Adv Pharm Final - ID Flashcards
1
Q
GPC in clusters =
A
staph species
2
Q
GPC in chains =
A
strep species
3
Q
Gram-Positive Organisms of Importance
A
- Staphylococcus aureus–Methicillin-susceptible (MSSA) & Methicillin-resistant (MRSA)
- Streptococcus pneumoniae
- Streptococcus pyogenes (Group A Strep)
- Enterococcus faecalis and Enterococcus faecium
- Clostridium difficile (anaerobic organism)
4
Q
Gram-Negative Organisms of Importance
A
- Escherichia coli (E. coli)
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Bacteroides fragilis (anaerobic organism)
5
Q
What do we look for on asusceptibility panel?
A
- Organism and drugs thatwere tested against it
- Minimum inhibitory concentration
- Interpretation from MIC
6
Q
Minimum Inhibitory Concentration values determine
A
if sensitive, intermediate or resistant
7
Q
Concentration-dependent
A
Greater bactericidal activity as drug concentration (Cmax) exceeds the MIC
8
Q
Time-dependent
A
Greater bactericidal activity as drug concentration remains above the MIC
9
Q
what family does penicillin belong to?
A
beta-lactam
10
Q
penicillin MoA
A
Bind to penicillin binding proteins (PBPs) within the cell wall–>inhibiting cell wall synthesisa–>cell lysis–>destruction
11
Q
What are natural penicillins?
A
Penicillin G, Penicillin V
12
Q
Natural penicillin specturm
A
Staph aureus (penicillin-susceptible), Streptococcus spp., Syphilis
13
Q
how much gram-negative activity with natural penicillins?
A
minimal to none
14
Q
what was penicillin initally successful against?
A
skin infections
15
Q
what is the drug of choice for syphillis?
A
penicillin
16
Q
IV natural penicillin
A
Pencillin G
17
Q
PO natural penicillin
A
Pen V
18
Q
Does Pen V have good absorption?
A
no
19
Q
Anti-Staphylococcal Penicillins
A
Oxacillin, Nafcillin, Dicloxacillin
20
Q
Anti-Staphylococcal Penicillins Spectrum:
A
Methicillin-susceptible Staph aureus (MSSA)
21
Q
Drug of choice for serious MSSA infections
A
Anti-Staphylococcal Penicillins
22
Q
Anti-Staphylococcal Penicillins half life
A
dosed every 4 hours
23
Q
where are Anti-Staphylococcal Penicillins cleared?
A
liver
24
Q
are most beta lactams renally adjusted?
A
yes
25
Oral option of Anti-Staphylococcal Penicillins
dicloxacillin
26
Why isn't dicloxacillin commonly used?
requires frequent dosing
27
What were Anti-Staphylococcal Penicillins Created to treat?
Penicillin-resistant Staph aureus
28
What was the original Anti-Staphylococcal Penicillin?
methicillin
29
Why was methicillin discontinued?
hepatotoxicity
30
Amino-penicillins
Amoxicillin (Amoxil®), Ampicillin
31
Amino-penicillins Spectrum:
Streptococcus spp., E. coli, Haemophilus influenzae, Enterococcus faecalis
32
are Amino-penicillins reliable for Staph aureus? Why/why not?
no--often resistant to becta-lactamase production
33
Ampicillin route
IV and PO - MAINLY IV
34
Amoxicillin route
PO
35
What penicillins are used for otitis media and pharyngitis?
Amino-penicillins
36
why aren't amino-penicillins used for hosptial infections?
gram negatives are usually resistant
| inactivated by beta-lactamases
37
What is a Beta-lactamase?
