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NRP 507 > antimicrobials > Flashcards

antimicrobials Flashcards

1
Q

What are the goals of administering antimicrobials?

A
  • to inhibit growth of microorganisms but not hurting the host* give as narrow a spectrum as possible so that the normal flora can be maintained.* consider if the pt is seriously ill or immunocompromised * these patients will need bacteriocidal antibiotics
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2
Q

what are some types of adverse reactions that can be had with antimicrobials?

A
  • hypersensitivity reaction (dose dependent)* direct organ toxicity (dose related)* potential for superinfections* cross-reactions with other medications we give
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3
Q

What is an SSI? How is it defined?

A
  • An infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure * purulent exudate from surgical site * a positive culture obtained from a surgical site that was closed initially * A surgeon’s diagnosis * A surgical site that requires reopening due to at least one of the following: * tenderness, swelling, redness, or heat
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4
Q

What specific aspects of a surgery can increase the risk of infection?What surgeries have the highest incidence of infection?

A
  • procedure type* skill of surgeon* use of foreign meterial or implantable device* degree of tissue trauma* highest incidence: Carotid endarterectomy, urologic, colon
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5
Q

What patient traits increase the risk of surgical site infection?

A
  • DM* smoking* obesity* malnutrition* systemic steroid use* immunosuppressive therapy* intraoperative hypothermia* trauma* prosthetic heart valves
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6
Q

What adverse outcomes are associated with hypothermia?

A
  • increased blood loss* increased transfusion requirements* prolonged PACU stay* post-op pain* impaired immune function* compromised neutrophil function causing vasoconstriction and tissue hypoxia; increasing incidence of SSI
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7
Q

What are the appropriate antibiotics for Cardiothoracic and vascular surgery?What if the pt has a b-lactam allergy?

A
  • Cefazolin, cefuroxime, or vancomycin* b-lactam allergy: vancomycin or clindamycin
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8
Q

What is the difference between bacteriocidal and bacteriostatic?

A
  • Bacteriocidal: kills the susceptible bacteria* Bacteriostatic: reversibly inhibits the growth of bacteria * for bacteriostatic, the duration of the therapy must be long enough to allow the person’s defense mechanisms to eradicate the bacteria
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9
Q

What are some bacteriocidal antibiotics?

A
  • PCNs and cephalosporins* Isoniazid* metronidazole* polymyxins* rifampin* bacitracin* aminoglycosides* vancomycin* quinolones* PIMP-R-BAVQ (this mneumonic has been censored due to adult content)
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10
Q

What are some bacteriostatic antibiotics?

A
  • Chloramphenicol* clindamycin* macrolides* sulfonamides* tetracyclines* trimethoprim* Cora carries more sulfur than Tim—————-from the list of ABX she elaborated on during lecture, “the list is SLiM”: (by default the rest she talked about are bacteriocidal)* Sulfa* cLindamycin* Macrolides
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11
Q

What is the structure of Penicillin?-

A
  • dicyclic nucleus that has a thiazolidine ring connected to a B-lactam ring
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12
Q

Is Penicillin bacteriocidal or bacteriostatic?MOA?What kind of organisms can affect?

A
  • interferes with the synthesis of peptidoglycan which is an essential component to cell walls of susceptible bacteria* Organisms: * pneumococcal * meningococcal * streptococcal * actinomycosis
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13
Q

How is Penicillin excreted?What can increase the E 1/2t?

A
  • Rapid renal excretion; plasma concentration decreases 50% in 1st hour * 10% is excreted through glomerular filtration * 90% secreted by renal tube * anuria increases elimination half time by 10x
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14
Q

Penicillin adverse reactions

A
  • Most allergenic antimicrobial (up to 10%)* rash, with or without fever* hemolytic anemia* maculopapular rash (delayed)* immediate sensitivity: anaphylaxis* cross-sensitivity common with all PCN drugs AND cephalosporins
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15
Q

Why is there cross sensitivity between PCN and cephalosporins?How common is it?

