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141 Cards in this Set
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Chloramphenicol:
MOA: Binds reversibly to the ____ subunit of the bacterial ribosome __________ broad spectrum antibiotic Active against both gram (+) & gram (-): Neisseria meningitides Haemophilus influenzae Some strains bateriodes Dose adjustment: not needed in renal insufficiency; required in ________ |
50S
Bacteriostatic hepatic failure |
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Chloramphenicol-Clinical Uses
mostly obsolete due to toxicity & resistance Maybe considered for use in treatment of serious infections: Typhus or Rocky mountain fever in children < 8yrs where _________ is contra-indicated Alternative to β-lactam ATBs for _____________ in pts hypersensitive to PCN or PCN resistant strains of pneumococcus Adult dose: ______ mg/kg/day in ___ divided doses Occasional used for eye infections due to penetration of occular tissues |
Tetracycline
meningococcal meningitis 50-100 mg/kg/day in 4 divided doses |
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Chloramphenicol - Adverse Effects
GI disturbances – N/V, diarrhea __________ - alteration of normal microbial flora Bone Marrow disturbances - Decreased _______ production-doses >50mg/kg/day x 1-2wks _________ – rare, irreversible, can be fatal Newborn Toxicities _________ from doses >50mg/kg/day - caused by drug accumulation Vomiting Flaccidity Hypothermia Gray color Shock & collapse |
Oral or vaginal candidiasis
red cell Aplastic anemia Grey baby syndrome |
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Chloramphenicol - drug Interactions
prolonged t½ & increased serum concentrations of: ________ ________ __________ - tolbutamide, chlorpropamide antagonize bactericidal drugs such as _____ & _______ |
Phenytoin
Warfarin Anti-diabetics PCNs, Aminoglycosides |
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TETRACYCLINE: OVERVIEW
TCNs are _________ broad spectrum antibiotics Mechanism of Action: Inhibit protein synthesis- bind to the ___ subunit of the bacterial ribosome |
bacteriostatic
30S |
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TETRACYCLINE : ACTIVITY
Active against g(+)& g (-) bacteria (_______): Chlamydia Mycoplasmas Protozoa Anaerobes Antibacterial activity of most TCNs similar except: TCN resistant strains may remain susceptible to __________ & __________ |
atypicals
doxycycline & minocycline |
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TETRACYCLINE: RESISTANCE
Decreased _________ accumulation due to either impaired influx or efflux _________ protection due to production of proteins that interfere with TCN binding ribosome Enzymatic _________ of TCN |
intracellular
Ribosome inactivation |
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TETRACYCLINE: PHARMACOKINETICS
Absorption impaired by _____ Absorption impaired by divalent ______ - Ca, Mg, Fe, Al, dairy products, antacids Widely distributed to tissue & blood, fluid except for _____ Minocycline – high conc in ______, useful eradication of ____________ carrier state TCN crosses the placenta to reach fetus –chelates with Ca & damage growing ______ & ______ |
food
cations CSF saliva meningococcal bones & teeth |
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TETRACYCLINE: PHARMACOKINETICS
_________ - unlike other TCNs, eliminated by non renal mechanisms Doxy- does not accumulate significantly in renal failure - TCN of choice in __________ Dose: ________ (tetracycline, Oxytetracycline) Dose: ________ (Doxycycline, Minocycline) |
Doxycycline
renal insufficiency 250-500mg PO qid 100mg PO qd or bid |
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TETRACYCLINE:CLASSIFICATION
Short Acting TCNs (t½ 6-8hrs) Chlortetracyline Tetracycline (______®) Oxytetracycline (_______®) Intermediate Acting TCNs (t½ 12hrs) Demeclocyline (________®) Methacycline (________®) Long Acting TCNs (t½ 16-18hrs) Doxycycline (_______®) Minocycline (_______®) |
Achromycin
Terramycin Declomycin Rondomycin Vibramycin Minocin |
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TETRACYCLINE - CLINICAL USES.
1.TCNs are drugs of choice for infections with: _________ _________ _________ 2. Used in combination regimens (w/ PPI) to treat gastric & duodenal ulcers caused by __________ 3. Maybe used for g (+) & g (-) bacterial infections including _______ 4. Effective in _______ infections - including sexually transmitted diseases (NOT GC) |
Mycoplasma pneumoniae
Ricketsiae Spirochetes Helicobacter pylori vibrio chlamydia |
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TETRACYCLINE - CLINICAL USES
Also used for treatment of: Exacerbation of bronchitis - ______ Pneumonia - TCN + _____ Acne - _______ Lyme disease Relapsing fever SIADH - ______ Elimination of menigococal carrier state - Minocycline 200mg po qd x 5days, but ______ now preferred |
doxy
3rd gen cephalosporin minocycline demeclocyline rifampin |
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TETRACYCLINE - CLINICAL USES.
