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NAPLEX 2024 > 22. Infectious Diseases I: Background + Abx by Drug Class > Flashcards

22. Infectious Diseases I: Background + Abx by Drug Class Flashcards

1
Q

S/sx of infection

A

Fever, elevated WBC, site-specific symptoms (e.g. dysuria with UTI)
Dx findings like culture results, X-rays, and markers of inflammation (e.g. procalcitonin)

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2
Q

___ shows susceptibility patterns and can be used to monitor resistance trends over time

A

Antibiogram

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3
Q

Gram-positive organisms: have (thick/thin) cell wall and stain (pink/purple) from ___

A

thick cell wall
purple
crystal violet stain

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4
Q

Gram-negative organisms: have (thick/thin) cell wall and stain (pink/purple) from ____

A

thin cell wall
pink
safranin counterstain

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5
Q

T/F: Atypical organisms do not have a cell wall and do not stain well

A

True

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6
Q

Gram-positive: Cocci: Clusters examples

A

Staphylococcus spp. (including MSSA, MRSA)

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7
Q

Gram-positive: Cocci: Pairs + Chains examples

A

Streptococcus pneumoniae (diplococci, pairs)
Streptococcus spp. (including Streptococcus pyogenes)
Enterococcus spp. (including VRE)

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8
Q

Gram-positive: Bacilli (rods) examples

A

Listeria monocytogenes
Corynebacterium spp.

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9
Q

Gram-positive: Anaerobes examples

A

Peptostreptococcus
Propionibacterium acnes
Clostridioides difficile
Clostridium spp.

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10
Q

Gram-negative: Cocci examples

A

Neisseria spp.

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11
Q

Gram-negative: Coccobacilli examples

A

Acinetobacter baumannii
Bordetella pertussis
Moraxella catarrhalis

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12
Q

Gram-negative: Anaerobes examples

A

Bacteriodes fragilis
Prevotella spp.

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13
Q

Gram-negative: Bacilli (rods): Colonize gut “enteric” examples

A

Proteus mirabilis
Escherichia coli
Klebsiella spp.
Serratia spp.
Enterobacter cloacae
Citrobacter spp.

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14
Q

Gram-negative: Bacilli (rods): Do not colonize gut examples

A

Pseudomonas aeruginosa
Haemophilus influenzae
Providencia spp.

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15
Q

Gram-negative: Curved or spiral shaped gram-negative rods examples

A

H. pylori
Campylobacter spp.
Treponema spp.
Borrelia spp.
Leptospira spp.

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16
Q

Atypicals examples

A

Chlamydia spp.
Legionella spp.
Mycoplasma pneumoniae
Mycobacterium tuberculosis

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17
Q

Common groups of organisms: PEK

A

Proteus
E. coli
Klebsiella

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18
Q

Common groups of organisms: HNPEK

A

Haemophilus
Neisseria
Proteus
E. coli
Klebsiella

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19
Q

Common groups of organisms: CAPES

A

Citrobater
Acinetobacter
Providencia
Enterobacter
Serratia

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20
Q

Common groups of organisms: mouth flora (anaerobes)

A

Peptostreptococcus

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21
Q

____ can be differentiated with a coagulase (enzyme) test. ___ is coagulase-positive

A

Staphylococci
Staphylococcus aureus
Note: other Staphylococcus spp. (e.g. S. epidermidis) are sometimes referred to as coagulase-negative staphylococci (CoNS)

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22
Q

Explain how aminoglycosides and beta-lactams can have a synergistic effect when used for infective endocarditis

A

The beta-lactam allows the aminoglycoside to reach its intracellular target (the ribosome, where it causes lethal damage to the bacteria. without the beta-lactam, aminoglycosides cannot penetrate the cell wall at safe doses.
This synergy permits lower dose of aminoglycoside and clears the bloodstream infection more quickly

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23
Q

What is intrinsic resistance?

A

The resistance is natural to the organism
For example, E. coli is resistant to vancomycin because the abx is too large to penetrate the bacterial cell wall of E. coli

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24
Q

What is selection pressure?

A

Resistance occurs when abx kill off susceptible bacteria, leaving behind more resistant strains to multiply
For example, normal GI flora includes enterococcus. when abx (e.g. vancomycin) eliminate susceptible enterococci, vancomycin-resistant Enterococcus (VRE) can become more predominant

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25
Q

What is acquired resistance?

A

Bacterial DNA containing resistant genes can be transferred between different species and/or picked up from dead bacterial fragments in the environment

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26
Q

What is enzyme inactivation?

A

Enzymes produced by bacteria break down the abx
Examples: Beta-lactamase, extended-spectrum beta-lactamases (ESBLs), carbapenemases

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27
Q

Common resistant pathogen mnemonic: Kill Each And Every Strong Pathogen (KEAESP)

A

Klebsiella pneumoniae (ESBL, CRE)
Escherichia coli (ESBL, CRE)
Acinetobacter baumannii
Enterococcus faecalis, Enterococcus faecium (VRE)
Staphylococcus aureus (MRSA)
Pseudomonas aeruginosa

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28
Q

What does ESBL stand for?

A

Extended-spectrum beta-lactamase

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29
Q

What does VRE stand for?

A

Vancomycin-resistant Enterococcus

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30
Q

What does CRE stand for?

A

Carbapenem-resistant Enterobacterales

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31
Q

S/sx of C.diff infection (CDI)

A

Mild - loose stools and abdominal cramping
Severe - psuedomembranous colitis that can require colectomy or be fatal)

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32
Q

Which antibiotics have a warning for risk of CDI?

A

All abx have a warning for the risk of CDI but risk is highest with broad-spectrum penicillins and cephalosporins, quinolones, carbapenems, and clindamycin
Clindamycin has a boxed warning!

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33
Q

Which abx are cell wall inhibitors?

A

Beta-lactams (penicillins, cephalosporins, carbapenems)
Monobactams (aztreonam)
Vancomycin, dalbavancin, telavancin, oritavancin

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34
Q

Which abx are cell membrane inhibitors?

A

Polymixins
Daptomycin
Telavancin
Oritavancin

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35
Q

Which abx are DNA/RNA inhibitors

A

Quinolones (DNA gyrase, topoisomerase IV)
Metronidazole, tinidazole
Rifampin

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36
Q

Which abx are folic acid synthesis inhibitors?

A

Sulfonamides
Trimethoprim (often combined with sulfamethoxazole to overcome resistance)
Dapsone

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37
Q

Which abx are protein synthesis inhibitors?

A

Aminoglycosides
Macrolides
Tetracyclines
Clindamycin
Linezolid, tedizolid
Quinupristin/dalfopristin

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38
Q

Which antibiotics are hydrophilic?

A

Beta-lactams
Aminoglycosides
Vancomycin
Daptomycin
Polymixins

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39
Q

What are some PK characteristics predicted for hydrophilic agents?

A

1) small Vd (less tissue penetration)
2) mostly renally eliminated (drug accumulation and side effects (e.g. nephrotoxicity, seizures) can occur if not dose adj
3) Low intracellular conc (not active against atypical (intracellular) pathogens)
4) poor-moderate bioavailability (IV:PO ratio is not 1:1)

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40
Q

Which antibiotics are hydrophilic?

A

Quinolones
Macrolides
Rifampin
Linezolid
Tetracyclines

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41
Q

What are some PK characteristics predicted for lipophilic agents?

A

1) Large Vd (better tissue penetration)
2) Mostly hepatically metabolized (potential for hepatotoxicity and DDIs)
3) Achieve intracellular conc (active against atypical (intracellular) pathogens)
4) Excellent bioavailability (IV:PO ratio is often 1:1)

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42
Q

Concentration or time dependent killing?: dose less frequently and in higher doses to maximize conc about MIC

A

Concentration-dependent killing

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43
Q

Concentration or time dependent killing?: dose frequently or longer duration to maximize time above MIC

A

time-dependent killing

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44
Q

What are some examples of abx that are concentration-dependent (Cmax:MIC)? What is the goal and dosing strategies for these agents?

