ID Exam 3 Flashcards
Remdesivir MOA
Converted to monophosphate and phosphorylated to its active metabolite which interfered with the action of viral RNA causing a decrease in viral RNA production
Remdesivir route
IV
Remdesivir ADE
Nausea
Elevated ALT and AST
Remdesivir DDIs
Chloroquine phosphate or hydroxychloroquine sulfate
CYP 2C8, 2D6, 3A4
Paxlovid MOA
Acts as covalent inhibitor binding directly to catalytic cysteine interfering with the replication of SARS
Paxlovid ADME
High fat meal increase exposure
Paxlovid side effects
Dysgeusia
Diarrhea
HTN
Myalgia
Paxlovid contraindications
USE during pregnancy
Paxlovid DDIs
Cyp3A4
Molnupiravir MOA
Competitive inhibitor for viral RNA dependent RNA polymerase. Indices an antiviral effect via viral error catastrophe
Molnupiravir ADE
Maculopapular rash
BBW serious infections possible
Oseltamivir (prodrug) MOA
Inhibition of neuraminidase activity leading to viral aggregation at cell surface
Oseltamivir ADME
Rapid absorbed
Renal entirely excretion
Oseltamivir DDIs
Live attenuated flu vaccine (intranasal)
Zanamivir MOA
Inhibitor viral neuraminidase and causes viral aggregation at cell surface and reduced spread of virus within respiratory tract
Zanamivir ADME
Deposited in lower respiratory tract and oropharynx
Zanamivir DDIs
Love attenuated flu vaccine (intranasal)
Zanamivir ADE
Sinusitis, dizziness
Muscle and nerve aches
Amantadine and Rimantadine MOA
Inhibit viral replication
Interfere with viral assembly
Amantadine and Rimantadine ADME
Well absorbed
Large Vd
Dose adjust in renal patients
Amantadine and Rimantadine ADE
CNS/GI
Neurotoxic
Pregnancy category C
Viral infection depend on host cell metabolic process for survival and obligate intracellular what
Parasites
What are the 5 sites that could be a drug target
Attachment
Entry
Uncoating (replication and gene expression)
Assembly (plus budding if envelope)
Release
Pathogenesis of viral infections
Enter through mucosa of respiratory or GI through direct inoculation
Replicate at site of entry
Few spread through neural cells
Pathogenesis: viral shedding, cell injury, clinical illness
viral shedding: into environment to perpetuate virus, occurs from body surface
cell injury: destruction of infected cells
clinical illness: organ function, inflammatory response to tissue injury
What is the highest burden population for flu
Children younger than 5
Adults 75 years and older
What is the initial side of virus for flu
Nasopharyngeal
(Can cause pneumonia)
What is the flu life cycle
Adhesion of virus
Endocytosis and fusion
Uncoating
RNA replication
Packaging and Building
Release of progeny virus
What is antigenic drift
Small changes and mutation to in genes leading to changes to HA and NA (viral antigens)
What is antigenic shift
Abrupt acquisition of new hemagglutinin and neuraminidase by flu
Results in novel flu virus
Flu pathophysiology
Person to person from respiratory droplets
Incubation period of 1 and 7 days
Viral shedding can persist for weeks to months
Who is at high risk for flu complications
Pregnant women
Children over 6 months
Elderly
People with aphasia
Immunocompromised
Chronic disease pts
Obese
Health care workers
Non pharmacotherapy for flu
Sleep
Rest and prevent spread
Fluids
Who to treat for flu
Hospital with flu
Outpatient (illness, high risk, under 2 over 65, pregnancy)
Oseltamivir indication, age, dose
treatment: any age
prophylaixs: >3 months
dose: 75mg bid x5d w/in 48 hours of symptoms onset
reduction of 1.5 days of improvement
drug of choice in severe flu
Zanamivir indication, age, dose
treatment: >7 years
prophylaixs: >5 years
10 mg inhaled bidx5d w/in 48 hours of symptoms onset
reduction of 1.5 days of improvement