Used with ________ to treat Plague, Tularemia, Brucellosis Used in protozoa infections caused by __________ or ___________ |
Aminoglycosides
entamoeba histolytica or Plasmodium falciparum |
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TETRACYCLINE - DOSING
Tetracycline - Adults: _________ Children (8yrs & older): _________ Methacycline - _________ Demeclocyline - ________ Doxycycline - _________ Minocycline - _________ __________ is the TCN of choice because it can be given once/day & absorption not affected by food |
250-500mg PO QID
20-40mg/kg/day in 4 divided doses 100mg po 1-2x/day 300 mg PO bid 100mg IV/PO qd or bid 100mg po bid Doxycycline |
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Precautions:
All TCNs chelate ______ Do not give with _____, antacids or ferrous sulfate Contraindications: Avoid in ________ & children < ___ of age to avoid deposition in bones & teeth |
metals
milk pregnant women 8yrs |
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TETRACYCLINE: ADVERSE EFFECTS
GI- _________ → direct irritation of GI tract (give with food to decrease effects) _________ Oral or Vaginal __________ ___________ - C. difficile Bone & teeth structure - teeth _________ |
N/V, diarrhea
Pruritis candidiasis Pseudomembranous enterocolitis discoloration |
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TETRACYCLINE: ADVERSE EFFECTS
Liver toxicity –hepatic necrosis with daily doses of ______ _______ toxicity- renal tubular injury (All TCNs accumulate – except _________) Local _______ injury - IV venous thrombosis, IM painful irritation Photosensitization - esp _________ Vestibular Rxns - dizziness, vertigo - esp _________ |
4gm IV
Kidney doxycycline tissue Demecocycline Minocycline |
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MACROLIDES- OVERVIEW
MOA: Inhibition of protein synthesis by binding to ____ ribosomal RNA _________ maybe inhibitory or bactericidal esp. at high concentrations for susceptible organisms Prototype drug: Erythromycin - 1952 Semi-synthetic derivatives of erythromycin: _________ & _________ |
50S
Erythromycin Clarithromycin & Azithromycin |
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ERYTHROMYCIN PHARMACOKINETICS
Erythromycin ____ - destroyed by stomach acid Must be given as ________ _____ & ______ are acid resistant & better absorbed _____ impairs absorption Excreted in bile & feces Adjustment unnecessary in _________ Not removed by _______ - don't give extra doses Crosses the ______ - reaches the fetus |
base
enteric coated Stearates & esters Food renal failure dialysis placenta |
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ERYTHROMYCIN ANTIMICROBIAL ACTIVITY
Effective against ____ organism especially: Pneumococci Streptococci Staphylococci Corynebacteria Also effective against Mycoplasma Legionella Chlamydia C.Pneumoniae Helicobacter Listeria - DOC is _______ Mycobacterium (certain) for atypicals, use in combo w/ a ______ |
g (+)
ampicillin cephalosporin |
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ERYTHROMYCIN ANTIMICROBIAL ACTIVITY
Active against ___ organisms such as: Neisseria species Bordetella pertusis Treponema Pallidum Campylobacter specie Haemophilus influenzae Rikettsiae (some species |
G (-)
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ERYTHROMYCIN CLINICAL USES:
Drug of choice for __________ infections (diphtheria ,corynebacterium sepsis) Prophylaxis against ________ during dental procedures in persons with valvular disease - _______ is a better alternative As a PCN susbstitute for PCN allergic pts with infections caused by ______ & ______(assuming susceptibility) Tx of ____ Respiratory , neonatal occular or genital ______ infections |
corynebacterium
endocarditis Clindamycin staph & strept CAP chlamydia |
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MACROLIDES-ERYTHROMYCIN DOSING
Erythromycin base, stearate or estolate Adults _________ Children _________ Estolate is best absorbed, greatest risk of ADR _______ preferred b/c of less GI SE E. Ethylsuccinate __________ Erythromycin base ______ + ______ as pre-op for surgery of the colon Erythromycin Lactobioate given IV at _______ (not used b/c of GI irritation) |
250-500mg PO q6hr
40mg/kg/day PO Stearate 400-600mg PO Q6hrs 1gm PO + Neomycin 0.5-1gm q6hrs |
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MACROLIDES-ERYTHROMYCIN ADR
GI - ________, N/V & diarrhea-gut stimulation Liver toxicity (esp estolate) - _________: fever, jaundice, impaired liver function _______ rxns - fever, eosinophilia, rash |
Anorexia
cholestatic hepatitis allergic |
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MACROLIDES: ERYTHROMYCIN DRUG INTERACTIONS
Inhibits cytochrome P450 enzymes causing increased serum concentrations for drugs like: Theophylline _________ (Oral) Cyclosporine _________ ________ |
Anticoagulants
Methylprednisone Digoxin |
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MACROLIDES: ERYTHROMYCIN-RESISTANCE
3 Mechanisms exist Reduced ________ of cell membrane or active efflux Production of _______ that hydrolyze macrolides Modification of _________ |
permeability
esterases ribosomal binding site |
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MACROLIDES - CLARITHROMYCIN(______®)
Derived from erythromycin - addition of methyl group MOA- same as erythromycin Antibacterial activity: Same as erythromycin, except active against _____ Erythromycin resistant ____ & _____ also resistant to Biaxin |
BIAXIN
MAC (mycobacterium avium complex) staph & strept |
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CLARITHROMYCIN - KINETICS
Has improved acid stability & _____ absorption, compared to erythromycin Metabolized in the _____; major metabolite eliminated in urine Dose __________ XL ________ Pts w/ CrCl < 50ml/min - LD 500mg x1, then ________ |
oral
liver 500 mg PO bid 1 gm qd 250mg q24hrs |