Enzyme that hydrolyzes the beta-lactam ring à antibiotic becomes inactive
38
Beta-lactamase Inhibitors (drugs)
Amoxicillin-clavulanate (Augmentin®)
Ampicillin-sulbactam (Unasyn®)
Piperacillin-tazobactam (Zosyn®)
39
Why were beta-lactamase inhibitors developed?
to inhibit the activity of simple beta-lactamases
40
Which beta-lactamase inhibitor is avail IV only?
zosyn and unasyn
41
which beta-lactamase inhibitor is avail PO only?
augmentin
42
useful action of beta-lactamase inhibitors
preserves/expands the activity of its counterpart
43
therapuetic use of beta-lactamase inhibitors
hospital infections (except c diff)
44
Which beta-lactamase inhibitor is associated with high rates of GI complaints?
Augmentin
45
Penicillin Class Adverse Effects
```
Hypersensitivity reactions (10%, usually rash)
Almost all agents are renally eliminated (requires adjustments)
GI intolerances (e.g. diarrhea)--mainly with oral agents
```
46
Which penicillins are hepatically eliminated?
Oxacillin, Nafcillin
47
Cephalosporins MoA
Inhibit cell wall synthesis
48
How are cephalasporings divided into generations
based on gram negative and gram positive coverage
49
Which generation of cephalasporin has the most gram-positive coverage?
first
50
Which generation of cephalasporin has the most gram-negative coverage?
fifth
51
Why where 3rd gen cephalasporins developed?
Developed to further expand gram-negative spectrum
52
First Generation Cephalosporins (drugs)
Cephalexin (Keflex®) – PO
| Cefazolin (Acnef®) - IV
53
Which drug class is an alternative to anti-staphylococcal penicillin?
1st gen cephalosporins
54
1st gen cephalosporins Spectrum:
Streptococcus, Staph aureus (MSSA) – not MRSA
55
How often are 1st gen cephalosporins dosed?
3-4x a day
56
what are 1st gen cephalosporins commonly used for?
skin infections and propylaxis prior to surgeries
57
Third Generation Cephalosporins (drugs)
Ceftazidime
Ceftriaxone
Cefpodoxime
Cefdinir
58
Which 3rd gen cephalosporins are IV?
Ceftazidime and Ceftriaxone
59
Which 3rd gen cephalosporins are PO?
Cefpodoxime and Cefdinir
60
Third Generation Cephalosporins Spectrum:
Streptococcus spp., MSSA, E. coli, K. pneumoniae, Proteus spp.
61
Ceftriaxone dosing
once a day (for UTI, pneumonia, skin infections)/longer half life, very protein bound
62
3rd gen common indications
community- acquired pneumonia, skin, bacteremia, osteomyelitis, CNS infections
63
Fourth Generation Cephalosporins
Cefepime (Maxipime®)
64
Cefepime route
IV
65
4th gen ceph Spectrum:
Same as 3rd generation, + additional gram-negatives including Pseudomonas aeruginosa
66
4th gen ceph--cefepime is reserved for _____________
serious hospital-associated infections
67
Concern for ________________if 4th gen ceph not dosed properly
encephalopathy (including seizure)
68
highest risk for encephalopathy with 4th gen ceph
elderly and renal impairment
69
5th gen cephalosporin
Ceftaroline (Teflaro®)
70
Ceftaroline (5th gen) route
IV
71
Ceftaroline (5th gen ceph) spectrum
Covers methicillin-resistant Staph aureus (MRSA) by binding to PBP-2a
72
Does ceftaroline (5th gen ceph) cover Pseudomonas aeruginosa?
no
73
Which drug is approved for CAP and ABSSSI?
Ceftaroline (5th gen ceph)
74
Used off-label for bacteremia, endocarditis and osteomyelitis (as salvage therapy)?
Ceftaroline (5th gen ceph)
75
Cephalosporin AE
hypersensitivity
| seizure if not dosed properly
76
When to request allergy test or discontinue ceph?
hives, swelling, anaphylaxis
77
What ceph has highest risk for seizure?
cefepime
78
CarbaPENEMs
Ertapenem
Meropenem
Imipenem/cilastatin
Doripenem
79
Carbapenem route
IV for all
80
Which carbapenem is also avail IM?
