ID Part 3 Flashcards
Which of the following statements are true regarding Zyvox? (Select ALL that apply.)
A. Myelosuppression can occur with the use of Zyvox.
B. It is cleared primarily by the kidney requiring dose adjustments in the setting of renal impairment.
C. There is a risk for serotonin syndrome if used with SSRI antidepressants.
D. Nephrotoxicity is a common toxicity with prolonged use.
E. It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion.
Myelosuppression can occur with the use of Zyvox.
There is a risk for serotonin syndrome if used with SSRI antidepressants.
It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion.
Zyvox is primarily cleared by the liver, not the kidney. It is an MAO inhibitor.
It is contraindicated within 2 weeks of MAO inhibitors. It should be used with other serotonergic drugs only when clearly indicated. Ideally, an SSRI would be stopped before starting linezolid.
Myelosuppression (e.g., thrombocytopenia) is a duration-related toxicity.
Oxazolidinones Meds
Linezolid (Zyvox)
Tedizolid (Sivextro)
Oxazolidinones Coverage
Similar to Vancomycin + VRE
Vancomycin covs gram (+) bacteria (including MRSA)
Linezolid & Daptomycin DOC for VRE
Linezolid Indications
Skin/soft-tissue infections (SSTIs)
VRE infections
Pneumonia
Bloodstream infections
Tedizolid Indication
SSTI only
Oxazolidinones Bioavailability
IV:PO ratio = 1:1
Both comes in IV & PO
Don’t shake linezolid (Zyvox) sus
Linezolid CI
MAO inhibitor use w/in 14 days
Linezolid Warnings
Duration related myelosuppression (thrombocytopenia) - monitor CBC weekly
Optic neuropathy
Oxazolidinones & Serotonin Syndrome
Both are weak MAO inhibitors
Caution w/ serotonergic drugs (e.g., SSRIs, SNRIs, TCAs, meperidine, buspirone)
Avoid tyramine-containing foods
CPis a 22-year-old female who has been started on Macrobid for a five day treatment course for a urinary tract infection. Counseling on Macrobid should include the following points?
A. Do not take antacids or calcium supplements at the same time as your Macrobid dose.
B. This medication should be taken four times daily in evenly spaced intervals (every 6 hours).
C. This medication may cause the urine to turn dark yellow or brown in color.
D. This medication can make the skin more sensitive to the sun. Use sunscreen and protective clothing.
E. This drug should be taken on an empty stomach.
This medication may cause the urine to turn dark yellow or brown in color.
Nitrofurantoin (Macrobid) is dosed twice daily, hence the brand name MacroBID.
Nitrofurantoin does not have chelation interactions and does not cause photosensitivity.
It is associated with GI upset and should be taken with food.
The urine discoloration is harmless.
Nitrofurantoin
Common Dosing regimen
Macrobid 100 mg BID x 5 d
Macrodantin QID
Nitrofurantoin
Warnings
Avoid in G6PD deficiency
Can cause hemolytic anemia (+ Coombs test)
What is the DOC for uncomplicated UTI?
Nitrofurantoin
Nitrofurantoin
Do not use when?
CrCl < 60
Nitrofurantoin
Counseling
Take w/ food
Can discolor urine (brown)
Wt: 105 lbs
The physician asks the pharmacist on rounds to assist with transitioning the patient to oral Bactrim20 mg/kg/day in preparation for hospital discharge. What is the correct dose?
A. Bactrim SS 2 tabs BID
B. Bactrim SS 2 tabs TID
C. Bactrim DS 1 tab TID
D. Bactrim DS 2 tabs BID
E. Bactrim DS 2 tabs TID
Bactrim DS 2 tabs TID
105 pounds = 47.7 kg. 47.7 kg x 20 mg/kg = 954 mg Bactrim/day.
Bactrim is dosed from the TMP component and DS tabs have 160 mg TMP per tab.