A

Aminoglycosides, quinolones, daptomycin
Goal: high peak (more killing), low trough (low toxicity)
Dosing strategies: large dose, long interval

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45
Q

What are some examples of abx that are exposure-dependent (AUC:MIC)? What is the goal and dosing strategies for these agents?

A

Vancomycin, macrolides, tetracyclines, polymyxins
Goal: exposure over time
Dosing strategies: variable

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46
Q

What are some examples of abx that are time-dependent (time > MIC)? What is the goal and dosing strategies for these agents?

A

Beta-lactams (penicillins, cephalosporins, carbapenems)
Goal: maintain drug level > MIC for most of dosing interval
Dosing strategies: shorter dosing interval, extended, or continuous infusions

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47
Q

What characterizes beta-lactams? Which abxs are included in this class?

A

Beta-lactam ring
Penicillins, cephalosporins, and carbapenems

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48
Q

MOA of beta-lactams

A

Inhibit bacterial cell wall synthesis by binding to penicillin binding protein (PBPs). Prevents the final step of peptidoglycan synthesis in bacterial cell walls.

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49
Q

Coverage: Natural penicillins (Penicillin V Potassium, Penicillin G Benzathine (Bicillin L-A))

A

Gram-positive cocci (streptococci and enterococci, but not staphylococci) and gram-positive anaerobes (mouth flora)

No GN activity

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50
Q

Coverage: Antistaphylococcal penicillins (Dicloxacillin, nafcillin, oxacillin)

A

Streptococci, MSSA

No activity against Enterococcus, GN pathogens, and anaerobes

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51
Q

Coverage: Aminopenicillins (Amoxicillin, Amox/Clav (Augmentin), Ampicillin, Amp/sulbactam (Unasyn))

A

Streptococci, enterococci, GP anaerobes (mouth flora), GN bacteria Haemophilus, Neisseria, Proteus, and E. coli

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52
Q

Coverage: Aminopenicillins + beta-lactamase inhibitors (Amoxicillin/Clavulanate (Augmentin), Ampicillin/Sulbactam (Unasyn))

A

Aminopenicillin coverage: Streptococci, enterococci, GP anaerobes (mouth flora), GN bacteria Haemophilus, Neisseria, Proteus, and E. coli

Additional coverage: MSSA, more resistant strains of GN bacteria (Haemophilus, Neisseria, Proteus, E. coli, Klebsiella (HNPEK) and GN anaerobes (B. fragilis)

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53
Q

Coverage: extended-spectrum penicillins + beta-lactamase inhibitors (piperacillin/tazobactam (Zosyn))

A

Broad-spectrum
Same as aminopenicillin/beta-lactamase inhibitor combinations PLUS other GN bacteria including Citrobacter, Acinetobacter, Providencia, Enterobacter Serratia (CAPES), and Pseudomonas)

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54
Q

Your NPO patient is indicated to use natural penicillins. Which options can you use?

A

Penicillin G Aqueous (Pfizerpen) - IV formulation
Penicillin G Benzathine (Bicillin L-A) - IM formulation

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55
Q

Which natural penicillin has a boxed warning? Why?

A

Penicillin G benzathione: not for IV use; can cause cardio-respiratory arrest and death

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56
Q

Your NPO patient is indicated to use antistaphylococcal penicillins. Which options can you use?

A

Nafcillin - IV/IM formulation
Oxacillin - IV formulation

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57
Q

What are contraindications for penicillins?

A

Type 1 hypersenstivity reaction to another penicillin or beta-lactam abx

Augmentin and Unasyn - hx of cholestatic jaundice or hepatic dysfunction a/w previous use

Severe renal impairment (CrCl <30): do not use ER oral forms of amoxicililn and amoxicillin/clavulanate (Augmentin XR) or the 875mg strength of amoxicillin/clavulanate

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58
Q

Which aminopenicillins come in chewable formulations?

A

Amoxicillin
Amoxicillin/clavulanate

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59
Q

What are common side effects of penicillins

A

Seizures (with accumulation when not correctly renal dose adj)
GI upset, diarrhea
Rash (SJS/TEN)/allergic reactions/anaphylaxis
Hemolytic anemia (identified with positive Coombs test)
Renal failure, myelosuppression with prolonged use, increased LFTs

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60
Q

What should you monitor for penicillins?

A

Renal function
Symptoms of anaphylaxis with 1st dose
CBC, and LFTs with prolonged courses

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61
Q

___ penicillins are preferred for MSSA soft tissue, bone and joint, edocarditis and bloodstream infections

A

Antistaphylococcal penicillins (dicloxacillin, nafcillin, oxacillin)

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62
Q

T/F: antistaphylococcal penicillins require renal dose adj

A

Flase - no renal dose adj

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63
Q

Which penicillin is a vesicant? What should be done if extravasation occurs?

A

Nafcillin is a vesicant - administration through central line is preferred
If extravasation occurs, use old packs and hyaluronidase injections

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64
Q

___ PO is rarely used d/t poor bioavailability. Amoxicillin is preferred if switching from IV.

A

Ampicillin

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65
Q

What ratio of amox/clav should be used to decrease diarrhea caused by clav component?

A

14:1

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66
Q

IV ampicillin and ampicillin/sulbactam must be diluted in ___ only

A

NS

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67
Q

Piperacillin/tazobactam contains ___mg Na per 1 gram of piperacillin

A

65mg

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68
Q

What is a typical dose for prolonged or extended infusion for piperacillin/tazobactam?

A

3.375-4.5g IV Q8H (each dose infused over 4 hours)

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69
Q

____ can increase the levels of beta-lactams by interfering with renal excretion
This combination is sometimes used intentionally in severe infections to increase abx levels

A

Probenecid

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70
Q

Penicillins can increase serum conc of ___

A

methotrexate

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71
Q

Beta-lactams except __ and ___ can enhance the anticoagulant effect of warfarin by inhibiting the production of vitamin K-dependent clotting factors. The excepts can inhibit the anticoagulant effect of warfarin.

A

nafcillin and dicloxacillin (CYP enzyme inducers)

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72
Q

Outpatient or oral options for penicillins

A

Penicillin VK
Amoxicillin
Amoxicillin/clavulanate (Augmentin)
Dicloxacillin

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73
Q

Inpatient options for penicillins

A

Penicillin G Benzathine (Bicillin L-A) - NOT used IV only PO
Nafcillin and Oxacillin
Piperacillin/Tazobactam (Zosyn)

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74
Q

What is penicillin VK typically used for?

A

First line treatment for pharyngitis (“strep throat”) and mild non-purulent skin infections (no abscess)

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75
Q

What is amoxicillin typically used for?

A

First line treatment for acute otitis media (pediatric dose: 80-90mg/kg/day)
Drug of choice for infective endocarditis prophylaxis before dental procedures (2g PO x1, 30-60min before procedure)
Used in H. pylori treatment

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76
Q

What do we typically give to patients for infective endocarditis ppx before dental procedures?

A

Amoxicillin 2g PO x1, 30-60min before procedure

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77
Q

What is a typical pediatric amoxicillin dose for acute otitis media?

A

80-90mg/kg/day

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78
Q

What is amoxicillin/clavulanate (Augment) typically used for?

A

First line treatment for acute aotitis media (pediatric dose: 90mg/kg/day) and bacterial sinusitis (if abx indicated)
Note: use lowest dose of clavulanate to decrease diarrhea

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79
Q

What is a typical pediatric amox/clav dose for acute otitis media?

A

90mg/kg/day

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80
Q

What is dicloxacillin, nafcillin, and oxacillin typically used for?

