Chapter 5: Infection Part 1 Flashcards
1
Q
What are the safest classes of antibiotics to use in pregnancy?
A
Penicillins, erythromycin and Cephalosporins (cefalexin (1st gen cefalexin, 2nd gen ceftriaxone, 1st gen cefadroxil)- all but Cefopime a 4th generation cephalosporin
2
Q
What antibiotic treatment is indicated for septicaemia (community or hospital acquired)?
A
BROAD SPEC antibiotics: e.g. tazocin (pipericillin and tazobactam)
If MRSA suspected: add Vancomycin
Anaerobic: Metronidazole
Meningococcal: Benzylpenicillin
Pen/Ceph allergy: chloramphenicol
3
Q
What antibiotic Is very good against anaerobic bacteria so usually infections of the colon?
A
Metronidazole - V high anaerobic activity, narrow spectrum
Used for bacteria growing where there isn’t much oxygen: Gut (H pylori, Chron’s), Bacterial vaginosis, Leg ulcers
4
Q
How is bacterial meningitis empirically treated?
A
1) BENZYPENICILLIN- can be given before transfer to hospital,
2) If penicillin allergy- CEFOTAXIME (a cephalosporin)3)
If hypersensitivity to penicillin & cephalosporins: CHLORAMPHENICOL
4) Can consider addition of Dexamethasone
5) Consider Vancomycin if multiple use of antibiotics in previous 3 months
5
Q
What is the treatment for meningococcal meningitis?
A
Benzylpenicillin or cefotaxime 2nd line: Chloramphenicol For 7 days
6
Q
What is the treatment for pneumococcal meningitis?
A
- Benzylpenicillin
- Cefotaxime (OR ceftriaxone)
- If allergic: chloramphenicol
- If resistant: vancomycin/rifampicin
For 14 days consider adding dexamethasone
7
Q
What is the treatment for meningitis caused by haemophilus influenza?
A
Cefotaxime (OR ceftriaxone)For 10 daysConsider adding dexamethasone
8
Q
What antibiotics are used in endocarditis (infection of the heart)?
A
1) amoxicillin
If resistant MRSA or pen allergy: vancomycin
2) staph: flucloxacillin, strep: benzylpenicillin
^ All +/- low-dose gentamicin hence the lower target level range for gentamicin in endocarditis (trough<1, peak 3-5)
9
Q
What antibiotic is indicated for gastro-enteritis?
A
This is usually self-limiting and an antibiotic not indicated
10
Q
What is the antibiotic indicated for C. diff?
A
First episode: oral Metronidazole (high anaerobic activity)
Second episode/2nd line: oral Vancomycin
Use together if combo not worked: oral Fidaxomicin ALL FOR 10-14 DAYS DURATION
11
Q
Which antibiotics are commonly used for GU infections?
A
Azithromycin- used in chlamydia, gonorrhoea
Doxycycline- alternative in chlamydia, pelvic inflammatory disease, syphilis
Metronidazole- used for bacterial vaginosis, pelvic inflammatory disease
12
Q
What class of AB’s is Amikacin? When is amikacin usually indicated?
A
An aminoglycoside usually indicated for gentamicin resistant infections as amikacin is more stable than gentamicin to enzyme inactivation.
13
Q
What is the target One hour peak concentration of gentamicin? (multiple daily dosing)
A
5 - 10 mg/L (3-5mg/L if endocarditis)
14
Q
What is the target pre-dose trough concentration of gentamicin? (multiple daily dosing)
A
under 2 mg/L (<1mg/L if endo)
15
Q
What is the target One hour peak conc of gentamicin in treatment of ENDOCARDITIS? and target trough level?
A
Peak: 3 - 5 mg/L Trough: <1mg/L
16
Q
Which aminoglycoside is too toxic to be administered parenterally, therefore is taken by mouth?
A
NEOMYCIN - used for bowel sterilisation before surgery as its so strong it will wipe the bowel clean of bacteria
17
Q
Etrapenem, Imipenem and Meropenem are all examples of what kind of antibiotics?
A
The carbapenems. These are beta-lactam antibacterials
NB: imipenem is administered with cilastatin which is a specific enzyme inhibitor that stops it being renally metabolised
18
Q
Which two cephalosporins are suitable for infections of the CNS?
A
Cefotaxime + Ceftriaxone (TAX AND TRAX) (Hint: these are the two we see used in meningitis, a CNS infection!)
19
Q
Talk me through treatment of UTI’s in pregnancy?
A
Nitrofurantoin: okay to use but avoid at term
Trimethoprim: Teratogenic risk in first trimester as it is a folate antagonist
Cefalexin: a cephalosporin, these are safe in pregnancy
Cranberry juice or other cranberry products are not recommended as no evidence to support their use
20
Q
What classes, other than penicillins, do we have to be wary of with penicillin allergic patients?
A
Cephalosporins- cefalexin, cefadroxil, ceftriaxone, cefixime, cefotaxime
All cephalosporins begin with C
(0.5-6.5% cross-sensitiviry)
21
Q
What is Co-trimoxazole? What is it used for?
A
Contains SULFAMETHOXAZOLE and TRIMETHOPRIM!
Resistance to sulphonamides has increased so there are restrictions on the use of co-trimoxazole.
LIMITED USE:It IS indicated for: Pneumonia caused by p.jiroveci/ carinii.
Also for toxoplasmosis + nocardiasis
Should only be used in bronchitis exacerbation/ UTI’s/ otitis media in children when culture and sensitivities evident
ONLY use when there is GOOD EVIDENCE to use this COMBO rather than just a single due to resistance!
22
Q
What antibiotics require reporting on blood disorders/ rash?
A
Co-trimoxazole (contains trimethoprim and sulfamethoxazole)- discontinue immediately if: signs of a blood disorder such as anaemia, thrombocytopenia or rash: stevens johnsons syndrome, photosensitivity
Trimethoprim: Blood disorders: fever, sore throat, ulcers, bruising, bleeds
Penicillamine: not really an anti-bacterial: used as a disease-modifying anti-rheumatic drug Same as above: fever, sore throat, ulcers, bruising
23
Q
What do you see fusidic acid commonly used for?
A
Staphylococcal infection of the SKIN e.g. impetigo & also EYES comes as tablet, cream, eye drops
24
Q
What happens if a patient on clindamycin develops diarrhoea?
A
Antibiotic associated colitis with clindamycin can be fatal- discontinue immediately + start vancomycin
25
Why antibiotic has been associated with Myopathy/ Muscle effects?
Daptomycin monitor creatinine kinase every 2 days if muscle effects reported
26
Which antibiotics can cause cholestatic jaundice?
Co-amoxiclav
Nitrofurantoin
Flucloxacillin ( even upto 2 months after)
Be careful in liver patients
27
What is the important safety information associated with Flucloxacillin?
Hepatic disorders: Cholestatic Jaundice and HEPATITIS have been reported in patients even up to 2 months after the drug has been stopped.
Use flucloxacillin with caution in patients with liver impairment!!
28
A few antibiotics have been associated with visual problems. Can you think of any?
LINEZOLID- optic nephropathy
QUINOLONES (Ciprfloxacin, Levofloxacin)- retinal detachment
Ethambutol (used for TB)- ocular toxicity
Rifampicin- colours tears/ contacts red
Rifabutin- Uveitis (eye inflammation)
29
What two things need to be looked out for with Linezolid treatment?
Optic neuropathy (visual problems)- report any visual disturbance IMMEDIATELY
Blood disorders: Aneamia, thrombocytopenia
FBC monitored WEEKLY, monitor especially for treatment of 10-14 days or more
30
What are the TWO very important safety warnings with QUINOLONES (ciprofloxacin, levofloxacin)?
May induce CONVULSIONS especially if also taking NSAIDS - even in those that are not epileptic.
Caution in EPILEPSY.
Caution with THEOPHYLLINE as also causes seizures. TENDON DAMAGE-
Tendonitis, tendon rupture (NB: this has also been reported with prednislone!)( also can PROLONG QTc interval- this is a caution)
31
When should patients discontinue treatment with Quinolones?
If any of the following occur:Psychiatric reactions (hallucinations, anxiety, depression)Neurological reactions (tremor, asthenia [abnormal weakness])
32
WHAT ANTIOBIOTICS CAN CAUSE QT PROLONGATION??!
