BNF - Chapter 5 - Infection - (Part 1) Flashcards
What is an amoeba infection?
Amebiasis (am-uh-BYE-eh-sis) is an infection of the intestines with a parasite called Entamoeba histolytica (E. histolytica).
The parasite is an amoeba (uh-MEE-buh), a single-celled organism. People can get this parasite by eating or drinking something that’s contaminated with it.
Which antiprotozoal can be used for treatment of amoebic infection?
Mepacrine hydrochloride
Before selecting an antibacterial what three factors must the clinician consider?
- The patient
- The known or likely causative organism
- The risk of bacterial resistance with repeated courses
What factors related to the patient must be considered when selecting an antibacterial?
- history of allergy
- renal and hepatic function
- susceptibility to infection (i.e. whether immunocompromised)
- Ability to tolerate drugs by mouth
- severity of illness
- risk of complications
- ethnic origin
- age
- other medications
- if female (pregnant, breast-feeding or taking an oral contraceptive)
In patients receiving antibacterial prophylaxis who require acute treatment of bacterial infection what must be noted about the drug of choice?
an antibacterial from a different class should be used.
can viral infections be treated with antibacterials?
No
Can antibacterial be used to treat secondary bacterial infections?
antibacterials may be used to treat secondary bacterial infection (e.g. bacterial pneumonia secondary to influenza);
Is a narrow-spectrum antibacterial preferred over broad-spectrum?
Generally, narrow-spectrum antibacterials are preferred to broad-spectrum antibacterials unless there is a clear clinical indication (e.g. life-threatening sepsis);
What does the route of administration of an antibacterial often depend on?
The severity of the infection.
What route of administration of antibacterial do life threatening infections require?
Intravenous therapy
Antibacterials that are well absorbed may be given by mouth even for some serious infections.
Can intramuscular administration of antibacterial be used in children?
Whenever possible, painful intramuscular injections should be avoided in children;
What must the prescription for an antibacterial specify in terms of duration?
The prescription for an antibacterial should specify the duration of treatment or the date when treatment is to be reviewed.
Within how many hours should you review intravenous antibacterials?
within 48 hours and consider stepping down to oral antibacterials where possible.
Should patients identified as being at high risk of severe illness or death due to suspected sepsis be given a narrow or broad spectrum sepsis?
Should be given a broad spectrum antibacterial at the maximum recommended dose without delay (ideally within one hour)
In management of sepsis - patients at high risk should be monitored continuously if possible, and no less than every …. minutes?
No less than every 30 minutes
In England and Wales, registered medical practitioners must notify the proper officer at their local council or local health protection team of any patient(s) suspected of suffering from which diseases?
Anthrax Botulism Brucellosis Cholera COVID-19 Diarrhoea (infectious bloody) Diphtheria Encephalitis (acute) Food poisoning Haemolytic uraemic syndrome (HUS) Haemorrhagic fever (viral) Hepatitis (acute infectious) Legionnaires’ disease Leprosy Malaria Measles Meningitis (acute) Meningococcal septicaemia Mumps Paratyphoid fever Plague Poliomyelitis (acute) Rabies Rubella Severe acute respiratory syndrome (SARS) Scarlet fever Smallpox Streptococcal disease (Group A, invasive) Tetanus Tuberculosis Typhoid fever Typhus Whooping cough Yellow fever
What is Rheumatic fever?
Rheumatic fever (acute rheumatic fever) is a disease that can affect the heart, joints, brain, and skin. Rheumatic fever can develop if strep throat and scarlet fever infections are not treated properly. Early diagnosis of these infections and treatment with antibiotics are key to preventing rheumatic fever.
What are the antibacterials of choice for prophylaxis of rheumatic fever?
Phenoxymethylpenicillin or sulfadiazine.
What is meant by invasive group A streptococcal infection?
Some group A strep infections cause invasive disease. Invasive disease means that germs invade parts of the body that are normally free from germs.
What are the antibacterials of choice for prophylaxis of invasive group A streptococcal infection - prevention of secondary cases?
Phenoxymethylpenicillin.
Patients who are penicillin allergic, either erythromycin or azithromycin [unlicensed indication].
What are the antibacterials of choice for secondary prevention of meningococcal meningitis: prevention of secondary cases?
- Ciprofloxacin or
- Rifampicin or
- i/m ceftriaxone (unlicensed)
with haemophilius influenzae type b (Hib), the index case has a small, but significant risk of secondary Hib infection, particularly within how many months of the first episode?
- Within 6 months of the first episode
What does antibacterial prophylaxis of Hib aim to do?
Antibacterial prophylaxis aims to reduce the risk of secondary disease in the index case and among close contacts by eliminating asymptomatic pharyngeal carriage of Hib.
how many cases of Hib within how many days is considered as an outbreak for a pre-school or primary school setting?
2 or more cases of invasive Hib disease within 120 days
For all eligible contacts, antibacterial prophylaxis should be offered up to how many weeks after illness onset in the index case?
offered up to 4 weeks after illness onset in the index case
What are the drug of choice for antibacterial prophylaxis for Haemophilus influenzae type b infection: prevention of secondary disease?
First line:
Rifampicin;
Alternative if rifampicin unsuitable: ceftriaxone [unlicensed] (based on limited evidence), or oral ciprofloxacin [unlicensed] or azithromycin [unlicensed] (however effectiveness in healthy individuals has not been determined)
What are the drug of choice for prevention of secondary cases of diphtheria in non-immune patients?
Erythromycin (or another macrolide e.g. azithromycin or clarithromycin).
Treat for further 10 days if nasopharyngeal swabs positive after first 7 days treatment.
What is pertussis?
Pertussis, also known as whooping cough, is a highly contagious respiratory disease. It is caused by the bacterium Bordetella pertussis. Pertussis is known for uncontrollable, violent coughing which often makes it hard to breathe.
What is the antibacterial of choice for prophylaxis of pertussis?
Clarithromycin (or azithromycin or erythromycin).
Which antibacterial prophylaxis choices are used for operation on stomach or oesophagus?
Single dose of i/v gentamicin or i/v cefuroxime or i/v co-amoxiclav (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
How long before the operational procedure on stomach or oesophagus should the prophylactic antibiotic be given?
Intravenous antibacterial prophylaxis should be given up to 30 minutes before the procedure.
What if the patient is at high risk of meticillin-resistant staphyloccous aureus in prophylaxis of operations on stomach or oesophagus?
Add i/v teicoplanin (or vancomycin) if high risk of meticillin-resistant Staphylococcus aureus
What about prophylaxis of antibacterial of open biliary surgery?
Single dose of i/v cefuroxime + i/v metronidazole or i/v gentamicin + i/v metronidazole or i/v co-amoxiclav alone (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
Where i/v metronidazole is suggested, it may alternatively be given by suppository but to allow adequate absorption, it should be given 2 hours before surgery.
Which antibacterial prophylaxis is used in joint replacement including hip and knee?
Single dose of i/v cefuroxime alone or i/v flucloxacillin + i/v gentamicin (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
Which antibacterial prophylaxis is used in closed fractures?
Single dose of i/v cefuroxime or i/v flucloxacillin (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
Which antibacterial prophylaxis is used in high lower-limb amputation?
Use i/v co-amoxiclav alone or i/v cefuroxime + i/v metronidazole.
Intravenous antibacterial prophylaxis should be given up to 30 minutes before the procedure.
Continue antibacterial prophylaxis for at least 2 doses after procedure (max. duration of prophylaxis 5 days). If history of allergy to penicillin or to cephalosporins, or if high risk of meticillin-resistant Staphylococcus aureus, use i/v teicoplanin (or vancomycin) + i/v gentamicin + i/v metronidazole.
For the termination of pregnancy which antibacterial is used as prophylaxis?
Metronidazole single dose
What is endocarditis?
Endocarditis is a rare and potentially fatal infection of the inner lining of the heart (the endocardium).
It’s most commonly caused by bacteria entering the blood and travelling to the heart.
Is chlorhexidine mouthwash recommended for the prevention of infective endocarditis in at risk patients undergoing dental procedures?
No
Antibacterial prophylaxis is not routinely recommended for the prevention of infective endocarditis in patients undergoing which procedures?
dental;
upper and lower respiratory tract (including ear, nose, and throat procedures and bronchoscopy);
genito-urinary tract (including urological, gynaecological, and obstetric procedures);
upper and lower gastro-intestinal tract.
Patients at risk of infective endocarditis should be advised to do what?
advised to maintain good oral hygiene;
told how to recognise signs of infective endocarditis, and advised when to seek expert advice.
Do patients with prosthetic joint implants (including total hip replacements) require antibiotic prophylaxis for dental treatment?
No
What is the definition of septicemia?
Septicemia, or sepsis, is the clinical name for blood poisoning by bacteria. It is the body’s most extreme response to an infection. Sepsis that progresses to septic shock has a death rate as high as 50%, depending on the type of organism involved. Sepsis is a medical emergency and needs urgent medical treatment.
What is the antibacterial drug treatment for community acquired septicaemia?
A broad-spectrum antipseudomonal penicillin (e.g. piperacillin with tazobactam, ticarcillin with clavulanic acid) or a broad-spectrum cephalosporin (e.g. cefuroxime)
- If meticillin-resistant Staphylococcus aureus suspected, add vancomycin (or teicoplanin).
- If anaerobic infection suspected, add metronidazole to broad-spectrum cephalosporin.
- If other resistant micro-organisms suspected, use a more broad-spectrum beta-lactam antibacterial (e.g. meropenem).
What is the antibacterial of choice for hospital-acquired septicaemia?
A broad-spectrum antipseudomonal beta-lactam antibacterial (e.g. piperacillin with tazobactam, ticarcillin with clavulanic acid, ceftazidime, imipenem with cilastatin, or meropenem)
If meticillin-resistant Staphylococcus aureus suspected, add vancomycin (or teicoplanin).
If anaerobic infection suspected, add metronidazole to broad-spectrum cephalosporin
What is the treatment for septicaemia related to vascular catheter?
Vancomycin (or teicoplanin)
- If Gram-negative sepsis suspected, especially in the immunocompromised, add a broad-spectrum antipseudomonal beta-lactam.
- Consider removing vascular catheter, particularly if infection caused by Staphylococcus aureus, pseudomonas, or Candida species
What is the treatment for meningococcal septicaemia?
