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424 Pharmacology > Infections > Flashcards

Infections Flashcards

1
Q

What are some causes of drug antibiotic resistance?

A
  • Recent use of antibiotics
    • Overuse of broad-spectrum antibiotics
    • Over prescription of antibiotics for viral illness, simple URIs, sinusitis, bronchitis
  • Age less than 2 years or greater than 65 years
  • Daycare center attendance
  • Exposure to young children
  • Multiple medical comorbidities
  • Immunosuppression
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2
Q

Vaccination with which vaccine has helped to decrease antimicrobial resistance to antibiotics?

A

Pneumococcal vaccine

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3
Q

What are some common organisms for the following diagnoses?: eye infections, bacterial meningitis, otitis media, sinusitis, URI, gastritis, food poisoning, STIs, UTIs

A
  • Eye infections: s. aureus, n. gonorrheae, chlamydia trachomatis
  • Bacterial meningitis: strep pneumonia, n. meningitidis, h. influenzae, s. agalactiae, listeria monocytogenes
  • Otitis media: strep pneumoniae
  • Sinusitis: strep pneumoniae, h. influenzae
  • URI: strep. Pyogenes, h. influenzae
  • Gastritis: h. pylori
  • Food poisoning: campylobacter jejuni, salmonella, shigella, clostridium, s. aureus, e. coli
  • STIs: chlamydia trachomatis, n. gonorrhoeae, treponema pallidum, ureplasma urealyticum, h. ducreyi
  • UTIs: e. coli, other enterobacteriaecae, s. saprophylicus, p.aeruginosa
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4
Q

What are some common organisms that cause community acquired, atypical and TB pneumonia?

A
  • Community acquired: s. Pneumoniae, h. influenzae, s. aureus
  • Atypical: Mycoplasma pneumoniae, chlamydia pneumoniae, legionella pneumophilia
  • TB: mycobacterium tuberculosis
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5
Q

What are some common organisms that cause skin infections? Impetigo?

A

s. aureus, s. pyogenes, pseudomonas aeruginosa

Impetigo: s. aureus and streptococcus

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6
Q

In what instances would you prescribe antibiotics?

A
  • Empiric: based on evidence based guidelines
  • Prophylactic: pretreating patients with implanted prosthetic devices
  • Definitive: based on culture
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7
Q

How long after starting an antibiotic will a patient usually feel relief of symptoms?

A

24-72 hours

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8
Q

What are some examples of gram positive vs. negative organisms?

A

Gram positive: Staph aureus, strep pneumonia, clostridium

Gram negative: E coli, pseudomonas, h pylori, Neisseria gonorrhea, salmonella

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9
Q

Which topical antibacterials can be used for mild cases of impetigo? (up to 5 lesions)

What is the target organism?

A
  1. Mupirocin (Bactroban, centany)
  2. bacitracin
  3. bacitracin + polymyxin B (double antibiotic)
  4. bacitractin + neomycin + polymyxin B (triple antibiotic)

Target organism: s. aureus

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10
Q

What is the MOA of mupirocin?

A

Bactericidal, inhibits bacterial protein synthesis by binding to bacterial isoleucyl tRNA synthetase

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11
Q

How many times should mupirocin be applied vs. bacitracin?

A

Mupirocin: 3x per day for 5-14 days

Bacitracin: 2-5 times per day until clear

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12
Q

What patient education is needed for topical antibacterials against impetigo?

A
  1. Do not touch tip of the ointment container to the infected area, use glove if possible
  2. wash hands before/after
  3. do not share towels/utensils, wash with antibacterial soap
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13
Q

What can be used to treat oral candidiasis?

A
  • topical nystatin
  • clotrimazole lozenges
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14
Q

What can be used to treat vulvovaginal yeast infections?

A
  • topical miconazole and clotrimazole
  • one-time dose fluconazole
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15
Q

What can be used to treat tinea infections?

A
  • topical terbinafine
  • miconazole
  • ketoconazole
  • clotrimazole
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16
Q

What can be used to treat herpes simplex? What is the frequency of dosage?

A
  • Topical acyclovir (Zovirax): every 3 hours x 7 days
  • Penciclovir (Denavir) for herpes labialis: every 2 hours while awake
  • Docosanol (Abreva): 5 times per day
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17
Q

Beta-lactams

Penicillin V & Penicillin G Benzathine

What is the indication and what organisms do these medications target?