MACROLIDES especially prone: Erythromycin, Clarithromycin, AzithromycinQUINOLONES: Ciprofloxacin, Levofloxacin, especially Moxifloxacin
33
Linezolid is an antibacterial used in pneumonia. It also had Monoamine oxidase inhibition activity (part of MAOI family). What should patients be advised to avoid?
Avoid consuming large amounts of Tyramine rich foodsRemember: Linezolid will still have interactions/ tyramine effects 2 weeks after discontinuation!!
34
What can happen if VANCOMYCIN is infused too rapidly?
Flushing of upper body= RED MAN SYNDROMEAlso:Severe HypotensionWheezingPruritisPain/ muscle spasm in back
35
After how many doses should Vancomycin plasma levels be measured?
After 3 or 4 doses if renal function is normal (earlier if its impaired!)
36
What side effects do Vancomycin and Gentamicin both have in common? What drugs should be avoided with these?
OtotoxicityNephrotoxicityObviously avoid use of vancomycin and gentamicin together!Ototoxic drugs:Loop diuretics- furosemide!!Nephrotoxic drugs:CICLOSPORINPlatinum chemotherapy
37
Treatment with Vancomycin required Full Blood count monitoring. Why is this?
Risk or neutropenia- monitor neutrophils and platelets
38
Which antibiotics could cause CHOLESTATIC JAUNDICE (a liver disorder where bile builds up in the blood stream as it gets blocker from being excreted)?
FLUCLOXACILLIN- may even occur up to TWO MONTHS after flucloxacillin stopped, more likely after TWO WEEKS of treatmentCo-fluampicil (contains amoxicillin and flucloxacillin) Co-amoxiclav NitrofurantoinUse these with caution in those with liver dysfunction!!
39
Which antibiotics are commonly used to treat acne??
Tetracyclines most common:tetracycline, doxycycline, oxytetracyclineErythromycin (a macrolide) sometimes used
40
What conditions can Tetracyclines exacerbate?
Systemic Lupus ErythematosusMyasthenia Gravis (increased muscle weakness)
41
Which antibiotics can cause photosensitivity?
DoxcyclineDemeclocycline
42
Which antibiotics are not recommended in children and adolescences under 18 years old? And why?
Quinolones: Ciprofloxacin, levofloxacin, moxifloxacinThis is because of the risk of TENDON DAMAGE/ JOINT DISEASE (Aropathy)
43
What is an important monitoring parameter with Linezolid?
WEEKLY Full Blood Countsdue to risk of blood disorder/ anaemia
44
Which antibiotics may cause a false positive result on urinary GLUCOSE tests- i.e. be careful when testing for diabetes?
CEPHALOSPORINSCefalexin, Ceftriaxone etc
45
Which antibiotic is a FOLATE SYNTHESIS INHIBITORS and is therefore teratogenic?
TrimethoprimCo-trimoxazole (contains sulfamethoxazole and trimethoprim)Therefore AVOID in pregnancy- especially first trimester when folate is needed
46
What frequency of administration is Vancomycin given?
BD12 hourly due to long half life Teicoplanin: even longer acting: OD dosing after loading dose
47
Name 2 Glycopeptide antibiotics?
VancomycinTeicoplanin (less nephrotoxic than vancomycin)
48
What are the target pre-dose TROUGH levels for vancomycin?? (only trough levels are used with Vancomycin)
10 - 15 mg/ L
49
First line antibiotic for Cellulitis?
Flucloxacillin (250-500mg QDS)If penicillin allergic: Clindamycin
50
Which antibiotics/ antifungals may cause STEVENS JOHNSON SYNDROME (skin rash)?
Co-trimoxazole Clindamycin Fluconazole
51
What are some of the more common side effects experienced with Metronidazole (its quite an unpleasant antibiotic)?
Lots of GI disturbance- sick, stomach painMouth effects: Taste disturbance, oral mucositis (mouth ulcers), furry tongueAlcohol- disulfiram like reaction
52
What is fusidic acid used for?
Narrow spectrum antibiotic used for STAPHYLOCOCCAL SKIN infectionsUsed for impetigo (topical) Fucidin creamStaph eye infections (topical)
53
Which antibiotic is cautioned in problems to do with:LungsLiverNeurones
Nitrofurantoin:Pulmonary FibrosisCholestatic JaundicePeripheral Neuropathyalso can cause Vit B/ Folate deficiency
54
Which antifungal medication can cause QT prolongation?
FLUCONAZOLE
55
What antibiotics/ antifungals should be stopped if signs ofdark urinevomitingfatigueanorexia occur?
This indicated LIVER FAILUREDiscontinue drugs that are hepatotoxic: ItraconazoleFluconazoleKetoconazole (no longer available oral)!Terbinafine RifampicinIsoniazidPyrizinamide (R.I.P liver: TB drugs)
56
Which antifungal is cautioned in patients at a high risk of heart failure?
ITRACONAZOLEAs can worsen this More at risk if on negatively ionotropic drug e.g. CCB
57
What skin condition may Terbinafine (antifungal) exacerbate?
Psoriasis
58
Which antifungal can cause renal toxicity?
AMPHOTERICINCan also cause electrolyte disturbance: Hypokaleamia and hypmagneseamia
59
Which antimalarials are unsuitable in patients with epilepsy/ has a history of epilepsy?
CHLOROQUINEMEFLOQUINE
60
A woman, 4 weeks pregnant, comes and asks you what she can do to avoid malaria when she goes to Bolivia next month.Which antimalarials are ok to use in pregnancy?
Chloroquine andProguanil can both be used at normal doses in pregnancy as benefit of malaria prophylaxis outweighs any riskBUT recommend FOLIC ACID 5mg to be taken with proguanil
61
What does the antimalarial malarone contain?
Proguanil & AtovaquoneThis is fine to use in epilepsy; does not contain chloroquine or mefloquine
62
What is the most common causative bacteria of a UTI?
E. coli
63
Lonely frail old linda sat in her smelly flat
Lonely linda= Clindamycin (class of its own)Frail= bones - clindamycin used for osteomyelitis as it concentrates in the bonesSmelly= diarrhoea= discontinue immediately
64
Daktocort cream (containing Miconazole and Hydrocortisone) needs to be stored where?? Why??Where is the ointment stored?
Daktocort CREAM stored in fridge- creams are more water based so more liable to bacterial growthOintment on shelf- more stable, less water less bacteriaSimilar to chloramphenicol eye drops/ ointment- DROPS in FRIDGE as more water based, ointment on shelf
65
What drugs are used to treat Bacterial Vaginosis?
Metronidazole vaginal gelClindamycin cream
66
Which antifungal requires an Alert card as it is so Hepato-toxic?
Voriconazole
67
What two toxicities may Voriconazole cause?
HepatotoxicityPhototoxcity- avoid sunlight!
68
When should a penicillin be discontinued? Describe the affects.
Individuals with a history of anaphylaxis, urticaria, or rash immediately after a penicillin should discontinue and not receive penicillins as these are at risk of immediate hypersensitivity. The rash would come up straight away, be wide spread, all over body, confluent, raised and itchy (urticaria= hives like rash).Those with history of a minor rash (non-confluent, localised to one area, non-itchy) that occurred more than 72 hours after starting the penicillin are probably not truly allergic, and if a penicillin is absolutely needed they may receive it.
69
What antibiotics are commonly seen prescribed for chest infections?
Penicillins- Amoxicillin or AmpicillinOr if not: A Macrolide - Azithromycin, Clarithromycin or ErythromycinCo-amoxiclav used for more serious chest infections as it has broader action over the typical bacteria (e.g. H. influenzae)
70
How is oral thrush managed?
Initially TOPICAL treatment with either Miconazole oromucosal gel or NYSTATIN oral suspension (use pipette provided, hold in mouth, used after food)If these don't work or patient has a dry mouth can use Oral fluconazole capsule
71
Which anti-epileptic does Meropenem reduce the levels of?
Sodium Valproate
72
What is the usual organism (Not atypical) causing Lower respiratory tract infections?
