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256 Cards in this Set
- Front
- Back
Clinical importance:
Enterococci |
UTI
Endocarditis |
|
Clinical importance:
Group A Strep |
gram+
Cellulitis Pharyngitis |
|
Clinical importance:
Group B Strep |
gram+
neonatal sepsis |
|
Clinical importance:
Viridans strep |
gram+
endocarditis dental caries abscess |
|
Clinical importance:
Strep pneumo |
gram+ diplococci
CAP meningitis bacteremia/septic shock |
|
Clinical importance:
Staph aureus |
gram+
furunculosis (boils) cellulitis abscess endocarditis bacteremia |
|
Clinical importance:
coag-negative staphylococcus |
gram+
infection of prosthetic devices bacteremia |
|
Clinical importance:
E.coli |
gram-
UTI bacteremia/septic shock hemorrhagic colitis |
|
Clinical importance:
Klebsiella |
gram-
UTI pneumonia bacteremia |
|
Clinical importance:
Enterobacter/citrobacter |
gram-
UTI pneumonia bacteremia |
|
Clinical importance:
Pseudomonas aeruginosa |
gram-
UTI pneumonia bacteremia |
|
Clinical importance:
Neisseria meningitidis |
gram-
meningitis bacteremia/sepsis |
|
Clinical importance:
H.flu |
gram-
respiratory tract infections bacterial conjunctivitis otitis media |
|
most common organism(s) in bacterial conjunctivitis
|
Strep pneumo
Staph aureus H.flu |
|
Clinical importance:
Clostridium spp. |
anaerobe
intestinal disease tetanus botulism abscess abdominal sepsis |
|
Clinical importance:
Bacteroidies (e.g. fragilis) |
anaerobe
abscess abdominal sepsis soft tissue infections |
|
common bacterial pathogens:
burns |
Staph aureus
Pseudomonas aeruginosa |
|
common bacterial pathogens:
throat |
Streptococcus pyogenes (Group A Strep, =Strep throat)
|
|
common bacterial pathogens:
skin infections |
Staph aureus
|
|
common bacterial pathogens:
otitis media |
Strep pneumo
H.flu Moraxella |
|
common bacterial pathogens:
Pneumonia |
Strep pneumo
H.flu |
|
common bacterial pathogens:
endocarditis |
Staph aureus
Enterococcus faecalis Viridans strep |
|
common bacterial pathogens:
GI tract |
Salmonella enterica
H. pylori E.coli Shigella dystentariae C.diff |
|
common bacterial pathogens:
UTI |
Enterococcus
E.coli |
|
common bacterial pathogens:
Toxic Shock Syndrome |
Staph aureus
Strep pyogenes |
|
general mechanism of tetracycline antibiotics
|
protein synthesis inhibitors
bacteriostatic |
|
RULE OF THUMB COVERAGE:
Tetracyclines |
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 |
|
Clinical uses for tetracyclines
|
Acne
Chlamydia Rickettsial infections (Rocky Mtn Fever, typhus) Lyme Disease Atypical pneumonias (Mycoplasma pneumoiae & Chlamydia pneumoniae) H. pylori traveler's diarrhea anthrax (Bacillus anthracis) |
|
Which tetracycline antibiotic can be used in renal failure?
|
doxycycline (all others have prolonged t1/2 in renal failure)
|
|
tetracycline antibiotics administration
|
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) |
|
tetracycline antibiotics:
adverse effects? |
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) |
|
Tygacil
dosing? |
tigecycline (a glycylcycline, structurally related to minocycline)
100mg LD 50mg Q12H NOTE: prolonged post-antibiotic effect! |
|
tigecycline should not be used empirically for nosocomial pneumonia because...?
|
it is not active against Pseudomonas
|
|
tigecycline & UTI's
|
should not be used, poor urinary drug concentration
|
|
tigecycline metabolism & elimination
|
largely hepatic, ok to use in renal failure, no adjustment
note that clearance is inhibited in hepatic failure tigecycline does NOT affect P450 pathways |
|
tigecycline MOA
|
protein synthesis inhibitor
bacteriostatic |
|
RULE OF THUMB COVERAGE:
tigecycline |
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) |
|
tigecycline admin
|
IV
food does not affect pharmacokinetics, but even though tigecycline is IV, food may increase tolerability PAE |
|
adverse effects of tigecycline
|
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 |
|
tigecycline:
clinical uses |
only approved for complicated skin infections (e.g. MRSA) and complicated intraabdominal in resistant to other options (e.g. MRSA)
|
|
Most commonly isolated Enterococcus? DOC?