A

Because both classes have a b-lactam ringanywhwere from 2-8% of people with PCN allergy are also allergic to cephalosporins

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16
Q

What is the difference between 1st and 2nd generation PCNs?Examples?

A
  • The later generations are also efective on some gram- bacilli * haemophilus influenza * E coli* Examples: Amoxicillan, ampicillin
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17
Q

If your patient is allergic to 1st generation PCN, can you give them a 2nd?

A

No! You should substitue it with clindamycin or vancomycin

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18
Q

Are cephalosporins (Cefazolin) -cidal or -static?MOA?

A
  • Bactericidal- inhibits bacterial cell wall synthesis and have low toxicity
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19
Q

Facts about Cefazolin:spectrum of activity?allergy incidence?excretion?

A
  • Broad spectrum activity* allergy incidence is 1-10% * anaphylaxis is 0.02%, * PCN and cephalosporin allergy 1-3%* Renal excretion
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20
Q

Which generation of cephalosporin is best for Menningitis?

A
  • 3rd generation* achieves therapeutic levels in the CSF and they also have lower toxicity than earlier generations
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21
Q

What is the structure of Macrolides?two examples?Which is the prototype?

A
  • macrolytic lactone ring containing 14-16 atoms with a deoxy sugar attached* Erythromycin, Azithromycin* Prototype: erythromycin
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22
Q

Is Erythromycin -cidal or -static?MOA?What kinds of bacteria is it effective against?

A
  • It can be either, depending on the type of organism they are treating* MOA: inhibits bacterial protein synthesis* Effective against: * Gram + bacilli * pneumococci * streptococci * staphylococci * mycoplasma * chlamydia
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23
Q

How is Erythromycin metabolized?How might this effect other meds?

A
  • metabolized by the CYP450 and excreted in bile * ay increase serum concentration of theophylline, warfarin, cyclosporine, methylprednisone, and digoxin* no need to alter dose in renal patients
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24
Q

What are the side effects of Erythromycin?

A
  • GI intolerance * promotes gastric emptying- causes cramping * N/V* Cholestasic hepatitis * decreased bile secretion from hepatocytes or decreased flow of bile through ducts* QT effects * prolongs cardiac repolarization * torsades de pointes* thrombophlebitis * common with prolonged IV use
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25
Q

Clindamycinclass?-cidal or -static?Effective against what kinds of bacteria?

A
  • Class: Linomycins* Bacteriostatic* Effective against: (similar to Erythromycin) * gram + bacilli * pneumococci * streptococci * staphylococci * mycoplasma * chlamydia* **more effective against anaerobes
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26
Q

Why is Clindamycin’s use limited to infections that are difficult to treat?What surgeries is it most commonly used for?

A
  • Severe GI complications * pseudomembranous colitis (stop abx if pt has diarrhea)* most commonly used in female GU surgeries
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27
Q

What are the side effects of Clindamycin?

A
  • Severe GI complications* skin rash* Prolonged NMB * prolonged pre and post junctional effects at NMJ * these effects cannot be antagonized with anticholinesterases of calcium
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28
Q

Vancomycin:structure-cidal or -static?MOA

A
  • Glycopeptide derivative* Bacteriocidal* impairs cell wall synthesis
29
Q

What kinds of infections is Vancomycin effective against?When else would we give vanco?

A
  • Gram + bacteria * severe staph infections * streptococcal, enterococcal endocarditis* PCN/Cephalosporin allergy* administered with aminoglycoside for endocarditis* drug of choice for MRSA* procedures with prosthetic devices* CSF and shunt related infections
30
Q

How is vanco eliminated?E1/2t?

A
  • Renal excretion 90% unchanged in the urine* E1/2t = 6 hours * can be prolonged (up to 9 days) in renal failure patients
31
Q

What is the dose of Vanco?

A
  • 10-15 mg/kg over 60 minutes* 1 gram mixed in 250 ml
32
Q

What are side effects of vanco?

A
  • profound hypotension- if administered rapidly* Red man syndrome* ototoxicity- when concentrations >30mcg/ml; worsened with aminoglycosides* nephrotoxicity-rare unless given with aminoglycosides* return of Neuromuscular blockade* phlebitis
33
Q

When is the combination of vancomycin and aminoglycosides indicated?

