FINALSSSSS Flashcards
IC6, IC13-19
Class side effect of carbapenem
Some neurotoxicity
only BETA LACTAM active against MRSA
ceftaroline
Does vancomycin require dosage adjustment in renal impairment or hepatic impairment? WHYYYYYYY?
renal impairment.
75% of drug excreted unchanged in urine. renal impairment will affect PK of drugs and require dosage adjustment
Is vancomycin renally cleared or hepatically cleared?
Renally cleared
(and hence requires renal adjustments)
(it is also nephrotoxic)
(i also dont want to study anymore)
co-trimoxazole is time/concentration/AUC dependent killing?
concentration dependent killing
spectrum of activity for co-trimoxazole
susceptible to enterobacterales (E. coli, klebsiella, proteus)
yellow for MRSA, MSSA, strep pneumo, H. influenzae, ESBL-producing and AmpC-type
main indication for co-trimoxazole
mostly used in UTI
(more for UTI in men but local resistance to co-trimoxazole is quite high so yellow susceptibility)
main elimination pathway for sulfamethoxazole and trimethoprim
sulfamethoxazole - renal elimination + hepatic metabolism
trimethoprim - renal elimination mainly
contraindications to co-trimoxazole (& reasons)
- severe hepatic/renal impairment (due to elimination)
- pregnancy (both, due to possible folate deficiency, and can cross placenta)
- infants (sulfo, risk of kernicterus due to displacement of bilirubin from serum albumin)
- history of co-trimoxazole induced thrombocytopenia (dont want to risk this again)
- existing folate deficiency induced megaloblastic anemia (already deficient and anemic, dont want to worsen)
monitoring parameters for co-trimoxazole & reasoning
- CBC with differential (hematological disorders)
- LFT & RP (renal and hepatic function)
- Serum K (K-sparing diuretic - trimethoprim)
- Urine (in case of crystalluria due to sulfamethoxazole)
- Allergy reactions (in case of hypersensitivity)
Difference between MOA for linezolid VS macrolide/clindamycin
linezolid is a protein synthesis inhibitor that binds to 50s ribosomal subunit near INTIATOR COMPLEX SITE
macrolide/clindamycin: it binds to 50s ribosomal subunit near PEPTIDYL TRANSFER SITE
spectrum of activity for linezolid
gram positive & some anaerobes
subjected to efflux in gram negative (no gram neg coverage)
common use of linezolid
against MRSA in SSTIs (either vancomycin/linezolid)
Can I use linezolid with paroxetine/venlafaxine?
No, risk of serotonin syndrome. Should not use linezolid with MAOi/SSRIs/SNRIs/Serotonin agonists. Avoid tyramine-rich food.
elimination pathway for linezolid
hepatic metabolism > renal excretion
–> caution in severe impairment
monitoring parameters for linezolid
- CBC with differential (hematological disorders)
- fingertip numbness/tingling/weaknes & eyesight changes (due to potential irreversible peripheral neuropathy/optic neuritis with >28days of use)
how to prevent crystalluria for co-trimoxazole
take with water and hydrate regularly
spectrum of activity for clindamycin
gram pos and anaerobes (intrinsic resistance by gram neg and c diff)
local resistance to clindamycin quiet high.. so all gram pos yellow except
enterococcus faecalis & C diff.
ONLY GREEN FOR gram pos anaerobe (finegoldia magna)
elimination pathway of clindamycin
hepatic metabolism»_space;> renal excretion
–> caution in severe liver impairment (and maybe severe renal impairment)
–> monitor liver function
contraindications of clindamycin
pseudomembranous colitis (like in C diff infection), ulcerative colitis or any colonic inflammation
monitoring parameters for clindamycin
- Liver function (major elimination pathway)
- changes in bowel frequency / colitis (monitor for colonic inflammation)
Why does metronidazole only target anaerobes (so well)
my favourite antibiotics <3
少给我麻烦 <3
metronidazole has cytotoxic free radicals that cause protein and DNA damage which requires strong reducing conditions (aka anaerobic cnditions)
common side effect of metronidazole for PO
unpleasant, metallic taste
elimination pathway of metronidazole
(BOTH)
hepatic metabolism + renal excretion.
caution in renal/hepatic impairment, may need dose adjustment in severe hepatic impairment
monitoring parameters for metronidazole
- liver function (major elimination pathway)
- neurological symptoms (eyesight changes, fingertip numbness/weakness, seizures, mental state) (due to CNS/PNS ADR such as convulsive seizures, optic and peripheral neuropathy, confusion. vertigo, hallucinations)
DDI and DFI with metronidazole
- warfarin (increase PTT & INR)
- disulfiram
- alcohol (disulfiram-like reaction with alcohol intake)
Antibiotics used to treat CNS infection (6)
penicillin
ceftriaxone
cefepime
ceftazidime
meropenem
vancomycin
first line therapy for TB (4+1)
- rifampicin
- isoniazid
- pyrazinamide
- ethambutol
- streptomycin
for latent TB, what is the regimen?
single agent therapy
- 4mth rifampicin OR
- 6mth isoniazid
standard regime for active TB
(2RIPE/4RI)
intensive phase: 2 months x RIPE OD
continuous phase: 4 months x RI OD/3X/WEEK
role of streptomycin as part of first line TB therapy
May sometimes replace ethambutol in intensive phase due to lower frequency of acquired resistance
how to determine cure of TB?
