections in infants by 6
-contraindications - allergy to Neomycin and yeast (don't use Neosporin on kids! the neomycin exposure can lead to s/sx allergic rxn when vaccines given)
Pentacel
Combo DTaP, polio and HiB
DAT
equine diptheria antitoxin
-CDC provides to US physicians under IND protocol
-diptheria presents & manifests insidiously as a membranous nasopharyngitis or obstructive laryngotracheitis, accompanied by a low grade fever
Adult Tetanus & Diptheria
given Q10 years

give tetanus toxoid if 5-7 years since vaccine and pt w/ puncture wound, or if 7-8 years just give vaccine
Polio
spread by oral-fecal contamination
OPV - oral, live attenuated poliovirus - aka Sabin
- IgA production in gut and oropharynx
-NOT for immunocompromised pts/families
-PO = lifelong immunity

IPV - inactivated poliovirus vaccine (aka Salk)
- minimal IgA production
- for immunocompromised/hospitalized pts
- given SQ
Hep A
-no long term neg effects like other Hep vaccines

- given to pts w/ clotting factor disorder, liver disease, travelers, men who have sex w/ men, illicit drug users, or ppl who work w/ Hep A positive primates
Hep B
- vaccine provides long term protection - recommended for pre and post exposure prophylaxis

- Immune globulin provides temporary protection
- recommended for some post-exposure situations

Recombivax & Energix-B - 3 doses within a year

Heplisav - 2 doses one month apart

ALL NEWBORNS receive first HepB vaccine b/f hospital discharge, if mom HepB+, infant gets an extra dose, first one doesn't count towards the series (4 injections instead of 3)
-if mom's status unknown or unable to determine, give infant vaccine + HBIG
MMR - viral illnesses
Mumps - droplet spread viral infection
- fever, swelling/tenderness salivary glands,
-can affect testes, ovaries, pancreas, meninges, brain
-most cases ages 5y-14y, rare in <1y

Measles - highly infectious, acute viral
-NOT endemic to US d/t vaccine coverage but still common elsewhere
-infants have antibodies approx. 1mo from mom if mom was vaccinated, or approx. 4mo if mom had the disease

Rubella - mild, highly contagious viral illness
HIGLY TERATOGENIC!!!
-RASH, lymphadenopathy, joint pain (esp. adults).
*Congenital Rubella Syndrome*
-cataracts/congenital glaucoma, CHD (PDA, periph pulmonary arterial stenosis), hearing loss, pigmentary retinopathy
-purpura, spenomegaly, jaundice, microcephaly, mental retardation, meningoencephalitis, radiolucent bone disease
MMR - vaccine
Either a trivalent preparation (MMR) or single antigen of each

-ALL contain live, attenuated antigens
-given SQ
-contraindications: -anaphylaxis to eggs or hypersensitivity to neomycin, immunocompromised, or PREGNANCY - b/c of teratogenic effects of rubella
-SE - arthralgia, may be migratory - inform family
Varicella
-Benign, highly contagious - part of herpes family
-vaccine contains live attenuated virus
-any disease after vaccination is gen. mild
-latent form: Shingles!
-Contraindications - neomycin allergy, pregnancy, immunocompromised
Varicella Zoster Immune Globulin
postexposure prophylaxis of varicells
- for pts w/ high risk for severe disease who lack evidence of immunity or if varicella vaccine contraindicated
Shingles
virus lays dormant in neurons & reactivates as shingles - primary infection virus latent in dorsal root ganglia - provocation may be decades later, reactivates and travels centrifugally in peripheral nerves, causing shingles

-VERY painful - "on fire"
-single dose for adults >60, reduces occurrence and pain by 50%
-contraindications: immunocompromised, or w/ TB, allergic to gelatin or neomycin, pregnant women
Synagis
Immunoglobulin for RSV
-most infections mild but can cause severe illness in preemies or w/ CLD. also for infants w/ heart defects as prevention

-given Q30 days during RSV season
-SE: mild tenderness & erythema @ site
Haemophilius Influenza
CONJUGATE H influenza type B (98% effective)

-causes invasive or non-invasive disease - meningitis, septicemia, arthritis, pneumonia, eppiglottitis, otitis media, cellulitis, osteomyelitis, pericarditis

-common SE: minor tenderness @ site, possible low grade fever
Neisseria Meningitidis
CONJUGATE meningococcal vaccine for A, B, C & W-135 (99% effective)
Recommendation: 11-18yrs
High risk pop: 6wks to 55yrs +
-close quarters - military, college dorm etc.
-travelling to area where common (W. Africa)
-damaged spleen, including sickle cell
-immunocompromised - complement deficiency

Contraindicated - previous severe rxn to vaccine or moderate/severe illness warrants postponement of vaccine

OK for Pregnant women!!!

SE: - mild tenderness & erythema at site, transient fever, HA, malaise
Streptococcus Pneumoniae
pneumococcal vac prevents bacteremia, sepsis, pneumonia, sinusitis, otitis (notorious), meningitis from invasive bacteria

Recommendations: sickle cell asplenia or functional asplenia, HIV, immunocompromised states, cochlear implant, CSF leak, smokers

Contraindications: moderate/severe febrile illness, previous allergic rxn to vaccine, pregnant women

Common SE: mild tenderness & erythema at site, fever
Influenza
Trivalent (inactivated) - for 6mo to 18yrs

FluMist: >2y to 49yrs (if healthy and nonpregnant)
-live attenuated, burns when given
-must remain on mucous membranes to be absorbed

FluMist Quadravalent: 2-49yrs

FluBlock trivalent recombinant hemagglutinin
-18-49yr
-NO USE OF eggs/virus
-highly purified, no preservatices, antibiotics, etc.

Fluzone High Dose: >/= 65yrs
-contains 4x more hemagglutinin per dose than standard vaccines
- >60yrs only produce 1/3 response to antibodies

For pts 19-40 or 50-death who are diabetics, chronic heart, lung, renal disease or immunocompromised
-recommend inactivated vaccine

H1N1 - can be given same day as regular flu, same requirements - live attenuated to each nare
Rotavirus
Rotashield - causes intussusceptions, increased peristalsis

Rotateq - oral pentavalent live virus vaccine

Rotarix - contraindicated if allergy to vaccines or for immunocompromised infants
HPV
-precursor for cervical, vulvar, anal & penile cancers
-cervical CA 2nd leading cause of cancer deaths among women world wide.
-Most common newly aquired STI

Gardasil = broader coverage - vaccine of choice
-approved males and females 9-26yrs
-coverage min. 5 yrs, still monitoring for need for boosters etc.

Ceravix - 100% effective but less types than gardasil
-ages 10-25yrs