Chapter 5: Infections

Question 1

Updates

Answer 1

 Nitrofurantoin (can change urine color to brown, harmless): reminder of the risks of pulmonary (difficulty breathing, wheezing, SOB) and hepatic (dark urine, jaundice, abdominal pain, n+v, abdominal discomfort) adverse drug reactions [MHRA/CHM advice]=>stop and refer
 Quinolones: reminder of the risk of disabling and potentially long- lasting or irreversible side effects (aortic aneuryms) [MHRA/CHM advice] (see example in ciprofloxacin).Fluoroquinolone=>refer to A+E
 Quinolones: suicidal thoughts and behavior [MHRA/CHM advice] (see example in ciprofloxacin). Fluoroquinolone=>stop and refer to A/E
***signs of ototoxicity (aminoglycosides)
 PHARMACY FIRST SCHEME !!! 7 CONDITIONS: self-refer/GP/111 can send to pharmacy for infections, able to give antibiotics (uncomplicated meaning no blood in urine/recurrent UTI Female 16-64, Impetigo, Acute Sore Throat, Shingles, Infected Insect Bites in Adults and Children over 1 (redness, inflammation, discharge, hot)=>flucloloxaciilin=>allergic: clarithromycin/doxy, Acute Sinusitis, Acute Otitis Media)

Question 2

Notifable Diseases

Answer 2

 Inform government within 3 days (24 hrs for urgent cases)  Examples
 ●Anthrax
 ●Cholera
 ●COVID
 ●Food poisoning
 ●Malaria
 ●Measles
 ● Meningitis/meningococcal septicaemia
 ●Mumps
 ●Polio
 ●Rabies
 ●Rubella

Question 3

Antibiotics in Pregnancy

Answer 3

Which antibiotics are generally/commonly regarded as safe in pregnancy?
>Amoxicillin, Cefalexin, Erythromycin (consider)
>Different trimesters carry different risks for certain drugs.
>Trimethoprim – Avoid in 1st trimester (1st 3 months)
>Nitrofurantoin – Avoid at term (40 weeks): last 4 weeks before due date cause cause infant haemolysis (bleeding)
>Doxycycline – Avoid but entire course must be completed before 15 weeks of pregnancy for malaria
>Chloramphenicol – avoid . Can also cause grey baby syndrome in 3rd trimester, do not sell OTC for pregnant/breastfeeding/under 2
>Aminoglycosides - AVOID

Question 4

A 7-year-old child presents with Bolus impetigo. She feels unwell and has had the symptoms for 3 days. She had a previous allergy to cefalexin. Which micro- organism is a likely cause of impetigo?
A. Helicobacter pylori
B. E. Coli
C. Streptococcus p.
D. Pseudomonas aureginosa
E. MRSA

Answer 4

E. MRSA (methylene resistant stapholococcuss aureus)

Bolus: flucloloxacillin

Question 5

A 62-year-old woman has been admitted to hospital with urinary tract infection. She has a history of long QT, her eGFR is 35ml/min, she is allergic to penicillin and also takes simvastatin for hypercholesteremia.
 Which of the following antibiotics would you recommend for this patient based on the information provided?
a) Trimethoprim
b) Ceftriaxone: cephelosponir/carbapenam similar to penicillin
c) Nitrofurantoin (min eGFR 45)
d) Amoxicillin (allergic)
e) Clarithromycin (QT prolongation, interacts with statins)

Answer 5

a) Trimethoprim

Question 6

QuickPoints

Answer 6

 Doxycycline, Demeclocycline (photosensitivity most common than with any other tetracyclines) Antibiotics that Pts should avoid sunlight (widespread rashes, affluence: discharge)
 Flucloxacillin: Cholestatic jaundice and hepatitis (2 week, MAX)
 Co-amoxiclav: cholestatic jaundice (^bilirubin, ^ALT/AST)
 Ethambutol (TB)– visual effects
 Linezolid: blood disorders (methotrexate, vancomycin, mirtazipine, trimethoprim, carbimazole) (sore throat, fever, purpura, bruising, bleeding, mouth ulcer) and optic neuropathy
 Co-trimoxazole: Steven Johnson syndrome
 Quinolones : tendon damage (increases risk with steroids), arthropathy (joint problems) in children and possible convulsions (with NSAIDS)

Question 7

Site of Infection Task

Answer 7

UTI: E. coli
Skin infections: staphylococcus aureus (MRSA)
Community Acquired Pneumonia:
Otitis Media: streptococcus pneumonia

***use tablet

Question 8

Anti-biotic Therapy

Answer 8

GENITAL SYSTEM INFECTIONS
 Bacterial vaginosis – oral metronidazole, clindamycin topical (dalacin)
 Chlamydia - Age 16-25, doxycycline 100mg BD for 7 days, 2nd Line: azithromycin 1g STAT, abstain from intercourse for 7 days
**mention to partners

 Urinary Tract infection:
 Nitrofurantoin and Trimetoprim (not pregnant, on methotrexate) (can use amoxicillin, ampicillin, oral cephalosporin)
 Nitrofurantoin – Avoid if Egfr is less than 45ml/min. 3 days treatment for women and 7 days for men and pregnant women.
 G6PD DEFICIENCY=>nitrofurantoin can cause bleeding in pts with this

Question 9

You work as an independent prescriber pharmacist in a GP surgery. Mary a-35-year-old female patient presents with a lower-urinary-tract infection without haematuria. Mary tells you that she is 3 months pregnant and has a chronic kidney impairment as well. She also mentions that despite making lifestyle changes such as drinking loads of water and cranberry juice over the last 72 hours, her symptoms continue to get worse. She is also severely allergic to penicillin. She takes no other medication.
 Her latest test results show an eGFR of 31ml/min
 What is the most appropriate next line of action?
 A. Recommend a course of Nitrofurantoin for 7 days.
 B. Recommend a course of amoxicillin for 7 days
 C. Recommend a course of Trimethoprim for 7 days
 D. Recommend a course of cefalexin for 7 days
 E. Recommend a course of Fosfomycin 3g STAT

Answer 9

 E. Recommend a course of Fosfomycin 3g STAT

Question 10

Anti-Biotic Therapy

Answer 10

G. I. INFECTIONS
 campylobacter (most likely cause of food poisoning)
clarithromycin or ciprofloxacin
 Salmonella – ciprofloxacin Gastro-enteritis (gastritis)- SELFLIMITING
 Shigellosis - ciprofloxacin
 E.COLI – ciprofloxacin