Streptococcus pneumoniae - major cause of pneumonia S. pneumoniae is also one of the major causes of meningitis (pneumonococcal) along with Neisseria meningitidis (meningococcal)
73
What antibiotic should be used for resistant strains of pneumonia?
Co-amoxiclav.This contains amoxicillin plus clavulanic acid which is a beta lactamase inhibitor- this makes this antibiotic very effective against more resistant strains.
74
Aside from antibiotics like clindamycin etc, what can cause C.diff?
PPI's
75
What is the difference between the discharge in bacterial vaginosis and Trichomoniasis Vaginalis?
bacterial vaginosis= thick, white and fishy discharge- cottage cheese like in appearance Trichomoniasis Vaginalis= frothy-smell, green/ yellow coloured!
76
Pink and frothy sputum=?
Heart Failure: the pulmonary oedema (fluid on lungs) can result in coughing up blood and requiring more pillows to sleep on to take weight off the chest
77
What are the most common causative organisms of Community Aquired pneumonia? (2)
Streptococcus pneumoniaeHaemophilus influenzaeAtypical (less common):Chlamydia pneumoniaeMycoplasma pneumoniaeLegionella
78
What antibiotics are suitable in pregnancy?
Penicillins and Cephalosporins
79
What are the indications for aminoglycosides?
Used for serious infectionsCNS infections e.g meningitisTB (streptomycin)Pyelonephritis, pneumonia, endocarditis
80
What is the therapeutic range for gentamicin?
5-10mg/L
81
Which aminoglycoside is given orally? and why?
Neomycin- too toxic for IV use
82
What are the side effects of aminoglycosides? (3)
1) Nephrotoxicity 2) Ototoxicity 3) Peripheral neuropathy
83
Aminoglycosides shouldn't be used in...? (2)
1) Myasthenia gravis (impairs neuromuscular transmission)2) Pregnancy (ear damage)
84
Aminoglycosides interact with what drugs?
1) Loop diuretics and Vancomycin (ototoxicity)2) Cisplatin, Ciclosporin and vancomycin (nephrotoxicity)
85
IV treatment with aminoglycosides should not exceed how many days?
7 days
86
Monitoring requirements for aminoglycosides? (3)
1) Plasma concentration (18-24 hours after dose)2) Renal function (especially during periods of dehydration)3) Auditory and vestibular function
87
Common bacteria in meningitis? (3)
1) Neisseria meningitidis 2) Streptococcus pneumoniae3) Haemophilius influenza
88
Antibiotics used in meningitis?
Benzylpenicillin, cefotaxime, chloramphenicol
89
Name 8 cephalosporins?
1) Cefalexin 2) Cetrotide 3) Cefaclor 4) Cefuroxime 5) Cefixime 6) Ceftriaxone 7) Ceftaroline 8) Fosamil
90
Are cephalosporins broad spectrum?
Yes
91
Indications for cephalosporins?
2nd or 3rd line treatment for UTI and RTIIV for severe resistant organisms Pneumonia, meningitis, gonorrhoea
92
Side effects of cephalosporins? (2)
1) GI effects2) Penicillin hypersensitivity (avoid in known allergy)
93
Do IV cephalosporins require approval by a microbiologist?
YES and are now mainly restricted to antibiotic associated colitis
94
Does warfarin interact with cephalosporins? if so, how?
YES, cephalosporins kill the gut flora responsible for synthesizing vitamin K this results in a reduction in the production of vitamin K dependent blood clotting factors-results in increased anticoagulant effect of warfarin.
95
What is the first line antibiotic group for MRSA?
Glycopeptides e.g vancomycin, Teicloplanin etc
96
What indications are glycopeptides generally used for?
MRSAC.diff endocarditissurgical prophylaxis (MRSA risk)
97
What are the main side effects of glycopeptides? (5)
1) Nephrotoxicity 2) Blood disorders3) Ototoxicity4) 'Red man syndrome'5) Thrombophlebitis (IV)
98
When would you avoid using glycopeptides?
elderly, history of deafness, renal impairment, pregnancy (ear damage)
99
What are the monitoring requirements for glycopeptides? (5)
1) FBC2) WCC3) Hepatic and renal function4) Urinalysis 5) Auditory function in elderly
100
What drugs do glycopeptides interact with?
Ciclosporin, cisplatin, aminoglycosides, loop diuretics Suxamethonium- (Increases vancomycin conc)
101
What are the indications for clindamycin (lincosamide)? (3)
1) Staphylococcal joint and bone infections2) Intra abdominal sepsis 3) Cellulitis and skin and soft tissue infections (effective against penicillin resistant streptococci)
102
Important side effects of clindamycin? (4)
1) Antibiotic associated colitis-REPORT diarrhoea 2) Esophageal disorders 3) Jaundice4) SJS, rash
103
In what patient groups is clindamycin CI?
Existing diarrhoea Caution in middle aged/ elderly women after an operation
104
What are the indications for macrolides?
Respiratory infections (in addition to penicillin), Lyme disease, severe pneumonia (added to penicillin), skin and soft tissue infections (alternative to penicillin)
105
Important side effects of macrolides? (4)
1) Antibiotic associated colitis2) QT prolongation 3) Ototoxicity4) Cholestatic jaundice
106
Why would you avoid using macrolides in myasthenia gravis?
Macrolides cause electrolyte abnormalities which can aggravate myasthenia gravis
107
Main CI for macrolides?
1) Hepatic impairment (cholestatic jaundice)2) Arrhythmia (QT prolongation)
108
What drugs interact with macrolides?
1) CYP450 substrates 2) Drugs that prolong QT interval
109
What are the main indications of metronidazole? and appropriate doses? (3)
1) Antibiotic associated colitis (400mg TD 5 days)2) Oral infections (200mg TD 3 days for gingivitis)3) Gynecological infections e.g trichomonas vaginal infection
110
Main side effects associated with metronidazole? (3)
1) Neurological effects e.g peripheral and optic neuropathy 2) Mouth-Taste disturbance, furred tongue and mucositis 3) Hearing loss
111
Is metronidazole a CYP450 inhibitor?
NO, it is a substrate of CYP450
112
What happens if you drink alcohol while taking metronidazole?
'di-sulfram like' reaction will occur. Metronidazole inhibits the clearing of acetylaldehyde (intermediary metabolite)- this causes flushing, headache, tachycardia
113
How long after stopping metronidazole should you avoid alcohol?
2 days
114
What drugs does metronidazole interact with? (4)
1) CYP450 inhibitors 2) CYP450 inducers3) CYP450 substrates4) Lithium (reduces clearance of lithium resulting in toxicity)
115
What effect will ketoconazole have on metronidazole?
Ketoconazole is a CYP450 inhibitor, metronidazole is a substrate of CYP450 therefore ketoconazole will reduce the metabolism of metronidazole. Metronidazole is a pro-drug so this will reduce the efficacy of metronidazole.
116
What duration of treatment with metronidazole requires FBC and hepatic monitoring?
10 days
117
Are penicillins broad spectrum?
Yes
118
What are the main indications for penicillins? (7)
1) Tonsillitis (streptococcal)2) Otitis media 3) Cellulitis 4) RTI5) Meningitis6) Tetanus (C.diff)7) Skin and soft tissue infections
119
Main side effects of penicillin's? (2)
1) Penicillin allergy 2) CNS toxicity (convulsions, coma)-do not give intrathecal injection
120
Main drug interaction of penicillin's?
Methotrexate- reduced renal excretion and increased toxicity
121
What are the main indications for co-amoxiclav? (3)Main side effect of co-amoxiclav?
1) Pneumonia 2) UTI (250-500mg 8hrly)3) H.pylori (combo therapy)Same as penicillin's + Cholestatic jaundice (no more than 14 days treatment)
122
What are the main indications for flucloxacillin? (3)Main side effect of flucloxacillin?
1) Skin and soft tissue infections e.g cellulitis 2) Osteomyelitis/septic arthritis 3) Endocarditis Same as penicillin's +Cholestatic jaundice
123
Name two diaminopyrimidine antibiotics
1) Trimethoprim 2) Co-trimoxazole
124
How do diaminopyrimidines work?
Bacteriostatic-inhibit folate synthesis
125
Main indications of diaminopyrimidines?
