Therapeutics Winter Test 2

Front 1

Risk factors for Infection with TB

Back 1

1) immunocompromised (transplant, '-mabs')
2) close contacts with pulmonary TB patients (family, homeless, jail, nursing homes)
3) History of or current alcoholism or IVDA
4) co-infection with HIV/AIDS
5) foreign born (mexico, philippines, vietnam, india, china)

Front 2

Risk Factors for Disease with TB

Back 2

1) Lifetime risk of active TB-10%
2) Immunosuppression
3) HIV/AIDS

Front 3

Pathogen that causes TB (Acid Fast Bacilli)

Back 3

Mycobacterium tuberculosis

Front 4

Transmission of TB

Back 4

1) coughing
2) person-to-person via inhalation
3) close contacts

Front 5

Pathophys of TB

Back 5

1) Immune Response
2) Primary Infection
3) Reactivation

Front 6

Immune Response for TB

Back 6

-T-lymphocyte resonse REQUIRED
-CD4 lymphocytes secrete interferon gamma to activate macrophages
-macrophages encase granulomas

Front 7

Primary Infection for TB

Back 7

-organism transported to lymph nodes or spread thru blood
-likes upper lobes of lungs

Front 8

Reactivation for TB

Back 8

-organism emerges from granuloma
-inflammatory response causes caseating granulomas
-cytokines/lysozymes released causing necrosis and collapse
-hypoxia, respiratory acidosis, death

Front 9

HIV/AIDS and TB

Back 9

CD4 cells depleted = poor immune response
CD4 cells multiply, HIV replicates
HIV replication accelerates patient deterioration

Front 10

Clinical Presentation of TB

Back 10

1) weight loss, fatigue, productive cough/possible blood, fever, night sweats
2) dullness to chest percussion, rales
3) elevated WBC

Front 11

Gold Standard of diagnosis of TB

Back 11

Sputum culture - daily collection for 3 days

Front 12

Tuberculin Skin Test

Back 12

Tissue hypersensitivity occurs once an adequate number of CD4 lymphocytes are activated

1) Quantitative
2) Intracutaneous injection of PPD
3) induration (bump) measured after 48-72 hours

Front 13

PPD induration >/=5mm as Positive

Back 13

1) HIV infection
2) recent contact w/ active TB infected person
3) changes on CXR consistent w/ prior TB
4) organ transplant patients receiving >/= 15mg/day of prednisome for >1 month
5) immunosuppressed

Front 14

PPD induration >/= 10mm as Positive

Back 14

1) recent immigrants (<5 years)
2) IVDA
3) residents and employees of prisons, nursing homes, LTCF
4) healthcare workers
5) patients with high risk conditions
6) children <4yrs, infants, high-risk adolescents

Front 15

PPD induration >/=15mm as positive

Back 15

1) Persons with no risk factors for TB

Front 16

First line agents for treatment of TB

Back 16

RIPE:
Rifampin
Isoniazid
Pyrazinamide
Ethambutol

Front 17

Rifampin in TB

Back 17

Daily Dose: 600mg PO daily

MOA: bactericidal; inhibits DNA-dependent RNA polymerase

ADRs: Gi upset, hepatotoxicity, rash, orange discoloration of body fluids

Front 18

Drug interactions with TB

Back 18

1) Protease Inhibitors - can use rifabutin
2) NRTIs - doses of NRTIs increased
3) fluconazole - dose adjusted
4) warfarin - REALLY increase dose of warfarin
5) digoxin
6) Benzos

Front 19

Isoniazid in TB

Back 19

Dose: 300mg PO daily

MOA: bactericidal; disrupts cell wall synthesis via inhibition of mycolic acid synthesis