If meningococcal disease suspected, a single dose of benzylpenicillin sodium should be given before urgent transfer to hospital, so long as this does not delay the transfer; cefotaxime may be an alternative in penicillin allergy; chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or to cephalosporins.
To eliminate nasopharyngeal carriage, ciprofloxacin, or rifampicin, or ceftriaxone may be used.
What is the treatment (antibacterial) for initial ‘blind’ therapy?
Native valve endocarditis, amoxicillin (or ampicillin)
Consider adding low-dose gentamicin
If penicillin-allergic, or if meticillin-resistant Staphylococcus aureus suspected, or if severe sepsis, use vancomycin + low-dose gentamicin
If severe sepsis with risk factors for Gram-negative infection, use vancomycin + meropenem
If prosthetic valve endocarditis, vancomycin + rifampicin + low-dose gentamicin
What is the antibacterial of choice for endocarditis (native valve) caused by staphylococci?
Flucloxacillin:
Suggested duration of treatment 4 weeks (at least 6 weeks if secondary lung abscess or osteomyelitis also present)
If penicillin-allergic or if meticillin-resistant Staphylococcus aureus, vancomycin + rifampicin
Suggested duration of treatment 4 weeks (at least 6 weeks if secondary lung absecess or osteomyelitis also present)
What is the antibacterial of choice for endocarditis caused by fully-sensitive streptococci?
Benzylpenicillin sodium
Suggested duration of treatment 4–6 weeks (6 weeks for prosthetic valve endocarditis)
If penicillin-allergic, vancomycin (or teicoplanin) + low-dose gentamicin
Suggested duration of treatment 4–6 weeks (stop gentamicin after 2 weeks)
If meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) suspected should benzylpenicillin sodium be given before transfer to hospital?
Yes so long as this does not delay the transfer.
If meningococcal disease is suspected but patient has penicillin allergy meaning first line benzylpenicillin sodium is not suitable, what alternative can be given?
Cefotaxime
What if both benzylpenicillin and cefotaxime are not suitable?
chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or to cephalosporins.
In particularly in adults if pneumococcal meningitis in hospital what other drug should be considered as adjunct treatment?
In hospital, consider adjunctive treatment with dexamethasone (particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial; avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery.
In hospital for treatment of meningitis if aetiology is unknown then which drugs are adminstered?
Suggested duration of treatment at least 10 days
Adult and child 3 months–50 years,
- cefotaxime (or ceftriaxone
Adult over 50 years - cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin
(Over 50 years old - add amoxicillin or ampicillin)
What is the treatment for meningitis caused by meningococci?
Benzylpenicillin sodium or cefotaxime (or ceftriaxone)
(Suggested duration of treatment 7 days)
If history of immediate hypersensitivity reaction to penicillin or to cephalosporins, chloramphenicol
Suggested duration of treatment 7 days.
What is the treatment of meningitis caused by pneuomococci?
Cefotaxime (or ceftriaxone)
Consider adjunctive treatment with dexamethasone, preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial (may reduce penetration of vancomycin into cerebrospinal fluid).
If micro-organism penicillin-sensitive, replace cefotaxime with benzylpenicillin sodium.
If micro-organism highly penicillin- and cephalosporin-resistant, add vancomycin and if necessary rifampicin.
Suggested duration of antibacterial treatment 14 days
What is the treatment of Meningitis caused by Haemophilus influenzae?
Cefotaxime (or ceftriaxone)
Consider adjunctive treatment with dexamethasone, preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial.
Suggested duration of antibacterial treatment 10 days.
For H. influenzae type b give rifampicin for 4 days before hospital discharge to those under 10 years of age or to those in contact with vulnerable household contacts
What is the treatment of meningitis caused by listeria?
Amoxicillin (or ampicillin) + gentamicin
Suggested duration of treatment 21 days.
Consider stopping gentamicin after 7 days.
If history of immediate hypersensitivity reaction to penicillin, co-trimoxazole
Suggested duration of treatment 21 days.
What diabetic foot infection defined as?
as any type of skin, soft tissue or bone infection below the ankle in patients with diabetes.
It includes cellulitis, paronychia, abscesses, myositis, tendonitis, necrotising fasciitis, osteomyelitis, and septic arthritis
What id diabetic foot infection clinically defined by the presence of?
It is defined clinically by the presence of at least 2 of the following: local swelling or induration, erythema (type of rash caused by injured or inflamed blood capillaries), local tenderness or pain, local warmth, or purulent discharge.
What is the treatment for mild diabetic foot infection?
Oral first line - Flucloxacillin
- Alternative in penicillin allergy or flucloxacillin unsuitable: clarithromycin, doxycycline, or erythromycin (in pregnancy)
What is oteomyelitis?
Osteomyelitis is an infection that usually causes pain in the long bones in the legs.
What is the antibacterial treatment for moderate to severe diabetic foot infection?
Oral or Intravenous first line:
Flucloxacillinwith or without intravenous gentamicin and/or metronidazole, or co-amoxiclav with or without intravenous gentamicin, or intravenous ceftriaxone with metronidazole.
Alternative in penicillin allergy: co-trimoxazole [unlicensed] with or without intravenous gentamicin and/or metronidazole.
Additional antibacterial choices if Pseudomonas aeruginosa suspected or confirmed: intravenous piperacillin with tazobactam, or clindamycin with ciprofloxacin and/or intravenous gentamicin.
If meticillin-resistant Staphylococcus aureus (MRSA) confirmed or suspected add intravenous vancomycin, or intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).
Other antibacterials may be appropriate based on microbiological results and specialist advice.
What does otitis mean?
inflammation of the ear - inflammation is usually due to an infection
What is the difference between otitis externa and otitis media?
Otitis externa means that the inflammation is confined to the external part of the ear canal and does not go further than the eardrum.
(Otitis Media), is an infection of the middle ear.
Which organisms can cause otitis externa?
Otitis externa is inflammation of the external ear canal; it can be triggered by a bacterial infection caused by Pseudomonas aeruginosa or Staphylococcus aureus.
Oral antibacterials are rarely indicated but if they are required, consider seeking specialist advice.
What is the choice of antibacterial therapy for otitis externa?
No penicillin allergy -
Flucloxacillin
Penicillin allergy or intolerance -
Clarithromycin (or azithromycin or erythromycin)
If pseudomonas suspected -
Ciprofloxacin (or an aminoglycoside)
Which is seen commonly in children - otitis externa or media?
Otitis media
What is the choice of antibacterial therapy in children for otitis media?
No penicillin allergy
First line: amoxicillin.
Second line (worsening symptoms despite 2 to 3 days of antibacterial treatment): co-amoxiclav.
Penicillin allergy or intolerance First line: clarithromycin or erythromycin. Second line (worsening symptoms despite 2 to 3 days of antibacterial treatment): consult local microbiologist.
Does gastro-enteritis require antibiotic treatment?
Frequently self-limiting and may not be bacterial.
Antibacterial not usually indicated
Does campylobacter enteritis require antibiotic treatment?
Frequently self-limiting; treat if immunocompromised or if severe infection.
Clarithromycin (or azithromycin or erythromycin)
Alternative, ciprofloxacin
Strains with decreased sensitivity to ciprofloxacin isolated frequently
What is diverticulitis, acute?
Acute diverticulitis is a condition where diverticula (small pouches protruding from the walls of the large intestine) suddenly become inflamed or infected.
Which patients should be treated for acute diverticulitis?
For patients with acute diverticulitis who are systemically well, consider a watchful waiting and a no antibacterial prescribing strategy. Advise patients to re-present if symptoms persist or worsen.
For patients who are systemically unwell, immunosuppressed, or have significant comorbidities, an antibacterial prescribing strategy should be offered.
What is the choice of antibiotic therapy for acute diverticulitis?
Patients unable to take oral treatment should be referred to hospital.
Suspected or confirmed uncomplicated acute diverticulitis
Oral first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: cefalexin (caution in penicillin allergy) with metronidazole, or trimethoprim with metronidazole, or ciprofloxacin (only if switching from intravenous route with specialist advice) with metronidazole.
Suspected or confirmed complicated acute diverticulitis
Intravenous first line:
Co-amoxiclav, or cefuroxime with metronidazole, or amoxicillin with gentamicin and metronidazole.
Alternative in penicillin and cephalosporins allergy: ciprofloxacin with metronidazole.
For alternative antibacterials consult local microbiologist.
Are all patients with salmonella treated with antibiotics?
Treat invasive or severe infection. Do not treat less severe infection unless there is a risk of developing invasive infection (e.g. immunocompromised patients, those with haemoglobinopathy, or children under 6 months of age).
Which antibiotics are used in salmonella?
Ciprofloxacin or cefotaxime
What is the antibiotic therapy for typhoid fever?
Cefotaxime (or ceftriaxone)
azithromycin may be an alternative in mild or moderate disease caused by multiple-antibacterial-resistant organisms
In which patients is C.difficile most common in?
in patients who are currently taking or have recently taken antibacterials.
Which antibiotics have been associated with causing C.difficile infection?
Clindamycin, cephalosporins (especially third and fourth generation), fluoroquinolones, and broad-spectrum penicillins have been frequently associated with C. difficile infection.
Other than antibiotics, what are other risk factors of C.difficile?
Other risk factors for C. difficile infection include current use of acid suppressing drugs (such as proton pump inhibitors), age over 65 years, prolonged hospitalisation, underlying comorbidity, exposure to other people with the infection, and previous history of C. difficile infection(s).
Are antibacterial recommended for preventing C.difficile?
No
How long may diarrhoea symptom associated with C.difficile infection take to resolve while on antibiotics?
1-2 weeks
What is the treatment of first episode of mild, moderate or severe C.difficile infection?
Oral first line:
Vancomycin.
Oral second line:
Fidaxomicin.
If first and second line antibacterials are ineffective: seek specialist advice.
What is the treatment for further episode of C.difficile infection?
Oral first line for infection within 12 weeks of symptom resolution (relapse):
Fidaxomicin.
Oral first line for infection more than 12 weeks after symptom resolution (recurrence):
Vancomycin or fidaxomicin.
For life threatening C-Difficile what may be offered?
pecialist may offer oral vancomycin with intravenous metronidazole
Which drugs would you use in biliary-tract infections?
- Ciprofloxacin or gentamicin or cephalosporin
What is peritonitis?
Peritonitis is a redness and swelling (inflammation) of the tissue that lines your belly or abdomen. This tissue is called the peritoneum. It can be a serious, deadly disease.
