CIS Pharm of resp infections Flashcards by Andrea Parsons

basic MOA’s
spectrum of activity
notable resistance patterns
common/important side effects

list the antibiotic treatments recommended by current guidelines for initial empiric treatment of CAP for:
-outpatients
inpatients
-ICU
-another

know it!

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what are the resp fluoroquinolones

ciprofloxacin
-variable to s. pneumonia

levofloxacin
-suscept to s. pneumonia

moxifloxacin
-suscept to s. pneumoniae

for HAP when we are worried about pseudomonas–> cipro is most effective against this bacteria

levofloxacin –> use if concerned for multiple organsims causing resp infections

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chloramphericol

last line antibiotic

causes adverse effects

MOA: inhibits protein synthesis

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translation and the protein synthesis inhibitors ….

binding to P site first - both subunits come together and initiate protein synthesis

aminoglycosides 30S
Linezolid 50S

tRNA brings AA’s to ribosomes to form proteins

Tetracylines (30S)
streptogrammins (50S)

translocation
-Macrolides 50S
Clindamycin 50S

peptide elongation

protein synthesis

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56 year old male
primary care with fever, chills, productive cough

sputum shows gram positive diplococci

what is the most common identified pathogen in community acquired pneumonia?

most common–> strep pneumoniae

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what drug works most appropriate for strep pneumoniae

sputum
gram positive diplococci

outpatient recommendations
in previously healthy???

At risk for DRSP
comorbidities,age >65
use of antimicrobials within 3 months???

Previously healthy:
Macrolide (azithromycin)
Doxycycline

At risk for DRSP:
Respiratory fluoroquinolone PO (levofloxacin, moxifloxacin, gemifloxacin)
B-lactam PO [high dose amoxicillin or amoxicillin-clavulanate preferred (alternates: ceftriaxone, cefuroxime)] PLUS a macrolide PO

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drugs of choice for strep pneumo

Penicillin G

Amoxicillin

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MOA of azithromycin

blocks protein synthesis by inhibiting translocation

50S

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micro report indicates that the pathogen is strep pneumoniae with high level resistance to penicillin. what would you treat?

levofloxacin

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what is the mechanism of resistance of strep pneumoniae ? (resistance to penicillin)

alteration of the penicillin binding protein

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what organism would be seen in a patient on a cruise recently or in a hotel….

legionella

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68 year old female
two day history of productive cough and fever

she complains of SOB and sharp pains in her chest when she breathes in deeply

3 weeks ago treated for resp infection

left lower lobe infiltrate

sats 88%
RR 32
age 68

what is her CURB 65

CURB-65
Confusion
Uremia (BUN > 19 mg/dL)
Respiratory rate (≥ 30 breaths/min)
Low blood pressure 
SBP 3 admit to ICU

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beta lactamases are more thought of in what bacteria

staph aureus

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patient is admitted to the hospital with CAP. which of the following is most appropriate?

she was recently on cipro

ceftriaxone plus azithromycin (b/c she had cipro recently) so we need to use something with a different MOA

Inpatient, non-ICU:
Respiratory FQ IV or PO (levofloxacin)
B-lactam IV (ceftriaxone) PLUS macrolide IV (azithromycin)

Inpatient, ICU
B-lactam IV (ceftriaxone, cefotaxime, or ampicillin/sulbactam preferred) PLUS azithromycin IV OR a respiratory FQ (levofloxacin, moxifloxacin)

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For our ICU patients that are admitted that have previous anaphylaxis to penicillin is an indication to use….

aztreonam

doesn’t show cross reactivity with other B-lactam antibiotics

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which is routinely monitored during antibiotic therapy to determine response….

temp- 90
Arterial O2 sats >90
Ability to maintain oral intake
normal mental status

CXR lag behind in improvement by about 3 weeks so doesn’t help determine improvement

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which antimicrobial regiment does not cover atypical pathogens

ceftriaxone

which of the following does NOT need to be dose adjusted if prescribed to our patient ? for renal impairment

ceftriaxone and moxifloxacin

Amoxicillin does
Levofloxacin does (CNS side effects) 
Ertapenem - does
Ampicillin - does

76 year old male
admitted to the hospital

right lower lobe infiltrate
sputum–> 4+ WBC and gram negative bacilli

put on ventilator

what is the most likely diagnosis and infecting agent?

pseudomonas aeruginosis

VAP

what is appropriate for the treatment of VAP?

piperacillin-tazobactam plus gentamicin

55 year old male
6 hr history of bloody nose
multiple bruises on lower legs and forearms
INR 5.8
you ask if he has taken any other antibiotics

he says he was recently prescribed an antibiotic

what is the MOA of the antibiotic prescribed ?