ADRs: hepatotoxicity, hepatitis, peripheral neuropathy

Front 20

Pyridoxine 50mg PO daily

Back 20

given with isoniazid to prevent peripheral neuropathy

Front 21

Pyrazinamide in TB

Back 21

DOSE: 25 mg/kg PO daily, max 2000mg

MOA: bactericidal; exact unknown

ADRs: GI upset, arthralgias, hepatotoxicity

Front 22

Ethambutol in TB

Back 22

DOSE: 15 mg/kg PO daily, max 1600mg

MOA: bacteriostatic, inhibits enzymes involved in biosynthesis of cell wall

ADRs: optic neuritis, decreased visual acuity or red-green discrimination

Front 23

Second line agents in TB

Back 23

1) Streptomycin
2) Fluoroquinolones

Front 24

Non-Pharm intervention for TB

Back 24

**Infection Control**
1) negative pressure rooms
2) N-95 masks
3) BCG vaccine
4) report to department of health

Front 25

Directly Observed Therapy in TB

Back 25

health department provides meds directly to patient and observes them swallowing the meds

Recommended: treatment failure, HIV co-infection, history of non-adherence

Front 26

Latent TB infection

Back 26

Isoniazid preferred treatment (plus pyridoxine)

Front 27

Treatment of Latent TB with HIV

Back 27

a) Isoniazid 300mg PO qd x 9 months
b) Isoniazid 900mg PO twice weekly x 9 months (DOT)

Front 28

Treatment of Latent TB with no risks

Back 28

a) Isoniazid 300mg PO daily x 6 months
b) Isoniazid 900mg PO twice weekly x 6 months (DOT)

Front 29

Optional treatment of Latent TB in INH resistant

Back 29

Rifampin 600mg daily x 4 months
Isoniazid/rifapentine 900mg/900mg PO once weekly x 3 months (DOT)

Front 30

Monitoring in Latent TB treatment

Back 30

Monthly: ADRs, LFTs, Progression to active (symptoms)

Front 31

Treatment of Active TB

Back 31

Initial: RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) x 2 months

Continuation: Rifampin + Isoniazid x 4 months

**Best case scenario**

Front 32

Cystic Fibrosis

Back 32

most common lethal, genetically inherited disease in caucasian population

Front 33

Inheritance Patterns for CF

Back 33

via an autosomal recessive mode

Front 34

Cellular Pathophys of CF

Back 34

1) not all CFTRs work correctly
2) get some Chloride (most stays in)
3) get some Sodium (most stays in)
4) bulk stays intracellular
5) H2O doesn't move out (stays in)
6) No water in lumen = Increased concentration of NaCl

Front 35

Gold standard for diagnosis of CF

Back 35

Sweat test 60 mEq/L or higher

Normal: 30-40 mEq/L

Front 36

Effect of CF on the body

Back 36

1) Respiratory system
2) Reproductive System
3) Exocrine/Endocrine System
4) GI system
5) Pulmonary System

Front 37

Effect on Reproductive System in CF

Back 37

1) late maturation in both genders (delayed puberty to 16-18 years old)
2) 90% of males are sterile, 60% females can't have kids
3) No known treatments

Front 38

Cystic Fibrosis Related Diabetes Mellitus

Back 38

1) may be asymptomatic
2) symptomatic if untreated T2DM

Front 39

Treatment of CFDM

Back 39

Insulin therapy automatically

1) humulin R or Humalog on sliding scale in hospital
2) Split mixed dosing with Humulin N and Humulin R OR 1 dose Lantus with premeal Humalog

Front 40

GI System involvement in CF

Back 40

related to viscosity of mucus secretions and deficiency of pancreatic enzymes to aid in digestion

initially related to increased viscosity = meconium ileus OR distal intestinal obstructive syndrome later in life

Front 41

GI involvement in CF - peancreatic enzyme deficiency leads to

Back 41

Fat malabsorption also leads to decreased absorption of hte four fat soluble vitamins

Vitamins A, D, E, K

Front 42

Treatment of GI issues in CF

Back 42

1) Nutrition - high in calories, easily absorbed (Ensure)
2) Vitamin Replacement - A, D, E, K separately; AquaDEK daily
3) Pancreatic Enzyme Replacement

Front 43

Pancreatic Enzyme Replacement

Back 43

Dose based on number of Lipase units

products are microencapsulated

Front 44

Dosing for Pancreatic Enzyme Replacement

Back 44

Infants: 2000-4000 units lipase per 120ml bottle

Weight based:
1) 1000 units lipase/kg prior to each meal
2) 500 units lipase/kg prior to each snacks