Ertapenem
81
Which class is broadest beta lactam class?
carbapenem
82
Which class is used as last-line options in gram-negative resistant infections
carbapenem
83
Carbapenem spectrum:
Streptococcus, MSSA, essentially all GNRs (including P. aeruginosa) and anaerobic gram-negatives
84
Which carbapenem does not cover psuedomonas?
ertapenem
85
Drug of choice for ESBL’s
Carbapenem
86
Which carbapenem has the highest risk for seizures?
Imipenem/cilastatin (Primaxin)
87
Which carbapenems are interchangeable?
Meropenem, doripenem, imipenem
88
Are carbapenems stable against many beta-lactamases?
yes
89
Fluoroquinolones (drugs)
ciprofloxacin
Levofloxacin
Moxifloxacin
90
fluoroquinolones route
IV and PO
91
fluoroquinolones MOA
Interferes with normal DNA processes by inhibiting DNA topoisomerases à leading to cell death
92
flouroquinolones spectrum:
Broad coverage including gram-positive (not MRSA) and gram-negatives
93
which fluor has poor streptococcus coverage?
Cipro
94
Do fluor have good bioavailabity?
yes! nearly 100%
95
Is there a problem of resistance development with fluor?
yes
96
Do fluor have good distrubtion among infection types?
yes used for nearly all infection types
97
Fluor AE
QTc prolongation
peripheral neuropathy
tendonitis
hyperglycemia
98
Fluor BBW:
Exacerbate myasthenia gravis, peripheral neuropathy, tendinitis
99
What pop are fluors contraindicated?
pregnant and kids
100
Tetracyclines (drugs)
doxycycline
minocycline
tigecycline
101
Tetracycline MOA
Inhibit protein synthesis by binding to the 30S ribosomal subunit and preventing tRNA from binding and forming aminoacid sequencing
102
tetracyclines spectrum:
Expanded gram-positive coverage (including MRSA) and gram-negative (NOT Pseudomonas)
103
Do tetracyclines cover pseudomonas?
no
104
Which tetracycline has anaerobic activty and works against VRE?
Tygacil
105
What conditions are tetracyclines good for?
bone and skin infections
106
What conditions are tetracyclines bad for?
bacteremia and urine infection
107
Tetracyclines AE
GI intolerances
Photosensitivity
Bone deformity and teeth staining
108
which tetracycline has more cases of vertigo?
Minocycline
109
Which tetracyline has higher levels of N/V?
Tygacil
110
Which groups are contraindicated for tetracyclines?
pregnant and children under 8
111
Macrolides (drugs)
Azithromycin
| Clarithromycin
112
Macrolides route
Azithro - IV, PO
| Clarithro - PO
113
Macrolides MOA
Inhibits protein synthesis via the 50S ribosomal subunit
114
Macrolides Spectrum:
- variable Streptococcus spp., H. influenzae, Moraxella catarrhalis, otherwise weak gram-negative coverage
- Respiratory pathogens that may cause CAP and other respiratory infections
- atypicals - mycoplasma pneumoniae and chlamydophilia pneumoniae
115
Which macrolide is used for chlamydia trachomitis
azythromycin
116
What is the post-antibiotic effect with macrolides?
Continues to work despite subtherapeutic concentrations
117
macrolides AE
GI upset, QTc prolongation
118
Should pts take macrolides with food?
yes; helps minimize GI upset
119
Why is Clarithromycin rarely used?