A
  • endocarditis caused by strep. viridans or enterococci(combo increases risk of otoxicity and nephrotoxcity**)
34
Q

Vancomycin:excretionDoes it penetrate the CSF?

A
  • Renal excretion by glomerular filtration (80-90% is 24 hours* Slow CSF penetration unless there is meningeal inflammation
35
Q

What are 5 Aminoglycosides?

A
  • Streptomycin & Kanamycin * older, not often used* Gentamicin * broad spectrum, used for GU procedures * toxic > 9mcg/ml* Amikacin (derivative of kanamycin) * heavy hitter; used for gentamicin or tobramycin resistang gram - bacilli* Neomycin * for skin, eye, or mucous membrane infections * only topical b/c most nephrotoxic
36
Q

What antibiotic can be used to treat hepatic coma? How?

A

Neomycin- used to bring down ammonia levels

37
Q

Aminoglycosides-cidal or -static?what kind of bacteria?excretionE1/2t?

A
  • Bactericidal * effective for aerobic gram - and + bacteria* Extensive renal excretion through glomerular filtration* E1/2t 2-3 hours * increased 20-40x with renal failure
38
Q

Which antibiotics potentiate NDMRs?

A
  • Aminoglycosides * can be reversed with neostigmine or calcium gluconate* Clindamycin * cannot be reversed with reversal agents or calcium
39
Q

What are two fluroquinolones and what are they used to treat?

A
  • Ciprofloxacin * respiratory infections * TB * anthrax * bone and soft tissue infections* Moxifloxacin * acute sinusitis * bronchitis * complicated abdominal infections
40
Q

What are side effects of Fluoroquinolones?

A
  • QT prolongation* peripheral neuropathy* psychosis* Stevens-Johnson Syndrome* Mild GI disturbance- N/V* dizziness, insomnia* tendon or achilles rupture* muscle weakness in patients with myasthenia gravis
41
Q

Fluoroquinolones:-cidal or -static?effective against what kind of bacteria?

A
  • Bactericidal- broad spectrum* effective for enteric gram - bacilli and mycobacterium * GI/GU infections
42
Q

FluoroquinolonesExcretionE1/2t?

A
  • Renal excretion, through glomerular filtration and renal tubular secretion * decrease dose in renal dysfunction* E1/2t: 3-8 hours* can inhibit CYP450
43
Q

Sulfonamides:-cidal or -static?MOA?

A
  • Bacteriostatic* prevent normal use of PABA by bacteria to synthesize folic acid
44
Q

Sulfonamides:clinical useelimination

A
  • Clinical uses: * UTI * inflammatory bowel disease * burns* Elimination: portion of drug is acetylated in the liver and other is renally excreted * reduce dose in renal dysfunction
45
Q

Sulfonamides Side effects

A
  • skin rash* anaphylaxis* photosensitivity* allergic nephritis* drug fever* hepatotoxicity* acute hemolytic anemia* thrombocytopenia* increased effect of PO anticoagulant
46
Q

Metronidazole-cidal or -static?types of bacteriaClinical use

A
  • Bactericidal* Anaerobic gram - bacilli clostridium* Useful in many infections * CNS infections * abdominal and pelvic sepsis * C-diff (with vanco) * endocarditis * pre-op prophylaxis for colorectoal surgery
47
Q

Metronidazoleadministrationside effects

A
  • PO or IV * well absorbed orally and widely distributed in tissue including CNS* Side effects * dry mouth * metallic taste * nausea * avoid alcohol
48
Q

What are the 1st line antimycobacterial agents?