Question 11

Nose Infections

Answer 11

NOSE INFECTIONS
 SINUSITIS treatment: infected–produce mucous that is green/yellow, foul smell, systemic illness (lethargic, tired, fever)
 RX
 PHENOXYMETHYLPENICILLIN  CO-AMOXICLAV
 DOXYCYCLINE OR CLARITHROMYCIN IF ALLERGIC TO PENICLLIN

Question 12

CNS: Bacterial Meningitis

Answer 12

> Meningitis–initial empirical therapy
**glass test: press against rashes on skin, if rash doesn’t disappear=>serious
Transfer patients to hospital
immediately
with non-blanching rash , Give Benzylpenicillin (Pencillin G) before transfer to hospital if appropriate.
Cefotaxime – alternative >Chloramphenicol–alternative
**Dexamethasone (particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial; avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery.

Question 12

MENINGITIS: IF AETIOLOGY IS UNKNOWN

Answer 12

 In hospital, if aetiology unknown:
* Adult and child 3 months–59 years, cefotaxime (or ceftriaxone)
* Consider adding vancomycin if prolonged or multiple use of other antibacterials in the last 3 months, or if travelled, in the last 3 months, to areas outside the UK with highly penicillin- and cephalosporin-resistant pneumococci.
* Suggested duration of treatment at least 10 days***
* Adult aged 60 years and over cefotaxime (or ceftriaxone)
+ amoxicillin (or ampicillin)
* Consider adding vancomycin if prolonged or multiple use of other antibacterials in the last 3 months, or if travelled, in the last 3 months, to areas outside the UK with highly penicillin- and cephalosporin-resistant pneumococci.
* Suggested duration of treatment at least 10 days

Question 13

ANTI-BIOTIC THERAPY – RESPIRATORY SYSTEM

Answer 13

RESPIRATORY SYSTEM INFECTIONS
CAP (first 48 hrs)
✓ COMMUNITY-ACQUIREDPNEUMONIA–(LOW-SEVERITY)
 Amoxicillin
✓ COMMUNITY-ACQUIRED PNEUMONIA (MODERATE)
AMOXICILLIN
✓ COMMUNITY-ACQUIRED PNEUMONIA(HIGH)  CO-AMOXICLAV …..2nd levofloxacin (quinolone, tendon damage)

✓ HOSPITAL-ACQUIRED PNEUMONIA – OVER 48 hours
 Day 3,4,5…EARLY ONSET/ non severe – CO-AMOXICLAV (2nd line:
…Day 6,7,+LATE ONSET / severe– higher risk of resistance: PIPERACILLIN AND TAZOBACTAM IV

Question 14

Consider the pic of a 34-year-old patient who presents with the symptom shown. He noticed it this morning According to NICE guidelines, what should your advice the patient to be ?
 A. Ask him to buy some chloramphenicol eye drops.
 B. Ask him to buy some chloramphenicol eye ointment.
 C. Ask him to do nothing.
 D. Refer him to his GP.
 E. Ask him to use warm flannel.

Answer 14

 E. Ask him to use warm flannel.

stye: self-limit measures for 3 days, if persistent can give ointment

Question 15

Blood Infections

Answer 15

What are the symptoms of sepsis? fever, lethargic, tired, pale, **dry nappy, high pitch cry
 Septicaemia hospital acquired ——- piperacillin and tazobactam
 Septicaemia community acquired –—– piperacillin and tazobactam
 Septicaemia related to vascular catheter - —– vancomycin (VV)

EAR INFECTIONS
 OTITIS EXTERNA (outer ear, warm to touch)– First Line – Spray (acetic acid=>earcalm/if doesn’t help, refer to GP=>otomize) or FLUCLOXACILLIN , Second Line - clarithromycin
 OTITIS MEDIA (discharge, loss of hearing, pain, middle of ear)– FL - AMOXICILLIN SL – COAMOXICLAV / CLARITHROMYCIN

EYE INFECTIONS
 CONJUCTIVITIS – first line: self-limiting, Chloramphenicol or fusidic acid eye drops

Question 16

Skin Infections

Answer 16

 Diabetic foot ulcer (staph a)- mild and severe cases – flucloxacillin
Impetigo –
bolus (yellow brown, likely to cause systemic illness): fluclox
non-bolus (common, golden brown crust): hydrogen peroxide, fuscidic acid cream, mupirocin cream, fluclox
 Cellulitis / Erysipelas (staph a)- Flucloxacillin, clarithromycin or doxycycline
 Animal and Human bites – Co-amoxiclav, Doxycycline+ METRONIDAZOLE
 Mastitis – FLUCLOXACILLIN /// Erithromycin 10 to 14 days

Question 17

You work as a hospital pharmacist. An infant presents with scarlet fever. The infant is 9 months old. Given that the infant has penicillin allergy history, which antibiotic would you expect to be prescribed for this child as first line treatment according to NICE guidelines ?
 A. A course of metronidazole
 B. A COURSE of Azithromycin
 C. A course of Flucloxacillin
 D. A course of doxycycline
 E. A course of phenoxymethylpenicillin

Answer 17

Refer pts with scarlet fever
first line: pen V, allergic=>azitrhymicon

 B. A COURSE of Azithromycin

Question 18

C. Diff (PPIs can increase risk)

Answer 18

Some antibiotics cause C.Diff infection as a side-effect.
 Examples include –
 CO-Amoxiclav, **Clindamycin (worried about as can cause C.Diff), Cephalosporins (2nd & 3rd generation), Ampilcillin, Amoxicillin, Quinolones

TREAT WITH
New change in BNF Jan 2022
 VANCOMYCIN (1st) or (alternative) FIDAXOMICIN Orally
 only if first choice not available - metronidazole

