BNF - Chapter 5 - Infection - (Part 2)

Question 1

What is latent tuberculosis?

Answer 1

The initial infection with tuberculosis clears in the majority of individuals. However, in some cases the bacteria may become dormant and remain in the body with no symptoms (latent tuberculosis) or progress to being symptomatic (active tuberculosis) over the following weeks or months.

Question 2

Does everyone with latent TB go on to develop active tuberculosis?

Answer 2

In individuals with latent tuberculosis only a small proportion will develop active tuberculosis.

Question 3

The standard treatment of tuberculosis is treated in how many phases?

Answer 3

In two phases.

An initial phase and a continuation phase

Question 4

How many drugs are used in the initial phase?

Answer 4

4 drugs

Question 5

How many drugs are used in the continuation phase?

Answer 5

2 drugs in fully sensitive cases

Question 6

Within the UK there are two regimens recommended for the treatment of tuberculosis, what are they?

Answer 6

Unsupervised and supervised

Question 7

For standard treatment for individuals with active tuberculosis which four drugs are given for the initial phase?

Answer 7

Rifampicin
Isoniazid (with pyridoxine)
Pyrazinamide
Ethambutol

(RIPE - acronym)

Question 8

How long is initial phase of TB treatment continued for?

Answer 8

For 2 months

Question 9

What is offered in the continuation phase after the initial phase?

Answer 9

Rifampicin
Isoniazid (with pyridoxine)

(RI of the RIPE - acronym)

Question 10

How long is the continuation phase treatment for TB offered for?

Answer 10

For 4 months after the 2 months initial phase - for patients with active TB without central nervous involvement

Question 11

Longer treatments should be offered in individuals with active TB of the central nervous system with or without spinal involvement - how long for?

Answer 11

Longer treatment for 10 months after the 2 months initial phase.

Question 12

Who is unsupervised treatment offered to?

Answer 12

The unsupervised treatment regimen is for individuals who are likely to take antituberculosis drugs reliably and willingly without supervision.

Question 13

What does supervised TB treatment involve?

Answer 13

(directly observed therapy, DOT), this is offered as part of enhanced case management.

Question 14

How many times a week administration can be considered for supervised TB treatment if daily directly observed therapy is not available?

Answer 14

A 3 times weekly dosing schedule can be considered in individuals with tuberculosis if they require enhanced case management and daily directly observed therapy is not available.

Question 15

Are anti TB treatment dosing regimens of fewer than 3 times a week recommended?

Answer 15

No

Question 16

Directly observed therapy should be offered to which individuals?

Answer 16

To individuals who:
have a current risk or history of non-adherence;
have previously been treated for tuberculosis;
have a history of homelessness, drug or alcohol misuse;
are in prison or a young offender institution, or have been in the past 5 years;
have a major psychiatric, memory or cognitive disorder;
are in denial of the tuberculosis diagnosis;
have multi-drug resistant tuberculosis;
request directly observed therapy after discussion with the clinical team;
are too ill to self-administer treatment.

Question 17

Who should individuals with comorbidities or coexisting conditions such as HIV, severe liver disease etc. be treated by for TB?

Answer 17

should be managed by a specialist multidisciplinary team with experience in managing tuberculosis and the comorbidity or coexisting condition.

Question 18

For individuals who are HIV positive with active TB, treatment with the standard regimen should not routinely exceed how many months?

Answer 18

6 months, unless the TB has central nervous system involvement, in which cases should not routinely extend beyond 12 months

Question 19

Care should be taken to avoid drug interactions when co-prescribing antituberculotic drugs with which drugs?

Answer 19

Antiretrovirals with antituberculosis

Question 20

Summarise the treatment initial phase and continuation phase and their duration of treatment for individuals with central nervous system tuberculosis?

Answer 20

standard treatment with initial phase drugs for 2 months (RIPE)

After completion of the initial treatment phase, standard treatment with continuation phase drugs should then be offered (RI) for a further 10 months)

Question 21

What other treatment should be considered if there are signs and clinical symptoms to suggest it?

Answer 21

Treatment for tuberculous meningitis should be offered if clinical signs and other laboratory findings are consistent with the diagnosis, even if a rapid diagnostic test is negative.

Question 22

Which drug should be offered at the same time as antituberculosis treatment in patients with central nervous system involvment?

Answer 22

An initial high dose of dexamethasone or prednisolone should be offered at the same time as antituberculosis treatment, then slowly withdrawn over 4–8 weeks.

Question 23

In which patients would you consider referral for surgery?

Answer 23

Referral for surgery should only be considered in individuals who have raised intracranial pressure; or have spinal TB with spinal instability or evidence of spinal cord compression.

Question 24

What is the pericardium?

Answer 24

The pericardium is a membrane, or sac, that surrounds your heart. It holds the heart in place and helps it work properly. Problems with the pericardium include: Pericarditis - an inflammation of the sac.

Question 25

What drug should also be prescribed at the start same time as antituberculosis treatment for patients with active pericardial tuberculosis?

Answer 25

An initial high dose of oral prednisolone should be offered to individuals with active pericardial tuberculosis, at the same time as antituberculosis treatment, then slowly withdrawn over 2–3 weeks.

Question 26

Some individuals with latent TB are at an increased risk of developing active tuberculosis - which groups?

Answer 26

such as individuals who are HIV-positive, diabetic, injecting drug users, or receiving treatment with an anti-tumor necrosis factor alpha inhibitor).

Question 27

What information about close contacts of those with active or recently treated for TB should you know?

Answer 27

Anyone aged under 65 years who is a close contact (prolonged, frequent or intense contact, for example household contacts or partners) of a person with pulmonary or laryngeal tuberculosis should be tested for latent tuberculosis.

Drug treatment should be offered to all individuals aged under 65 years with evidence of latent tuberculosis, if the close contact has suspected infectious or confirmed active pulmonary or laryngeal drug-sensitive tuberculosis.

Question 28

What is the treatment for latent TB?

Answer 28

RI -
Rifampicin + Isoniazid (with pyridoxine) for 3 months

or 
Isoniazid (with pyridoxine) for 6 months

Question 29

What should individuals be tested for before starting treatment for latent TB?

Answer 29

Testing for HIV, hepatitis B and hepatitis C should be offered before starting antituberculosis treatment as this may affect choice of therapy.

Question 30

What are the major causes of treatment failure?

Answer 30

incorrect prescribing by the clinician and inadequate compliance by the infected individual.

Question 31

What can multidisciplinary tuberculosis team implement to help?

Answer 31

Multidisciplinary tuberculosis teams should implement strategies (such as random urine tests, pill counts, home visits, health education counselling, and language appropriate reminder services) to help with adherence to, and successful completion of treatment.

Question 32

What is classified as a treatment interruption for antituberculosis treatment?

Answer 32

A break in antituberculosis treatment of at least 2 weeks (during the initial phase) or missing more than 20% of prescribed doses is classified as treatment interruption.

Question 33

In individuals with severe or highly infection tuberculosis who need to interrupt the standard regimen due to drug-drug hepatoxicity - which drugs should be continued?

Answer 33

onsider continuing treatment with at least 2 drugs with low risk of hepatotoxicity, such as ethambutol hydrochloride and streptomycin (with or without a fluoroquinolone antibiotic, such as levofloxacin or moxifloxacin), with ongoing monitoring by a liver specialist.

Question 34

What is the treatment regime for TB that is resistant to isoniazid?

Answer 34

First 2 months (initial phase): rifampicin, pyrazinamide and ethambutol hydrochloride;

Continue with (continuation phase): rifampicin and ethambutol hydrochloride for 7 months (up to 10 months for extensive disease).

Question 35

What is the treatment regimen for TB that is resistant to Pyrazinamide?

Answer 35

First 2 months (initial phase): rifampicin, ethambutol hydrochloride and isoniazid (with pyridoxine hydrochloride);

Continue with (continuation phase): rifampicin and isoniazid (with pyridoxine hydrochloride) for 7 months.

Question 36

What is the treatment regime for TB that is resistant to ethambutol?

Answer 36

First 2 months (initial phase): rifampicin, pyrazinamide and isoniazid (with pyridoxine hydrochloride);

Continue with (continuation phase): rifampicin and isoniazid (with pyridoxine hydrochloride) for 4 months.

Question 37

What is the treatment regime for TB that is resistant to rifampicin?

Answer 37

Offer treatment with at least 6 antituberculosis drugs to which the mycobacterium is likely to be sensitive.

Question 38

Which drug class does rifampicin belong to?

Answer 38

Antimycobacterials - Rifamycin

Question 39

Can rifampicin affect contact lenses?

Answer 39

Yes - discolour soft contact lenses

Question 40

What is a common side effect of rifampicin?

Answer 40

Nausea, thrombocytopenia and vomiting

Question 41

Does rifampicin affect hormonal contraceptive use?

Answer 41

Yes - effectiveness of hormonal contraception is reduced

Question 42

List other drugs that are used in multiple resistant tuberculosis?