A

MSSA soft tissue, bone and joint, endocarditis, and bloodstream infections (does NOT cover MRSA)
Note: no renal dose adj needed)

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81
Q

What is penicillin G Benzathine typically used for?

A

Drug of choice for syphilis (2.4 million units IM x1)
Note: NOT for IV use; can cause death

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82
Q

What is piperacillin/tazobactam (Zosyn) typically used for?

A

Only penicillin active against Pseudomonas
Note: extended infusions (4hrs) can be used to maximize T > MIC

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83
Q

Penicillins coverage varies by subgroup or type. As a class, they are NOT active against ___ or ___

A

MRSA or atypical

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84
Q

Cephalosporins coverage varies by generation. As a class, they are NOT active against ___ or ___

A

Enterococcus spp. or atypical

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85
Q

Coverage: 1st generation cephalosporins (cefazolin, cephalexin (Keflex), cefadroxil)

A

Excellent activity against GP cocci (e.g. streptococci and staphylococci)
Some activity against GN rods PEK
Generally less GN coverage compared to other generations

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86
Q

___ generation cephalosporins are preferred when a cephalosporin is used for MSSA infections

A

First generation cephalosporins

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87
Q

Coverage: 2nd generation cephalosporins (Cefuroxime, cefotetan, cefoxitin, cefaclor, cefprozil)

A

Cefuroxime - staphylococci, more resistant strains of S. pneumoniae and HNPEK
Cefoteta and cefoxitin - added activity against GN anaerobes (B. fragilis)

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88
Q

Coverage: 3rd generation cephalosporins: Group 1 (cefdinir, ceftriaxone, cefotaxime, cefixime (Suprax), cefpodoxime

A

Resistant streptococci (S. pneumoniae and viridans group streptococci)
Staphylococci
GP anaerobes
Resistant strains of HNPEK

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89
Q

Coverage: 3rd generation cephalosporins: Group 2 (ceftazidime (Fortaz, Tazicef))

A

Lacks GP activity but covers Pseudomonas

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90
Q

Coverage: 4th generation cephalosporins (cefepime)

A

Broad GN activity (HNPEK, CAPES, and pseudomonas)
Similar GP activity to ceftriaxone

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91
Q

Coverage: 5th generation cephalosporins (ceftaroline (Teflaro))

A

GN activity similar to ceftriaxone but broad GP activity
Only beta-lactam that covers MRSA

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92
Q

What is the only beta-lactam that covers MRSA

A

Ceftaroline (5th gen cephalosporin)

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93
Q

Coverage: beta-lactamase inhibitor combinations (ceftzidime/avibactam (Avycaz), ceftolozane/tazobactam (Zerbaxa))

A

Similar spectrum as ceftazidime but with added activity against MDR gram-negative rods

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94
Q

Coverage: Siderophore cephalosporin (cefiderocol (Fetroja))

A

E.coli, Enterobacter, Klebsiella, Proteus, and Pseudomonas
Note: uses iron transport system to enter GN cell wall

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95
Q

What is a typical dosing for cephalexin (Keflex)

A

250-500mg PO Q6-12H

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96
Q

What are contraindications for ceftriaxone?

A

Hyperbilirubinemic neonates (0-28 days) (causes biliary sludging, kernicterus)
Concurrent use with calcium-containing IV products in neonates ≤28 days old

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97
Q

All penicillins should be avoided in patients with a beta-lactam allergy. What is an exception?

A

Treatment of syphilis during pregnancy (all patients) or in patients with poor compliance/follow-up - desensitize and treat with penicillin G benzathine

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98
Q

D/t a small risk of cross-reactivity, cephalosporins should not be chosen on the NAPLEX if the patient has a penicillin allergy. What is an exception?

A

Pediatric patients with acute otitis media and a mild penicillin allergy (delayed onset reaction > 48 hrs after first abx dose, appearing as nonpruritic or mildly pruritic, maculopapular rash, but lacking systemic symptoms (e.g. hives, bronchospasm, anaphylaxis) or other serious reactions (SJS)

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99
Q

Cephalosporins as a class has a risk of ___ if accumulation occurs (e.g. failure to renal dose adj)

A

Seizures

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100
Q

Outpatient or oral options for cephalosporins

A

1st gen: cephalexin
2nd gen: cefuroxime
3rd gen: cefdinir

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101
Q

Inpatient options for cephalosporins

A

1st gen: cefazolin
2nd gen: cefotetan, cefoxitin
3rd gen: ceftriaxone, cefotaxime, ceftazidime
4th gen: cefepime
5th gen: ceftaroline
Combo: ceftolozane/tazobactam, ceftazidime/avibactam

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102
Q

What is cephalexin typically used for?

A

Skin infections (MSSA), strep throat

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103
Q

What is cefuroxime typically used for?

A

Acute otitis media, community-acquired pneumonia (CAP)

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104
Q

What is cefdinir typically used for?

A

Acute otitis media

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105
Q

What is cefazolin typically used for?

A

Surgical ppx

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106
Q

What is cefotetan and cefoxitin typically used for?

A

Anaerobic coverage (B. fragilis)
Surgical ppx (GI procedures)

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107
Q

___ (2nd get cephalosporin) can cause a disulfiram-like reaction with alcohol ingestion

A

Cefotetan

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108
Q

What is ceftriaxone and cefotaxime typically used for?

A

CAP, meningitis, spontaneous bacterial peritonitis, pyelonephritis

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109
Q

T/F: Ceftriaxone does not require renal dose adj

A

True

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110
Q

Which patient population cannot use ceftriaxone?

A

Neonates (0-28 days)

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111
Q

What is ceftazidime and cefepime typically used for?

A

Pseudomonas coverage

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112
Q

What is ceftolozane/tazobactam and ceftazidime/avibactam typically used for?

A

MDR gram-negative organisms (including Pseudomonas)

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113
Q

What is ceftaroline typically used for?

A

Only beta-lactam active against MRSA
CAP, skin and soft tissue infections

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114
Q

Coverage: Carbapenems

A

Very broad-spectrum, generally reserved for MDR gram-negative infections
Active against most GP, GN (including ESBL-producing bacteria) and anaerobic pathogens

Do NOT cover atypical pathogens, MRSA, VRE, C. diff or Stenotrophomonas

ErtAPenem does NOT cover PEA (Pseudomonas, Acinetobacter, or Enterococcus)

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115
Q

Which carbapenem does not have activity against Pseudomonas, Acinetobacter, or Enterococcus?

A

ertapenem

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116
Q

What are some warnings for carbapenems?

A

Do not use with PCN allergy (small risk of cross-reactivity)

CNS adverse effects, including confusion and seizures - higher risk with imipenem/cilastatin, larger doses, or impaired renal function

Doripenem: do not use for treatment of pneumonia, including HAP and VAP

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117
Q

What is a warning specific for doripenem?

A

do not use for treatment of pneumonia, including HAP and VAP

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118
Q

Which carbapenem is stable in NS only?

A

Ertapenem (Invanz)

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119
Q

What are some ADEs for carbapenems?

A

Diarrhea, rash/severe skin reaction (DRESS), bone marrow suppression with prolonged use, increased LFTs

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120
Q

What should you monitor for carbapenems?

A

Renal function, s/sx of anaphylaxis with 1st dose, CBC, LFTs

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121
Q

Why is imipenem combined with cilastin?

A

To prevent drug degradation by renal tubular dehydropeptidase

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122
Q

Carbapenems can decrease serum conc of ___, leading to a loss of seizure control

A

Valproic acid

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123
Q

What causes higher risk for seizure with carbapenem use?

A

imipenem/cilastatin use, larger doses, or failure to renal dose adj (renal impairment)

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124
Q

What are carbapenems typically used for?