Uncomplicated UTI (200mg 12 hourly)RTI, pneumocystis pneumonia (co-trimoxazole)
126
What are the main side effects associated with diaminopyrimidines? (2)
1) Blood disorders (look out for bruising, bleeding, ulcers etc)2) SJS
127
What are the main CI for diaminopyrimidines? (2)
1) Pregnancy (Teratogenic-especially in first trimester)2) Caution in folate deficiency
128
Drugs that interact with diaminopyrimidines?
K+ elevating drugs e.g ACE inhibitors, ARB'sFolate antagonists e.g methotrexate Phenytoin, warfarin (reduced clearance)
129
Name five Quinolone antibiotics?
1) Ciproflaxacin 2) Monoflaxacin 3) Levofloxacin 4) Ofloxacin 5) Norfloxacin
130
Why are quinolones typically 2nd and 3rd line drugs?
Rapid resistance developing
131
Main indications that quinolones are used for? (4)
1) UTI 2) severe GI infections including travelers diarrhoea3) LRTI4) Gonorrhoea
132
What are the main side effects associated with quinolones? (5)
1) C. diff2) Neurological-seizures and hallucinations3) Inflammation and rupture of tendons-STOP4) Prolong QT interval-arrhythmia 5) Photosensitivity
133
What is an important side effect of monoflaxacin?
Life threatening hepatotoxicity
134
In what conditions should quinolones be use with caution?
1) Epilepsy 2) GPD6 deficiency 3) Joint disorders e.g myasthenia gravis 4) Children and adolescents (disease of joints)
135
What drugs do quinolones interact with?
1) Calcium and antacids (reduce absorption)2) Theophylline (quinolones inhibit CYP450)3) NSAIDS 4) Prednisolone (tendon rupture)5) QT prolonging drugs e.g amiodarone, antipsychotics etc
136
What is the last resort antibiotic for MRSA?
Linezolid (vancomycin resistant cocci)
137
What types of infections is Linezolid used for?
Complicated skin and soft tissue infections and pneumonia
138
What type of drug is linezolid (HINT-psychiatric effects)
MAOI
139
What are the main side effects associated with Linezolid?
1) Bipolar and confusional states 2) History of seizures 3) Uncontrolled hypertension 4) Elderly (increased risk of eosinophilia)
140
What foods should be avoided while taking linezolid?
Tyramine rich foods
141
What monitoring is required for Linezolid if the treatment exceeds 14 days?
FBC monitoring unless patient has existing myelosuppression, taking blood drugs and renal impairment (check for eosinophilia)
142
What monitoring is required for Linezolid if treatment exceeds 28 days?
Check for optic neuropathy
143
What drugs does Linezolid interact with and why?
SSRIs, triptans, tricylic antidepressants, sympathomimetics, buspirone, opioids, pethidine, antipsychotics (MAOI inhibitor)
144
Which TWO drugs cause peripheral neuropathy?
Metronidazole and nitrofurantoin
145
What type of infection is nitrofurantoin used for and what are the typical doses?
1st line for UTI (100mcg m/r BD for 3 days) and as prophylaxis for UTI (50-100mg nightly for max 6 months)
146
What are the main side effects associated with nitrofurantoin? (4)
1) Dark yellow/ brown urine2) Pulmonary reactions 3) Peripheral neuropathy 4) Hepatitis
147
In what patient groups would nitrofurantoin be an inappropriate choice? (2)
1) Pregnancy 2) CI in renal impairment
148
What are the TWO monitoring requirements for LT nitrofurantoin use?
Hepatic and pulmonary function
149
In what patient groups would a specimen and culture be collected before treatment for UTI?
Men, pregnant women, children <3, Upper UTI, resistant organism suspected e.g Klebsiella suspected
150
What are the treatment options for an uncomplicated UTI in a child >3mo?
Trimethoprim, Nitrofurantoin, Cefalexin, amoxicillin
151
What are the treatment options for an uncomplicated UTI in a child <3mo?
IV ampicillin with gentamicin or cefotaxime in hospital, then oral treatment
152
What are the antibiotic treatment options for recurrent UTI's in children?
Trimethoprim or nitrofurantoin
153
Name FIVE tetracyclines?
Tetracyline, doxycycline, minocycline, lymecyline, oxytetracyline
154
What are the main indications for tetracylines? (4)
1) Chlamydia and PID 2) Acne 3) LRTI (including COPD)4) Malaria, lyme disease, rickettsia
155
Main side effects associated with tetracylines? (5)
1) Photosensitivity 2) Esophageal irritation 3) Hepatotoxicity 4) benign intracranial pressure- headache and visual disturbances-STOP5) Discoloration of tooth enamel
156
In what patient groups would you want to avoid tetracylines?
1) Children <12 (binds to teeth)2) Pregnancy and breastfeeding
157
Name TWO conditions that require prolonged courses of antibiotics?
TB and osteomyelitis
158
Antibiotic used to prevent pneumococcal infection in sickle cell disease?
Phenoxymethylpenicillin, if CI then erythromycin
159
Antibiotic used as prevention for early onset neonatal infection?
Benzylpenicillin (IV)
160
Name FOUR beta lactam antibiotics?
1) Penicillins2) Cephalosporins3) Carbapenems4) Monobactams
161
What is the main use for fusidic acid?
narrow spectrum for staph infections, topically on the skin or eye or IV/oral for osteomyelitis and endocarditis
162
What is the first line treatment for C.diff?
Metronidazole(or vancomycin or fidoxamicin)
163
What can a tobramycin dry powder inhaler be used for?
Pseudomonas lung infection in CF
164
Name TWO carbapenems?
Imipenem and Meropenem
165
Name TWO cephalosporins that can be used for CNS infections?
1) Cefotaxime 2) Ceftriaxone
166
Which cephalosporin has good activity against haemophillus influenza?
Cefaclor
167
Which cephalosporin should be used in history of hypercalciuria (history of renal stones)?
Ceftriaxone
168
What is the maximum duration of treatment for fusidic acid?
10 days
169
What are the specific monitoring requirements for minocycline if the treatment is longer than 6 months?
Monitor every 3 months for hepatotoxicity, pigmentation of the skin and systemic lupus erythromtosus
170
Name TWO antimycobacterials?
Clofazimine and Dapsone (both used for leprosy)
171
Name the FOUR antibiotic groups that can be used in lyme disease?
1) Macrolides2) Amoxicillin3) Macrolides
172
Name SEVEN bacteria that can cause UTI?
1) E coli2) Staph saprophyticus3) Proteus4) Klebsiella5) Pseudomonas aeruginosa 6) Staph epidermidus 7) Enterococcus Faecalis
173
What is the antibacterial prophylaxis and treatment of choice for animal bites?
Co-amoxiclav (if penicillin allergic- doxycyline + metronidazole for up to 5 days) and give the tetanus jab
174
What is the treatment for a >50 year old with meningitis?
Cefotaxime or ceftriaxone AND Amoxicillin or Ampicillin Consider adding vancomycin (10 days)
175
How long is the initial phase of TB treatment?
2 months
176
How long is the second phase of TB treatment?
4 months
177
What drugs are used in the initial phase of treatment for TB?
Isonazid (300mg OD) Rifampicin (<50kg=450mg OD, >50kg=600mg OD)Pyrazinamide (<50kg=1.5g, >50kg=2g OD)Ethambutol (15mg/kg OD)
178
What drugs are used in the second phase of treatment for TB?
Isonazid (300mg OD)Rifampicin (same as initial)
179
Which TB drugs cause liver toxicity?
IsonazidRifampacinPyrazinamide
180
Which TB drugs cause peripheral neuropathy?
Isonazid
181
Which TB drugs cause occular toxicity?
Ethambutol
182
What are the monitoring requirements for TB treatment?
Plasma levels e.g ethambutolUrinalysisVisual acuity testingBlood countsLiver and hepatic functionAuditory function in the elderly
183
What is the duration of treatment for extrapulmonary TB?
10 months
184
What is a specific CI of pyrazinamide?
Acute attack of gout
185
Name the antibiotics in the aminoglycoside class
AmikacinGentamicinNeomycinStreptomycinTobramycin
186
What aminoglycosides are active against Pseudomonas and what one is the treatment of choice?
