Chapter 5: Infection Part 1 Flashcards
What are the safest classes of antibiotics to use in pregnancy?
Penicillins, erythromycin and Cephalosporins (1st gen cefalexin, 2nd gen ceftriaxone)
What antibiotic treatment is indicated for septicaemia (community or hospital acquired)?
BROAD SPEC antibiotics: e.g. tazocin (pipericillin and tazobactam)
If MRSA suspected: add Vancomycin
Anaerobic: Metronidazole
Meningococcal: Benzylpenicillin
Pen/Ceph allergy: Chloramphenicol
What antibiotic Is very good against anaerobic bacteria so usually infections of the colon?
Metronidazole
Used for bacteria growing where there isn’t much oxygen: Gut, Bacterial vaginosis, Leg ulcers
How is bacterial meningitis empirically treated?
1) BENZYPENICILLIN- can be given before transfer to hospital
2) If penicillin allergy- CEFOTAXIME
3) If hypersensitivity to penicillin & cephalosporins: CHLORAMPHENICOL
4) Consider Vancomycin if multiple use of antibiotics in previous 3 months
What is the treatment for meningococcal meningitis?
Benzylpenicillin or cefotaxime
2nd line: Chloramphenicol For 7 days
What is the treatment for pneumococcal meningitis?
Benzylpenicillin
Cefotaxime (OR ceftriaxone)
If allergic: chloramphenicol
If resistant: vancomycin/rifampicin
What is the treatment for meningitis caused by haemophilus influenza?
Cefotaxime or ceftriaxone
For 10 days
What antibiotics are used in endocarditis (infection of the heart)?
1) Amoxicillin
If resistant MRSA or pen allergy: Vancomycin
+/- low-dose gentamicin hence the lower target level range for gentamicin in endocarditis (trough<1, peak 3-5)
Staph: flucloxacillin
Strep: Benzylpenicillin
What antibiotic is indicated for gastro-enteritis?
This is usually self-limiting and an antibiotic not indicated
What is the antibiotic indicated for C. diff?
First episode: oral Metronidazole (high anaerobic activity)
Second episode/2nd line: oral Vancomycin
Use together if combo not worked: oral Fidaxomicin
10-14 day treatment length
Which antibiotics are commonly used for genitourinary infections? Excluding UTI.
Azithromycin- used in chlamydia, gonorrhoea
Doxycycline- alternative in chlamydia, pelvic inflammatory disease, syphilis
Metronidazole- used for bacterial vaginosis, pelvic inflammatory disease
What class of antibiotic is Amikacin? When is amikacin usually indicated?
An aminoglycoside usually indicated for gentamicin resistant infections as amikacin is more stable than gentamicin to enzyme inactivation.
What is the target one hour peak concentration of gentamicin? (multiple daily dosing)
5 - 10 mg/L
(3-5mg/L if endocarditis)
What is the target pre-dose trough concentration of gentamicin? (multiple daily dosing)
Under 2 mg/L
(<1mg/L if endocarditis)
What is the target one hour peak conc of gentamicin in treatment of ENDOCARDITIS? And target trough level?
Peak: 3 - 5 mg/L
Trough: <1mg/L
Which aminoglycoside is too toxic to be administered parenterally, therefore is taken by mouth?
What is the indication for this?
NEOMYCIN
Used for bowel sterilisation before surgery
Etrapenem, Imipenem and Meropenem are all examples of what kind of antibiotics?
Carbapenems- beta-lactam antibacterials
Imipenem is administered with cilastatin which is a specific enzyme inhibitor that stops it being renally metabolised
Which two cephalosporins are suitable for infections of the CNS?
Cefotaxime + Ceftriaxone (TAX AND TRAX)
What is used in the treatment of UTIs in pregnancy?
Nitrofurantoin: okay to use but avoid at term
Cefalexin: a cephalosporin, these are safe in pregnancy
Trimethoprim: Teratogenic risk in first trimester as it is a folate antagonist
Cranberry juice or other cranberry products are not recommended as no evidence to support their use
What classes, other than penicillins, do we have to be wary of with penicillin allergic patients?