|
E. faecalis (80-85%)
Ampicillin +/- gentamicin |
|
DOC:
Staph aureus (MSSA) alternatives? |
Nafcillin
cefazolin Septra clindamycin vancomycin |
|
DOC:
Moraxella catarrhalis |
Septra
Augmentin doxycycline 2nd or 3rd Generation Cephalosporin erythromycin |
|
DOC:
Chlamydia spp. |
doxycycline
azithromycin erythromycin |
|
aminoglycosides MOA
|
inhibits bacterial protein synthesis
bactericidal requires oxygen-dependent transport system, so ineffective against anaerobes PAE |
|
aminoglycoside elimination
|
renal
|
|
aminoglycoside spectrum
|
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) |
|
side effects of Aminoglycosides
|
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) |
|
risk factors for Aminoglycoside-induced nephrotoxicity
|
prolonged duration of therapy
increased age pre-existing renal insufficiency concurrent use of other nephrotoxins volume depletion |
|
clinical uses of aminoglycosides
|
- 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 |
|
DOC:
Pseudomonas aeruginosa alternatives? |
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 |
|
AECB
|
Acute Exacerbations of Chronic Bronchitis
|
|
Macrolide spectrum
|
Strep
Staph E.coli H.flu Moraxella Neisseria H.pylori ATYPICALS Legionella Chlamydophila pneumoniae Mycoplasma pneumoniae |
|
telithromycin
|
ketolide macrolide
better coverage than other macrolides less susceptible to resistance mechanisms |
|
the only macrolide available in IV formulation
|
azithromycin
|
|
Erythromycin is now rarely recomoneded above otehr macrolides. Why?
|
more frequent GI side effects
QT prolongation (note: QT prolongation still occurs with other macrolides, but not as much) |
|
Macrolides & CYP enzymes
|
many drug interactions involving CYP 3A enzymes
the only macrolide that doesn't have this problem is azithromycin |
|
fatal interaction involving a macrolide
|
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 |
|
clinical use of macrolides
|
upper respiratory tract infections
treatment & prevention of MAC (mycobacterium avium complex) clarithromycin & azithromycin chlamydia (azithromycin) note: erythromycin used mostly ophthalmically now |
|
chloramphenicol MOA
|
protein synthesis inhibitor
|
|
chloramphenicol class
|
amphenicols
|
|
chloramphenicol spectrum
|
Strep
Staph Enterococcus E.coli H.flu Moraxella Neisseria Proteus Salmonella Shigella Stenotrophomonas ANAEROBES/B.frag ATYPICALS: Bacillus anthracis (anthrax) Listeria |
|
chloramphenicol adverse effects
|
N/V/D
hypersensitivity mental status changes fever headache serious blood dyscrasias gray syndrome |
|
gray syndrome
|
a serious side effect associated with chloramphenicol:
myocardial depression circulatory collapse cyanosis acidosis abdominal distension coma death |
|
chloramphenicol drug interactions
|
inhibits CYP 2C9 & 3A4
caution with substrates |
|
quinupristin/dalfopristin:
class MOA brand name |
streptogramin
inhibits bacterial protein synthesis Synercid |
|
quinupristin/dalfopristin:
clinical use |
complicated skin & skin structure infections caused by Strep pyogenes, Staph aureus
Sometimes used for MRSA bacteremia when resistant to vanco |
|
quinupristin/dalfopristin:
side effects |
COMMON:
hyperbilirubinemia arthralgia/myalgia LESS COMMON: headache rash N/V/D |
|
quinupristin/dalfopristin:
spectrum |
Strep
Staph MRSA Enterococcus Moraxella Legionella |
|
peri-operative antibiotic treatment usually begins ________ before surgery, and continues no longer than ________ after surgery
|
within 1 hour before
24 hours after |
|
antibiotic of choice for surgical prophylaxis
|
generally 1st or 2nd gen Cephalosporin (cefazolin, cefuroxime)
penicillin-allergic patients: vancomycin bowel surgeries: cefotetan (because of anaerobic coverage) |
|
empiric therapy:
outpatient skin/soft-tissue infection (cellulitis) |
