Chapter 5: Infection Flashcards
Name the antibiotics in the aminoglycoside class x5
Amikacin Gentamicin Neomycin Streptomycin Tobramycin
What aminoglycosides are active against Pseudomonas aeruginosa (x3) and what one is the treatment of choice?
Gentamicin - treatment of choice
Amikacin
Tobramycin - usually via inhalation in CF
What aminoglycoside is active against TB? Against what bacteria?
Streptomycin
(mainly reserved for this indication)
Mycobacterium tuberulosis
Can aminoglycosides be given orally?
No- destroyed by the gut so must be given via injection
Are not absorbed from the gut (risk of absorption in inflammatory bowel disease and liver failure) and must be given by injection for systemic infections.
Is gentamicin a broad or narrow antibiotic?
What strains does it have poor activity against?
Broad but it is inactive against anaerobes and poor activity against haemolytic streptococci and pneumococci
Very good for gram negative organisms
Which aminoglycoside is used for encocarditis?
If it is resistant to this, what is an alternative aminoglycoside?
Gentamicin plus another antibiotic
Streptomycin is an alternative if resistant to gentamicin
Are aminoglycosides more active against gram positive or gram negative?
Gram negative but are broad
Can neomycin be given IV?
No
too toxic
Can only be used for skin/mucous membrane infections… However BNF states the cream is less suitable for prescribing
(Can also be used to reduce the bacterial population of the colon prior to bowel surgery or in hepatic impairment)
What is the problem with using aminoglycosides in myasthenia gravis?
Contraindicated
May impair neuromuscular transmission
What antibiotics can be used for prophylaxis in rheumatic fever?
Pen V or sulfadiazine
phenoxymethylpenicillin
What anitbiotics can be used for prevention of secondary case of menincoccal meningitis?
Ciprofloxacin or rifampicin
Or IM ceftriaxone (unlicensed)
What antibiotic can be used for prevention of secondary infection for Group A strep?
Pen V
Phenoxymethylpenicillin
pen allergic - erythromycin or azithromycin
What antibiotic can be used for prevention of secondary infection in Influenza Type B?
Rifampicin
If rifampicin cannot be used – IM or IV ceftriaxone
What antibiotic can be used for prevention of secondary cases of diphtheria in non-immune patients?
Erythromycin (or another macrolide e.g. azithromycin or clarithromycin)
What is pertussis?
Whooping cough
What antibiotic is used for prophylaxis of pertussis (whooping cough)?
Clarithromycin
What antibiotic is used post splenectomy or in patients with sickle cell disease for prevention of pneumococcal infection?
Pen V
Erythromycin is penicillin allergic
What antibacterial prophylaxis/treatment is used in animal and human bites?
If the patient is penicillin allergic, what should be used instead?
Co-amox
If penicillin allergic: Doxycycline and metronidazole
Up to 5 days and give tetanus jab
What antibacterial prophylaxis do you use in hip and knee replacement?
Single dose IV cefuroxime
OR IV flucloxacillin + IV gent
What antibacterial prophylaxis do you use in high lower limb amputation?
Use i/v co-amoxiclav alone or i/v cefuroxime + i/v metronidazole
What antibacterial prophylaxis do you use in caesarean section?
Single dose IV cefuroxime
What is 1st line for aspergillosis?
What is 2nd line if this cannot be used?
Voriconazole
Liposomal amphotericin
If a patient with aspergillosis is intolerant/refractory to voriconazole and liposomal amphotericin, what other antifungals can be used?
Caspofungin
Itraconazole
What antifungal is used in vaginal candidiasis?
For resistant organisms, what can be used?
Locally acting antifungals or with fluconazole given by mouth.
Itraconazole PO as an alternative for resistant organisms
What is micafungin licensed for?
Invasive candidiasis
Oesophageal candidiasis
Prophylaxis of candidiasis in patients undergoing bone marrow transplantation or who are expected to become neutropenic for over 10 days
Cryptococcal meningitis, a fungal infection, is especially common in which group of immunocompromised patients?
How is this treated?
HIV positive
IV amphotericin & IV flucytosine followed by PO fluconazole
What is tinea capitis?
Fungal infection (ringworm) of scalp
What is tinea pedis?
Athlete’s foot
How do you treat tinea captis?
Systemically
Griseofulvin
Can also used an additional topical application
True or false:
In fungal nail infections, topical therapy is more effective than systemic
False
Systemic is more effective
Is fluconazole active against Aspergillus?
No
Is caspofungin effective against CNS fungal infections?
No
What is the advantage of lipid amphotericin formulations over conventional amphotericin?
Significantly less toxic and are recommended when the conventional formulation of amphotericin is contra-indicated because of toxicity, especially nephrotoxicity or when response to conventional amphotericin is inadequate
However, more expensive
What are echinocandin antifungals active against? (Caspofungin, micafungin)
Aspergillus and Candida
Not active against CNS fungal infections
What can be used for MRSA?
Glycopeptides mainly:
Teicoplanin
Vancomycin
Alternatives:
Tigecyline
Daptomycin
Linezolid (if glycopeptide unsuitable)
Tetracyclines can be used for skin or soft tissue infections or UTI caused by MRSA
Clindamycin can be used for bone and joint MRSA infections
Are carbapenems useful against MRSA?
No
Do carbapenems have good activity against pseudomonas? What is the exception to this?
Yes apart from ertapenem
Why does imipenem have to be administered with cilastatin?
Imipenem is partially inactivated in the kidney by enzymatic activity and is therefore administered in combination with cilastatin, a specific enzyme inhibitor, which blocks its renal metabolism
If meningitis is suspected, what antibiotic should be given before being transferred to hospital (as long as this doesn’t delay treatment)?
What would be an alternative?