Cephalosporins- cefalexin, cefadroxil, ceftriaxone, cefixime, cefotaxime
(0.5-6.5% cross-sensitivity)
What is co-trimoxazole? What is it used for?
Contains SULFAMETHOXAZOLE and TRIMETHOPRIM!
Resistance to sulphonamides has increased so there are restrictions on the use of co-trimoxazole.
LIMITED USE. 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
What antibiotics require reporting on blood disorders/ rash?
Co-trimoxazole (contains trimethoprim and sulfamethoxazole)
Discontinue immediately if signs of a blood disorder such as anaemia, thrombocytopenia, rash (Steven-Johnson syndrome), photosensitivity
Trimethoprim- risk of blood disorders, signs include fever, sore throat, ulcers, bruising, bleeds
Penicillamine: used as a disease-modifying anti-rheumatic drug but same as above, to report fever, sore throat, ulcers, bruising
What do you see fusidic acid commonly used for?
What formulations are available?
Staphylococcal infection of the SKIN e.g. impetigo & also EYES
Tablet, cream, eye drops
What happens if a patient on clindamycin develops diarrhoea?
Antibiotic associated colitis with clindamycin can be fatal
Discontinue immediately + start vancomycin
Why antibiotic has been associated with myopathy/muscle effects?
Daptomycin
Monitor creatinine kinase every 2 days if muscle effects reported
Which antibiotics can cause cholestatic jaundice?
Co-amoxiclav
Nitrofurantoin
Flucloxacillin (even upto 2 months after)
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!!
A few antibiotics have been associated with visual problems. Name them.
Linezolid- optic nephropathy
Quinolones (Ciprofloxacin, Levofloxacin)- retinal detachment
Ethambutol- ocular toxicity
Rifampicin- colours tears/ contacts orange
Rifabutin- uveitis (eye inflammation)
What two adverse events should be monitored during Linezolid treatment?
Optic neuropathy (visual problems)- report any visual disturbance IMMEDIATELY
Blood disorders- aneamia, thrombocytopenia
FBC monitored especially in treatment of 10-14 days or more
What are the two safety warnings with QUINOLONES (ciprofloxacin, levofloxacin)?
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
This has also been reported with prednislone.
Can also prolong QTc interval- caution
When should patients discontinue treatment with Quinolones?
If any of the following occur:
Psychiatric reactions- hallucinations, anxiety, depression
Neurological reactions- tremor, asthenia (abnormal weakness)
Which antibiotics can cause QT prolongation?
MACROLIDES
Erythromycin
Clarithromycin
Azithromycin
QUINOLONES
Ciprofloxacin
Levofloxacin
Especially Moxifloxacin
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 foods
Remember: Linezolid will still have interactions/tyramine effects 2 weeks after discontinuation
What can happen if vancomycin is infused too rapidly?
RED MAN SYNDROME
Severe Hypotension
Wheezing
Pruritis
Pain
Muscle spasm in back
After how many doses should Vancomycin plasma levels be measured?
Pre fourth dose if renal function is normal
What side effects do Vancomycin and Gentamicin both have in common? What drugs should be avoided with these?
Ototoxicity
Nephrotoxicity
Ototoxic drugs: Loop diuretics
Nephrotoxic drugs: ciclosporin, platinum chemotherapy
Treatment with Vancomycin requires full blood count monitoring. Why is this?
Risk of neutropenia
Which antibiotics could cause CHOLESTATIC JAUNDICE?
FLUCLOXACILLIN- may even occur up to 2 months after flucloxacillin stopped, more likely after TWO WEEKS of treatment.
Co-fluampicil (contains amoxicillin and flucloxacillin)
Co-amoxiclav
Nitrofurantoin
Which antibiotics are commonly used to treat acne??
Tetracyclines most common: tetracycline, doxycycline, oxytetracycline
Erythromycin (a macrolide) sometimes used
What conditions can Tetracyclines exacerbate?