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 |
|
empiric therapy:
inpatient skin/soft-tissue infection |
(MRSA risk compared to outpatient)
vancomycin OR linezolid IV or PO OR daptomycin OR televancin OR clindamycin Duration of therapy: 7 to 14 days |
|
definition: uncomplicated UTI
|
not associated with structural or neurologic abnormalities that may interfere with the normal flow of urine
|
|
definition: complicated UTI
|
generally results from an obstruction/abnormality or neurologic deficit of the bladder
|
|
cystitis
|
lower urinary tract infection
|
|
pyelonephritis
|
upper urinary tract infection
|
|
synonym for upper UTI
|
pyelonephritis
|
|
synonym for lower UTI
|
cystitis
|
|
typical symptoms of lower UTI
|
dysuria
urgency frequency burning nocturia suprapubic heaviness hematuria fever is UNCOMMON |
|
typical symptoms of upper UTI
|
flank pain
abdominal pain fever N/V costovertebral angle pain malaise |
|
acute, uncomplicated cystitis in females:
pathogens? treatment? |
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) |
|
acute, uncomplicated cystitis:
prophylaxis? |
if 3+ episodes in 1 year:
SMX/TMP SS daily OR macrodantin 50 mg daily OR 1 SMX/TMP post-coitus |
|
acute, uncomplicated cystitis in pregnancy
|
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 |
|
moxifloxacin dosing in cystitis
|
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) |
|
which 2 drugs should NOT be used in UTIs (that may be mistakenly prescribed because of their drug class)
|
MOXIFLOXACIN: does not reach high levels in urine
GEMIFLOXACIN: poor to limited activity against normal UTI pathogens |
|
ciprofloxacin vs. moxifloxacin vs. levofloxacin
which of these FQ's should NOT be used in UTI's? |
moxifloxacin:
does not reach high levels in urine (also do not use gemifloxacin; limited activity against normal UTI pathogens) |
|
ciprofloxacin vs. moxifloxacin vs. levofloxacin
which of the FQ's is/are considered "respiratory" fluoroquinolone(s)? |
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 |
|
ciprofloxacin vs. moxifloxacin vs. levofloxacin
which of these FQ's has/have activity against Pseudomonas aeruginosa? |
ciprofloxacin + levofloxacin
|
|
acute uncomplicated pyelonephritis pathogens & treatment
|
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 |
|
complicated UTI pathogens & treatment
|
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 |
|
when would an uncomplicated UTI require longer duration of therapy?
|
(longer than 3-5 days)
men pregnancy elderly diabetics children |
|
phenazopyridine class
|
azo dye & urinary analgesic
|
|
phenazopyridine dose & administration
|
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 |
|
Signs of acute otitis media in children
|
rapid onset
middle ear effusion fever middle ear inflammation tugging or rubbing ears crying |
|
Acute Otitis Media:
observation period |
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 |
|
Acute Otitis Media:
how do you treat pain in children? |
acetaminophen
or ibuprofen >5 years: can use topical benzocaine (Auralgan, Americaine otic) |
|
Acute Otitis Media:
primary treatment in children |
amoxicillin
90 mg/kg/day (divided Q12 or Q8) the higher dose will cover most Strep pneumoniae |
|
Acute Otitis Media:
When would you not use the standard treatment? |
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 |
|
Which of the Acute Otitis Media medications can be given for children who cannot tolerate oral medication?
|
ceftriaxone (Rocephin)
50 mg/kg (max 1000 mg/day) IV or IM x3 days |
|
Prevnar
|
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) |
|
When is Pneumovax recommended for children?
|
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 |
|
Infective Endocarditis is determined by __________?