Which drugs are offered for peitonitis?
A cephalosporin + metronidazole or gentamicin + metronidazole or gentamicin + clindamycin or piperacillin with tazobactam alone
What is the antibiotic of choice for bacterial vaginosis?
Oral metronidazole
Suggested duration of treatment 5–7 days (or high-dose metronidazole as a single dose)
Alternatively, topical metronidazole for 5 days or topical clindamycin for 7 days
What are the antibiotic choices for treating chlamydia infections and duration of each?
Azithromycin (as a single dose)
or
Doxycycline for 7 days
Alternatively,
Erythromycin for 14 days
When is treatment for gonorrhoea recommended?
Treatment is only recommended for those presenting within 14 days of exposure, or those presenting 14 days after exposure with a positive test.
For gonorrhoea, how long should sexual intercourse be avoided while getting treated?
Sexual intercourse should be avoided until 7 days after patients and their partner(s) have completed treatment.
What are the drug choices for gonorrhoea (uncomplicated)?
First line:
If antimicrobial susceptibility unknown: intramuscular ceftriaxone.
If micro-organism is sensitive to ciprofloxacin: oral ciprofloxacin.
Alternatives due to allergy, needle phobia or contra-indications:
Intramuscular gentamicin plus oral azithromycin.
If parenteral administration is not possible: oral cefixime [unlicensed] plus oral azithromycin.
In non-pharyngeal infections: intramuscular spectinomycin [unlicensed] plus oral azithromycin.
If unable to take standard therapy: oral azithromycin.
What is the treatment choice for pelvic inflammatory disease?
Doxycycline + metronidazole + single-dose of i/m ceftriaxone
or
ofloxacin + metronidazole
Suggested duration of treatment 14 days (except i/m ceftriaxone).
What is the recommended antibiotic treatment for early syphilis (infection of less than 2 years)?
Benzathine benzylpenicillin
Suggested duration of treatment single-dose (repeat dose after 7 days for women in the third trimester of pregnancy)
Alternatively, doxycycline or erythromycin
Suggested duration of treatment 14 days
What is the recommended antibiotic treatment for late latent syphilis (Asymptomatic infection of more than 2 years)?
Benzathine benzylpenicillin
Suggested duration of treatment once weekly for 2 weeks
Alternatively, doxycycline
Suggested duration of treatment 28 days
What antibiotic is recommended for asymptomatic contacts of patients with infectious syphyllis?
Doxycycline
Suggested duration of treatment 14 days
What is the antibiotic drug treatment for osteomyelitis?
Flucloxacillin
Consider adding fusidic acid or rifampicin for initial 2 weeks.
Suggested duration of treatment 6 weeks for acute infection
If penicillin-allergic, clindamycin
Consider adding fusidic acid or rifampicin for initial 2 weeks.
Suggested duration of treatment 6 weeks for acute infection
If meticillin-resistantStaphylococcus aureussuspected, vancomycin (or teicoplanin)
Consider adding fusidic acid or rifampicin for initial 2 weeks.
Suggested duration of treatment 6 weeks for acute infection
Which antibiotics are recommended for septic arthritis?
Flucloxacillin
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If penicillin-allergic, clindamycin
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If meticillin-resistantStaphylococcus aureussuspected, vancomycin (or teicoplanin)
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If gonococcal arthritis or Gram-negative infection suspected, cefotaxime (or ceftriaxone)
Suggested duration of treatment 4–6 weeks (longer if infection complicated; treat gonococcal infection for 2 weeks).
What is the causative organism for sinusitis (acute)?
Acute sinusitis is generally triggered by a viral infection, although occasionally it may become complicated by a bacterial infection caused by Streptococcus pneumoniae, Haemophylus influenzae, Moraxella catharrhalis, or Staphylococcus aureus.
What is the antibiotic treatment for sinusitis for someone with no penicillin allergy?
No penicillin allergy
First line:
Non-life threatening symptoms: phenoxymethylpenicillin.
Systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications: co-amoxiclav.
Second line (worsening symptoms despite 2 or 3 days of antibiotic treatment):
Non-life threatening symptoms: co-amoxiclav.
Systemically very unwell, signs and symptoms of a more serious illness or at high-risk of complications: consult local microbiologist.
What is the antibiotic treatment for sinusitis for someone with a penicillin allergy or intolerance?
First line: doxycycline or clarithromycin (erythromycin in pregnancy).
Second line (worsening symptoms despite 2 or 3 days of antibiotic treatment): consult local microbiologist.
If the oral infection fails to respond to antibacterial treatment within 48 hours what should you do about the antibacterial?
The antibiotic should be changed, preferably on the basis of bacteriological investigation.
Which combination may sometimes be helpful for the treatment of severe oral infections or oral infections that have not responded to initial antibacterial treatment?
- Combination of a penicillin (or a macrolide) with metronidazole
Which penicillin is effective for dentoalveolar abscess?
Phenoxymethylpenicillin
Which is better absorbed - amoxicillin or phenoxymethylpenicillin?
Amoxicillin however it may encourage emergence of resistant organisms
Are phenoxymethylpenicillin or amoxicillin effective against bacteria that produce beta-lactamases?
No they are not effective
Which antibiotic can be used and is active against beta-lactamase-producing bacteria that are resistant to amoxicillin?
Co-amoxiclav is active against beta-lactamase-producing bacteria that are resistant to amoxicillin
Out of the three (doxycycline, tetracycline or oxytetracyline) which has a longer duration of action?
Doxycycline
Which antibiotics are recommended in bronchiectasis (non-cystic fibrosis)?
The recommended total duration of treatment is 7–14 days.
Treatment should be guided by the most recent sputum culture and susceptibility results when available.
Oral first line:
Amoxicillin, clarithromycin, or doxycycline.
Alternative if at high risk of treatment failure (repeated courses of antibacterials, previous culture with resistant or atypical bacteria, or high risk of complications): co-amoxiclav, or levofloxacin.
Intravenous first line (severely unwell or unable to take oral treatment):
Co-amoxiclav, piperacillin with tazobactam, or levofloxacin.
For COPD acute exacerbations - what should be taken into account when considering antibiotic treatment?
Many exacerbations are not caused by bacterial infections, but instead can be triggered by other factors such as smoking or viral infections.
Consider antibacterial treatment taking into account:
The severity of symptoms, sputum colour changes and increases in volume and thickness;
The need for hospital admission;
Previous exacerbations and hospital admission history, and risk of developing complications.
What is the treatment options for COPD acute exarcerbations?
The recommended total duration of treatment is 5 days.
Oral first line:
Amoxicillin, clarithromycin, or doxycycline.
Alternative if at high risk of treatment failure (repeated courses of antibacterials, previous culture with resistant or atypical bacteria, or high risk of complications): co-amoxiclav, or levofloxacin.
Oral second line (if no improvement after at least 2 to 3 days):
Use a first line antibacterial from a different class to the antibacterial used previously.
Alternative if at high risk of treatment failure: co-amoxiclav, levofloxacin, or co-trimoxazole (only when sensitivities are available and there is good reason to use co-trimoxazole over single antibacterials).
Intravenous first line (severely unwell or unable to take oral treatment):
Amoxicillin, co-amoxiclav, clarithromycin, co-trimoxazole, or piperacillin with tazobactam.
Acute cough is usually self limiting and often resolves within how many weeks?
3-4 weeks without antibacterials
Which patients with an acute cough be offered antibacterials?
Patients with an acute cough who are systemically very unwell should be offered immediate antibacterial treatment.
Which patients are at a higher risk of complications if they present with an acute cough?
Patients with a pre-existing co-morbidity, young children who were born prematurely, and patients aged over 65 years of age and the presence of certain criteria (hospitalisation in the previous year, type 1 or 2 diabetes, history of congestive heart failure, or currently taking oral corticosteroids)
What is the choice of antibacterial therapy for acute cough?
The recommended duration of oral treatment is 5 days.
First line
Doxycycline.
Alternative first line choices: amoxicillin, clarithromycin, or erythromycin.
Choice during pregnancy:
Amoxicillin or erythromycin.
Which organ does pneumonia affect?
Lungs
What are the symptoms of pneumonia?
cough, chest pain, dyspnoea, and fever.
For community acquired pneumonia treatment within how many hours of diagnosis should antibacterial treatment be started?
As soon as possible within 4 hours
within 1 hour if the patient has suspected sepsis and meets any of the high risk criteria for this
In patients with moderate or high-severity community acquired pneumonia - what should be obtained?
obtain blood and sputum cultures and consider performing pneumococcal and legionella urinary antigen tests.
Which tools are used to assess community-acquired pneumonia?
CRB65 or CURB65
What is the antibiotic drug choice in community acquired pneumonia?
Low severity
Oral first line:
Amoxicillin.
Alternative in penicillin allergy or amoxicillin unsuitable (e.g. atypical pathogens suspected): clarithromycin, doxycycline, or erythromycin (in pregnancy).
Moderate severity
Oral first line:
Amoxicillin.
If atypical pathogens suspected: amoxicillin with clarithromycin or erythromycin (in pregnancy).
Alternative in penicillin allergy: clarithromycin, or doxycycline.
High severity
Oral or Intravenous first line:
Co-amoxiclav with clarithromycin or oral erythromycin (in pregnancy).
Alternative in penicillin allergy: levofloxacin (consult local microbiologist if fluoroquinolone not appropriate).
For hospital acquired pneumonia - within how many hours of hospital hours if symptoms show should you follow recommendations for patients with community acquired pneumonia?
Within 48 hours
What factors cause a higher risk of resistance in hospital-acquired pneumonia?
Higher risk of resistance includes signs or symptoms starting more than 5 days after hospital admission, relevant comorbidity, recent use of broad-spectrum antibacterials, colonisation with multidrug-resistant bacteria, and recent contact with a health or social care setting before the current admission.
For Hospital acquired pneumonia - for non severe signs or symptoms and not at higher risk of resistance which antibiotics are recommended?
Oral first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable (based on specialist microbiological advice and local resistance data): doxycycline, cefalexin (caution in penicillin allergy), co-trimoxazole [unlicensed], or levofloxacin [unlicensed] (only if switching from intravenous levofloxacin under specialist advice).
For Hospital acquired pneumonia - for severe signs or symptoms or at a higher risk of resistance - which antibiotics are recommended?
ntravenous first line:
Piperacillin with tazobactam, ceftazidime, ceftazidime with avibactam, ceftriaxone, cefuroxime, levofloxacin [unlicensed], or meropenem.