Gentamicin - treatment of choice AmikacinTobramycin - usually via inhalation in CF
187
What aminoglycoside is active against TB?
Streptomycin(mainly reserved for this indication)
188
Can aminoglycosides be given orally?
No- destroyed by the gut so must be given via injection
189
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 pneumococciVery good for gram negative organisms
190
Which aminoglycoside is used for encocarditis?If it is resistant to this, what is an alternative aminoglycoside?
Gentamicin plus another antibioticStreptomycin is an alternative if resistant to gentamicin
191
Are aminoglycosides more active against gram positive or gram negative?
Gram negative but are broad
192
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)
193
What is the problem with using aminoglycosides in myasthenia gravis?
ContraindicatedMay impair neuromuscular transmission
194
What antibiotics can be used for prophylaxis in rheumatic fever?
Pen V or sulfadiazine
195
What anitbiotics can be used for prevention of secondary case of menincoccal meningitis?
Ciprofloxacin or rifampicin Or IM ceftriaxone (unlicensed)
196
What antibiotic can be used for prevention of secondary infection for Group A strep?
Pen V
197
What antibiotic can be used for prevention of secondary infection in Influenza Type B?
Rifampicin
198
What antibiotic can be used for prevention of secondary cases of diphtheria in non-immune patients?
Erythromycin
199
What is pertussis?
Whooping cough
200
What antibiotic is used for prophylaxis of pertussis (whooping cough)?
Clarithromycin
201
What antibiotic is used post splenectomy or in patients with sickle cell disease for prevention of pneumococcal infection?
Pen V(Erythromycin is penicillin allergic)
202
What antibacterial prophylaxis/treatment is used in animal and human bites?If the patient is penicillin allergic, what should be used instead?
Co-amoxIf penicillin allergic: Doxycycline and metronidazoleUp to 5 days and give tetanus jab
203
What antibacterial prophylaxis do you use in hip and knee replacement?
Single dose IV cefuroxime/flucloxacillinAdd in gent
204
What antibacterial prophylaxis do you use in high lower limb amputation?
Use i/v co-amoxiclav alone or i/v cefuroxime + i/v metronidazole
205
What antibacterial prophylaxis do you use in caesarean section?
Single dose cefuroxime
206
What is 1st line for aspergillosis?What is 2nd line if this cannot be used?
VoriconazoleLiposomal amphotericin
207
If a patient with aspergillosis is intolerant/refractory to voriconazole and liposomal amphotericin, what other antifungals can be used?
CaspofunginItraconazole
208
What systemic antifungal is used in vaginal candidiasis?For resistant organisms, what can be used?
FluconazoleItraconazole as an alternative
209
What is micafungin licensed for?
Invasive candidiasisOesophageal candidiasisProphylaxis of candidiasis in patients undergoing haematopoietic stem cell transplantation
210
Cryptococcal meningitis, a fungal infection, is especially common in which group of immunocompromised patients?How is this treated?
HIV positive IV amphotericin followed by PO fluconazole
211
What is tinea capitis?
Fungal infection (ringworm) of scalp
212
What is tinea pedis?
Athlete's foot
213
How do you treat tinea captis?
SystemicallyGriseofulvin Can also used an additional topical application
214
True or false:In fungal nail infections, topical therapy is more effective than systemic
FalseSystemic is more effective
215
Is fluconazole active against Aspergillus?
No
216
Is caspofungin effective against CNS fungal infections?
No
217
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 inadequateHowever, more expensive
218
What are echinocandin antifungals active against? (Caspofungin, micafungin)
Aspergillus and CandidaNot active against CNS fungal infections
219
What can be used for MRSA?
Glycopeptides mainly:TeicoplaninVancomycinAlternatives:TigecylineDaptomycinLinezolid (if glycopeptide unsuitable)Tetracyclines can be used for skin or soft tissue infections or UTI caused by MRSAClindamycin can be used for bone and joint MRSA infections
220
Are carbapenems useful against MRSA?
No
221
Do carbapenems have good activity against pseudomonas? What is the exception to this?
Yes apart from ertapenem
222
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
223
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 benpenCefotaxime if penicillin allergic / chloramphenicol if history of immediate hypersensitivity to penicillin and cephalosporins
224
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 startingAvoid using dex in septic shock, meningococcal septicaemia, immunocompromised, or meningitis following surgery
225
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 ceftriaxoneConsider adding vancomycin10 days
226
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 ampicillinConsider adding vanc10 days
227
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/ceftriaxoneChloramphenicol is an alternative if history of immediate hypersensitivity to penicillins or cephalosporins 7 days
228
What bacteria can be the cause of meningitis?
Meningococcal (neisseria)PneumococcalHaemophilus influenzaeListeria
229
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 benpenIf penicillin and cephalosporin resistant, vancomycin and rifampicin can be added14 days
230
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
231
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 daysAlternative- co-trimoxazole for 21 days
232
How should the following be managed:Patients presenting with sinusitis symptoms of 10 days or less
Paracetamol, ibuprofen, nasal salineAntibiotics not usually required
233
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.
234
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 illnessOr if bacterial sinusitis is suspected
235
What is 1st and 2nd line in a non-penicillin allergic sinusitis patient if antibiotics are indicated?
1st line- Pen V2nd line- Co-amox (especially if more serious illness)
236
What is 1st line in a penicillin allergic sinusitis patient if antibiotics are indicated?
Doxycycline or clarithyromycin
237
What is 1st line in a penicillin allergic sinusitis PREGNANT patient if antibiotics are indicated?
Erythromycin
238
What antibiotic can be used in a pregnant UTI patient?
Cefalexin
239
If antibiotics are clinically appropriate, what would be used for otitis externa?What if the patient is penicillin allergic?
FlucloxacillinClarithromycin
240
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
241
Otitis media is most common in which age group?
Children
242
What antibiotics are likely to cause C.Diff?
ClindamycinPenicillinsCephalosporinsFluoroquinolones
243
What 3 antibiotics can be used in C.Diff?
VancomycinMetronidazoleFidaxomicin
244
For first episode of mild-moderate C.Diff, what should be used and for how long?
Oral metronidazole for 10-14 days
245
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 infection10-14 days
246
What antibiotic is used for bacterial vaginosis and how long for?
Metronidazole 5-7 days
247
What antibiotics cover chlamydia?
Azithromycin (single dose)DoxycyclineErythromycin
248
What is the recommended length of treatment for osteomyelitis?
6 weeks
249
Osteomyelitis and septic arthritis antibiotic choice:1. First line2. If penicillin allergic3. If MRSA suspected
1. Flucloxacillin2. Clindamycin3. Vancomycin or teicoplanin
250
What penicillins can you use for oral infections e.g. dental?
Pen VAmoxicillinHowever these are not effective against bacteria that produces beta lactamasesCo-amox can be used in severe cases
251
What is the drug of choice for acute ulcerative gingivitis?
Metronidazole
252
Is haemophilus influenzae a bacteria or a virus?
Bacteria
253
What is the recommended therapy for Haemophilus influenzae?
Cefotaxime or ceftriaxone
254
What antibiotics do you use to treat an acute exacerbation of chronic bronchitis and how long for?
Amoxicillin or a tetracycline for 5 days
255
What antibiotic therapy is recommended in low severity CAP and how long for?What would be alternatives?
AmoxicillinAlternatives= doxycycline, clarithromycin7 days (if infection caused by staph, it would be 14-21 days)
256
What antibiotic therapy is recommended in moderate severity CAP and how long for?
Amoxicillin AND clarithromycinOr doxycycline alone 7 days
257
What antibiotic therapy is recommended in high severity CAP and how long for?
Benpen AND clarithromycin/doxycycline7-10 daysIf MRSA suspected, add teic/vanc
258
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 + clarithromycin7-10 daysAlternative to co-amox would be cefuroxime or ceftriaxone
259
In CAP, the usual treatment duration is 7-10 days. When would you extend this to 14-21 days?
If staphylococci suspected
260
If MSRA was suspected in CAP, what would you add on to the treatment?
Teic/vanc
261
What are the main organisms that cause pneumonia?
Streptococcus pneumoniaeHaemophilus influenzaeChlamydia pneumoniaeMycoplasma pneumoniaeLegionella pneumophila
262
What would you use to treat pneumonia caused by chlamydial/mycoplasma?