Infective Endocarditis treatment is based on _________? |
the Modified Duke Criteria
AHA Guidelines |
|
PRIMARY DRUG REGIMEN FOR:
Infective Endocarditis due to Viridans strep? |
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) |
|
PRIMARY DRUG REGIMEN FOR:
Infective Endocarditis due to Streptococcus bovis? |
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) |
|
PRIMARY DRUG REGIMEN FOR:
Infective Endocarditis due to sensitive Enterococci |
(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) |
|
PRIMARY DRUG REGIMEN FOR:
Infective Endocarditis due to Enterococci that is resistant to gentamicin |
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) |
|
PRIMARY DRUG REGIMEN FOR:
Infective Endocarditis due to Enterococci that is resistant to PenG/ampicillin |
vancomycin 15 mg/kg Q12H
+ gentamicin 1 mg/kg IV Q8H (both x 6 weeks) |
|
PRIMARY DRUG REGIMEN FOR:
Infective Endocarditis due to Enterococcus faecium species that is resistant to penicillin, vancomycin, gentamicin |
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) |
|
When using gentamicin for synergy in the treatment of Infective Endocarditis, what are the goal peak and trough levels?
|
gentamicin peak levels:
do not need to exceed 4 mcg/mL (~3 mcg/mL is sufficient) gentamicin trough levels: < 1 mcg/mL |
|
Do not use _______________ dosing for aminoglycosides when treating Infective Endocarditis.
|
extended-interval dosing
|
|
Do not use extended-interval dosing for aminoglycosides when treating _______________.
|
Infective Endocarditis
|
|
Do not use extended-interval dosing for _________________ when treating Infective Endocarditis.
|
aminoglycosides
|
|
Why/when is prophylaxis for dental procedures recommended?
|
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 |
|
oral prophylaxis in dental procedures?
|
(for prevention of endocarditis or total joint replacement in last 2 years)
amoxicillin 2 g (adults) amoxicillin 50 mg/kg (children) |
|
prophylaxis for dental procedures in patients unable to take oral medication?
|
(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 |
|
prophylaxis for dental procedures in patients allergic to penicillins?
|
(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) |
|
prophylaxis for dental procedures in patients allergic to penicillins AND unable to take oral medications?
|
(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 |
|
classic triad of meningitis?
other sx of meningitis? |
fever
nuchal rigidity altered mental status OTHER SX: chills vomiting photophobia severe headache |
|
lumbar puncture in meningitis
|
mandatory for all suspected bacterial meningitis, helps differentiate between bacterial & viral; cultures & sensitivities
|
|
T or F:
A gram stain for meningitis is usually rapid and sensitive. |
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. |
|
general rule of thumb for antibiotic dosing for bacterial meningitis
|
maximize dosing (for optimal penetration of the CNS)
|
|
most likely organisms for bacterial meningitis?
|
Streptococcus pneumoniae
Neisseria meningitidis Haemophilus influenza Listeria monocytogenes |
|
EMPIRIC THERAPY:
acute bacterial meningitis |
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 |
|
EMPIRIC THERAPY:
acute bacterial meningitis with severe PCN allergy |
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 |
|
Rickettsia species are carried by ___________.
|
ticks, fleas, lice
|
|
TREATMENT:
Rocky Mountain Spotted Fever |
(a Rickettsial disease)
doxycycline 100mg BID PO/IV x 7 days |
|
TREATMENT:
Lyme disease |
(a Rickettsial disease)
doxycycline 100mg BID PO or amoxicillin 500mg TID PO (x 14-21 days) |
|
TREATMENT:
typhus |
(a Rickettsial disease)
doxycycline 100mg BID PO/IV x 7 days |
|
TREATMENT:
ehrlichiosis |
(a Rickettsial disease)
doxycycline 100mg BID PO/IV x 7-14 days |
|
TREATMENT:
tularemia |
(a Rickettsial disease)
gentamicin or tobramycin (5 mg/kg/day div. Q8 IV x 7-14 days) |
|
Systemic fungal infections usually don't occur unless __________________.
|
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%) |
|
Aspergillus
|
fungal spp.
|
|
Candida
|
fungal spp.
|
|
Crytococcosis
|
fungal spp.
|
|
Coccidiodomycosis
|
fungal spp.