Question 19

Quick Points

Answer 19

Colourful urine:
Rifampicin —- Orange/brown urine (harmless, reassure it is fine)
 Nitrofurantoin—— yellow/brown urine
 METRONIDAZOLE - DARK urine color
Trimethoprim, Co-trimoxazole – CAUSE Blood disorders (sore throat, fever, malaise, rash, mouth ulcers, bruising and bleeding)
 Vancomycin can cause ………….. Syndrome? red man’s syndrome (splotchy deep redness, develops from drug being infused too quickly but is reversible), vancomycin can cause nephrotoxicty (happens over time)

blue urine: amitryptiline, triamterene

Question 20

Aminoglycosides

Answer 20

narrow therapeutic index=>monitor

**serum conc, hearing, skin reactions, histamine related reactions
tailor dose to specific patient taking into account ideal body weight

 SUMMARY
 They are not absorbed from the gut although its possible in IBD/Liver disease (eye and ear drops formulated, injections)
 Loading dose may be calculated based on patient’s weight or renal function.
 ONCE daily administration is preferred to multiple-daily dose regimens except in patients with ***endocarditis due to gram+ bacteria. (once daily preferred bc monitoring check peak and trough levels less)
 Monitor serum concentration to prevent excessive and sub-therapeutic concentrations – narrow therapeutic index
 PREGNANCY

Question 21

Aminoglycosides SE

Answer 21

Side – effects
 Ototoxicity
 Nephrotoxicity
 Skin reactions
 histamine related adverse reactions – gentamicin (has an allergy will become worse as they will have an increased reaction taking this medication)
 NB– Naseptin cream contains (arachis) peanut oil . Check allergy!!
 TROUGH AND PEAK: after 1 hr, measure peak which is max in the bloodstream, before next dose between 18-24 hrs (6hrs), check plasma condo again which will be the trough, if trough is higher than meant to be=>delay dose and increase interval time until drops within range then administer
 learn gentamicin and amikacin

Question 22

Vancomycin for C. Diff

Answer 22

 PRE – DOSE TROUGH LEVEL – 10 – 15mg
 Avoid in pregnancy
 Nephrotoxicity
 Ototoxicity
 Red mans syndrome: infuse too quickly
 Skin disorders: rashes
 monitoring: plasma, renal, blood disorders

Question 23

Beta Lactam Antibiotics

Answer 23

3 types: all carry beta lactam ring–allergy to one=all
Penicilins
Cephalosporins
Carbapenams

**betalatamous producing bacteria, do not treat with beta lactums

**sodium valproate+carbapenams=carbapenums reduce effects of SV=>more seizures

Question 24

Cephalosporins

Answer 24

 BROAD SPECTRUM (most popular: cefalexin)
 Learn examples of cephalosporin generations
 The principal side-effect of cephalosporins is hypersensitivity.
 About 0.5% - 6.5% of penicillin-sensitive patients will also be allergic to CEPHALOSPORINS
 False positive urinary glucose test
 Also used to treat UTI, soft tissue infections e.g cellulitis, abscess

Question 24

Metronidazole

Answer 24

SUMMARY POINTS on metronidazole (Dentists love prescribing)
 Metronidazole is active against anaerobic bacteria.
 Metronidazole should be taken with or after food. (nitrofurantoin should be taken with food)
 Metronidazole interacts with warfarin, alcohol – avoid + 48 hrs after
 Disulfiram–like reaction (headache, nausea, vomitting, flushing, tired) can occur with alcohol
 Metronidazole can turn urine colour dark (safe)

*can only give with warfarin if INR stable

Question 25

Macrolides

Answer 25

Popular alternative to penicillin allergy
Mechanism - Inhibit bacterial protein synthesis.
 are enzyme inhibitors (increase plasma conc. of other drugs) NB drug Interaction: statins=>myopathy, rhabdolylosis
 can cause ototoxicity in high doses
 QT prolongation (SSRI, quinolones, amiodarone, domperidone)– NB drug Interaction………………..
 Azithromycin 1g used to treat chlymidia
 Good alternative if patient is allergic to penicillin.
 New change – intrx with hydroxychloroquine and chloroquine to cause cardiovascular events

Question 26

Tetracyclines

Answer 26

 SUMMARY
 Tetracyclines are broad-spectrum antibiotics
 Tetracyclines are photosensitive
 Can cause teeth discolouration – should not be give to children under 12 years
 Headache and visual disturbances may indicate benign intracranial hypertension=>stop and refer
 Tongue and tear discolouration can occur with minocycline .
 minocycline can cause lupus and irreversible pigmentation . Pg 609
 Do not give to pregnant women .and breastfeeding.

Question 27

DOGS LIKE MILK- DOXYCYCLINE , LYMECYCLINE, MINOCYCLINE

Answer 27

cautionary labels: do not take with milk, indigestion remedies: dogs like milk

Question 28

Quinolones (-loxacins)

Answer 28

> See MHRA and CHM safety information on the use of systematic and inhaled fluoroquinolones. BNF 82
The CSM has warned that quinolones may induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them. Discontinue if psychiatric, neurological or hypersensitivity reactions (including severe rash) occur.
risk of tendon damage
quinolones are contra-indicated in patients with a history of tendon disorders related to quinolone use
patients over 60 years of age are more prone to tendon damage
the risk of tendon damage is increased by the concomitant use of corticosteroids
if tendinitis is suspected, the quinolone should be discontinued immediately.

Question 29

quinolones

Answer 29

Learn drug interactions associated with quinolones
 QT prolongation
 ANTACIDS? 2hrs before/after
 WARFARIN (increase risk of bleeding), Methotrexate (reduces excretion via the kidneys)
 may affect blood glucose
 May affect growth in children  visual disorders

Question 30

Clindamycin key points

Answer 30

 Clindamycin is well concentrated in bone and excreted in bile and urine.
 gram+cocci, bacteroides fragilis, penicillin resistant staphlococci, causes C. Diff infections
 Skin reactions are very common
 Clindamycin has been associated with antibiotic –associated colitis.
 if treatment exceeds 10 days. Monitor liver and renal function
 warn patients and carers - Discontinue if diarrhoea occurs especially prolonged, severe or bloody.