IV benpen
Cefotaxime if penicillin allergic / chloramphenicol if history of immediate hypersensitivity to penicillin and cephalosporins
When would you use dexamethasone in meningitis?
In what situations would you avoid this?
Particularly in pneumococcal meningitis in adults, either before starting antibacterial therapy or within 12 hours of starting
Avoid using dex in septic shock, meningococcal septicaemia, immunocompromised, or meningitis following surgery
What is the recommended antibiotic therapy for children 3 months - adults 50 years in meningitis if the cause is unknown?
What is the suggested duration of treatment?
Cefotaxime or ceftriaxone
Consider adding vancomycin
10 days
What is the recommended antibiotic therapy for adults over 50 years in meningitis if the cause is unknown?
What is the suggested duration of treatment?
Cefotaxime or ceftriaxone
AND amoxicillin or ampicillin
Consider adding vanc
10 days
What is the recommended antibacterial therapy for meningitis caused by meningococci (neisseria)?
What would be an alternative if not suitable?
What is the suggested duration of treatment?
Benpen
Or cefotaxime/ceftriaxone
Chloramphenicol is an alternative if history of immediate hypersensitivity to penicillins or cephalosporins
7 days
What bacteria can be the cause of meningitis?
Meningococcal (neisseria)
Pneumococcal
Haemophilus influenzae
Listeria
What is the recommended antibacterial therapy for meningitis caused by pneumococcal?
If the organism if penicillin and cephalosporin resistant, what can be added?
What is the suggested duration of treatment?
Cefotaxime or ceftriaxone
Consider adding dex before first dose or within 12 hours of starting antibacterial therapy
If penicillin sensitive, change to benpen
If penicillin and cephalosporin resistant, vancomycin and rifampicin can be added
14 days
What is the recommended antibacterial therapy for meningitis caused by Haemophilus influenzae?
What is the suggested duration of treatment?
Cefotaxime or ceftriaxone
Consider adding dex before first dose or within 12 hours of starting antibacterial therapy
10 days
What is the recommended antibacterial therapy for meningitis caused by Listeria?
What is the suggested duration of treatment?
If history of immediate penicillin hypersensitivity, what could be an alternative?
Amoxicillin/ampicillin
AND gentamicin
21 days - can consider stopping gentamicin after 7 days
Alternative- co-trimoxazole for 21 days
How should the following be managed:
Patients presenting with sinusitis symptoms of 10 days or less
Paracetamol, ibuprofen, nasal saline
Antibiotics not usually required
How should the following be managed:
Patients presenting with sinusitis symptoms of 10 days or more
Could be considered for treatment with a high-dose nasal corticosteroid, such as mometasone furoate [unlicensed use] or fluticasone [unlicensed use] for 14 days. Supply of a back-up antibiotic prescription could be considered and used if symptoms do not improve within 7 days, or if they worsen rapidly or significantly.
In what situations would you offer antibiotics for sinusitis?
Should only be offered to patients with acute sinusitis who are systemically very unwell, have signs and symptoms of a more serious illness
Or if bacterial sinusitis is suspected
How should the following be managed:
Patients presenting with sinusitis symptoms of 10 days or more
Could be considered for treatment with a high-dose nasal corticosteroid, such as mometasone furoate [unlicensed use] or fluticasone [unlicensed use] for 14 days. Supply of a back-up antibiotic prescription could be considered and used if symptoms do not improve within 7 days, or if they worsen rapidly or significantly.
What is 1st and 2nd line in a non-penicillin allergic sinusitis patient if antibiotics are indicated?
1st line- Pen V
2nd line- Co-amox
especially if more serious illness
What is 1st line in a penicillin allergic sinusitis patient if antibiotics are indicated?
Doxycycline or clarithyromycin
What is 1st line in a penicillin allergic sinusitis PREGNANT patient if antibiotics are indicated?
Erythromycin
What antibiotic can be used in a pregnant UTI patient?
Cefalexin
If antibiotics are clinically appropriate, what would be used for otitis externa?
What if the patient is penicillin allergic?
Flucloxacillin
Clarithromycin
If antibiotics are clinically appropriate, what would be used for otitis media?
What if the patient is penicillin allergic?
Amoxicillin (or co-amox as second line)
Clarithromycin
Otitis media is most common in which age group?
Children
What antibiotics are likely to cause C.Diff?
Clindamycin
Penicillins
Cephalosporins
Fluoroquinolones
What 3 antibiotics can be used in C.Diff?
Vancomycin
Metronidazole
Fidaxomicin
For first episode of mild-moderate C.Diff, what should be used and for how long?
Oral metronidazole for 10-14 days
For second/subsequent C.Diff infection not responding to metronidazole, what can be used and for how long?
Oral vancomycin
Fidaxomicin can be used for severe infection
10-14 days
What antibiotic is used for bacterial vaginosis and how long for?
Metronidazole 5-7 days
What antibiotics cover chlamydia?
Azithromycin (single dose)
Doxycycline
Erythromycin
What would you use to treat gonorrhoea?
If the IM route is not possible, what would you use instead?
Single dose
Azithromycin and IM ceftriaxone
Cefixime instead (unlicensed)
What is the recommended length of treatment for osteomyelitis?
6 weeks
Osteomyelitis and septic arthritis antibiotic choice:
- First line
- If penicillin allergic
- If MRSA suspected
- Flucloxacillin
- Clindamycin
- Vancomycin or teicoplanin
What penicillins can you use for oral infections e.g. dental?
Pen V
Amoxicillin
However these are not effective against bacteria that produces beta lactamases
Co-amox can be used in severe cases
What is the drug of choice for acute ulcerative gingivitis?
Metronidazole
Is haemophilus influenzae a bacteria or a virus?
Bacteria
What is the recommended therapy for Haemophilus influenzae?
