Exam 5 memorization Flashcards
1
Q
DOC in C. albincans
A
fluconazole
2
Q
DOC in C. glabrata
A
echinocandins
3
Q
DOC in C. parapsilosis
A
fluconazole
4
Q
DOC in C. tropicalis
A
fluconazole
5
Q
DOC in C. krusei
A
echinocandins
6
Q
DOC in C. lusitaniae
A
fluconazole or echinocandins
7
Q
DOC in C. auris
A
echinocandins
8
Q
DOC in cryptococcus
A
fluconazole or Amphotericin B + flucytosine
9
Q
DOC in Blastomyces
A
itraconazole
10
Q
DOC in Histoplasma
A
itraconazole
11
Q
DOC in Coccidioides
A
fluconazole
12
Q
DOC in Aspergillus
A
voriconazole
13
Q
DOC in Mucor
A
amphotericin B
14
Q
tx duration for oral candidiasis (thrush)
A
7-14 days
15
Q
tx duration for esophageal candidiasis
A
14-21 days
16
Q
oral candidiasis tx options
A
nystatin (most common but 4x/day)
clotrimazole lozenge
miconazole buccal tab
17
Q
esophageal candidiasis tx options
A
fluconazole 200-400mg po/iv daily is preferred tx
18
Q
uncomplicated VVC may be treated by what
A
susceptible to all anti-fungals regardless of duration
19
Q
most common 2 species in VVC
A
C. albicans (80-92%)
non-C. albicans (8-20%)
20
Q
most common causes of VVC
A
ANTIBIOTIC USE
contraceptives (high dose pill or IUD/spermicide/etc)
21
Q
common misconception –> these things do not cause VVC
A
diet, douching, tight-fitting clothing
22
Q
aspergillosis commonly affects what patients and starts where in their body
A
immunocompromised (neutropenia)
pulmonary system
23
Q
name the 3 endemic fungi species
A
histo (lungs)
blasto (lungs)
coccidioides
24
Q
cryptococcus occurs where in the body
A
CNS (especially in HIV, transplant, and immunocompromised)
25
SOA of amphotericin
-1st line in:
cryptococcus
blasto
histo
mucor
26
amphotericin deoxycholate dosing
0.5-1mg/kg/day (use more for more severe infections up to 1.5)
27
amphotericin liposomal dosing
1.5-6mg/kg/day (more commonly 3-5, especially for use in severe, disseminated)
28
AE amphotericin
nephrotoxicity
electrolytes
anemia
29
flucytosine main use
in combo with amphotericin B for cryptococcal meningitis
30
flucytosine renally dose adjusted or not?
yes
31
flucytosine AE
GI
hematologic (bone marrow suppression)
monitor: CBC, platelets, SCr, BUN
32
fluconazole (Diflucan) renally dose adjusted or not?
yes
33
fluconazole dosed based on what weight
TBW
34
fluconazole clinical use
invasive candidiasis (candidemia)
cryptococcal meningitis (consolidation and maintenance)
35
fluconazole AE
QTc prolongation
36
SOA fluconazole
-1st line in:
C. albicans
C. parapsilosis
C. tropicalis
C. lusitaniae
coccidioides
37
itraconazole (Sporanox) tx considerations
-Cl decreases with higher doses due to saturable hepatic metabolism (CYP3A4)
-capsules absorption dependent on gastric acidity (take with acidic meal or drink to improve)
-oral solution not dependent on gastric acidity
38
SOA itraconazole
-1st line in:
histo and blasto: 200mg PO TIDx3days, then 200mg PO BID
39
itraconazole AE
heptotox.
QTc prolongation
40
itraconazole goal serum conc.