KS would need 6 tabs per day (954 mg Bactrim / 160 mg TMP per tab) to treat her infection.
To avoid errors, mg/kg doses should reference the TMP component.
When using higher SMX/TMP doses like this, monitor the patient carefully for side effects.
KS is diagnosed with PCP and stabilized. She is ready for discharge. Her provider is concerned that the cellulitis has not healed as well as he had hoped. He asks the pharmacist about a single dose medication for bacterial skin and skin structure infections that he heard about. He thinks this patient would be a good candidate for this drug. Which drug is he referring to?
A. Vancomycin
B. Telavancin
C. Oritavancin
D. Tedizolid
E. Polymyxin
Oritavancin
Oritavancin (Orbactiv) and dalbavancin (Dalvance) are lipoglycopeptides with similar spectrum of activity to vancomycin: both have activity against Staphylococci (MSSA and MRSA) and Streptococci.
Oritavancin and dalbavancin are a one-time dose.
Lipoglycopeptides
Meds
Telavacin (Vibativ)
Oritavancin (Orbactiv, Kymyrsa)
Dalbavancin (Dalvance)
Lipoglycopeptides
Coverage
Similar to IV Vancomycin:
Gram (+) Cocci including MRSA
Does not cover VRE
Lipoglycopeptides
Approved for
Skin infections
Telvancin (Vibativ) approved for HAP/VAP
Lipoglycopeptides
Which one is approved for HAP/VAP?
Telvancin (Vibativ)
Lipoglycopeptides
Can cause what syndrome?
Red Man
Lipoglycopeptides
Which ones are single-dose regimens?
Oritavancin (Orbactiv, Kymyrsa)
Dalbavancin (Dalvance)
Lipoglycopeptides: Tealvancin (Vibativ)
Boxed Warnings
Fetal risk, Nephrotoxicity, ↑ mortality compared to vancomycin in Pneumonia trials (pts w/ CrCl ≤ 50)
Lipoglycopeptides: Telavancin (Vibativ)
CI
Concurrent use of IV UFH
Lipoglycopeptides: Telvancin (Vibativ)
Warnings
Falsely ↑ aPTT/PT/INR
Lipoglycopeptides: Oritavancin (Orbactiv, Kymyrsa)
CI
Use of IV UFH for 5d after
Lipoglycopeptides: Oritavancin (Orbactiv, Kymyrsa)
Warnings
↑ PT/INR (up to 12 hrs) &
↑ aPTT (up to 120 hrs)
Which two antibiotics should be separated from multivitamin supplements?
A. Flagyl andcefuroxime
B. Minocyclineand levofloxacin
C. Avelox and amoxicillin
D. Bactrim and Zithromax
E. Biaxin and Zyvox
Minocyclineand levofloxacin
Tetracyclines and quinolones should be separated from divalent cations (e.g., calcium, iron, magnesium, zinc) as they may inhibit absorption through chelation.
Which of the following statements is correct in regardto ceftriaxone?
A. It is considered a broad-spectrum antimicrobial agent with activity against Pseudomonas.
B. It is cleared unchanged by the kidney and requires dose adjustments in renal impairment.
C. It is adrug of choice for spontaneous bacterialperitonitis.
D. It should be avoided in patients who are pregnant.
E. It can be used with calcium containing IV products in neonates
It is adrug of choice for spontaneous bacterialperitonitis.
Which of the following medications is/are associated with seizures and/or decreasing the seizure threshold? (Select ALL that apply.)
A. Imipenem/Cilastatin
B. Ciprofloxacin
C. Cefuroxime
D. Penicillin G
E. Azithromycin
Imipenem/Cilastatin
Ciprofloxacin
Cefuroxime
Penicillin G
Ciprofloxacin and the other quinolones decrease the seizure threshold.
Beta-lactams have been associated with seizures, especially if the drug accumulates (e.g., longer courses, renal failure).