A

Polymicrobial infections (e.g. severe diabetic foot infection)
Empiric therapy when resistant organisms suspected
ESBL-positive infections
Resistant Pseudomonas or Acinetobacter infections (except ertapenem)

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125
Q

T/F: Doripenem comes in PO formulation

A

False - all carbapenems are IV only

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126
Q

MOA of monobactam (aztreonam)

A

similar to beta-lactams
Inhibits cell wall synthesis by binding to penicillin binding proteins (PBPs), which prevents the final step of peptidoglycan synthesis in bacterial cell walls

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127
Q

Coverage: monobactam (aztreonam)

A

Many GN organisms, including pseudomonas and CAPES
No GP or anaerobic activity

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128
Q

T/F: aztreonam cannot be used when beta-lactam allergy is present d/t cross-reactivity

A

False - monobactam structure makes cross-reactivity with a beta-lactam unlikely, it is primarily used when a beta-lactam allergy is present

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129
Q

What are some ADEs of aztreonam (Azactam)

A

Similar to penicillin, rash, N/V/D, increased LFTs

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130
Q

What brand name of aztreonam is inhaled and used for cystic fibrosis?

A

Cayston

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131
Q

T/F: aztreonam requires renal dose adj

A

True

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132
Q

Which beta-lactams have atypical coverage

A

None

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133
Q

Penicillin Coverage Summary

A

Penicillin - strep/entero // mouth (peptostrepto)
Amoxicillin - strep/entero // PEK/HNPEK (no kleb coverage) // mouth
Oxacillin, Nafcillin - staph/strep ONLY
Amox/calv, amp/sulb - staph/strep/entero // PEK/HNPEK // mouth/B.frag
Pip/tazo - staph/strep/entero // PEK/HNPEK/CAPES/Pseudo // mouth/B.frag

MEMORIZE:
- categories from p345 (MRSA, MSSA, Strep pneumo, Viridans strepto, Entero, PEK, HNPEK, CAPES, pseudo, mouth, B. frag, atypicals)
- Nonsense but helps remember: Penicillin = strep enters through the mouth, amox = let him take a peek (HNPEK) but found no klebs

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134
Q

Which penicillins can be used for CAPES or pseudomonas?

A

Pip/tazo

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135
Q

Which penicillins can be used B.frag?

A

Amox/clav, amp/sulb, or pip/tazo

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136
Q

Which penicillins can be used for MSSA?

A

Oxacillin, nafcillin, amox/clav, amp/sulb, or pip/tazo

137
Q

Which penicillins can be used for PEK or HNPEK?

A

Amoxicillin (no kleb coverage), amox/clav, amp/sulb, or pip/tazo

138
Q

Which beta-lactam has only GN coverage?

A

Aztreonam (covers PEK/HNPEK/CAPES/Pseudo)

139
Q

Which cephalosporins can be used for B. frag?

A

ceftazidime/avibactam or ceftolozane/tazobactam (must be given with metronidazole for full anaerobic coverage)

140
Q

Which beta-lactam has similar coverage to pip/tazo?

A

Carbapenems except ertapenem
(MSSA to B.frag except they don’t cover all enterococcus, only E. faecalis)

141
Q

MAO of aminoglycosides

A

Bind to ribosome, which interferes with bacterial protein synthesis and results in a defective bacterial cell membrane

142
Q

T/F: aminoglycosides are typically used as part of an empiric regimen as monotherapy given broad GN coverage

A

False - typically given with other antibiotics
Synergistic with beta-lactams for some GP organisms

143
Q

T/F: aminoglycosides demonstrate time-dependent activity

A

False - conc-dependent activity

144
Q

Aminoglycoside coverage

A

GN bacteria, including pseudomonas (primarily tobramycin)

145
Q

Gentamicin and streptomycin are used for synergy, in combination with ___ or ___, when treating GP infections (e.g. enterococcal endocarditis)

A

beta-lactams or vancomycin

146
Q

What are the 2 dosing strategies for aminoglycosides?

A

traditional dosing - lower doses more frequently
Extended interval dosing - higher doses (to attain higher peaks) less frequently

147
Q

Although not proven to be clinically superior to traditional dosing, what is the benefit of using extended interval dosing for aminoglycosides?

A

Less accumulation of the drug
Lower risk of nephrotoxicity
Decrease cost
(gives kidneys time to recover between doses)

148
Q

T/F: Aminoglycosides do not have post-antibiotic effect

A

False - it does have a post-antibiotic effect (bacterial killing continues after serum level drops below MIC)

149
Q

What should be monitored with aminoglycosides?

A

Nephrotoxicity, ototoxicty (may be irreversible hearing loss/tinnitus/balance problems)

150
Q

Aminoglycoside examples

A

Gentamicin, tobramycin, amikacin, streptomycin, plazomicin

151
Q

What is typical gentamicin and tobramycin IV traditional dosing

A

1-2.5 mg/kg/dose (lower doses for GP infections, higher doses for GN infections)

152
Q

For CrCl ≥ 60, what is the dosing interval for aminoglycosides (traditional dosing)?

A

Q8H

153
Q

What is the renal dose adj CrCl cut off for aminoglycosides?

A

CrCl < 60

154
Q

What is typical gentamicin and tobramycin IV extended interval dosing?

A

4-7 mg/kg/dose (commonly 7mg/kg)
Frequency determined by nomogram (shortest interval is Q24H if renal function normal)

155
Q

When should extended interval IV dosing be avoided for aminoglycosides?

A

when clearance and/or Vd are altered (e.g. pregnancy, ascites, brunes, cystic fibrosis, CrCl < 30 including ESRD on dialysis)

156
Q

What are boxed warnings for aminoglycosides?

A

Nephrotoxicity, ototoxicity, neuromuscular blockade, and respiratory paralysis
AVOID with other neurotoxic/nephrotoxic drugs
Fetal harm if given in pregnancy

157
Q

What are warnings for aminoglycosides?

A

Use caution in patients with impaired renal function, in the elderly, and concomitant use with nephrotoxic drugs (amphotericin B, cisplatin, polymyxins, cyclosporine, loop diuretics, NSAIDs, radio constrast dye, tacrolimus, vancomycin)

158
Q

What to monitor for aminoglycosides?

A

Drug levels, renal function, hearting tests, urine output
Traditional dosing: trough immediately before 4th dose, peak 30 min after end of 30 min infusion for 4th dose
Extended interval dosing: random level per the timing on the nomogram

159
Q

What is trough goal for gentamycin (GN infection ) and tobramycin traditional dosing?

A

<2 mcg/mL

160
Q

For obese patients (TBW > 120% IBW), what body weight should be used for aminoglycoside dosing?

A

adjusted body weight

161
Q

For underweight patients (TBW < IBW), what body weight should be used for aminoglycoside dosing?

A

Total body weight

162
Q

MOA of quinolones

A

inhibit bacterial DNA topoisomerase IV and DNA gyrase (topoisomerase II), prevents supercoiling of DNA and promotes breakage of double-stranded DNA

163
Q

T/F: Quinolones have time-dependent abx activity

A

False - conc-dependent

164
Q

Which quinolones are referred to as “respiratory quinolones” d/t their enhanced coverage of S. pneumoniae and atypical pathogens?

A

Levofloxacin and moxifloxacin

165
Q

Which quinolones have enhanced GN activity, including pseudomonas?

A

Ciprofloxacin and levofloxacin

166
Q

____ is active against MRSA and is the preferred quinolone if treating skin infections suspected to be caused by MRSA. Other quinolones should generally be avoided d/t high rates of MRSA resistance.

A

Delafloxacin

167
Q

What is in combo med ear drops Ciprodex?

A

Ciprofloxacin + dexamethasone

168
Q

All quinolones require renal dose adj EXCEPT ____

A

Moxifloxacin

169
Q

What are boxed warnings for quinolones

A

Tendon inflammation and/or rupture (increased risk with concurrent use of systemic steroids, organ transplant patients, >60 yo)

Peripheral neuropathy

CNS effects - seizures!