Cefotaxime or ceftriaxone
What antibiotics do you use to treat an acute exacerbation of chronic bronchitis and how long for?
Amoxicillin or a tetracycline for 5 days
What antibiotic therapy is recommended in low severity CAP and how long for?
What would be alternatives?
Amoxicillin
Alternatives= doxycycline, clarithromycin
7 days (if infection caused by staph, it would be 14-21 days)
What antibiotic therapy is recommended in moderate severity CAP and how long for?
Amoxicillin AND clarithromycin
Or doxycycline alone
7 days
What antibiotic therapy is recommended in high severity CAP and how long for?
Benpen AND clarithromycin/doxycycline
7-10 days
If MRSA suspected, add teic/vanc
For life-threatening CAP, what would be the recommended treatment and how long for?
If the patient was penicillin allergic, what would be the alternative?
Co-amox + clarithromycin
7-10 days
Alternative to co-amox would be cefuroxime or ceftriaxone
In CAP, the usual treatment duration is 7-10 days. When would you extend this to 14-21 days?
If staphylococci suspected
If MSRA was suspected in CAP, what would you add on to the treatment?
Teic/vanc
What are the main organisms that cause pneumonia?
Streptococcus pneumoniae Haemophilus influenzae Chlamydia pneumoniae Mycoplasma pneumoniae Legionella pneumophila
What would you use to treat pneumonia caused by chlamydial/mycoplasma?
Doxycycline
What is the difference between early onset vs late onset HAP (in terms of days in hospital)?
Early onset = less than 5 days admission to hospital
Late onset = more than 5 days after admission to hospital
How do you treat early onset HAP?
Co-amox or cefuroxime
How do you treat late onset HAP?
Antipseudomonal penicillin e.g. Pip Taz
OR
Broad spectrum cephalosporin e.g. ceftazidime
OR
Quinolone e.g. ciprofloxacin
MRSA- add vanc
What would you use to treat a small area of impetigo?
Fusidic acid
What would you use to treat a widespread infection of impetigo?
If penicillin allergic, what would be an alternative?
Oral flucloxacillin
Clarithromycin
What would you use to treat cellulitis?
If penicillin allergic, what can be used?
High dose flucloxacillin
Clindamycin/clarithromycin
What antibiotic would you use for mastitis during breastfeeding?
What if penicillin allergic?
Flucloxacillin
Erythromycin
10-14 days
What are the side effects of aminoglycosides?
Hearing impairment (ototoxicity - patients should report tinnitus, hearing loss, vertigo)
Nephrotoxicity
May impair muscle transmission-c/i in myasthenia gravis
What is the risk of aminoglycosides to the infant in pregnancy?
Risk of auditory or vestibular nerve damage
What is a possible problem with carbapenems that means it is cautioned in CNS disorders?
Seizure inducing potential
Also increased risk of seizures if renal impairment is present
Should you give carbapenems if there is a history of immediate hypersensitivity to penicillins?
No
True or false:
Cephalosporins penetrate the meninges poorly unless they are inflamed
True
What are some common side effects of cephalosporins?
Abdo pain
Eosoniphilia
Thrombocytopenia
Should you give cephalosporins if there is a history of penicillin allergy?
Used in caution
But should not be given if there is immediate hypersensitivity
What are the glycopeptide antibiotics?
Dalbavancin
Teicoplanin
Telavancin
Vancomycin
Which of the following antibiotics has a lower incidence of nephrotoxicity:
Teicoplanin
Vancomycin
Teicoplanin
What drugs are associated with red man syndrome?
Glycopeptides
Teicoplanin
Vancomycin
What is the main advice to give to patients on clindamycin and should stop taking if this happens?
Diarrhoea
Stop and contact doctor
What are the cautions in macrolides?
QT prolongation
and electrolyte disturbances
Amoxicillin can cause an increased risk of erythematous rash in what conditions?
Acute lymphocytic leukaemia
Chronic lymphocytic leukaemia
CMV
Glandular fever
Why should you maintain adequate hydration with high doses of IV amoxicillin?
Risk of crystalluria
Especially in renal impairment
What is the dose of amoxicillin in susceptible infection for a child 1-11 months?
125mg TDS
increased up to 30mg/kg TDS if needed
What is the dose of amoxicillin in susceptible infection for a child 1-4 years?
250mg TDS
increased up to 30mg/kg TDS if needed
What is the dose of amoxicillin in susceptible infection for a child 5-11 years?
500mg TDS
increased up to 30mg/kg TDS if needed
What is the dose of amoxicillin in susceptible infection for a child 12-17 years?
500mg TDS
Increased up to 1g TDS if needed
What is the dose of amoxicillin in susceptible infection for an adult?
500mg TDS
What is the MHRA warning surrounding flucloxacillin?
Cholestatic jaundice and hepatitis
What is a side effect of oral amoxicillin and co-amox in terms of colouring the patient’s tongue?
Black hairy tongue
Ciprofloxacin is a type of what antibiotic?
Quinolone
What is the important safety information regarding fluoroquinolones?
May induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them.
Tendon damage (including rupture) has been reported rarely in patients receiving quinolones. Tendon rupture may occur within 48 hours of starting treatment
Small increased risk of aortic aneurysm and dissection
Should quinolones be used in MRSA?
No
What quinolone is active against pseudomonas?
Ciprofloxacin
What are some common side effects of quinolones?
QT prolongation
Hearing impairment
Decreased appetite
Rhabdomylosis
Drug should be discontinued if psychiatric, neurological reactions occur
Cautioned in young adults and children- risk of arthropathy
What antibiotic would you use for PCP prophylaxis and treatment?
Co-trimoxazole
What is a rare but serious side effect of co-trimoxazole?
Blood disorders
Rash - steven johnson’s syndrome
What age group are tetracyclines contraindicated in?