Macrolide
binds the 50S ribosomal subunit

results in CYP3A4 inhibition–> prolongs effects of Warfarin

bactram also does this

25 year old female
presents for CF tune up
CF history
yellow green sputum production
post tussive emesis
weight loss
decreased appetite

most common organisms?

what is the purpose of tazobactam in the antibiotic combination piperacillin/tazobactam?

staph aureus- for younger patients (MRSA)
pseudomonas aeruginosa
h. influenzae

our patient cultures pseudomonas aeruginosa

what maintenance therapy may be inititaed that acts as anti-inflammatory and may decrease the virulence of pseudomonas aeruginosa

azithromycin

8 year old
suspected CAP
want to treat her as outpatient

what should NOT be used to treat her ?1

levofloxacin - b/c achilles tendon rupture in kids

doxycyline - tooth discoloration

IV only for cefotaxmine

85 year old female cough productive mother has not been tolerating solid food may have choked several days ago she may have aspirated you admit to gen medical floor and diagnose with aspiration pneumonia... you would like to use a Beta-lactam and azithromycin to follow the cAP guidelines... what Beta lactam has anaerobic activity?

ampicillin - sulbactam

which protein synthesis inhibitor has anaerobic activity and is used to treat aspiration pneumonia?

clindamycin

47 year old male raised chickens 16 lb weight admitted to the hospital

histoplasma capsulatum

antifungal that causes visual changes?

voriconazole

``` 32 male cough diff breathing began 2 weeks ago trouble walking up stairs PMH - HIV infection fever diffuse bilateral patchy infiltrates presumed diagnosis diagnosis? ```

pneumocystis jirovecii -fungal infection

which first line anti-TB agent is most likely to cause hepatotoxicity

pyrazinamide - most common INH rifampin

36 year old woman classic TB presentation well controlled type I DM poor nutritional status the most active drug for the treatment of TB caused by susceptible strains is prescribed.... what is the MOA what are some mechanisms of resistance ? related second line agent?

inhibition of mycolic acid synthesis INH mutations of resistance: -mutations in KatG gene- this produces an enzyme inside mycobacteria that metabolizes the drug and makes it active ! - mutations in inhA - mutations in kasA related second line agent is ethionamide

how are mycobacteria different from Gram Positive or gram negative

don't have outer membrane do have peptidoglycan layer have mycolic acid rich layer - resistance to lots of antibiotics

what is the combination for TB why isn't streptomycin included in this regimen

isonizaid, rifampin, pyrazinamide,ethambutol need to use 4 drugs b/c single agent therapy will select mutants with resistance b/c aminoglycosides aren't orally available and usually adminstered IM and is reserved for very serious disease

isolates with mutations in the embB gene have been identified . what agent is ineffective

ethambutol mechanism of resistance: embB gene is involved in forming the cell wall for TB and ethambutol is involved in inhibiting the product of embB gene . mutations in emb gene products now is resistant should now take away ethambutol

serum aminotransferase activity is increased in what drugs

anti-TB agents- INH, rifampin, pyrzinamide

INH biotransformation

occurs with phase II first (acetylated by NAT2) then CYP450's convert to intermediate intermediate has to be acetylated again to nontoxic form ***Polymorphism in NAT2 causes variation in the rate of acetylation reduced expression of NAT2 (slow acetylator) - accumulate more of the hepatotoxic intermediate

inducer of CYP450's

rifampin use with caution in patients who are taking protease inhibitors and NNRTI's because these are metabolized more quickly and levels are reduced efficacy of HIV drugs is reduced

vitamin B6 deficiency?

adverse effect of INH b/c INH promotes the excretion of Vitamin B6 commonly seen in patients with diabetes and poor nutritional status

patient with HIV and TB CD4 <25 HCT 23 % low Aspartate transferase 95 high alanine aminotransferase 135 high

patients with HIV are more susceptible to having active TB TB is an AIDS defining illness

not all rifamycins are the same in inducing CYP's

rifampin is the most potent P450 inducer Rifabutin is the least potent

adverse effects of rifamycin

harmless Red/orange to urine, feces, sweat, tears, contacts rashes, thrombocytopenia, nephritis hepatotoxicity