Question 31

Penicillin

Answer 31

> sensitivity (may have rashes or tummy ache) vs true allergy (anaphylaxis: serious type of allergic reaction)
Inhibit bacterial cell wall synthesis by preventing peptidoglycan cross- linking
Penicillin resistance can be cause by beta-lactamase bacteria.
Some people have an allergy to penicillins.
Up to 10% of patients report allergy but Less than 1 percent of people are dangerously allergic to penicillin
C ross-sensitivity- Patients with a history of immediate hypersensitivity to penicillins may also react to the cephalosporins and other beta-lactam antibiotics, they should not receive these antibiotics.
 Amoxicillin is safe in pregnant and breast-feeding patients.
 avoid in Glandular fever (kissing disease) , rare side effect Amoxicillin – black hairy tongue

Question 32

Penicillin

Answer 32

> Learn doses for common penicillins in children. (amox, fluclox, pen V); Pen V 250mg, 6yrs min age
Taken in an empty stomach: PAF, Pen V, Ampicillin, Fluclox
broad-spectrum penicillins (Ampicillin, Amoxicillin), can cause antibiotic-associated colitis. C.diff
Penicillins can interact with methotrexate
Flucloxacillin can cause liver impairment if used for more than 2 weeks
Ampilcilin absorption can be reduced by the presence of food
Benzylpenicillin sodium is inactivated by bacterial beta- lactamases – used to treat ……….. Caution in hypertension due to sodium content.

Question 33

Tuberculosis

Answer 33

 ACTIVE TUBERCULOSIS (symptoms and knows) AND LATENT TUBERCULOSIS (can infect others and dont know they have it)
 Early infection causes no symptoms as the body’s immune system protects spread, and in many cases, it remains inactive - this stage is referred to as “Latent TB” . Early diagnosis and treatment is necessary to control the spread of the infection. Latent TB can develop into an Active TB.
>Active TB is a stage where immediate medications and care is necessary, the common symptoms include:
 Persistent cough (which lasts for more than 2 weeks)
 Cough with blood in sputum
 Fever for more than 2 weeks
 Pain in chest
 Weight loss
 Night sweats
 Loss of appetite
 CHECK FOR TB BEFORE PRESCRIBING which drugs ? canakinumab (monoclonal antibody)

Question 34

TB Treatment

Answer 34

 TREATMENT FOR TUBERCULOSIS
 PHASE 1 ( 2 MONTHS initial) – RIPE
 RIFAMPICIN
 ISONIAZID
 PYRAZINAMIDE
 ETHAMBUTOL
 PHASE 2 ( 4 MONTHS CONTINUATION ) – R.I.
 RIFAMPICIN AND ISONIAZID (can cause peripheral neuropathy, depletion of vitamin B6/peridoxin=>give supplements)

Question 35

TB Key Points

Answer 35

KEY POINTS
 RIFAMPICIN is a potent enzyme inducer.
Turns bodily fluids to Orange colour
Liver toxicity e.g. dark urine , nausea, jaundice, vomiting, fatigue etc..
 ISONIAZID is a potent enzyme inhibitor.
Can cause low B6 – Pyridoxine leading to neuropathy
Liver toxicity e.g. dark urine , nausea, jaundice, vomiting, fatigue etc.
 PYRAZINAMIDE - Liver toxicity e.g. dark urine , nausea, jaundice, vomiting, fatigue etc.
 ETHAMBUTOL – CAN cause visual effects

Question 36

Fungal Infections

Answer 36

 ORAL THRUSH (candida orbicans)– Miconazole , Nystatin
 VAGINAL THRUSH – Fluconazole, Clotrimazole
 TINEA CORPORIS – Miconazole, clotrimazole , Terbinafine cream ( continue for 7- 10 days after symptoms disappear)
 TINEA CRURIS a.k.a jock itch – Miconazole or clotrimazole (do no give daktacort as it contains steroid, not to be applied to groin)
 TINEA PEDIS - Miconazole, clotrimazole , Terbinafine
 TINEA CAPITIS – Ketoconazole ( can cause liver problems if given orally)
 FUNGAL NAIL INFECTION – ONYCHOMYCOSIS – Amorolfine – refer if more than 2 nails affected. (must be at least 18yrs to be treated OTC)
 SERIOUS FUNGAL INFECTIONS –AMPHOTERICIN B- Nephrotoxic, stick to same brand

***patient with oral thrush on warfarin=>do not sell any -azoles as it interacts and leads to bleeding=>refer to get nystatin

Question 37

Anna has symptoms of oral thrush as shown in the picture. Her regular medication include salbutamol inhaler, warfarin, desogestrel and Qvar inhaler. Which of the following is appropriate treatment for Anna?
She has NKDA
 A. Miconazole oral gel
 B. Fusidic acid
 C. Fluconazole
 D. Flucloxacillin
E. Nystatin

Answer 37

E. Nystatin (bc of drug interaction)

Question 38

Malaria Prophylaxis

Answer 38

LIFE-STYLE ADVICE
 Reduce time spent outdoors in the evening/night.
 long sleeves and trousers worn after dusk.
 Mosquito nets impregnated with permethrin, mats with vaporised insecticides.
 Diethyltoluamide (DEET, Jungle formula) 20–50% formulations is safe and effective when applied to the skin of adults and children over 2 months of age. It can also be used with caution during pregnancy and breast- feeding. DEET reduces the SPF of sunscreen, so a sunscreen of SPF 30-50 should be applied, DEET should be applied after the sunscreen.

Question 39

Malaria Treatment

Answer 39

THERAPY
>Mefloquine - 2-3 weeks before traveling, every week during, and.4 weeks after (weekly dose)
>Atavaquone and proguanil - (malarone) 1-2 days before, everyday, and for 7 days after
>Doxycycline – 1-2 before, everyday during, 28 days after
>Epilepsy- Chloroquine and mefloquine are unsuitable due to neuropsychiatric reactions
>Anticoagulants - Travellers taking warfarin should begin chemoprophylaxis 2–3 weeks before departure; INR should be stable before departure, and should be measured before starting chemoprophylaxis, 7 days after starting, and after completing the course.
>Asplenia - Increased risk of severe malaria, need to be extra cautious against contracting malaria
Pregnancy - …………………………

Question 40

A mother brings her 13-year-old daughter to your pharmacy. She explains that her daughter was bitten on her right leg by an insect whilst in the garden. The bite area was red and inflamed initially but now feels hot to touch and oozes out yellow fluid. Her symptoms have lasted three days, and she would like your advice. You decide to recommend an antibiotic. Which of the following is most suitable for the patient?
A. Azithromycin
B. Trimethoprim
C. Vancomycin
D. metronidazole
E. Doxycycline