Front 45

Pulmonary System in CF

Back 45

closely related to morbidity and mortality

thickened mucus in the lungs is problematic for 2 reasons
1) Chronic 2) Acute

Front 46

Chronic Pulmonary Issue

Back 46

mucus makes gas exchange difficult and makes patient hypoxic which creates a COPD-like syndrome

Cor Pulmonale
(Colonization)

Front 47

Acute Exacerbation of Pulmonary Issue in CF

Back 47

Pathogen: Pseudomonas

Treatment: combo therapy must be used and must cover to assume pseudomonas

Front 48

Treatment of Acute Exacerbation of Pulmonary Issue in CF

Back 48

1) aminoglycoside (tobramycin) and extended spectrum PCN (zosyn)

2) aminoglycoside (tobramycin) and 3rd/4th gen ceph (ceftazidime)

Front 49

Tobramycin dosing in CF

Back 49

Initial: 7.5-9 mg/kg/day divided Q8 or Q12 h

Target Peaks 10-14 mcg/ml

Duration: 14-21 days

Front 50

Cornerstone of therapy in Chronic pulmonary issues in CF

Back 50

percussion and postural drainage

*less obstruction from air exchange
*decrease amount of media for bacterial growth
*dislodges mucus manually and allows to be spit out (2-4 x/day)

Front 51

Percussion and Postural drainage

Back 51

1)Precede with nebulization with sterile water or 0.9% NaCl
2) prior to one session receive nebulized Pulmozyme (DNase)
3) pound on back for 30 minutes

Front 52

Pulmozyme (DNase)

Back 52

reduces viscosity of CF sputum

lengthens time between acute exacerbations and improve QOL

2.5mg daily or BID

Front 53

Colonization in Pulmonary Issues in CF

Back 53

*Pseudomonas predominates
*Acute exacerbation - overgrowths
*chronic oral antibiotics - not used

Front 54

Use of Tobramycin nebulizations for colonization in CF (TOBI)

Back 54

6+ years having a high number of exacerbations in a short period (4 in 6 months or 6 in 1 year)

300mg BID for 28 days, off for 28 days

Front 55

Hypertonic (7%) Saline in CF

Back 55

1) some may benefit but not standard of care
2) MOA: pulls extra water to mucus layer
3) May trigger bronchospasm

Front 56

Long term Ibuprofen therapy in CF

Back 56

1) shown to slow pulmonary deterioration due to anti-inflammatory effects
2) Target serum: 50-100 mcg/dL
3) Dose: 20-30 mg/kg/dose BID to TID

Front 57

Azithromycin in CF

Back 57

1) increase FEV1 and overall lung function
2) doesn't decrease Pseudomonas
3) predominantly anti-inflammatory
Dose: less 40kg: 250 mg daily on M, W, F
40kg or over: 500 mg daily on M, W, F

Front 58

Ivacaftor (Kalydeco) in CF

Back 58

MOA: potentiates the CFTR in patients with G551D mutation
Indicated: patients 6+ years old with G551D mutation

Dose: 150 mg q12h with fat containing foods (must also take pancreatic enzyme)

Metabolized: CYP3A4
Monitor: Liver enzymes @ baseline, q3months for 1st year, annually

Front 59

Risk Factors for Otitis Media

Back 59

1) Young age
2) Males > Females
3) Winter
4) Race
5) Poor population
6) Environmental (mom smokes, Downs Syndrome, cleft palate, allergy, recurrent URI, day care, HIV)

Front 60

Function of Eustachian Tubes

Back 60

1) maintain equilibrium of the pressure between middle ear and nasopharynx
2) Clear secretions from middle
3) prevent reflux of nasopharyngeal secretions

Front 61

Pathophys of Otitis media

Back 61

1) infection of upper respiratory process of the respiratory mucosa
2) Congestion and obstruction of eustachian tubes
3) acute suppurative infection

Front 62

Children and infants more prone to otitis media

Back 62

1) difference in angle of eustachian tube (10 vs 45 degrees)
2) improper drainage
3) increased risk of reflux (short tubes, supine position while feeding, bottle feeding)