Systemic Lupus Erythematosus
Myasthenia Gravis (increased muscle weakness)
Which antibiotics can cause photosensitivity?
Doxcycline
Demeclocycline
Which antibiotics are not recommended in children and adolescences under 18 years old? And why?
Quinolones: Ciprofloxacin, levofloxacin, moxifloxacin
This is because of the risk of TENDON DAMAGE/ JOINT DISEASE (Aropathy)
What is an important monitoring parameter with Linezolid?
WEEKLY Full Blood Counts due to risk of blood disorder/ anaemia
Which antibiotics may cause a false positive result on urinary glucose tests- i.e. be careful when testing for diabetes?
CEPHALOSPORINS
Cefalexin, Ceftriaxone etc
Which antibiotic is a FOLATE SYNTHESIS INHIBITORS and is therefore teratogenic?
Trimethoprim
Co-trimoxazole (contains sulfamethoxazole and trimethoprim)
Therefore AVOID in pregnancy- especially first trimester when folate is needed
What frequency of administration is Vancomycin given?
What about Teicoplanin?
12 hourly due to long half life
Teicoplanin: even longer acting OD dosing after loading dose
Name 2 Glycopeptide antibiotics?
Vancomycin
Teicoplanin (less nephrotoxic than vancomycin)
What are the target pre-dose TROUGH levels for vancomycin?
10 - 15 mg/ L
First line antibiotic for Cellulitis?
And in penicillin allergy?
Flucloxacillin (250-500mg QDS)
If penicillin allergic: Clindamycin
Which antibiotics/ antifungals may cause STEVEN-JOHNSON SYNDROME?
Co-trimoxazole
Clindamycin
Fluconazole
What are some of the more common side effects experienced with Metronidazole?
Lots of GI disturbance- sick, stomach pain
Mouth effects: Taste disturbance, oral mucositis (mouth ulcers), furry tongue
Alcohol- disulfiram like reaction
What is fusidic acid used for?
Narrow spectrum antibiotic used for STAPHYLOCOCCAL SKIN infections
Used for impetigo (topical)
Staph eye infections (topical)
Which antibiotic is cautioned in problems to do with the following?
Lungs
Liver
Neurones
Nitrofurantoin:
Pulmonary Fibrosis
Cholestatic Jaundice
Peripheral
Neuropathy
Can cause Vit B/ Folate deficiency
Which antifungal medication can cause QT prolongation?
FLUCONAZOLE
What antibiotics/antifungals should be stopped if signs of dark urine, vomiting, fatigue, anorexia occur?
This indicated LIVER FAILURE
Discontinue drugs that are hepatotoxic: Itraconazole
Fluconazole
Ketoconazole
Terbinafine
Rifampicin
Isoniazid
Pyrizinamide
Which antifungal is cautioned in patients at a high risk of heart failure?
ITRACONAZOLE
As can worsen this
More at risk if on negatively ionotropic drug e.g. CCB
What skin condition may Terbinafine (antifungal) exacerbate?
Psoriasis
Which antifungal can cause renal toxicity?
AMPHOTERICIN
Can also cause electrolyte disturbance- Hypokaleamia and hypomagneseamia
Which antimalarials are unsuitable in patients with epilepsy/history of epilepsy?
CHLOROQUINE
MEFLOQUINE
Which antimalarials are ok to use in pregnancy?
Chloroquine and Proguanil can both be used at normal doses in pregnancy as benefit of malaria prophylaxis outweighs any risk
BUT recommend FOLIC ACID 5mg to be taken with proguanil
What does the antimalarial Malarone contain?
What condition is this recommended in?
Proguanil & Atovaquone
This is fine to use in epilepsy- does not contain chloroquine or mefloquine
What is the most common causative bacteria of a UTI?
E. coli
What is the main indication for clindamycin?
Why?
Osteomyelitis
Good bone penetration
Daktacort cream (containing Miconazole and Hydrocortisone) needs to be stored where?