Children < 12 due to deposition in growing bones and teeth
Staining of teeth can occur
What are the common side effects of tetracyclines?
Angiodema
Henoch Schonlein purpura (spotty rash)
Photosensitivity reaction
Headaches and visual disturbances- may indicate benign intercranial hypertension - discontinue if intercranial pressure increases
Is there any special patient advice with doxycycline?
Should be taken with meals
Avoid exposure to sunlight and sun lamps
Do not take zinc, indigestion remedies 2 hours before or after
What is a serious side effect of chloramphenicol when given systemically?
Haemotological side effects (agranulocytosos, bone marrow disorder)
Aplastic anaemia- reports of leukaemia
Should only be reserved for life-threatening conditions e.g. typhoid fever
What muscle side effect can daptomycin cause?
Myopathy
Report any muscle weakness and monitor creatine kinase if necessary
Need to monitor CK twice a week whilst on it
What monitoring requirements are needed for systemic fusidic acid?
Elevated liver enzymes, hyperbilirubinaemia and jaundice can occur with systemic use
Manufacturer advises monitor liver function with high doses or on prolonged therapy
What is the important safety information regarding linezolid?
Severe optic neuropathy- patients should report visual impairment
Blood disorders - thrombocytopenia, anaemia,
What food does linezolid interact with and why?
Tyramine-rich foods (such as mature cheese, salami)
Avoid consuming large amounts
Also is a reversible MAOI
Is linezolid active against gram-ve, gram+ve or both?
Gram +ve
What would be the dose of trimethoprim in an adult for UTI?
200mg BD
Can you use trimethoprim in renal impairment?
Yes- monitor
May need to half normal dose
What is the patient advice surrounding rifampicin?
May stain contact lenses red
Report signs of liver disorder
May colour urine red - harmless
How does rifampicin interact with hormonal contraceptives?
Effectiveness of hormonal contraceptives are reduced - alternative method needed
What antibiotics are used in the initial phase of TB treatment?
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin- hardly used but may be useful if resistant to isoniazid
How many antibacterials are used in the initial phase of TB treatment and how long for?
4
2 months
How many antibacterials are used in the continuous phase of TB treatment and how long for?
2
4 months
If someone is isoniazid, what else must be prescribed and why?
Pyridoxine (vitamin B6)
Prophylaxis of isoniazid-induced neuropathy
Generally speaking, after 2 months of RIPE treatment for TB, what antibiotics are continued for a further 4 months?
Rifampicin and isoniazid (needs to be on pyridoxine for prevention of neuropathy)
What treatment for TB should be given in pregnancy and breastfeeding?
RIPE for 2 months and then RI (Rifampicin and isoniazid) for a further 4 months
Should NOT be given streptomycin
DOT TB therapy should be offered to which groups of people?
Directly observed therapy should be offered to patients who:
-Have a history of non-adherence;
-Have previously been treated for tuberculosis;
-Are in denial of the tuberculosis diagnosis;
have multidrug-resistant tuberculosis;
have a major psychiatric or cognitive disorder;
-Have a history of homelessness, drug or alcohol misuse;
-Are in prison, or have been in the past 5 years;
-Are too ill to self-administer treatment;
-Request directly observed therapy.
In a patient with HIV and TB, starting antiretrovirals in the first 2 months of TB treatment can increase the risk of what?
Immune reconstitution syndrome
In patients with HIV and TB, how long should the TB treatment be for?
What is the exception to this?
6 months
However if the TB has CNS involvement, 12 months max
What is the general TB treatment regimen?
RIPE for 2 months and then RI (Rifampicin and isoniazid) for a further 4 months
What is the general CNS TB treatment?
RIPE for 2 months and then RI (Rifampicin and isoniazid) for a further 10 months
Initial high dose of dexamethasone or prednisolone should be started at the same time and slowly withdrawn over 4-8 weeks
What would be the treatment regimen for latent TB?
Isoniazid for 6 months - recommended if interactions with rifampicin a concern
OR rifampicin and isoniazid for 3 months - recommended if hepatotoxicity a concern
A break in TB treatment of how many weeks is classed as a treatment interruption?
2 weeks
What are the 6 toxicity syndromes associated with intermittent TB treatment?
Influenza-like, abdominal, and respiratory symptoms, shock, renal failure, and thrombocytopenic purpura
What is the brand name of the medicine that contains RIPE for TB?
Voractiv
What is the brand name of medicine that contains RI (rifampicin and isoniazid) for TB?
Rifinah
Why is ethambutol cautioned in young children?
Can cause visual impairment
Ethambutol should be used with caution in children until they are at least 5 years old and capable of reporting symptomatic visual changes accurately.
What kind of toxcity can ethambutol cause?
Ocular - report any visual disturbances
Nephrotoxicity
Other side effects include red-green colour blindness, hepatotoxicity
What are the main side effects to look out for in a patient on isoniazid?
Peripheral neuropathy
Hepatic disorders
Ototoxicity
What are the main side effects to look out for in a patient on pyrazinamide?
Hepatoxicity
Aggravates gout
What antibiotics respond to a lower UTI?
Trimethoprim
Nitrofurantoin
Amoxicillin
Ampicillin
Cefalexin
What is the recommended duration of treatment for uncomplicated UTI in women?
3 days
What antibiotics for a UTI should be used in pregnancy?
Penicillins and cephalosporins are the best choices
At what EGFR should you avoid prescribing nitrofurantoin in?
<45
Does does caspofungin interact with and what should be done about the dose?
Some enzyme inducers e.g. rifampicin, carbamazepine, phenytoin
increase dose to 70mg daily (if not already on it)
What is the risk of giving an infusion of amphotericin?