drug interactions (inhibits CYP 450 enzymes), increased GI intolerance and more frequent dosing
120
Sulfamethoxazole-trimethoprim (Bactrim®) route
IV and PO
121
Bactrim MOA
Inhibits DNA synthesis via inhibition of folic acid synthesis (synergistic activity as each component works in a different step)
122
Bactrim spectrum
Very broad, gram-negatives (NOT Pseudomonas aeruginosa) and gram-positives (including MRSA)
123
Bactrim bioavailabity
85% (IV and PO interchangable)
124
Bactrim contraindicated
patients with sulfa allergies
pregnant or trying
on warfarin
potassium issues
125
Use caution prescribing bactrim when
pt has hematological issues
renal disease
has used bactrim before (20% of ecoli are resistant)
126
Bactrim is dosed based on the ____________
trimethorprim
127
Bactrim indications
pneumonia, skin infections, UTI, bone infections
128
Bactrim AE
Skin reactions (can be very severe), neutropenia, nephrotoxicity, hyperkalemia
129
When to adjust bactrim?
renal dysfunction
130
Metronidazole (Flagyl®) route
– IV, PO
131
Metronidazole MOA
Damages DNA of the organism and leads to cell death
132
Metronidazole (Flagyl) Spectrum:
Anaerobic gram-negative organisms, Clostridium difficile (C.diff) which is a gram-positive anaerobic organism
133
Metronidazole (Flagyl) AE
GI upset, metallic taste, headache, dark urine, peripheral neuropathy
134
what happens when you mix Metronidazole (flagyl) and alcohol?
disulfram like reaction--extreme vomiting
135
Metronidazole (Flagyl) bioavailabiity
excellent - IV and PO interchangeable
136
gram pos antibiotics
vancomycin, linezolid, daptomycin
137
vanco MOA
Inhibits cell wall synthesis
138
vanco spectrum
gram pos only
139
drug of choice for MRSA
Vanco
140
When is vanco given IV?
pneumonia, CNS, UTI, bone, blood
141
When is vanco given PO?
Clostridium difficile infection (not absorbed systemically)
142
What must you do when administering IV vanco?
monitor drug levels for efficacy and toxicity
143
Vanco AE
Nephrotoxicity - high levels
Ototoxicity - very high levels
Red Man's syndrome - with rapid infusion
144
What should you do when vanco pt gets red man syndrome?
slow the infusion time --it's not an allergic reaction!
145
when is trough measurement taken for vanco
serum conc taken 30 minutes prior to the 4th dose
146
desired vanco concentrations for serious infections (blood and lung)
15 - 20 mcg/ml
147
desired vanco concnetrations for mild infections (skin and UTI)
10-15 mcg/ml
148
Linezolid route
IV and PO
149
LInezolid MOA
Inhibits protein synthesis
150
Linezolid spectrum
VERY broad gram-positive coverage including MRSA and VRE
| No gram-negative coverage
151
Linezolid clinical uses
drug-resistant enterococcus (VRE), staphylococcal infections of the lungs, patients with vancomycin intolerance
152
Linezolid AE
```
Thrombocytopenia (use > 14 days)
Drug interactions with SSRIs (may cause serotonin syndrome)
Optic neuritis (use >28 days)
```
153
Linezolid contraindications
patients taking an MAO-I
154
Linezolid bioavailabity
100%
155
Daptomycin MOA
Causes rapid depolarization leading to inhibition of protein, DNA and RNA synthesis
156
Daptomycin Spectrum
Same as linezolid
157
Is Daptomycin available PO?
no
158
Daptomycin clinical Uses
Alternative agent to linezolid for resistant gram-positive infections and linezolid intolerance
NOT used to treat pneumonia (Inactivated by lung surfactant)
159
linezolid Adverse effects
myopathy
160
what to monitor on daptomycin
CPK
161
Pseudomonas aeruginosa agents
```
piperacillin/tazobactam
ceftazidime
carapenems (except ertrapenem)
Levofloxacin
Cipro
```
162
MRSA agents
```
Vanco
Linezolid
Daptomycin
Tetracyclines
Bactrim
Ceftaroline
```
163
Antifungals
flucanozole
voriconazole
echinocandins
164
Does flucanazole have good bioavailability?
yes
165
What is the only azole that concentrates
well in the urine
fluconazole
166
Flucanazole indication
C. albicans infections (thrush, UTI, blood)
167
How often is flucanozole dosed for yeast infections?