Answer 42

• Aminosalicylic acid
• Bedaquiline
• Capreomycin
• Cycloserine
• Delamnid

Question 43

What toxicity is tubercolusis drug treatments (RIPE) associated with?

Answer 43

Link with liver toxicity, so liver function should be checked before treatment begins.

Question 44

Is rifampicin an enzyme inhibitor or inducer?

Answer 44

• Rifampicin induces hepatic enzymes which accelerates the metabolism of corticosteroids, phenytoin and anticoagulants. Combined oral contraceptive pills will become ineffective (metabolised)

Question 45

What is a common side effect of isoniazid?

Answer 45

• peripheral neuropathy

- should be given with pyridoxine

Question 46

During treatment with isoniazid, which B vitamin may become deficient?

Answer 46

Vitamin B6

Question 47

As part of RIPE - is ethambutol essential?

Answer 47

Ethambutol is not essential as RI since its main purpose is a backup in case there is isoniazid resistance

Question 48

What side effect can ethambutol cause which requires patients to stop and report it?

Answer 48

Ethambutol can cause visual problems including blurry vision + colour blindness – patients should be told to stop using ethambutol if this is the case

Question 49

What is pyrazinamide useful for - specifically which type of TB condition/ complication?

Answer 49

• Pyrazinamide is a bactericidal drug which exerts its main effect only in the first 2 or 3 months. It is particularly useful for tuberculous meningitis because of good meningeal penetration

Question 50

Is streptomycin used commonly for treatment of TB?

Answer 50

• Streptomycin is rarely used except for resistant organisms.

Question 51

Following treatment interruption due to drug-induced hepatotoxicity… once hepatic function has recovered; anti-tuberculosis therapy should be re-introduced at the same dose within how many days?

Answer 51

Within 10 days

Question 52

Which part of the urinary tract can be affected by Urinary-tract-infections (UTIs)?

Answer 52

It can affect any part of the urinary tract

Question 53

Who do urinary tract occur more in?

Answer 53

More frequently in women, and are usually independent of any risk factor.

Question 54

How are UTIs predominantly caused?

Answer 54

Caused by bacteria from the GI tract entering the Urinary tract.

Question 55

Which is the most common causative organism responsible for UTIs?

Answer 55

Escherichia Coli

Question 56

Is UTIs due to Candida albicans common or rare?

Answer 56

Rare - but may occur in hospitalised patients who are immunocompromised or have an indwelling catheter

Question 57

What is inflammation of the bladder known as?

Answer 57

Cystitis

Question 58

What is inflammation of the urethra known as?

Answer 58

Urethritis

Question 59

What are lower UTIs associated with?

Answer 59

Associated with inflammation of the bladder (cystitis) and urethra (Urethritis).

Question 60

What parts do upper UTIs affect?

Answer 60

Upper UTIs affect the proximal part of the ureters (pyelitis) or the proximal part of the ureters and the kidneys (pyelonephritis), and can cause renal scarring, abscess or failure, and sepsis

Question 61

What are the most common signs and symptoms of lower UTIs?

Answer 61

• Dysuria
• Increased urinary frequency and urgency
• urine that is strong smelling
• cloudy or contains blood
• persistent lower abdominal pain

Question 62

What symptoms do upper UTIs usually present additionally with?

Answer 62

• Loin pain and

- fever

Question 63

In pregnant women, asymptomatic bacteriuria is a risk factor for what?

Answer 63

For pyelonephritis (a type of urinary tract infection where one or both kidneys become infected) and premature labour.

Question 64

What have UTIs in pregnancy been associated with?

Answer 64

been associated with developmental delay and cerebral palsy in the infant, as well as fetal death.

Question 65

Is inserting a catheter a risk factor for developing UTIs?

Answer 65

Insertion of a catheter into the urinary tract increases the risk of developing a UTI, and the longer the catheter is in place for, further increases the risk of bacteriuria.

Question 66

How many episodes within how many months is considered as having recurrent UTIs?

Answer 66

At least two episodes within 6 months or three or more episodes within 12 months

Question 67

What is acute prostatitis?

Answer 67

It is an infection of the prostrate gland and is usually caused by a UTI?

Question 68

What are the common symptoms of UTIs?

Answer 68

Common symptoms include sudden onset of fever, acute urinary retention or irritative voiding symptoms.

Question 69

What are some complications of acute prostatitis?

Answer 69

Possible complications include prostatic abscess, bacteraemia, epididymitis, and pyelonephritis.

Question 70

What is chronic prostatitis?

Answer 70

Chronic prostatitis is a complication of acute prostatitis and is defined as at least 3 months of urogenital pain usually associated with lower urinary tract symptoms

Question 71

What are the non-drug treatment advice to give for UTIs?

Answer 71

• drink plenty of water to avoid dehydration
• self care strategies to reduce risk of infection (such as wiping front to back after defaecation, not delaying urination, and not wearing occlusive underwear

Question 72

Can you recommended cranberry products for UTIs?

Answer 72

To reduce the risk of recurrent infections, some women (non-pregnant) with recurrent UTIs may wish to try cranberry products (evidence of benefit uncertain) or D-mannose.

Patients should be advised to consider the sugar content of these products. There is no evidence to support the use of cranberry products for the treatment of UTIs.

Question 73

Is asymptomatic bacteriuria routinely treated with antibacterials?

Answer 73

With the exception of pregnant women, asymptomatic bacteriuria is not routinely treated with antibacterials.

Question 74

Can both paracetamol and ibuprofen be used for pain relief in UTIs?

Answer 74

Yes

Question 75

Can codeine be used for pyelonephritis or prostatitis?

Answer 75

Yes where appropriate

Question 76

Is there much evidence to support the use of alkalinising agents for the treatments of UTIs?

Answer 76

No evidence

Question 77

For non-pregnant women with acute uncomplicated lower UTIs is it self-limiting?

Answer 77

Yes it is self-limiting and for some, delaying antibacterial treatment with a backup prescription to see if symptoms will resolve, may be an option.

Question 78

What is the choice of antibacterial therapy for non-pregnant women (acute, uncomplicated lower UTI)?

Answer 78

Oral first line:
Nitrofurantoin, or trimethoprim (if low risk of resistance).

Oral second line (if no improvement after at least 48 hours, or first line not suitable):
Nitrofurantoin (if not used first line), fosfomycin, pivmecillinam hydrochloride, or amoxicillin (high rate of resistance, so only use if culture susceptible)

Question 79

For men with UTI, what must be taken or done before treatment?

Answer 79

An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.

Question 80

What is the choice of antibacterial for treatment of lower UTI in men?

Answer 80

Oral first line:
Nitrofurantoin, or trimethoprim.

Oral second line (if no improvement after at least 48 hours, or first line not suitable):
Consider pyelonephritis or prostatitis. See pyelonephritis, acute, or prostatitis, acute below for guidance.

Question 81

For pregnant women must a midstream urine sample be obtained before treatment like men?

Answer 81

An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.

Question 82

What is the choice of antibacterial for treating lower UTI in pregnant women?

Answer 82

Oral first line:
Nitrofurantoin.

Oral second line (if no improvement after at least 48 hours, or first line not suitable):
Amoxicillin (only if culture susceptible), or cefalexin.

Alternative second line:
Consult local microbiologist.

Question 83

What are the treatment options for pregnant women for asymptomatic bacteriruria?

Answer 83

Amoxicillin, cefalexin or nitrofurantoin

Question 84

Before treating prostatitis (acute) what must be done?

Answer 84

An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.

Question 85

What is the choice of antibiotics to treat prostatitis?

Answer 85

Oral first line:
Ciprofloxacin, or ofloxacin.
Alternative first line (if unable to take fluoroquinolones): trimethoprim.

Oral second line (on specialist advice):
Levofloxacin, or co-trimoxazole.

Intravenous first line (if severely unwell or unable to take oral treatment). Antibacterials may be combined if concerned about sepsis.
Amikacin, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, or levofloxacin.

Question 86

What should be considered before the pyelonephritis (infection of the kidneys)?

Answer 86

An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.

Consider referring or seeking specialist advice for patients with acute pyelonephritis who are significantly dehydrated or are unable to take oral fluids and medicines, are pregnant, or have a higher risk of developing complications.

Question 87

What is the treatment (antibiotics) choice for treating pyelonephritis for non-pregnant women and men?

Answer 87

Oral first line:
Cefalexin, or ciprofloxacin. If sensitivity known: co-amoxiclav, or trimethoprim.
Intravenous first line (if severely unwell or unable to take oral treatment). Antibacterials may be combined if concerned about susceptibility or sepsis.

Amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin. Co-amoxiclav may be used if given in combination or sensitivity known.

Intravenous second line:
Consult local microbiologist.

Question 88

What is the treatment (antibiotics) choice for treating pyelonephritis for pregnant women?

Answer 88

Oral first line:
Cefalexin.

Intravenous first line (if severely unwell or unable to take oral treatment):
Cefuroxime.

Second line or combining antibacterials if concerned about susceptibility or sepsis:
Consult local microbiologist.

Question 89

For recurrent UTIs in non-pregnant women what can you consider?