|
|
Histoplasmosis spp.
|
fungal spp.
|
|
Candida infections can generally be treated with ____________.
|
fluconazole
|
|
fluconazole-resistant Candida spp?
|
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) |
|
amphotericin B
MOA |
amphotericin B binds to ergosterol altering cell membrane permeability in susceptible fungi and causing cell death
|
|
Amphocin
|
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 |
|
Abelcet
|
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 |
|
AmBisome
|
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 |
|
Amphotec
|
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 |
|
T or F:
amphotericin B is compatible with D5W |
true
amphotericin B formulations are compatible with D5W |
|
the most nephrotoxic formulation of amphotericin B
|
Amphocin
(amphotericin B desoxycholate) |
|
the most expensive formulation of amphotericin B
|
AmBisome
(liposomal amphotericin B) |
|
which formulation of amphotericin B can cause back/chest pain with the 1st dose?
|
AmBisome
(liposomal amphotericin B) |
|
the formulation of amphotericin B most likely to cause infusion related reactions
|
Amphotec
(amphotericin B cholesteryl sulfate complex) |
|
adverse effects of amphotericin B
|
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.) |
|
infusion reactions from amphotericin B
|
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 |
|
risk of nephrotoxicity with amphotericin B will be increased when?
|
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 |
|
amphotericin B & electrolytes
|
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 |
|
Ancobon MOA
|
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 |
|
5-FC
|
flucytosine
(antifungal) |
|
Ancobon
|
flucytosine
(antifungal) |
|
Ancobon monotherapy
|
(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) |
|
Ancoban adverse effects
|
(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 |
|
Sporanox
- generic - class - dosing/administration |
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 |
|
azole antifungals:
MOA |
decrease ergosterol synthesis and inhibit cell membrane formation
|
|
azole antifungals:
adverse effects |
N/V/D
rash hypertriglyceridemia, hypokalemia, HTN, edema increased LFTs |
|
azole antifungals:
Warnings & Contraindications |
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 |
|
Diflucan dosing
|
(fluconazole, azole antifungal)
100 - 400 mg QD PO/IV PO:IV conversion - 1:1 |
|
VFEND
- dosing - admin |
(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) |
|
VFEND adverse effects
|
(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 |
|
VFEND contraindications
|
(voriconazole, azole antifungal)
CI with many 3A4 substrates (rifampin, rifabutin, ergot alkaloids, long-acting barbiturates, carbamazepine, pimozide, quinidine, cisapride, efavirenz, St. John's wort) |
|
VFEND monitoring
|
(voriconazole, azole antifungal)
LFT's, electrolytes, visual function Caution driving at night! Avoid direct sunlight |
|
which azole antifungal is generally considered more active against a variety of fungal infections?
|
voriconazole (VFEND)
more active against: - Aspergillus - C. glabrata - C. krusei - Fusarium spp. ...compared to itraconazole & fluconazole |
|
Noxafil
- dosing - admin |
(posaconazole, azole antifungal)
40 mg/mL suspension in a 4 oz bottle shake well before use MUST BE TAKEN WITH A FULL MEAL |
|
Noxafil adverse effects
|
(posaconazole, azole antifungal)
N/V/D, headache, rash increased LFTs hypokalemia QT prolongation correct K, Ca, Mg before initiating therapy |
|
Noxafil contraindications
|
(posaconazole, azole antifungal)
concurrent administration with ergot alkaloids, pimozide, cisapride, quinidine or sirolimus |
|
Noxafil monitoring
|
(posaconazole, azole antifungal)
LFTs, renal fxn electrolytes (correct Ca, Mg, K before starting) visual fxn (though not as bad as voriconazole) |