Risk of arrhythmias if given too rapidly
Anaphylaxis- test dose is needed and close observation is needed for first 30 mins after this test dose
What are some side effects of amphotericin?
- Abnormal hepatic function (discontinue)
- Renal impairment
- Agranulocytosis
- Arrhythmias
- Anaemia
- Chills
Are different preparations of amphotericin interchangeable?
No
Vary in PD, PK
Should preferably prescribe by brand to avoid confusion
What are some side effects of fluconazole?
- QT prolongation
- Oedema
- If rash occurs, discontinue - could be SCARSs (severe cutaneous reaction)
What is a specific side effect with IV isavuconazole?
Infusion related reactions:
Hypotension, SOB, paraesthesia
Nausea, headache
Discontinue if these occur
What is the important safety information regarding itraconazole?
Reports of heart failure, especially in high risk patients:
- High dose and long courses
- Patients on negative ionotropic drugs- CCBs
- Elderly
- Chronic heart disease
Should be avoided in those with a history of heart failure unless the infection is serious
Also, hepatotoxicity that can be life-threatening can occur. Patient should be aware of liver disorder signs
What are the specific side effects for voriconazole that requires patient counselling?
Hepatotoxicity- patients should be aware of liver disorder signs
Phototoxicity- patients should avoid intense or prolonged exposure to direct sunlight, avoid sunbeds
If they get sunburnt, seek medical attention
It is the antifungal that is most associated with hallucinations
Keep an alert card on them
What is the contraception and conception advice for both men and women who are on griseofulvin (antifungal for dermatophyte infections of the skin)?
Women:
Should continue effective contraception at least 1 month after administration. The effectiveness of the pill may reduce so use an additional barrier method
Men:
Avoid fathering a child during and for at least 6 months after administration
What adjunctive therapy is recommended in PCP treatment in patients with HIV?
For moderate to severe infections, prednisolone for 21 days
True or false:
All members in a household must be treated if one person in the house has threadworm
True
What is the drug of choice for threadworm?
Mebendazole
For malaria prophylaxis, what are mosquito nets usually impregnated with?
Permethrin (insecticide)
Can DEET spray be used during pregnancy and breastfeeding?
Yes
When applying DEET and suncream, what should be applied first?
Suncream
Then DEET
How does DEET spray affect the SPF of suncream?
Lowers it so a factor 30-50 should be used
Generally speaking, how much time before travelling should malaria prophylaxis be started?
What are the exceptions to this?
1-2 weeks before
Mefloquine is 2-3 weeks before
Malarone and doxycycline is 1-2 days before
In warfarin patients- 2-3 weeks before
How much time before travelling should malaria prophylaxis with Malarone be started?
1-2 days before
How much time before travelling should malaria prophylaxis with doxycycline be started?
1-2 days before
How much time before travelling should malaria prophylaxis with mefloquine be started?
2-3 weeks before
How long can Malarone be used for in malaria prophylaxis?
Up to 1 year
How long can doxycycline be used for in malaria prophylaxis?
Up to 2 years
How long can mefloquine be used for in malaria prophylaxis?
Up to 1 year
What antimalarials are unsuitable for those with epilsepy?
What would be alternatives?
Chloroquine
Mefloquine
Proguanil is recommended in areas with chloroquine resistance
Doxycyline or Malarone is recommended in areas without chloroquine resistance
Which group of patients are at a particularly high risk of severe malaria?
Those without a spleen
What antimalarials can be given at their usual dose during pregnancy?
Chloroquine
Proguanil
However, resistance exists so may have to look at other options, only if benefit outweighs risk and travel is unavoidable
If a pregnant lady is on proguanil during malaria prophylaxis, what else must she be on?
Folic acid at high dose (5mg) for at least the first trimester
How long should malaria prophylaxis continue after leaving the at risk country?
What is the exception to this?
Continue for 4 weeks after
Except for Malarone which is 1 week
In warfarin patients, when should malaria prophylaxis begin?
2-3 weeks before travelling
INR should be stable before departure
When should INR be checked in warfarin patients on malaria prophylaxis?
Before starting the course
7 days after starting the course
After completing the course
For prolonged stays, INR needs to be checked at regular intervals
What is standby malaria treatment?
Travellers visiting remote, malarious areas for prolonged periods should carry standby treatment if they are likely to be more than 24 hours away from medical care. Self-medication should be avoided if medical help is accessible.
In order to avoid excessive self-medication, the traveller should be provided with written instructions that urgent medical attention should be sought 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.
When travelling to different places that require 2 different malaria prophylaxis regimens, what do you do?
The regimen for the higher risk area should be used for the whole journey
What combination of antimalarials is in Malarone/Maloff?
Atovaquone and proguanil
For the treatment of malaria, is the infective species is unknown/mixed, what are the options?
Malarone
Riamet
Quinine
What is P. Falciparum resistant to?
Chloroquine
What are the treatment options for malaria caused by P.Falciparum?
Quinine (with doxycycline or clindamycin)
Malarone
Riamet
What are the treatment options for malaria caused by P.Falciparum in pregnancy?
Quinine followed by clindamycin
cannot use doxycycline
What are the treatment options for non-falciparum malaria?
Chloroquine
However, if resistant- Malarone or Riamet
What are the treatment options for non-falciparum malaria in pregnancy?
Chloroquine
What antimalarials does Riamet contain?
Artemether and lumefantrine
What is the important safety information with chloroquine?
Occular toxicity
Very toxic in overdose
What are some side effects of chloroquine?
- QT prolongation
- Seizures
- Hypoglycaemia- cautioned in diabetes
What is a main neurological side effect of mefloquine?
Mefloquine is associated with potentially serious neuropsychiatric reactions. Abnormal dreams, insomnia, anxiety, and depression occur commonly.