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CLARITHROMYCIN
Drug Interactions –similar to erythromycin Advantages over Erythromycin Lower frequency of _________ Less frequent ______ Otherwise, therapeutically equivalent Disadvantages over erythromcyin Clarithromycin, more ______ |
GI intolerance
dosing costly |
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MACROLIDES-AZITHROMYCIN (_________)
Derived from erythromycin by addition of a methyl group Microbial activity & clinical uses similar to clarithromycin- active against M.avium, T. gondii, H. influenzae Highly active against _______ Slightly < active against _______ & _______ than erythromycin & clarithromycin |
ZITHROMAX
chlamydia staph & strept |
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AZITHROMYCIN KINETICS
Half Life : 2-4 days; allows for __ dosing, shorter duration Penetrates most tissues except the ____ Give __________ meals Does not inactivate the Cytochrome P450enzymes therefore free of drug interactions that occur with erythromycin & clarithromycin |
QD
CSF 1hr before or 2hrs after |
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AZITHROMYCIN DOSING
Available IV & PO CAP: __________ Chlamydia cervicitis, urethritis: ________ Above as effective as 7 days of doxycycline |
LD 500mg, then 250mg IV/PO q24hrs x 4days
1gm PO x1 dose |
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________
Are semi-synthetic 14 member ring macrolides Differ from erythromycin by the substitution of a 3 keto group |
KETOLIDES
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KETOLIDES - TELITHROMYCIN (_______)
Active against: S.pyogenes S. pneumoniae H.Influenzae Moraxella catarrhalis N. gonorrhea *Mycoplasma* *Legionella* *Chlamydia* Bacteriodes fragilis - *Anaerobe* T. gondii Mycobacteria (non tuberculous) *Many macrolide resistant strains susceptible to ketolides* |
Ketek
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KETOLIDES - TELITHROMYCIN
Oral bioavailabilty – 57% Tissue penetration good Metabolized by ______, eliminated by biliary & urinary route Treatment of respiratory tract infections including ____: Acute exacerbation of bronchitis or Sinusitis ________ pharyngitis Dose: ________ It is a reversible inhibitor of the CYP3A4 enzyme system |
liver
CAP Streptococcal 800mg PO qd |
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VARIOUS ANTIMICROBIALS: ________ - Derivative of Lincomycin
MOA- Inhibition of protein synthesis, by binding to the ____ subunit of the bacterial ribosome |
CLINDAMYCIN
50S |
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CLINDAMYCIN: Antimicrobial Activity
_____ & ______ coverage - Streptococci Staphylococci Pneumococci Bacteriodes & other anaerobes Enterococci & g (-) organisms resistant to Clindamycin in contrast to susceptibility to erythromycin |
G+ & anaerobic
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CLINDAMYCIN: Kinetics
Excreted in liver bile & urine Penetrates into _______ Half life 2.5hrs Typical Dose: PO ________ IV ________ PID Dose: ______ Abscess dose: ______ |
abscesses
150-300mg PO q6hrs 600-900mg IV q8hrs 900 mg IV q8hrs 600 mg IV q8hrs then PO |
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CLINDAMYCIN: Clinical Uses
Severe _______ infections Combined with _______ or _______ for penetrating wounds & abscesses Clindamycin + _______, effective alternative to Bactrim for ___________ |
anaerobic
aminoglycosides or cephalosporins Primaquine pneumocystis carinii |
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CLINDAMYCIN: Adverse Effects
GI- N/V, severe diarrhea & ________ (use Flagyl or Vanc qid to treat) Dermatological - _______ Impaired _____ function |
enterocolitis
skin rashes liver |
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Various Antimicrobials: Streptogramins
Quinupristin-Dalfopritin (________) ________ for most organisms except enterococcus faecium Active against multi-drug resistant strains of S. Pneumoniae, MSSA, MRSA T1/2 - 1hr Prolonged antibiotic effect Dose: ________ Dose adjustment unnecessary in renal failure Toxicities: pain at injection site Arthralgia therefore give in a _______ |
Synercid
Bactericidal 7.5mg/kg IV Q8-12hrs Pain central line |
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Sulfonamides Overview
MOA: structural analogues of _____ Inhibit growth of organisms by reversibly blocking ____________ Divided into 3 groups __________ __________ __________ Plus IV Sulfamethoxazole/trimethoprim |
PABA
folic acid synthesis Oral Absorbable Oral Non-absorbable Topical |
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Sulfonamides Antimicrobial Coverage
Inhibit growth of _______ bacteria including: Nocardia Chlamydia trachomatis Protozoa (some) Enteric bacteria such as: E. Coli Klebsiella Salmonella Shigella Enterbacter No activity against ________ |
both gram (+) and gram (-)
rikettsiae |
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Sulfonamides – Oral Absorbable Kinetics
Classified into 3 categories based on _____: Short Acting Medium Acting Long Acting Well absorbed into body fluids, CNS & CSF Excreted in urine Dose adjustment necessary in _________ |
half life
renal impairment |
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Sulfonamides –Oral Absorbable (Clinical Uses)
Infrequently used as a ____ agent Formerly drugs of choice for infections such as: Pneumocystis carini pneumonia Toxoplasmosis Nocardiosis Used in fixed combinations - ___________ |
single
trimethoprim/sulfamethoxazole |
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Sulfonamides – Oral Absorbable (Clinical Uses)
Many strains formerly susceptible to organism listed below, but now ______: Meningococci Pneumococci Streptococci Staphylococci Gonococci |
resistant
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Sulfonamides – Oral Absorbable