Question 41

The most common cause of red man syndrome associated with vancomycin is …………………………….?
A. Rapid infusion of the drug
B. Oral administration of the drug
C. Prolong Intravenous infusion of the drug
D. Rectal administration of the drug.
E. Slow infusion of the drug

Question 42

Mr. G. a 63-year-old male patient has been prescribed ciprofloxacin 500mg BD for 5 days to treat an infection. You notice on his PMR that he takes the following medicines and check for drug interaction.
* Ramipril 5mg OD
* Warfarin 5mg OD
* Bisoprolol 2.5mg OM
* Zopiclone 3.75mg ON
What is the most likely outcome of taking ciprofloxacin alongside
his regular medication?
A. Increased risk of QT prolongation
B. Increased risk of blood clot formation.
C. Increased risk of hypokalaemia
D. Increased risk of bleeding
E. Increased risk of intracranial hypertension

Question 43

Jimmy is a 3-year-old child who presents in hospital with neutropenic sepsis and has been admitted in your hospital ward. His symptoms include dry nappy, high temperature, shivering and feels poorly generally. The doctor on the ward asks you which antibiotic you would recommend as first line treatment for Jimmy given that he is allergic to macrolides. Choose a correct option below.
A. Metronidazole
B. Vancomycin
C. Piperacillin + Tazobactam
D. Vancomycin + Piperacillin + Tazobactam E. Gentamicin

Question 44

Lucy is a 28-year-old female patient who has just been diagnosed with Tuberculosis. Her doctor prescribed Rifampicin which she is supposed to take for 6 months. Lucy also takes desogetrel tablets and would like to discuss the effects of Rifampicin with you. Choose a statement which is most appropriate from the options below.
A. Refer Amy to her GP to get desogestrel changed to microgynon for the duration of treatment.
B. Recommend an IUD which she can use for the duration of treatment plus 4 weeks after.
C. Recommend an IUD which she can use for the duration of treatment plus 6 weeks after.
D. Inform her that there is no drug interaction, so no need to worry.
E. Ask her to use a barrier method like condoms for the duration of Rx.

Question 45

What is the first line treatment of chlamydia according to recent NICE guidelines in 2023?
A. Doxycycline 100mg BD for 1 week
B. Azithromycin 1g STAT
C. Clarithromycin 500mg BD for 1 week D. Amoxicillin 500mg TDS for 1 week E. Ciprofloxacin 500mg BD for 5 days

Question 46

Maria is a 50-year-old patient who is currently suffering from Acute pyelonephritis otitis. Due to her allergy to penicillin, her doctor decides to prescribe Ofloxacin 400mg BD 7/7. She hands the prescription to you but you notice on her PMR that she takes the following medication.
Bendroflumethiazide 2.5mg OD
Oxybutynin 5mg M/R OD
Naproxen 500mg BD
State a potentially serious drug reaction - …………………………………………
What is the main risk of not notifying her doctor of a potential drug interaction?
A. Seizures
B. Hyperkalaemia
C. Myopathy
D. QT-prolongation
E. Ototoxicity

Question 47

You work as a locum pharmacist in a community pharmacy. One Saturday morning, a young lady comes into the pharmacy and asks for the ‘’morning after pill’’. She explains that unprotected sexual intercourse took place on Thursday night, and she is worried about getting pregnant. Her regular medication include –
* Levothyroxine 25mcg for hypothyroidism
* Doxycycline 100mg for acne management
* Omeprazole 20mg for acid reflux
What is the correct next line of action?
A. Supply Ella-one due to sexual intercourse occurring over 72 hours.
B. Refer to the doctor due to drug interaction with doxycycline.
C. Supply levonelle-one-step as there is no drug interaction.
D. Refer to a sexual clinic for Copper -IUD.
E. Refer to the doctor due to drug interaction with omeprazole.

Question 48

CHOOSE A CAUTIONARY LABEL THAT BEST APPLIES TO OXYTETRACYLINE 250MG TABLETS.
A. Do not drink alcohol.
B. Do not take indigestion remedies, or medicines containing iron or zinc, 2 hours before or after you take this medicine.
C. Do not take milk, indigestion remedies, or medicines containing iron or zinc, 2 hours before or after you take this medicine.
D. Do not take anything containing aspirin while taking this medicine. E. This medicine may colour your urine. This is harmless.

Question 49

Lucy is a 22-year-old patient who uses your pharmacy regularly. She comes into your pharmacy to see you one day and complains of headache, dizziness, and visual impairment. She explains that her symptoms are ‘’on and off’. Lucy is on Microgynon, Duac gel, Loratadine and lymecycline long-term. Which of the following is appropriate advice for Lucy?
A. Tell her to book an appointment to get her blood pressure checked since she is on microgynon.
B. Advise her to take paracetamol and return to the pharmacy after a few days if her symptoms do not get better.
C. Ask her to STOP Duac and Refer her to her doctor immediately.
D. Refer her to Accident and Emergency straight away.
E. Ask her to STOP lymecycline and refer her to her doctor immediately.

Question 50

Choose an incorrect statement from the options A – E listed below.

A. Women over 16yrs and under 60 years can be sold canesten capsules for vaginal thrush OTC.
B. Both men and women can be sold canesten cream for the treatment of thrush.
C. Common symptoms of cystitis include frequent visits to the toilet, cloudy urine, burning sensation whilst passing urine and cottage-cheese like discharge.
D. Men should not be sold treatment of cystitis OTC according to current
guidelines.
E. Ringworm in the groin area is also known as Tinea cruris.