Therefore, contraindicated in those with history of psychiatric disorders including depression
Has a long half life so can persist up to several months after discontinuation
What screening should be done before a patient starts taking primaquine and why?
G6PD as if deficient, can cause haemolysis
What is the difference between quinine sulphate and quinine bisulphate?
Bisulphate has less quinine in
Should not be used for malaria, only quinine sulphate
What is the important safety information regarding quinine?
QT prolongation
What are the initial treatment options for chronic Hep B?
Peginterferon alpha
Interferon alpha
Treatment with the above should be stopped if no improvement after 4 months
Entecavir
Tenofovir
Treatment should be changed to other antivirals if no improvement after 6-9 months
What determines treatment route for chronic Hep C?
Before starting treatment, 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.
What is used for the initial treatment of chronic Hep C?
Combination of ribavirin and peginterferon alpha
Ribavirin monotherapy=ineffective
What is the MRHA warning regarding direct-acting antivirals to treat chronic Hep C?
Risk of interaction with Vitamin K antagonists and changes in INR.
INR needs to be monitored closely
Risk of Hep B reactivation (if patient has both B and C)
Need to be screened for Hep B before starting treatment
What is herpes labialis?
Cold sore
What is herpes zoster?
Shingles
What is varicella?
Chicken pox
In shingles, within how many hours of rash onset should antivirals be started?
How long is it continued for?
Within 72 hours
Continued for 7-10 days
In adults with chickenpox, within how many hours of rash onset should antivirals be started to reduce duration and severity of symptoms?
Within 24 hours
What kind of drug is foscarnet?
Antiviral
What antivirals are used for CMV?
Ganciclovir IV
Valganciclovir PO
Foscaret - toxic and causes renal impairment
During CMV treatment, what does ganciclovir cause if given with zidovudine (for HIV)?
Myelosuppression
Initial treatment of HIV-1 includes what combination types of antiretroviral drugs?
Triple therapy
2 nucleoside reverse transcriptase inhibitors and ONE of the following;
- Boosted protease inhibitor
- Non-nucleoside reverse transcriptase inhibitor
- Integrase inhibitor
What is used for HIV pre-exposure prophylaxis?
Emtricitabine with tenofovir
Why are some HIV medicines used in combination with cobicistat?
It is a pharmacokinetic enhancer that boosts the concentrations of other antiretrovirals, but it has no antiretroviral activity itself.
Name the nucleoside reverse transciptase inhibitors for HIV
Zidovudine Abacavir Didanosine Emtricitabine Lamivudine Stavudine Tenofovir disoproxil.
Name the protease inhibitors used for HIV
Atazanavir Darunavir Fosamprenavir Ritonavir Saquinavir Tipranavir
Metabolised by cytochrome P450 enzyme systems
Name the integrase inhibitors used for HIV
Dolutegravir, elvitegravir and raltegravir
Name the non-nucleoside reverse transcriptase inhibitors used for HIV
Efavirenz, etravirine, nevirapine, and rilpivirine
What is Maraviroc?
Antagonist of the CCR5 chemokine receptor. It is licensed for patients exclusively infected with CCR5-tropic HIV.
What has been reported in patients with advanced HIV disease or following long-term exposure to antiretroviral treatment?
Osteonecrosis
What is the MHRA advice regarding preparations containing dolutegravir (integrase inhibitor used for HIV)?
Increased risk of neural tube defects; do not prescribe to women seeking to become pregnant; exclude pregnancy before initiation and advise use of effective contraception
What CNS effects can efavirenz cause and how can this be reduced?
Depression, psychosis, confusion, hallucination, abnormal behaviour, suicidal ideations
Take the dose at bedtime, especially during the first 2-4 weeks of treatment
What reaction can occur with HIV medicines?
Hypersensitivity e.g. Rash, lesions, oedema, SOB
Which HIV medicine is associated with a high incidence of rash including Stevens-Johnson syndrome?
Nevirapine
What is the important information that requires patient counselling for patients on nevirapine for HIV?
- Hepatotoxicity can occur so patients need to be made aware of symptoms
- Rash, hypersensitivity reaction
Efavirenz for HIV is associated with an increase in plasma concentration of what substance?
Cholesterol
What are the long term effects of HIV treatment?
1.Immune reconstitution syndrome: as the immune system stands up on its feet again due to antiretroviral treatment, marked inflammatory reactions happen against opportunistic organisms
- Lipodystrophy syndrome: this is made up of insulin resistance, fat redistribution and dyslipidaemia
Blood lipids and sugars should be measured before, 3-6 months after and yearly after HIV treatment. - Osteonecrosis: following long-term exposure to treatment.
Protease inhibitors are mainly associated with what side effects?
Lipodystrophy and metabolic effects.
What can be used for the treatment of influenza and within how many hours of symptom onset should it be started?
Oseltamivir (Tamiflu) first line and zanamivir is reserved for those who are immunocompromised or when oseltamivir cannot be used
Within 48 hours
What can be used for post-exposure prophylaxis of influenza and within how many hours of exposure?
Oseltamivir (Tamiflu) within 48 hours of exposure and zanamivir within 36 hours of exposure
How long should influenza treatment be for?
Twice daily dosing for 5 days
How long should post-exposure prophylaxis for influenza be for?
Once daily dosing for 10 days
What is a particular caution with co-amoxiclav in in terms of side effects?
Cholestatic jaundice can occur either during or shortly after the use of co-amoxiclav.
What is a rare but potentially fatal side effect of ketoconazole?
Associated with fatal hepatotoxicity. The CSM advise that prescribers should
weigh the potential benefits of ketoconazole treatment against the risk of liver damage and should
carefully monitor patients both clinically and biochemically.
What penicillin based antibiotics must you take on an empty stomach (1 hour before food or 2 hours after food)?