SULFISOXAZOLE & SULFAMETHOXAZOLE - short to medium acting Used to treat ____ Dose ________ SULFADIAZINE - Achieves therapeutic conc. In CSF First treatment for acute _________ when used in combination with _________ |
UTI
1gm PO QID toxoplasmosis pyrimethamine |
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Sulfonamides – Oral Absorbable
SULFADIAZINE + pyrimethamine = synergistic Pyrimethamine (Daraprim)-_________, potent inhibitor of dihydrofolate reductase Dose: Sulfadizine _______ plus Pyrimethamine ____________ Combination given with ___________ to minimize marrow suppression |
antiprotozoa
1gm po qid 75mg po x 1 dose, then 25mg po qd folic acid 10mg po qd |
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Sulfonamides – Oral Non Absorbable
SULFASALAZINE (________) widely used to treat _________ & other inflammatory bowel disease Dose LD: __________ MD: __________ |
Azulfidine
ulcerative colitis 1 gm tid or qid 1 gm bid |
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Sulfonamides – Oral Non Absorbable
SULFADOXINE – only long acting sulfonamide in US Results in prolonged levels Sulfadoxine + Pyrimethamine = _______ 1 tab = __________ Dose acute malaria: ________ Prophylaxis: one tablet weekly or 2 tabs q2wks |
Fansidar
Sulfadoxine 500mg + Pyrimethamine 25mg 2-3 tabs x 1 dose |
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Sulfonamides – Topical Agents
SODIUM SULFACETAMIDE ______ soluntion & oint Used to treat _________ & adjunctive treatment for trachoma MAFENAMIDE ACETATE Used topically to prevent bacterial colonization in ________ Absorbed from burn sites - inhibits carbonic anhydrase causing _________ (S/E limits use) |
Ophthalmic
conjunctivitis burn wounds metabolic acidosis |
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Sulfonamides – Topical Agents
SILVER SULFADIAZINE (_________) Less _____ topical sulfonamide Preferred over Mafenamide for prevention of ________ of burn wounds |
Silvadene
toxic infection |
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Sulfonamides - Adverse Effects
For sulfonamides & their derivatives (thiazide, loop diuretics, diazoxide & sulfonylureas, cross allergenic) Most common adverse effects: _____ Skin ______ Exfoliative dermatitis _________ Urticaria Nausea/Vomiting ________ |
Fever
Rashes Photosensitivity Diarrhea |
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Sulfonamides - Adverse Effects
________ – rare (<1%) but potentially fatal type of skin & mucous membrane eruption ________ disturbances - May precipitate in urine producing crystalluria, hematuria & obstruction e.g. sulfadiazine, sulfizoxazole TX- ______ to alkalinize urine, ______ for hydration |
Stevens Johnson’s syndrome
Urinary NaHCO3 fluids |
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Sulfonamides - Adverse Effects
___________ Disturbances - Hemolytic & Aplastic anemia, granulocytopenia, thrombocytopenia Risk of _________ in newborns if taken at end of pregnancy |
Hematopoietic
kernicterus |
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Sulfonamides - combination drugs
_________ - inhibits bacterial dihydro folic acid reductase _________ - inhibits activity of dihydro folic acid reductase of protozoa Trimethoprim + sulfonamide or Pyrimethamine + sulfonamide = results in marked enhancement of activity of both drugs Combination, _________ compared to bacteriostatic activity of sulfonamides |
TRIMETHOPRIM
PYRIMETHAMINE bactericidal |
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Sulfonamides - Trimethoprim Clinical Uses
Trimethoprim: Can be given alone in ____ Dose - ________ Trimethoprim/Sulfamethoxazole: Pneumocystis Carini Shigellosis Salmonella Respiratory Organisms Haemophilus species Moraxella catarrhalis Klebsiella (but not mycoplasma pneumoniae) |
UTI
100mg po bid |
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Sulfonamides - Trimethoprim
UTI: Bactrim DS (Trimethoprim ____/sulfamethoxazole ____) given q12hrs Prophylaxis of recurrent UTI: ___ tab Bactrim DS 3x/wk x months Salmonella/shigella: Bactrim DS _______ Pneumocystis Carini: ____ trimethoprim / ____ sulfamethoxazole per 5ml in 125ml D5W over 60-90mins |
Trimethoprim 160mg / sulfamethoxazole 800mg
0.5 tab 1 tab q12hrs 80mg trimethoprim / 400mg sulfamethoxazole |
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Sulfonamides - Trimethoprim
Pneumocystis Carini: 80mg trimethoprim/400mg sulamethoxazole per 5ml in 125ml D5W over 60-90mins Dose: 5mg/kg 3-4x/day based on ________ portion of agent Typical dose: __________ |
Trimethoprim
15-20ml IV q6-8hrs |
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Sulfonamides - Trimethoprim Adverse Effects
________ N/V Vasculitis ____ damage ____ pts –fever, rashes, leukopenia, diarrhea |
Leuokopenia
Renal AIDS |
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Acetaminophen Antidote:
N-Acetylcysteine (_________) - also for carbon tetrachloride OD LD: __________ MD: __________ Admit pt for 3 days _______ - IV form dose: ________ admit for only 1 day |
Mucomyst
140 mg/kg PO 70 mg/kg q4hr for 17 doses Acetadote 150 mg/kg over 1 hr then 50 mg/kg over 4 hrs then 100 mg/kg over 16 hrs |
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Acetaminophen Overdose:
Peds - follow adult dosing dilute to 5% ineffective if _________ is used prior to administration If pt vomits w/in 1 hr - _________ |
activated charcoal
repeat dose |
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Potential hepatotoxic serum acetaminophen leves at intervals after ingestion:
4 hr - 6 hr - 10 hr - 20 hr - 24 hr - dont check levels earlier than ___ b/c hasnt reached peak yet |
150 mcg/mL
100 mcg/mL 50 mcg/mL 8 mcg/mL 3.5 mcg/mL 4 hrs |
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Acetaminophen Overdose:
administer Mucomyst for levels > ____ at ___ hrs toxic concentrations w/ probably hepatoxicity - _________ |
150 mcg/mL at 4 hrs
> 200 mcg/mL at 4 hrs or 50 mcg/mL at 12 hrs |