Answer 89

In non-pregnant women, consider a trial of antibacterial prophylaxis if behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or appropriate.

Single-dose antibacterial prophylaxis [unlicensed indication] should be considered for use when exposed to an identifiable trigger. Daily antibacterial prophylaxis should be considered in non-pregnant women who have had no improvement after single-dose antibacterial prophylaxis, or who have no identifiable triggers.

Question 90

If on antibacterial prophylaxis for UTI, within how many months should the patient return for a review?

Answer 90

Within 6 months

Question 91

Which antibiotics can be used as prophylaxis for men and women?

Answer 91

Oral first line:
Trimethoprim, or nitrofurantoin.

Oral second line:
Amoxicillin [unlicensed indication], or cefalexin.

Question 92

What should you consider for a patient with a catheter associated urinary tract infection?

Answer 92

onsider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days, without delaying antibacterial treatment

An immediate antibacterial prescription should be given and a urine sample obtained before treatment is taken and sent for culture and susceptibility testing

Question 93

For non pregnant women and men what is the antibiotic treatment for UTIs associated with catheters?

Answer 93

Oral first line (if no upper UTI symptoms):
Amoxicillin (only if culture susceptible), nitrofurantoin, or trimethoprim (if low risk of resistance).

Oral second line (if no upper UTI symptoms and first-line not suitable):
Pivmecillinam hydrochloride.

Oral first line (upper UTI symptoms):
Cefalexin, ciprofloxacin, co-amoxiclav (if culture susceptible), or trimethoprim (if culture susceptible).

Intravenous first line (if severely unwell or unable to take oral treatment). Antibacterials may be combined if concerned about susceptibility or sepsis.
Amikacin, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, or co-amoxiclav (only in combination, unless culture results confirm susceptibility).

Question 94

For pregnant women what is the antibiotics of choice for UTI associated with catheter?

Answer 94

Oral first line:
Cefalexin.

Intravenous first line (if severely unwell or unable to take oral treatment):
Cefuroxime.

Question 95

What type of drug is methanamine hippurate?

Answer 95

Antibacterial

Question 96

What are the indications of methanamine hippurate?

Answer 96

prophykaxis and long term treatment of chronic or recurrent uncomplicated lower urinary-tract infections
and also in patients with catheters

Question 97

Is methanamine hippurate suitable for use in upper tract infections?

Answer 97

No

Question 98

Can nitrofurantoin be used in renal impairment?

Answer 98

Avoid if eGFR less than 45ml/min/1.73m2 may be used with caution if eGFR 30-44ml/min/1.73m2 as a short course only (3 - 7 days) to treat uncomplicated lower urinary tract infection.

Question 99

A urine sample should be collected for culture and sensitivity testing before starting treatment in which patients?

Answer 99

• Men
• Pregnant women
• children under 3
• Suspected upper UTI
• If resistant organisms are suspected

Question 100

Once a sample has been taken, can treatment begin while waiting for test results?

Answer 100

Yes

Question 101

For women uncomplicated Lower UTI - how long is the treatment?

Answer 101

Usually 3 days

pregnant women - 7 days

Question 102

What is the treatment and suggested duration for acute pyelonephritis?

Answer 102

• Acute Pyelonephritis can lead to septicaemia and is treated initially by injection of a broad-spectrum antibacterial e.g. cephalosporin, quinolone or gentamicin. Suggested duration of treatment is 10-14 days

Question 103

What is the duration treatment for prostatitis?

Answer 103

• Prostatitis can be difficult to cure and requires treatment for several weeks with an antibacterial that penetrates the prostatic tissue e.g. quinolone like ciprofloxacin or trimethoprim. Suggested duration of treatment is 28 days.

Question 104

In pregnancy which antibiotics are useful and safe to use for UTIs?

Answer 104

In pregnancy Penicillin’s and Cephalosporins can be used but avoid Nitrofurantoin during 3rd Trimester and Trimethoprim during 1st Trimester.

Question 105

What is the treatment of choice for aspergillosis (fungal infection)?

Answer 105

Variconazole

Liposomal amphotericin B is an alternative first-line treatment when voriconazole cannot be used.

Caspofungin, or itraconazole, can be used in patients who are refractory to, or intolerant of voriconazole

Question 106

What is posaconazol licensed for?

Answer 106

Posaconazole is licensed for use in patients with invasive aspergillosis who are refractory to, or intolerant of itraconazole or amphotericin B.

Question 107

What are the options for vaginal candidiasis?

Answer 107

Vaginal candidiasis may be treated with locally acting antifungals or with fluconazole given by mouth; for resistant organisms in adults, itraconazole can be given by mouth.

Question 108

What are the options for oropharyngeal candidiasis?

Answer 108

Oropharyngeal candidiasis generally responds to topical therapy; fluconazole is given by mouth for unresponsive infections; it is effective and is reliably absorbed. Itraconazole may be used for infections that do not respond to fluconazole. Topical therapy may not be adequate in immunocompromised patients and an oral triazole antifungal is preferred.

Question 109

What should be considered for the initial treatment of CND candidiasis?

Answer 109

Amphotericin B

Question 110

Which antifungal can be used for infections caused by fluconazole-resistant Candida spp.?

Answer 110

Voriconazole can be used for infections caused by fluconazole-resistant Candida spp. when oral therapy is required, or in patients intolerant of amphotericin B or an echinocandin.

Question 111

Is cryptococcosis common?

Answer 111

Cryptococcosis is uncommon but infection in the immunocompromised, especially in HIV-positive patients, can be life-threatening; cryptococcal meningitis is the most common form of fungal meningitis

Question 112

What is the treatment choice in cryptococcal meningitis?

Answer 112

Amphotericin B by intravenous infusion and flucytosine by intravenous infusion for 2 weeks, followed by fluconazole by mouth for 8 weeks or until cultures are negative.

Question 113

In cryptococcosis can fluconazole be used as an alternative?

Answer 113

In cryptococcosis, fluconazole is sometimes given alone as an alternative in HIV-positive patients with mild, localised infections or in those who cannot tolerate amphotericin B. Following successful treatment, fluconazole can be used for prophylaxis against relapse until immunity recovers.

Question 114

What is the treatment for histoplasmosis?

Answer 114

Itraconazole can be used for the treatment of immunocompetent patients with indolent non-meningeal infection, including chronic pulmonary histoplasmosis.

Amphotericin B by intravenous infusion is used for the initial treatment of fulminant or severe infections, followed by a course of itraconazole by mouth. Following successful treatment, itraconazole can be used for prophylaxis against relapse until immunity recovers.

Question 115

What is infection of the nails known as?

Answer 115

• Onchomycosis

Question 116

What is a fungal infection of the scalp known as?

Answer 116

• Tinea Capitis

Question 117

Why are oral imidazole or triazole antifungals (particularly itraconazole) used for systemic skin and nail infections?

Answer 117

Oral imidazole or triazole antifungals (particularly itraconazole) and terbinafine are used more frequently than griseofulvin because they have a broader spectrum of activity and require a shorter duration of treatment.

Question 118

What is the treatment for tinea capitis?

Answer 118

Tinea capitis is treated systemically; additional topical application of an antifungal may reduce transmission. Griseofulvin is used for tinea capitis in adults and children; it is effective against infections caused by Trichophyton tonsurans and Microsporum spp. Terbinafine is used for tinea capitis caused by T. tonsurans [unlicensed indication]. The role of terbinafine in the management of Microsporum infections is uncertain.

Question 119

For tine infection of the nails what is used?

Answer 119

Antifungal treatment may not be necessary in asymptomatic patients with tinea infection of the nails. If treatment is necessary, a systemic antifungal is more effective than topical therapy.

Question 120

What is the drug of choice for onychomycosis?

Answer 120

terbenafine

Terbinafine and itraconazole have largely replaced griseofulvin for the systemic treatment of onychomycosis, particularly of the toenail

Question 121

For immunocompromised patients due to increased risk of fungal infections what is the drug of choice for prophylactic antifungal therapy?

Answer 121

Oral triazole antifungals are the drug of choice for prophylaxis

Question 122

Is fluconazole or itraconazole more reliably absorbed?

Answer 122

Fluconazole, but fluconazole is not effective against Aspergillus spp.

Question 123

When is itraconazole preferred?

Answer 123

Itraconazole is preferred in patients at risk of invasive aspergillosis

Question 124

Name the triazole antifungals?

Answer 124

Fluconazole
Itraconazole
Posaconazole
Voriconazole

Question 125

Does fluconazole penetrate the cerebrospinal fluid?

Answer 125

achieves good penetration into the cerebrospinal fluid to treat fungal meningitis.

Question 126

Can fluconazole be used to treat candiduria?

Answer 126

Fluconazole is excreted largely unchanged in the urine and can be used to treat candiduria.

Question 127

What environment in the stomach do itraconazole require?

Answer 127

. Itraconazole capsules require an acid environment in the stomach for optimal absorption.

Question 128

What has itraconazole been associated with?

Answer 128

With liver damage and should be avoided or used in caution in patients with liver disease

Question 129

Which is more frequently associated with liver disease - fluconazole or itraconazole?