What about Daktacort ointment?
Daktocort CREAM stored in fridge- creams are more water based so more liable to bacterial growth
Ointment on shelf- more stable, less water less bacteria
Similar to chloramphenicol eye drops/ ointment- DROPS in FRIDGE as more water based, ointment on shelf
What drugs are used to treat Bacterial Vaginosis?
Metronidazole vaginal gel
Clindamycin cream
Which antifungal requires an Alert card as it is so Hepato-toxic?
Voriconazole
What two toxicities may Voriconazole cause?
Hepatotoxicity
Phototoxcity
What antibiotics are commonly seen prescribed for chest infections?
Penicillins- Amoxicillin or Ampicillin
Or if not: A Macrolide - Azithromycin, Clarithromycin or Erythromycin
Co-amoxiclav used for more serious chest infections as it has broader action over the typical bacteria (e.g. H. influenzae)
How is oral thrush managed?
Initially topical treatment with either Miconazole oromucosal gel or NYSTATIN oral suspension
If these don’t work or patient has a dry mouth can use Oral fluconazole capsule
What is the key drug interaction with meropenem?
Sodium Valproate level significantly reduced
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)
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.
Aside from antibiotics like clindamycin etc, what can cause C.diff?
PPI
What is the difference between the discharge in bacterial vaginosis and Trichomoniasis Vaginalis?
Bacterial vaginosis- thick, white and fishy discharge-
Trichomoniasis Vaginalis- frothy-smell, green/ yellow coloured
What are the most common causative organisms of Community Aquired pneumonia?
Streptococcus pneumoniae
Haemophilus influenzae
Atypical (less common):
Chlamydia pneumoniae
Mycoplasma pneumoniae
Legionella
What antibiotics are suitable in pregnancy?
Penicillins and Cephalosporins
What are the indications for aminoglycosides?
Used for serious infections
CNS infections e.g meningitis, TB
Pyelonephritis, pneumonia, endocarditis
What is the therapeutic range for gentamicin?
5-10mg/L
Which aminoglycoside is given orally? And why?
Neomycin
Too toxic for IV use
What are the side effects of aminoglycosides?
1) Nephrotoxicity
2) Ototoxicity
3) Peripheral neuropathy
Aminoglycosides shouldn’t be used in what conditions? Why?
1) Myasthenia gravis (impairs neuromuscular transmission)
2) Pregnancy (ear damage)
Aminoglycosides interact with what drugs?
1) Loop diuretics and Vancomycin (ototoxicity)
2) Cisplatin, Ciclosporin and vancomycin (nephrotoxicity)
IV treatment with aminoglycosides should not exceed how many days?
7 days
Monitoring requirements for aminoglycosides?
1) Plasma concentration (18-24 hours after dose)
2) Renal function (especially during periods of dehydration)
3) Auditory and vestibular function
Common bacteria in meningitis? (3)
1) Neisseria meningitidis
2) Streptococcus pneumoniae
3) Haemophilius influenza
Antibiotics used in meningitis?
Benzylpenicillin, cefotaxime, chloramphenicol
Name 8 cephalosporins?
1) Cefalexin 2) Cetrotide 3) Cefaclor 4) Cefuroxime 5) Cefixime 6) Ceftriaxone 7) Ceftaroline 8) Fosamil
Are cephalosporins broad spectrum?
Yes
Indications for cephalosporins?
2nd or 3rd line treatment for UTI and RTIIV for severe resistant organisms Pneumonia, meningitis, gonorrhoea
Side effects of cephalosporins? (2)
1) GI effects
2) Penicillin hypersensitivity (avoid in known allergy)
Do IV cephalosporins require approval by a microbiologist?
YES and are now mainly restricted to antibiotic associated colitis
What is the interaction between cephalosporins and warfarin?
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.
What is the first line antibiotic group for MRSA?
Glycopeptides e.g vancomycin, Teicloplanin etc
What indications are glycopeptides generally used for?