Avoid in patients with myasthenia gravis (may exacerbate muscle weakness)

Use last-line (only if no other possible treatment) for: acute bacterial sinusitis, acute exacerbation or chronic bronchitis and uncomplicated UTI

170
Q

Contraindications for ciprofloxacin

A

Concurrent administration of tizanidine

171
Q

What are warnings for quinolones ?

A

QT prolongation (highest risk with moxi > levo > cipro)

Hypoglycemia and hyperglycemia

Psychiatric disturbances

Avoid systemic quinolones in children and in pregnancy/breastfeeding (musculoskeletal toxicity, exception: anthrax exposure)

Aortic aneurysm and dissection (increased risk with longer durations of therapy or history of peripheral vascular disease, atherosclerosis or prior aneurysms)

Photosensitivity, hepatotoxicity, crystalluria (stay hydrated)

172
Q

Side effects for Quinolones

A

N/D, HA, dizziness, SJS/TEN

173
Q

Which quinolone should not be used for UTIs as it does not concentrate in the urine?

A

Moxifloxacin

174
Q

What are some things to note for ciprofloxacin and patients with feeding tubes?

A

Cipro oral solution: shake vigorously for 15 sec before each dose. Do NOT put through NG or other feeding tube (oil-based suspension adheres to tubing)

Cipro: can crush IR tablets, mix with water and give via a feeding tube. Hold tube feedings at least 1 hour before and 2 hours after the dose

175
Q

Which cipro formulation is most appropriate for patients with feeding tubes: crushed PO tabs or PO solution?

A

PO Tab - IR tabs can be crushed, mixed with water and given via feeding tube

PO solution should NOT be given via feeding tube (oil-based suspension - adheres to tubing)

176
Q

What increases risk of tendon inflammation and/or rupture with quinolone use?

A

Concurrent use of systemic steroids
Organ transplant patients
Age > 60yo

177
Q

Which drugs should be separated from quinolones d/t chelation and inhibition of quinolone absorption?

A

Antacids and other polyvalent cations (Mg, Al, phosphate, Ca, iron, zinc), multivitamins, sucralfate, and bile acid resins

178
Q

Phosphate binders lanthanum carbonate and sevelamer can (increase/decrease) serum conc of oral quinolones. Separate administration by at least _____ before and at least ____ after lanthanum or ___ after sevelamer

A

Decrease serum conc of oral quinolones
2 hrs before
2 hrs after (with lanthanum)
6 hrs after (with sevelamer)

179
Q

Quinolones can (increase/decrease) effects of warfarin

A

increase

180
Q

Quinolones can (increase/decrease) effects of SU, insulins, and other hypoglycemic drugs

A

Increase

181
Q

Ciprofloxacin is a strong CYP ____ inhibitor, a weak CYP3A4 inhibitor, and a Pgp substrate. Ciprofloxacin can (decrease/increase) levels of caffeine, theophylline, and tizanidine.

A

CYP1A2
Increase levels

182
Q

Common uses of quinolones

A

Varies by agent: pneumonias, UTIs, intra-abdominal infections, traveler’s diarrhea

183
Q

Which quinolones are respiratory quinolones?

A

Levofloxacin, moxifloxacin
(Reliable strep pneumo activity in pneumonia)

184
Q

Which quinolones have pseudomonal coverage?

A

Ciprofloxacin, levofloxacin
(used for pseudomonas infections, including pneumonia)

185
Q

Which quinolones have a IV to PO 1:1 ratio?

A

Levofloxacin and moxifloxacin

186
Q

Quinolone profile review tips

A

Caution with CVD, Decrease K/Mg, and with other QT-prolonging drugs (e.g. azole antifungals, antipsychotics, methadone, macrolides)
Avoid in pts with seizure hx or if using seizure drugs
Avoid in children

187
Q

Some counseling points for quinolones

A

Avoid sun exposure, separate from polyvalent cations, monitor BG (in diabetes)
Watch fro tendon rupture, neuropathy, CNS, or psychiatric side effects

188
Q

MOA of macrolides

A

Bind to 50S ribosomal subunit, resulting in inhibition of RNA-dependent protein synthesis

189
Q

Quinolones end in “-____”

A

-floxacin

190
Q

Macrolides end in “-____”

A

-thromycin

191
Q

Azithromycin (Z-pak) dosing

A

500mg on day 1 and then 250mg on days 2-5
(two 250mg x1, 250mg PO daily x4 days)

192
Q

Azithromycin (Tri-Pak) dosing

A

500mg daily for 3 days

193
Q

Contraindications for Macrolides

A

History of cholestatic jaundice/hepatic dysfunction with prior use

Clarithromycin and erythromycin: do NOT use with lovastatin or simvastatin, pimozide, ergotamine, or dihydroergotamine

Clarithromycin: concurrent use with colchicine in pts with renal or hepatic impairment

194
Q

Which macrolides do NOT require renal dose adj

A

Azithromycin and erythromycin

195
Q

Macrolide warnings

A

QTC prolongation (highest risk with erythromycin>azithromcyin>clarithromycin)
Hepatotoxicity
Exacerbation of myasthenia gravis

Clarithromycin: caution in pts with CAD (increased mortality documented ≥ 1 yr after end of 2 week course of treatment)

196
Q

Macrolide side effects

A

GI upset (diarrhea, abd pain, cramping)
Taste perversion
Ototoxicity (rare, reversible) severe (but rare) skin reactions (SJS/TEN/DRESS)

197
Q

Erythromycin and clarithromycin are major substrates and (mod for erythro, strong clarithro) inhibitors of CYP___

A

CYP3A4
Lovastatin and simvastatin contraindicated to use with erythromycin and clarithromycin for this reason
Caution with warfarin

198
Q

Which macrolide is a minor substrate of CYP3A4 and a weak inhibitor of CYP1A2 and P-gp; fever clinically significant drug interactions that other macrolides

A

Azithromcyin

199
Q

Common uses of macrolides in general

A

CAP and as an alternative to beta-lactam for pharyngitis (“strep throat”)

200
Q

Common uses of azithromycin

A

COPD exacerbations, pertussis, chlamydia (in pregnant patients), prophylaxis for Mycobacterium avium complex, severe traveler’s diarrhea (including dysentery, diarrhea with bloody stools)

201
Q

Common uses of clarithromycin

A

H. pylori treatment regimens

202
Q

Common uses of erythromycin

A

Gastroparesis (erythromycin increases gastric motility)

203
Q

MOA of tetracyclines

A

Inhibit bacterial protein synthesis by reversibly binding to 30S ribosomal subunit

204
Q

Which tetracycline has broader indications than the other tetracyclines including respiratory tract infections (e.g. CAP), tickborne/rickettsial diseases, spirochetes and STIs (e.g. chlamydia)?

A

Doxycycline

205
Q

Which tetracycline is an option for the treatment of mild CA-MRSA skin infections and VRE UTIs?

A

Doxycycline

206
Q

Which tetracycline is often preferred for acne?

A

Minocycline

207
Q

Which tetracycline does not require renal dose adj: minocycline or doxycycline?

A

Doxycycline

208
Q

What are some warnings for tetracyclines?

A

Children <8yo, pregnancy and breastfeeding (suppress bone growth and skeletal development, and permanently discolors teeth)

Photosensitivity, tissue hyperpigmentation, severe skin reactions (DRESS/SJS/TEN), exfoliative dermatitis

GI inflammation/ulceration

Minocycline: drug-induced lupus erythematosus (DILE)

209
Q

Which tetracycline has a warning for drug-induced lupus erythematosus (DILE)?

A

Minocycline

210
Q

ADEs of tetracyclines

A

N/V/D, rash

211
Q

Which tetracyclines have IV:PO ratio 1:1?

A

Doxycycline, minocycline

212
Q

What are some things to note for administration of tetracycline?