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Mucomyst: other indications
adjunctive mucolytic therapy in pts w/ abnormal or viscid mucous secretions such as _________ or _________ Usual Dose: nebulize _______ |
COPD or Cystic fibrosis
6-10 mL of 10% solution OR 3-5 of 20% solution |
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Mucomyst: other indications
prevention of radio contrast induced renal dysfunction Dose: ________ beginning the day before the procedure dilute with juice or soda |
600 mg PO bid x2 days
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Ethylene Glycol/Methanol Antidote: _______
LD - ________ MD - non drinkers ________ MD - dialysis pts ________ MD - alcoholics ________ MD - alcoholics on dialysis ________ |
Ethanol
600-700 mg/kg IV/NG/PO non drinker: 66-154 mg/kg/hr alcoholics: start at 154 mg/kg/hr dialysis pts: 169 mg/kg/hr alcoholics on dialysis: 257 mg/kg/hr |
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Ethanol:
has great affinity for enzymes responsible for methanol metabolism (ADH) give IV or PO to maintain Ethanol level at > _______ thereby saturating ADH w/ Ethanol in the liver Give Ethanol when: methanol level is > _____ greater than _____ has been ingested when acidosis or visual disturbances are present in suspected methanol poisoning |
100 mg/dl
20 mg/ml 30 ml |
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continue tx unitl ethylene glycol or methanol level is < _____
Fomepizole (_______) inhibits elimination of ethanol administration w/ concomitant ethanol ingestion, not recommended since toxic ethanol levels may result Ethanol ADR: ________ - DIC, leukocytosis, leukopenia, thrombocytopenia ________ - a. fib, v. tach |
10 mg/dl
Antizol Hematologic Cardiovascular |
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Fomepizole (Antizol)
also an antidote for ethylene glycol or methanol OD IV dose: LD - ________ MD - ________ continue MD until level is < ______ & pt is asx w/ normal pH PO Dose: LD - _________ MD - _________ continue until levels are undectable OR LD - ________ MD - ________ continue for for up to 96 hrs |
LD - 15 mg/kg IV
MD - 10 mg/kg q12hr x 4 doses then 15 mg/kg q12hr 20 mcg/dl LD - 15 mg/kg PO q12hr MD - 5 mg/kg q12hr x 1 dose then 10 mg/kg q12hr LD - 10 mg/kg PO MD - 5 mg/kg bid up to 36 hrs then 10 mg/kg bid up to 96 hrs |
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Fomepizole (Antizol):
in cases of renal failure, _____ should be considered in addition to Antizol Monitor during Tx b/c of: severe metabolic acidosis elevated anion gap significant creatinine increase Check: urine oxalate plasma urinary osmolality renal/hepatic fxn serum electrolytes blood gases WBC in comatose pts, do an ____ Continue until ethylene glycol/methanol levels are < _____ |
dialysis
EEG 20 mg/dl |
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Fomepizole (Antizol):
Administer dilute doses in at least ____ NS or D5W, infuse over ____ Do not give w/ _____ b/c toxicity can occur a pre-existing ethanol level does not preclude the use |
100 ml
30 min ethanol |
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Fomepizole (Antizol) ADR:
____ - bradycardia, tachycardia, hypotension ____ - dizziness, HA, seizure, abnormal sense of smell, roaring in ears, agitation, anxiety _____ - lipid abnormalities, hypertriglyceridemia ____ - mild nausea, bad taste _____ - visual disturbances |
CV
CNS Endocrine GI Ocular |
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Rattlesnake/Copperhead Antidote: Polyvalent crotalid antivenim immune fab (________)
LD: _________ can repeat dose in 1 hr is sx are not controlled MD: _________ |
Crofab
4-6 vials over 1 hr 2 vials q6hrs for 18 hrs (3 more doses) |
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Rattlesnake/Copperhead Antidote: Crofab
use w/in ___ of snake bites local sx (______) & neuro manifestations (_____) improve during a 1 hr infusion local sx can recur in 6-18 hrs coagulopathy (________, _______) has been evident for up to 2 wks |
6 hrs
swelling myokimia thrombocytopeniz, hypofibrinogenemia |
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Crofab MOA:
bind & neutralize venom toxins facilitate the re-distribution & ulimate elimination from affected body tissue ADR: ________ Cost: 2 vials = $8920 |
hypersensitivity rxns
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Digoxin Antidote: Digoxin immue fab (_______)
_____ will bind approximately 0.5 mg digoxin or digitoxin DOSE (in vials): (serum digoxin conc [ng/ml] x wt [kg])/100 levels higher than ____ requires the antidote Normal dig level is 0.8-2 ng/mL toxic at > 3 ng/mL |
Digibind
38 mg 4-6 ng/ml |
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Digoxin Antidote: Digoxin immue fab ovine (_______)
available in 40 mg vials shorter half life dosing is same as Digibind costs less |
Digifab
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Digoxin Antidote
Infuse IV over _____ using 0.22 micron filter Life threatening - __ vials (760 mg) IV Adult or peds acute ingestion - if unknown amt give ___ vials (380-400 mg) IV, observe response then repeat prn Pediatric chronic toxicity - infants 20 kg or less give __ vial initially |
30 mins
20 vials 10 vials 1 vial |
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Methylphenidate (________) can cause ___________
also called MAOI crisis caused by inhibited uptake of serotonin |
Ritalin
Serotonin syndrome |
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Dehydroeipandrosterone (DHEA)
Indications (3) |
weight loss
aging Alzheimer's dz |
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Melatonin
Sleep Dose: __________ Jet Lag Dose: __________ |
.3-10 mg (max 20 mg)
5-8 mg |
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Feverfew
Garlic Gingseng Gingko Biloba |
All are CI w/ anticoagulants