>0.5-1
>3 = more AE
41
posaconazole (Noxafil) formulations
oral suspension: absorption affected by gastric pH (decreased with PPIs)
DR tabs: not affected by gastric pH, preferred oral form
IV: contains cyclodextrin (nephrotox), so avoid if CrCl less than 50
42
posaconazole AE
QTc prolongation
43
SOA posaconazole
-1st line in:
none
44
Voriconazole (Vfend) ADME
-IV contains cyclodextrin (nephrotox) so avoid if CrCl less than 50
-oral has great bioavailability and not affected by PPIs, antacids or H2 antagonists
45
voriconazole clinical use (SOA, 1st line)
invasive aspergillosis
46
voriconazole AE
-visual disturbances
-elevated LFTs
-QTc prolongation
-phototoxic skin reaction
-diffuse, painful periostitis
47
Isavuconazole (Cresemba) formulations
-IV does not contain cyclodextrin (safe IV option, not used much since oral is great)
48
isavuconazole AE
N/V/D
HA
hepatic (increased LFTs)
QTc SHORTENING
49
Isavuconazole clinical uses
mucor or aspergillosis
-not 1st line though
50
SOA echinocandins
-1st line in:
C. glabrata
C. krusei
C. lusitaniae
C. auris
"the more drug-resistant types"
51
echinocandins AE
-histamine mediated sx: rash, swelling, flushing, itching
-fever
-phlebitis
-N/V
-HA
52
micafungin must be given orally or IV?
IV
-no dose adjust for renal
-few DIs
53
ibrexafungerp (Brexafemme) clinical use
CI in pregnancy (use contraception during and 4 days after tx)
use in VVC
54
which LTBI medication would you typically want to avoid or be cautious in pts living with HIV?
rifampin (and rifapentine)
-safest to just avoid the rifamycins and use INH
-reaction seen in 1-7 days
55
forms of active TB (name the 5)
1. drug susceptible TB
2. monoresistant TB
3. polyresistant TB
4. MDR TB
5. XDR TB
56
describe drug susceptible TB
TB strains that are sensitive to the standard 1st line drugs
57
describe monoresistant TB
TB strains that are sensitive to just one anti-TB drug
58
describe polyresistant TB
Tb strains that are resistant to more than one anti-TB drug but not INH and RIF
59
describe MDR TB
Tb strains that are resistant to RIF and INH
60
describe XDR TB
TB strains that are resistant to RIF and INH + at least one injectable agent (amikacin, kanamycin or capreomycin) + any of the fluoroquinolones
61
How is resistance different in TB than other bacteria?
-spontaneous rate of mutation
-slow replication cycle (reason for long treatment, reason why adherence plays a huge role in tx and resistance)
-monotherapy contributes to resistance more
-increased bacterial load = increased number of resistant bacteria
62
tx of drug susceptible TB
-new 4 month regimen as of January 2025
intensive phase:
rifapentine 1200mg +
isoniazid 300mg +
moxifloxacin 400mg +
pyrazinamide 1-2g
all once daily, all x8 weeks
continuation phase:
rifapentine 1200mg +
isoniazid 300mg +
moxifloxacin 400mg
all once daily, all x9 weeks
63
TB progression relating to testing
64
which drug relates to inhA and katG?
isoniazid
-activated by katG in mycobacterium
-inhibits inhA in mycobacterium
65
isoniazid AE
hepatitis
peripheral neuropathy
66
how do you reverse peripheral neuropathy caused by isoniazid?
administer pyridoxine (vit. B6)
67
pncA activates which TB drug?
pyrazinamide (converts it to pyrazinoic acid, active form)
-most resistance also seen here
68
for activation of pyrazinamide, does it prefer acidic or basic conditions?
acidic, pH <5.5
69
pyrazinamide inhibits what?