HW is a 71-year-old male who has been in the intensive care unit for several weeks and is now being treated for pneumonia, with a lower respiratory culture positive forPseudomonas aeruginosa. His weight is 225 pounds and height is 6’0”. His current serum creatinine is 2.4 mg/dL. Based on the culture sensitivities, the medical team decides to start tobramycin at 2.5 mg/kg. They ask the pharmacist to write the order and administer the first dose at 8:00 AM. Which doseof tobramycin should be administered at 8:00 AM?
A. 560 mg
B. 410 mg
C. 340mg
D. 220 mg
E. 100 mg
220 mg
Aminoglycosides are dosed using adjusted body weight for obese patients.
2.5 mg/kg x 87.47 kg = 218.68 mg; round to 220 mg.
Which quinolone antibiotic is preferred for treatment of MRSA skin and soft tissue infections?
A. Delafloxacin
B. Ciprofloxacin
C. Levofloxacin
D. Moxifloxacin
E. Gemifloxacin
Delafloxacin
Brand: Baxdela
Delafloxacin has activity against MRSA and is indicated for skin and soft tissue infections.
Other quinolones should be avoided due to higher rates of resistance.
MT should be counseled to take the Levaquin2 hours before or 2 hours after which medication?
A. Zinc
B. Simvastatin
C. Warfarin
D. Aspirin
E. Hydrochlorothiazide
Zinc
Quinolones should not be given with zinc or other divalent cations, due to decreased absorption with chelation.
Preferred Initial ART Regimens in Most Tx-Naive Adults
Biktarvy
Triumeq
Dovato
Tivicay + Truvada
Tivicay + Descovy
Do not use if CrCl < 30
All contain an integrase inhibitor w/ a high barrier to resistance
Dovato
Dolutegravir + lamivudine
Dovato
Criteria for use
VL < 500,000
No HBV
No resistance to either component
Dolutegravir + lamivudine
Emtriva
Generic
emtricitabine
Complete HIV Antiretroviral Regimens
Base (Choose 1)
NRTI (2 in most cases)
Complete HIV Antiretroviral Regimens
Base
INSTi (eg, raltegravir)
OR
Boosted PI (eg, darunavir/ritonavir)
OR
NNRTI (eg, doravirine)
Complete HIV Antiretroviral Regimens
NRTI Backbone
Abacavir or Tenofovir
PLUS
Emtricitabine or lamivudine
ART in Pregnancy
Already on ART
May continue pre-pregnancy ART regimen in most cases
ART in Pregnancy
New starts
3 components recommended:
Dolutegravir or boosted darunavir, PLUS
Dual NRTI backbone (eg, emtricitabine/tenofovir)
ART in Pregnancy
Perinatal transmission PPx
Maternal administration of IV zidovudine prior to delivery
Neonatal administration of ART (exact regimen & duration dependent on risk)
Immune Reconstitution Inflammatory Syndrome (IRIS)
Worsening of an underlying condition after ART initiation & as the CD4 count begins to recover
Can be known or previously unidentified condition
More likely when ART initited at low CD4 counts
Immune Reconstitution Inflammatory Syndrome (IRIS)
Key points
Continue ART
Treat underlying condition (eg, opportunistic infection)
Provide supportive care (eg, fluids, antipyretics)
Which of the following statements is correctregarding piperacillin/tazobactam?
A. Tazobactam is added to inhibit beta-lactamase activity.
B. The brand name is Zofran.
C. It exhibits concentration-dependent killing.
D. The dosing is 0.375 grams/3 grams of piperacillin/tazobactam respectively.
E. It is available as an oral suspension and intravenous formulation.
Tazobactam is added to inhibit beta-lactamase activity.
Piperacillin/tazobactam (Zosyn) is available IV only and exhibits time-dependent killing.
Tazobactam is a beta-lactamase inhibitor that expands its spectrum of activity to include anaerobes and more resistant organisms.