not for asthma or COPD
Peramivir indication, age, dose
treatment: >2 years
600 mg IVx1 infused 15 min w/in 48 hours of symptoms onset
reduction of 1 day of improvement
only IV
Baloxavir indication, age, dose
treatment: >12 yrs
weight based:
40-79 kg 40 mg
>80 kg 80 mg
w/in 48 hours of symptoms onset
reduction of 1.5 days of improvement
no dairy, not for high risk
What is the main genera within the subfamily virology of corona
betacoronavirus
What does the alpha and beta CoV genera known to infect? what about gamma and sigma
alpha and beta: infect mammals
gamma and sigma: infect birds
What has a higher affinity SARS-CoV-2 spike or SARS-CoV spike
SARS-CoV-2 spike
What are the three phases of disease progression of COVID
Stage 1: viral response (inhibit viral replication)
Stage 2: pulmonary phase
Stage 3: host response hyperinflammation (immune modulation)
Stages of clinical presentation of COVID
stage 1: cold like, smell disorders, lymphopenia, one week from onset
stage 2: respiratory distress and coughing, one week to 10 days
stage 3: ARDS, SIRS/shock, cardiac failure, after 10 days
HSV presentation
eye
skin
brain
neonatal transmission
EBV presentation
infectious mononucleosis (fever, sore throat)
contagious
no treatment
nasopharyngeal carcinoma and burkitts lymphoma
CMV presentation
problem in immunosuppressed host (transplant, HIV)
CNS, retina, lungs
treatment: ganciclovir, valganciclovir
prophylaxis: letermovir, ganciclovir, valganciclovir
Varicella Zoster
primary form of infection (contagious)
chickenpox
-rash, malaise, pruritis, scabs
infectious up to 5 days after vesicles crusted
Chicken Pox presentation
first exposure to varicella zoster
full body rash
highly contagious
common in children
live virus vaccine
Shingles presentation
reactivation of varicella zoster
local rash
post herpetic neuralgia
>50 yo
recombinant vaccine
Chickenpox treatment
itching: cut nails, calamine, benadryl, burows soln
fever: apap
virus: acyclovir
Herpes Zoster shingles cause and effects
shingles can occur w/out chickenpox
thoracic and lumbar regions most common place
can effect eyelids (could lead to eyesight loss)
Shingles treatment
pain precedes eruption of lesions
lesion crust over 3-5 d and resolve in 14 d
painful
acyclovir and valacyclovir treatment started w/in 72 h
How to prevent herpes zoster
vaccine
>50 yo
>19 if immunocompromised
can vaccinate if had singles
What is the most common otitis media pathogens
strep pneumoniae***
haemophilus influenzae
moraxella catarrhalis
What disease most commonly occurs following a brief, upper respiratory illness, including the “common cold”
otitis media
Otitis media may be recognized in kids that do what
tug on ears
hearing may be muffles (louder volumes on toys, tv)
Diagnosis of otitis media is dependent upon PE of what
bulging tympanic membrane + onset + pain
otorrhea may be present
What are the three indications for antibiotics of otitis media
children aged 6 months or older w/ severe symptoms (toxic) pain >48 hr or temp >102.2 F
children aged 6 months or older with otorrhea
children btw 6-23 months w/ bilateral otitis media
First line therapy for otitis media
amoxicillin (BID)
augmentin (BID, used if other criteria present)
2nd/3rd gen cephalosporins (PCN allergy)
Therapy for otitis media if failure at 48-72 hours
ceftriaxone IM
augmentin (use if not already used)
What is the specific criteria for using augmentin as first line therapy for otitis media
recent amoxicillin use w/in 30 days
concurrent purulent conjunctivitis
history of recurrent infections unresponsive to amoxicillin
Duration of treatment for Otitis Media
5-10 days
10 days for children <2 or complicated course