-MOA
panD leading to inhibition of CoA synthesis
70
pyrazinamide MOA considerations
-POA (active form) binds to panD for inhibition
--binding affinity is low
-PZA does not bind
71
pyrazinamide AE
joint pain (most common)
hepatitis (most dangerous)
72
ethambutol MOA
inhibits mycobacterial arabinosyl transferases
-bacteriostatic
73
ethambutol AE
optic neuritis
-don't use in children
-can be irreversible if tx not stopped
74
rifampin MOA
binds to RNA polymerase deep in RNA/DNA channel blocking path of elongating RNA
-similar to NNRTIs
75
rifampin AE
orange bodily fluids
CYP interactions (makes other drugs less effective because they're cleared faster)
76
FQ (moxi) MOA
traps gyrase on DNA as ternary complex
77
pretomanid MOA relates to
Ddn
78
LUFS
antibiotic characteristics that influence CSF/CNS penetration:
Lipid soluble
Unionized
Free drug (not protein bound)
Small (Low) molecular weight
79
Abx not achieving therapeutic conc. with OR without inflamed meninges
macrolides
aminoglycosides
B-lactamase inh.
1st and 2nd gen ceph
clindamycin
tetracyclines (except doxy)
echinocandins
80
is empiric abx therapy started before or after LP performed?
immediately after
81
which of the following does not achieve therapeutic conc. in CSF even in inflamed meninges?
cefazolin
pen G
ceftriaxone
ertapenem
A and D
A and D
82
empiric therapy for acute bacterial meningitis
neonates (<1m):
amp +ceftriaxone/cefepime
OR
amp + aminoglycoside
infants (1-23m):
vanco +ceftriaxone
children and adults (2-50y):
vanc + ceftriaxone
older adults (50y+):
vanc + ceftriaxone + amp
83
GRAM STAIN
streptococcus
-gram positive diplococci
-pen G
-amp
duration: 10-14 days
84
role of steroids in STREP PNEUMO meningitis
-only useful in this type
-in children older than 2 months
-in pneumococcal meningitis in adults
-admin before or with first dose of abx
-duration: 2-4 days
85
GRAM STAIN
S. aureus
-gram positive cocci in clusters
-MSSA: nafcillin
-MRSA: vanco (goal is trough 15-20)
-duration: 14-21 days
86
GRAM STAIN
Listeria monocytogenes
-gram positive rod, non spore forming
-amp +/- gent
-alt: TMP/SMX, meropenem, linezolid
-duration: 21 days
87
GRAM STAIN
Neisseria meningitidis
-gram negative intra cellular diplococci
-PCN MIC <0.1: pen G cont. or amp
-PCN MIC 0.1-1: ceftriaxone 2g q12h
-duration: 7 days
88
GRAM STAIN
H. Flu
-gram negative coccobacillus
-B-lactamse (-): amp
-B-lactamse (+): ceftriaxone
-duration: 7 days
89
GRAM STAIN
enterobacteriaceae
-E. coli
-ceftriaxone 2g q12h
-duration: 21 days
90
3 aspects to initial fungal meningitis therapy
1. therapy phases
a. induction
b. consolidation
c. maintenance
2. control of CSF pressure
3. addressing immune suppression
91
induction phase fungal meningitis
-ampho B 07.1mg/kg/day 24hr inf.