The correct dosing formulation is 3 g/0.375 g of piperacillin/tazobactam, respectively.
Common Resistant Pathogens
Mnemonic
Kill Each And Every Strong Pathogen
Klebsiella pneumoniae (ESBL, CRE)
E. coli (ESBL, CRE)
Acinetobacter baumannii
Enterococcus facecalis & faecium (VRE)
Staphylococcus aureus
Pseeudomonas aeruginosa
A prescription for generic minocycline is filled. Which of the following statements regarding minocycline are correct? (Select ALL that apply.)
A. This medication has been associated with drug-induced lupus.
B. Take on an empty stomach 1 hour before or 2 hours after meals.
C. This medication may increase the risk of sunburn.
D. This medication should be separated when given with antacids.
E. This medication does not interact with other medications.
This medication has been associated with drug-induced lupus.
This medication may increase the risk of sunburn.
This medication should be separated when given with antacids.
Minocycline should not be used in children younger than 8 years old or in patients who are pregnant due to the risk of tooth discoloration, bone growth retardation and reduced skeletal development.
Phosphate binders like fosrenol also decrease minocycline absorption.
Tetracyclines
Drugs
Doxycyline (Vibramycin)
Minocycline (Minocin, Solodyn)
Eravacycline (Xerava)
Omadacycline (Nuzyra)
Sarecycline (Seysara)
Tetracycline
Tetracyclines
Coverage
Gram (+): Staph, Strep, Entero, Propionibacterium
Gram (-): including respiratory flora (Haemophilus, Moraxella, atypicals)
Other: Rickettsiae, Bacillus antracis, Treponema pallidum & other spirochetes)
Tetracyclines
Doxycycline Coverage
Respiratory tract infections (e.g., CAP)
Tickborne/rickettsial diseases
Spirochetes
Sexually transmitted infections (e.g., chlamydia)
Tetracyclines
Common Uses
CA-MRSA skin infections
Acne
Minocycline is preferred for acne
Tetracyclines
Doxycycline Common Uses
First line for
* Tickborne illnesses (Lyme disease, Rocky Mountain Spotted Fever)
* Chlamydia
Treatment option for
* CAP,
* COPD exacerbations,
* Bacterial sinusitis (if antibiotic indicated),
* VRE UTI
Tetracyclines
Tetracycline Common Uses
H. pylori Tx regimens
Tetracyclines
Warnings
Avoid in Children < 8 y/o (supresses bone growth & discolors teeth)
&
Pregnancy & breastfeeding
Causes Photosensitivity
Tetracyclines
Intxn
Inhibit absorption
Antacids & other polyvalent cations (eg, Mg, Al, PO4, Ca, Fe, Zinc)
Multivitamins
Sucrafate
Bismuth Subsalicylate
Bild Acid Renins
Tetracyclines
IV:PO
1:1
Doxycyline, minocycline
Which antibiotic induces drug induced lupus erythematosus (DILE)?
Minocycline (Minocin, Solodyn)
Which are
Hydrophilic Agents
Beta-Lactams
Aminoglycosides
Glycopeptides
Daptomycin
Polymyxins
Hydrophilic Agents
Proporties
Small Vd
Renal elimination
Low intracellular concentrations
Increased clearance in sepsis
Poor-moderate bioavailability
Which are
Lipophilic Agents
Quinolones
Macrolides
Rifampin
Linezolid
Tetracycline
Chloramphenicol
Lipophilic Agents
Properties
Large Vd
Hepatic metabolism
Achieve intracellular concentrations
Clearance changed minimally in sepsis
Excellent bioavailability
Recommended Initial HIV ART for most pts
INSTI plus 2 NRTIs:
Bictegravir/tenofovir alafenamide/emtricitabine (Biktarvy)
Dolutegravir/abacavir2/lamivudine (Triumeq)
Dolutegravir (Tivicay) plus:
* Emtricitabine/tenofovir alafenamide (Descovy)
* Emtricitabine/tenofovir disoproxil fumarate (Truvada)
INSTI plus 1 NRTI: Dolutegravir/lamivudine (Dovato)
Do not use INSTI + 1 NRTI if pretreatment HIV RNA > 500,000 copies/mL, there is known hepatitis B coinfection, or HIV genotyping is not available.