|
azole antifungals:
drug interactions |
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 |
|
VFEND drug interactions
|
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 |
|
drug of choice for Aspergillus infections
|
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) |
|
echinocandins
MOA |
(antifungal class)
inhibit synthesis of Beta(1,3)-D-glucan, an essential component of the fungal cell wall |
|
Cancidas
- dosing - admin |
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 |
|
Cancidas monitoring
|
(caspofungin, echinocandin antifungal)
LFTs |
|
Cancidas adverse effects
|
(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 |
|
Mycamine
- dosing - admininstration |
micafungin, echinocandin antifungal
CANDIDEMIA DOSING: 100 mg IV daily ESOPHAGEAL CANDIDIASIS DOSING: 150 mg IV daily, over 60 minutes |
|
Mycamine adverse effects
|
micafungin, echinocandin antifungal
increased LFTs, bone marrow suppression fever, headache, N/V/D hypomagnesemia, hypokalemia rare: anaphylaxis |
|
Mycamine monitoring
|
micafungin, echinocandin antifungal
LFTs minor 3A4 interactions |
|
Eraxis dosing
|
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 |
|
Eraxis adverse effects
|
anidulfungin (echinocandin antifungal)
increased LFTs diarrhea hypokalemia rare: anaphylaxis |
|
Eraxis monitoring
|
anidulafungin, echinocandin antifungal
LFTs |
|
T or F:
echinocandin antifungals are usually dosed Q12 |
False
echinocandin antifungals: - caspofungin (Cancidas) - micafungin (Mycamine) - anidulafungin (Eraxis) all 3 agents are usually dosed once daily |
|
echinocandin drug interactions
|
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 |
|
T or F:
echinocandin antifungals do not require adjustment in renal impairment |
True
echinocandin antifungals: - caspofungin (Cancidas) - micafungin (Mycamine) - anidulafungin (Eraxis) |
|
TREATMENT:
Candida albicans |
(bloodstream infection)
fluconazole (Diflucan) OR caspofungin (Cancidas) OR micafungin (Mycamine) OR anidulafungin (Eraxis) treatment duration: 2 weeks AFTER the last positive blood culture |
|
TREATMENT:
oral candidiasis |
(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) |
|
TREATMENT:
esophageal candidiasis |
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) |
|
dermatophytoses
|
superficial mycotic (fungal) infections of the skin
|
|
Superficial mycotic infections of the skin are called ___________.
|
dermatophytoses (mycotic = fungal)
|
|
risk factors for fungal skin infection
|
prolonged exposure to sweaty clothes
infrequent bathing many skin folds sedentary lifestyle confinement to bed |
|
diagnosis of dermatophytoses
|
(i.e. fungal skin infections)
history & physical direct microscopic exam of a specimen after the addition of potassium hydroxide |
|
treatment of dermatophytoses
|
(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 |
|
% of women who have at least one vaginal candida infection
% of women who will have recurrent vaginal candida infections |
75%
<5% |
|
vaginal "yeast infection":
- causative agent - predisposing factors |
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 |
|
vaginal candidiasis:
signs & symptoms |
intense pruritis
thick, curd-like (white) vaginal discharge soreness vulvar pain, swelling and irritiation (itching is universal, discharge may or may not be present) |
|
T or F:
Itching and vaginal discharge are present in most cases of vaginal candidiasis, but not all. |
False.
itching is universal discharge may or may not be present |
|
diagnosis of vaginal candidiasis
|
confirmed by a wet preparation of vaginal secretions using a 10% potassium hydroxide solution showing budding yeast and pseudohyphae
|
|
TREATMENT:
vaginal candidiasis |
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 |
|
which topical agents are generally used to treat vaginal candidiasis?