one time
168
Drug of choice for invasive pulmonary aspergillosis
Voriconazole
169
Voriconazole has excellent distribution, except for __________
urine
170
Voricanazole route
IV and oral
171
Goal for voriconazole monitoring
2 - 5.5 mcg/ml
172
Voriconazole AE
visual disturbances and hallucinations
173
Azoles AE
increase QTc interval (except newest--isavunonazole)
| liver injurry
174
All azoles can inhibit __________ leading to drug interactions
the CYP 450 enzyme system
175
Azoles can cause transient _______________
LFT elevations
176
Echinocandins (drugs)
Micafungin, caspofungin and anidulafungin
177
Echinocandins route
IV only
178
Echinocandins distribute well with the exception of ______ and ______
CNS, urine
179
Echinocandins is recommended for
coverage of candidemia in severely septic patients
180
Antivirals
Acyclovir
Valacyclovir
Oseltamivir (tamiflu)
181
Cyclovirs MOA
Terminates DNA replication
182
Which cyclovir is only PO?
valacyclovir (valtrex)
183
cycolivr side effects
headaceha and nausea
184
IV cycolivr potential AE
nephrotoxicity
185
Valacyclovir has a _____________ so it's dosed less frequently
longer half life
186
Valacyclovir is a _____________ that's converted to __________
prodrug, acyclovir
187
Oseltamivir (tamiflu) MOA
Treatment and/or prophylaxis via neuraminidase inhibition (halts replication)
188
Tamiflu dosing for treatment of flu
twice a day
189
tamiflu dosing for prophylaxis of flu
once a day
190
tamiflu side effects
nausea and vomiting
191
Empiric data
No culture data to guide antibiotic selection
Takes into account common pathogens
Takes into account patient history and local resistance
192
Definitive data
based on culture data
193
CAP Diagnosis
```
Fever
Tachypnea
Cough
Sputum production (send for culture) ¤ Confusion
Fatigue
Chest X-ray showing infiltrate
```
194
In the elderly, _______may be the only initial symptom
of CAP
confusion
195
CAP usually straight forward diagnosis, except in those with ___________and_____________
structural lung disease, congestive heart failure
196
CAP first line treatment (uncomplicated)
Azithromycin OR doxycycline
197
CAP first line treatment (allergy or complicated)
Levofloxacin or Moxifloxacin
198
CAP treatment duration
5 days
199
Cystitis presentation
Urgency to urinate
Increased frequency of urination
Dysuria
Suprapubic pain/tenderness
200
Cystitis diagnosis
Urinalysis (UA) – sample of urine analyzed for bacteria, WBC,
inflammatory markers and organism growth
Urine Culture – Should be obtained if the UA is abnormal
201
Preferred Agents for cystitis
Nitrofurantoin (Macrobid®) – uncomplicated disease
Trimethoprim/sulfamethoxazole (Bactrim®)
Fosfomycin
Fluoroquinolones
Beta-lactams (amoxicillin-clavulanate, cefpodoxime)
202
Typical duration for cystitis treatment
3-5 days
203
____________ are NO LONGER recommended as first-line therapy for UTIs
Fluoroquinolones
204
drug for uncomplicated cystitis
Nitrofurantoin
205
What is the patient requirement for nitrofurantoin (macrobid)
CrCl > 40
206
Minimum days of treatment of Nitrofurantoin (macrobid)
5
207
Is nitrofurantoin (macrobid) safe in pregnancy?
yes
208
nitrofurantoin (macrobid) covers______
many gram negative organisms causing cystitis (eg E. coli)
209
Fosfomycin use
refractory cases of cystitis
210
Dosing for fosfomycin
one time (in uncomplicated disease)
211
Fosfomycin side effects
Diarrhea, nausea (more common)
| Headache and dizziness
212
How often should a patient be prescribed Fosfomycin?