MRSAC.diff endocarditissurgical prophylaxis (MRSA risk)
What are the main side effects of glycopeptides? (5)
1) Nephrotoxicity
2) Blood disorders
3) Ototoxicity
4) Red man syndrome
5) Thrombophlebitis (IV)
When would you avoid using glycopeptides?
Elderly, history of deafness, renal impairment, pregnancy (ear damage)
What are the monitoring requirements for glycopeptides? (5)
1) FBC
2) WCC
3) Hepatic and renal function
4) Urinalysis
5) Auditory function in elderly
What drugs do glycopeptides interact with?
Ciclosporin, cisplatin, aminoglycosides, loop diuretics, suxamethonium (Increase vancomycin conc)
What are the indications for clindamycin (lincosamide)? (3)
1) Staphylococcal joint and bone infections
2) Intra abdominal sepsis
3) Cellulitis and skin and soft tissue infections (effective against penicillin resistant streptococci)
Important side effects of clindamycin? (4)
1) Antibiotic associated colitis-REPORT diarrhoea
2) Esophageal disorders
3) Jaundice
4) SJS, rash
In what patient groups is clindamycin CI?
Existing diarrhoea
Caution in middle aged/ elderly women after an operation
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)
Important side effects of macrolides? (4)
1) Antibiotic associated colitis
2) QT prolongation
3) Ototoxicity
4) Cholestatic jaundice
Why would you avoid using macrolides in myasthenia gravis?
Macrolides cause electrolyte abnormalities which can aggravate myasthenia gravis
Main CI for macrolides?
1) Hepatic impairment (cholestatic jaundice)
2) Arrhythmia (QT prolongation)
What drugs interact with macrolides?
1) CYP450 substrates
2) Drugs that prolong QT interval
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
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
Is metronidazole a CYP450 inhibitor?
NO, it is a substrate of CYP450
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
How long after stopping metronidazole should you avoid alcohol?
2 days
What drugs does metronidazole interact with? (4)
1) CYP450 inhibitors
2) CYP450 inducers
3) CYP450 substrates
4) Lithium (reduces clearance of lithium resulting in toxicity)
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.
What duration of treatment with metronidazole requires FBC and hepatic monitoring?
10 days
Are penicillins broad spectrum?
Yes
What are the main indications for penicillins? (7)
1) Tonsillitis (streptococcal)
2) Otitis media
3) Cellulitis
4) RTI5) Meningitis
6) Tetanus (C.diff)
7) Skin and soft tissue infections
Main side effects of penicillins? (2)
1) Penicillin allergy
2) CNS toxicity (convulsions, coma)
Main drug interaction of penicillins?
Methotrexate- reduced renal excretion and increased toxicity
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 penicillins- Cholestatic jaundice (no more than 14 days treatment)
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 penicillins +Cholestatic jaundice
Name two diaminopyrimidine antibiotics.
1) Trimethoprim
2) Co-trimoxazole
How do diaminopyrimidines work?
Bacteriostatic-inhibit folate synthesis
Main indications of diaminopyrimidines?
Uncomplicated UTI (200mg 12 hourly), RTI, pneumocystis pneumonia (co-trimoxazole)
What are the main side effects associated with diaminopyrimidines? (2)
1) Blood disorders (look out for bruising, bleeding, ulcers etc)
2) SJS
What are the main CI for diaminopyrimidines? (2)
1) Pregnancy (Teratogenic-especially in first trimester)
2) Caution in folate deficiency
Drugs that interact with diaminopyrimidines?
K+ elevating drugs e.g ACE inhibitors, ARB’sFolate antagonists e.g methotrexate Phenytoin, warfarin (reduced clearance)
Name five Quinolone antibiotics?
1) Ciproflaxacin
2) Monoflaxacin
3) Levofloxacin
4) Ofloxacin
5) Norfloxacin
Why are quinolones typically 2nd and 3rd line drugs?