Question 51

A 45-year-old male patient presents with cellulitis on his right foot. Samples are taken and sent to the lab for microbiology analysis. The tests confirm the presence of a common microorganism which is known to cause cellulitis. Which of the following microorganisms is a common cause of soft tissue infections such as cellulitis?
* Select an appropriate answer from the list below.
A. Escherichia Coli
B. Streptococcus pyrogens C. Candida Albicans
D. Campylobacter
E. Staphylococcus aureus

Question 52

A 30-year-old female patient presents with lower urinary tract infection. Samples are taken and sent to the lab for microbiology analysis. The tests confirm the presence of a common microorganism which is known to cause lower UTIs. Which of the following microorganisms is a common cause of lower UTIs?
* Select an appropriate answer from the list below.
A. Escherichia Coli
B. Streptococcus pyrogens C. Candida Albicans
D. Campylobacter
E. Staphylococcus aureus

Question 53

A. Linezolid ………………………….
B. Phenoxymethylpenicillin ……………….
C. Ciprofloxacin ………………………
D. Co-amoxiclav …………………….
E. Lymecycline ………………………

• Can interact with warfarin
• Is photosensitive
• Should be taken on an empty stomach
• Can cause blood disorder symptoms
• Can be linked to cholestatic jaundice

Question 54

A 67-year-old patient takes Methotrexate 10mg once a week for rheumatoid arthritis. She has been taking methotrexate for the past 5 years. She presents a prescription for Trimethoprim 200mg BD for 7 days for a UTI. You are aware that there is a drug interaction between both drugs, which of the following is the most likely outcome of taking both drugs together?
A. Hepatic toxicity
B. Respiratory effects C. Myelosuppression D. Stomatitis
E. Renal impairment

Question 54

One Sunday afternoon, Amy, a 9-year-old child presents with scarlet fever. She is accompanied by her father. He informs you that Amy’s symptoms include – fever, sore throat, swollen glands in the neck and strawberry tongue. Amy has had the symptoms for three days. She no known drug allergies What is the correct next line of action?
A. Refer Amy to A & E immediately for urgent medical attention.
B. Explain that the symptoms are self-limiting and will get better in a few days without medication.
C. Sell Calpol over the counter and advise Amy to stay away from school. D. Refer Amy to her GP surgery for medical attention.
E. Advice Amy’s father to call NHS 111 (out of service) and request for flucloxacillin oral suspension.

Question 55

A 34-year-old woman started to take isoniazide 300mg once daily prescribed by her GP to treat tuberculosis, alongside Lithium for Bipolar disorder. When collecting her repeat prescription for lithium, she complains of having dark urine, nausea, and fatigue for the last one week. She wonders if her medicines are to blame.
Which of the following is the most appropriate advice to give to this patient?
Select only one option.
A. she is experiencing a side-effect of Isoniazide, and whilst safe to continue taking it, she may wish to see her GP for an alternative.
B. she should see her GP as the dose of Isoniazide may need to be increased.
C. she should see her GP as the dose of Isoniazide may need to be reduced.
D. stop taking Isoniazide straight away and see her GP as soon as possible.
E. stop taking Isoniazide straight away and see her GP as soon as possible.

Question 56

Mr. Kenny, a 23-year-old, presents in your pharmacy with severe headaches and difficulty with his vision which has lasted for about four days. He tells you that he takes an antibiotic prescribed by his doctor. You decide to refer him to his GP as you deem his symptoms as ‘’red flag’ symptoms. He has no known drug allergies and is otherwise fit and well. Which of the antibiotics listed above is more likely to cause the red flag symptoms described?
* A. Clarithromycin
* B. Lymecycline
* C. Clindamycin
* D. Ciprofloxacin
* E. Vancomycin
* F. Metronidazole
* G. Nitrofurantoin
* H. Flucloxacillin
* I. Fidaxomicin

Question 57

You work as a hospital pharmacist. After been administered an antibiotic for a few days, Mr. A, aged 69 years, presents with mouth ulcers, purpura, sore throat, unexplained bruising, and fever. You decide to inform the rest of the team about your observation. His regular medication includes carbimazole, amlodipine and Ezetimibe. Which of the antibiotics listed above is more likely to cause the symptoms you observed?
* A. Clarithromycin
* B. Lymecycline
* C. Clindamycin
* D. Ciprofloxacin
* E. Vancomycin
* F. Metronidazole
* G. Nitrofurantoin
* H. Flucloxacillin
* I. Fidaxomicin

Question 58

An elderly patient who suffers from dementia comes into your pharmacy. He tells you he has been prescribed an antibiotic and instructed to take it on an empty stomach. He cannot remember which drug it is. Which of the antibiotics listed above should be taken on an
empty stomach?
* A. Clarithromycin
* B. Lymecycline
* C. Clindamycin
* D. Ciprofloxacin
* E. Vancomycin
* F. Metronidazole
* G. Nitrofurantoin
* H. Flucloxacillin
* I. Fidaxomicin

Question 59

A 50-year-old was treated for C-diff infection with vancomycin, but he developed an intolerance to the drug. The doctor on duty asks you to suggest an alternative treatment since Vancomycin is not suitable for the patient. Note – the patient is allergic to penicillin and takes Citalopram for depression. What is the next line treatment for C-diff infection in this case according to recent NICE guidelines?
* A. Clarithromycin
* B. Lymecycline
* C. Clindamycin
* D. Ciprofloxacin
* E. Vancomycin
* F. Metronidazole
* G. Nitrofurantoin
* H. Flucloxacillin
* I. Fidaxomicin

Question 60

Lisa has symptoms of oral thrush as shown in the picture. Her regular medication include Amlodipine, Clenil inhaler, warfarin and metformin. Which of the following is appropriate advice to prevent re-occurrence of oral thrush?
Select one option below.
 A. Drink water before using clenil inhaler.
 B. Stop using the clenil inhaler
 C. Recommend a spacer
 D. Recommend the use of her inhaler ‘’AS required’ ’or less often.
 E. Prescribe salbutamol instead of Clenil.

Question 61

Mr. T. a 54-year-old man weighing 70kg of body weight takes phenytoin 300mg OD regularly for the management of epilepsy and has been stabilized on the drug. He was recently diagnosed with tuberculosis and has been prescribed Rifampicin 600mg once a day for six months. Due to drug interaction between both drugs , select the most likely effect and correct intervention from the options below.
 A. Phenytoin increases rifampicin plasma concentration, so decrease rifampicin dose.
 B. Phenytoin decreases rifampicin plasma concentration, so increase rifampicin dose.
 C. Rifampicin increases phenytoin plasma concentration, so decrease phenytoin dose
 D. Rifampicin decreases phenytoin plasma concentration, so increase phenytoin dose
 E. Rifampicin interacts with phenytoin, so stop phenytoin whilst on rifampicin for six months.