A
  • Indication: Strep pharyngitis
  • aerobic, gram positive organisms, including s. pneumoniae, group A beta-hemolytic strep (GABHS)
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18
Q

Beta-lactams

Penicillin V & Penicillin G Benzathine

Which are the preferred diagnoses for treatment with these medications?

A
  • Penicillin G is great against T. pallidum (syphilis)
  • Penicillin V preferred for beta-hemolytic strep as G is an injectable with higher failure rate
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19
Q

Beta-lactams

Penicillin V & Penicillin G Benzathine

Amoxicillin and Amoxicillin/clavulanic acid (Augmentin)

MOA - bacteriostatic or bactericidal?

A
  • Inhibit the biosynthesis of peptidoglycan bacterial cell wall, causes cell wall death
  • Bactericidal
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20
Q

Beta-lactams

Penicillin V & Penicillin G Benzathine

What medications can be used to broaden the spectrum?

A
  • Combination with beta-lactamase inhibitors to broaden their spectrum: clavulanate, sulbactam, tazobactam
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21
Q

Beta-lactams

Penicillin V & Penicillin G Benzathine, Amoxicillin and Amoxicillin/clavulanic acid (Augmentin)

When to avoid, take caution, pregnancy/lactation and pediatrics considerations

A
  • Avoid: hx of hypersensitivity reaction
  • Caution: renal impairment
  • Pregnancy/lactation: compatible
  • Peds: approved
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22
Q

Beta-lactams

Penicillin V & Penicillin G Benzathine; Amoxicillin and Amoxicillin/clavulanic acid (Augmentin

Adverse fx (6)

A
  • GI: N/V/D, c. diff
  • Candidiasis
  • maculopapular rash within 7-10 days (most common with amoxicillin, does not indicate a true allergy - if pt has mono, more likely to have a rash if treated with amoxicillin)
  • Rare anaphylaxis usually occurs within 2-30 minutes
  • PCN G: pain at injection site
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23
Q

Beta-lactams

Amoxicillin and Amoxicillin/clavulanic acid (Augmentin)

Indications of each (7 & 4)

A
  • Amoxicillin: endocarditis prophylaxis, CAP, H. pylori, acute otitis media, sinusitis, lyme disease (children under 8), UTI in pregnancy
  • Amoxicillin/clavulanic acid (Augmentin): COPD acute exacerbation, acute bacterial rhinosinusitis, CAP, bites
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24
Q

Beta-lactams

Amoxicillin and Amoxicillin/clavulanic acid (Augmentin)

Target organisms

A

gram positive organisms, including s. pneumoniae, group A beta-hemolytic strep, enterococcus and greater activity against gram negative bacteria

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25
Q

Beta-lactams

Amoxicillin, Amoxicillin/clavulanic acid (Augmentin) & Penicillin V & Penicillin G Benzathine

Other considerations: pharmacokinetics

A
  • Formulation tastes good
  • Well absorbed from GI tract, several and unstable in acid - dicloxacillin and amoxicillin better absorbed than ampicillin
  • Protein-bound, so good distribution
  • Small amt is metabolized, most are excreted as unchanged drug in urine
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26
Q

Beta-lactams

1st generation cephalosporins: Cefazolin, cephalexin (keflex)

Indications & target organisms

A
  • Indications: cellulitis, uncomplicated cystitis, impetigo, GABHS, strep pharyngitis
  • Target organisms: gram positive cocci, methicillin-sensitive s. aureus, s. epidermis, streptococci, e. coli
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27
Q

Beta-lactams

All cephalosporins

MOA - bacteriostatic or bactericidal

A

inhibits mucopeptide synthesis in the bacterial cell wall synthesis during active multiplication, causing cell wall death; bactericidal

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28
Q

Beta-lactams

All cephalosporins

Pharmacokinetics

A
  • oral formulations absorbed from GI tract
  • widely distributed to most tissues
  • some highly bound to proteins, some are metabolized to less active compounds
  • most excreted via kidneys in various degrees as unchanged drug
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29
Q

Beta-lactams

All cephalosporins

When to avoid, caution, pregnancy/lactation, peds

A

Avoid: hypersensitivity reaction

Caution: history of anaphylaxis or hypersensitivity reaction with PCN allergy; renal and hepatic impairment

Pregnancy/lactation: compatible

Peds: approved

Ceftriaxone avoided in neonates (esp preterm) as it can displace bilibrubin from albumin binding sites

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30
Q

Beta-lactams

All cephalosporins

Monitoring

A
  • c. Diff
  • Renal function if prolonged
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31
Q