The vast majority of sinusitis diagnosis is _____ in nature
viral
What is the common pathogens for acute bacterial rhinosinusitis
s. pneumoniae***
h. influenzae
m. catarrhalis
The majority of acute bacterial rhinosinusitis cases initiate as a respiratory tract infection what is the pathophysiology
respiratory infection causes mucosal inflammation
inflammation allows bacteria to migrate
outflow of sinus cavity becomes impaired
Hallmark symptoms of bacterial rhinosinusitis
last for 10 d w/out clinical improvement (pain, pressure)
fever >102.2 F
worsening symptoms (new fever, headache, increase nasal discharge)
First line therapy for acute bacterial rhinosinusitis
augmentin (BID)
clindamycin + cephalosporin (TID, PCN allergy)
Levofloxacin (PCN allergy)
Moxifloxacin (PCN allergy)
Doxycyclin (BID, for adults
What are the hospital therapies to use for acute bacterial rhinosinusitis
amp/sub
ceftriaxone
levofloxacin
Duration of therapy for acute bacterial rhinosinusitis
uncomplicated infection: 5-7
children and complicated infection: 10-14
What is the most common pathogen and the incubation period for pharyngitis
group A strep (GAS)
2-5 days
Pharyngitis: GAS symptoms
sore throat
painful swallowing
fever
headache, GI
enlarged lymph node
swollen uvula, petechiae, spots on soft palate
Pharyngitis: Viral symptoms
conjunctivitis
cough
First line therapy for pharyngitis
pen V (BID), pen G (IM)
amoxicillin (1 qd)
cephalosporins (PCN allergy)
clindamycin (TID, PCN allergy)
macrolides: azithromycin, clarithomycin (PCN allergy)
Pharyngitis therapy for eradication of GAS
augmentin (TID)
clindamycin (TID)
pen V + rifampin
pen g + rifampin
What disease occurs in winter months or in presence of irritating substances (pollution, cig smoke)
Bronchitis
What are the common pathogens of bronchitis
m. pneumoniae***
s. pneumoniae
h. influenzae
What is the clinical presentation of acute bronchitis
cough***
increase sputum production
fever
nasopharyngeal symptoms
What is the treatment for acute bronchitis
antipyretics
antitussives (little evidence)
antibiotics (symptoms >4-6 d, immunocompromised, elderly)
- 2nd or 3rd gen ceph + macrolide or doxycycline
What disease is classified by chronic cough productive of sputum lasting more than 3 months for 2 consecutive years without an underlying etiology of bronchietasis or tuberculosis
Chronic Bronchitis
What are the risk factors for Chronic Bronchitis
smoking
continuous exposure to airway irritants
recurrent respiratory tract infections in childhood
What disease state is classified as an acute viral infection that affects children, peak during winter through spring, and RSV is the main cause
bronchiolitis
What is the treatment for bronchiolitis
supportive care
ribavirin or prophylaxis with RSA immunoglobulin or palivizumab in infants with underlying disease
What are the risk factors for CAP
> 65 yo
COPD
alcohol/tabacco abuse
asplenia
DM
pulmonary, CV, renal, liver disease
What is the diagnostic criteria for CAP
chest x-ray**
-cough
- >100.4F
-sputum production
-pleuritic chest pain
+/- microbio data
What patients are blood cultures are recommended for CAP
inpatients with severe disease
inpatients receiving MRSA/PsA treatment
perviously infected MRSA/PsA
hospitalized and received parenteral antibiotics w/in previous 90 days
What are the most common pathogens in CAP
s. pneumoniae
h. influenzae
s. aureus
What are the most common pathogens in atypical pneumonia
m. pneumoniae
c. pneumoniae
l. pneumophila
What is CURB-65
confusion
urea >7
RR >30
SBP <90 or DBP <60
>65 yo
What is the 3 risk groups for CURB-65
1: 0-1 criteria, 1.5% death
2: 2 criteria, 9.2% death, admission or outpatient