Question 62

You work as a hospital pharmacist when you are presented with the case of Mr. R who has been admitted to hospital due to a respiratory tract infection. Mr. R. is a 45-year-old who suffers from COPD and takes salbutamol inhaler, beclomethasone inhaler, salmeterol inhaler and theophylline tablets. Mr. R. is also a smoker and smokes about 20 cigarettes a day. Whilst in hospital, he has been prescribed co-amoxiclav to treat his infection.
 His latest test results show a bilirubin level of 28 micromol/L (normal range <21 micromole/L).
 What is the most likely cause of this test result?
 A. This is as a result of Mr. R being a heavy smoker.
 B. This is as a result of drug interaction between theophylline and tobacco in cigarette.
 C. This is as a result of side-effect of co-amoxiclav .
 D. This is as a result of adverse drug reaction of theophylline.
 E. This is as a result of the side-effect of salmeterol.

Question 63

You work as an independent prescriber pharmacist in a GP surgery. Mary a-35-year-old female patient presents with a lower-urinary-tract infection without haematuria. Mary tells you that she is 3 months pregnant and has a chronic kidney impairment as well. She also mentions that despite making lifestyle changes such as drinking loads of water and cranberry juice over the last 72 hours, her symptoms continue to get worse. She is also severely allergic to penicillin. She takes no other medication.
 Her latest test results show an eGFR of 31ml/min
 What is the most appropriate next line of action?
 A. Recommend a course of Nitrofurantoin for 7 days.
 B. Recommend a course of amoxicillin for 7 days
 C. Recommend a course of Trimethoprim for 7 days
 D. Recommend a course of cefalexin for 7 days
 E. Recommend a course of Fosfomycin 3g STAT

Question 64

You work as a community pharmacist, and you are presented with Mr. Z. a 65-year- old man who was treated for acute pyelonephritis prescribed by his doctor at the local surgery. He was prescribed ofloxacin 400mg tablets twice a day for 10 days. He is also diabetic and takes metformin, gliclazide and Insulin aspart. He comes into your pharmacy to discuss the side-effects of his medication with you in the consultation room.
 Which of the side-effects is most likely caused by ofloxacin?
 A. Low B12 levels
 B. Hyperkalaemia
 C. Tendinitis
 D. Weight gain
 E. Intracranial hypertension

Question 65

You are working in a community pharmacy on a Saturday morning. Jay a 25-year-old male comes in to see you. He explains that he was recently prescribed metronidazole 400mg tablets by his dentist for a severe tooth infection. He collected the antibiotic from another pharmacy yesterday. However, he left the antibiotic at his workplace and is not due back to work until Monday. Jay wonders if you could make an emergency supply as he is currently enduring severe tooth ache.
What would be the correct next line of action?
 A. Make an emergency supply for 2 days
 B. Make an emergency supply for a week in case he does not find the tablets he forgot at work.
 C. Ask Jay to wait until Monday and collect his tablets from his workplace.
 D. Ask Jay to get back in touch his dentist as this is the only way he can get a new script for
metronidazole.
 E. Refer Jay to out of hours services

Question 66

Mr. V. a 65-year-old is about to receive an infusion of vancomycin for the treatment of septicaemia associated with vascular catheter. Mr. V also takes Amlodipine, ramipril , atorvastatin and finasteride. Which of the following effects is most likely to develop if vancomycin is administered to Mr. V. rapidly via infusion.
Select the most appropriate answer lettered A - E
 A. Increased risk of ototoxicity
 B. Increased risk of red man’s syndrome
 C. Increased risk of nephrotoxicity.
 D. Increased risk of QT prolongation.
 E. Increased risk of steven Johnson’s syndrome

Question 68

Ms. Rachel a 75-year-old is about to receive an infusion of clarithromycin for the treatment of severe cellulitis. She is allergic to penicillin and takes Amlodipine, Citalopram , atorvastatin, alfuzosin and lansoprazole regularly. Which of the following effects will most likely develop if clarithromycin is administered to Ms. Rachel alongside all her medication.
Select the most appropriate answer lettered A - E
 A. Increased risk of blood disorders
 B. Increased risk of red man’s syndrome
 C. Decreased risk of QT prolongation
 D. Increased risk of myopathy.
 E. Increased risk of steven Johnson’s syndrome

Question 69

A mother walks into your pharmacy with her daughter who is asthmatic. She would like you to take a look at the rashes on her daughter’s body. She further mentions that her daughter has a slight fever, headache and doesn’t seem to ‘’like bright lights’’. On observation, the rashes appear to be non-blanching. What advice would you give based on the symptoms presented.
Select the most appropriate answer lettered A - E
 A. Give lifestyle advice as symptoms are self-limiting.
 B. Sell Calpol suspension over the counter.
 C. Book an appointment for asthma review.
 D. Refer to the GP surgery
 E. Refer to Accident & Emergency

Question 70

Ms. Y. a 60-year-old woman was diagnosed with Tuberculosis having travelled back to the UK from her one-month holiday in Cameroun. She has been started on specialistmanagementtotreattheinfection. Sheisallergictopenicillin.
Select the most appropriate option lettered A - E regarding specialist management for Ms. Y.
 A. Specialist management will involve a combination of pyrazinamide and ethambutol for 6 months.
 B. Specialist management will involve a combination of pyrazinamide and Isoniazid for 4 months.
 C. Specialist management will involve a combination of rifampicin and isoniazid for 6 months.
 D. Specialist management will involve only ethambutol for 6 months.
 E. Specialist management will involve a combination of rifampicin and ethambutol
for 6 months.

Question 71

You work in the outpatient’s pharmacy department of King’s Hospital. One morning, a 25-year-old patient presents a prescription for 28 Lymecycline 400mg capsules , once daily. You dispense the prescription and proceed to give counselling to the patient.
Select the counselling point below that is least appropriate for this drug.
 A. This medicine is photosensitive, so avoid direct sun-light.
 B. This medicine may make you drowsy, so avoid skilled tasks such as driving and operating heavy machines.
 C. Do not drink milk, indigestion remedies, iron or zinc , 2 hours before or after taking this medicine.
 D. If you develop headaches or visual impairment, stop taking this medicine and report to your doctor.
 E. Do not take this medicine if you are pregnant.