Beta-lactams

All cephalosporins

Adverse fx (11)

A
  • Nausea/Vomiting/Diarrhea
  • blood dyscrasias
  • maculopapular rash
  • Arthralgia
  • Fever
  • Seizures
  • Renal/hepatic failure
  • c.diff
  • hypersensitivity reaction (Rare)
  • hemolytic anemia (rare)
  • pain at injection site
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32
Q

Beta-lactams

2nd generation: cefuroxime, cefprozil, cefaclor

Indications, target organisms

A
  • indications: cellulitis, COPD acute exacerbation, acute otitis media, GABHS, lyme disease, uncomplicated UTI
  • gram positive cocci, methicillin-sensitive s. aureus, s. epidermis, streptococci, e. coli; increased activity against h. influenzae
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33
Q

Beta-lactams

3rd generation: ceftriaxone, cefdinir, cefpodoxime, ceftazadin

Indications, target organisms

A
  • Indications:
    • Ceftriaxone: bacterial meningitis, CAP, uncomplicated gonorrhea, PID, complicated UTI (male patient, pregnant patient, upper urinary tract infection)
    • Cefpodoxime: bacterial bronchitis, CAP, acute bacterial rhinosinusitis, GABHS
    • Cefdinir: COPD exacerbation, acute otitis media, strep pharyngitis
  • Target organisms: gram positive cocci, methicillin-sensitive s. aureus, s. pneumoniae, n. gonorrhoeae, h. flu, n. meningitidis, e. coli
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34
Q

Beta-lactams

4th generation: Cefepime & 5th genderation: Cetaroline

Indications and Target organisms

A
  • 4th gen
    • Severe infections, given IV
    • Gram positive bacteria
  • 5th gen
    • IV only, more severe infections
    • Active against MRSA
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35
Q

Fluoroquinolones

Ciprofloxacin, levofloxacin

Indications & target organisms

A
  • Indications:
    • Cipro: , traveler’s diarrhea, anthrax
    • Levo: COPD exacerbation, h. pylori eradication, CAP, acute bacterial rhinosinusitis, anthrax
    • Both: Pyelonephritis, chronic bacterial prostatitis, skin infections, bone/joint infections, complicated intraabdominal
  • broad spectrum with esp good coverage for gram negative bacteria, including e.coli, h. flu, m. catarrhalis, p. aeruginosa, s. pneumonia, mycoplasma
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36
Q

Fluoroquinolones

Ciprofloxacin, levofloxacin

MOA

A

bactericidal through interference with enzymes required for synthesis and repair of bacterial DNA and promote breakage of DNA strands

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37
Q

Fluoroquinolones

Ciprofloxacin, levofloxacin

Other considerations

A
  • Can no longer be used for gonorrhea, resistant TB
  • Well absorbed; take on empty stomach for best absorption.
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38
Q

Fluoroquinolones

Ciprofloxacin, levofloxacin

Avoid, caution, other considerations, pregnancy/lactation, peds

A
  • Avoid: myasthenia gravis
  • Caution: renal and hepatic impairment, elderly patients
  • Other considerations: risk of QT prolongation
  • Pregnancy/lactation: avoid
  • Peds: 18+
    • May use under 18 for pyelonephritis, anthrax, allergies to other meds
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39
Q

Fluoroquinolones

Ciprofloxacin, levofloxacin

Black box warning

A
  • BBW: risk of tendon rupture and tendinitis
  • Older adults at higher risk
  • Can have delayed onset - days to months after administration
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40
Q

Fluoroquinolones

Ciprofloxacin, levofloxacin

Patient education

A
  • avoid alcohol use
  • Food delays absorption
  • Take with full glass of water
  • Notify provider if tendon tenderness
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41
Q

Fluoroquinolones

Ciprofloxacin, levofloxacin

Adverse fx (11, 4 rare)

A
  • GI fx: Nausea/vomiting/diarrhea, psuedomembranous colitis
  • CNS fx: Sleep disorders, dizziness, headache
  • CV fx: angina, atrial flutter, increased risk of aortic aneurysm or dissection
  • Other: Acidosis, renal/hepatic failure, phototoxicity
  • Rare: hypersensitivity reactions, tendinitis, tendon rupture, c. diff
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42
Q

Lincosamides

Clindamycin (Cleocin)