Answer 129

Fluconazole

Question 130

What is posaconazole licensed for?

Answer 130

is licensed for the treatment of invasive fungal infections unresponsive to conventional treatment.

Question 131

When is voriconazole used?

Answer 131

Voriconazole is a broad-spectrum antifungal drug which is licensed for use in life-threatening infections.

Question 132

List the imidazole antifungals?

Answer 132

clotrimazole, econazole nitrate, ketoconazole, and tioconazole.
Miconazole

Question 133

List the polyene antifungals?

Answer 133

• amphotericin B and Nystatin

Question 134

Are polyene antifungals absorbed when given by mouth?

Answer 134

No neither of them are

Question 135

What are the uses of nystatin?

Answer 135

Nystatin is used for oral, oropharyngeal, and perioral infections by local application in the mouth. Nystatin is also used for Candida albicans infection of the skin.

Question 136

When is amphotericin B used?

Answer 136

Amphotericin B by intravenous infusion is used for the treatment of systemic fungal infections and is active against most fungi and yeasts.

Question 137

why doesnt amphotericin B penetrate well into body fluids and tissues?

Answer 137

It is highly protein bound and penetrates poorly into body fluids and tissues. When given parenterally amphotericin B is toxic and side-effects are common.

Question 138

What formulations of amphotericin B are significantly less toxic?

Answer 138

Lipid formulations

Question 139

List the enchinocandin antifungals?

Answer 139

anidulafungin, caspofungin and micafungin.

Question 140

Are enchinocandins effective against fungal infections of the CNS?

Answer 140

No

Question 141

which drug is flucytosine used with?

Answer 141

Amophotericin B in a synergistic combination

Question 142

What limits the use of flucytosine?

Answer 142

Bone marrow depression can occur which limits its use, particularly in HIV-positive patients; weekly blood counts are necessary during prolonged therapy.

Resistance to flucytosine can develop during therapy and sensitivity testing is essential before and during treatment

Question 143

What role does flucytosine have?

Answer 143

. Flucytosine has a role in the treatment of systemic candidiasis and cryptococcal meningitis.

Question 144

What is Griseofulvin used for?

Answer 144

Use has reduced alot due to newer antifungals.

It is the drug of choice for trichophyton infections in children. Duration of therapy is dependent on the site of the infection and may extend to a number of months.

Question 145

What is the drug of choice for fungal nail infections?

Answer 145

Terbinafine and is also used for ringworm infections where oral treatment is considered appropriate

Question 146

Can fluconazole be given in pregnancy

Answer 146

No - avoid

Question 147

Which drugs may fluconazole interact with?

Answer 147

It may interact with statins, warfarin, diazepam, phenytoin and theophylline (all effects are increased).

Question 148

Does amphotericin need to be prescribed by brand?

Answer 148

Yes since formulations are not interchangable

Question 149

To use amphotericin what must be given first?

Answer 149

A test dose

Question 150

Who does pneumocytis pneumonia occur in?

Answer 150

Pneumonia caused by Pneumocystis jirovecii (Pneumocystis carinii) occurs in immunosuppressed patients; it is a common cause of pneumonia in AIDS.

Question 151

What is used to assess disease severity of pneumocystis pneumonia?

Answer 151

Blood gas measurement

Question 152

What is the treatment for mild to moderate disease of pneumocystis pneumonia?

Answer 152

Co-trimoxazole in high dosage is the drug of choice for the treatment of mild to moderate pneumocystis pneumonia.

Atovaquone is licensed for the treatment of mild to moderate pneumocystis infection in patients who cannot tolerate co-trimoxazole. A combination of dapsone with trimethoprim is given by mouth for the treatment of mild to moderate disease [unlicensed indication].

A combination of clindamycin and primaquine by mouth is used in the treatment of mild to moderate disease [unlicensed indication]; this combination is associated with considerable toxicity.

Question 153

What is the treatemtn of pneumocystis pneumonia for severe disease?

Answer 153

Co-trimoxazole in high dosage, given by mouth or by intravenous infusion, is the drug of choice for the treatment of severe pneumocystis pneumonia.

Pentamidine isetionate given by intravenous infusion is an alternative for patients who cannot tolerate co-trimoxazole, or who have not responded to it

Question 154

What side effect can pentamidine cause?

Answer 154

Pentamidine isetionate is a potentially toxic drug that can cause severe hypotension during or immediately after infusion.

Question 155

Which class of drug may be life saving in those with severe pneumocystis pneumonia?

Answer 155

Corticosteroid

Question 156

Which corticosteroids are given as adjunctive therapy?

Answer 156

In moderate to severe infections associated with HIV infection, prednisolone is given by mouth for 5 days (alternatively, hydrocortisone may be given parenterally); the dose is then reduced to complete 21 days of treatment. Corticosteroid treatment should ideally be started at the same time as the anti-pneumocystis therapy and certainly no later than 24–72 hours afterwards. The corticosteroid should be withdrawn before anti-pneumocystis treatment is complete.

Question 157

Who should prophylaxis against pneumocystis pneumonia be given to?

Answer 157

Prophylaxis against pneumocystis pneumonia should be given to all patients with a history of the infection.

Question 158

What is the drug choice for prophylaxis of pneumocystis pneumonia?

Answer 158

Co-trimoxazole

It is given daily or on alternate days (3 times a week); the dose may be reduced to improve tolerance.

Question 159

Which is better tolerated - pentamidine inhaled or parenteral pentamidine?

Answer 159

Inhaled is better tolerated

Question 160

In patients unable to tolerate co-trimoxazole - which drug is used for prophylaxis of pneumocystis pneumonia?

Answer 160

• Intermittent inhalation of pentamidine isetionate

Question 161

Pentamidine is effect for prophylaxis but may cause extrapulmonary infection, which other drug can be used as an alternative?

Answer 161

• Dapsone

Question 162

Which drug class does pentamidine belong to?

Answer 162

Antiprotozoals

Question 163

Which class of drugs are effective in treating threadworms and what does it needs to be done in combination with this?

Answer 163

Anthelmintics are effective in threadworm (pinworms, Enterobius vermicularis) infections, but their use needs to be combined with hygienic measures to break the cycle of auto-infection

Question 164

For treating threadworms, does only the infected individual need to be treated or everyone in the family?

Answer 164

All members of the family require treatment.

Question 165

Adult threadworms do not live longer than how many weeks?

Answer 165

6 weeks

Question 166

Where do adult female worms lay ova?

Answer 166

On the perianal skin which causes pruritus; scratching in the area then leads to ova being transmitted on fingers to mouth, often via food eaten with unwashed hands.

Question 167

what is essential advice to do to prevent and to break the cycle?

Answer 167

ashing hands and scrubbing nails before each meal and after each visit to the toilet is essential.
A bath taken immediately after rising will remove ova laid during the night.

Question 168

What is the drug of choice to treat threadworm infection in patients of all ages over 6 months?

Answer 168

Mebendazole - single dose

Question 169

As reinfection of threadworm is very common, when may a second dose be given?

Answer 169

After 2 weeks.

Question 170

Which is the drug of choice for common roundworm infections?

Answer 170

Mebendazole is effective against Ascaris lumbricoides and is generally considered to be the drug of choice.

Levamisole [unlicensed] (available from ‘special-order’ manufacturers or specialist importing companies) is an alternative when mebendazole cannot be used. It is very well tolerated.

Question 171

can mebendazole be used in pregnant women?

Answer 171

No

Question 172

What is the OTC licensing age of mebendazole?

Answer 172

2 years and over

Question 173

What should the choice of drug for prophylaxis of malaria for a particular individual take into account?

Answer 173

• Risk of exposure to malaria
• Extent of drug resistance
• Efficacy of the recommended drugs
• side effects of the drugs
• patient-related factors (e.g. age, pregnancy, renal or hepatic impairment, compliance with prophylactic regimen)

Question 174

Is protection against prophylaxis of malaria 100% effective?

Answer 174

Prophylaxis is not absolute, and breakthrough infection can occur with any of the drugs recommended.

Question 175

Is personal protection against bite important?

Answer 175

Personal protection against being bitten is very important and is recommended even in malaria-free areas as a preventive measure against other insect vector-borne diseases.

Question 176

Which pyrethroid insecticide may help?

Answer 176

Mosquito bed nets impregnated with a pyrethroid insecticide (such as permethrin), improve protection and should be used unless sleeping in a well screened room, or the room is fitted with functioning air conditioning and sufficiently well sealed into which mosquitoes cannot enter; vaporised insecticides are also useful.

Question 177

What other advice can be given to provide protection against mosquito biteS?

Answer 177

Long sleeves, long trousers, and socks worn after sunset also provide protection against bites.

Question 178

What formulation is available (ingredient) which gives protection against insect bites?

Answer 178

Diethyltoluamide (DEET) is available in various preparations, including sprays and modified-release formulations.

Question 179

What % DEET based repellent is recommended as first choice?