Question 72

You are presented with Ian, a- 21-year-old lad who had a takeaway meal over the weekend whilst out with his friends. Ian presents with stomach upset, fever, extreme sweating, diarrhoea, nausea and dehydration. Microbiology test results confirm that the causative organism is Escherichia Coli. He had a previous allergy to cefalexin but is otherwise fit and well.
Select the antibiotic that is most likely to treat Ian.
 A. A course of Ciprofloxacin
 B. A course of Metronidazole
 C. A course of Flucloxacillin
 D. A course of Clindamycin
 E. A course of Doxycycline

Question 73

You are presented with Ms. Debs. a 33-year-old female who has taken a course of flucloxacillin for erysipelas. She explains that the infection did not subside after the course of flucloxacillin, and she would like an alternative treatment. During the consultation, Ms. Debs mentions that she is also 30-weeks pregnant. What is the second line of treatment according to NICE guidelines ? Select the antibiotic that is the most appropriate alternative for Ms. Debs to take.
 A. A course of Clarithromycin
 B. A course of Doxycycline
C. AcourseofCefalexin
 D. A course of Clindamycin
 E. A course of Erythromycin

Question 74

Mr and Mrs Jones present in your pharmacy for anti-malarial prophylaxis. They explain to you that they will be going on holiday to Spain for a week then to Uganda for 2 weeks before returning to the UK. They would like you to recommend anti-malarial prophylaxis if necessary. You check their PMR and realise that Mr. Jones also take carbamazepine for epilepsy and Mrs Jones takes Warfarin regularly Which of the options below represents the most appropriate next line of action.
 A. Recommend lifestyle advice as Uganda does not need anti-malarial prophylaxis medication.
 B. Recommend 30 capsules of doxycycline 100mg to Mr. Jones and 30 doxycycline 100mg
capsules to Mrs. Jones.
 C. Recommend 23 malarone tablets to Mr. Jones and 23 malarone tablets to Mrs. Jones.
 D. Recommend 23 malarone tablets to Mr. Jones and 9 mefloquine tablets to Mrs. Jones.
 E. Recommend 9 mefloquine tablets to Mr. Jones and 23 malarone tablets to Mrs. Jones.

Question 75

Mr P. a 60-year-old man has been prescribed 14 clarithromycin 500mg tablets. Mr P. also takes the following
 Ramipril 5mg capsules
 Simvastatin 40mg tablets
 Bisoprolol 10mg tablets
 Indapamide 2.5mg tablets
 What is the best advice for Mr. P as regards potential drug interaction
 A. Stop statins whilst on his taking clarithromycin and restart statins 24 hours after.
 B. Stop statins whilst on his taking clarithromycin and restart statins 7 days after.
 C. Take all the medicines together as the drug interaction is mild.
 D. Stop indapamide whilst his taking clarithromycin to prevent hypokalaemia
 E. Stop statins whilst taking his clarithromycin as clarithromycin is a potent enzyme inducer.

Question 75

Mr. K has just returned from Taiwan three days ago having been on holiday for 6 weeks. He complains that he has been feeling dehydrated , vomiting persistently and has symptoms of diarrhoea. This morning he noticed a bit of blood in his stools. He needs your advice.
 a. Advice Mr. K to wait two more days and contact his GP if no improvement.
 b. Sell him loperamide and dioralyte sachets
 c. Advise him that it is self-limiting, so he does not need to worry and give him advice on what to eat whilst he has the symptoms.
 d. Advise him to contact his GP immediately and this must be reported within 24 hours to Public Health England as per notifiable disease requirements
 e. Advise him to contact his GP immediately and this must be reported within 72 hours to Public Health England as per notifiable disease requirements

Question 76

You are presented with Miss. E. a 23-year-old female who was bitten on her left arm by her neighbour’s new cat. She explains that the incident occurred this morning and she wonders if she needs antibiotics and vaccination to prevent an infection. During the consultation, Miss. E also mentions that she is allergic to penicillin. What is the next line of treatment according to NICE guidelines ? Select the option that is the most appropriate for Miss. E.
 A. Clarithromycin and Rabies vaccine
 B. Doxycline and Rabies vaccine
 C. Doxycycline + Metronidazole and tetanus vaccine.
 D. Clindamycin + metronidazole and tetanus vaccine.
 E. Co-amoxiclav and tetanus vaccine.

Question 77

Mrs. Johnson aged 66-years presents with symptoms of fever, sore throat and difficulty swallowing. You also discover that she has inflamed tonsils with white spots and a temperature of 37.8 centigrade . You calculate a Fever-PAIN score of 4 and recommend that Mrs. Johnson commences on antibiotics. Mrs. Johnson also takes folic acid, methotrexate, ramipril and metformin regularly. Select the most appropriate choice of antibiotic therapy below
 A. Amoxicillin
 B. Doxycycline
 C. Fosfomycin
 D. Clarithromycin
 E. Phenoxymethylpenicillin

Question 78

Mrs. S. a 64-year-old woman weighing 65kg of body weight takes warfarin 5mg OD regularly for the management of Atrial fibrillation and has been stabilized on the drug. She is also diabetic. Recently, she was diagnosed with diabetic foot ulcer and has been prescribed Clarithromycin 500mg tablets by a locum doctor for one week. Due to drug interaction between both drugs , select the most likely effect and correct intervention from the options below.
 A. Warfarin increases clarithromycin plasma concentration, so decrease warfarin dose.
 B. Clarithromycin decreases warfarin plasma concentration, so increase warfarin dose.
 C. Clarithromycin increases warfarin plasma concentration, so decrease clarithromycin dose
 D. Clarithromycin increases warfarin plasma concentration, so change antibiotic to
co-amoxiclav.
 E. Clarithromycin increases warfarin plasma concentration, so change antibiotic to flucloxacillin.

Question 79

A mother enters your pharmacy with her 2-year-old daughter and explains to you that her daughter has been very agitated and crying a lot lately, she has a temperature and has been taking paracetamol for three days but just today she noticed a few white spots on the inside of her cheek surrounded by an inner red ring, with gritty eyes. Which of the following would be the best advice for the mother regarding her daughter’s symptoms?
 A. Sell her chloramphenicol eye drops and more Calpol suspension.
 B. Tell the mother not to worry as this is normal and it will go away in a couple of days
 C Tell the mother to continue with paracetamol but sell her ibuprofen to help with the symptoms
 D Tell the mother to take her daughter to the doctor because she might be suffering from meningitis.
 E Tell the mother to take her daughter to the doctor because she might be suffering from measles.