A

Tabs and caps should be taken with 8 oz of water
For doxycycline, sit upright for at least 30 min after dose to avoid esophageal irritation

213
Q

For which tetracycline is it recommended to sit up for 30 min after taking to avoid esophageal irritation?

A

Doxycycline

214
Q

Which drugs should be separated from tetracyclines to avoid chelation and inhibition of tetracycline absorption?

A

Antacids, polyvalent cations (e.g. Mg, Al, phosphate, Ca, iron, zinc), multivitamins, sucralfate, bismuth subsalicylate, and bile acid resins

Separate 1-2 hours before or 4 hours after chelating drug
Dairy products should be avoided 1 hr before and 2 hrs after tetracycline

215
Q

Lanthanum can (increase/decrease) conc of tetracycline derivatives; take tetracycline at least 2 hours before or after lanthanum

A

Decrease

216
Q

MOA of sulfamethoxazole/trimethoprim (Bactrim)

A

SMX = inhibits dihydrofolic acid formation from para-aminobenzoic acid, which interferes with bacterial folic acid synthesis
TMP = inhibits dihydrofolic acid reduction to tetrahydrofolate, resulting in inhibition of folic acid pathway

217
Q

Is SMX/TMP dosing based on SMX or TMP components?

A

TMP

218
Q

How much of each component is in Bactrim single strength (SS)

A

400mg SMX
80mg TMP

219
Q

How much of each component is in Bactrim double strength (DS)

A

800mg SMX
160mg TMP

220
Q

All SMX/TMP products are formulated with a SMX:TMP ratio of ____

A

5:1

221
Q

What is typical Bactrim dosing to uncomplicated UTI?

A

1 DS tablet PO BID x 3 days

222
Q

What is typical Bactrim dosing to Pneumocystis Pneumonia (PCP) Prophylaxis?

A

1 DS or SS tablet daily

223
Q

Contraindications for SMX/TMP

A

Sulfa allergy
Anemia d/t folate deficiency, renal or hepatic disease, infants <2 mo

224
Q

Warnings for SMX/TMP

A

Blood dyscrasias, including agranulocytosis and aplastic anemia
Skin reactions: SJS/TEN, TTP
Hemolytic anemia: can be immune-mediated (identified with positive Coombs test) or caused by G6PD deficiency (do NOT use with known deficiency)

Hypoglycemia, thrombocytopenia

Pregnancy - only use if benefit outweighs risk (blocks folic acid metabolism = congenital defects)

225
Q

ADEs for SMX/TMP

A

Photosensitivity, increased K, crystalluria (take with 8oz of water)
N/V/D
anorexia, skin rash, decreased folate, false elevations in SCr (d/t inhibition of creatinine tubular secretion), renal failure

226
Q

SMX/TMP is a moderate-strong CYP ___ and CYP___ inhibitor and can cause significantly (increase/decrease) in INR if used with warfarin

A

2C8 and 2C9 inhibitor
Increase INR

227
Q

SMX/TMP can enhance toxic effects of ____

A

Methotrexate

228
Q

Therapeutic effects of SMX/TMP can be diminished by use of ___ or ___

A

leucovorin or levoleucovorin

229
Q

What increases risk of hyperkalemia in patients using SMX/TMP

A

renal dysfunction or if used in combo with ACEi/ARBs, aliskiren, aldosterone receptor antagonists, K-sparing diuretics, cyclosporin, tacrolimus, NSAIDs, drospirenone-containing oral contraceptives or canagliflozin

230
Q

Common uses for SMX/TMP

A

CA-MRSA skin infections, UTI, Pneumocystis pneumonia (PCP)

231
Q

MOA of vancomycin

A

Inhibits bacterial cell wall synthesis by binding to the D-alanyl-D-alanine cell wall precursor and blocking peptidoglycan polymerization

232
Q

Coverage of vancomycin

A

GP coverage only, includes MRSA, streptococci, enterococci (not VRE), and C. difficile (PO vanc only)

233
Q

Vancomycin is typically first-line treatment for moderate-severe systemic RMSA infections. When would we consider an alternative drug?

A

If MRSA MIC ≥ 2mcg/mL

234
Q

Typical vancomycin IV dosing

A

15-20mg/kg q8-12h
dosing based on total body weight
Q24H if CrCl 20-49

235
Q

What type of weight is vancomycin dosing based on?

A

Total body weight

236
Q

Typical vancomycin PO dosing

A

125 QID x 10 day
No renal dose adj required

237
Q

T/F: PO vancomycin does not require renal dose adj

A

True

238
Q

Warnings for vancomycin

A

Ototoxicity and nephrotoxicity
PO only for C.diff (not for systemic infections)
Vancomycin infusion reaction

239
Q

Monitoring for vancomycin

A

Renal function, drug levels (AUC/MIC ratio, or trough after 4th or 5th dose)
Serious MRSA infections (e.g. bacteremia, sepsis, endocarditis, pneumonia, osteomyelitis, meningitis): AUC/MIC ratio of 400-600 or goal trough of 15-20mcg/mL

240
Q

Vancomycin has increased risk of nephrotoxicity when used with other nephrotoxic drugs such as ____

A

Aminoglycosides, amphotericin B, cisplatin, polymyxins, cyclosporine, tacrolimus, loop diuretics, NSAIDs, and radiographic contrast dye

241
Q

Vancomycin has increased risk of ototoxicity when used with other ototoxic drugs such as ____

A

aminoglycosides, cisplatin, loop diuretics

242
Q

Lipoglycopeptides end with “-____”

A

-vancin

243
Q

MOA of lipoglycopeptides (telavancin, oritavancin, dalbavancin)

A

Inhibit bacterial cell wall synthesis by 1) binding to D-alanyl-D-alanine portion of the cell wall, blocking polymerization and cross-linking of peptidoglycan and 2) disrupting bacterial cell membrane potential and changing cell permeability (d/t presence of lipophilic side chain)

244
Q

T/F: lipoglycopeptides have time-dependent activity

A

False - conc-dependent

245
Q

Lipoglycopeptides have similar coverage to vancomycin with the exception of ___

A

they only come in IV form and cannot be used to treat C. diff infections

246
Q

Boxed warnings for telavancin

A

Fetal risk - requires pregnancy test prior to starting therapy
Nephrotoxicity
Increased mortality with pre-existing moderate-to-severe renal impairment (CrCl ≤ 50) compared to vancomycin in pneumonia trials

247
Q

Contraindications for oritavancin

A

Do NOT use IV UFH for 120 hours (5 days) after oritavancin d/t interference (false elevations ) with aPTT laboratory results

248
Q

Contraindications for telavancin

A

Do NOT use with IV UFH

249
Q

Warnings for lipoglycopeptides

A

General: infusion reaction (similar to vancomycin) with rapid IV administration
Oritavancin and telavancin: can falsely increase aPTT/PT/INR but do NOT increase bleeding risk
Telavancin: QT prolongation
Oritavancin: use a diff abx if osteomyelitis is confirmed or suspected
Dalbavancin: increased ALT > 3x ULN

250
Q

T/F: Oritavancin and telavancin are contraindicated with concurrent use of IV UFH because increased bleeding risk

A

False - they are contraindicated with concurrent use of IV UFH because they falsely increase aPTT/PT/INR but do NOT increase bleeding risk

251
Q

MOA daptomycin (cyclic lipopeptide)

A

Binds to cell membrane components, causing rapid depolarization; inhibits all intracellular replication processes, including protein synthesis, and causes cell death

252
Q

Daptomycin has __-dependent activity against most gram-___ bacteria, including __ and ___

A

concentration-dependent activity
gram-positive bacteria including MRSA and VRE
Note: NO activity against GN

253
Q

Why can you NOT use daptomycin for pneumonia?

A

Drug is inactivated in the lungs by surfactant

254
Q

Which antibiotic cannot be used for pneumonia because it is inactivated in the lungs by surfactant?