Flucloxacillin
Ampicillin
Penicillin V
What shouldn’t a patient take at the same time as tetracycline antibiotics?
Do not take milk, indigestion remedies, or medicines
containing iron or zinc at the same time of day as this medicine (prevents absorption of the antibiotic
and should be taken 2-3 hours apart)
Oxytetracycline and tetracycline should be taken on an empty stomach
Which tetracycyline antibiotics should be taken on an empty stomach?
Oxytetracycline and tetracycyline
What is the patient advice surrounding trimethoprim?
On long-term treatment, patients and their carers should be told how to recognise signs of blood disorders and advised to seek immediate medical attention if symptoms such as fever, sore throat, rash, mouth ulcers, purpura, bruising or bleeding develop.
True or false:
Rifampicin should be taken on an empty stomach
True
True or false:
Metronidazole should be taken on an empty stomach
False
Take with or just after food
What shouldn’t a patient take at the same time as ciprofloxacin?
Do not take milk, indigestion remedies, or medicines containing iron or
zinc at the same time of day as this medicine.
What specific monitoring should you do with daptomycin?
Creatine kinase twice a week
What is the CHMP advice regarding the use of oral ketoconazole to treat fungal infections?
Marketing authorisation for oral ketoconazole to treat fungal infections should be suspended. The CHMP concluded that the risk of hepatotoxicity associated with oral ketoconazole is greater than the benefit in treating fungal infection
People with a prescription for oral ketoconazole should be referred back to their doctors
How does calcium carbonate interact with doxycycline? What do you recommend the patient does if the patient is normally on calcium carbonate e.g. Adcal and is prescribed doxycycline?
Calcium carbonate is predicted to decrease the absorption of doxycycline
Separate administration by 2-3 hours
What CD4 count is classed as AIDs?
<200
Which of the following is active against pseudomonas:
- Benpen
- Flucloxacillin
- Ampicillin
- Piperacillin
Piperacillin (Pip taz)
Which antibacterial drug increases the risk of serotonin syndrome?
Linezolid
Vancomycin
Telvancin
Septrin
Linezolid as it is a weak MAOI
Serotonin syndrome risk increases with: SSRIs TCAs Macrolides Amiodarone Fluoroquinolones Antipsychotics Quinine
Risk of hypertensive crisis
Which drug class is most associated with lipodystrophy? Antiretroviral drugs Alkylating agents TCAs ARBs
Antiretroviral drugs can cause redistribution of fat around the body
Quinine can be very toxic - what are the signs of toxicity?
Life-threatening features include arrhythmias (which can have a very rapid onset) and convulsions (which can be intractable).
What are adverse effects of quinine?
Tinnitus Deafness Blindness QT prolongation Hypoglycaemia GI upset Hypersensitivity reactions
What advice should you give to a patient on metronidazole regarding their urine?
May darken urine (brown)
Which of these is used to boost the effects of protease inhibitors?
Elvitegravir
Maraviroc
Ritonavir
Etravirine
Ritonavir - it is a protease inhibitor itself but it inhibits CYP enzymes that would otherwise metabolise other protease inhibitors
What are the side effects of trimethoprim?
Megaloblastic anaemia GI effects Taste disturbance Elevated creatinine levels Skin rash Hyperkalaemia
Trimethoprim can cause high levels of what electrolyte?
Potassium
What is the advice surrounding ribavirin and contraception?
Effective contraception essential during treatment and for 4 months after treatment in females and for 7 months after treatment in males of childbearing age.
What is the standard dose of oseltamivir in:
i) Treatment of flu
ii) Prevention of flu
i) 75mg BD for 5 days for treatment
ii) 75mg OD for 10 days for prophylaxis
Is vancomycin good for treating gram negative or positive organisms?
Gram positive
Is teicoplanin good for treating gram negative or positive organisms?
Gram positive
Allopurinol and what antibiotic can result in a skin rash?
Amoxicillin
True or false:
NSAIDs and fluoroquinolones together increase seizure risk
True
Can macrolides cause QT prolongation?
Yes
What tetracyclines can you take with milk?
Does Like Milk acronym
Doxycline
Lymecycline
Minocycline
What is 1st line treatment for chlamydia (both the patient and partner)?
If this is not suitable, what regimes can be used instead?
Doxycycline 100 mg BD for 7 days
Alternatives:
Azithromycin 1 g orally for one day, then 500mg orally once daily for two days
Erythromycin 500 mg BD for 10–14 days
How you manage a pregnant lady with chlamydia?
Azithromycin 1 g orally for one day, then 500mg orally once daily for two days
Erythromycin 500 mg BD for 10–14 days
If a patient is thought to have chlamydia and presents in a primary care setting, where should you refer to?
GUM clinic
When should you do an STI screen in a patient with chlamydia?
1 week after completing treatment
If a patient and their partner are being treated for chlamydia, how long should they abstain from sexual intercourse?
With what antibiotic is this different?
Until they have both finished treatment
With azithromycin, you need to wait 7 days after
Does a partner of someone of chlamydia need to be treated if their screen result is negative?
Yes
How many weeks after the start of treatment do you do a test of cure treatment for chlamydia?
5 weeks
What age should you offer repeat testing of chlamydia in 3-6 months after treatment?
<25 years
What can a high ESR indicate?
Inflammation, infection
Is ESR usually low or raised in infection?
Raised
Why aren’t quinolones e.g. ciprofloxacin, ofloxacin generally used in children?
Quinolones cause arthropathy and therefore are not recommended in children and growing adolescents.
What is the cut off eGFR for nitrofurantoin?
45
Can you use tetracyclines in renal impairment?
No - should not be given at all in renal impairment
Apart from doxycycline and minocycline (but these should be used with caution)
Can tetracyclines cause hepatotoxicity?