Rapid resistance developing
Main indications that quinolones are used for? (4)
1) UTI
2) severe GI infections including travelers diarrhoea
3) LRTI
4) Gonorrhoea
What are the main side effects associated with quinolones? (5)
1) C. diff
2) Neurological-seizures and hallucinations
3) Inflammation and rupture of tendons-STOP
4) Prolong QT interval-arrhythmia
5) Photosensitivity
What is an important side effect of monoflaxacin?
Life threatening hepatotoxicity
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)
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
What is the last resort antibiotic for MRSA?
Linezolid (vancomycin resistant cocci)
What types of infections is Linezolid used for?
Complicated skin and soft tissue infections and pneumonia
What type of drug is linezolid? (HINT-psychiatric effects)
MAOI
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)
What foods should be avoided while taking linezolid?
Tyramine rich foods
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)
What monitoring is required for Linezolid if treatment exceeds 28 days?
Check for optic neuropathy
What drugs does Linezolid interact with and why?
SSRIs, triptans, tricylic antidepressants, sympathomimetics, buspirone, opioids, pethidine, antipsychotics (MAOI inhibitor)
Which TWO drugs cause peripheral neuropathy?
Metronidazole and nitrofurantoin
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)
What are the main side effects associated with nitrofurantoin? (4)
1) Dark yellow/ brown urine
2) Pulmonary reactions
3) Peripheral neuropathy
4) Hepatitis
In what patient groups would nitrofurantoin be an inappropriate choice? (2)
1) Pregnancy
2) CI in renal impairment
What are the TWO monitoring requirements for LT nitrofurantoin use?
Hepatic and pulmonary function
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
What are the treatment options for an uncomplicated UTI in a child >3mo?
Trimethoprim, Nitrofurantoin, Cefalexin, amoxicillin
What are the treatment options for an uncomplicated UTI in a child <3mo?
IV ampicillin with gentamicin or cefotaxime in hospital, then oral treatment
What are the antibiotic treatment options for recurrent UTI’s in children?
Trimethoprim or nitrofurantoin
Name FIVE tetracyclines?
Tetracyline, doxycycline, minocycline, lymecyline, oxytetracyline
What are the main indications for tetracylines? (4)
1) Chlamydia and PID
2) Acne
3) LRTI (including COPD)
4) Malaria, lyme disease, rickettsia
Main side effects associated with tetracylines? (5)
1) Photosensitivity
2) Esophageal irritation
3) Hepatotoxicity
4) benign intracranial pressure- headache and visual disturbances-STOP
5) Discoloration of tooth enamel
In what patient groups would you want to avoid tetracylines?
1) Children <12 (binds to teeth)
2) Pregnancy and breastfeeding
Name TWO conditions that require prolonged courses of antibiotics?
TB and osteomyelitis
Antibiotic used to prevent pneumococcal infection in sickle cell disease?
Phenoxymethylpenicillin, if CI then erythromycin
Antibiotic used as prevention for early onset neonatal infection?
Benzylpenicillin (IV)
Name FOUR beta lactam antibiotics?
1) Penicillins
2) Cephalosporins
3) Carbapenems
4) Monobactams
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
What is the first line treatment for C.diff?
Metronidazole(or vancomycin or fidoxamicin)
What can a tobramycin dry powder inhaler be used for?
Pseudomonas lung infection in CF
Name TWO carbapenems?
Imipenem and Meropenem
Name TWO cephalosporins that can be used for CNS infections?
1) Cefotaxime
2) Ceftriaxone
Which cephalosporin has good activity against haemophillus influenza?
Cefaclor
Which cephalosporin should be used in history of hypercalciuria (history of renal stones)?
Ceftriaxone
What is the maximum duration of treatment for fusidic acid?
10 days
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
Name TWO antimycobacterials?
Clofazimine and Dapsone (both used for leprosy)
Name the FOUR antibiotic groups that can be used in lyme disease?
1) Macrolides
2) Amoxicillin
3) Macrolides
Name SEVEN bacteria that can cause UTI?