OR
-liposomal ampho B 3-4mg/kg/day
PLUS
-flucytosine 25mg/kg po QID
-duration: 2 weeks
92
consolidation phase fungal meningitis
HIV or non-HIV pt:
preferred: fluconazole 400-800mg PO or IV once daily
duration: 8 weeks
93
maintenance phase fungal meningitis
preferred: fluconazole 200mg PO once daily
duration:
-6-12 months (non-HIV pts)
-12+ months AND CD4 >200 AND suppression of viral load on ART (HIV pts)
94
viral encephalitis clinical presentation most important sx
altered mental status
95
CSF interpretation chart:
normal
WBC: <5
differential: -
protein: <50
glucose: 30-70 (2/3 peripheral)
96
CSF interpretation chart:
bacterial
WBC: >1000-5000
differential: >80% neutrophils
protein: >150
glucose: <50
97
CSF interpretation chart:
fungal
WBC: 10-500
differential: >50% lymphs
protein: 40-150
glucose: <30-70
98
CSF interpretation chart:
bacterial
WBC: 5-300
differential: 50% lymphs
protein: 30-150
glucose: <40-70
99
tx of viral encephalitis
majority of cases are benign and self limiting with full recovery in 7-10 days
-provide supportive care, fluid, analgesics, antipyretics
100
HSV or VZV tx
acyclovir
101
CMV encephalitis tx
ganciclovir
+foscarnet if HIV +
102
T/F: tx kills live adults and unhatched eggs of lice
F: only kill live adults (except Spinosad)
103
OTC lice options
-naturally occurring pyrethrins
-synthetic pyrethroids (permethrin)
104
prescription lice options
Spinosade suspension (main one used)
Benzyl alcohol lotion
Ivermectin lotion
Malathion lotion
105
spinosad MOA
-broad spectrum insectiside
-nicotinic acetylcholine receptor agonist
-rapid excitation (stimulant) of the insect nervous system causes death
106
perethrins MOA
-chrysanthemum flower derivatives
-nerve membrane sodium channel toxins that do not affect potassium channels
-rapidly metabolized if absorbed by humans, nontoxic
107
home remedies tx options
none of these work
108
main ways worms enter human body
-from soil through open skin wound
-fecal oral
109
tx options for helminths
albendazole (DOC)
-broad spectrum
-3 others in same class (benzimidazoles -"bendazoles")
110
benzimidazoles MOA
-binds to tubulin
-inhibits formation of microtubules
-cap microtubules
-CAN bind mammalian tubulin
-binds with higher affinity to helminth tubulin
111
can you use the benzimidazoles in pregnancy?
no
112
pyrantel pamoate facts
-broad spectrum antihelminth
-OTC
-effective for pinworms and ascaris
-highly insoluble
two uses:
-ascaris: one dose
-pinworms: 2 doses two weeks apart
113
pyrantel pamoate MOA
-depolarizing neuromuscular blocking agent
-causes release of acetylcholine and inhibition of cholinesterase
-worms are paralyzed and expelled
114
most common malaria parasite species
-plasmodium falciparum
-plasmodium vivax
115
drug classes for malaria
-tissue schizonticides: kill liver stage parasites
-blood schizonticides: kill erythrocytic forms
-gametocytocides: kill sexual stages, block transmission
116
which drug hits all stages of malaria growth?
none, multiple drugs may be needed
117
artemisinin MOA
not completely known
-must be activated, via heme-iron
-may form free radicals
-may inhibit phosphatidylinositol-3-kinase (PfPI3K)
118
artemisinin active/not active against liver stage
not
119
is artemisinin a prodrug?
yes
120
key structural feature of artemisinin
endoperoxide bridge
C-O-O-C across ring structure
121
Resistance to artemisinin
mutations in kelch 13 gene
122
4-aminoquinolones structure
-aminoquinolone part is two rings with N in it is the iron complexing group
-Cl causes inhibition of B-haematin formation
-weak base chains are good at accumulating drug via pH trapping
123
MOA of:
quinine
mefloquine
chloroquine
-interfere with heme polymerization
124
chloroquine resistance
mutations in PfCRT1
-no cross resistance to others
125
primaquine (8-aminoquinolone) DOC for
liver stages of P. vivax and P. ovale
126
primaquine metabolized by
CYP2D6
-may involve free radicals
127
primaquine MOA
2 steps:
1. hydroxylation by CYP2D6
2. not known for sure but produces H2O2 which kills parasites
128