Indications & target organisms

A
  • Indications
    • MRSA skin infection
    • strep pharyngitis
    • PID
    • first line therapy in peds/pregnancy
    • Infections in PCN-allergic patients
    • Drug-resistant strep pneumoniae
    • Dental infections
  • Target organisms gram positive organisms, including s. pneumoniae, s. pyogenes, MRSA, p. acnes, select anaerobic pathogens
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43
Q

Lincosamides

Clindamycin (Cleocin)

MOA - bacteriostatic or bactericidal

A

bacteriostatic; bind to 50s subunit of bacterial ribosome, suppressing protein synthesis

44
Q

Lincosamides

Clindamycin (Cleocin)

Pharmacokinetics, considerations for administration & monitoring

A
  • Pharmacokinetics: Oral dosing completely absorbed as it is not affected by gastric acid
  • Other considerations: Take with food and a full glass of water, sit or stand for 30 min after admin to decrease risk of esophageal irritation
  • Monitoring: Stop if significant diarrhea occurs and do not start loperamide
45
Q

Lincosamides

Clindamycin (Cleocin)

Black box warning, caution, pregnancy/lactation, peds

A
  • BBW: colitis, c. diff
  • Caution: history of GI disease, hepatic impairment
  • Pregnancy: compatible, lactation: caution
  • Peds: approved, but others preferred
46
Q

Lincosamides

Clindamycin (Cleocin)

Adverse fx (8, 3 rare)

A
  • GI: N/V, abd pain
  • Skin: maculopapular rash, burning, itching, erythema
  • Dizziness
  • Blood dyscrasias (Transient eosinophilia, neutropenia, thrombocytopenia)
  • Rare: hypersensitivity reaction, anaphylaxis, agranulocytosis
47
Q

Macrolides and Azalides

Azithromycin, erythromycin, clarithromycin (ACE)

Indications & Target organisms

A
  • indications:
    • Azithromycin: h. flu, m. catarrhalis, pertussis, COPD exacerbation, chlamydia (in combo with ceftriaxone to treat gonorrhea at the same time)
    • Erythromycin: ophthalmic preparation for bacterial conjunctivitis, acne
    • Clarithromycin: COPD exacerbation, H. pylori, pertussis
  • Target organisms: broad spectrum gram positive and negative - commonly resistant to beta-lactam abx, including s. pneumoniae, MSSA, h. flu, Bordetella pertussis, mycoplasma, chlamydia, m. catarrhalis, h. pylori
48
Q

Macrolides and Azalides

Azithromycin, erythromycin, clarithromycin (ACE)

MOA

A

bind to 50s subunit of the bacterial ribosome and inhibit RNA-dependent protein synthesis

49
Q

Macrolides and Azalides

Azithromycin, erythromycin, clarithromycin (ACE)

Pharmacokinetics, pharmacodynamics

A
  • Pharmacodynamics
    • Weak bases, activity increases in alkaline media
    • Atypical and intracellular organisms commonly resistant to beta-lactam antibiotics are often susceptible
  • Cross-resistance seen in all classes
  • Pharmacokinetics
    • well absorbed from duodenum
    • Potent inhibitors of cytochrome 3A4 (CYP3A4)
    • Combination with statins may increase risk for myopathy
    • Exhibit enterohepatic recycling, which can lead to buildup in the system and can cause n/v; tissue levels are higher than serum levels
50
Q

Macrolides and Azalides

Azithromycin, erythromycin, clarithromycin (ACE)

Avoid, caution, other considerations, pregnancy/lactation, preds

A
  • Avoid: pts at risk for torsades de pointes (azithromycin)
  • Caution: renal and hepatic impairment
  • Other considerations: risk for QT prolongation (azithromycin)
  • Pregnancy/lactation: compatible (clarithromycin not compatible in pregnancy)
  • Peds: approved - 6 months + for clarithromycin & azithromycin
51
Q

Macrolides and Azalides

Azithromycin, erythromycin, clarithromycin (ACE)

Interactions & monitoring

A
  • Interactions
    • Erythromycin & clarithromycin are potent inhibitors of the P450 system
    • Inhibitors of the CYP3A4
  • Monitoring
    • Hepatic/renal impairment
    • Hearing loss
52
Q

Macrolides and Azalides

Azithromycin, erythromycin, clarithromycin (ACE)

Adverse fx (7, 2 rare)

Which is associated with the most GI distress?