If meticillin-resistant Staphylococcus aureus confirmed or suspected add vancomycin, or teicoplanin, or linezolid (under specialist advice only if vancomycin cannot be used)
Does impetigo (a bacterial infection of the skin) affect all age groups?
Yes but it is more common in young children.
What are the two main clinical forms of impetigo?
Non-bullous impetigo (most common)
Bullous impetigo
What is the difference between non-bullous and bullous impetigo?
Non-bullous impetigo is characterised by thin-walled vesicles or pustules that rupture quickly, forming a golden-brown crust, while bullous impetigo is characterised by the presence of fluid-filled vesicles and blisters that rupture, leaving a thin, flat, yellow-brown crust.
What is the first line treatment for localised non-bullous impetigo for someone who is not systemically unwell or at high risk of complications?
- Hydrogen peroxide 1% cream
- If unsuitable (e.g. impetigo is around the eyes), offer a topical antibacterial
In widespread non-bullous impetigo in patients who are not systemically unwell or at high risk of complications, what is used for the treatment?
offer a topical or oral antibacterial.
In patients with non-bullous impetigo who are systemically unwell or at high risk of complications and in all patients with bullous impetigo, what is offered?
- Offer an oral antibacterial
For impetigo, is a combination treatment of oral and topical antibacterial recommended?
No
What is the choice of antibacterial therapy for impetigo?
Topical first line if hydrogen peroxide unsuitable or ineffective:
- fusidic acid
Alternative if fusidic acid resistance suspected or confirmed:
- Mupirocin (bactroban)
Oral first line:
Flucloxacillin.
Alternative if penicillin allergy or flucloxacillin unsuitable: clarithromycin or erythromycin (in pregnancy).
Cellulitis and erysipelas are infections of which part of the tissues?
Of the subcutaneous tissues, which usually result from the contamination of a break in the skin
Are lesions more superficial in cellulitis or erysipelas?
In erysipelas and have well-defined and raised margin
What are the first choice antibiotics for Cellulitis or erysipelas
Flucloxacillin.
Alternative in penicillin allergy or flucloxacillin unsuitable: clarithromycin, oral erythromycin (in pregnancy), or oral doxycycline.
Oral or Intravenous first line if infection near the eyes or nose:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: clarithromycin with metronidazole.
What are the alternative choice antibiotics for severe cellulitis or erysipelas infection?
Oral or Intravenous:
Co-amoxiclav, clindamycin, intravenous cefuroxime, or intravenous ceftriaxone (ambulatory care only).
If meticillin-resistant Staphylococcus aureus confirmed or suspected, add intravenous vancomycin, intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).
For ambulatory care, and in MRSA confirmed or suspected infections, other antibacterials may be appropriate based on microbiological results and specialist advice.
In which patients who have had cellulitis or erysipelas may prophylactic antibiotics be considered?
For patients who have been treated in hospital, or under specialist advice, for at least 2 separate episodes of cellulitis or erysipelas in the previous 12 months, a trial of antibacterial prophylaxis may be considered by a specialist.
What if cellulitis or erysipelas returns even when on prophylactic antibiotics?
If cellulitis or erysipelas recurs, stop or change the prophylactic antibacterial to an alternative once the acute infection has been treated.
Where do leg ulcers usually develop?
On the lower leg - between the shin and the ankle
how long do leg ulcers take to heal?
Take more than 4-6 weeks to heal
What are the signs and symptoms of an infected leg ulcer?
- redness (may be less visible on darker skin tones)
- swelling spreading beyond the ulcer
- localised warmth
- Increased pain
- fever
Is taking a sample for microbiological testing at initial presentation with a leg ulcer recommended?
No even if the ulcer is infected
What is the antiobiotic of choice for leg ulcer in non-severely unwell patients?
Oral first line:
Flucloxacillin.
Alternative in penicillin allergy or flucloxacillin unsuitable: doxycycline, clarithromycin, or erythromycin (in pregnancy).
Oral second line (guided by microbiological results when available):
Co-amoxiclav.
Alternative in penicillin allergy: co-trimoxazole [unlicensed].
What is the anitibiotic of choice for leg ulcer in severely unwell patients?
Oral or Intravenous first line (guided by microbiological results if available):
Intravenous flucloxacillin with or without intravenous gentamicin and/or metronidazole, or intravenous co-amoxiclav with or without intravenous gentamicin.
Alternative in penicillin allergy: intravenous co-trimoxazole [unlicensed] with or without intravenous gentamicin and/or metronidazole.
Oral or Intravenous second line (guided by microbiological results when available or following specialist advice):
Intravenous piperacillin with tazobactam, or intravenous ceftriaxone with or without metronidazole.
Which antibacterials can be added if MRSA infection suspected or confirmed?
Oral or Intravenous (in addition to antibacterials listed above):
Intravenous vancomycin, intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).
Which patients with insect bites and stings should be considered for referral?
Consider referral or seeking specialist advice for patients with fever or persistent lesions after an insect bite or sting from outside the UK, as this may indicate a more serious illness such as rickettsial infection or malaria.
Patients with a human or animal bite should be assessed for what?
their risk of tetanus, rabies, or a blood-borne viral infection (such as HIV, and hepatitis B and C), and should be managed accordingly.
In which conditions would you offer antibacterial prophylaxis for an uninfected bite?
ffer antibacterial prophylaxis to patients with a:
cat or human bite that has broken the skin and drawn blood; or
dog or other traditional pet bite (excluding cat bites) that has broken the skin and drawn blood if it:
has penetrated bone, joint, tendon or vascular structures;
is deep, a puncture or crush wound, or has caused significant tissue damage; or
is visibly contaminated (for example if there is dirt or a tooth in the wound).
In which conditions would you consider antibacterial prophylaxis for an uninfected bite?
Consider antibacterial prophylaxis in a patient with:
a cat bite that has broken the skin but not drawn blood and the wound could be deep; or
a human bite that has broken the skin but not drawn blood, or a dog or other traditional pet bite (excluding cat bites) that has broken the skin and drawn blood, if it:
involves a high-risk area (such as the hands, feet, face, genitals, skin overlying cartilaginous structures, or an area of poor circulation), or
is in an individual at risk of a serious wound infection because of a comorbidity (such as diabetes, immunosuppression, asplenia, or decompensated liver disease).
What are the choice of antibacterial for human/ animal bites?
Oral first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: doxycycline with metronidazole; seek specialist advice in pregnancy.
Intravenous first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: cefuroxime or ceftriaxone, with metronidazole; seek specialist advice if a cephalosporin is not appropriate.
What are some common secondary bacterial infections of common skin conditions?
eczema, psoriasis, scabies, and shingles
Are antibacterial recommended for chickenpox, psoriasis, scabies and shingles?
No - there is no evidence available for antibacterial use
What are the signs and symptoms of secondary bacterial infection of eczema?
weeping, pustules, crusts, no response to treatment, rapidly worsening eczema, fever, and malaise.
Even if weeping and crusts are present, not all eczema flares are caused by a bacterial infection.
What are the antibacterial of choice for secondary bacterial infection of eczema?
Topical first line:
Fusidic acid.
If fusidic acid unsuitable or ineffective: offer an oral antibacterial.
Oral first line:
Flucloxacillin.
Alternative if penicillin allergy or flucloxacillin unsuitable: clarithromycin or erythromycin (in pregnancy).
What is mastitis?
Mastitis is an inflammation of breast tissue that sometimes involves an infection. The inflammation results in breast pain, swelling, warmth and redness. You might also have fever and chills. Mastitis most commonly affects women who are breast-feeding (lactation mastitis).
When would you treat mastitis with antibacterials?
Treat if severe, if systemically unwell, if nipple fissure present, if symptoms do not improve after 12–24 hours of effective milk removal, or if culture indicates infection. Continue breast-feeding or expressing milk during treatment.
What are the drug treatment of choice for treating mastitis during breast-feeding?
Flucloxacillin
Suggested duration of treatment 10–14 days.
If penicillin-allergic, erythromycin
Suggested duration of treatment 10–14 days.
As a summary, what is endocarditis treated with?
Treated ‘blind’ with amoxicillin then gentamicin until the causative organism is identified
What is acute exacerbations of COPD or chronic bronchitis treated with?
Amoxicillin or a tetracycline (Doxycyline usually)
What is used to treat community acquired pneuomonia?
Amoxicillin + clarithromycin (if atypical pathogens present)
What is used to treat non severe hospital acquired pneumonia?
Co-amoxiclav
What are used to treated UTIs in general?
Trimethoprim or nitrofurantoin
What are chlamydia and gonorrhoea treated with?
Azithromycin
What is used for septicaemia?
PIPERACILLIN WITH TAZOBACTAM
What is used to treated gingivitis?
Metronidazole
What is otitis externa treated with?
Flucloxacillin
What is otitis media treated with?
Amoxicillin
What antibiotic is cellulitis treated with?
Flucloxacillin
Patients with Asplenia or Sickle-cell disease are prophylactically treated for Pneumococcal infection with which antibiotic?
Phenoxymethylpenicillin
Which antibiotics are used for the prophylaxis of meningococcal meningitis?
Ciprofloxacin or rifampicin
Is vancomycin an aminoglycoside or a glycopeptides antibiotic?
glycopeptide
Give examples of aminoglycoside antibiotics?
- Amikacin
- Gentamicin
- Neomycin sulfate
- Streptomycin
- tobramycin
Are all of the aminoglycoside antibiotics bacteriostatic or bactericidal?
Bactericidal
What activity do aminoglycosides have on gram positive and gram negative bacteria?
Are active against some gram-positive and many gram-negative organisms
Which aminoglycosides are also active against pseudomonas aeruginosa?
Amikacin, gentamicin and tobramycin
Which aminoglycoside is active against mycobacterium tuberculosis?
streptomycin is active against Mycobacterium tuberculosis and is now almost entirely reserved for tuberculosis.
Why must aminoglycosides be given by injection for systemic infections?
The aminoglycosides are not absorbed from the gut (although there is a risk of absorption in inflammatory bowel disease and liver failure) and must therefore be given by injection for systemic infections.
Which aminoglycoside is the drug of choice in the UK?
Gentamicin
Is gentamicin broad spectrum?
Yes
Is gentamicin active against anaerobes?
inactive against anaerobes and has poor activity against haemolytic streptococci and pneumococci.