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Echinacea - usually taken at the first sign of a cold
reduces ________ |
duration
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Gingko Biloba
Effects: increase blood flow decreased viscosity antioxidant effects Tx for cerebral insufficiency Dose: ___________ ADR: GI (______), ______ affects _______ fxn - causes bleeding |
120-240 mg given 2-3 divided doses
Nausea, vomiting platelets |
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Tetanus Prophylaxis:
if a bite in minor & the wound is clean, a shot is not indicated unless it has been _____ since last dose If wound is major and/or not clean, a prophylaxis Td shot is recommended if it has been more than ___ since last dose |
10 yrs
5 yrs |
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Rabies Immunization:
pts w/ a bite from a ______ dog are at higher risk for infxn Pre-exposure prophylaxis (3) Post-exposure prophylaxis (5) |
non-provoked
0, 7, 21 days 0, 3, 7, 14, 28 days |
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_______ is when you administer an antigen to the host to induce the formation of antibodies
can be inactivated (killed) or attuenuated (live) _______ is when you transfer immunity to a host animal or human immunoglobins are used IV Ig dose ________ |
active immunity
passive immunity 200-400 mg |
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all vaccinations doses are __________
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0.5 mL IM per dose
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Antidote for bradyarrhythmia-producing drugs (B-blockers, CCB, digitalis glycosides): _______
dose:_______ |
atropine sulfate
1-2 mg IV, repeat q15-30min prn |
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GI decontamination: ________
Iron overload: _______ Dose: _______ |
activated charcoal
deferoxamine mesylate (Desferal) 15 mg/kg/hr IV |
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Benzodiazepine antidote: ________
Dose: ________ Opoid antidote: _______ Dose: ______ Oral sulfonyurea antidote: _________ also used for diarrhea |
flumazenil (Romazicon)
0.2 mg IV over 30 secs naloxone (Narcan) 0.4-2mg IV, may repeat at 2-3min intervals up to 10 mins octreotide (Sandostatin) |
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Warfarin antidote: _______
dose: ________ Enoxaparin or Heparin Antidote: _________ |
phytonadione (vitamin K)
2.5-10mg SC/PO/IM rarely up to 50mg may repeat in 6-8hrs protamine sulfate |
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Polyenes (5)
1. Amphotericin B o Conventional Formulation (___________) o Lipid Formulations (_______,_______,_______) 2. __________ |
Fungizone
Abelcet, Ambisome, Amphotec Nystatin |
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Polyenes (5)
MOA: binds to ________ causing loss of cell membrane integrity and leakage of cellular contents (cell dies). |
ergosterol
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_________
o Ampho B -- Conventional formulation o More ________than lipid formulations (use lower doses) o Requires test dose – _ mg in __ ml D5 over 20-30min |
Fungizone
nephrotoxic 1mg in 20ml |
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Fungizone
o Adverse Effects: o ________/electrolyte imbalance – supplement with K/Mg o ___-like sx – give benedryl or Tylenol o Extravasation o ______tension o GI effects – N/V/D |
Nephrotoxic
Flu Hypotension |
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Fungizone
Dose Available __only General dosing: o _______ mg/kg/day IV o Empirical tx (neutropenic pt) Low dose o Proven fungal inf. high dose __________ o total dose up to 3.6g over 11 months ___fungal infection (severe) o 0.01-0.1 mg ______Q 48-72 hrs _____ fungal infection (severe) o LD: 5mg _______ injection o MD: 50mg daily _____________(severe) o 30-50mg diluted in 20-100ml sterile H2O o Administration: BLADDER IRRIGATION |
IV
0.25 – 1 mg/kg/day IV Aspergillosis CNS : INTRATHECALLY Lung : INTRACAVITARY Urinary Tract Mycosis |
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Fungizone
Indications Potenially life-threatening fungal infections **___________** Candidiasis (if life threatening) _____________ Cryptococcosis Amer Mucocutaneous ___________ ____________ Basidiobolus infection Conidiobolus infection Mucomycosis N. Amer Blastomycosis Sporotrichosis all dosed .25-1 mg/kg/day IV |
Aspergillosis
Coccidioidomycosis leishmaniasis Histoplasmosis |
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Lipid Formulations (Abelcet, Amphotec, Ambisome)
o Less ________– can use higher doses o Expensive o Adverse Effects: o Hypotension o GI: N/V/D |
nephrotoxic
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Lipid Formulations (Abelcet, Amphotec, Ambisome)
General Dosing: o_______ mg/kg/day IV |
3 – 5 mg/kg/day IV
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Lipid Formulations (Abelcet, Amphotec, Ambisome) Indications:
Patients with severe fungal infections who are unable to tolerate __________ |
conventional formulation (Fungizone)
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Abelcet
o Ampho B -- Lipid Complex General dosing: o __ mg/kg/day IV TX: ___________ Blastomycosis Candidiasis _____________ Leishmaniasis Systemic _________ |
5 mg/kg/day IV
Aspergillosis Cryptococcal meningitis mycosis |
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___________
o Ampo B – Cholesterol Sulfate Complex o Not used much due to infusion reactions Aspergillosis o ____ mg/kg/day o MAX: 7.5 mg/kg/day Candidiasis (non-FDA) o _______ mg/kg/day |
Amphotec
3-4 mg/kg/day 3.9 – 6 mg/kg/day |
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________
o Ampo B – Liposome Cryptococcal meningitis (HIV) o ___ mg/kg/day IV once daily _________(Aspergillus, candida, or Cryptococcus) o 3-5 mg/kg/day Visceral ____________ Mycosis, empiric tx for __________ o 3 mg/kg/day o immunocomp: 4mg/kg/day |