A
  • GI fx: N/V/D, abdominal pain
  • Skin: skin rash, bullous eruptions, eczema
  • Stevens-Johnson syndrome
  • hearing loss
  • Rare: liver abnormalities, hypersensitivity reactions
  • Erythromycin associated with the most GI distress
53
Q

Fidaxomicin (dificid)

Indication, considerations, interactions

A
  • Indication: c.diff infections
  • Considerations:
    • safe in pregnancy
    • 18+
  • Interactions: Rifampin, rifamixin
54
Q

Oxazolidinones: Linezolid

A
  • Indications:MRSA pneumonia, uncomplicated skin infections
  • Target organisms: Gram-positive bacteria
  • MOA: inhibits bacterial ribosomal protein synthesis
  • Considerations
    • Expensive, resistance is emerging
    • Pharmacokinetics: Well absorbed orally, does not use CYP450 enzymes
55
Q

Sulfonamides & Trimethoprim: Sulfamethoxazole/trimethroprim (Bactrim)
Indications & Target organisms

A
  • UTI, including suppression, MRSA, PCP pneumonia
  • gram positive and gram negative, including e.coli, toxoplasma gondil, pneumocystitis jirovecii (PCP pneumonia)
56
Q

Sulfonamides & Trimethoprim: Sulfamethoxazole/trimethroprim (Bactrim)

MOA of each

A
  • Sulfonamides block folic acid synthesis
  • trimethoprim inhibits DNA synthesis
  • nitrofurantoin may inhibit acetyl coenzymes
57
Q

Sulfonamides & Trimethoprim: Sulfamethoxazole/trimethroprim (Bactrim)

Avoid, caution, pregnancy/lactation, peds, monitoring

A
  • Avoid: sulfa allergy, G6PD deficiency
  • Caution: folate deficiency, renal impairment
  • Pregnancy/lactation: alternative agents should be used
  • Peds: 2months+
  • Monitoring
    • CBC for long-term use
    • Chest x-ray for those on nitrofurantoin that develop a cough
58
Q

Sulfonamides & Trimethoprim: Sulfamethoxazole/trimethroprim (Bactrim)

Adverse fx (8, 6 rare)

A
  • GI: N/V/D, abd pain, stomatitis, anorexia
  • CNS: headache, dizziness, photosensitivity
  • Hyperkalemia
  • Rare: crystalluria, hypersensitivity reactions, hemolytic anemia, kernicterus (bilirubin-associated brain damage), Steven-Johnson syndrome, agranulocytosis
59
Q

Tetracyclines: Doxycycline, tetracycline

Indications & target organisms

A
  • chlamydia, gonorrhea, lyme disease, CAP, COPD exacerbation, H. pylori eradication, Rocky mountain spotted fever
  • broad spectrum with good coverage against gram positive & negative including s. aureus, s. pneumoniae, p. acnes, h. flu, chlamydia, mycoplasma pneumoniae, rickettsia, t. pallidum, h. pylori
60
Q

Tetracyclines: Doxycycline, tetracycline

MOA & patient education

A
  • inhibit protein synthesis by reversibly binding to 30s subunit of the bacterial ribosome
  • Patient education:
    • photosensitivity
    • need back up birth control method for tetracycline
    • best with food but not with dairy
    • take with a full glass of water and standing 30 minutes upright after admin to decrease esophageal irritation
61
Q

Tetracyclines: Doxycycline, tetracycline

Caution, pregnancy/lactation, peds

A
  • Caution: renal & hepatic impairment
  • Pregnancy: avoid; lactation: short term use only
  • Peds: avoid younger than 8 except for if treating rocky mountain spotted fever
62
Q

Tetracyclines: Doxycycline, tetracycline

Adverse fx (6, 2 rare)

A
  • GI: N/V/D, anorexia
  • CNS: Lightheadedness, dizziness, photosensitivity
  • Hypertension
  • Rare: c. diff, severe skin reactions
63
Q

Glycopeptides: Vancomycin, telavancin (Vibativ), dalbavancin (Zeven)

Indications, target organisms

A
  • Indications
    • MRSA resistant to first-line abx
    • Oral vanco: c.diff
  • Target organisms: severe gram positive organisms, including c. diff and s. enterocolitis; bactericidal
64
Q

Glycopeptides: Vancomycin, telavancin (Vibativ), dalbavancin (Zeven)

MOA, how is it usually administered?