When gentamicin is given in ‘blind’ therapy for undiagnosed serious infections which other drugs is it usually given with?
with a penicillin or metronidazole (or both)
What are the loading and maintenance doses of gentamicin calculated based on?
on the basis of the patient’s weight and renal function (e.g. using a nomogram); adjustments are then made according to serum-gentamicin concentrations. High doses are occasionally indicated for serious infections, especially in the neonate, in the patient with cystic fibrosis, or in the immunocompromised patient.
Whenever possible, treatment with gentamicin should not exceed how many days?
Should not exceed 7 days
Which is more stable to enzyme inactivation - Gentamicin or amikacin?
Gentamicin
When is Amikacin used?
Amikacin is used in the treatment of serious infections caused by gentamicin-resistant Gram-negative bacilli.
Is tobramycin more active against Ps.aeruginosa than gentamicin?
Slightly more active
Tobramycin can be administered by nebuliser or by inhalation of powder on a cyclical basis - how many days of treatment and how many days of free interval period?
28 days of tobramycin followed by a 28-day tobramycin-free interval) for the treatment of chronic pulmonary Ps. aeruginosa infection in cystic fibrosis;
Is neomycin given parenterally e.g. IV?
Neomycin sulfate is too toxic for parenteral administration and can only be used for infections of the skin or mucous membranes or to reduce the bacterial population of the colon prior to bowel surgery or in hepatic failure.
What may oral administration of neomycin lead to?
Malabsorption
Is once daily administration of aminoglycosides preferred and is it possible to do?
Once daily administration of aminoglycosides is more convenient, provides adequate serum concentrations, and in many cases has largely superseded multiple-daily dose regimens (given in 2–3 divided doses during the 24 hours).
A once daily, high dose regimen of aminoglycosides should be avoided in which patients?
should be avoided in patients with endocarditis due to Gram-positive bacteria, HACEK endocarditis, burns of more than 20% of the total body surface area, or creatinine clearance less than 20 mL/minute.
Is aminoglycosides safe to use in pregnancy?
The risk is greatest with streptomycin.
The risk is probably very small with gentamicin and tobramycin, but their use should avoided unless it is essential.
When should blood levels of aminoglycosides be taken after a dose?
1 hour after dose and just before the next dose to establish the PEAK and TROUGH concentrations.
Can gentamicin be given at the same time as furosemide?
No - due to the risk of ototoxicity and nephrotoxicity
The use of aminoglycosides is associated with rare cases of what?
- Ototoxicity
increased risk with certain mitochondrial mutations
To minimise risk of adverse effects of aminoglycosides, what monitoring is recommended?
- Continuous monitoring of renal and auditory function, as well as hepatic and laboratory parameters.
What is myasthenia gravis?
Myasthenia gravis is a rare long-term condition that causes muscle weakness.
It most commonly affects the muscles that control the eyes and eyelids, facial expressions, chewing, swallowing and speaking. But it can affect most parts of the body.
It can affect people of any age, typically starting in women under 40 and men over 60.
Which condition is contraindicated for use of aminoglycosides?
Myasthenia gravis - aminoglycosides may impair neuromuscular transmission).
Are the main side effects of aminoglycosides dose related?
Yes
What are some common side effects of aminoglycosides?
Skin reactions
Tinnitus
How is aminoglycosides predominantly excreted?
Via the kidneys and accumulation occurs in renal impairmen
What occurs with aminoglycoside use in patients with renal impairment
Ototoxicity and nephrotoxicity
- therefore they require a reduced dose/ increased interval time between doses
When monitoring serum levels of aminoglycosides - if the pre-dose (trough) concentration is high what must you do?
The interval between the doses must be increased.
What is the post dose (peak) concentration is high?
Then the dose must be decreased
What are the carbapenems?
The carbapenems are beta-lactam antibacterial with a broad-spectrum of activity which includes many gram-positive and gram negative bacteria and anaerobes
Which carbapenem have activity against pseudomonas aeruginosa?
Imipenem (imipenem with Cilastatin)
Meropenem
Are the carbapenems active against MSRA?
No
Are the carbapenems active against Enterococcus faecium?
No
What are the use of imipenem and meropenem?
are used for the treatment of severe hospital-acquired infections and polymicrobial infections including septicaemia, hospital-acquired pneumonia, intra-abdominal infections, skin and soft-tissue infections, and complicated urinary-tract infections.
What is the use of Ertapenem?
Ertapenem is licensed for treating abdominal and gynaecological infections and for community-acquired pneumonia, but it is not active against atypical respiratory pathogens and it has limited activity against penicillin-resistant pneumococci.
It is also licensed for treating foot infections of the skin and soft tissue in patients with diabetes.
Is Ertapenem active against pseudomonas?
No
Unlike the other carbapenems, ertapenem is not active against Pseudomonas or against Acinetobacter spp.
Why is imipenem given in combination with cilastatin?
Imipenem is partially inactivated in the kidney by enzymatic activity and is therefore administered in combination with cilastatin (imipenem with cilastatin), a specific enzyme inhibitor, which blocks its renal metabolism.
Meropenem and ertapenem are stable to the renal enzyme which inactivates imipenem and therefore can be given without cilastatin.
Which carbapenem can be used to treat CNS infections due to lower risk of inducing seziure?
Meropenem has less seizure-inducing potential and can be used to treat central nervous system infection.
Are cephalosporins narrow or broad spectrum antibiotics?
Broad spectrum
What are some uses of cephalosporins?
re used for the treatment of septicaemia, pneumonia, meningitis, biliary-tract infections, peritonitis, and urinary-tract infections
How are cephalosporins excreted?
Via renal mostly
Cephalosporins penetrate the cerebrospinal fluid poorly unless the meninges are ….?
Unless the meniges are inflamed
Which cephalosporins are suitable to be used for infections of the CNS (e.g. meningitis)?
- Cefotaxime
- Ceftriaxone
What is the principal side effect of cephalosporins?
Hypersensitivity
If a cephalosporin is essential in patients with a history of immediate hypersensitivity to penicillin, because a suitable alternative antibacterial is not available then which cephalosporins can be used?
cefixime, cefotaxime, ceftazidime, ceftriaxone, or cefuroxime can be used with caution;
If a cephalosporin is essential in patients with a history of immediate hypersensitivity to penicillin, because a suitable alternative antibacterial is not available then which cephalosporins should be avoided?
cefaclor, cefadroxil, cefalexin, cefradine, and ceftaroline fosamil should be avoided
Are the first generation cephalosporins orally active?
Yes
What are the first generation cephalosporins cefalexin, cefradine, and cefadroxil and the ‘second generation’ cephalosporin, cefaclor, - useful for?
They are useful for urinary-tract infections, respiratory-tract infections, otitis media, and skin and soft-tissue infections
What does cefaclor have a good activity against?
Against H.influenzae
Does the first generation cephalosporin - Cefadroxil have a long or short duration of action?
Cefadroxil has a long duration of action and can be given twice daily; it has poor activity against H. influenzae.
Does Cefuroxime (second generation cephalosporin) need to be administered with or without food?
it is poorly absorbed and needs to be given with food to maximise absorption.
Is cefixime (third generation) cephalosporin orally active?
Yes - and has longer duration of action that the other cephalosporins that are active by mouth.
What is cefixime (third generation) cephalosporin only licensed for?
For acute infections
is Cefuroxime (Second generation) more susceptible to inactivation by beta-lactamases than earlier cephalosporins?
Less susceptible
It is, therefore, active against certain bacteria which are resistant to the other drugs and has greater activity against Haemophilus influenzae.
Which are the third generation cephalosporins?
Cefotaxime, ceftazidime and ceftriaxone are ‘third generation’ cephalosporins with greater activity than the ‘second generation’ cephalosporins against certain Gram-negative bacteria.
However, they are less active than cefuroxime against Gram-positive bacteria, most notably Staphylococcus aureus.
What may the broad spectrum activity of third generation cephalosporins cause?
Their broad antibacterial spectrum may encourage superinfection with resistant bacteria or fungi.
Which cephalosporin is active against pseudomonas?
Third generation ceftazidime - it also is active against other gram-negative bacteria
Does the third generation cephalosporin Ceftriaxone have a short or long half life?
Ceftriaxone has a longer half-life and therefore needs to be given only once daily.
What do indications of ceftriaxone include?
Indications include serious infections such as septicaemia, pneumonia, and meningitis.
Which cephalosporin has activity against MRSA?
Ceftaroline fosamil is a ‘fifth generation’ cephalosporin with bactericidal activity similar to cefotaxime; however, ceftaroline fosamil has an extended spectrum of activity against Gram-positive bacteria that includes meticillin-resistant Staphylococcus aureus and multi-drug resistant Streptococcus pneumoniae.
What is Ceftaroline fosamil (5th generation) licensed for the treatement of?
for the treatment of community-acquired pneumonia and complicated skin and soft-tissue infections, but there is no experience of its use in pneumonia caused by meticillin-resistant S. aureus.
What is Cefiderocol and what use does it have?
Cefiderocol, a siderophore cephalosporin, is used for treating infections due to Gram-negative aerobic organisms in individuals who have limited treatment options, particularly when other antimicrobial agents have failed.
Are cephalosporins bacteriacidal?
Yes
What is the MAO of cephalosporins?
They attach to the penicillin binding proteins to interrupt cell wall biosynthesis, leading to bacterial cell lysis and death.
What are the first generation cephalosporins?
- Cefadroxil
- Cefalexin
- cefazolin
- cefradine
What are the second generation cephalosporins?
- Cefaclor
- cefoxitin
- cefuroxime
What are the third generation cephalosporins?
- Cefixime
- cefotaxime
- Ceftazidime
- Ceftriazone
Give examples of third generation cephalosporin with beta lactamase inhibitor?
- Ceftazidime with avibactam
- ceftolozane with tazobactam
Give an example of a siderophore cephalosporin?
Cefiderocol
What are the fourth generation cephalosporins?
Cefepime
What are the fifth generation cephalosporins?
- ceftroline fosamil
- Ceftobiprole
Which cephalosporin are useful for UTIs?
first generation’ cephalosporins (cefalexin) and the ‘second generation’ cephalosporin, cefaclor, are useful for UTIs which do not respond to other drugs or which occur in pregnancy.
Can first generation cefalexin be given in pregnancy?
Yes it can by mouth and also in breast feeding women
How often a day is cefalexin taken?
Usually taken four times a day
What interaction should you be aware of with cephalosporins?