Clindamycin Brand
Cleocin
Topical: Clocin-T, Clindagel
Clindamycin Coverage
Staph (including CA-MRSA), Strep & Anaerobes
Clindamycin Renal
No dose adjustment
D-test
Induction test on Saureus susceptible to clindamycin but resistant to erythromycin
Flattened zone indicates clindamycin resistance (don’t use)
Clindamycin Box Warning
C. diff
Metronidazole Coverage
Anaerobes & Protozoal
Metronidazole IV:PO
1:1
Metronidazole CI
Pregnancy
Alcohol (disulfiram rxn)
Metronidazole SE
Metalic Taste
Metronidazole Drug Intxn
↑ INR w/ warfarin
Which antibiotics are
Cmax:MIC (concentration-dependent)
Aminoglycosides
Quinolones
Daptomycin
Which antibiotics are
AUC:MIC
Vancomycin
Macrolides
Tetracyclines
Polymyxins
Technically also concentration dependent but AUC is not usually measure in practice
Which antibiotics are
Time > MIC (time-dependent)
Beta-lactams
OTC HIV testing
Brand
OraQuick In-Home HIV Test
Other might be available but might require labs
OTC HIV testing
Sample & timing
Oral fluid sample to detect the presence of HIV antibodies
Perform ≥ 3 months from exposure to avoid false negative
OTC HIV testing
Testing procedure
Swab upper & lower gums with test stick
Insert test stick into tube containing testing solution
After 20 minutes, read the results:
* One line indicates a positive control (ie, valid test)
* Two lines indicates a positive HIV result
Positive results require follow-up laboratory confirmation for diagnosis
Aminoglycoside Boxed Warning
Nephrotoxicity
Ototoxicity
Neuromuscular blockage
Maraviroc (Selzentry)
CCR5 Antagonist
Hepatotoxicity (boxed warning)
Hypersensitivity reactions (including SJS/TEN)
Orthostatic hypotension (in patients with renal impairment)
Tropism test required prior to starting
CYP3A4 substrate
Fostemsavir (Rukobia)
Attachment Inhibitor
Must maintain effective HBV treatment if coinfected
Can ↑ SCr (especially if underlying renal disease)
Is a substrate of CYP3A4: check for drug interactions!
Ibalizumab-uiyk (Trogarzo)
Post-Attachment Inhibitor
IV injection
Infusion-related reactions (observe for 1 hour after 1st infusion)
Other side effects: diarrhea, dizziness, nausea, rash
Enfuvirtide (Fuzeon)
Fusion Inhibitor
SC injection
Risk of bacterial pneumonia, hypersensitivity reactions
Injection site reactions: pain, erythema, nodules & cysts, ecchymosis
Other side effects: nausea, diarrhea, fatigue
Lenacapavir (Sunlenca)
Initial: PO loading dose then
Then SC injections Q6 months
Safety & Monitoring
* Contraindicated with strong CYP3A4 inducers
* Injection site reactions: erythema, induration, nodule, pain, swelling
DOC for Acinetobacter
Meropenem
Vancomycin
Target AUC/MIC ratio for serious MRSA infections
400-600
An antibiogram is: (Select ALL that apply.)
A. Another name for a culture and susceptibility report
B. A collection of culture and susceptibility reports over a period of time
C. Used to select empiric therapy
D. Used to help establish local resistance trends
E. Provides information on the MIC of specific bacteria
A collection of culture and susceptibility reports over a period of time
Used to select empiric therapy
Used to help establish local resistance trends
The culture and susceptibility report is for a single patient specimen and provides MIC information.