once or twice (base on cultures after)
213
Fosfomycin MOA
interferes with cell wall syntehsis
214
Sulfamethoxazole-trimethoprim (Bactrim®) for cystitis safe during pregnancy?
not in pregnancy
215
Levo/cipro (fluors) for cystitis
use in allergic patients or sever/refractory cases
| Avoid in pregnancy
216
which fluor should be avoided for UTIs and why?
moxifloxacin because it has low urinary concentrations
217
Beta lactams for cystitis
Augmentin and oral cephs
218
ABSSSI drugs
```
Cephalexin
Tetra
Bactrim
Clinda
Linezolid
Dalbavancin or ortiavancin
```
219
Last line ABSSI drug and why
Clinda, GI and C. Diff
220
Which ABSSI drug causes toxicites after two weeks?
linezolid
221
Good drug for MSSA and strep
cephalexin
222
Drug reserved for MRSA or VRE
linezolid
223
Cephalexin is dosed _____ times a day
4
224
Dalba/oritavancin is similar to __________
vancomycin
225
Dalba/oritavancin is useful for
ABSSI non-compliant pts or drug resistance
226
ABSSSI treatment duration
7-10 days
227
with minimal response to ABSSSI treatment consider
patient compliance
resistance to agent
source issues
228
When should we treat a URI with antibiotics?
```
Strep throat
otitis externa (usually bacterial)
Otitis media with pus
Sinusitis with fever
Worsening URI not treated may be bacterial
```
229
Strep treatment
Amoxicillin or augmentin in those with amox exposure
230
Treatment for CAP, inpatient
Ceftriaxone + Azithromycin
231
Treatment of CAP, inpatient with PCN allergy
Levofloxacin OR moxifloxacin
232
gram positive anaerobic organism
C Diff
233
which drugs are hepatically eliminated?
ceftriaxone
| Anti-staph penicillins
234
Why would a patient need to switch from oxacillin to cefazolin?
hepatotoxicity
235
Which class of drug is inactivated by ESBLs?
3rd gen cephalosporins
236
Alternative to vanco
linezolid
237
which antibiotic can inhibit MAO?
linezolid
238
Daptomycin is not useful for_____________
pneumonia
239
The number given on an antibiogram indicates
percent susceptible
240
Of the azoles, only Flucanizole has adequate_________
urinary concentrations
241
All azoles can cause QTc prolongations except
isavunonazole
242
This azole can cause hallucinations
voriconazole
243
Fungins are part of this class
Echinocandins
244
Which ID drugs cause QT prolongation?
macrolides, azoles, fluoroquinolones
245
Which ID drugs can inhibit CYP 450 enzymes? (and therefore cause drug interactions?)
clarithromycin and azoles
246
Which ID drugs mess with the cell wall?
beta lactams and vancomycin
247
which ID drugs mess with protein?
tetracyclines, macrolides, linezolid
248
Which ID drugs mess with DNA?
Fluoros, Bactrim, Flagyl
249
Which drug is inactivated by lung surfactant?
Daptomycin
250
UTI drugs
```
Macrobid
Bactrim
Fosfomycin
Fluoros
Beta-Lactams—augmentin and cefpodoxime
```
251
Name 3 adverse effects of the Penicillin class
Hypersensitivity reactions - 10% of US population (esp. rash)
Almost all renally eliminated with two exceptions
GI intolerances such as diarrhea, usually more with oral agents
252
Name a cephalosporin that has a long half life, is highly protein bound and can be used to treat UTIs, Pneumonia, and Skin Infection
ceftriaxone
253
Way to remember pseudomonas aeruginosa
Zosyn Forts Maximize the Cipro Levo Penem
Zosyn, Fortaz (Ceftrazidime), Maxipime (Cefepime), Ciprofloxacin, Levofloxacin, carbaPenems (not ertapenem)
254
What’s used with vanco for c diff?
Flagyl