|
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) |
|
Femstat-3
|
butaconazole 2% vaginal cream
FOR VAGINAL CANDIDIASIS: x 3 days |
|
Gynazole-1
|
butaconazole 2% vaginal cream
FOR VAGINAL CANDIDIASIS: x 1 day |
|
Gyne-Lotrimin-7
|
clotrimazole 1% vaginal cream
FOR VAGINAL CANDIDIASIS: x 7 days |
|
Mycelex-7
|
clotrimazole 1% vaginal cream
FOR VAGINAL CANDIDIASIS: x 7 days |
|
clotrimazole 100 mg vaginal tabs
|
FOR VAGINAL CANDIDIASIS:
daily for 7 days OR two tabs daily for 3 days |
|
clotrimazole 500 mg vaginal tabs
|
FOR VAGINAL CANDIDIASIS:
one tab once |
|
Monistat-7
|
miconazole 2% vaginal cream
FOR VAGINAL CANDIDIASIS: x 7 days |
|
Monistat-3
|
miconazole 200 mg vaginal suppository
FOR VAGINAL CANDIDIASIS: 1 suppository daily x 3 days |
|
Monistat-7
|
miconazole 100 mg vaginal suppository
FOR VAGINAL CANDIDIASIS: 1 suppository daily for 7 days |
|
Monistat-1
|
miconazole 1200 mg vaginal suppository
FOR VAGINAL CANDIDIASIS: 1 suppository once |
|
Mycostatin
|
nystatin 100,000 unit vaginal tab
FOR VAGINAL CANDIDIASIS: 1 tab intravaginally daily x 14 days |
|
Vagistat-1
|
tioconazole 6.5% vaginal ointment
FOR VAGINAL CANDIDIASIS: x 1 |
|
Terazol
|
terconazole 0.4% OR 0.8% vaginal cream
FOR VAGINAL CANDIDIASIS: x 7 days (0.4%) x 3 days (0.8%) |
|
Zazole
|
terconazole 80 mg vaginal suppository
FOR VAGINAL CANDIDIASIS: x 3 days |
|
Diflucan for Vaginal Candidiasis
|
fluconazole oral tab
150 mg PO x 1 |
|
patient counseling for vaginal azole antifungal treatment of vaginal candidiasis
|
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 |
|
antibiotic suspensions & refrigeration
|
all need shaking
most should be refrigerated, but NOT: - azithromycin - clarithromycin - clindamycin - voriconazole (antifungal) |
|
antibiotics & C. diff
|
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) |
|
COUNSELING:
Zovirax |
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 |
|
COUNSELING:
amoxicillin products |
with meal or snack, usually every 8-12 hours
see doc right away if you develop a rash suspensions should be refrigerated (especially Augmentin) |
|
COUNSELING:
Zithromax |
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 |
|
COUNSELING:
Biaxin |
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 |
|
COUNSELING:
Cipro |
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) |
|
COUNSELING:
Levaquin |
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) |
|
COUNSELING:
Doryx |
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 |
|
COUNSELING:
erythromycin |
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 |
|
COUNSELING:
Pediazole |
erythromycin + sulfisoxazole suspension
same counseling as for erythromycin also: refrigerate solution |
|
COUNSELING:
Diflucan |
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 |
|
COUNSELING:
Cleocin |
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 |
|
COUNSELING:
Flagyl |
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 |
|
COUNSELING:
Tamiflu |
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 |
|
COUNSELING:
Macrodantin |
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 |
|
COUNSELING:
Macrobid |
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 |
|
COUNSELING:
Bactrim |
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 |
|
COUNSELING:
Lamisil |
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 |
|
COUNSELING:
Valtrex |
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 |
|
COUNSELING:
VFEND |
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 |
|
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 |
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 |
|
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 |
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) |
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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 |
D
Doribax (doripenem) covers pseudomonas remember that Invanz (ertapenem) is the only carbapenem that does NOT cover Pseudomonas |
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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 |
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 |
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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 |
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 |
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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 |
D
nitrofurantoin 100 mg PO BID x 5 days |
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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 |
A: Bactrim IV should be protected from light
(Bactrim IV should be stored at room temp) (Bactrim IV should be diluted with D5W) |
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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 |
E:
ceftriaxone 250 mg IM + azithromycin 1 g PO x 1 |
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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 |
A
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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 |
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 |
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which of the following medications will prevent peripheral neuropathies in patients taking INH?
a. pyrazinamide b. pyridoxine e. pyridium d. pyridostigmine e. pyrimethamine |
B:
pyridoxine (vitamin B6) |
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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 |
E:
hypokalemia and hypomagnesemia |
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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 |
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) |
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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 |
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) |
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Which of the following antibiotics do NOT require dose adjustment in renal impairment?
a. gentamicin b. clarithromycin c. cefixime d. tigecycline e. daptomycin |
D:
tigecycline does not require renal adjustment |
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Which of the following antibiotics should be refrigerated?
a. Cipro b. Keflex c. Levaquin d. Septra e. Zithromax |
B: Keflex (oral suspension)
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