Answer 179

A 50% DEET-based insect repellent is recommended as the first choice; there is no further increase in duration of protection beyond a DEET concentration of 50%

Question 180

DEET is safe to apply in adults and children over what age?

Answer 180

Children over 2 months of age

Question 181

Can DEET be used during pregnancy and breast feeding?

Answer 181

Yes, However, ingestion should be avoided, therefore breast-feeding mothers should wash their hands and breast tissue before handling infants.

Question 182

When sunscreen is also needed to be applied, which do you apply firsrt sunscreen or DEET?

Answer 182

When sunscreen is also required, DEET should be applied after the sunscreen

Question 183

Does DEET increase or decrease the SPF of sunscreen?

Answer 183

DEET reduces the SPF of sunscreen, so a sunscreen of SPF 30–50 should be applied.

Question 184

How long before travel chloroquine and proguanil be used?

Answer 184

1 week before travel

Question 185

How long before travel should mefloquine be used?

Answer 185

2-3 weeks before trave;

Question 186

How long before travel should atovaquone with proguanil or doxycycline be used?

Answer 186

1-2 days before travel

Question 187

Prophylaxis should continue for how many weeks after leaving the area?

Answer 187

4 weeks after leaving the area (except for atovaquone with proguanil hydrochloride prophylaxis which should be stopped 1 week after leaving)

Question 188

In those requiring long term prophylaxis of malaria which drugs can be used?

Answer 188

Chloroquine and proguanil

Question 189

Mefloquine is licensed for use up to how long?

Answer 189

use up to 1 year (although, if it is tolerated in the short term, there is no evidence of harm when it is used for up to 3 years).

Question 190

How long can doxycycline be used up to for malaria prophylaxis?

Answer 190

Doxycycline can be used for up to 2 years

Question 191

How long can atovaquone with proguanil be used for?

Answer 191

For up to 1 year

Question 192

I important to consider that any illness that occurs within how long might indicate malaria?

Answer 192

any illness that occurs within 1 year and especially within 3 months of return

Question 193

Is malaria a notifiable disease for HCPs?

Answer 193

Yes

Question 194

Which antimalarial drug is unsuitable for malaria prophylaxis in patients with history of epilepsy?

Answer 194

Both chloroquine and mefloquine are unsuitable for prophylaxis in individuals with a history of epilepsy

Question 195

Which antimalarial can be sued in patients with a history of epilepsy?

Answer 195

Doxycycline or
Atovaquone with proguanil

However, doxycycline may interact with some antiepileptics and its dose may need to be adjusted

Question 196

Are asplenic individuals at higher or lower risk for severe malaria?

Answer 196

Asplenic individuals (or those with severe splenic dysfunction) are at particular risk of severe malaria. If travel to malarious areas is unavoidable, rigorous precautions are required against contracting the disease.

Question 197

Which antimalarial can be used in prophylaxis in pregnant women?

Answer 197

Chloroquine and proguanil but these drugs are not appropriate for most areas because their effectiveness has declined.

Question 198

When proguanil is being used in pregnancy which other drug should be given with it?

Answer 198

folic acid (dosed as a pregnancy at ‘high-risk’ of neural tube defects) should be given for the length of time that it is used during pregnancy.

Question 199

If travelling to high risk areas or there is resistance to the other drugs (chloroquine or proguanil for pregnant women) then which drug can be used?

Answer 199

mefloquine may be considered during the second or third trimester of pregnancy.

Mefloquine can be used in the first trimester with caution if the benefits outweigh the risks

Question 200

Can doxycycline be used for antimalaria in pregnancy?

Answer 200

it is CI in pregnancy,
however, it can be used for malaria prophylaxis if other regimens are unsuitable, and if the entire course of doxycycline can be completed before 15 weeks’ gestation.

Question 201

Is prophylaxis required in breast-fed infants if the mother is receiving antimalaria prophylaxis?

Answer 201

Yes they are still required to be on prophylaxis treatment; although the antimalarials are present in milk; the amounts are too variable to give reliable protection

Question 202

What must be noted for travellers on warfarin?

Answer 202

Travellers taking warfarin sodium should begin chemoprophylaxis 2–3 weeks before departure and the INR should be stable before departure.

It should be measured before starting chemoprophylaxis, 7 days after starting, and after completing the course.

For prolonged stays, the INR should be checked at regular intervals.

Question 203

What should travellers visiting remote malarious areas carry?

Answer 203

should carry standby emergency treatment if they are likely to be more than 24 hours away from medical care.

Standby emergency treatment should also be considered in long-term travellers living in or visiting remote, malarious areas that may be far from appropriate medical attention; this does not replace the need to consider prophylaxis.

Question 204

In order to use standby treatment appropriately, what should the traveller be provided with?

Answer 204

should be provided with written instructions which include seeking urgent medical attention if fever (38°C or more) develops 7 days (or more) after arriving in a malarious area and that self-treatment is indicated if medical help is not available within 24 hours of fever onset.

Question 205

What should be noted for those that have migrated from a malarious country to the UK

Answer 205

Settled immigrants (or long-term visitors) in the UK may be unaware that any immunity they may have acquired while living in malarious areas is lost rapidly after migration to the UK, or that any non-malarious areas where they lived previously may now be malarious.

Question 206

How many codes for regimens are there for prophylaxis of malaria used for ranking risk in coutries?

Answer 206

4

Question 207

What are the different code regimens?

Answer 207

• No risk

1 = chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever present

2 = chloroquine only (very rare)

3 = (Risk present) chloroquine with proguanil

4 = (High risk) Atovaquone with proguanil or doxycycline or mefloquine

Question 208

For the treatment of malaria - if infective species is not known, or if the infection is mixed and includes falciparum parasites then what must initial treatment be treated as?

Answer 208

initial treatment should be as for falciparum malaria.

Question 209

Falciparum malaria is caused by which organism?

Answer 209

Plasmodium falciparum

Question 210

Patients with falciparum malaria should usually be admitted where?

Answer 210

usually be admitted to hospital initially due to the risk of rapid deterioration even after starting treatment.

Question 211

what is the treatment for falciparum malaria?

Answer 211

Artemisinin combination therapy is recommended for the treatment of uncomplicated P. falciparum malaria.

Artemether with lumefantrine is the drug of choice;

artenimol with piperaquine phosphate is a suitable alternative.

Oral quinine or atovaquone with proguanil hydrochloride can be used if an artemisinin combination therapy is not available

Question 212

Can quinine be used in prolonged treatment?

Answer 212

Quinine is highly effective but poorly-tolerated in prolonged treatment and should be used in combination with an additional drug, usually oral doxycycline (or clindamycin [unlicensed] in pregnant women and young children).

Question 213

In most parts of the world, P.falciparum is now resistant to which antimalarial drug?

Answer 213

Chloroquine which should not therefore be used for treatment of malaria

Question 214

why is mefloquine no longer recommended for treatment of maria?

Answer 214

Mefloquine is also no longer recommended for treatment because of concerns about adverse effects and non-completion of courses.

Question 215

What organism is non-falciparum malaria usually caused by?

Answer 215

Plasmodium Vivax and less commonly by P. ovale, P. malariae, and P. knowlesi. P. knowlesi is present in the Asia-Pacific region.

Question 216

What should be sued for treatment of non-falciparum malaria?

Answer 216

Either an artemisinin combination therapy (such as artemether with lumefantrine or artenimol with piperaquine phosphate) or chloroquine can be used for the treatment of non-falciparum malaria.

Question 217

What should patients be screened for before initiating primaquine?

Answer 217

Patients should be screened for G6PD deficiency before initiating primaquine treatment, as primaquine may cause haemolysis in G6PD deficient individuals.

Question 218

Which drug can be used in pregnancy for non-falciparum malaria treatment?

Answer 218

Chloroquine can be given for non-falciparum malaria treatment throughout pregnancy

Artemisinin combination therapy can be used in the second and third trimesters, and quinine may be used in the first trimester if there is concern about chloroquine-resistant P. vivax.

In the case of P. vivax or P. ovale however, the radical cure with primaquine should be postponed until the pregnancy (and breast-feeding) is over; instead weekly chloroquine prophylaxis should be continued until delivery or completion of breast-feeding.

Question 219

To summarise which two antimalarials are not suitable in history of epilepsy?

Answer 219

• Mefloquine and chloroquine

Question 220

What type of malaria can chloroquine be used to treat?

Answer 220

It is no longer recommended for the treatment of falciparum malaria due to widespread resistance.
- But it is still recommended for the treatment of non-falciparum malaria.

Question 221

What caution is required for mefloquine - what has it been associated with?

Answer 221

Associated with serious neuropsychiatric reactions

Question 222

What other side effects may occur with mefloquine?

Answer 222

• dreams, insomnia, anxiety and depression

Adverse reactions may occur and persist for several months after discontinuation due to the long half-life of the drug.

Question 223

What is malarone a combination of?

Answer 223

Atovaquone and proguanil

Question 224

Which type of malaria is malarone licensed to treat?

Answer 224

Acute flaciparum malaria

Question 225

Why is malrone (atovaquone and proguanil) suitable for short trips to chloroquine resistant areas?