Ambisome
6 mg/kg/day IV once daily Systemic mycosis leishmaniasis febrile neutropenia |
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Nystatin (Mycostatin)
o Not used to tx _______ inf. o Topical & Oral suspension o Low cost o Adverse Effects o Oral: N/V/D o Topical: ____, skin irritaion |
systemic
rash |
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Nystatin (Mycostatin)
Oral ______ (Candidiasis) Candida __________ Candidiasis of skin GI _________ ___________ Candidiasis ***Not Used for Systemic Infections |
Thrush
Vaginitis Mycoses Mucocutaneous |
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Nystatin (Mycostatin)
Candida Vaginitis o vaginal cream (100,000 U/g) o _________ daily |
100,000 units VAGINALLY qd
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Nystatin (Mycostatin)
Mucocutaneous Candidiasis o Apply powder ______daily to affected area Candidiasis of skin o *same dose as above* |
2-3 x
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Nystatin (Mycostatin)
GI Candidiasis (non-esophageal) o Oral suspension (100,000 U/ml) o ___________ tid SWISH & Swallow Oral Candidiasis o ___________ units suspension qid OR o 200,000-400,000 U troche units 4-5 x daily |
500,000 U (5ml) – 1,000,000 U (10ml) tid SWISH & Swallow
300,000 – 400,000 |
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Antifungals: Echinocandins (3)
MOA: Blocks the synthesis of β (1.3)-D-glucan, an important part of the________ o Excellent coverage of ________species o Advantages: improved safety profile and limited drug interactions o Disadvantage: poor _________ (must be given IV) |
cell wall
Candida PO bioavailability |
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Caspofungin (________)
o Safety Concerns o Adjust for ________ insufficiency (35mg MD) o ________ rxns o No need to adjust in renal insuff. o Better SE profile |
Cancidas
hepatic Infusion site |
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Caspofungin (Cancidas)
Indications Refractory invasive _________ Candidal septicemia Candidal intra-abdomina ____________ __________(empirical tx) |
Aspergillosis
abcess or peritonitis Febrile Neutropenia |
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Caspofungin (Cancidas)Dose
Available IV only Typical dose o LD: __ mg IV (day 1) o MD: __ mg daily Esophageal Candidiasis o 50mg daily o ________ better (PO) |
LD: 70mg IV (day 1)
MD: 50 mg daily diflucan |
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Micafungin (_________)
o _________dosing o Safety concerns: o ___________rxns o ___________rxns o Exacerbation of ________ impairment |
Mycamine
Prophylaxis Infusion site Hypersensitivity renal |
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Micafungin (Mycamine) IV ONLY
Prophylaxis for Candidiasis o Stem Cell Transplant o __ mg daily Esophageal Candidiasis o ___ mg daily |
50 mg daily
150 mg daily |
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Anidulafungin (_________)
o Has shown superiority over diflucan in tx of ________ o Safety concerns o Worsening of _______ fxn |
Eraxis
candidemia hepatic |
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Anidulafungin (Eraxis)
Available IV only Candidemia & ________ disseminated candidiasis o LD: ____mg (day 1) o MD: ____mg daily Esophageal Candidiasis o LD: ____mg (day 1) o MD: ___ mg daily |
Intra-abdominal and peritoneal
LD: 200 mg (day 1) MD: 100 mg daily LD: 100mg (day 1) MD: 50 mg daily |
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Antifungals: Antimetabolites (1)
MOA: Converted to 5-fluorouracil inside the fungal cell and inhibits thymidylate synthetase and interferes with ________ Flucytosine (______) |
DNA synthesis
Ancobon |
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Flucytosine (Ancobon)
Rarely used due to SE and limited indications Used in combo with _____ for severe infections Drawbacks: ______ quickly develops Extreme caution with _______ Adverse Effects: Skin Dz GI: _____ Elevated _______ Cardiotoxicity Leukopenia, Thrombocytopenia Neurological Complications |
Ampho B
Resistance renal impairment N/V/D liver enzymes |
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Flucytosine (Ancobon): Dosing
Candidiasis (meningitis or pulmonary) Cryptococcosis (septicemia, endocarditis, UTI, pulmonary) - _________ |
50 – 150 mg/kg/day PO in 4 equal doses
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Antifungals: Triazoles (5)
MOA: Block the activity of 14-α-demethylase which inhibits ________ synthesis (an essential part of the cell membrane) all triazoles impact __ system |
ergosterol
CYP |
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Antifungals: Triazoles
Fluconazole (______) DOC for ________ Effective against most Candida species EXCEPT: C. krusei C. glabrata Good coverage of Cryptococcus PO is less expensive Drawbacks: Inhibitor of CYP3A4 (weak) and CYP2C9 (strong) -- Drug interactions Does not cover ____ Renal elimination – adjust dose in _________ Adverse Effects: Thrombophlebitis (IV) GI Rash ______ |
Diflucan
Candida albicans molds renal insufficiency SJS |
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Antifungals: Triazoles
Fluconazole (Diflucan) - dosing Available IV & PO Candida Vaginitis - ________ Esophageal or Oral Candidiasis - LD: ________ MD: ________ Candiduria - _______ Prophylaxis for Candidiasis (bone marrow transplant) - ___________ Cryptococcal Meningitis (severe) - LD: ______ MD: ______ Disseminated Candidiasis (severe) - _________ |
150 mg PO 1 x dose
LD: 200 mg IV/PO MD: 100 mg QD 50-200 mg IV/PO QD 400 mg IV/PO qd LD: 400 mg IV/PO MD: 200 mg qd 400 mg IV/PO qd |
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Antifungals: Triazoles
Fluconazole (Diflucan) - Indications Candidiasis - Generally 1st line in tx of ______ ________ infections |
C. albicans
Cryptococcal |