Doxycycline
263
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 hospitalLate onset = more than 5 days after admission to hospital
264
How do you treat early onset HAP?
Co-amox or cefuroxime
265
How do you treat late onset HAP?
Antipseudomonal penicillin e.g. Pip TazORBroad spectrum cephalosporin e.g. ceftazidimeORQuinolone e.g. ciprofloxacinMRSA- add vanc
266
What would you use to treat a small area of impetigo?
Fusidic acid
267
What would you use to treat a widespread infection of impetigo?If penicillin allergic, what would be an alternative?
Oral flucloxacillin Clarithromycin
268
What would you use to treat cellulitis?If penicillin allergic, what can be used?
High dose flucloxacillin Clindamycin/clarithromycin
269
What antibiotic would you use for mastitis during breastfeeding?What if penicillin allergic?
FlucloxacillinErythromycin10-14 days
270
What are the side effects of aminoglycosides?
Hearing impairment (ototoxicity - patients should report tinnitus, hearing loss, vertigo)NephrotoxicityMay impair muscle transmission-c/i in myasthenia gravis
271
What is the risk of aminoglycosides to the infant in pregnancy?
Risk of auditory or vestibular nerve damage
272
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
273
Should you give carbapenems if there is a history of immediate hypersensitivity to penicillins?
No
274
True or false:Cephalosporins penetrate the meninges poorly unless they are inflamed
TRUE
275
What are some common side effects of cephalosporins?
Abdo painEosoniphiliaThrombocytopenia
276
Should you give cephalosporins if there is a history of penicillin allergy?
Used in cautionBut should not be given if there is immediate hypersensitivity
277
What are the glycopeptide antibiotics?
DalbavancinTeicoplaninTelavancinVancomycin
278
Which of the following antibiotics has a lower incidence of nephrotoxicity:TeicoplaninVancomycin
Teicoplanin
279
What drugs are associated with red man syndrome?
GlycopeptidesTeicoplaninVancomycin
280
What is the main advice to give to patients on clindamycin and should stop taking if this happens?
Diarrhoea Stop and contact doctor
281
What are the cautions in macrolides?
QT prolongationand electrolyte disturbances
282
Amoxicillin can cause an increased risk of erythematous rash in what conditions?
Acute lymphocytic leukaemiaChronic lymphocytic leukaemiaCMVGlandular fever
283
Why should you maintain adequate hydration with high doses of IV amoxicillin?
Risk of crystalluria Especially in renal impairment
284
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)
285
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)
286
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)
287
What is the dose of amoxicillin in susceptible infection for a child 12-17 years?
500mg TDSIncreased up to 1g TDS if needed
288
What is the dose of amoxicillin in susceptible infection for an adult?
500mg TDS
289
What is the MHRA warning surrounding flucloxacillin?
Cholestatic jaundice and hepatitis
290
What is a side effect of oral amoxicillin and co-amox in terms of colouring the patient's tongue?
Black hairy tongue
291
Ciprofloxacin is a type of what antibiotic?
Quinolone
292
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 treatmentSmall increased risk of aortic aneurysm and dissection
293
Should quinolones be used in MRSA?
No
294
What quinolone is active against pseudomonas?
Ciprofloxacin
295
What are some common side effects of quinolones?
QT prolongationHearing impairmentDecreased appetiteRhabdomylosisDrug should be discontinued if psychiatric, neurological reactions occurCautioned in young adults and children- risk of arthropathy
296
What antibiotic would you use for PCP prophylaxis and treatment?
Co-trimoxazole
297
What is a rare but serious side effect of co-trimoxazole?
Blood disorders Rash - steven johnson's syndrome
298
What age group are tetracyclines contraindicated in?
Children < 12 due to deposition in growing bones and teeth Staining of teeth can occur
299
What are the common side effects of tetracyclines?
AngiodemaHenoch Schonlein purpura (spotty rash)Photosensitivity reactionHeadaches and visual disturbances- may indicate benign intercranial hypertension - discontinue if intercranial pressure increases
300
Is there any special patient advice with doxycycline?
Should be taken with mealsAvoid exposure to sunlight and sun lamps Do not take zinc, indigestion remedies 2 hours before or after
301
What is a serious side effect of chloramphenicol when given systemically?
Haemotological side effects (agranulocytosos, bone marrow disorder) Aplastic anaemia- reports of leukaemiaShould only be reserved for life-threatening conditions e.g. typhoid fever
302
What muscle side effect can daptomycin cause?
MyopathyReport any muscle weakness and monitor creatine kinase if necessaryNeed to monitor CK twice a week whilst on it
303
What monitoring requirements are needed for systemic fusidic acid?
Elevated liver enzymes, hyperbilirubinaemia and jaundice can occur with systemic useManufacturer advises monitor liver function with high doses or on prolonged therapy
304
What is the important safety information regarding linezolid?
Severe optic neuropathy- patients should report visual impairment Blood disorders - thrombocytopenia, anaemia,
305
What food does linezolid interact with and why?
Tyramine-rich foods (such as mature cheese, salami)Avoid consuming large amountsAlso is a reversible MAOI
306
Is linezolid active against gram-ve, gram+ve or both?
Gram +ve
307
What would be the dose of trimethoprim in an adult for UTI?
200mg BD
308
Can you use trimethoprim in renal impairment?
Yes- monitorMay need to half normal dose
309
What is the patient advice surrounding rifampicin?
May stain contact lenses red Report signs of liver disorder May colour urine red - harmless
310
How does rifampicin interact with hormonal contraceptives?
Effectiveness of hormonal contraceptives are reduced - alternative method needed
311
What antibiotics are used in the initial phase of TB treatment?
Rifampicin IsoniazidPyrazinamideEthambutolStreptomycin- hardly used but may be useful if resistant to isoniazid
312
How many antibacterials are used in the initial phase of TB treatment and how long for?
42 months
313
How many antibacterials are used in the continuous phase of TB treatment and how long for?
24 months
314
If someone is isoniazid, what else must be prescribed and why?
Pyridoxine (vitamin B6)Prophylaxis of isoniazid-induced neuropathy
315
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)
316
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 monthsShould NOT be given streptomycin
317
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.
318
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
319
In patients with HIV and TB, how long should the TB treatment be for?What is the exception to this?
6 monthsHowever if the TB has CNS involvement, 12 months max
320
What is the general TB treatment regimen?
RIPE for 2 months and then RI (Rifampicin and isoniazid) for a further 4 months
321
What is the general CNS TB treatment?
RIPE for 2 months and then RI (Rifampicin and isoniazid) for a further 10 monthsInitial high dose of dexamethasone or prednisolone should be started at the same time and slowly withdrawn over 4-8 weeks
322
What would be the treatment regimen for latent TB?
Isoniazid for 6 months - recommended if interactions with rifampicin a concernOR rifampicin and isoniazid for 3 months - recommended if hepatotoxicity a concern
323
A break in TB treatment of how many weeks is classed as a treatment interruption?
2 weeks
324
What are the 6 toxicity syndromes associated with intermittent TB treatment?
Influenza-like, abdominal, and respiratory symptoms, shock, renal failure, and thrombocytopenic purpura
325
What is the brand name of the medicine that contains RIPE for TB?
Voractiv
326
What is the brand name of medicine that contains RI (rifampicin and isoniazid) for TB?
Rifinah
327
Why is ethambutol cautioned in young children?
Can cause visual impairmentEthambutol should be used with caution in children until they are at least 5 years old and capable of reporting symptomatic visual changes accurately.
328
What kind of toxcity can ethambutol cause?
Ocular - report any visual disturbancesNephrotoxicityOther side effects include red-green colour blindness, hepatotoxicity
329
What are the main side effects to look out for in a patient on isoniazid?
Peripheral neuropathyHepatic disordersOtotoxicity
330
What are the main side effects to look out for in a patient on pyrazinamide?
HepatoxicityAggravates gout
331
What antibiotics respond to a lower UTI?
TrimethoprimNitrofurantoinAmoxicillinAmpicillinCefalexin
332
What is the recommended duration of treatment for uncomplicated UTI in women?