A

Daptomycin

255
Q

Warnings for daptomycin

A

Myopathy and rhabdomyolysis: d/c in pts with s/sx and CPK > 1000 units/L (5x ULN) or in asymptomatic patients with a CPK ≥ 2000 units/L (10x ULN); consider holding statins
Can falsely increase PT/INR but does NOT increase bleeding risk
Peripheral neuropathy
Eosinophilic pneumonia - generally develops 2-4 weeks after treatment initiation

256
Q

Side effects for daptomycin

A

Increase CPK, abdominal pain, pruritus, chest pain, edema, HTN, AKI

257
Q

Monitoring for daptomycin

A

CPK (more frequent if on statin or with renal impairment; muscle pain/weakness, s/sx of neuropathy, dyspena

258
Q

Notes for daptomycin and diluent compatibility

A

Cubicin: compatible with NS and LR (no dextrose )
Cubicin RF: compatible with NS (no dextrose) but must use only sterile or bacteriostatic water for injection to reconstitute the lyophilized powder (before diluting further with NS)

259
Q

MOA of oxazolidinones (linezolid, tedizolid)

A

Bind to 50S subunit of bacterial ribosome, inhibiting translation and protein synthesis.

260
Q

Contraindications for linezolid

A

Do NOT use with or within 2 weeks of MAOi

261
Q

Warnings for linezolid

A

Duration-related myelosuppression (thrombocytopenia, anemia, leukopenia) when used > 14 days, peripheral and optic neuropathy when used >28 days, serotonin syndrome, hypoglycemia (caution with insulin or other hypoglycemic drugs), seizures, lactic acidosis, increased BP (caution and monitor BP in pts with uncontrolled HTN and untreated hyperthyroidism)

262
Q

Side effects for linezolid

A

Decreased platelets, Hgb, WBC
HA, nausea, diarrhea
Increased LFTs

263
Q

Monitoring for linezolid

A

Weekly CBC, HR, BP, BG (in DM), visual function

264
Q

T/F: linezolid suspensions should be shaken vigorously for 15 seconds prior to administration.

A

False - do NOT shake linezolid suspensions

265
Q

Linezolid and tedizolid are reversible ____ inhibitors. Avoid ___ containing foods and ____ drugs

A

Reversible MAO inhibitors
Tyramine-containing foods
Seotonergic drugs

266
Q

MOA Quinuprisitin/Dalfopristin (Synercid)

A

50 S ribosomal subunit inhibiting protein synthesis

266
Q

Quinupristin/Dalfopristin covers most gram-positive bacteria, including MRSA and VRE but only VRE caused by ___ but not ____

A

Covers E. faecium but not E. faecalis

267
Q

T/F: Quinupristin/dalfopristin is often drug of choice for complicated SSTIs and well tolerated

A

False - not well-tolerated, typically limited to vancomycin-resistant E. faecium infections

268
Q

Side effects for quinupristin/dalfopristin (Synercid)

A

Arthralgias/myalgias, infusion reactions (edema and pain at infusion site), phlebitis, hyperbilirubinemia, CPK elevations, GI upset, increased LFTs

269
Q

Quinupristin/dalfopristin can only be diluted in ___

A

D5W only

270
Q

Quinupristin/dalfopristin should be administered via ___ to avoid phlebitis

A

central line, such as a peripherally inserted central catheter (PICC)

271
Q

MOA Tigecycline

A

Binds to 30S ribosomal subunit and inhibits protein synthesis; structurally related to tetracyclines

272
Q

Coverage Tigecycline

A

Broad-spectrum including MRSA, VRE, GN bacteria, anaerobes, and atypical
Among gram-negatives, NO activity against 3 Ps: Pseudomonas, Proteus, Providencia

273
Q

Boxed warning for tigecycline

A

Increased risk of death (only use when alt treatments not suitable)

274
Q

Common uses for tigecycline

A

complicated SSTIs
Intra-abdominal infections
CAP
Note: Do NOT use for bloodstream infections, does not achieve adequate concentrations in the blood since it is lipophilic drug

275
Q

T/F: tigecycline is a broad-spectrum abx that can be used for complicated SSTIs and bloodstream infections

A

It is used for complicated SSTIs but cannot be used for bloodstream infections as it does not achieve adequate concentrations in the blood (lipophilic drug)

276
Q

T/F: When tigecycline is reconstituted, it should be a light purple solution; discard if not this color

A

False - should be yellow-orange; discard if not this color

277
Q

Warnings for Colistimethate

A

dose-dependent nephrotoxicity
Neurotoxicity

278
Q

Which polymyxin is a prodrug?

A

Colistimethate is a prodrug that is converted to colistin (active form)

279
Q

1 mg = ____ units polymyxin B

A

10,000 units

280
Q

Boxed warning for polymyxin B

A

Nephrotoxicity (dose-dependent)
Neurotoxicity (dizziness, tingling, numbness, paresthesia, vertigo) - can result in respiratory paralysis from neuromuscular blockade!
Should only be administered to hospitalized patient
Avoid concurrent or sequential use of other neurotoxic or nephrotoxic drugs

281
Q

MOA chloramphenicol

A

Reversible binds to 50S subunit of bacterial ribosome, inhibiting protein synthesis

282
Q

Boxed warning for chloramphenicol

A

Serious and fatal blood dyscrasias (aplastic anemia, pancytopenia - may be irreversible)

283
Q

Chloramphenicol can cause ___ with high serum levels - circulatory collapse, cyanosis, acidosis, abdominal distention, myocardial depression, coma, and death

A

Gray syndrome

284
Q

T/F: Chloramphenicol is rarely used d/t adverse effects

A

True

285
Q

MOA clindamycin

A

Reversibly binds to 50S subunit of bacterial ribosome, inhibiting protein synthesis

286
Q

Boxed warning with clindamycin

A

Colitis (C. diff)

287
Q

___ test should be performed on S. aureus that is susceptible to clindamycin but resistant to erythromycin

A

induction test (D-test)
A flattened zone between disks (positive D-test) indicated inducible clindamycin resistance and clindamycin should NOT be used

288
Q

Common uses of clindamycin

A

Purulent and non-purulent skin infections, beta-lactam alternative for dental abscesses and surgery prophylaxis

289
Q

T/F: clindamycin does not require renal dose adj

A

True

290
Q

MOA metronidazole

A

Cause loss of helical DNA structure and strang breakage resulting in inhibition of protein synthesis

291
Q

Coverage metronidazole

A

Anaerobes and protozoal organisms

292
Q

Common uses for metronidazole (Flagyl)

A

Bacterial vaginosis, trichomoniasis, giardiasis, amebiasis, C.diff (not preferred), and used in combo regimens for intra-abdominal infections

293
Q

Contraindications for metronidazole/tinidazole

A

Pregnancy (1st trimester), use of alcohol or propylene-glycol-containing products during treatment or within 3 days of treatment d/c (disulfiram reaction - abdominal cramping, HA, N/V, flushing)
Metronidazole: use of disulfiram within the past 2 weeks
Tinidazole: breastfeeding

294
Q

Warnings for metronidazole/tinidazole

A

CNS effects: seizures, peripheral neuropathy
Metronidazole: aseptic meningitis, encephalopathy, optic neuropathy

295
Q

Side effects for metronidazole/tinidazole

A

Metallic taste, HA, nausea, furry tongue, darkened urine, dizziness, rash/severe skin rxn (SJS/TEN)

296
Q

Side effects for secnidazole (Solosec)

A

Vulvovaginal candidiasis, HA, N/D

297
Q

Which antibiotic should not be used with alcohol (during and for 3 days after discontinuation) d/t potential disulfiram-like reaction?