Cephalosporins possibly increase the anticoagulant effect of Warfarin
(raise the INR)
What bacteria are glycopeptides effective against?
Both aerobic and anaerobic bacteria
Are glycopeptides given orally or by injection for systemic infections?
By injection
Which two glycopeptides can be given orally for the treatment of C.diffcile?
- Vancomycin and teicoplanin
They should not be given orally for any other indication as they are not well absorbed
Is plasma concentration required to be monitored throughout therapy for glycopeptides?
Yes
Is glycopeptides safe to use in pregnancy?
Should be generally avoided
What is there a risk of with glycopeptides?
A risk of nephrotoxicity and ototoxicity
Give examples of glycopeptides?
- Dalbavacin
- Teicoplanin
- Telavancin
- vancomycin
Which has a longer duration of action - teicoplanin or vancomycin?
Teicoplanin - allowing once daily administration after the loading dose
Which is associated with a lower incidence of nephrotoxicity - teicoplanin or vancomycin?
Teicoplanin less risk
With vancomycin why should rapid infusion with intravenous use be avoided?
- Risk of anaphylactoid reactions (red man syndrome) - and rotate infusion sites.
Which group of antibiotics does clindamycin belong to?
Lincosamide
What activity does clindamycin have?
it is active against gram-positive cocci, including streptococci and penicillin resistant staphylococci, and also against many anaerobes, especially bacteroides fragilis.
It is well concentrated in bone and excreted in bile and urine.
What important information for clindamycin side effect is given in the BNF - it can induce what?
Clindamycin has been associated with antibiotic-associated colitis, which may be fatal.
Although antibiotic-associated colitis can occur with most antibacterial, it occurs more frequently with clindamycin.
If C.difficile is suspected when on clindamycin treatment - what should you do?
Discontinue the antibiotic if appropriate. Seek specialist advice if the antibiotic cannot be stopped and the diarrhoea is severe.
Should monitor liver and renal function when clindamycin treatment exceeds how many days?
More than 10 days treatment
However, in children and neonates you would monitor liver and renal function
What about clindamycin and diarrhoea should patients be given advice on?
Advised to discontinue and contact a doctor immediately if severe, prolonged or bloody diarrhoea develops.
What some indications of macrolides?
ampylobacter enteritis, respiratory infections (including pneumonia, whooping cough, Legionella, chlamydia, and mycoplasma infection), and skin infections.
Give examples of the macrolides?
- clarithromycin
- erythromycin
- Azithromycin
Does erythromycin have a good or poor activity against Haemophilus influenzae?
Poor activity
What side effect does erythromycin cause?
Erythromycin causes nausea, vomiting, and diarrhoea in some patients; in mild to moderate infections this can be avoided by giving a lower dose, but if a more serious infection, such as Legionella pneumonia, is suspected higher doses are needed.
Compare azithromycin activity against erythromycin?
Azithromycin is a macrolide with slightly less activity than erythromycin against Gram-positive bacteria, but enhanced activity against some Gram-negative organisms including H. influenzae.
With azithromycin are plasma or tissue concentrations higher?
Plasma concentrations are very low, but tissue concentrations are much higher. It has a long tissue half-life and once daily dosage is recommended.
Which has a greater activity - clarithromycin or erythromycin?
Clarithromycin
Tissue concentrations are higher than with erythromycin.
Which macrolide is used in the eradication of H.pylori?
Clarithromycin
Spiramycin is also a macrolide - what is it used for?
used for the treatment of toxoplasmosis.
Are macrolides bacteriostatic or bactericidal?
are either bactericidal (kill bacteria), or bacteriostatic (inhibit growth of bacteria).
Which ribosomal unit do macrolides inhibit?
The mechanism of action of macrolides revolves around their ability to bind the bacterial 50S ribosomal subunit causing the cessation of bacterial protein synthesis
Are macrolides narrow or broad spectrum antibiotics?
Broad spectrum like penicillin’s but are unrelated
Hence, they can be given as an alternative in penicillin-allergic patients.
How often a day is clarithromycin given?
Twice a day - administration
Can clarithromycin be used in pregnancy?
No should be avoided
Which drugs may macrolides interact with?
- Statins, CCBs and warfarin (increasing their concentration)
Enzyme inhibitor
With macrolide use what disturbances can predispose to QT prolongation?
electrolyte imbalances
an interaction between erythromycin and which DOAC has been identified?
Rivaroxaban - increased risk of bleeding
Which macrolide can be used in pregnancy if potential benefits outweighs risk?
Erythromycin
Give an example of a monobactam antibiotic?
Aztreonam
What is the activity of Aztreonam (monobactam)?
It is a monocyclic beta-lactam (monobactam) antibiotic with an antibacterial spectrum limited to Gram negative aerobic bacteria including Pseudomonas Aeruginosa, Nesseria Meningitidis, and haemophilius Influenzae.
It should not be used alone for blind treatment since it is not active against Gram-positive organisms.
which antibiotic class does metronidazole belong to?
Nitromidazole derivative
What activity does metronidazole have?
High activity against anaerobic bacteria and protozoa
Is it safe to drink alcohol while taking metronidazole?
No - should be avoided
Disilfurim like reactions
Can metronidazole be taken in pregnancy or whilst breastfeeding?
avoid unless essential - but high doses completely avoid
What side effects can metronidazole cause?
nausea, vomiting, taste disturbances and furred tongue.
How often is metronidazole administered daily?
Three times a day
Is metronidazole taken with or without food?
With Food and a full glass of water
Which antibiotic class does tinidazole belong to?
- Nitromidazole derivative
Which has a longer duration of action - metronidazole or tinidazole?
Tinidazole
Is benzylpenicillin sodium inactivated by bacterial beta-lactamases?
Yes
what is benzylpenicillin sodium also known as?
Penicillin G
Is benzylpenicillin still the drug of first choice for pneumococcal meningitis?
No - third generation cephalosporin
It is still first choice for streptococci meningitis
Is benzylpenicillin given orally or by injection and why?
Benzylpenicillin is inactivated by gastric acid and absorption from the gastro-intestinal tract is low; therefore it must be given by injection.
What is the use of benzathine benzylpenicllin?
used for the treatment of early syphilis and late latent syphilis; it is given by intramuscular injection.
what phenoxymethylpenicillin also known as?
Penicillin V
Which is more active Penicillin G or V?
Penicillin G
Is penicillin V gastric acid stable?
Yes and is suitable for oral adminstration
Why isn’t penicillin V recommended to be used for serious infections?
because absorption can be unpredictable and plasma concentrations variable.
What is Penicillin V usually indicated for?
It is indicated principally for respiratory-tract infections in children, for streptococcal tonsillitis, and for continuing treatment after one or more injections of benzylpenicillin sodium when clinical response has begun.
Phenoxymethylpenicillin is used as prophylaxis for which conditions?
prophylaxis against streptococcal infections following rheumatic fever and against pneumococcal infections following splenectomy or in sickle-cell disease.
Why are most staphylococci now resistant to benzylpenicillin?
Because they produce penicillinases
Is flucloxacillin penicillinase resistant?
Flucloxacillin, however, is not inactivated by these enzymes and is thus effective in infections caused by penicillin-resistant staphylococci, which is the sole indication for its use.
Is flucloxacillin well absorbed by the gut?
Yes
What is temocillin active against?
Temocillin is active against Gram-negative bacteria and is stable against a wide range of beta-lactamases. It should be reserved for the treatment of infections caused by beta-lactamase-producing strains of Gram-negative bacteria, including those resistant to third-generation cephalosporins. Temocillin is not active against Pseudomonas aeruginosa or Acinetobacter spp.
Is ampicillin a broad spectrum penicillin?
Yes
What is ampicillin indicated to be used for?
indicated for the treatment of exacerbations of chronic bronchitis and middle ear infections, both of which may be due to Streptococcus pneumoniae and H. influenzae, and for urinary-tract infections.
Can ampicillin be given by mouth?
Yes - can be given by mouth but less than half the dose is absorbed, and absorption is further decreased by the presence of food in the gut.
What type of rashes may occur with ampicillin or amoxicillin?
Maculopapular rashes commonly occur with ampicillin (and amoxicillin) but are not usually related to true penicillin allergy.
When do these rashes usually occur?
hey almost always occur in patients with glandular fever; broad-spectrum penicillins should not therefore be used for ‘blind’ treatment of a sore throat.
The risk of rash is also increased in patients with acute or chronic lymphocytic leukaemia or in cytomegalovirus infection.
Which is better absorbed when given by mouth - ampicillin or amoxicillin?
Amoxicillin
Like ampicillin is amoxicillin absorption affected by the presence of food in the stomach when given by mouth?
No
Is amoxicillin used in the treatment of lyme disease?
Yes
What does co-amoxiclav consist of?
Amoxicillin with the betalactamase inhibitor clavulanic acid
What is is the combination of drugs in co-fluampicil?
Ampicillin with flucloxacillin
Is piperacillin (an antipseudomonal penicillin) available on its own?
no it is only available in combination with the beta-lactamase inhibitor tazobactam
Which is more active piperacillin with tazobactam vs ticarcillin with clavulanic acid?
Piperacillin with tazobactam has activity against a wider range of Gram-negative organisms than ticarcillin with clavulanic acid and it is more active against Pseudomonas aeruginosa.
Are the previous two antibacterials active against MRSA?
These antibacterials are not active against MRSA.
For severe pseudomonas infections these antipseudomonal penicillins can be given with which class of antibiotic?
can be given with an aminoglycoside (e.g. gentamicin) since they have a synergistic effect.
List the antipseudomonal penicillins?
Piperacillin with tazobactam
Ticarcillin with calvulanic acid
what type of penicillin is pivmecillinam?
Mecillinam
Is pivmecillinam active against pseudomonas aeruginosa?
No
What is pivmecillinam hydrolysed to?
to mecillinam which is the active drug
Are penicillins bacteriostatic or bacteriacidal?
Bactericidal
What is the MAO of penicillin?
Penicillins are bactericidal and act by interfering with bacterial cell wall synthesis.
do penicillins penetrate well into the cerebral spinal fluid?
They diffuse well into body tissues and fluids, but penetration into the cerebrospinal fluid is poor except when the meninges are inflamed
Which penicillin antibacterial is classed under ‘antipseudomonal with beta-lactamase inhibitor’?
Piperacillin with tazobactam
Which antibiotics - penicillin- are sensitive to beta lactamase?