A
  • inhibit bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to the D-A1a-D-A1a portion of the cell wall precursor
  • Admin
    • Poorly absorbed orally - usually given IV
    • Oral for c.diff
65
Q

Glycopeptides: Vancomycin, telavancin (Vibativ), dalbavancin (Zeven)

Pregnancy/lactation, peds, monitoring

A
  • Pregnancy/lactation: compatible
  • Peds: approved
  • Monitoring: hearing, renal function
66
Q

Glycopeptides: Vancomycin, telavancin (Vibativ), dalbavancin (Zeven)

Adverse fx (10)

A
  • GI: nausea, bitter taste, mouth irritation, abd pain
  • CNS: fatigue, HA
  • peripheral edema
  • Red man syndrome if administered too fast
  • Ototoxicity
  • Nephrotoxicity
67
Q

Nitrofurantoin

Indication & Target organisms

A
  • uncomplicated UTIs including long-term suppression UTIs
  • gram positive and gram negative bacilli that cause UTIs; most often caused by e.coli
68
Q

Nitrofurantoin

MOA

A

activated by bacteria to reactive intermediates that inactivate or alter bacterial ribosomes, leading to inhibition of protein synthesis, aerobic energy metabolism, DNA, RNA, cell wall synthesis; may inhibit acetyl coenzymes

69
Q

Nitrofurantoin

Avoid, caution, pregnancy/lactation, peds

A
  • Avoid: CrCl less than 30, G6PD
  • Caution: CrCl less than 60
  • Pregnancy: avoid at term (38-42 weeks); lactation: avoid when infant is less than one month old
  • Peds: 1month+
70
Q

Nitrofurantoin

Adverse fx (4, 5 rare)

A
  • HA
  • Nausea
  • Rash
  • urine discoloration
  • Rare: hepatic dysfunction, agranulocytosis, hemolytic anemia, peripheral neuropathy, hypersensitivity reaction
71
Q

Nucleoside analgogues

Acyclovir, famciclovir, valacyclovir

Indications

A
  • Acyclovir: herpes simplex, genital herpes, herpes zoster, varicella, gingivostomatitis, CMV
  • Famciclovir: herpes simplex, oral and genital herpes; herpes zoster, epstein-barr, hep B
  • Valacylovir: herpes - genital, oral & zoster, varicella, gingivostomatitis (converted to acyclovir after oral admin - active against same viruses)
  • Ganciclovir: CMV
  • Herpes simplex: if greater than 6 occurrences per year, suppressive therapy should be considered; treat within 72 hours of an outbreak; decrease pain, duration of viral shedding and time to complete resolution
72
Q

Nucleoside analgogues

Acyclovir, famciclovir, valacyclovir

MOA, prescribing considerations

A
  • interfere with DNA synthesis and inhibit viral replication
  • Acyclovir: frequent dosing but not expensive
  • Valacyclovir: favored over acyclovir due to less frequent dosing
73
Q

Nucleoside analogues

Acyclovir, famciclovir, valacyclovir

Caution, pregnancy, peds, monitoring

A
  • Caution: renal impairment
  • Pregnancy/lactation: acyclovir recommended
  • Peds: acyclovir for 2+
  • Monitoring: BUN and creatinine may be assessed before therapy in those who have risk factors for renal impairment
74
Q

Nucleoside analogues

Acyclovir, famciclovir, valacyclovir

Adverse fx (7, 1 rare; 2 for valacyclovir; 3 for ganciclovir)

A
  • GI: N/V, nasopharyngitis
  • CNS: HA, fatigue, depression
  • skin rash
  • elevated transaminases
  • Rare: crystalluria
  • Valacyclovir: thrombocytopenia purpura, hemolytic uremic syndrome in immunocompromised patients
  • Ganciclovir: granulocytopenia, anemia, thrombocytopenia
75
Q

Antivirals for Hep C

Ledipasvir/sofosbuvir, sofosbuvir/velpatasvir

How is treatment determined? MOA

A
  • Treatment based on genotype and stage of disease - therapy usually started by a hepatologist, lasts approximately 12 weeks
  • inhibit HCV protein necessary for viral replication
76
Q

Antivirals for Hep C

Ledipasvir/sofosbuvir, sofosbuvir/velpatasvir

Black box warning, pregnancy/lactation

A
  • BBW for hep B virus reactivation - test for Hep B prior to starting therapy, hold therapy if need Hep B treatment first
  • Pregnancy: avoid; lactation: limited data
77
Q

Antivirals for Hep C

Ledipasvir/sofosbuvir, sofosbuvir/velpatasvir

Interactions, monitoring

A
  • Interactions: co-administration of ledipasvir and sofosbuvir (Harvoni) and amiodarone may cause serious symptomatic bradycardia
  • Monitoring
    • Bilirubin
    • Liver enzymes
    • Serum creatinine
78
Q