Front 63

Most common pathogens for causing Otitis Media

Back 63

1) STREP PNEUMONIAE
2) H. influenza
3) Moraxella

Front 64

Signs/Symptoms of Otitis Media

Back 64

1) onset after a head cold
2) rhinitis
3) cough
4) ear pain and ear pulling/rubbing
5) vomiting/diarrhea
6) fever

Front 65

Appearance of Tympanic membrane in acute otitis media

Back 65

red
bulging
impaired mobility
can't see features

Front 66

Intracranial complications of AOM

Back 66

All are rare with right treatment
1) meningitis
2) abscesses
3) otitis hydrocephalus
4) lateral sinus thrombosis
5) focal encephalitis

Front 67

Extracranial complications of AOM

Back 67

1) tympanic membrane perforation
2) mastoiditis
3) facial paralysis
4) hearing loss

Front 68

Children at highest risk for Drug Resistant Strep pneumoniae (DRSP)

Back 68

1) < 4 years especially with recurrent AOM
2) treated with multiple antibiotics
3) attend large day care centers

Front 69

Primary change in therapy for AOm

Back 69

try to wait 48 hours before starting antibiotic treatment

Front 70

Supportive care of AOM

Back 70

1) Antihistamines/decongestants - not beneficial

2) Antipyretics/Analgesics - comfort

3) Analgesic/anesthetic ear drops - use cautiously

Front 71

Dosing of a) tylenol for kids and b) ibuprofen

Back 71

a) 10-15 mg/kg/dose q4-8 hrs prn

b) 5-10 mg/kg/dose q6-8 hrs prn

Front 72

Analgesic/anesthetic ear drops for AOM

Back 72

use for 1-2 days or pain
may mask symptoms of possible worsening
1) Auralgan
2) Typangesic

Front 73

Step one of treatment AOM

Back 73

**Determine Severity**
1) Severe - mod/severe pain OR fever >/= 102.2 (39)

2) Non-Severe - mild pain AND temp < 102.2 (39)

Front 74

first type of treatment recommended in a children with unilateral AOM without otorrhea (drainage)

Back 74

Observation

Front 75

Treatment of AOM

Back 75

Amoxicillin 90 mg/kg/day divided bid (or TID)

Front 76

Duration range of treatment for AOM

Back 76

7-10 days

Front 77

Kids at risk for Treatment failure in AOM

Back 77

1) < 2 years old
2) < 6 months at first onset
3) recurrent
4) bilateral disease
5) continuous antimicrobial therapy
6) large group day care centers

Front 78

Treatment for treatment failure in AOM

Back 78

Amoxicillin/Clavulanate 90 mg/kg/day divided BID

Front 79

Chronic Otitis Media

Back 79

>4 episodes in 6 months or >6 episodes in 12 months

Myringotomy tubes - allows drainage

Front 80

Causes of Otitis Externa

Back 80

1) introduction of sharp object into the ear canal (disrupts integrity of lining of auditory canal)

2) intro and accumulation of moisture in ear canal (softens lining of canal and provides medium for bacteria)

Front 81

Signs/Symptoms of otitis Externa

Back 81

1) pruritis
2) fullness
3) throbbing pain
4) hearing loss
5) Edema and erythema in canal
6) foul-smelling secretions

Front 82

Most common pathogens that cause otitis externa

Back 82

1) Pseudomonas
2) Staph aureus

Front 83

Treatment of Otitis Externa

Back 83

antibiotic and corticosteroid combination ear drops

Front 84

Single agent ear drops for otitis externa

Back 84

1) Floxin
2) Cipro

Front 85

Combo agent ear drops for otitis externa

Back 85

1) Colymycin S
2) Cortisporin
3) Ciprodex
4) Otic Tridesilon
5) Vosol HC

Front 86

General Ear Health - OTC (GENERAl CLEANING)

Back 86

1) normal washing is sufficient
2) do not insert anything into ear
3) gently flush with warm water via an ear bulb for excessive ear wax (Carbamide peroxide)