3: 3-5 criteria, 22%, admission
Treatment for CAP in low risk outpatients
amox
doxycycline
macrolide (DONT USE)
Treatment for CAP for outpatients with risk factors for MRSA or PsA
option 1:
augmentin OR cephalosporin
AND macrolide OR doxycycline
option 2:
levofloxacin or moxifloxacin (po)
Treatment for non-severe inpatient CAP
option 1:
beta lactam + macrolide
option 2:
levofloxacin or moxifloxacin (IV)
What is the severe CAP major criteria
1 major or 3 or more minor
-septic shock w/ need for vasopressors
-respiratory failure requiring mechanical ventilation
Treatment for severe CAP
option 1:
beta lactam + macrolide
option 2:
beta lactam + levofloxacin or moxifloxacin (IV)
Treatment for cap with prior history of MRSA
vanco
linezolid
ceftroline
(NOT dapto)
Treatment for cap with prior history of PsA
pip-taz
aminoglycoside
carbapenem
What is HAP
occurs at least 48 hours of inpatient admission but not present at time of admission
What is VAP
occurs at least 48 hours following endotracheal intubation
What are the HAP and VAP risk factors
aspiration
COPD, ARDS, coma
antacids, h2ra, ppi
supine position
enteral nutrition, ng tube
re-inubation, trache, pt transport
prior antibiotic exposure
head trauma, ICP monitoring
>60 yo
What is the diagnosis for HAP and VAP
chest x ray
AND
>100.4 F, leukocytosis, purulent secretions, decline in o2
What are the HAP and VAP multidrug resistant (MDR) pathogens
PsA
ESBL + kleb and e.coli
serratia sp
acinetobacter sp
stenotrophomonas maltophilia
PCN resistant strep pneumoniae
MRSA
What are the VAP and HAP MDR pathogen risk factors
prior IV antibiotic use w/in 90 days (both)
septic shock at time of VAP
ARDS preceding VAP
5 or more days hospitalization prior to VAP
acute renal replacement therapy prior to VAP
What is the high risk of mortality for VAP and HAP
septic shock or need for ventilatory support due to pneumonia
What are the MRSA risk factors for VAP and HAP
prior IV antibiotic use w/in 90 days
OR
MRSA prevalence >20%
HAP treatment for not at risk of mortality, no MRSA risk
PsA drugs
pip-taz
cefepime
levofloxacin
imipenem-cilastatin
meropenem
HAP treatment for low risk of mortality, MRSA risk factors present
PsA drug
AND
vanco or linezolid
HAP treatment for high risk mortality, IV antibiotics received in past 90 days (MRSA/MDR risk)
Two or more PsA drugs (pip-taz, cefepime, cipro, etc.)
AND
Vanco or linezolid
What are the antipseudomonal beta lactams (category A for VAP treatment)
pip-taz
cefepime
ceftazidime
imipenem-cilastatin
meropenem
aztreonam
What are the antipseudomonal non beta lactams (category B for VAP treatment)
cipro
levofloaxcin
genta
tobra
amikacin
colistin
polymyxin B
VAP treatment: if patients has no VAP MDR risk factors and <10% gram negative resistance to monotherapy agents
group A: antipseudomonal beta lactams
OR
group B: antipseudomonal non beta lactams
VAP treatment: pt has no VAP MDR risk factors and >10% gram negative resistance to monotherapy agents
group A: antipseudomonal beta lactams
AND
group B: antipseudomonal non beta lactams
VAP treatment: if MRSA prevalence >10-20%
group A: antipseudomonal beta lactams
AND
group B: antipseudomonal non beta lactams
AND
dapto or linezolid
VAP treatment: if MRSA prevalence <10-20%
pip-taz
cefepime
levofloxacin
imipenem
meropenem
VAP treatment: if patient has a VAP MDR risk factor
group A: antipseudomonal beta lactams
AND
group B: antipseudomonal non beta lactams
AND
dapto or linezolid
What disease is classified as non-infectious etiology resulting from the introduction of stomach/bile acids into respiratory tract
aspiration pneumonia
Aspiration pneumonia clinical presentation and treatment