- Benzathine benzylpenicillin
- Benzylpenicillin sodium (Penicillin G)
- phenoxymethylpenicillin (penicillin V)
which penicillins are classed as broad spectrum penicillin?
- Amoxicillin
- Ampicillin
- Co-fluampicil
- Co-amoxiclav
Which penicillin is classes as broad spectrum with beta-lactamase inhibitor?
Co-amoxiclav (amoxicillin + Clavulanic acid)
Which penicillin can cause a black hairy tough (rare side effect)?
Amoxicillin
Is amoxicillin safe to use in pregnancy?
Yes not known to be harmful
When are amoxicillin 3g sachets used?
For dental abscess - 3g then 3g after 8 hours
Is ampicillin safe to use in pregnancy?
Yes not known to be harmful
Which antibacterial penicillin comes under the class - penicillinase resistant?
Flucloxacillin
What MHRA warning regarding hepatic disorders has been issued with flucloxacillin use?
Cholestatic jaundice and hepatitis may occur very rarely, up to two months after treatment with flucloxacillin has stopped.
Administration for more than 2 weeks and increasing age are risk factors.
Is flucloxacillin safe to use in pregnancy?
Yes - not known to be harmful
In adults what eGFR prompts you to reduce dose of flucloxacillin?
Less than 10ml/min/17.73m2
Name another penicillin that is penicillinase resistant?
Temocillin
Are penicillins excreted in the urine?
Yes
Patients with penicillin allergy to one penicillin may be allergic to what other antibiotics?
will be allergic to all penicillin’s and possibly to cephalosporins + beta-lactam antibiotics, so they should not receive these.
Is there a risk of encephalopathy in penicillin use?
Yes - the risk is increased with very high doses or in severe renal failure.
What is a common side effect of penicillins?
Diarrhoea which can cause colitis
Is penicillin V taken with food or after food?
Taken on an empty stomach
Can penicillin V be used in pregnancy and breastfeeding?
Yes
How many times a day is penicillin V adminsitered?
4 times a day orally on an empty stomach
Which other penicillin other than flucloxacillin can cause cholestatic jaundice?
Co-amoxiclav
- Cholestatic jaundice can occur either during or shortly after use of co-amoxiclav. It is more common in those >65 + men, but self-limiting. 14 days is the maximum treatment duration.
what is the maximum treatment duration with co-amoxiclav?
14 days
Which quinolones are the only ones available in the UK?
Fluoroquinolone
What is ciprofloxacin active against?
Both gram positive and gram negative bacteria.
It is particularly active against Gram-negative bacteria, including Salmonella, Shigella, Campylobacter, Neisseria, and Pseudomonas.
Can ciprofloxacin be used for pneumococcal pneumonia?
No it should be usedfor that
Is ciprofloxacin active against chlamydia?
Yes and some mycobacteria
What else can ciprofloxacin be used for?
Ciprofloxacin can be used for respiratory tract infections (but not for pneumococcal pneumonia), infections of the gastro-intestinal system (including typhoid fever), bone and joint infections, gonorrhoea and septicaemia caused by sensitive organisms.
What is ofloxacin licensed for?
urinary-tract infections, lower respiratory-tract infections, gonorrhoea, and non-gonococcal urethritis and cervicitis.
What is levofloxacin active against?
Levofloxacin is active against Gram-positive and Gram-negative organisms. It has greater activity against Pneumococci than ciprofloxacin.
Can quinolones be used in MRSA?
Many Staphylococci are resistant to quinolones and their use should be avoided in MRSA infections.
What is moxifloxacin active against?
Moxifloxacin is active against Gram-positive and Gram-negative organisms. It has greater activity against Gram-positive organisms, including Pneumococci, than ciprofloxacin.
Is moxifloxacin active against pseudomonas?
Moxifloxacin is not active against Pseudomonas aeruginosa or meticillin-resistant Staphylococcus aureus (MRSA).
Which quinolone is active against MRSA?
Delafloxacin is active against Gram-positive (including MSRA) and Gram-negative organisms. It may be used for treating acute bacterial skin and skin structure infections (ABSSSI) in individuals when the use of standard treatments is considered inappropriate.
What has the MHRA warned about use of quinolones and convulsions?
Quinolones may induce convulsions in patients with or without a history of convulsions
What is the effect of taking quinolones and NSAIDs at the same time?
It may induce convulsions
What MHRA warning has been released regarding tendon damage?
Tendon rupture has been reported rarely in patients receiving quinolones - Tendon rupture may occur within 48 hours of starting treatment; cases have also been reported several months after stopping a quinolone
What should be noted for prescribers regarding use of quinolones?
- It is contraindicated in patients with a history of tendon disorders related to quinolone use;
- patients over 60 years of age are more prone to tendon damage
- the risk of tendon is increased by the concomitant use of corticosteroids;
- if tendinitis (inflammation or irritation of a tendon) is suspected, the quinolone should be discontinued immediately
What signs and symptoms should patients be advised to look for taking quinolones that could indicate aortic aneurysm and dissection?
If sudden-onset severe abdominal, chest, or back pain develops
What should fluoroquinolones not be prescribed for?
Should not be prescribed for non-severe or self-limiting infections, or non-bacterial infections.
In general patients using quinolones should seek medical attention if they experience which side effects?
a rapid onset of shortness of breath (especially when lying down flat in bed),
swelling of the ankles, feet or abdomen
- or new onset heart palpitations
Can quinolones prolong QT interval?
Yes
Does treatment with quinolone require protection from sun?
Yes exposure to excessive sunlight and UV radiation should be avoided during treatment and for 48 hours after stopping treatment
Are quinolones recommended in children and growing adolescents?
No - quinolones cause arthropathy in the weight being joints of immature animals and are therefore generally not recommended in children and growing adolescents.
However, significance of this is uncertain and may in some specific circumstances use of ciprofloxacin may be justified in children
Are quinolones safe to use in pregnancy?
No
When should quinolones be discontinued?
if neurological, psychiatric, tendon disorders or hypersensitivity reactions (including severe rash) occur.
Give examples of quinolones?
- Ciprofloxacin
- Delafloxacin
- Levofloxacin
- Moxifloxacin
- Ofloxacin
Are quinolones effective against anaerobes?
No
If photosensitivity occurs when on quinolones what should happen?
Treatment should be discontinued
What counselling advice on administration of quinolone should be given?
Usually taken twice a day
- Should not be taken with milk, indigestion remedies, iron or zinc.
- quinolones may impair skilled tasks like driving
Give examples of sulfonamide antibiotics?
Co-trimoxazole
sulfadiazine
What is the MAO of co-trimoxazole?
Sulfamethoxazole and trimethoprim are used in combination (as co-trimoxazole) because of their synergistic activity (the importance of the sulfonamides has decreased as a result of increasing bacterial resistance and their replacement by antibacterial which are generally more active and less toxic)
What is the MAO of sulfadiazine?
It is a short acting sulphonamide with bacteriostatic activity against a broad spectrum of organisms. the importance of the sulfonamides has decreased as explained on previous card.
Are tetracyclines broad or narrow spectrum?
They are broad spectrum antibiotics
Despite the increasing bacterial resistance they remain treatment of choice for which conditions?
chlamydia (trachoma, psittacosis, salpingitis, urethritis, and lymphogranuloma venereum), rickettsia (including Q-fever), brucella (doxycycline with either streptomycin or rifampicin), and the spirochaete, Borrelia burgdorferi (See Lyme disease).
Which other conditions are tetracyclines used in?
They are also used in respiratory and genital mycoplasma infections, in acne, in destructive (refractory) periodontal disease, in exacerbations of chronic bronchitis (because of their activity against Haemophilus influenzae), and for leptospirosis in penicillin hypersensitivity (as an alternative to erythromycin).
Do tetracyclines have a role in the management of MSRA?
Yes
Microbiologically is there much difference to choose between the various tetracyclines?
No - the only exception being minocycline which has a broader spectrum;
it is active against Neisseria meningitidis and has been used for meningococcal prophylaxis but is no longer recommended because of side-effects including dizziness and vertigo.
Compared to the other tetracyclines - minocycline is associated with a greater risk of what?
minocycline is associated with a greater risk of lupus-erythematosus-like syndrome
Furthermore, minocycline can sometimes cause something which is irreversible, what is it?
Irreversible pigmentation
Can tetracyclines be given to pregnant women or breastfeeding women?
No
List the tetracyclines?
- Democlocycline hydrochloride
- Doxycycline
- Lymecycline
- minocycline
- Oxytetracycline
- tetracycline
- tigecycline
What is the mechanism of action of tetracyclines?
Tetracyclines specifically inhibit the 30S ribosomal subunit, hindering the binding of the aminoacyl-tRNA to the acceptor site on the mRNA-ribosome complex. When this process halts, a cell can no longer maintain proper functioning and will be unable to grow or further replicate
Why do tetracyclines cause staining of teeth?
• Tetracyclines may deposit in growing bones + teeth by binding to calcium resulting in staining of teeth, hence they cannot be used in children under 12.
Why shouldnt tetracyclines be given in pregnancy?
They should not be given in pregnancy due to effects on skeletal development in the 1st trimester. Administration during the 2nd or 3rd trimester may cause discolouration of the child’s teeth
Why shouldn’t tetracyclines be given during breastfeeding?
They should not be given during breast-feeding as they may cause discolouration of the child’s teeth
The intestinal absorption of tetracyclines may be impaired if given with which ingredients?
- Magnesium, Iron, Calcium, Aluminium, Zinc and antacids.
Can tetracyclines be taken with milk?
Do not take milk, milk formulas, or other dairy products within 1 to 2 hours of the time you take tetracyclines (except doxycycline and minocycline) by mouth. They may keep this medicine from working properly
What colour staining of the teeth do tetracycline cause?
Tetracycline and doxycycline can cause yellow or grey staining of the teeth
Which tetracyclien can cause oesophageal irritation?
Doxycycline
Which tetracycline is associated with a higher risk of lupus-erythematous-like syndrome?
Minocycline
Is chloramphenicol narrow or broad spectrum?
Potent broad spectrum antibiotic
Why is chloramphenicol avoided in pregnancy?
Due to risk of causing grey baby syndrome when used in third trimester
Does breastfeeding while on chloramphenicol cause grey baby syndrome?