1) E coli
2) Staph saprophyticus
3) Proteus
4) Klebsiella
5) Pseudomonas aeruginosa
6) Staph epidermidus
7) Enterococcus Faecalis
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
What is the treatment for a >50 year old with meningitis?
Cefotaxime or ceftriaxone AND Amoxicillin or Ampicillin Consider adding vancomycin (10 days)
How long is the initial phase of TB treatment?
2 months
How long is the second phase of TB treatment?
4 months
What drugs are used in the initial phase of treatment for TB?
At what doses?
Isonazid (300mg OD)
Rifampicin (<50kg=450mg OD, >50kg=600mg OD)
Pyrazinamide (<50kg=1.5g, >50kg=2g OD)
Ethambutol (15mg/kg OD)
What drugs are used in the second phase of treatment for TB?
Isonazid (300mg OD)
Rifampicin (same as initial)
Which TB drugs cause liver toxicity?
Isonazid
Rifampacin
Pyrazinamide
Which TB drugs cause peripheral neuropathy?
Isonazid
Which TB drugs cause occular toxicity?
Ethambutol
What are the monitoring requirements for TB treatment?
Plasma levels e.g ethambutol
Urinalysis
Visual acuity testing
Blood counts
Liver and hepatic function
Auditory function in the elderly
What is the duration of treatment for extrapulmonary TB?
10 months
What is a specific CI of pyrazinamide?
Acute attack of gout
Name the antibiotics in the aminoglycoside class
Amikacin
Gentamicin
Neomycin
Streptomycin
Tobramycin
What aminoglycosides are active against Pseudomonas 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?
Streptomycin (mainly reserved for this indication)
Can aminoglycosides be given orally?
No- destroyed by the gut so must be given via injection
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
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
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
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
What antibiotic can be used for prevention of secondary infection in Influenza Type B?
Rifampicin
What antibiotic can be used for prevention of secondary cases of diphtheria in non-immune patients?
Erythromycin
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 if 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/flucloxacillin
Add in 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 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 systemic antifungal is used in vaginal candidiasis?For resistant organisms, what can be used?
Fluconazole
Itraconazole as an alternative
What is micafungin licensed for?
Invasive candidiasis
Oesophageal candidiasis
Prophylaxis of candidiasis in patients undergoing haematopoietic stem cell transplantation
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
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 vanc10 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 benpenIf penicillin and cephalosporin resistant, vancomycin and rifampicin can be added14 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
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 is the recommended length of treatment for osteomyelitis?
6 weeks
Osteomyelitis and septic arthritis antibiotic choice:1. First line2. If penicillin allergic3. 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:TeicoplaninVancomycin
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 prolongationand 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 treatmentSmall 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?
42 months
How many antibacterials are used in the continuous phase of TB treatment and how long for?
24 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 monthsInitial 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
Are different preparations of amphotericin interchangeable?
No
Should preferably prescribe by brand to avoid confusion
What is a specific side effect with IV isavuconazole?
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 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 alphaInterferon 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
Efavirenz for HIV is associated with an increase in plasma concentration of what substance?
Cholesterol
What are the long term effects of HIV treatment?
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 usedWithin 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 shouldweigh the potential benefits of ketoconazole treatment against the risk of liver damage and shouldcarefully monitor patients both clinically and biochemically.
What penicillin based antibiotics must you take on an empty stomach?
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 orzinc 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 drugsAlkylating agentsTCAsARBs
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 fluii) 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 do 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 treatmentWith 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?TeicoplaninVancomycin
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
With which quinolone should you protect yourself from sunlight?
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
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
Start 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
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
Should mefloquine be taken on an empty stomach?
No, take just after food
What are the side effects associated with glycopeptides?
Infusion reactions, headache, nausea, diarrhea, skin rash and pruritus
C. diff
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? Treatment duration?
Amoxicilin, clarithromycin or doxycycline for 5 days
What is first line for acute exacerbation of bronchietasis? Treatment duration?
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