mimic bacterial infections, increase fever, increase WBC
NO antibiotics
There is no anaerobes in pneumonia, you only consider adding anaerobic coverage if what
empyema
pulmonary abscesses evident on exam/imaging
Acyclovir and valacyclovir MOA
inhibits viral DNA synthesis
Acyclovir and valacyclovir ADME
valacyclovir has higher bioavailability
crosses placenta
dose adjust in renal patients
Acyclovir and valacyclovir ADEs
renal insufficiency or neurotoxicity
Acyclovir, Valacyclovir, and Famciclovir DDIs
probenecid
Famciclovir MOA
competitive inhibitor of viral DNA polymerase
Famciclovir ADME
> 90% excreted unchanged in urine
dose adjust in renal patients
Famciclovir ADEs
elderly - rash, hallucination
topical site reactions
Does chlamydia trachomatis infect intracellular or extracellular
intracellular
cannot replicate extracellularly
incubation period 7-21 days
What are the disnosis tests for Ct and GC
NAAT
urogenital
-urine (both)
-vaginal swab (F)
-urethral swab (M)
rectal swab (both)
orophayngeal throat swab (both)
What women to screen for Ct and GC
annual screen for sexually active women <25yo (highest incidence) and >25 have increased risk
pregnant at first prenatal visit and 3rd trimester
rectal and throat based on reported sexual activity
What men to screen for Ct and GC
men with women only (low risk, dont screen)
MSM (annual test)
Ct men presentation for urethritis, epididymitis, anorectal, oropharyngeal
urethritis: asymptomatic
epididymitis: symptoms (scrotal pain)
anorectal: asymptomatic
oropharyngeal: asymptomatic
Ct women presentation for cervicitis, urethritis, PID, anorectal, oropharyngeal
cervicitis: asymptomatic
urethritis: asymptomatic
PID: symptoms (ab pain, vaginal discharge)
anorectal: asymptomatic
oropharyngeal: asymptomatic
Ct treatment for urogenital, rectal, and pharyngeal
Doxycycline 100 mg po BID x7
alternatives:
azithromycin 1 g PO x1 (pregnancy)
levofloxacin 500 mg po q24h x7d
Chlamydia follow up for urogenital, rectal, and pharyngeal
repeat testing at 2 months
retest only for recurrence of symptoms
What to do for Ct partners
evaluate and treat all w/in last 60 days from onset
last partner >60 d, evaluate and treat
no sex for 7 days after end of treatment
What is neisseria gonorrhoeae
gram negative diplococci
use cephalosporins
(pen and fluoroquinolones resistance increasing)
GC presentation men for urethritis, epididymitis, anorectal, oropharyngeal
urethritis: symptoms (discharge)
epididymitis: symptoms (scrotal pain)
anorectal: asymptomatic
oropharyngeal: asymptomatic
Ct women presentation for cervicitis, urethritis, PID, anorectal, oropharyngeal
cervicitis: asymptomatic
urethritis: asymptomatic
PID: symptoms (ab pain, vaginal discharge)
anorectal: asymptomatic
oropharyngeal: asymptomatic
GC alone treatment for urogenital, rectal, or pharyngeal
Ceftriaxone 500 mg IM x 1 dose
(use 1000 mg if wt over 150)
alternative:
genta 240 mg IM + azithromycin 2 gm po (use if highly allergic)
Treatment for GC when chlamydia is not excluded
Ceftriaxone 500 mg IM x1 + doxycycline 100 mg BID x7
Treatment for disseminated GC (spread over multiple areas)
Ceftriaxone 1 g IM or IV q24h
Ceftotaxime 1 g IV q8h
Treatment for GC in pregnancy
Ceftriaxone 500 mg IM x1
Chlamydia not excluded: add azithromycin 1000 mg POx1
GC follow up
urogenital or rectal:
repeat test at 3 months
pharyngeal:
test-of-cure recommended between 7-14d
*only retest for recurrent symptoms
GC partners
evaluate and treat all partners w/in last 60 days from onset or diagnosis
last partner >60d evaluate and treat
no sex for 7 days after treatment
Syphilis main pathogen
treponema pallidum
Syphilis screening tests
non-specific:
-measure IgM/IgG antibodies specific to cellular breakdown products
-VDRL
-RPR
specific:
-measure antibody specific to t. pallidum
-FTA
-TP-PA
What is primary syphilis
incubation period 10-90 days
chancre appears at site of spirochete penetration
-painless and resolves spontaneously w/in 1-8 wks
-highly infectious
What us secondary syphilis
develop 4-8 wks after onset of primary
-hematogenous or lymphatic spread resulting in rash
-lymphadenopathy
-malaise, fever, non-specific symptoms
-resolves 4-6 weeks
What is latent syphilis
positive serologic test
no other signs of disease related to other stages
can develop tertiary disease
What is tertiary syphilis: gumms, neurosyphilis, CV
affect any organ of body
gummas
-granulomatous lesion often affecting bone, skin, upper resp tract
neurosyphilis
-general paresis, deafness, optic atrophy and blindness, occur at any stage
CV
-aortic insufficiency, aortic aneurysms
Treatment for primary, secondary, and early latent (<1 yr) syphilis
Benzathine PCN G 2.4 MU IM x1
Treatment for tertiary and late latent or unknown duration of latency syphilis
Benzathine PCN G 2.4 MU IM qw x3
Treatment for neurosyphilis
aqueous PCN G 3-4 MU q4h (4-6wk)
continuous infusion possible
Treatment for pregnancy syphilis
PCN
desensitize to PCN if allergic
Syphilis follow up
resolution of signs/symptoms
primary and secondary:
-check RPR at 6 and 12 months
latent:
-check RPR 6, 12, 24 months
RPR titel drop >4 fold
What to do for partners of syphilis for pri/sec/early latent and latent
pri/sec/early latent:
-evaluate and treat all partners w/in 90 days
-last partner >90 days evaluate and treat if positive serology
latent:
evaluate and treat based on serology
no sex 7 days after treatment
When to use Doxy PEP (post exposure for chlamydia, gonorrhea, and syphilis)
MSM and transgender female who have condomless vaginal, anal, or oral sex
at least one STI in last 12 months
What are the issues with doxy PEP
well tolerated
counsel for usual ADR and DDI
What is the most common cause of genital ulcerations
herpes simplex
What is herpes simplex primary infection
lesion appear 2-14 days after exposure
lesions painful (most pain 7-10 days)
can have systemic symptoms
most contagious when symptoms present
viral shedding when asymptomatic
Latency herpes simplex
in root of sensory or autonomic nerve ganglia
Recurrent herpes simplex
emotional or physical stress
duration is shorter than primary
no systemic effects
have tingling, itching, local tenderness
occur 12-24 hours prior to lesion
Treatment for herpes simplex initial episode
Acyclovir 400 mg po tid
Acyclovir 200 mg po 5x/d
Famciclovir 250 mg po tid
Valacyclovir 1 g po bid x7-10d
Treatment for herpes simplex episodic/recurrent
Acyclovir 400 tid x5
Acyclovir 800 bid x5
Valacyclovir 500 mg bid x3
Valacyclovir 1 g d x5
Famciclovir 125 mg bid x5
Famciclovir 1000 mg bid x1
What is trichomonas vaginalis
motile protozoan
more common in women
half asymptomatic
vaginal discharge (malodorous)
Treatment for trichomonas
Metronidazole 2 g po x1
(pregnant and non-pregnant)
Human Papillomavirus (HPV): low risk and high risk
non-oncogenic (low):
genital warts, cervical cellular changes
oncogenic:
associated with cancer mainly cervical (majorly associated with 16 and 18)
Self applied treatment for HPV genital warts
prdofilox 0.5%
imiquimod 5%
sinecarechins 15%
Physician applied treatment for HPV genital warts
cryotherapy with liquid nitrogen or cyroprobe
podophyllin resin 10-25% in compound tincture of benzoin
trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90%
HCP prevention
vaccine
(9-valent HPV is only one currently available)
-recommended for 9-26 yo
-shared decision making 27-45yo