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Antifungals: Triazoles
Itraconazole (_______) Broader spectrum than Diflucan Covers ________ Covers C. glabrata Drawbacks: Does not cross ____ – not effective against cryptococcal meningitis Strong inhibitor of CYP3A4 Decreased PO absorption with drugs that _____ gastric pH Adverse Effects: Nausea and abd discomfort _________(limits use) Hypokalemia |
Sporanox
aspergillus BBB increase Hepatic toxicity |
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Antifungals: Triazoles
Itraconazole (Sporanox) - dosing Available PO & IV Aspergillosis, Blastomycosis, Histoplasmosis PO: ________ IV: ________ Febrile Neutopenia (empiric tx) IV: ________ Onychomycosis (fingernail) - __________ Onychomycosis (toenail) - ________ Tinea - _______ Oral Candidiasis - ____________ Esophageal Candidiasis - _________ |
PO: 200 mg qd or bid
IV: 200 mg bid for 4 doses; then 200 mg qd 200 mg bid for 4 doses; then 200 mg qd 200 mg BID x 1 wk, 3 wks off, then 200 mg BID x 1 wk 200 mg qd x 12wks 200 mg qd 200 mg solution swish/swallow qd 100-200 mg swish/swallow qd |
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Antifungals: Triazoles
Voriconazole (______) Spectrum similar to itraconazole (broader than diflucan) but better coverage of: Aspergillosis Fusarium Can switch from ______ as sx improve Reserved for very sick – can send home if need – change IV to PO Adverse Effects: ______ disturbances Rash Photosensitiviy Increased transaminase (______) |
Vfend
IV to PO Visual elevated LFTs |
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Antifungals: Triazoles
Voriconazole (Vfend) Available IV & PO Invasive Aspergillosis, Disseminated Candidiasis, Fusarium infection, Monosporium apiospermum infection - ________ Candidal Septicemia - _________ Esophageal Candidiasis - _______ (pt >40kg) _______ (pt <40kg) IV to PO step-down - _______ (>40kg) _______ (<40kg) |
6 mg/kg IV q 12hrs for 2 doses; then 4 mg/kg IV Q 12hrs
6 mg/kg IV q 12hrs for 2 doses; then 3 mg/kg IV Q 12hrs 200 mg PO q 12hrs (pt >40kg) 100 mg PO q 12hrs (pt <40kg) 200-300 mg PO q 12hrs (>40kg) 100-150 mg PO q 12hrs (<40kg) |
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Antifungals: Triazoles
Voriconazole (Vfend) - indications ______(DOC along with Ampho B) Fusarium Monosporium apiospermum Candida species resistant to _________ |
Aspergillosis
Fluconazole |
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Antifungals: Triazoles
Ketoconazole (______) Seldom used PO due to adverse events - Fatal ________ Effective as a topical tx Effective against dimorphic fungi: Histoplasmosis Blastomycosis Coccidioidomycosis Not for use in _______ (no IV formulation) Adverse Effects: Fatal hepatic necrosis Decrease ________ levels Inhibit steriodogenesis and decrease plasma cortisol Anorexia, N/V Dizziness Pruritis/rash Decreased ______ _____ irregularities |
Nizoral
hepatic necrosis systemic infections testosterone libido Menstrual |
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Antifungals: Triazoles
Ketoconazole (Nizoral) Available PO & Topical PO Dose: ________ Candidiasis of the skin - ______ daily Dandruff - _____ daily to wet hair Pityriasis Vesicolor - _____ daily to damp skin Seborrheic Dermatitis - ________ daily Tinea - _______ OR _______ |
200-400 mg qd
2% cream topically 2% shampoo 2% shampoo 2% cream or gel 2% cream daily OR 200-400 mg PO daily |
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Antifungals: Triazoles
Posaconazole (_______) New in market Used prophylaxis during ________ Good coverage of yeasts and molds Safety concerns: Severe _______ reactions Drug interactions (CYP3A4) ________, ____ |
Noxafil
neutropenia hepatic Arrythmias, QT |
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Antifungals: Triazoles
Posaconazole (Noxafil) Available in Oral suspension only Dose - _________ Indications: Disseminated _______(prophylaxis in severely immunocompromised) ________(prophylaxis) |
200 mg (5ml) orally tid
Candidiasis Aspergillus |
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o Candida
o C. albicans __________ is DOC |
Fluconazole (Diflucan)
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o Aspergillosis (typicall __wks of therapy)
o DOC: Conventional Ampho B (________) • 1 mg/kg/day IV (increase to 1.5 if low dose not working) _________(Vfend) • 6 mg/kg IV q 12hrs x 2; then 4 mg/kg IV q12hrs • Switch to PO with sx improvement (200 mg PO bid) |
10 WKS
Fungizone Voriconazole |
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Aspergillosis
Alternatives ________ (Sporanox) • ____ mg IV q __ hrs x 2; then 200 mg IV qd OR 200mg PO tid _________(Cancidas) • __ mg IV x 1; then __ mg IV qd |
Itraconazole
200 mg IV q 12hrs x 2 Caspofungin 70mg IV x 1; then 50 mg IV qd |
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o Cryptococcosis
o DOC is a combination of the following ________ 0.5-1 mg/kg/day IV __________(Ancobon) • 100 mg/kg/day PO for 2 weeks THEN __________ • 400 mg PO pd for 8wks (take @ home) |
Conventional Ampho B (Fungizone)
Flucytosine Fluconazole (Diflucan) |
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o Cryptococcosis
o Alternatives _________ – can use in place of fluconazole • ___ mg PO bid |
Itraconazole (Sporanox)
200 mg PO bid |
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o Blastomyces
o DOC: Itraconazole (Sporanox) • ___mg PO bid for ____months Ampho B (Fungizone) • ______mg/kg/day IV for ________wks o Alternatives Fluconazole • ______ mg PO qd |
200 mg PO bid for 6-12 months
0.5 -1 mg/kg/day IV for 6-12 wks 400-800 mg PO qd |
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o Histoplasmosis
o DOC __________(Sporanox) • 200 mg PO bid for ___ months Ampho B (________) • 0.5 – 1 mg/kg/day IV for ____ wks o Alternatives __________ • 400-800 mg PO qd |
Itraconazole
6-18 Fungizone 10-12 Fluconazole |