Antivirals for Hep C

Ledipasvir/sofosbuvir, sofosbuvir/velpatasvir

Adverse fx (5)

A
  • GI: N/D
  • CNS: HA, fatigue
  • Myalgias
  • Pruritis
79
Q

Antivirals for influenza

Neuraminidase inhibitors: oseltamivir, zanamivir, peramivir

Indications & MOA

A
  • Oseltamivir, zanamivir: Prophylaxis and treatment Influenza A & B
  • Peramivir: acute influenza 18
  • MOA: neuraminidase is a viral enzyme responsible for cleaving viral attachment to the host cell surface, allowing for viral circulation; inhibiting this enzyme prevents release of virus and halts the spreading of infection
80
Q

Antivirals for influenza

Neuraminidase inhibitors: oseltamivir, zanamivir, peramivir

Prescribing considerations

A
  • Start oseltamivir within 48 hours of sx onset, treatment up to 5 days after onset may reduce morbidity and mortality in hospitalized patients
  • Oseltamivir: well absorbed after oral administration.
  • Zanamivir: inhaled; 4% to 17% is absorbed.
  • Peramivir: administered intravenously (IV).
81
Q

Antivirals for influenza

Neuraminidase inhibitors: oseltamivir, zanamivir, peramivir

Avoid, caution, pregnancy/lactation, peds

A
  • Avoid: zanamivir with hx of respiratory disease
  • Caution: renal & hepatic impairment
  • Pregnancy: caution; oseltamivir ok in lactation
  • Peds: each has an approved age
82
Q

Antivirals for influenza

Neuraminidase inhibitors: oseltamivir, zanamivir, peramivir

Monitoring

A
  • Renal function in older and debilitated patients
  • Older: confusion, hallucinations, cognitive impairment
83
Q

Antivirals for influenza

Neuraminidase inhibitors: oseltamivir, zanamivir, peramivir

Adverse fx (2, 2 rare; 3 for zanamivir)

A
  • HA
  • N/V
  • Rare: anaphylaxis, neuropsychiatric events
  • Zanamivir: bronchitis, cough, SOB
84
Q

Antivirals for influenza

Baloxavir marboxil

Indications, MOA

A
  • influenza A & B
  • dependent endonuclease inhibitor that interferes with viral RNA transcription, resulting in inhibition of influenza virus replication
85
Q

Antivirals for influenza

Baloxavir marboxil

Pregnancy/lactation, peds, other considerations; adverse fx

A
  • Pregnancy/lactation: other agents recommended
  • Peds: 12+
  • Other considerations: administered as a single dose due to long half-life, more expensive
  • Adverse fx: Diarrhea, nasopharyngitis
86
Q

Systemic Azoles

Fluconazole, Itraconazole, Terbinafine

Indications for each

A
  • Fluconazole: candidiasis - vaginal, oropharyngeal, esophageal
  • Itraconazole: onychomycosis; off-label use for extensive tinea infections
  • Terbinafine: 1st line systemic treatment for onychomycosis; off-label use for extensive tinea infections
87
Q

Systemic Azoles

Fluconazole, Itraconazole, Terbinafine

MOA

A
  • Fluconazole & Itraconazole: interferes with fungal cytochrome P450 activity, decreasing ergosterol synthesis and inhibiting cell membrane formation
  • Terbinafine: synthetic allylamine derivative that inhibits squalene epoxidase, a key enzyme in sterol biosynthesis in fungi; results in fungal cell death
88
Q

Systemic Azoles

Fluconazole, Itraconazole, Terbinafine

Prescribing considerations

A
  • Fluconazole
    • inhibitor of cytochrome 3A4 (CYP3A4) and CYP2C9
    • Requires loading dose
  • Itraconazole: Absorption enhanced by food
  • Terbinafine: metabolized by CYP450 system
89
Q

Systemic Azoles

Fluconazole, Itraconazole, Terbinafine

What is there a risk for in all of these medications?