A
  • Isoniazid- bacteriostatic, -cidal if bacteria are dividing * hepato-renal toxicity* Rifampin- bacteriocidal * Induces CYP450 * hepato-renal toxicity, thrombocytopenia, anemia* Ethambutol- bacteriostatic * optic neuritis* Pyrazinamide- bacteriostatic * liver toxicity
49
Q

Amphotericin BUseelimination

A
  • Given for yeasts and fungi* slow renal excretion * renal function is impaired in 80% of pts * most recover, some have permanent decrease in GFR
50
Q

Amphotericin BSide effects

A
  • fever, chills, dyspnea, hypotension during infusion* impaired hepatic function* hypokalemia* allergic reactions* seizure* anemia* thrombocytopenia
51
Q

Acyclovirusesside effects

A
  • used to treat herpes* may cause renal damage if infused rapidly* thrombophlebitis* HA during infusion
52
Q

What are interferons?What are they used for?

A
  • glycoproteins produced in response to viral infections* bind to receptors on host cell membranes and induce the production of enzymes that inhibit viral replication* enhance tumoricidal activities of macrophages* used to treat Hep B & C
53
Q

Interferon side effects

A
  • flu like symptoms* hematologic toxicity* depression/irritability* decreased mental concentration* development of autoimmune conditions* rashes* alopecia* changes in CV, thyroid, hepatic function
54
Q

What anesthesia interactions can you expect with Nucleoside reverse transcriptase inhibitors?Other Side effects?

A
  • Can change drug clearance and effect of methadone* Nausea, diarrhea, myalgia, increase LFTs, peripheral neuopathy, marrow suppression, inhibition of CYP450
55
Q

What anesthesia interactions can you expect with Non-nucleoside reverse transcriptase inhibitors?Other side effects?

A
  • extends the half life and effects of: * midazolam, diazepam, triazolam * fentanyl, meperidine, methadone* Nevirapine- induces CYP450* Delavirdine- inhibition of CYP450- decreased fentanyl clearance by about 67%
56
Q

What anesthesia interactions can you expect with Rotanavir (protease inhibitors)?Other side effects?

A
  • Prolongs the half life and effects of: * amiodarone, digoxin * diazepam, midazolam, triazolam * fentanyl, meperidine, methandone* inhibits CYP450* hyperlipidemia, glucose intolerance, abnormal fat distribution
57
Q

What anesthesia interactions can you expect with integrase strand transfer inhibitors?

A

none

58
Q

What kind of anesthesia interactions can you expect with early inhibitors?

A
  • changes clearance and effect of midazolam
59
Q

Which antimicrobials are safe in pregnancy?

A
  • PCNs* cephalosporins* erythromycin
60
Q

Why must dosing for elderly be carefully considered?

A
  • renal impairment- decreased GFR* decreased plasma protein (mostly albumin)* reduced gastric motility and acidity* increased total body fat* decreased hepatil blood flow
61
Q

Which antimicrobials must you use with caution during pregnancy?contraindicated?

A
  • Caution: * aminoglycosides (ototoxicity in mom and baby) * clindamycin (colitis in mom)* contraindicated: * tetracyclines (tooth discoloration in baby)
62
Q

Which antimicrobials are safe in the elderly if creatinine level is normal?Which should you use caution with?

A
  • safe: * PCNs * cephalosporins* caution: * aminoglycosides and vancomycin
63
Q

Clindamycin pharmacokinetics

A
  • E1/2t = 2.5 hours* penetrates most tissues and abcesses* does NOT penetrate into CNS or intracellular* hepatic metabolism, no dose adjustment for renal failure
64
Q

Aminoglycoside pharmacokinetics

A
  • VD = 25% of body weight* adjust maintenance dosing based upon creatinine* plasma monitoring necessary
65
Q

Which antimicrobials are CYP450 inhibitors?

A

SulfonamidesErythromycinFluroquinolones

66
Q

Which antimicrobials cause muscle weakness?

A

CiprofloxacinClindamycin(moxifloxacin causes peripheral neuropathy)

67
Q

Which antimicrobials will you decrease your dose for if the pt has renal disease?

A

SulfonamidesFluroquinolonesVancPCNcephalosporinsaminoglycosides

68
Q

Which antimicrobials increase QT interval?

A

moxifloxacinmacroglides

69
Q

Which surgeries require cefazolin + Metronidazole?

A

Head and neck ( with entry into orpharynx)Colorectal (emergency surgery or obstruction)Appendectomy

NRP 507 (3 decks)

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