Answer 225

It only needs to be taken for 7 days after leaving an endemic area

Question 226

Is quinine suitable for prophylaxis of malaria?

Answer 226

No it is not suitable but can be used for the treatment of falciparum malaria, for malaria caused by unknown species and for mixed species.

Question 227

Is quinin bisulphate dose equivalent to quinine hydrochloride, dihydrochloride and sulphate?

Answer 227

doses are valid for quinine hydrochloride, dihydrochloride and sulphate. They are not valid for quinine bisulphate which contains a smaller amount of quinine.

Question 228

For malarone and doxycycline how long before travel should malaria prophylaxis start?

Answer 228

1-2 days before

Question 229

How long should prophylaxis generally be continued after leaving the endemic area?

Answer 229

4 weeks except for malrone which should be stopped 1 week after leaving

Question 230

Which antimalarials can be used in pregnancy?

Answer 230

Chloroquine and proguanil

Question 231

If proguanil is used for prophylaxis then what must be given alongside it?

Answer 231

Folic acid - high risk dose

Question 232

Can malarone be given during pregnancy?

Answer 232

• Malarone should be avoided during pregnancy but it can be considered during 2nd and 3rd trimester if there is no suitable alternative

Question 233

How long before travel should patient taken warfarin begin their prophylaxis for malaria?

Answer 233

2-3 weeks before

Question 234

When is promaquine given?

Answer 234

It is given after chloroquine to destroy parasites in the liver + thus prevetn relapses. in the treatment non-falciparum malaria

Question 235

What about in the treatment of non-falciparum malaria treatment in pregnancy?

Answer 235

The adult treatment doses of chloroquine can be given during pregnancy, however the radical cure with Primaquine should be postponed until pregnancy is over.

Question 236

What is Riamet a combination of?

Answer 236

Artemether with lumefantrine

• used for treatment of acute uncomplicated falciparum malaria

Question 237

Is chloroquine or hydroxychloroquine more retinotoxic?

Answer 237

Chloroquine

Question 238

What dose-dependent effect has quinine be associated with?

Answer 238

Quinine has been associated with dose-dependent QT-interval-prolonging effects and should be used with caution in patients with risk factors for QT prolongation or in those with atrioventricular block.

Question 239

What is the drug of choice for acute amoebic dysentery?

Answer 239

Metronidazole is drug of choice

Tinidazole is also effective

Treatment with metronidazole (or tinidazole) is followed by a 10-day course of diloxanide furoate.

Question 240

What is the drug of choice for asymptomatic patients with E.histolytica custs in the faeces?

Answer 240

Diloxanide furoate

metronidazole and tinidazole are relatively ineffective

Diloxanide furoate is relatively free from toxic effects and the usual course is of 10 days, given alone for chronic infections or following metronidazole or tinidazole treatment.

Question 241

What is the drug of choice for Trichomonas vaginalis infection?

Answer 241

Metronidazole

Contact tracing is recommended and sexual contacts should be treated simultaneously

If metronidazole is ineffective then tinidazole may be tried.

Question 242

What is the treatment of choice for Giardia lamblia?

Answer 242

Metronidazole

Question 243

Do most infections caused by Toxoplasma gondii require treatment?

Answer 243

Most infections caused by Toxoplasma gondii are self-limiting, and treatment is not necessary.

Exceptions are patients with eye involvement (toxoplasma choroidoretinitis), and those who are immunosuppressed.

Question 244

Toxoplasmic encephalitis is a common complication of which medical condition?

Answer 244

AIDs

Question 245

What is the treatment of choice for toxoplasmosis?

Answer 245

The treatment of choice is a combination of pyrimethamine and sulfadiazine, given for several weeks (expert advice essential). Pyrimethamine is a folate antagonist, and adverse reactions to this combination are relatively common (folinic acid supplements and weekly blood counts needed

Question 246

What are the common symptoms of COVID-19?

Answer 246

new continuous cough, loss or change in sense of smell or taste, loss of appetite, shortness of breath, and fatigue. Other symptoms, such as muscle aches, headache, sore throat, nasal congestion, nausea and vomiting, diarrhoea, chest pain, and skin rashes may also be present.

Question 247

Long COVID is symptoms that persist for how many weeks?

Answer 247

More than 4 weeks

Question 248

Individuals with COVID-19 have an increased risk of what?

Answer 248

Venous thromboembolism (VTE)

Question 249

Who should dexamethasone be offered to in COVID-19 management?

Answer 249

Dexamethasone should be offered to patients with COVID‑19 who need supplemental oxygen, or who have a level of hypoxia that requires supplemental oxygen but are unable to have or tolerate it. If dexamethasone is unsuitable or unavailable, either hydrocortisone or prednisolone can be used.

Question 250

Which monoclonal antibody can be used in the management of COVID-19?

Answer 250

Tocilizumab (a monoclonal antibody against interleukin-6)

Question 251

What are some of the other treatment options of COVID-19?

Answer 251

include antivirals (such as remdesivir, or molnupiravir, or a combination of nirmatrelvir with ritonavir), or SARS-CoV‑2 neutralising monoclonal antibodies (such as sotrovimab, or a combination of casirivimab with imdevimab).

Question 252

Are antibacterials recommended for preventing or treating pneumonia if it is likely to be caused by SARS-CoV-2, another virus or a fungal infection?

Answer 252

No

Question 253

When should antibiotics be used in COVID-19?

Answer 253

Empirical antibacterials should be started if a secondary bacterial infection is suspected in patients with COVID‑19

Question 254

should patients with cough be encouraged to lay down on their backs?

Answer 254

Patients with a cough should be encouraged to avoid lying on their backs, if possible, because this may make coughing less effective.

Question 255

What can be used for cough associated with COVID-19?

Answer 255

Cough should be initially managed using simple non-drug measures (such as honey). For cough that is distressing in a patient with COVID‑19, consider short-term use of a cough suppressant (such as codeine phosphate or morphine).

Question 256

Can patients with COVID-19 take ibuprofen or paracetamol?

Answer 256

Patients with fever should be advised to drink fluids regularly to avoid dehydration, and to take antipyretics (such as paracetamol or ibuprofen) as appropriate (whilst both fever and other symptoms that antipyretics would help treat are present)

Question 257

Which drugs are options for treatment of hepatitis B?

Answer 257

Entecavir, peginterferon alfa, tenofovir alafenamide, and tenofovir disoproxil are options for the treatment of chronic hepatitis B infection.

Question 258

Which of the previous drugs can be used to treat hep B for patients with decompensated liver disease?

Answer 258

Entecavir and tenofovir disoproxil

Question 259

What should you do if drug resistance emerges?

Answer 259

If drug-resistance emerges during treatment, consider switching to, or adding another antiviral drug to which the virus is sensitive; ensure the antiviral drug does not share cross-resistance.

Question 260

before starting treatment for hep C, what should be determined?

Answer 260

the genotype of the infecting hepatitis C virus should be determined and the viral load measured as this may affect the choice and duration of treatment.

Question 261

Give an example of a nucleoside reverse transcriptase inhibitor that is used in Hep B treatment?

Answer 261

Tenofovir alafenamide

Question 262

Give an example of a nucleotide analogue used in Hep B treatment?

Answer 262

Adefovir Dipivoxil

Question 263

Give an example of a nucleoside analgoue used in Hep C treatment?

Answer 263

Ribavirin

Question 264

What is herpes infection of the mouth and lips and in the ye generally associated with?

Answer 264

With herpes simplex virus serotype 1 (HSV-1); other areas of the skin may also be affected, especially in immunodeficiency

Question 265

What type of herpes is genital infection associated with?

Answer 265

most often associated with HSV-2 and also HSV-1.

Question 266

It topical antiviral treatment routinely recommended in immunocompetent individuals with uncomplicated infection of the lips (herpes labialis or cold sores) or herpetic gingivostomatitis?

Answer 266

No

Question 267

For herpes simplex can oral paracetamol and/or ibuprofen be given to relieve pain?

Answer 267

Yes

Question 268

What formulation is primary or recurrent genital herpes simplex infection treated with?

Answer 268

oral - given by mouth

Question 269

Can ocular herpes simplex be treated the same way?

Answer 269

No - if suspected they should be referred for urgent same day specialist referral.

Question 270

Does herpes simplex in pregnancy require referral?

Answer 270

Yes

Question 271

Give an example of a varicella-zoster infection?

Answer 271

Chicken pox - which is an acute disease caused by the varicella-zoster virus.

Question 272

When is chickenpox more severe?

Answer 272

In neonates - can cause complications

Adolescents (14 years and over) and in adults.

Question 273

In this high severity patients what may be considered?

Answer 273

Antiviral treatment started within 24 hours of the onset of rash may be considered, particularly for those with severe infection or at risk of complications.

Question 274

Which virus is shingles caused by?

Answer 274

herpes zoster

Question 275

What is shingles?

Answer 275

Shingles (herpes zoster) is a viral infection of an individual nerve and the skin surface affected by the nerve.

The infection is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox.