Caution, pregnancy/lactation, peds, black box warning

A
  • Risk for QT prolongation
  • Caution: arrythmias, renal & hepatic impairment
  • Pregnancy: avoid
    • Fluconazole - lactation: caution
    • Itraconazole & Terbinafine - lactation: avoid
  • Peds: approved
    • Itraconazole: limited data for peds
  • Itraconazole BBW: avoid in patients with HF; AHA has recommended not using in patients with underlying myocardial dysfunction
90
Q

Systemic Azoles

Fluconazole, Itraconazole, Terbinafine

Patient education, drug interactions & monitoring for Fluconazole

A
  • Patient education
    • Take with food
    • No alcohol
    • Signs of liver toxicity
  • Interactions: Drugs metabolized by CYP450
  • Monitoring for Fluconazole:
    • aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin before starting and every 3 to 4 months
91
Q

Systemic Azoles

Fluconazole, Itraconazole, Terbinafine

Adverse fx of each

A
  • All: headache, nausea, vomiting, diarrhea
    • Rare: hepatotoxicity
  • Fluconazole: dizziness
    • Rare: anaphylaxis, skin reactions
  • Itraconazole: skin rash, edema
    • Rare: skin reactions, CNS depression, hearing loss
  • Terbinafine: depression, taste disturbance
    • Rare: hepatic failure, skin reactions, ocular effects, blood dyscrasias
92
Q

Metronidazole (Flagyl)

Indications & Target organisms

A
  • c.diff (after tried vanco), bacterial vaginosis, h. pylori eradication, trichomoniasis, PID
  • Oral or topical (trichomoniasis, bacterial vaginosis)
  • gram positive and gram negative anaerobes including C. diff, bacteroides fragilis, h. pylori, t. vaginalis, garnerella vaginallis, g. lamblia, e. hystolica
93
Q

Metronidazole (Flagyl)

MOA

A

diffuses into organism and interacts with DNA to cause of loss of helical DNA structure and strand breakage, resulting in inhibition of protein synthesis and cell death

94
Q

Metronidazole (Flagyl)

Caution, pregnancy/lactation, peds, black box warning

A
  • Caution: renal and hepatic impairment, seizure disorder
  • Pregnancy: caution; lactation: avoid
  • Peds: approved
  • BBW: potentially carcinogenic
95
Q

Metronidazole (Flagyl)

Patient education

A
  • Avoid alcohol during treatment and 2 days post treatment to avoid disulfiram reactions
  • If treating for trichomoniasis or bacterial vaginosis: abstain from sexual intercourse
96
Q

What are symptoms of a disulfram reaction?

A

nausea, vomiting, flushing, dizziness, throbbing headache, chest and abdominal discomfort

97
Q

Metronidazole (Flagyl)

Adverse fx (8, 4 rare)

A
  • GI: Nausea, abdominal pain, anorexia, metallic taste, dry mouth, dark urine
  • CNS: Dizziness, HA
  • Rare: agranulocytosis, CNS effects, superinfections, hepatotoxicity
98
Q

Tinidazole

Indications & target organisms

A
  • bacterial vaginosis, h. pylori eradication (off-label), trichomoniasis, urethritis
  • bacteroides fragilis, h. pylori, t. vaginalis, gardnerella vaginalis, giardiasis, trichomoniasis, amebiasis
99
Q

Tinidazole

MOA

A

diffuses into organism and causes cytotoxicity by damaging DNA and preventing additional DNA synthesis

100
Q

Tinidazole

Caution, pregnancy/lactation, peds, black box warning

A
  • Caution: hepatic impairment
  • Pregnancy/lactation: avoid
  • Peds: 3+
  • BBW: potentially carcinogenic
101
Q

Tinidazole

Patient education

A
  • administer with food
  • avoid alcohol
  • abstain from sexual intercourse for VB and trichomoniasis
102
Q

Tinidazole

Adverse fx (4, 3 rare)

A
  • GI: nausea, anorexia, metallic taste
  • Fatigue
  • Rare: seizures, peripheral neuropathy, superinfection (c. diff, vaginal candidiasis)
103
Q

Why is there cross-sensitivity between PCN and cephalosporins? What medications are safer to use if the patient has a PCN allergy?

A
  • Cross-sensitivity between PCN and cephalosporins due to shared side chain - less than or equal to 1%
    • 1st and some 2nd gen have similar side chains to PCN
    • Safer if patient has PCN allergy: cefprozil, cefuroxime, cefpodoxime, ceftazidime, ceftriaxone
104
Q

Which drugs are no longer recommended for use to treat influenza due to resistance?

A

amantadine and rimantadine

105
Q

What medications are used for more serious cases of impetigo?

A
  • 5+ lesions or if no improvement within 2-3 days: cephalexin (keflex), amoxicillin/claulanate, dicloxacillin
106
Q

Which topical can be used for onychomycosis?

A

ciclopirox (penlac)

424 Pharmacology (12 decks)

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