3 days
333
What antibiotics for a UTI should be used in pregnancy?
Penicillins and cephalosporins are the best choices
334
At what EGFR should you avoid prescribing nitrofurantoin in?
<45
335
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)
336
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
337
What are some side effects of amphotericin?
#NAME?
338
Are different preparations of amphotericin interchangeable?
No Vary in PD, PKShould preferably prescribe by brand to avoid confusion
339
What are some side effects of fluconazole?
#NAME?
340
What is a specific side effect with IV isavuconazole?
Infusion related reactions:Hypotension, SOB, paraesthesiaNausea, headacheDiscontinue if these occur
341
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 diseaseShould 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
342
What are the specific side effects for voriconazole that requires patient counselling?
Hepatotoxicity- patients should be aware of liver disorder signsPhototoxicity- 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 hallucinationsKeep an alert card on them
343
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 methodMen: Avoid fathering a child during and for at least 6 months after administration
344
What adjunctive therapy is recommended in PCP treatment in patients with HIV?
For moderate to severe infections, prednisolone for 21 days
345
True or false:All members in a household must be treated if one person in the house has threadworm
TRUE
346
What is the drug of choice for threadworm?
Mebendazole
347
For malaria prophylaxis, what are mosquito nets usually impregnated with?
Permethrin (insecticide)
348
Can DEET spray be used during pregnancy and breastfeeding?
Yes
349
When applying DEET and suncream, what should be applied first?
Suncream Then DEET
350
How does DEET spray affect the SPF of suncream?
Lowers it so a factor 30-50 should be used
351
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 beforeMalarone and doxycycline is 1-2 days beforeIn warfarin patients- 2-3 weeks before
352
How much time before travelling should malaria prophylaxis with Malarone be started?
1-2 days before
353
How much time before travelling should malaria prophylaxis with doxycycline be started?
1-2 days before
354
How much time before travelling should malaria prophylaxis with mefloquine be started?
2-3 weeks before
355
How long can Malarone be used for in malaria prophylaxis?
Up to 1 year
356
How long can doxycycline be used for in malaria prophylaxis?
Up to 2 years
357
How long can mefloquine be used for in malaria prophylaxis?
Up to 1 year
358
What antimalarials are unsuitable for those with epilsepy?What would be alternatives?
ChloroquineMefloquineProguanil is recommended in areas with chloroquine resistanceDoxycyline or Malarone is recommended in areas without chloroquine resistance
359
Which group of patients are at a particularly high risk of severe malaria?
Those without a spleen
360
What antimalarials can be given at their usual dose during pregnancy?
ChloroquineProguanilHowever, resistance exists so may have to look at other options, only if benefit outweighs risk and travel is unavoidable
361
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
362
How long should malaria prophylaxis continue after leaving the at risk country?What is the exception to this?
Continue for 4 weeks afterExcept for Malarone which is 1 week
363
In warfarin patients, when should malaria prophylaxis begin?
2-3 weeks before travellingINR should be stable before departure
364
When should INR be checked in warfarin patients on malaria prophylaxis?
Before starting the course7 days after starting the course After completing the courseFor prolonged stays, INR needs to be checked at regular intervals
365
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.
366
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
367
What combination of antimalarials is in Malarone/Maloff?
Atovaquone and proguanil
368
For the treatment of malaria, is the infective species is unknown/mixed, what are the options?
MalaroneRiametQuinine
369
What is P. Falciparum resistant to?
Chloroquine
370
What are the treatment options for malaria caused by P.Falciparum?
Quinine (with doxycycline or clindamycin)MalaroneRiamet
371
What are the treatment options for malaria caused by P.Falciparum in pregnancy?
Quinine followed by clindamycin(cannot use doxycycline)
372
What are the treatment options for non-falciparum malaria?
ChloroquineHowever, if resistant- Malarone or Riamet
373
What are the treatment options for non-falciparum malaria in pregnancy?
Chloroquine
374
What antimalarials does Riamet contain?
Artemether and lumefantrine
375
What is the important safety information with chloroquine?
Occular toxicity Very toxic in overdose
376
What are some side effects of chloroquine?
#NAME?
377
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 depressionHas a long half life so can persist up to several months after discontinuation
378
What screening should be done before a patient starts taking primaquine and why?
G6PD as if deficient, can cause haemolysis
379
What is the difference between quinine sulphate and quinine bisulphate?
Bisulphate has less quinine inShould not be used for malaria, only quinine sulphate
380
What is the important safety information regarding quinine?
QT prolongation
381
What are the initial treatment options for chronic Hep B?
Peginterferon alphaInterferon alphaTreatment with the above should be stopped if no improvement after 4 monthsEntecavirTenofovirTreatment should be changed to other antivirals if no improvement after 6-9 months
382
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.
383
What is used for the initial treatment of chronic Hep C?
Combination of ribavirin and peginterferon alphaRibavirin monotherapy=ineffective
384
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 closelyRisk of Hep B reactivation (if patient has both B and C)Need to be screened for Hep B before starting treatment
385
What is herpes labialis?
Cold sore
386
What is herpes zoster?
Shingles
387
What is varicella?
Chicken pox
388
In shingles, within how many hours of rash onset should antivirals be started?How long is it continued for?
Within 72 hoursContinued for 7-10 days
389
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
390
What kind of drug is foscarnet?
Antiviral
391
What antivirals are used for CMV?
Ganciclovir IVValganciclovir POFoscaret - toxic and causes renal impairment
392
During CMV treatment, what does ganciclovir cause if given with zidovudine (for HIV)?
Myelosuppression
393
Initial treatment of HIV-1 includes what combination types of antiretroviral drugs?
Triple therapy2 nucleoside reverse transcriptase inhibitors and ONE of the following;- Boosted protease inhibitor- Non-nucleoside reverse transcriptase inhibitor- Integrase inhibitor
394
What is used for HIV pre-exposure prophylaxis?
Emtricitabine with tenofovir
395
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.
396
Name the nucleoside reverse transciptase inhibitors for HIV
ZidovudineAbacavirDidanosineEmtricitabineLamivudineStavudineTenofovir disoproxil.
397
Name the protease inhibitors used for HIV
AtazanavirDarunavirFosamprenavirRitonavirSaquinavirTipranavir*Metabolised by cytochrome P450 enzyme systems*
398
Name the integrase inhibitors used for HIV
Dolutegravir, elvitegravir and raltegravir
399
Name the non-nucleoside reverse transcriptase inhibitors used for HIV
Efavirenz, etravirine, nevirapine, and rilpivirine
400
What is Maraviroc?
Antagonist of the CCR5 chemokine receptor. It is licensed for patients exclusively infected with CCR5-tropic HIV.
401
What has been reported in patients with advanced HIV disease or following long-term exposure to antiretroviral treatment?
Osteonecrosis
402
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
403
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
404
What reaction can occur with HIV medicines?
Hypersensitivity e.g. Rash, lesions, oedema, SOB
405
Which HIV medicine is associated with a high incidence of rash including Stevens-Johnson syndrome?
Nevirapine
406
What is the important information that requires patient counselling for patients on nevirapine for HIV?
#NAME?
407
Efavirenz for HIV is associated with an increase in plasma concentration of what substance?
Cholesterol
408
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 organisms2. Lipodystrophy syndrome: this is made up of insulin resistance, fat redistribution and dyslipidaemiaBlood lipids and sugars should be measured before, 3-6 months after and yearly after HIV treatment.3. Osteonecrosis: following long-term exposure to treatment.
409
Protease inhibitors are mainly associated with what side effects?
Lipodystrophy and metabolic effects.
410
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 usedWithin 48 hours
411
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
412
How long should influenza treatment be for?
Twice daily dosing for 5 days
413
How long should post-exposure prophylaxis for influenza be for?
Once daily dosing for 10 days
414
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.
415
What is a rare but potentially fatal side effect of ketoconazole?
Associated with fatal hepatotoxicity. The CSM advise that prescribers shouldweigh the potential benefits of ketoconazole treatment against the risk of liver damage and shouldcarefully monitor patients both clinically and biochemically.
416
What penicillin based antibiotics must you take on an empty stomach (1 hour before food or 2 hours after food)?
FlucloxacillinAmpicillinPenicillin V
417
What shouldn't a patient take at the same time as tetracycline antibiotics?