primaquine and atovaqoune have what unique test to be done before starting
G6PD
-deficiency in this can cause hemolysis
129
can you use primaquine in pregnancy
no
130
when is malaria primarily transmitted
dawn and dusk
131
what chemoprophylaxis to choose in all malaria-endemic regions
-atovaquone/proguanil
-doxycycline
-tafenoquine
132
what chemoprophylaxis to choose in regions with chloroquine-sensitive malaria
-chloroquine
-hydroxychloroquine
133
what chemoprophylaxis to choose in regions primarily with P. vivax
primaquine
134
what chemoprophylaxis to choose in regions with mefloquine-sensitive malaria
mefloquine
135
most widely used malaria prophylaxis drug
atovaquone/proguanil (Malarone)
136
atovaquone/proguanil (Malarone) tx duration
begin 1-2 days before departure
continue 7 days after leaving endemic area
137
chloroquine tx duration
begin 1-2 weeks before departure
continue 4 weeks after leaving endemic area
138
hydroxychloroquine tx duration
begin 1-2 weeks before departure
continue 4 weeks after leaving endemic area
139
doxycycline tx duration
begin 1-2 days before departure
continue 4 weeks after leaving endemic area
140
mefloquine tx duration
*SE steer people away from this
begin at least 2 weeks before departure
continue 4 weeks after leaving endemic area
141
primaquine tx duration
begin 1-2 days before departure
continue 7 days after leaving endemic area
142
tafenoquine tx duration
begin 3 days before departure
continue 1 week after leaving endemic area
143
when to consider malaria:
when pt has fever
and has travelled to malaria endemic country before fever started
144
which disease state causes RBC lysing and what symptoms does it cause?
malaria
-fever
-HA
-fatigue
-rigors
-night sweats
-anemia
145
why consideration of plasmodium spp. is important:
-infection severity
P. falciparum and P. knowlesi are more likely to progress to severe disease/death
146
why consideration of plasmodium spp. is important:
-treatment
P. vivax and P. ovale also require tx of hypnozoites (dormant liver stage)
147
why consideration of plasmodium spp. is important:
-antimalarial resistance
P. falciparum and P. vivax have different drug resistance patterns in various regions
148
which type typically causes severe malaria?
P. falciparum
149
tx for uncomplicated malaria with presence of chloroquine resistance or unknown resistance
artemether-lumefantrine (Coartem)
OR
atovaquone-proguanil (Malarone)
OR
quinine sulfate plus
doxycycline*, tetracycline* or clindamycin
*preferred, avoid in children less than 8
150
tx for uncomplicated malaria with presence of chloroquine resistance, no mefloquine resistance or unknown resistance
mefloquine
151
tx for uncomplicated malaria with chloroquine sensitivity
chloroquine
OR
hydroxychloroquine
152
tx for malaria anti-relapse
primaquine phosphate
OR
tafenoquine (Krintafel)
*need G6PD testing for both
153
tx for uncomplicated P. falciparum, P. ovale, P. vivax or unknown species malaria
in area with no chloroquine resistance: chloroquine or hydroxychloroquine
with chloroquine resistance: artemether-lumefantrine
154
which two species don't ever show resistance to chloroquine?
P knowlesi and P. malariae
so use chloroquine or hydroxychloroquine
155
tx of severe malaria
1. repeat blood smear q12-24h
2. initiate tx ASAP
a. IV artesunate
b. transition to oral once blood smear shows density less than 1%
options:
-artemether-lumefantrine (preferred)
-atovaquone-proguanil
-quinine PLUS doxy or clinda
-mefloquine
156
pts with disseminated MAC should start ART when?
ASAP, preferably with initiation of MAC therapy
157
preferred tx regimen for MAC
clarithromycin 500mg po BID +
ethambutol 15mg/kg po daily
OR
azithromycin 500-600mg po daily (only when intolerance or allergies to clarithromycin present)+
ethambutol 15mg/kg po daily
158
if more severe MAC disease, which drug do you add?
rifabutin
159
how long should you treat for disseminated MAC?
at least 12 months
160
MAC primary prophylaxis when:
-CD4 less than 50
-not on ART (or ART not working)
161
MAC primary prophylaxis regimen:
azithromycin 1200mg po once weekly