Question 276

Who should oral antiviral treatment for shingles be given to?

Answer 276

Oral antiviral treatment should be offered to patients with shingles who are immunocompromised, have non-truncal involvement (e.g. neck, limbs, perineum), or to those with moderate to severe pain or rash. Consider oral antiviral treatment for patients aged over 50 years to reduce the risk of post-herpetic neuralgia.

Question 277

For shingles, how long within should treatment with antiviral start?

Answer 277

Treatment with the antiviral should be started within 72 hours of the onset of rash.

Question 278

Is aciclovir active aginst herpes viruses?

Answer 278

Aciclovir is active against herpesviruses but does not eradicate them

Question 279

What are some uses of aciclovir?

Answer 279

Uses of aciclovir include systemic treatment of varicella-zoster and the systemic and topical treatment of herpes simplex infections of the skin and mucous membranes. Aciclovir eye ointment is licensed for herpes simplex infections of the eye.

Question 280

What can famciclovir be used for?

Answer 280

Famciclovir, a prodrug of penciclovir, is similar to aciclovir and may be used in the treatment of herpes zoster (shingles) and genital herpes.

Question 281

What is the uses of valaciclovir?

Answer 281

Valaciclovir is an ester of aciclovir, which may be used in the treatment of herpes zoster and herpes simplex infections of the skin and mucous membranes (including genital herpes); it is also licensed for preventing cytomegalovirus disease following solid organ transplantation.

Question 282

Which group of viruses does cytomegalovirus (CMV) belong to?

Answer 282

Cytomegalovirus (CMV) is a member of the herpesvirus group

Question 283

Does CMV show symptoms in every patients?

Answer 283

In immunocompetent patients, CMV infection is often asymptomatic and self-limiting therefore treatment is not always required.

In immunocompromised patients, such as those with AIDS and transplant recipients, the infection manifests more severely causing diseases associated with greater morbidity and mortality.

Question 284

Which drugs are licensed for use in the management of CMV disease?

Answer 284

Drugs licensed for use in the management of CMV disease include ganciclovir (related to aciclovir), cidofovir, foscarnet sodium, letermovir, valaciclovir, and valganciclovir (an ester of ganciclovir). There is a possibility of ganciclovir resistance in those who repeatedly have a poor treatment response or when viral excretion continues despite treatment.

Question 285

What type of antiviral does aciclovir belong to?

Answer 285

Nucleoside analogue

Question 286

Name other nucleoside analgoues used in herpes treatment?

Answer 286

Famciclovir (pro drug of panciclovir)

Valaciclovir

Question 287

List the drugs that can be used in cytomegalovirus infections?

Answer 287

Cidofovir
Ganciclovir
Valganciclovir
Foscarnet sodium
Letermovir

Question 288

Is aciclovir safe to take in pregnancy?

Answer 288

Yes and usually taken 5 times a day

Question 289

What is HIV?

Answer 289

The human immunodeficiency virus (HIV) is a retrovirus that causes immunodeficiency by infecting and destroying cells of the immune system, particularly the CD4 cells

Question 290

What does AIDS stand for?

Answer 290

Acquired immune deficiency syndrome

Question 291

When does AIDS occur?

Answer 291

Acquired immune deficiency syndrome (AIDS) occurs when the number of CD4 cells fall to below 200 cells/microlitre;

Question 292

Why has prognosis of HIV and AIDS greatly improved?

Answer 292

The prognosis of HIV and AIDS has greatly improved due to more effective and better tolerated antiretroviral therapy (ART).

Question 293

What does HIV treatment aim to do?

Answer 293

Treatment aims to achieve an undetectable viral load, to preserve immune function, to reduce the mortality and morbidity associated with chronic HIV infection, and to reduce onward transmission of HIV, whilst minimising drug toxicity.

Question 294

Should all patients with diagnosed HIV be offered immediate treatment?

Answer 294

All patients diagnosed as being HIV positive should be offered immediate treatment, irrespective of CD4 cell counts.

Question 295

What can low adherence to HIV treatment lead to?

Answer 295

Low adherence can be associated with drug resistance, progression to AIDS, and death.

Question 296

What is treatment of HIV infection in treatment-naive patients initiated with?

Answer 296

with a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) as a backbone regimen plus one of the following as a third drug: an integrase inhibitor (INI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a boosted protease inhibitor (PI).

Question 297

For the regimen of choice for HIV what are the options?

Answer 297

The regimen of choice contains a backbone of emtricitabine and either tenofovir disoproxil or tenofovir alafenamide. An alternative backbone regimen is abacavir and lamivudine. The third drug of choice is either atazanavir or darunavir both boosted with ritonavir, or dolutegravir, or elvitegravir boosted with cobicistat, or raltegravir, or rilpivirine. Efavirenz may be used as an alternative third drug.

Question 298

What should patients who require treatment for both HIV and chronic hepatitis B be treated with?

Answer 298

with antivirals active against both diseases as part of fully suppressive combination ART.

Question 299

What are the choices of regimen in patients who require treatment for both HIV and Chronic hep B?

Answer 299

Regimens of choice are tenofovir disoproxil and emtricitabine, or tenofovir alafenamide and emtricitabine.

Question 300

Can ART be used during pregnancy?

Answer 300

Yes

Question 301

What is the recommended regimen for treating HIV in pregnant women?

Answer 301

The recommended regimen is a NRTI backbone of either tenofovir disoproxil or abacavir with either emtricitabine or lamivudine; the third drug should be efavirenz or atazanavir boosted with ritonavir.

Question 302

Can HIV positive women breastfeed?

Answer 302

No - Breast-feeding by HIV-positive mothers may cause HIV infection in the infant and should be avoided.

Question 303

What is the treatmetn for prophylaxis of HIV following potential sexual exposure to HIV?

Answer 303

The recommended treatment for post-exposure prophylaxis is emtricitabine with tenofovir disoproxil plus raltegravir for 28 days.

Question 304

Which nucleoside reverse transcriptase inhibitors (NRTI) are licensed for the treatment of HIV/AIDS?

Answer 304

abacavir (ABC); emtricitabine (FTC), lamivudine (3TC); tenofovir alafenamide fumarate (TAF), tenofovir disoproxil fumarate (TDF), and zidovudine (AZT).

Question 305

Which non-nucleoside reverse transcriptase inhibitors (NNRTI) are licensed for the treatment of HIV/AIDS?

Answer 305

doravirine (DOR), efavirenz (EFV), etravirine (ETR), nevirapine (NVP), and rilpivirine (RPV).

Question 306

Which protease inhibitors (PI) are licensed for the treatment of HIV/AIDS?

Answer 306

atazanavir (ATZ), darunavir (DRV), fosamprenavir (FOS-APV), lopinavir (LPV), ritonavir (RTV), saquinavir (SQV), and tipranavir (TPV).

Question 307

Which other drug classes are licensed to be used in treatment of HIV/AIDS?

Answer 307

CCR5 antagonists: maraviroc (MVC).

Integrase inhibitors (INI): bictegravir (BIC), cabotegravir (CAB), dolutegravir (DTG), elvitegravir (EVG), and raltegravir (RAL).

Fusion inhibitors: enfuvirtide (T-20).

Attachment inhibitors: fostemsavir (FTR).

Pharmacokinetic enhancers: cobicistat (c), and low-dose ritonavir (r). They boost the concentrations of other antiretrovirals metabolised by CYP3A4.

Question 308

To summarise, is there a cure for HIV?

Answer 308

There is no cure for infection caused by the Human Immunodeficiency Virus (HIV) but a number of drugs can slow disease progression, known as Antiretrovirals (stop the virus replicating in the body).

Question 309

treatment for HIV includes a combination of drugs known as what?

Answer 309

‘highly active antiretroviral therapy’

Question 310

Summarise the treatment for HIV?

Answer 310

• Treatment is initiated with 2 nucleoside reverse transcriptase inhibitors (usually Tenofovir + Emtricitabine) and either a non-nucleoside reverse transcriptase inhibitor (usually Efavirenz) or a boosted protease inhibitor (e.g. ritonavir) or an integrase inhibitor.

Question 311

The risk of acquiring HIVE is increased in which individuals?

Answer 311

• Men/transgender individuals who have had unprotected anal sex intercourse with men
• Sexual partners of people who are HIV-positive with a detectable viral load,
• HIV-negative heterosexual individuals who have unprotected intercourse with a HIV-positive person.

Question 312

Which antiretroviral is appropriate to use in prophylaxis of HIV?

Answer 312

Emtricitabine with Tenofovir are appropriate for pre-exposure prophylaxis to reduce the risk of sexually-acquired HIV infection.

Question 313

What is the role of ritonavir in low doses?

Answer 313

It boosts the activity of protease inhibitors - increasing their plasma concentration.

Question 314

What side effects are protease inhibitors associated with?

Answer 314

with lipodystrophy and metabolic effects

Question 315

What disorders are common with Efavirenz (NNRTI)?

Answer 315

Psychiatric and CNS disturbances

CNS disturbances are often self-limiting and can be minimised by taking the dose at bedtime.