Manufacturer advises avoid; use another antibiotic; may cause bone-marrow toxicity in infant; concentration in milk usually insufficient to cause ‘grey baby syndrome’
Is fidoxamicin used to treated systemic bacterial infections?
No - it is a macrocyclic antibacterial that is poorly absorbed from the GI tract and is therefore not used to treat systemic infections.
What is fidoximicin used for second line?
C.diifficile infection (200mg every 12 hours for 10 days)
What type of antibiotic is fosfomycin?
It is a phosphonic acid antibacterial
What indications are listed for fosfomycin in th eBNF?
UTIs
osteomyelitis when first line has failed
Bacterial meningitis when first line has failed or inappropriate
Is fusidic acid broad or narrow spectrum?
It is narrow spectrum used for staphylococcol infections
What MHRA warning has been issued on the use of linezolid?
Severe optic neuropathy may occur rarely, particularly if linezolid is used for longer than 28 days.
what sings and symptoms should patients taking linezolid report to their GP?
- symptoms of visual impairment (including blurred vision, visual field defect, changes in visual acuity and colour vision) immediately;
- Patients experiencing new visual symptoms regardless of treatment duration should be evaluated promptly and referred to an ophthalmologist if necessary;
Which blood disorders have been reported with linezolid use?
thrombocytopenia, anaemia, leucopenia, and pancytopenia
How often should FBC be monitored in patients taking linezolid?
Weekly
What electrolyte imbalance can trimethoprim cause?
Hyperkalaemia
What deficieny can prolong use of trimethorprim cause?
Folate deficiency
Can trimethoprim cause blood disroders?
Yes and patients should be advised on how to recognise symptoms and seek medical attention including - fever, sore throat, rash, mouth ulcers, purpura, bruising or bleeding.
Give two examples of drugs that belong to the antimycobacterials - Rifamycin?
- Rifabutin
- Rifaximin
Is anthrax a notifiable disease in the UK?
YEs
What is the treatment for inhalation or gastro-intestinal anthrax?
initially with either ciprofloxacin or, in patients over 12 years, doxycycline [unlicensed use] and combined with one or two other antibacterials (such as benzylpenicillin sodium, clindamycin, rifampicin, and vancomycin).
Alternatively, the combination of amoxicillin and imipenem with cilastatin, or meropenem and chloramphenicol may be given.
But when the condition improves treatment can be switched to a single antibacterial
What is the treatment for cutaneous anthrax?
Cutaneous anthrax should be treated with either oral ciprofloxacin [unlicensed use] or, in patients over 12 years, doxycycline [unlicensed use] for 7 days; treatment should be switched to amoxicillin if the infecting strain is susceptible.
Which antibiotics are given for post-exposure prophylaxis of anthrax?
Oral ciprofloxacin, doxycycline [unlicensed use], or amoxicillin may be given for post-exposure prophylaxis.
How long should antibacterial prophylaxis for anthrax coninute?
For up to 60 days, however short period may be recommended.
Is there a vaccine available for anthrax?
- yes and it may be considered in selected cases
Just to summarise what is anthrax?
It is a bacterial infection of cattle + Sheep which can be transmitted to humans causing skin ulceration or a form of pneumonia
Multibacillary leprosy should be treated with a combination of three drugs- which ones?
- Rifampicin
- Dapsone
- Clofazimine
For at least 2 years
Treatment should be continued unchanged during both type I (reversal) or type II (erythema nodosum leprosum) reactions
during reversal reactions what can neuritic pain or weakness do?
Can herald the rapid onset of permanent nerve damage
-Treatment with prednisolone should be instituted at once.
What may mild type II reactions respond to?
- Aspirin
Paucibacillary leprosy should be treated with which two drugs?
- Rifampicin AND
- Dapsone
For 6 months
If treatment is interrupted the regimen should be recommenced where it was left off to complete the full course
Are the treatments used for multibacillary or the paucibacillary leprosy sufficient to treat tuberculosis?
No
In summary what is leprosy?
It is a contagious disease which affects the skin, mucous membranes and nerves causing discolouration and lumps on the skin
What is a good way to remember how many drug combinations is required for each type of leprosy?
Multibacillary = many bacteria Paucibacillary = few bacteria
In multibacilliary leprosy what do type 1 reactions consist of?
During type 1 reactions, neuropathic pain or weakness can result in permanent nerve damage. At this point, prednisolone should be given.
In multibacilliary leprosy what do type 2 reactions involve?
Type 2 reactions involve painful and tender nodules on the skin which may respond to Aspirin
What may severe type 2 reactions require?
Severe type 2 reactions may require corticosteroids. Thalidomide (unlicensed) is useful for patients who become corticosteroid dependent, but it should be used under specialist supervision. It is teratogenic and thus, contraindicated in pregnancy. Increased doses of Clofazimine are also useful
What is lyme disease also known as?
Lyme borreliosis
What is lyme disease?
Lyme disease, also known as Lyme borreliosis, is an infection caused by bacteria called Borrelia burgdorferi. It is transmitted to humans by the bite of an infected tick. Ticks are mainly found in grassy and wooded areas including urban gardens and parks. Most tick bites do not cause Lyme disease, and the prompt and correct removal of the tick reduces the risk of infection.
What does lyme disease present with?
Lyme disease usually presents with a characteristic erythema migrans rash. This usually becomes visible 1–4 weeks after a tick bite, but can appear from 3 days to 3 months, and last for several weeks.
It may be accompanied by non-focal (non-organ related) symptoms, such as fever, swollen glands, malaise, fatigue, neck pain or stiffness, joint or muscle pain, headache, cognitive impairment, or paraesthesia.
How long after lyme disease may focal symptoms appear (relating to at least 1 organ system)?
months or years after the initial infection
What do focal symptoms include?
These include neurological (affecting cranial nerves, peripheral and central nervous systems), joint (Lyme arthritis), cardiac (Lyme carditis), or skin (acrodermatitis chronica atrophicans) manifestations.
In patients presenting with lyme disease with erythema migrans rash with or without non-focal symptoms - what is the first line treatment?
Oral doxycycline (unlicensed)
If this is not suitable then amoxicillin should be used as an alternative
What if both both are unsuitable?
Oral azithromycin (unlicensed indication)
What is the first line in patients presenting with focal symptoms of cranial nerve or peripheral nervous system involvement?
oral doxycycline [unlicensed indication] is recommended as first-line treatment. If doxycycline cannot be given, oral amoxicillin should be used as an alternative.
What’s the first line treatment for lyme disease if the patient presents with symptoms of central nervous system involvement?
Intravenous ceftriaxone is recommended as first-line treatment.
Oral doxycycline [unlicensed indication] should be used as an alternative if ceftriaxone cannot be given, or when switching to oral antibacterial treatment.
Whats first line in patients with symptoms of lyme arthritis or acrodermatitis chronica atrophicans?
oral doxycycline [unlicensed indication] is recommended as first-line treatment. If doxycycline cannot be given, oral amoxicillin should be used as an alternative. Intravenous ceftriaxone should be given if both doxycycline and amoxicillin are unsuitable.
What is the treatment in patients with symptoms of lyme carditis who are haemodynamiccaly stable?
oral doxycycline [unlicensed indication] is recommended as first-line treatment. If doxycycline cannot be given, intravenous ceftriaxone should be used as an alternative.
What about in patients with symptoms of lyme carditis who are haemodynamically unstable?
intravenous ceftriaxone is recommended.
Oral doxycycline [unlicensed indication] should be given when switching to oral antibacterial treatment.
A second course of antibacterial should be given to which patients?
A second course of antibacterial treatment should be given to patients presenting with signs and symptoms of re-infection.
Is a third course of antibiotic for lyme disease recommended?
A third course of antibacterial treatment is not recommended, and further management should be discussed with a national reference laboratory or suitable specialist depending on symptoms (for example, a rheumatologist or neurologist).
In summary, what is lyme disease?
It is a form of arthritis caused by bacteria that are transmitted by ticks (insect)
What is MRSA?
Meticillin-resistant Staphylococcus aureus (MRSA) are strains of Staphylococcus aureus that are resistant to a number of commonly used antibacterials including beta-lactam antibacterials (e.g. meticillin [now discontinued] and flucloxacillin).
What may MRSA colonise on the body?
As with Staph. aureus colonisation, MRSA may colonise the skin, gut, or nose without displaying signs or symptoms of infection.
Which antibiotics can be considered for lower-urinary tract infections caused by MRSA according to susceptibility?
- Doxycycline
- trimethoprim
- Ciprofloxacin
- Co-trimoxazole
Which antibiotics can be considered for complicated urinary-tract infections (MRSA)?
Glyco-peptide
Can rifampicin and fusidic acid be used alone in MRSA?
No because resistance may develop rapidly.
Can a tetracycline alone be used for skin and soft tissue infections caused by MRSA?
Yes or a combination of rifampicin + Fusidic acid
Which other drug is an alternative that can be used alone for skin and soft tissue infections caused by MRSA?
- Clindamycin
What can be used for severe skin + soft tissue infections associated with MRSA?
A glycopeptide (e.g. vancomycin)
If a glycopeptide is unsiuitable the Linezolid can be used on expert advice. But as this not active against gram negative organisms it must be given with other antibacterials if the infection involves gram negative organisms.
Which combination of drugs can be used if a single antibacterial has failed to treat skin + soft tissue infections infected with MRSA?
Glycopeptide + Fusidic acid
or
Glycopeptide + Rifampicin
Which drugs can be used for Bronchiectasis (widening of the bronchioles) caused by MRSA?
- A tetracycline
or - Clindamycin
Which antibiotic class can be used for pneumonia associated with MRSA?
A glycopeptide
If aglycopeptide is unsuitable then can use Linezolid
Which drugs can be used for urinary tract infections caused by MRSA?
- A tetracycline
- Alternatives include: Trimethoprim or Nitrofurantoin
- A Glycopeptide can be used for UTIS that are severe or resistant to other antibacterial
Which antibiotic drug class can be used for septicaemia associated with MRSA?
- A Glycopeptide
Is tuberculosis curable?
Yes
What is tuberculosis?
Tuberculosis is a curable infectious disease caused by bacteria of the Mycobacterium tuberculosis complex (M. tuberculosis, M. africanum, M. bovis or M. microti) and is spread by breathing in infected respiratory droplets from a person with infectious tuberculosis.
What is the most common form of tuberculosis infection?
The most common form of tuberculosis infection is in the lungs (pulmonary) but infection can also spread and develop in other parts of the body (extrapulmonary).