> =2x negative smears/culture (negative in the last month + >=1 other occasion)
failure = postive @ or after 5 months
monitoring parameters before starting TB therapy and during TB therapy.
before starting:
- baseline AST&ALT (ensure baseline liver function)
- weight
- vision acuity and colour vision check due to ocular toxicity risk by EMB
during therapy:
- monitor LFT if high risk for hepatic toxicity
- weight
- monitor for drug-induced hepatotoxicity
hepatotoxicity in drugs from high to low
PZA > INH > RMP
renal dosage adjustment in which TB drugs?
PZA & EMB - mainly renal excretion especially for <30ml/min
Streptomycin - reduce dose in impairment + nephrotoxic risk (aminoglycosides class effect)
4 steps for the antimicrobial approach
- confirm presence of infection
- identify likely pathogen
- select antimicrobial regimen
- monitor response & plan
What do you look for to confirm presence of infection?
- risk factors of patient
- subjective evidence
- objective evidence
- possible site of infection
Common sites of infection
Blood, Respi, GIT (intra-abdominal), SSTI, UTI
abnormal vital signs -
temperature:
BP:
HR:
RR:
mental:
temperature >=38.0degC
SBP < 100mmHg (may also need to observe baseline, patient’s normal BP trend)
HR > 90bpm
RR > 22bpm
mental: drop in Glasglow coma scale
abnormal labs:
Whites
Neutrophils
C-reactive protein
Erythrocyte sedimentation rate
- elevated (14-15) or depressed (2-3) x 10^9/L (normal is 4-10x10^9/L) white count
- ~90% neutrophils (observe trend; normal is 45-75%)
- infection CRP > 40mg/L
- increased ESR for bone and joint inflammation
how does procalcitonin aid in clinical diagnosis?
Guides starting/continuation of Abx in patients.
<=0.25mcg/L usually strongly discourages antibiotics
0.25-0.5 is discouraged also
above is more encouraged, if it increased or >1mcg/L, strongly encourage abx
Which groups of patients can have elevated procalcitonin without infection (and should take note)?
- traumatic brain injury (TBI)
- ESRF (procalcitonin cleared by kidneys, accumulation due to ESRF is possible)
In patients with G6PD deficiency, what antibiotics should they avoid?
Sulfonamide, nitrofurantoin, older generation fluoroquinolone
Antibiotic with no shared side chain as penicillins (can consider in penicillin allergy)?
Cefazolin
Abx classes generally SAFE in pregnancy & lactation
beta-lactams and macrolides
Abx classes generally CAUTIONED in pregnancy & lactation
co-trimoxazole, fluoroquinolones, tetracyclines
Nephrotoxic Abx
aminoglycosides, high dose vancomycin, amphotericin B
Hepatotoxic Abx
pyrazinamide, amoxicillin-clavulanate
Bactericidal drugs (better to use for immunocompromised patients)
beta-lactam, (fluoro)quinolones, aminoglycosides, vancomycin
Why is daptomycin not used in respiratory infections?
Daptomycin gets destroyed by lung surfactant
Why are ciprofloxacin and co-trimoxazole drugs of choice for prostatitis?
They distribute well to the prostate
Common bacteriostatic antibiotics (inhibit protein synthesis)
- macrolides
- tetracyclines
- trimethoprim & sulfonamides
Common CYP3A4 inhibitors
NDHPCCB - veramapil, diltiazem
azole antifungals - itraconazole, ketoconazole
macrolide antibiotics - clarithromycin, erythromycin
antiHIV - ritonavir, saquinavir
common CYP3A4 inducers
rifampin/rifampicin
HIV NNRTIs - efavirenz
Which antibiotics can cause QTc prolongation?
Macrolides - clarithromycin, erythromycin
Fluoroquinolons - levofloxacin, ciprofloxacin
azoles - itraconazole, etc
Which abx can cause photosensitivity?
tetracycline (doxycycline), sulfonamides, quinolones
Which conditions predisposes infections?
DM, cirrhosis, neutropenia, HIV, transplant&immunosuppressive medications
In SSTIs which bacteria infection commonly presents with pus?
Staphylococcus aureus
common pathogens for impetigo
staphylococci/streptococci
bullous form - toxic strains of S. aureus
mainly looking at MSSA
common pathogens for ecthyma
most frequently caused by group A streptococci
Regimen for mild, limited lesions in impetigo
topical mupirocin BD x 5days
What’s the concern for topical mupirocin?
Increasing resistance to mupirocin since it’s used to decolonise MRSA in hospitals