Yes
True or false:
Tetracyclines can be used during pregnancy
False
True or false:
Trimethoprim can be used during pregnancy
False - teratogenic in first trimester
True or false:
Nitrofurantoin can be used during pregnancy
True
But avoid at term
Can metronidazole be used during pregnancy?
No
Only use if benefit outweighs risk
Is Ben Pen active against streptococci?
Yes
Is linezolid active against MRSA?
Yes
Can chloramphenicol be used in pregnancy?
No
Should metronidazole be taken with or without food?
With or just after food
What electrolyte disturbances can be caused by aminoglycosides?
Hypokalaemia
Hypo Mg
Hypo Ca
What is the MHRA warning about gentamicin?
Potential for histamine-related adverse drug reactions with some batches
Is gentamicin used for MRSA?
No
Red man syndrome caused by vancomycin causes is associated with what other clinical features?
Hypotension
Bronchospasms
Caused by rapid infusion
Which is associated with a higher incidence of nephrotoxicity?
Teicoplanin
Vancomycin
Vancomycin
If a patient on a tetracycline develops a headache, what should they do?
Stop
Side effect of tetracyclines- benign intracranial hypertension
What tetracyclines should you avoid milk in? (DOT)
Demeclocycline
Oxytetracycline
Tetracycline
What tetracyclines can you have milk with? (DLM)
Doxycycline
Lymecycline
Minocycline
What tetracyclines cause oesophageal irritation and is recommended to take with plenty of fluid?
Doxycycline
Minocycline
Tetracycline
Can ciprofloxacin cause QT prolongation?
Yes
Are quinolones active against MRSA?
No
If a patient on a quinolone develops psychiatric disturbances, what should you recommend?
They should stop the drug
What is the interaction between ciprofloxacin and theophylline?
Ciprofloxacin is an enzyme inhibitor and causes theophylline toxicity - convulsions risk
Which quinolone should you protect yourself from sunlight if on it?
Ofloxacin
Cholestatic jaundice risk is increased with amoxicillin/flucloxacillin if on it for more than how many days?
14 days
What is the dosing regimen for Malarone for the prophylaxis of malaria?
1 tablet OD, started 1-2 days before, during, and 7 days after
Take with food/milky drink
Should Malarone be taken on an empty stomach or with food?
Take with food/milky drink to maximise absorption
What is the renal cut off for Malarone?
<30 mL/min
What is the dosing regimen for doxycycline for the prophylaxis of malaria?
1 tablet OD, started 1-2 days before, during, and 4 weeks after
How long do you continue malaria prophylaxis with doxycycline after leaving the area of risk?
4 weeks after
What is the dosing regimen for chloroquine in the prophylaxis of malaria?
2 tablets once a week
Start 1 week before, during and 4 weeks after
Take just after food
Should chloroquine be taken on an empty stomach?
No
Take just after food
Should proguanil be taken on an empty stomach?
No
Take just after food
What is the dosing regimen for proguanil in the prophylaxis of malaria?
2 tablets OD
Started 1 week before
Continue for 4 weeks after
Take just after food
Should mefloquine be taken on an empty stomach?
No
Take just after food
What are the side effects associated with glycopeptides?
- Nephrotoxicity
- Ototoxicity
- Red man syndrome - associated with too rapid infusions and other symptoms are hypotension and bronchospasms
- Phlebitis - rotate infusion sites
- Neutropenia
- Steven Johnsons
What is the dose of trimethoprim for a UTI?
200mg BD
What is the safest macrolide to use in pregnancy?
Erythromycin
What is penicillin G?
Benzylpenicillin
What is first line for acute infective exacerbation of COPD and how long for?
Amoxicilin, clarithromycin or doxycycline for 5 days
What is first line for acute exacerbation of bronchietasis and how long for?
Amoxicilin, clarithromycin or doxycycline for 7-14 days
What is low severity CAP in terms of CURB score?
0-1
What is moderate severity CAP in terms of CURB score?
2
What is high severity CAP in terms of CURB score?
3-5
What is the CURB score and what does each marker mean?
Confusion - mental test 8 or less Urea > 7 mmol/L Resp rate 30 breaths/min or more Blood pressure systolic < 90 or diastolic 60 or less 65 years and older
1 point for each
Low risk 0-1
Moderate 2
High risk 3-5
What is the dose of nitrofurantoin for a UTI?
50mg QDS
When would you add flucloxacillin to pneumonia treatment?
If staphylococcus is suspected
How would you manage someone with mild facial cellulitis?
What if the patient was penicillin allergic?
Co-amoxiclav
Clarithromycin for people with a penicillin allergy
How do you treat Scarlet fever?
Pen V
How long should you abstain from alcohol after a metronidazole course?
48 hours
Within what time should you notify PHE of a patient with a notifiable disease?
What about if it is urgent?
Send the form to the proper officer within 3 days, or notify them verbally within 24 hours if the case is urgent by phone, letter, encrypted email or secure fax machine.
What are the treatment options for recurrent thrush?
Initially:
3 doses of 150mg fluconazole ( 3 days apart)
or intravaginal antifungal for 10-14 days
After:
Maintenance of 6 months or oral fluconazole 150mg weekly or intravaginal clotrimazole 500mg weekly
What are the treatment options for recurrent UTIs if trigger is not known and if trigger is known?
Manage acute UTI first
Then,
i) If trigger is known, 1st choice is trimethoprim 200mg single dose after trigger exposure
Nitrofurantoin 100mg single dose after trigger exposure
Alternatives- amoxicillin 500mg or cefalexin 500mg
ii) If trigger is NOT known, 1st choice trimethoprim 100mg ON
Nitrofurantoin 50-100mg ON
Alternatives: Amoxicillin 250mg ON or cefalexin 125mg ON