A

Metronidazole

298
Q

Metronidazole is a weak inhibitor of CYP___ and can cause increase in INR in warfarin pts

A

2C9

299
Q

MOA lefamulin

A

Inhibits bacteria protein synthesis by binding to peptidyl transferase center of the 50S ribosomal subunit

300
Q

Contraindications of Lefamulin (Xenleta)

A

Use with CYP3A4 substates that prolong QT interval

301
Q

Warnings of Lefamulin (Xenleta)

A

Avoid in preganncy (teratogenic)
QT prolongation
C.diff assocaited diarrhea

302
Q

MOA fidaxomicin

A

inhibits RNA polymerase, resulting in inhibition of protein synthesis and cell death

303
Q

Common uses of fidaxomicin

A

C diff infections (not effective for systemic infections - absorption is minimal)

304
Q

MOA rifaximin

A

inhibits bacterial RNA synthesis by binding to bacterial DNA-dependent RNA polymerase

305
Q

Common uses for rifaximin

A

Travelers’ diarrhea
Decrease recurrence of hepatic encephalopathy
IBS-D
NOT effective for systemic infections (<1% absorption)
Used off-label for C. diff infections

306
Q

MOA Fosfomycin

A

Inhibits bacterial cell wall synthesis by inactivating the enzyme pyruval transferase, which is critical in the synthesis of cell walls

307
Q

What is typical dose for fosfomycin in uncomplicated UTI?

A

3 g PO x1, mixed in 3-4 oz of cold water (comes in packet granules)

308
Q

Fosfomycin comes in packet granules. How much is in 1 packet?

A

3g

309
Q

MOA nitrofurantoin

A

Bacterial cell wall inhibitor

310
Q

Typical nitrofurantoin (Macrobid) dosing

A

100mg BID x 5 days
Macrobid (macrocrystal formulation) dissolves more slowly and is given BID

311
Q

Contraindications for nitrofurantoin

A

Renal impairment CrCl <60 - inadequate urine conc and risk for accumulation of neurotoxins
Previous hx of cholestatic jaundice/hepatic dysfunction
Pregnancy (at term)

312
Q

Warnings for nitrofurantoin

A

G6PD deficiency (can cause hemolytic anemia; do not use if known deficiency)
Optic neuritis, hepatic toxicity, peripheral neuropathy, pulmonary toxicity

313
Q

Side effects for nitrofurantoin

A

GI upset (take with food), HA, rash, brown urine discoloration (harmless)

314
Q

Common uses for Mupirocin

A

topical antimicrobial nasal ointment for MRSA in the nostrils

315
Q

Commonly used abx used for C.diff

A

PO vanco
Fidaxomicin
Metronidazole (not preferred)

316
Q

Commonly used abx with B.fragilis coverage

A

Metronidazole
Beta-lactam combos: amox/clav, amp/sulb, pip/tazo, ceftazidime/avibactam, ceftolozane/tazobactam
Cefotetan, cefoxitin
Carbapenems
Moxifloxacin (reduced activity)

317
Q

Commonly used abx with Carbapenem-resistant GN rods (CRE) coverage

A

Ceftazidime/avibactam
Colistimethate, polymyxin B
Meropenem, vaborbactam
Imipenem/cilastin/relebactam

318
Q

Commonly used abx with ESBL producing GN rods (E.coli, K. pneumoniae, P. mirabilis) coverage

A

Carbapenems
Ceftazidime/avibactam, ceftolozane/tazobactam

319
Q

Commonly used abx with CAPES coverage

A

Pip/tazo
Cefepime
Carbapenems
Aminoglycosides
Colistimethate, polymyxin B

320
Q

Commonly used abx with Pseudomonas coverage

A

Pip/tazo
Cefepime
Ceftazidime
Ceftazidime/avibactam, ceftolozane/tazobactam
Carbapenems (except ertapenem)
Ciprofloxacin, levofloxacin
Aztreonam
Tobramycin
Colistimethate, polymyxin B

321
Q

Commonly used abx with HNPEK coverage

A

Beta-lactam combos: Amox/clav, amp/sulb, pip/tazo, ceftazidime/avibactam, ceftolozane/tazobactam
Cephalosporins (except 1st gen)
Carbapenems
Aminoglycosides
Quinolones
SMX/TMP

322
Q

Commonly used abx with atypical organisms coverage

A

Azithromycin, clarithromycin
Doxycycline, minocycline
Quinolones

323
Q

Commonly used abx with VRE coverage

A

Pen G or ampicillin (E. faecalis only)
Linezolid
Daptomycin
Cystitis only: nitrofurantoin, fosfomycin, doxycycline

324
Q

Commonly used abx with MRSA coverage

A

Vancomycin (consider alt if MIC ≥2)
Linezolid
Daptomycin (not in pneumonia)
Ceftaroline
SMX/TMP (CA-MRSA SSTIs)
Doxycycline, minocycline (CA-MRSA SSTIs)
Clindamycin (CA-MRSA SSTIs - D-test must be preformed before using clinda)

325
Q

Commonly used abx with MSSA coverage

A

Dicloxacillin, nafcillin, oxacillin
Cefazolin, cephalexin (and other 1st and 2nd gen cephalosporins)
Amox/clav, amp/sulb

326
Q

Liquid oral antibiotics: Refrigeration required after reconstitution

A

Pencillin VK
Ampicillin
Amoxicillin/clavulanate
(other to know: cephalexin, cefadroxil, cefpodoxime, cefprozil, cefuroxime, cefaclor, vancomycin PO, valganciclovir)

327
Q

Liquid oral antibiotics: Refrigeration recommended

A

Amoxicillin - improves taste

328
Q

Liquid oral antibiotics: Do NOT refrigerate

A

Cefdinir
(others to know: azithromycin, clarithromycin - bitter taste, thickens/gels, doxycycline, ciprofloxacin, levofloxacin, clindamycin - thickens, may crystalize, linezolid, SMX/TMP, acyclovir, fluconazole, posaconazole, voriconazole, nystatin)

329
Q

IV antibiotics: Do NOT refrigerate

A

Metronidazole
Moxifloxacin
SMX/TMP
Acyclovir - refrigeration causes crystallization

330
Q

Abx that do NOT require renal dose adj

A

Key drugs:
Antistaphylococcal PCN (e.g. dicloxacillin, nafcillin)
Ceftriaxone
Clindamycin
Doxycycline
Macrolides (azithromycin and erythromycin only)
Metronidazole
Moxifloxacin
Linezolid
(Others to know: Chloramphenicol, fidaxomicin, select tetracyclines (e.g. eravacycline, seracycline, omadacycline), quinupristin/dalfopristin, rifaximin, rifampin, tedizolid, tigecycline, tinidazole, vancomycin PO only)

331
Q

Most abx can be taken with food to decrease GI upset. Which ones should be taken on an empty stomach?

A

Ampicillin oral capsules and suspension
Levofloxacin oral soltion
Pneicillin VK
Rifampin
Isoniazid
Itraconazole solution
Voriconazole

332
Q

Which abx should be taken within 1 hour of finishing a meal

A

Amoxicillin ER

333
Q

Which abx have 1:1 IV to PO ratios?

A

Levofloxacin, moxifloxacin
Doxycycline, minocycline
Linezolid, tedizolid
Metronidazole
SMX/TMP
Fluconazole, isavuconazonium, posaconazole (oral tabs and IV), voriconazole

334
Q

Which abx require light protection?

A

Doxycycline
Micafungin
Pentamidine

335
Q

Which Abx are compatible with dextrose ONLY

A

quinupristin/dalfopristin
SMX/TMP
Amphotericin B (conventional, Abelcet, Ambisome)
Pentamidine

336
Q

Which abx are compatible with saline ONLY

A

Ampicillin
Amp/sulb
Ertapenem
Daptomycin (Cubicin RF)

337
Q

Which abx are compatible with NS/LR ONLY

A

Caspofungin
Daptomycin (Cubicin)

NAPLEX 2024 (74 decks)

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