Also associated with raised plasma-cholesterol concentration

Question 316

Is influenza highly infectious?

Answer 316

Yes

Question 317

How many types of influenza are there?

Answer 317

3 types (A,B and C)

Question 318

Which type of influenza is more virulent?

Answer 318

Influenza A and occurs more frequently

Question 319

Which is least symptomatic?

Answer 319

Influenza C - causes mild or asymptomatic disease, similar to the common cold

Question 320

How does transmission occur for influenza?

Answer 320

Transmission occurs via droplets, aerosols, or direct contact with respiratory secretions from an infected person, and the usual incubation period is 1–3 days.

Question 321

What are the symptoms of influenza?

Answer 321

Symptoms usually appear suddenly and may include chills, fever, headache, extreme fatigue, and myalgia. Dry cough, sore throat and nasal congestion may also be present.

Question 322

The risk of more serious illness caused by influenza is greater in which individuals?

Answer 322

for those in at-risk groups, such as children aged under 6 months; pregnant females (including females up to 2 weeks post-partum); adults aged over 65 years; patients with long-term conditions such as respiratory, renal, hepatic, neurological or cardiac disease, diabetes mellitus, or morbid obesity (BMI ≥ 40 kg/m²); or those with severe immunosuppression.

Question 323

Which two antivirals can be used for both the treatment and post exposure prophylaxis of influenza?

Answer 323

OZ

Oseltamivir
Zanamivir

Question 324

Which conditions of type of influenza has a higher risk of resistance to oseltamavir?

Answer 324

In general, the risk of developing oseltamivir resistance is considered to be greater for influenza A(H1N1)pdm09 compared to other strains (such as influenza A(H3N2) and influenza B), with the risk of resistance being higher in patients who are severely immunosuppressed.

Question 325

Where treatment with oseltamivir is indicated, it should be started as soon as possible, ideally within how many hours?

Answer 325

Within 48 hours of symptom onset

treatment initiation beyond 48 hours of onset is unlicensed and clinical judgement should be used.

Question 326

Where treatment with inhaled zanamivir is indicated, it should also be started as soon as possible, ideally within houw many hours?

Answer 326

8 hours (36 hours in children) of symptom onset;

treatment initiation beyond this time is unlicensed and clinical judgement should be used.

Question 327

Where treatment with intravenous zanamivir is indicated, it should be commenced as soon as possible and within how many days?

Answer 327

Within 6 days of symptom onset

Question 328

For patients who are otherwise healthy (excluding pregnant females), is antiviral treatment usually needed (uncomplicated influenza)?

Answer 328

No

Question 329

For those considered to be at serious risk of developing complication from influenza what drug should they be offerd?

Answer 329

Oseltamivir

Question 330

What about patients in at risk group (including pregnant females but excluding those who are severely immunosuppressed?

Answer 330

Offer oseltamivir - do not wait for laboratory test results to treat

Question 331

What about treatment of influenza for severely immunosuppressed patients?

Answer 331

For severely immunosuppressed patients, consider the subtype of influenza causing the infection, or if not yet known, take into account the current dominant circulating strain.

Offer oseltamivir first-line unless the strain has a higher risk for oseltamivir resistance, in which case inhaled zanamivir should be offered.

For patients unable to use inhaled zanamivir due to underlying severe respiratory disease or inability to use the device (including children under 5 years), offer oseltamivir and assess response to therapy.

Question 332

How long within should prophylaxis if required for influenza be started?

Answer 332

as soon as possible following exposure—ideally within 48 hours for oseltamivir and 36 hours for inhaled zanamivir. Initiation beyond these times is unlicensed and specialist advice should be sought.

Question 333

For patients in an at-risk group (including pregnant females but excluding severely immunosuppressed patients and children aged under 5 years), what should be offered first line for prophylaxis?

Answer 333

• Oseltamivir first line regardless of the risk of resistance of the circulating or index case strain

For patients exposed to a strain with suspected or confirmed oseltamivir resistance, offer inhaled zanamivir.

Question 334

Can oseltamivir be used for children under the age of 1? (unlicensed)

Answer 334

Yes for the treatment or post exposure of prophylaxis of influenza

Question 335

What is immune reconstitution syndrome?

Answer 335

Improvement in immune function as a result of antiretroviral treatment may provoke a marked inflammatory reaction against residual organisms. These reactions occur within the first few weeks or months of initiating treatment. Autoimmune disorders (e.g. graves’ disease) have also been reported.

Question 336

What is respiratory syncytial virus?

Answer 336

Respiratory syncytial (sin-SISH-uhl) virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious, especially for infants and older adults.

Question 337

Which drug is licensed for administration by inhalation for the treatment of severe bronchiolitis caused by the respiratory syncytial virus (RSV) in infants?

Answer 337

Ribavirin is licensed for administration by inhalation for the treatment of severe bronchiolitis caused by the respiratory syncytial virus (RSV) in infants, especially when they have other serious diseases.

However, there is no evidence that ribavirin produces clinically relevant benefit in RSV bronchiolitis.

Question 338

Which monoclonal antibody is licensed for preventing serious lower respiratory tract disease caused by respiratory syncytial virus in children at high risk of the disease?

Answer 338

Palivizumab

Question 339

Who is palivizumab recommended for?

Answer 339

recommended for:

children under 9 months of age with chronic lung disease (defined as requiring oxygen for at least 28 days from birth) and who were born preterm;
children under 6 months of age with haemodynamically significant, acyanotic congenital heart disease who were born preterm.

Question 340

Who else should palivizumab be considered for?

Answer 340

children under 2 years of age with severe combined immunodeficiency syndrome;
children under 1 year of age who require long-term ventilation;
children 1–2 years of age who require long-term ventilation and have an additional co-morbidity (including cardiac disease or pulmonary hypertension).

Question 341

With use of Linezolid what symptoms should patients report?

Answer 341

1. Severe optic neuropathy may occur rarely particularly if used for longer than 28 days. Thus, patients should report symptoms of visual impairment + visual function should be monitored regularly if treatment is for longer than 28 days.

Question 342

Why should FBC be monitored when on Linezolid?

Answer 342

2. Blood disorders (Inc. thrombocytopenia, anaemia and leucopenia) have been reported, so FBC’s must be monitored weekly. If significant bone marrow suppression occurs… treatment should be stopped unless it is considered essential.

Question 343

Which side effect should be looked out for when using daptomycin?

Answer 343

muscle effects if unexplained muscle pain, tenderness, weakness or cramps develop during treatment, measure creatine kinase every 2 days and discontinue if unexplained muscular symptoms and creatine elevated markedly.

Question 344

In which patients should itraconazole be avoided in?

Answer 344

following reports of heart failure, caution is advised when prescribing to patients at high risk of heart failure (older adults + those with cardiac disease, patients with chronic lung disease associated with pulmonary hypertension and those receiving negative inotropic drugs). Itraconazole should be avoided in patients with ventricular dysfunction or a history of heart failure.

Question 345

Which potentially life threatening side effect has been reported with itraconazole use?

Answer 345

: potentially life-threatening hepatotoxicity has been rarely reported. Discontinue if signs of hepatitis develop. Signs of liver disorder include anorexia, nausea, vomiting, fatigue, abdominal pain and dark urine -> patients should be told to recognise these symptoms. Thus, liver function should be monitored.

Question 346

What should patients on voriconazole be advised?

Answer 346

Hepatotoxicity (hepatitis, cholestasis and acute hepatic failure) has been reported.

: patients should be told to recognise symptoms of liver disorder and seek immediate medical attention if nausea, malaise, vomiting or jaundice develop.

Patients should be advised to avoid intense or prolonged exposure to sunlight and to avoid the use of sunbeds. In sunlight, patients should cover sun-exposed areas of the skin and use a sunscreen with a high sun protection factor. If patients experience sunburn or a severe skin reaction following exposure to sunlight… they should seek immediate medical attention

Question 347

Is the risk of hepatoxicity with oral ketoconazole greater it less than the benefit in treating fungal nail infections?

Answer 347

the risk of hepatotoxicity with oral ketoconazole is greater than the benefit in treating fungal infections. Thus, patients receiving ketoconazole should be reviewed with a view to stopping treatment or choosing an alternative.

Question 348

What monitoring requirements are there for ketoconazole?

Answer 348

Monitor ECG before and 1 week after initiation. Monitor adrenal function within one week of initiation, then regularly thereafter.

When cortisol levels are normalised or close to target and effective dose established, monitor every 3-6 months as there is a risk of autoimmune disease development after normalisation of cortisol levels.

Question 349

For oral ketoconazole - what are the symptoms suggestive of adrenal insufficiency?

Answer 349

fatigue, anorexia, nausea, hypoglycaemia, hyponatraemia, hypotension)

If these occur - measure cortisol levels and discontinue treatment temporarily, or reduce dose.

Question 350

With ketoconazole treatment, what should you do if liver enzymes increases?

Answer 350

Reduce dose if liver enzymes increase less than 3 times the normal limit but if liver enzymes are raised to 3 times or greater the normal limit, discontinue treatment permanently.