Do not take milk, indigestion remedies, or medicinescontaining iron or zinc at the same time of day as this medicine (prevents absorption of the antibioticand should be taken 2-3 hours apart)Oxytetracycline and tetracycline should be taken on an empty stomach
418
Which tetracycyline antibiotics should be taken on an empty stomach?
Oxytetracycline and tetracycyline
419
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.
420
True or false:Rifampicin should be taken on an empty stomach
TRUE
421
True or false:Metronidazole should be taken on an empty stomach
FalseTake with or just after food
422
What shouldn't a patient take at the same time as ciprofloxacin?
Do not take milk, indigestion remedies, or medicines containing iron orzinc at the same time of day as this medicine.
423
What specific monitoring should you do with daptomycin?
Creatine kinase twice a week
424
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 infectionPeople with a prescription for oral ketoconazole should be referred back to their doctors
425
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
426
What CD4 count is classed as AIDs?
<200
427
Which of the following is active against pseudomonas:- Benpen- Flucloxacillin- Ampicillin- Piperacillin
Piperacillin (Pip taz)
428
Which antibacterial drug increases the risk of serotonin syndrome?LinezolidVancomycinTelvancinSeptrin
Linezolid as it is a weak MAOI Serotonin syndrome risk increases with:SSRIsTCAsMacrolidesAmiodaroneFluoroquinolonesAntipsychoticsQuinineRisk of hypertensive crisis
429
Which drug class is most associated with lipodystrophy?Antiretroviral drugsAlkylating agentsTCAsARBs
Antiretroviral drugs can cause redistribution of fat around the body
430
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).
431
What are adverse effects of quinine?
TinnitusDeafnessBlindnessQT prolongationHypoglycaemiaGI upsetHypersensitivity reactions
432
What advice should you give to a patient on metronidazole regarding their urine?
May darken urine (brown)
433
Which of these is used to boost the effects of protease inhibitors?ElvitegravirMaravirocRitonavirEtravirine
Ritonavir - it is a protease inhibitor itself but it inhibits CYP enzymes that would otherwise metabolise other protease inhibitors
434
What are the side effects of trimethoprim?
Megaloblastic anaemiaGI effectsTaste disturbanceElevated creatinine levelsSkin rashHyperkalaemia
435
Trimethoprim can cause high levels of what electrolyte?
Potassium
436
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.
437
What is the standard dose of oseltamivir in:i) Treatment of fluii) Prevention of flu
i) 75mg BD for 5 days for treatmentii) 75mg OD for 10 days for prophylaxis
438
Is vancomycin good for treating gram negative or positive organisms?
Gram positive
439
Is teicoplanin good for treating gram negative or positive organisms?
Gram positive
440
Allopurinol and what antibiotic can result in a skin rash?
Amoxicillin
441
True or false:NSAIDs and fluoroquinolones together increase seizure risk
TRUE
442
Can macrolides cause QT prolongation?
Yes
443
What tetracyclines can you take with milk?
Does Like Milk acronymDoxyclineLymecyclineMinocycline
444
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 daysAlternatives:Azithromycin 1 g orally for one day, then 500mg orally once daily for two daysErythromycin 500 mg BD for 10–14 days
445
How you manage a pregnant lady with chlamydia?
Azithromycin 1 g orally for one day, then 500mg orally once daily for two daysErythromycin 500 mg BD for 10–14 days
446
If a patient is thought to have chlamydia and presents in a primary care setting, where should you refer to?
GUM clinic
447
When should you do an STI screen in a patient with chlamydia?
1 week after completing treatment
448
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 treatmentWith azithromycin, you need to wait 7 days after
449
Does a partner of someone of chlamydia need to be treated if their screen result is negative?
Yes
450
How many weeks after the start of treatment do you do a test of cure treatment for chlamydia?
5 weeks
451
What age should you offer repeat testing of chlamydia in 3-6 months after treatment?
<25 years
452
What can a high ESR indicate?
Inflammation, infection
453
Is ESR usually low or raised in infection?
Raised
454
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.
455
What is the cut off eGFR for nitrofurantoin?
45
456
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)
457
Can tetracyclines cause hepatotoxicity?
Yes
458
True or false:Tetracyclines can be used during pregnancy
FALSE
459
True or false:Trimethoprim can be used during pregnancy
False - teratogenic in first trimester
460
True or false:Nitrofurantoin can be used during pregnancy
True But avoid at term
461
Can metronidazole be used during pregnancy?
No Only use if benefit outweighs risk
462
Is Ben Pen active against streptococci?
Yes
463
Is linezolid active against MRSA?
Yes
464
Can chloramphenicol be used in pregnancy?
No
465
Should metronidazole be taken with or without food?
With or just after food
466
What electrolyte disturbances can be caused by aminoglycosides?
HypokalaemiaHypo MgHypo Ca
467
What is the MHRA warning about gentamicin?
Potential for histamine-related adverse drug reactions with some batches
468
Is gentamicin used for MRSA?
No
469
Red man syndrome caused by vancomycin causes is associated with what other clinical features?
HypotensionBronchospasms Caused by rapid infusion
470
Which is associated with a higher incidence of nephrotoxicity?TeicoplaninVancomycin
Vancomycin
471
If a patient on a tetracycline develops a headache, what should they do?
Stop Side effect of tetracyclines- benign intracranial hypertension
472
What tetracyclines should you avoid milk in? (DOT)
DemeclocyclineOxytetracyclineTetracycline
473
What tetracyclines can you have milk with? (DLM)
Doxycycline LymecyclineMinocycline
474
What tetracyclines cause oesophageal irritation and is recommended to take with plenty of fluid?
DoxycyclineMinocyclineTetracycline
475
Can ciprofloxacin cause QT prolongation?
Yes
476
Are quinolones active against MRSA?
No
477
If a patient on a quinolone develops psychiatric disturbances, what should you recommend?
They should stop the drug
478
What is the interaction between ciprofloxacin and theophylline?
Ciprofloxacin is an enzyme inhibitor and causes theophylline toxicity - convulsions risk
479
Which quinolone should you protect yourself from sunlight if on it?
Ofloxacin
480
Cholestatic jaundice risk is increased with amoxicillin/flucloxacillin if on it for more than how many days?
14 days
481
What is the dosing regimen for Malarone for the prophylaxis of malaria?
1 tablet OD, started 1-2 days before, during, and 7 days afterTake with food/milky drink
482
Should Malarone be taken on an empty stomach or with food?
Take with food/milky drink to maximise absorption
483
What is the renal cut off for Malarone?
<30 mL/min
484
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
485
How long do you continue malaria prophylaxis with doxycycline after leaving the area of risk?
4 weeks after
486
What is the dosing regimen for chloroquine in the prophylaxis of malaria?
2 tablets once a weekStart 1 week before, during and 4 weeks afterTake just after food
487
Should chloroquine be taken on an empty stomach?
No Take just after food
488
Should proguanil be taken on an empty stomach?
No Take just after food
489
What is the dosing regimen for proguanil in the prophylaxis of malaria?
2 tablets ODStarted 1 week beforeContinue for 4 weeks after Take just after food
490
Should mefloquine be taken on an empty stomach?
No Take just after food
491
What are the side effects associated with glycopeptides?
#NAME?
492
What is the dose of trimethoprim for a UTI?
200mg BD
493
What is the safest macrolide to use in pregnancy?
Erythromycin
494
What is penicillin G?
Benzylpenicillin
495
What is first line for acute infective exacerbation of COPD and how long for?
Amoxicilin, clarithromycin or doxycycline for 5 days
496
What is first line for acute exacerbation of bronchietasis and how long for?
Amoxicilin, clarithromycin or doxycycline for 7-14 days
497
What is low severity CAP in terms of CURB score?
0-1
498
What is moderate severity CAP in terms of CURB score?
2
499
What is high severity CAP in terms of CURB score?
03-May
500
What is the CURB score and what does each marker mean?
Confusion - mental test 8 or less Urea > 7 mmol/LResp rate 30 breaths/min or moreBlood pressure systolic < 90 or diastolic 60 or less65 years and older1 point for eachLow risk 0-1Moderate 2High risk 3-5