The antibiogram is a collection of C & S reports over a period of time (typically 1 year) that provides the percent of isolates that are susceptible.
It is used to help select therapy before the susceptibility report isavailable and to establish local guidelines (based on local resistance patterns).
Metronidazole is likely to be useful in which of the following infections? (Select ALL that apply.)
A. Urinary tract infection
B. Bacterial vaginosis
C. Trichomoniasis
D. Community-acquired pneumonia
E. Peritonitis after a perforated colon
Bacterial vaginosis
Community-acquired pneumonia
Peritonitis after a perforated colon
Metronidazole is an agent with anaerobic activity (including B. fragilis) and antiprotozoal activity.
Community-acquired pneumonia and urinary tract infections do not typically involve these pathogens.
BT is a 28-year-old female with a 2-day history of increased urinary frequency and burning with urination. She has suprapubic tenderness but no flank pain. Her vital signs are normal. A urinalysis is positive for white blood cells, leukocyte esterase, and nitrites, and a urine culture is pending. BT has a history of Escherichia coli urinary tract infections, the last of which was treated 2 months ago with sulfamethoxazole/trimethoprim. She has no known drug allergies. Which antibiotic is the best choice to empirically treat the infection while awaiting culture results?
A. Amoxicillin
B. Bactrim DS
C. Fosfomycin
D. Metronidazole
E. Zithromax
Fosfomycin
The first-line empiric treatment for acute cystitis (a lower urinary tract infection) is nitrofurantoin, fosfomycin, or sulfamethoxazole/trimethoprim.
An antibiotic that has not been used within the past 3 months should be selected.
Acute cystitis
Microbiology
Escherichia coli (most common)
Other gram-negative pathogens (eg, Proteus spp., Klebsiella spp.)
Staphylococcus saprophyticus
Acute cystitis
Clinical features
Dysuria
Increased urinary frequency and/or urgency
Suprapubic tenderness
Acute cystitis
Diagnosis
Urinalysis with pyuria (WBC > 10 cells/mm3), bacteria& positive leukocyte esterase and/or nitrites
Urine culture for organism identification & susceptibility
TM is a 42-year-old male who has been started on clarithromycin for treatment of pneumonia.Which of the following medications does not pose a drug interaction with the antibiotic treatment?
A. Amiodarone
B. Methadone
C. Simvastatin
D. Sucralfate
E. Voriconazole
Sucralfate
Clarithromycin (as well as erythromycin) is a strong CYP3A4 inhibitor andis contraindicated with simvastatin (and lovastatin) and can cause increased concentrationsof methadone and voriconazole.
Macrolides are associated with QT interval prolongation, which would be additive with amiodarone, methadone and voriconazole.
Macrolides do not have chelation issues with sucralfate.
A 23-year-old sexually active male visits his primary care physician concerned about multiple soft, nonpainful, mildly pruritic, skin-colored papules that have developed on the shaft of his penis. He is diagnosed with genital warts. What treatment is recommended?
A. Clindamycin PO
B. Imiquimod cream
C. Metronidazole gel
D. Mupirocin ointment
E. Tinidazole PO
Imiquimod cream
Human papillomavirus is a sexually transmitted disease that causes anogenital warts.
Imiquimod cream is an immune activator that can help resolve the appearance of the warts.
Genital warts
Etiology
Sexual transmission of HPV strains 6 & 11
Genital warts
Clinical features
Single or multiple pink or skin-colored lesions
Lesions range from smooth, flattened papules to cauliflower-like growths
Genital warts
Treatment
Common patient-applied therapies:
* Imiquimod cream (immune activator)
* Podofilox solution or gel (causes wart necrosis)
Provider-administered: cryotherapy, surgical removal
Genital warts
Prevention
Vaccination: HPV-9 (Gardasil 9) recommended for age 9–26
Barrier contraception
